CASE SCENARIO:

Mrs. Gonzalez a 33 year-old woman showed up stating she had experience drastic weight loss over the past 5 months despite increased
food intake and diarrhea for 3 days. The patient also noticed her eyes are easily irritated and it is hard to blink. Upon checking her vital signs and
physical examination they obtain a blood pressure of 130/90, heart rate of 118 beats per minute which is abnormally high for her age, BMI of 17.3
and protruding eyes. She said she felt anxious the whole time and has trouble sleeping at night. Before the doctor went in to the room, the patient
revealed to the nurse that her grandfather was diagnosed with Graves’ disease before.

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 PHINMA UNIVERSITY OF PANGASINAN
COLLEGE OF ALLIED HEALTH SCIENCES - DEPARTMENT OF NURSING
NURSING CARE PLAN

HYPERTHYROIDISM (PROBLEM-FOCUSED)
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE Imbalanced Imbalanced SHORT TERM INDEPENDENT  Within 3 hours,

nutrition: less than nutrition in the the goal was
“Hindi ko alam body requirements case of Less than Within 3 hours of  Monitor the  To be met. The
bakit ako related to Body nursing patient's dietary informed patient was able
nakararanas ng exaggerated Requirements can interventions, the noting. about the to verbalize
pagbaba ng metabolic rate, be defined as: patient will current understanding
timbang kahit na excessive appetite, “The state where verbalize condition with of her condition
dinadamihan ko and increased GI an individual understanding of the caloric and recognized
naman ang activity as experiences or her condition and requirements possible
pagkain ko. evidenced by suffers the risk of recognize possible of the patient complications.
Madalas din drastic weight loss experiencing complications.
akong magtae and diarrhea. reduced weight  Provide a  To help the
nitong mga due to insufficient healthy diet and patient reach
nakaraang tatlong intake or LONG TERM determine the the ideal body
araw.” as metabolism of lifestyle factors condition and  After 1 week,
verbalized by the nutrients After 1 week of that may affect to be aware of the goal was
patient. necessary for the nursing the weight. the elements partially met.
body’s metabolic interventions, the that may The patient
OBJECTIVE needs.” patient will influence the started to gain
maintain normal patient's some weight
• Altered weight balanced nutrition dietary choices and diarrhea is
loss. and no longer and no longer an
experience consumption. issue.
•V/S taken as diarrhea.
follows:  Avoid giving  To reduce the
peristalsis- risk of having
P: 118 inducing meals
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BP: 130/90 and drink that abnormal
causes diarrhea. gastrointestina
BMI: 17.3 l tract motility,
which can
result in
diarrhea and
impair
nutrition
absorption.

DEPENDENT  The
 Administer administration
medications as of diarrhea
ordered by the treatment aids
physician in the
regulation of
liquid flow via
the digestive
tract, while
nutritional
supplements
aid in weight
growth.

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 HYPERTHYROIDISM (POSSIBLE)
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATION
N

SUBJECTIVE:  Possible Depression can SHORT TERM: INDEPENDENT

depression intensify pain, as  Involve the  Maximizes  Approximately
“Ako ay nag-alala related to the well as fatigue  Approximately client in the potential 10 minutes the
dahil may threat to and sluggishness. 10 minutes the one-to-one for patient shows
posibilidad na ako physiologic patient will interactions improved mood
The combination activity.
ay magkaroon ng integrity show improved while as demonstrated
of chronic illness mood as minimizing by Beck
graves’ disease and depression demonstrated anxiety levels. depression
sapagkat ang might lead to by Beck Inventory
aking lolo ay isolate yourself, depression  Encourage  Clients can
nagkaroon nito which is likely to Inventory clients to learn alternative
noon at make the express feelings ways of dealing
nakararanas ako LONG TERM: with
depression even (anger, sadness,
ng sintomas nito overwhelming
worse. Serious After 12 to 20 guilt) and come emotions and
tulad ng pagbawas illness can cause up with gain a sense of  After 12 to 20
weeks of 30-60
ng timbang, tremendous life alternative control over weeks of 30-60
minutes per minutes per
pagtatae at pag- changes and limit ways to handle his/her life.
session with session the goal
umbok ng mata. your mobility and feelings of
nursing was met. The
Nakakaramdam independence. A anger and
interventions and patient showed
din ako ng chronic illness can frustration improvement in
cognitive
pagkabalisa at make it the way she
behavioral
nahihirapan akong  Assess think and
impossible to do therapy, the the  Depression is
matulog sa gabi.” the things you patient’s and behave.
patient will show a mood
as verbalized by enjoy, and it can significant disorder caused
improvement in
the patient. eat away at your other’s by the
the way she think knowledge
self-confidence cumulative
and behave. regarding factors of
OBJECTIVE: and a sense of
 BP depression and ongoing
hope in the future. its causes stressful events,
130/90
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  HR 118 genetics and
BPM chemical
 33 year imbalances in
old the brain.
 BMI of  Stay with the  Affirms to
17.3 patient, patient or SO
 protruding maintaining a that although
eyes calm manner. patient feels out
Acknowledge of control,
fear and allow environment is
the patient’s safe. Avoiding
behavior to personal
belong to the responses to
patient. inappropriate
remarks or
actions prevents
conflicts or
overreaction to
a stressful
DEPENDENT situation

 Allow the
patient to take  To help the
time and think patient have
about what to enough time to
say or do communication
and not to feel
rush or
bothersome

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  Encourage  These measures
relaxation induce sleep
measures in the and relaxation.
evening (e.g.,
drinking warm
milk, back rub,
or tepid bath).

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 HYPERTHYROIDISM (RISK)
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE Risk for corneal Corneal injury is SHORT TERM  Obtain history  These  Within 3 hours,
injury related to susceptible to of eye symptoms can the goal was
"Napapansin ko protruding of the infection or Within 3 hours of conditions when be associated met. The
parang naiirita eyeball. inflammatory nursing assessing client with corneal patient was able
yung mata ko lagi lesion in the interventions, the concerns injury and, if to verbalize
at nahihirapan ako corneal tissue that patient will overall. Listen present, require understanding
kumurap tapos can affect verbalize for reports of further of her condition
parang may pag- superficial or deep understanding of eye pain, foreign evaluation and and recognized
umbok na layers, which may her condition and body sensation, possible possible
nangyayari.” as compromise recognize light sensitivity treatment. complications.
verbalized by the health. possible (photophobia),
patient. complications. and blurred
vision.
OBJECTIVE  Evaluate the  To assess if the
LONG TERM client's ability to patient’s ability
maintain eyelid to blink is  After 1 week,
PHYSICAL After 1 week of closure on a improving. the goal was
EXAMINATION nursing daily basis and met. The
ARE TAKEN AS interventions, the as needed. patient
FOLLOW: patient will  Instruct patient  To protect the remained free
- protruding eyes remain free from to wear eyes from from injury.
injury. protective foreign objects.
eyewear in
situations or
sports where
objects may fly
into eyes or
face.
 Wear protective  To protect the
eyewear that eyes and avoid
gives 180- foreign objects

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 degree from entering
protection while the eyes.
using a grinding
wheel or
hammering on
metal.

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