hyperthyroidism final

8/7/2019 Hyperthyroidism Final

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CHAPTER I

INTRODUCTION

Hyperthyroidism, a term for overactive tissue within the thyroid gland, resulting in

overproduction and thus an excess of circulating free thyroid hormones: thyroxine (T4),

triiodothyronine (T3) or both. Thyroid hormone is important at a cellular level, affecting nearly

every type of tissue in the body. It functions as a stimulus to metabolism, and is critical to

normal function of the cell. It is considered as the second most common endocrine disorder. It

results from an excessive output of thyroid hormones due to abnormal stimulation of the thyroid

gland by circulating immunoglobulin. This disorder affects women eight times more frequently

than men and peaks between the second and fourth decades of life. It generally occurs between

20 and 40 years old and is more common in females. ( Medical surgical Nursing; Joyce Young

Johnson, 2000 )

Hyperthyroidism can occur when the thyroid gland is attacked by the body's own immune

system and causes it to become overactive and produce too much thyroid hormone. This form of

hyperthyroidism is a type of autoimmune thyroid disease.

Hyperthyroidism can also be caused by the growth of a thyroid nodule on the thyroid gland. A

thyroid nodule is a noncancerous cyst that produces additional thyroid hormone, resulting in high

levels of thyroid hormone. Making a diagnosis of hyperthyroidism begins with taking a

thorough medical history, including symptoms, and completing a physical examination. A

physician or health care provider may feel larger than normal thyroid gland or goiter in the neck.

( http://www.wrongdiagnosis.com/h/hyperthyroidism/intro.htm )


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According to the American Association of Clinical Endocrinologists, 2005. Hyperthyroidism

occurs in 1 percent of all Americans. Hyperthyroidism affects women five to 10 times more

often than men. As many as 15 percent of cases of hyperthyroidism occur in patients over 60

years old.

Prognosis

Up to 50% of people with Graves' disease who are treated with 12 to 24 months of anti-thyroid

drugs have prolonged remissions of their illness. Radioactive iodine also is an effective treatment

for Graves' disease and is almost always used in patients with overproducing thyroid nodules.

Many people will develop an underactive thyroid (hypothyroidism) following treatment with

radioactive iodine. However, this condition is easily treated with a single pill of thyroid

replacement medication daily. Surgery almost always cures hyperthyroidism. Similar to

treatment with radioactive iodine, surgery usually results in permanent hypothyroidism. (Harvard

Medical Publication)

Signs and Symptoms

Goiter (enlarged thyroid gland)

nervousness

mental impairment, memory lapses, diminished attention span

irritability

trembling hands

fatigue

insomnia

diarrhea


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itchy skin

unexplained weight loss despite increased appetite

heart palpitations

heat intolerance

increased sweating

muscle weakness, tremor

hair loss

increase bowel movements

decrease in menstrual periods

eye irritation

exopthalmic eyes (Graves disease only)

Risk factors

heredityGraves disease, also known as toxic diffuser goiter (enlargement of the thyroid gland)

and is the most common form of hyperthyroidism affecting the entire thyroid gland.

Graves disease is considered an autoimmune disorder (a condition in which the bodys

immune system develops antibodies against its own thyroid gland cells).

Plummers disease (involves a single mass or adenoma)

pituitary tumors

thyroiditis (caused by excessive amounts of thyroid hormone leaking out of the thyroid

gland and into the blood

too much thyroid hormone medication


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excessive dietary intake of iodine (found in seaweed and liver)

Me dical M anage me nt

1).Surgery

2.) Radioactive Iodine Therapy

3.) Drug Therapy.

Purpose and Obj e ctive s

This case history provided the nursing students with a specific opportunity to make use of the

nursing care process in the care of a client with hyperthyroidism.

Specifically, this study seeks to achieve the following objectives:

1. To be able to determine and perform proper and effective nursing intervention based from the

objective or subjective data gathered.

2. To be able to provide proper care to patients concerning hyperthyroidism that will lead to the

comfort of the patient.

3. To prevent any further complications that will aggravate the clients condition.

4. To assist client to explore methods for alleviation/ control of pain.

5. To be able to meet the clients needs (e.g. physiologic, social and etc) that will help improve

the clients health.


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6. To be able to compile or analyze all information from the health history, laboratory test

diagnostic procedures and assessment findings that will help produce a correct nursing outcome

Significance

and justificationThe outcomes of this study are beneficial to the following:

To our group and the other groups of this class, as this case study helps advance our

objective and critical thinking. It assists our nursing skills and applies it in our future duties. It

also gives us the knowledge and the idea of a patients sickness and how nurses deals with it.

