THYROI DI SM

over view

HYPERTHYROIDISM
Concept Mapping

Presenter s:
LEGEND SCENARI O Sonajo, Therese B.
Suminguit, Anna Mae E.
Mrs. Issabelle Rodriguez, a 29 year old female was brought to Negros Oriental Provincial Hospital Tan, Mariah Alexxa RJ C.
Clinical (NOPH) last February 01, 2021 at 1500H due to sudden high fever, palpitation, chest pain, fatigue Tigas, Mel Boy Jr. T.
Risk Factors
Manifestations and fine tremor (of fingers and tongue) on her way home after attending a birthday party celebration
NCM-54 Lecture B
at a seafood restaurant together with her college friends. Upon taking patient history, the husband
said that his wife is already experiencing diarrhea episodes since last 3 (three) days and is noticed
Diagnostic Complications
to lose weight for the past two (2) weeks however, pt does not want to be hospitalized and just
Procedure
wanted to medicate herself at home since she's afraid contracting COVID-19, considering the
increasing case of COVID-19 patients, and pt saw it as not that serious enough since the symptoms
would go away after taking some OTC medications. Just a week ago, pt already noticed something
Anaphysio/Pathophysiology
?weird? in her left eye because according to her, it looked like it?s ?slightly bulging?, however she
did not see it as something serious and just thought about it as a result of too much screen time
since she is currently working as an English Online teacher with a shift of 7 pm to 3 am. Upon
Nursing Medical admission, pt underwent a medical assessment and a bulge was noted upon palpation in her neck
Diagnoses Diagnosis area that is not visible when neck is held in normal position and was considered as grade 1 goiter.
Upon taking patient history, pt has a positive family history of thyroid disease. After three (3) days,
pt was advised to go home and was prescribed to take thyroid medications to achieve a euthyroid
Medical & Nursing state via long-term management. Pt is also scheduled for regular monitoring of her thyroid
Management hormones. (Additional assessment findings are shown below.)

OBJECTI VE DATA: SUBJECTI VE:

- BMI: 17 kg/m2 -Pt verbalized, ?Magsakit ug kusog kaayo ang buto-buto sa akong dughan
- Height (162.56 cm) karun, kapoy pud kaayo sa paminaw? when asked about how she is feeling.
- Weight (45 kg)
- Vital Signs: -Pt's husband verbalized, "Naglibog mi kay daghan ra man unta na siyang
- High fever (38.5C) gikaon pero nganong naniwang man noon". He futher added, "Atong niaging
- BP (140/100 mmHg) mga adlaw, gikalibanga pud na siya; ipa hospital na noon namo kaso siya man
Hypothalamus releases TRH - Pulse (130 bpm) ang mubalibad kay mahadlok lagi anang COVID kay naa man gud toy silingan
- Respiration (25 cpm) namo na nagka-COVID agi anang adto-adto'g hospital, maong ga amo-amo ra
- Significant laboratory findings: mi'g tambal sa balay ana niya, unya mawala raman pud noon".
- ?TSH
- ?T4 -Pt. verbalized, "Maglisod kog piyong sa akong isa ka mata, unya kadugayan
- ?T3 kay magsakit na siya tungod kay mauga man siya kadugayan. Ambot ngano
- ?LDLs pero nikalit ra man ni. Lain na kaayo lantawon kumpara sa una".
- Palpitation Blood Test: Physical Examination: Patient History taking: ECG: Reveals atrial fibrillation
- Bulging left eye; Lid lag and lid retraction -Pt's husband verbalized. "Hilig jud na siya'g tigkaon og seafoods. Halos taga Inspection: symmetrical neck
semana kay ganahan na siya mag seafood sige. Katong naa mi sa party, lipay
-T3 (225 ng/dL) (+) Herifofamilial thyroid disease:
- Frequent watery stool; increased peristalsis -T4 (15.6 ug/dL) area, no protusion visible when -Sister has thyroiditis RAIU test: reveals diffuse,
Anterior Pituitary Gland - Diaphoretic; warm, smooth, moist skin kaayo siya kay naa iyang favorite na talaba", when asked whether his wife is neck is held in normal position -Grandmother has Grave's
-TSH (0.3 uIU/mL) homogeneous uptake of 39%
(APG) senses TRH, which - Palmar erythema fond of eating seafoods. Palpation: thyroid gland disease
-TSI (145%)
leads APG to release TSH - Weight loss (from 50 kg to 45 kg in a span of two weeks) enlargement (grade 1)
-Vomitus (est. 200 ml) on the day of admission -Pt verbalized, "Mag maintain nalang sa dagway kog tambal sa pagkakarun, Auscultation: (+) bruit sound
mahadlok man ko magpa opera. Maygani na detect dayun akong sakit, unya dili
- Fine tremor
pa siya medyo komplikado kaayo, unsaon nalang akong bana og duha ka anak
Heredofamilial - Goiter (Grade 1), bruit sound noted
kung nigrabe akong sakit, mahal ra ba jud ang gastuonon pa hospital jud".
disease - Angina
- Heat intolerance
- Thin, brittle nails detached from nail bed
-(+) Family history of thyroid disease; sister has thyroiditis; grandmother
had Grave?s disease

