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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)
Inte rve ntions Evaluation
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
Inte rve ntions Evaluation
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
Inte rve ntions Evaluation
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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