Although were not yet in the performance stage, we are able to have the chance to find out some

of the interventions and the root background of ones case for ease.

To the patient , the primary source of quality nursing care, the results of this case history

will be beneficial in educating the patient regarding his condition and how to prevent it. And

most importantly, the application of the researchers knowledge and nursing care will contribute

to the improvement of the patients condition.

To the family members , this case study helps improve the awareness of each and every

family constituent. It will help them to identify the causes of such illness and will be able to learn

from the said case. This will also give them the knowledge on how to take care of the patient

when an instance this situation might happen again.

To the health care team , this studys outcome could be massive benefit for the patients

with similar situation. This may also be implemented for future health care advancements and

applied to patients with similar health state.


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To the future researchers , this study may serve as a reference for future use and a base

for new innovations and developments. It may also help future researchers to gain additional

knowledge in the said study.

Scope and Limitations

The study was conducted at a tertiary, government hospital in Makati on July 2, 2010 to

determine the case history about the Hyperthyroidism of a patient. Through this, the researchers

will have the opportunity to apply their understandings regarding the application of the nursing process to the patient concerning her condition.

The client M.R was interviewed and assessed with the guidance of the nursing history

form, concept map and nursing care plan. This will focus on its signs and symptoms, diagnosis,

treatment, prevention and the application of the proper nursing interventions. Developing and

planning promotion and curative methods are also parts of this case study.

This will only be limited to the patient assessed and diagnosed. Past illness dated within

the nursing history form is also assessed but it will not be included for elaboration of the study if

there is no significant relationship to the present concern of the client. This will only be focusing

on hyperthyroidism. Further results from the actualization of the dated interventions will not be

included because of limited time producing insufficient knowledge and data in accordance to the

performance of actual process.

B ackground of the Study

The case study was conducted at a tertiary, government hospital in Makati last July 2,

2010 located at Pembo, Makati City. The said hospital is a government hospital aimed at


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improving health and medical services to indigent communities in Pembo, Makati City. The said

hospital is among Makati hospitals that perform simple medical and surgical procedures, like

blood-letting programs, lip surgery among the kids, and rescue and quick response during

emergencies and disasters. The hospital has an Out-patient department which consists of ENT

(Fairy Lane Remya R.M.) Pedia (Anna Lee Dronila, RM) Ophthalmology (Rhiza Delosantos,

R.M) Surgery (Nelia Magpantay, R.M) OB (Ma. Eva Monte, R.M) and Medicine (Salome

Puenas, R.M). The schedules of surgery in the hospital are Minor - Mon and Thurs. Ortho- Tue,

Wed and Friday. Surgery-Mon to Friday. Authorized Bed capacity: 206. Functional Bed

capacities: 234.

The hospital also accepts maternity cases. With its present needs and challenges, the local

government of Makati is currently looking for options to address the need to improve this

hospital facility. The researchers study is about hyperthyroidism. The patient was interviewed

and assessed with the help of nursing tools like nursing history form.

The researchers study is about hyperthyroidism. The patient was interviewed and

assessed with the help of nursing tools like nursing history form. The client was chosen in the

interest of the researchers for their belief that the study will produce a learning opportunity to the

researchers as well as the readers.


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CHAPTER II

REVIEW OF RELATED LITERATURE

Trinidad, J. (2009), http://jegski.sulit.com.ph/index.php/page/id/12167/Health+Info

Hypothyroidism is an imbalance of thyroid hormones which is caused by its deficiency. It can be

generated due to several diseases like diabetes or lack of stimulation of pituitary gland. This

disease can affect anyone, at any age, but women who have age of 35-60 are mainly affected by

this. By this have a high risk period of infliction of hypothyroidism in health system of a woman.

Millions of people are affected by hypothyroidism symptoms and is not getting anyway to get

out of this disease. The most common symptoms are weight gain, infertility, dry flaky skin,

constipation, intolerance of cold, brittle hard nails feeling of depression. The most critical form

of hypothyroidism is known as myxedema which may turn into coma and ultimately cause death

of a person.