(Graves' disease): Immune system makes Thyroid gland senses TSH

Too much
thyroid-stimulating immunoglobulin (TSI) that and utilize Iodine to produce Iodine intake
attaches to thyroid cells. thyroid hormones

More thyroid hormones, more

than the normal range. are Hyperactive functioning of Hyperthyroidism
* Thyrotoxicosis
Hear t
* Brittle bones
Eye * Red, swollen
the thyroid hormones (Graves Disease) problems problems skin
released in the body
29 years old

Imbalanced nutrition: less than body Altered sleeping pattern r/t

Altered Thermoregulation r/t increased Body image disturbance r/t pathological
requirements r/t hypermetabolism Activity intolerance r/t fatigue, chest Self-care deficit r/t fatigue, and muscle Risk for fluid volume deficit r/t frequent
BMR secondary to increased thyroid hypersensitivity of SNS as evidenced by changes to the eyes and thyroid gland
secondary to increased thyroid hormone pain and heat intolerance weakness watery stool
hormone levels restlessness and irritability secondary to hyperthyroidism
levels

I ndependent I ndependent: I ndependent I ndependent: I ndependent: I ndependent: I ndependent : References:

1. Monitor vital signs regularly especially the
temperature to assess the effectivenes of the given drugs
2. Provide a calm, cool and quiet environment
3. Ensure that pt has adequate rest and instruct pt to
avoid body movements that require a lot of energy to
avoid further increasing the BMR
4. Inform pt and SO about the side effects of the
prescribed drugs and instruct to call for help if
unexpected outcomes happen.
Dependent
1. Administer methimazole (Tapazole) 1 tab 15 mg PO
OD
* Note: pt is scheduled for regular test to monitor the
liver and bone marrow since this drug has side effects to
these areas.
* Inform pt. not to stop taking medication eventhough
therapeutic effects are not noticed immediately since the
therapeutic effect of this medication takes time.
2. Administer paracetamol 500mg 1 tab PO 4-6H PRN
3. Administer IV fluid to replace fluid and electrolyte
losses
Note: Prior assessment regarding drug allergies must
be done before administering medications.
1. Monitor daily food intake. Weigh daily, same scale
same time, clothing, and note losses. (I& O monitoring)
2. Encourage the client to rest before meals.
3. Explain the need for adequate consumption of
carbohydrates, fats, protein, vitamins, minerals, and
fluids.
4. Encourage patient to eat and increase the number of
meals and snacks.
5. Avoid foods that increase peristalsis and fluids that
cause diarrhea.
6. Encourage and help the client to maintain good oral
hygiene
7. Take steps to promote appetite.
- Determine the client?s food preferences and arrange to
have them provided, as appropriate.
- Eliminate any offensive odors and sights from the
eating area.
- Control any pain and nausea before meals.
- Encourage the client?s family to bring permitted foods
from home, if possible.
- Provide a relaxed atmosphere and some socialization
during meals.
Dependent:
1. Administer methimazole (Tapazole) 1 tab 15 mg PO
OD
2. Consult with a nutritionist to establish appropriate
daily caloric and food type requirements
for the client.
1. Monitor and record vital signs regularly.
2. Assess the physical activity level and mobility of the
patient. Ask to rate pain and fatigue using 0-10 scale.
3. Eliminate nonessential activities or procedures to
conserve energy output, conserve strength for important
activities and ensure adequate rest.
4. Provide for a quiet environment, cool room,
decreased sensory stimuli, soothing colors, quiet music.
5. Assess the patient?s baseline cardiopulmonary status
(e.g., heart rate, orthostatic BP) before initiating
activity.
6. Monitor O2 sat. using portable pulse oximetry to
assess for oxygen desaturation during activity.
7. Assess emotional response to limitations in physical
activity.
8. Encourage the patient to dress in loose-fitting,
light-colored clothing and avoid overexertion,
especially during hot periods during the day.
9. Advise the patient to avoid direct exposure to
sunlight and keep environment as cool as possible.
10. Maintain the patient in a well-ventilated room
Dependent
1. Administer propranolol (Inderal) 10mg TID
2. Administer O2 @ 2L/min supplementation PRN
1. Assess cognitive functioning to determine client?s ability
to participate in care.
2. Determine individual strengths and skills of the client to
incorporate into plan of care enhancing likelihood of
achieving outcomes.
3. Provide accurate and relevant information regarding
current and future needs. Instruct in or review appropriate
skills necessary for self-care, using terms understandable to
client and with sensitivity to developmental needs for
practice, repetition, or reluctance.
4. Promote client?s/SO?s participation in problem
identification and desired goals and decision-making.
5. Implement measures to promote independence, but
intervene when the patient cannot function.
- Develop plan of care appropriate to individual
situation, scheduling activities to conform to client?s
usual or desired schedule.
- Practice and promote short-term goal setting and
achievement.
- Plan activities to prevent or accommodate fatigue
