NURSING CARE PLAN

NAME OF PATIENT:SHELL, PEARLY DATE OF ADMISSION:March 1, 2022 ROOM:210 AGE:25 SEX:Female CIVIL STATUS:N/A
CHIEF OF COMPLAINT: Feeling of fatigability, palpitations, severe headache, nausea and vomiting, tremors and moist hands.
RELIGION:N/A ATTENDING PHYSICIAN: DR. NGO
CUES SCIENTIFIC GOALS/OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
BASIS CRITERIA

March 1,2022 Ndx: Within 8 hours of 1. Monitor vital signs, 1. Orthostatic hypotension March 1,2022
2:30 PM Risk for decreased patient intervention including orthostatic can occur as a result of 8:20 PM
Subjective: cardiac output patient will be able to: BP assessment and increased metabolism,
Patient stated, “ And related to pulse/heart rate excessive peripheral Partially Met
even last week, parang uncontrolled Maintain adequate during sleep. vasodilation and a
kakaiba na talaga hyperthyroidism cardiac output decrease in circulating Within 8 hours of
grabe yung ginaw, characterized by: volume.Assessing the patient intervention
minsan grabe din ang Scientific Basis: ● Decrease in pulse during sleep gives patient was able to:
init. Kaya ako mismo It is well known that blood a more accurate
na we- weirdohan ng thyroid hormones pressure measure of tachycardia. Maintain adequate
feeling. I am afraid na raise the heart rate ● peripheral 2. Check for chest pain 2. It is a sign of increased cardiac output
feeling ko bumalik na and cardiac pulses or angina are oxygen demand by the characterized by:
yung sakit ko before contractility, ● no complained of by heart muscle or ✓↓BP:130/90mmHg
when I was working in improve the systolic dysrhythmias the patient. ischemia ✓RR: 16cpm
Dubai 1 month ago.” and diastolic ● Stable vital 3. Auscultation of 3. S1 and prominent ✓Temp:36.8
function of the signs heart sounds, note murmur associated ↓HR:120 bpm
Objective: heart, and decrease the extra heart with cardiac output (+)minimal palpitations
(+)palpitations systemic vascular sounds, a gallop increased in Headache 5/10
(+) hand tremors resistance. rhythm and a hypermetabolic state, ✓(-)hand tremors
(+)nausea and Cardiac effects of Manage signs and systolic murmur. the S3 as a sign of ✓(-)nausea and
vomiting hyperthyroidism symptoms of possible heart failure. vomiting
(+)moist hands include faster heart uncontrolled 4. ECG monitor, record 4. Tachycardia is a direct ✓(-)moist hands
(+)fatigue rate, stronger hyperthyroidism and note the speed reflection of the heart (+)fatigue
(+)plummer nails squeezing of the or rhythm of the muscle stimulation by (+)plummer nails
(+)smooth diffusely heart, increased heart and the thyroid hormone, (+)proptosis
enlarged thyroid blood pressure, and presence of dysrhythmias are
nodules irregular electrical dysrhythmias. common and can harm
(+)proptosis activity of the heart. cardiac function or
(+)patchy hair loss Kanji, A. (2022) cardiac output.
BMI: 17.2
ECG result:Sinus 5. Monitor 5. Fever occurs as a result
Tachycardia temperature, of excessive levels of
provide a cool hormones can increase
environment, limit diuresis / dehydration
Vital signs: the use of linens / and cause an increase
BP:160/100, clothing, and in peripheral
Temp:37.9, compress with warm vasodilatation, venous
HR: 150bpm, water. buildup, and
RR:22cpm, hypotension.
O2 Sat 94%, 6. Observation of signs 6. Dehydration can occur
pain scale and symptoms of quickly which will
of severe headache as severe thirst, dry reduce the volume of
claimed was 8/10. mucous circulation and
membranes, weak decrease cardiac
pulse, slow capillary output.
filling, decreased
urine output, and
hypotension.
7. Record input and 7. Loss of fluid a lot
output, record the (through vomiting,
specific gravity of diarrhea, diuresis,
urine. diaphoresis) can cause
severe dehydration,
concentrated urine and
weight loss.
8. Measure your 8. Activities will increase
weight every day, metabolic needs /
suggest bed rest, circulation potentially
limit unnecessary heart failure.
activity.
9. Administer 9. To manage underlying
medications as condition
prescribed:
○ Propranolol
(Inderal)
40mg 1 tab
now then 1
 tab OD for
palpitations
○ Methimazol
e (Tapdin)
5mg TID
○ Propylthiou
racil 50mg
1 tab TID
○ Motilium 1
tab TID for
vomiting
○ Norgesic
forte 1 tab
OD PRN for
headache
○ Citirizine
10mg 1 tab
for
itchiness at
bedtime
10. Educate patient of 10. Adherence to therapies
the importance of is a primary
strict adherence to determinant of
therapy. treatment success

Reference:
Kanji, A.(2022).4 Important cardiac effects of hyperthyroidism.https://www.ethosendo.com/blog/4-important-cardiac-effects-of-hyperthyroidism/
Vera, M.(2022).7 Hyperthyroidism nursing care plan.Risk for decreased cardiac output.Nurseslabs.https://nurseslabs.com/7-hyperthyroidism-nursing-care-plan-ncp/