H yperthyroidism can also cause gain of weight

Asian Hospital and Me dical Ce nte r, (2004) R e trie ve d from

http://www.asianhospital.com/he althdige stite m.aspx?qy=101

Hypothyroidism : The Silent Menace

Mrs. Nita Santos is a 40 year old elementary school teacher in Davao. Lately, she noticed that

she was gaining weight in spite of having a decreased appetite. She also complained of weakness

and not being as energetic as she was before. She would find herself falling asleep more and

more often, even while she is at work. Mrs. Santos was worried yet she did not do anything. She


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just thought that what she was experiencing was due to normal ageing and that she just needed

more rest or exercise.

Aling Mila, a 35 year old laundry woman in Manila also experienced the same symptoms as Mrs.

Santos. Additionally, she also complained of hair loss, brittle nails and pain in her joints. She

also had problems in bowel movement. Like Mrs. Santos, she ignored her symptoms and did not

do anything, thinking that it could just be due to her poor nutrition or too much stress from work.

Many Filipinos also silently suffer what these two women are experiencing. Although it is true

that symptoms of weight gain, weakness, joint pains and sleepiness could be due to many other

conditions, their failure to seek medical consult might have prevented them from discovering thatthey might have the condition called hypothyroidism.

According to Dr. Phillip R. Orlander of the American Association of Clinical Endocrinologists,

hypothyroidism is the most common disease of hormone deficiency. It is the failure of the

thyroid gland to produce adequate thyroid hormones hence it is also known as underactive

thyroid disease. Without proper examination and testing, this condition could be easily missed

even by medical professionals. This is primarily because the symptoms of hypothyroidism could

be similar to other medical conditions. In fact, hypothyroidism has been called the "great

imitator"; at least 50 medical conditions it can mimic.

H yperthyroidism is the most common endocrine disease and mostly present in women


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e He althM D, (2004) Is Hype rthyroidism se rious? R e tri e ve d from

http://www.e he althmd.com/library/hype rthyroidism/HYE_se rious.html

Is Hyperthyroidism Serious? How serious hyperthyroidism is depends on the severity of the

condition causing it. In people whose thyroid hormone levels are only slightly elevated, the

symptoms will be fewer and less severe than for those with very high levels of circulating

thyroid hormone.

The seriousness of hyperthyroidism also depends on how well the body can compensate for the

changes brought on by excess thyroid hormones. For example, a heart that is already stressed byheart disease may deteriorate and develop heart failure as the heart rate rises in response to the

increased level of thyroid hormone. In addition, serious eye complications are fortunately rare,

but need to be properly cared for.

Ignatavicious (2006).Me dical Surgical Nursing: critical thinking for collaborative care (5th

e

d.). USA: Else

vie

r Saunde

rs Excessive thyroid hormone secretion leads to hyperthyroidism. The manifestations of

hyperthyroidism are called thyrotoxicosis. Thyroid hormones affect metabolism in all body

organs. Increased thyroid function produces many different manifestations. Hyperthyroidism can

be temporary or permanent, depending on the cause.

In hyperthyroidism the normal feedback control over thyroid hormone secretion fails. Because

thyroid hormones stimulate most body systems, excessive thyroid hormones produce hyper

metabolism and increased sympathetic nervous system activity. Many of the manifestations are

caused by the bodys response to the demands of hyper metabolism.


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Thyroid hormones directly stimulate the heart. The resulting increased heart rate and stroke

volume cause increased cardiac output and blood flow.

Elevated thyroid hormone levels affect protein, lipid and carbohydrate metabolism. Protein

synthesis (buildup) and degradation (breakdown) are increased. Breakdown exceeds buildup,

causing a net loss of protein known as negative nitrogen balance. Glucose tolerance is decreased,

and the client has hyperglycemia (elevated blood glucose levels). Fat metabolism is increased,

and body fat decreases. Although the client has an increased appetite, food intake does not meet

energy demands, and the client loses weigh. With prolonged hyperthyroidism, the client has

chronic nutritional deficiency.Thyroid hormones are produced in response to the stimulation hormones secreted by the

hypothalamus and anterior pituitary glands. Thus over secretion of thyroid hormones changes the

secretion of hormones from the hypothalamus and anterior pituitary gland. In addition, thyroid

hormones have some influence over sex hormone production in both men and women. Women

have menstrual problems and decreased fertility. Both men and women with hyperthyroidism

have increased libido (sexual urge or interest).

Hyperthyroidism caused by multiple thyroid nodules is termed toxic multinodular goiter. The

nodules may be enlarged thyroid tissues or adenomas. These clients usually have had a goiter for

years. The overproduction of thyroid hormones is usually milder than that seen in Graves

disease, and the client does not have exophthalmos or pretibial edema.