and/or exacerbation of pain.
6. Listen actively to client?s/SO(s)?concerns and provide for
communication among those who are involved in caring for
or assisting the client.
7. Instruct client/SO to request assistance when needed.
8. Assist with medication regimen as necessary, ensure
timely intake of medications.
Dependent:
1. Collaborate with nutritionist or physician for special diet
or feeding methods necessary to provide adequate nutrition.
1. Assess vital signs, noting low blood pressure- severe
hypotension, rapid heart beat, and thready peripheral
pulses.
2. Monitor input and output. Assess skin turgor and oral
mucous membranes for signs of dehydration.
3.Monitor BP and HR for orthostatic changes.
4. Weigh patient daily and note decreased weight.
5. Educate the patient or caregiver about the dietary
measures to control diarrhea.
6. Assess color and amount of urine. Report urine
output less than 30 ml/hr for 2 consecutive hours.
7. Monitor active fluid loss from diarrhea
8. Encourage the patient to drink prescribed amount of
fluid.
Dependent
1. Administer loperamide (Imodium) 1 cap 4mg PO
BID.
2. Administer parenteral fluids as prescribed.
Note: Consider the need for an IV fluid with immediate
infusion for patients with abnormal vital signs.
1. Assess client?s usual sleeping patterns and compare with
current sleep disturbance, relying on client/SO report of
problem to ascertain intensity and duration of problems.
Listen to reports of sleep quality and response from lack of
good sleep.
2. Note environmental factors as these can affect client?s
ability to rest and sleep at a time when more rest is needed.
3. Provide an environment conducive to rest or sleep.
Manage environment for hospitalized client:
- Adjust ambient lighting.
- Request visitors to leave, close room door, post
?Quiet, patient sleeping? sign, to provide privacy.
- Encourage usual bedtime routines.
- Provide bedtime care.
- Encourage the pt to turn on soft music, using
earphones, or maintain quiet environment, as client
prefers to enhance relaxation.
- Minimize sleep-disrupting factors.
- Perform monitoring and care activities without waking
client whenever possible.
4. Introduce relaxing activities before bedtime. Render
bedtime nursing care such as back rub and other relaxation
techniques.
5. Educate the patient on the proper food and fluid intake
such as avoiding heavy meals, alcohol, caffeine, or smoking
before bedtime and about their sleep requirements.
Dependent:
1. Administer chlordiazepoxide (Librium)
Mild/moderate: 1 capsule 5mg PO q8hr
2. Administer sedatives: diazepam (Valium) 1 tablet 2 mg
PO q6-12hr
1. Encourage person to express feelings, especially
about the way he or she feels, thinks, or views self.
2. Acknowledge feelings of hostility, grief, fear, and
dependency; teach strategies for coping with emotions.
3. Encourage client to ask questions about health
problem, treatment, progress, and prognosis.
4. Provide reliable information and reinforce
information already given.
5. Assist the patient in incorporating actual changes into
ADLs, social life, interpersonal relationships, and
occupational activities.
6. Maintain nonjudgmental attitude while giving care,
and help patient identify positive behaviors that will aid
in recovery.
7. Be realistic and positive during treatments, in health
teaching, and in setting goals within limitations.
Dependent:
1. Oral glucocorticoids can be given at high doses, such
as prednisone (Deltasone) 80 mg/day followed by 10
mg/week taper to reduce the swelling & inflammation
of the eyes.
2. Administer methimazole (Tapazole) 1 tab 15 mg PO
OD
3. Refer to an ophthalmologist for the recommended
course of treatment.
Home Health M aintenance
1. Provide oral and written instruction regarding prescribed medications.
Note: Reinform pt and SO about the side effects of the prescribed drugs and instruct to call
for medical help if unexpected outcomes happen.
2. Instruct the pt to adhere with the medication regimen to achieve a euthyroid state
eventhough it is via long-term management.
3. Instruct the pt to maintain adequate consumption of carbohydrates, fats, protein, vitamins,
minerals, and fluids as directed by the physician/nutritionist. Instruct pt to weigh daily using
same scale at the same time of the day, with the same clothing, and inform pt to note losses.
4. Remind patient to avoid intake of heavy meals, alcohol, caffeine, iodine-rich foods.
5. Remind SOs to provide pt a quiet environment, cool room, decreased sensory stimuli,
soothing colors, quiet music during bed time to enhance relaxation.
Note: Discuss with pt for possible change of working shift so that pt will return back to her
normal sleep-wake cycle. This will also enhance sleeping quality since environmental noises
are minimized during nighttime, suitable for sleeping.
6. Reemphasize to the patient to dress in loose-fitting, light-colored clothing and avoid
overexertion, especially during hot periods during the day, and to avoid direct exposure to
sunlight and keep environment as cool as possible.
7. Remind pt and SOs for scheduled medical follow-up to monitor the pt's condition closely.
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