NURS 406 Concept Map (SLO #2 and 3)

S/S & Abnormal Assessment

Risk Factors: Findings:
Being a woman and 20-40 years old Priority nursing diagnoses:
It increases metabolism and tissue
Grave’s disease sensitivity to sympathetic NS stimulation

Toxic nodular goiter Goiter, bruit of thyroid gland,

exophthalmos, weight loss, warm and
Thyroiditis moist skin, heat intolerance, elevated
Excess iodine intake temperature, diaphoresis, clubbing,
hypertension, tachycardia, tachypnea,
Pituitary tumors Activity intolerance
palpitations, diarrhea, fatigue,
Thyroid cancer weakness, rapid speech, insomnia, Impaired nutritional status
tremor, agitation
Pathophysiology: HOW have these comorbidities
caused or potentiated the problem? Low or undetectable TSH, increased T3

Grave’s disease is an autoimmune disease, caused by the production of IgG
autoantibodies directed against the thyrotropin receptor. The antibodies
bind and activate the receptor, causing the excess production of thyroid
hormones and enlargement of the thyroid.
.
Medical Diagnosis:
Hyperthyroidism
Nursing Interventions: How are you preventing
potential complications? What care are we
implementing related to nursing diagnoses?

Complications: List high priority, No caffeine, fiber, or spices. Have pt on a HIGH calorie diet due to increased
potential complications. metabolism.

Post-surgical interventions: focus on ABC’s, watch for laryngeal stridor, assess for
Thyrotoxicosis is when excess amounts of thyroid hormones are released
signs of hemorrhage, or tracheal compression. Watch for thyrotoxic crisis due to the
into the circulation, due to stressors. All the symptoms of hyperthyroidism
gland being irritated during surgery. Place pt in semi-fowlers position and support
are prominent and severe. These include severe tachycardia, heart failure,
the head with pillows to avoid neck flexion. Monitor vital signs, check calcium levels,
shock, hyperthermia, agitation, delirium, seizures, abdominal pain,
and check for Trousseau’s and Chvostek’s sign. Assist with analgesia and ambulation.
vomiting, diarrhea, and coma