Hyperthyroidism also can be caused by excessive use of thyroid replacement hormones. This

type of problem is called exogenous hyperthyroidism.


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A condition called thyroid storm or thyroid crisis can occur when hyperthyroidism is untreated or

poorly controlled or when the client is severely stressed. This condition is an extreme state of

hyperthyroidism in which all manifestations are more severe and life threatening.

Incidence/prevalence

Lage rquist, S. (2006).Davis's NCLEX-RN Succe ss. Unite d State of Ame rica: F.A. Davis's

Company Ph

Diffuse hyperplasia of thyroid gland - overproduction of thyroid hormone and increased

blood serum levels. Hormone stimulates mitochondria to increase energy for cellular activitiesand heat production. As metabolic rate increases, fat reserves are utilized, despite increase

appetite and food intake. Cardiac output is increased to meet increased tissue metabolic needs,

and peripheral vasodilatation occurs in response to increased heat production. Neuromuscular

hyperactivity - accentuation of reflexes, anxiety, and increased alimentary tract mobility.

Graves disease is caused by stimulation of the gland by immunoglobulin of the IgG class.

Gaby, A., (Oct, 2004). "L-carnitine for hype rthyroidism - Lite ratur e R e vie w &

Comme ntary". Towns e nd Le tte r for Doctors and Patie nts. FindArticle s.com. R e tri e ve d

from http://findarticl e s.com/p/article s/mi_m0ISW/is_243/ai_109946525/

L-carnitine for hyperthyroidism - Literature Review & Commentary

Fifty healthy euthyroid female volunteers received a fixed TSH-suppressive dose of L-thyroxine

for six months. During that time they were randomly assigned to receive, in double-blind

fashion, 1 of 5 regimens: 1) placebo, 2) placebo for 2 months, then L-carnitine (2 g/day) for 2


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months, then placebo for 2 months, 3) placebo for 2 months, then L-carnitine (4 g/ day) for 2

months, then placebo for 2 months, 4) L-carnitine (2 g/day) for 4 months, then placebo for 2

months, or 5) L-carnitine (4 g/day) for 4 months, then placebo for 2 months. L-carnitine was

effective in both preventing and reversing symptoms of hyperthyroidism. The two doses of L-

carnitine were similarly effective. A slight increase in bone mineral density of the hip and spine

was seen in all L-carnitine-treated groups, although the difference in the change compared with

placebo was significant only for one of eight comparisons.

Comment: These results suggest that supplementation with 2 g/day of L-carnitine can prevent or

reverse symptoms of hyperthyroidism and might prevent thyroid hormone-induced bone loss.

Supplementation with L-carnitine should, therefore, be considered as part of the overall

treatment of hyperthyroidism, at least until thyroid-function tests can be brought into the normal

range.

Hyperthyroidism is known to deplete carnitine from the body. In a previous study, administration

of 1-3 g/day of L-carnitine to patients with hyperthyroidism resulted in an improvement in

symptoms within 1-2 weeks, although biochemical measures of thyroid function did not

improve. Thus, carnitine appears to be a peripheral antagonist of thyroid hormone action, rather

than an inhibitor of thyroid gland function. Other studies have shown that carnitine inhibits

thyroid hormone entry into the nucleus of cells.

De scription

Thyroid hormone stimulates the metabolism of the cells. They are produced by the

thyroid gland. The thyroid gland is located in the lower part of the neck, below Adams


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apple. The gland wraps around the windpipe (trachea) and has a shape that is similar to a

butterfly formed two wings (lobes) and attached by a middle part (isthmus)

Hormones are chemical messengers released into the bloodstream by specialized glands

called endocrine glands

The hormone circulates through the body in the bloodstream delivering a message to

other parts of the body. The message causes effects far from the gland that produced

the hormone.

WHAT DOES THYROID HOR M ONE DO?

Cells respond to thyroid hormone with an increase metabolic activity. Metabolic activity, or

metabolism, is a term used to describe the processes in the body that produce energy and the

chemical substances necessary for cells to grow, divide to form new cells, and perform other

vital functions.

Because thyroid hormone stimulates cells, it causes major body functions to go a bit faster.

Heart rate increases

Breathing rate increases

Uses of proteins, fats & carbohydrates increases

Skeletal muscles work more efficiently

Muscle tone in the digestive system, such as those in the walls of the intestines

that help to move food through the digestive system increases

Mental alertness & thinking skills are sharpened

HOW ARE B LOOD LEVELS OF THYROID HOR M ONE CONTROLLED?


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The bodys control system that regulates the cells to function at a steady, appropriate

metabolic rate may be explained as follows:

. Special detector cells in the brain monitor the level of thyroid hormone in the blood.

When the level of thyroid hormone drops, these cells send signals to a nearby

organ in the brain known as the pituitary gland.

These signals stimulate the pituitary gland to release a substance called thyroid-

stimulating hormone (TSH) into the bloodstream.

TSH signals cells in the thyroid gland to release more thyroid hormone into the bloodstream.

When the blood levels of thyroid hormone has increased enough, the detector

cells in the brain detect the increase in thyroid hormone level.

These detector cells send signals to the pituitary gland to stop release of TSH.

NOR M

AL RANGE OF THYROID HOR M

ONES

The following reference ranges represent commonly used thyroid function reference ranges.

However, ranges and units of measurement may vary from one laboratory to another.

Adult Reference Ranges:

T4 = 5.6 13.7 ug/dl (mcg/dl)

FT4 = 0.8 1.5 ng/dl

T3 = 87 180 ng/dl


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FT3 = 230 420 pg/dl

TSH = 0.4 4.5 mIU/L (mU/L)

Signs and Symptoms

Goiter (enlarged thyroid gland)

nervousness

mental impairment, memory lapses, diminished attention span

irritability

trembling hands

fatigue

insomnia

diarrhea

itchy skin

unexplained weight loss despite increased appetiteheart palpitations

heat intolerance

increased sweating

muscle weakness, tremor

hair loss

increase bowel movements

decrease in menstrual periods

eye irritation

exopthalmic eyes (Graves disease only)


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Etiology

Hyperthyroidism is also known as asthyrotoxicosis from the prefix thyro- meaning thyroid, the

term toxic meaning poisonous and the suffix -osis meaning condition.

Thyoid literally means shaped like a shield. The thyroid gland lies in front of the voice box.

The gland and its associated support tissues are shaped like a shield.

Epide miology

According to the American Association of Clinical Endocrinologists, 2005. Hyperthyroidism

occurs in 1 percent of all Americans. Hyperthyroidism affects women five to 10 times more

often than men. As many as 15 percent of cases of hyperthyroidism occur in patients over 60

years old. Hyperthyroidism is present in approximately 0.5% of the population.An additional

0.8% of the population has mildly suppressed or undetectable serum thyroid stimulating

hormone (TSH) levels but circulating thyroid hormone levels in the normal range. Additionally,

the rate of development of the various causes of hyperthyroidism varies according to geographic

location and is believed to be related to the iodine intake of the population. For example, an

epidemiologic survey comparing an area of normal iodine intake to one with insufficient iodine

intake found that Graves disease accounted for 80% of cases of hyperthyroidism in the iodine

sufficient population but toxic uninodular and multinodular goiter accounted for the majority of

cases in the iodine deficient population.

Risk factors

heredity


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Graves disease, also known as toxic diffuser goiter (enlargement of the thyroid gland)

and is the most common form of hyperthyroidism affecting the entire thyroid gland.

Graves disease is considered an autoimmune disorder (a condition in which the bodys

immune system develops antibodies against its own thyroid gland cells).

Plummers disease (involves a single mass or adenoma)

pituitary tumors

thyroiditis (caused by excessive amounts of thyroid hormone leaking out of the thyroid

gland and into the blood

too much thyroid hormone medicationexcessive dietary intake of iodine (found in seaweed and liver)

Pre ve ntion

There are no known prevention methods for hyperthyroidism, since its causes are either

inherited or not completely understood.

The best prevention tactic is knowledge of family history and close attention to

symptoms and signs of the disease.

Careful attention to prescribed therapy can prevent complications of the disease

Diagnosis

The diagnosis of hyperthyroidism is often obvious from the patients symptoms and

appearance. However, to confirm the diagnosis, blood tests may be done for TSH or other

thyroid hormones.


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Additionally, the doctor may do a thyroid scan. The thyroid scan or iodine uptake test,

involves the patient swallowing a solution containing radioactive iodine.

The physician then uses a scanning device to measure the amount of iodine that has been

absorbed by the thyroid; an elevated level further confirms that the gland is overactive.

Tr e atme nt

There is no treatment that is best for all patients with hyperthyroidism. Many factors will

influence the doctors choice of treatment, including the patients age, the form of

hyperthyroidism, the severity of the disease and other medical conditions which may be

affecting the patients health.

Currently, there are three principal ways to treat hyperthyroidism: drug therapy,

radioactive iodine therapy and surgery. The goal is to bring the body into homeostasis or

a healthy, balanced condition.

Pathophysiology

Thyroid is one of the most important glands in the body that is just located at the base of

the neck at front side. It is nearer to the voice box and Adams apple. Thyroid gland is

closely related with the bodys metabolism. This is because the thyroid gland secretes the

thyroid hormone that plays an important role in the metabolism of the body.

In the case of hyperthyroidism, the thyroid gland works in excess. Over active thyroid

gland produces more thyroid hormone in the body digests faster than what it assimilates

and absorbs the nutrients.


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Excess presence of thyroid hormone in the body is also known as thyrotoxicosis. One of

the common cause for this condition is Graves disease that falls under autoimmune

category.

Pre disposing factors

-abnormal iodine metabolism

-history

-age (39 yrs old)

-sex: Female (women are more prone)

-trauma to thyroid gland

Pre cipitating factors

.major stress

.excessive intake of iodine

Aggravating factors

-major stress

-maltreatment

-environment

-nutritional imbalance

Me dical M anage me nt


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1. Drug Therapy

a. Anti-thyroid drug ( prophythrouracil and methimazole [tapazole] ) : block synthesis of

thyroid hormone ; toxic effect include agranulocytosis

b. Adrenergic blocking agents ( commonly propanolol [inderal] ) : used to decrease

sympathetic activity and alleviate systems such as tachycardia

2. Radioactive Iodine therapy

a. Radioactive isotope of iodine given to destroy the thyroid gland, thereby decreasing

production of thyroid hormone.

b. Used in middle-age or older client who are resistant to or develop toxicity from drug

therapy.

c. Hyperthyroidism is a potential complication.

3. Surgery

a. Thyroidectomy performed in younger clients for whom drug theraphy has not been

effective.

Nursing M anage me nt

Assessment. By obtaining a complete history and asking questions concerning weight,

appetite, activity, heat intolerance, and bowel activity, you can assess for the presence of typical

manifestations of hyperthyroidism. Also ask about mood alterations.

Diagnosis: Imabalance Nutrition: Less Than Body Requirements.


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A client with hyperthyroidism is hypermetabolic, leading to the nursing diagnosis Imbalance

Nutrition: Less than body Requirements related to accelerated metabolic rate resulting in weight

loss and decreased energy levels.

Outcomes. The clients weight loss will end as evidenced by and ability to consum

sufficient calories to return to ideal body weight.

Interventions. Provide the client with a well-balance diet high in calories, protein,

carbohydrates, and minerals. Discourage the ingestion of foods that increase peristalsis and thus

result in diarrhea, such as highly seasoned, bulky, or fibrous foods.

Preoperative CareAssess the client for typical manifestations of Graves disease. A hypermetabolic state

may be obvious from apparent weight loss, and exophthalmos may be obvious as well. Also,

question the client about visual difficulties, fatigue, weakness, tremors, and insomnia.

Promote Preoperative Euthyroid State. The client must be carefully prepared for a

thyroidectomy to avoid complication (e.g., thyroid storm and hemorrhage). Outcomes of

successful preparation for thyroid surgery are as follows:

y The client is euthyroid before entering the operating room. Tests of thyroid function are

within normal limits.

y Manifestations of thyrotoxicosis are greatly diminished or absent. The client appears

rested and relaxed.

y Weight and nutritional status are normal; any weight lost earlier has been regained.

y Cardiac problems are under control, pulse rate is normal, and preoperative

electrocardiograms show no dangerous dysrhythmias.


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Postoperative Care

Assessment

Monitor for Postoperative Complication. Assemble the needed equipment at the bedside

before the client returns from surgery.

The equipment includes a blood pressure cuff and stethoscope, additional pillows, oxygen,

suction equipment, incubation supplies, and a tracheostomy set. Ampules of calcium gluconate

should be on hand in the medicine room or on the emergency cart.

Monitor and Treat HypocalcemiaMuscle twitching and hyperirritability of the nervous system may indicate hypocalcemic

tetany. Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally

removed during surgery. Manifestations may develop after thyroidectomy if the parathyroid

glands are accidentally removed during surgery. Manifestations may develop 1 to 7 days after

surgery. Monitor the client for Chvosteks and trousseaus signs, report positive responses to the

physician immediately. Also call a physician if the client develops numbness and tingling around

the mouth, fingertips, or toes; muscle spasms; more twitching. Make sure calcium gluconate

ampules are available at the bedside and that the client has a patent inravenous line.

Evaluation. The client should be discharged within several days of surgery without

difficulty. The wound should heal within 6 weeks without injection.


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M akati Me dical Ce nte r

Colle ge of NursingLibran House 144 Le gaspi St., Salce do Village , M akati City

SY 2010 2011

A Case History Pre se ntation on Hype rthyroidism in Partial Fulfillm e nt of the Course

R e quire me nt of NCM 101 R e late d Le arning Expe rie nce

Submitte d To:Viray, Gr e te l R.N, M .A.N

Submitte d B y:

GONZAGA, Jan M arie A.

M ARCOS, R e ina Charmain e R.

M ASUSI, Riffy Je an G.

M ELAD, M a. Isaiah C.

M ILANIO, Kathe rine Kaye R.

M OCON, Junabe l G.

ONG, M ary Grac e B .

OPEA, M a. Katrina D.

OPINION, Jaze l Jan S.

OREAL, Hanna J e anne V.

M AM ERTO, Robe rt Jayson P.

M ANALAYSAY, K e vin M ark N.


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CHAPTER III

CLIENT PRESENTATION

De mographic Profile

This is the case of patient M.R., a 39 year old female. She was born on the 19 th day of

April 1971 currently residing at Pembo, Makati City. The patient works as a part time employee

at the Coca Cola Company; patient has 3 children, widowed. On July 2, 2010, she was

interviewed for data assessing, diagnosing, planning, implementing and evaluating.

Asse ssme nt

The patient has a localized chest pain at the anterior area, throbbing in nature with a

pain scale of 5/10 which is moderate. The patient experienced Onset of pain during her working

hours; it was sudden which lasted for about 5 minutes recurrent before the confinement. . Her

looks are appropriate for his age and clothes.

The pain was aggravated by food and alleviated by drinking water. Associated symptoms

include joint pains and headache.

It was also noted that the patient was hospitalized last 2007 due to miscarriage. She

reveals to have a past history of rubeola (Measles). She is currently taking Methimazole (5mg)

once a day as ordered by the physician for her treatment of hyperthyroidism.

Family health history reveals that her father has asthma and her sister has a hypertension.

During her consultation, she stated that she defecate only once a week and has regular menstrual

period. The patient states that she is having difficulty in sleeping and has a passive lifestyle. Her

consultation shows that she still can perform full range of motion.

Vital signs were taken; all are within normal ranges except for the pulse rate and

respiratory rate which is 120 bpm and 27 cpm respectively.


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CLUSTERING

1 39 year old female

2

Widowed

3 Part time employee at Coca Cola

4 Nahihirapan akong huminga avb the pt

5 Localized and throbbing pain at the anterior part of the chest

6 pain scale of 5/10, moderate

7 sudden onset of signs and symptoms which lasted for 5 minutes, recurrent before

confinement8 associated symptoms of joint pains and headache

9 Aggravating factors: food relieving factors: drinking water

10 Madali akong mapagod kapag nagtatrabaho avb the pt

11 Nahihirapan akong matulog sa gabi avb the pt

12 Kumikirot yung dibdib ko pag sobrang pagod avb the friend

13 Hospitalization due to miscarriage

14 History of rubeola

15 Had complete immunizations

16 Family history of hypertension and asthma

17 Medications: Methimazole 5mg once a day

18 Irregular pattern defecation

19 Regular menstrual period

20 Difficulty in sleeping

21 no usage of alcohols and drugs22. passive and irregular lifestyle


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GORDONS FUNCTIONAL HEALTH PATTERNS

HEALTH PATTERNS

Health Perception- Health Managementy 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 18, 20, 22, 23, 24

Nutritional- Metabollic

y 11, 12, 22,

Elimination

y 17, 23

Activity- Exercise

y 5, 18, 19, 24

Sleep-Rest

y 21

Cognitive-Perceptual

y 5, 6, 7, 8, 9, 12

Self-Perception-Self-Concept

y 1, 2, 3, 9, 24

Role Relationship

y 2, 3, 9

Sexuality- Reproductive

y 1, 16, 17,,

Coping-Stress Tolerance

y 5, 6, 7, 8, 9,10, 13


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NURSING CARE PLAN

Nursing Diagnosis # 1:Ineffective Breathing Pattern related to airway obstruction asevidenced by increased respiratory rate.

Goal: to provide adequate ventilation

Expe cte d Outcome s: After 2 hours of nursing-client interaction, the patient willmanifest improvement in ventilation as evidenced by:

y Improved respiratory rate (client-centered)

y Participation in breathing exercise together with the technique to improve lungexpansion (functional)

Inte rve ntions Evaluation

Promotive 1.) Monitoring of respiratory rate

and depth. Note respiratoryeffort.

R ationale: to know what will be thenurses next intervention to be done for further attainment of adequateventilation.

2.) Assist client to learn breathingexercises.

R ationale: to improve respiratory rate.

Pre ve ntive 3.) Elevate head of bed, place in

upright or semi-fowlers position. R ationale: to stimulate respiratoryfunction/lung expansion. To prevent andresolve pulmonary congestion

Client responses are variable. Rate andeffort maybe increased by pain, fear, fever.

The client is seen able to perform breathingexercises. The client is now assessed tohave improved respiratory rate.

The client is seen to have no difficulty breathing. The client is seen morecomfortable in this position.


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Nursing Diagnosis # 2:Risk for Activity Intolerance related to presence of endocrine problems (hyperthyroidism)

Goal: to maintain daily activities within capabilities.

Expe cte d Outcome s: Within 8 hour of nurse-client interaction, the patient will be ableto perform daily activities as evidenced by:

y No signs of fatigue (functional)

y Normal respiratory rate and pulse rate (client-centered)

y No signs of irritability (functional)

y No signs of weakness (functional)

y No signs of respiratory distress (functional)


Promotive 1.) Encourage adequate rest periods

esp. before & after meals. R ationale: to prevent experience of fatigue

2.) Allow patient to perform tasks athis own rate. Stop the patientfrom doing non-essential

procedures/activities. R ationale: to know his present situationthrough performing activities withassistance and promotes independence

3.) Encourage physical activitiesconsistent with patient energyresources.

R ationale: to experience of fatigue andfeeling weak.

The patient has shown no signs of fatigue.

The client is seen performing dailyactivities independently.

The patient has shown no signs of fatigueand weakness. Normal Respiratory rate andPulse rate.


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Nursing Diagnosis # 3: Disturbed Sleep Pattern related to fatigue as evidenced byNahihirapan akong matulog sa gabi as verbalized by the patient.

Goal: to be able to sleep without disturbance.

Expe cte d Outcome s: After the 2 days of nurse-client interaction, the patient willmanifest improvement of sleep pattern as evidenced by:

y Identify appropriate interventions to promote sleepy Report improvement of sleep patterny Sleep without difficulty


Promotive

1.) Assess sleep patterns andchanges, nap times andfrequency, sleep problems,

pattern of awakenings andreason.

R ationale: to evaluate sleep pattern anddysfunction (s)

2.) Assess for fatigue, weakness andirritability.

3.) Provide an environment that isquiet, calm and warm

R ationale: to promote sleep withoutdifficulty.

R e habilitative 4.) Encourage patient to have

adequate rest and sleep toconserve energy.

R ationale: to maintain sufficient energyto perform activities.

The patient will verbalize improvement of sleep pattern and has been able to sleepwithout difficulty.

The patient has shown no signs of fatigue,weakness and irritability.

The patient was able to rest and sleepwithout disturbance.

The patient was able to do daily activitieswithout feeling weak and withoutexperiencing fatigue.


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Nursing Diagnosis # 4: Disturbed Body Image related to disease process(hyperthyroidism) as evidenced by swelling of neck.

Goal: to verbalize understanding of body changes.

Expe cte d Outcome s: After the 2 days of nurse-client interaction, the patient willverbalize acceptance of self-image as evidenced by:

y Interaction with the nurse on duty and student nursesy Verbalization of acceptance of body changes


Inde pe nde nt1.) Encourage to make own

decisions and accept bothinadequacies and strengths.

R ationale: to be able to appreciate self-worth.

De pe nde nt2.) Encourage patients significant

other to offer support. R ationale: social support enhances bothemotional and physical health.

The patient has been able to make owndecisions and to be able to utilize strengthsand weaknesses.

The patient has been encouraged bysignificant other and has accepted supportfrom the significant other.


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hyperthyroidism final

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