Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY College of Nursing Cabanatuan City
INTENSIVE CARE PRACTICUM Singalat, Palayan City By: NICANOR M. DOMINGO III ETHEL JOY F. FABROS Submitted to: HEIDI FAJARDO, R.N. Clinical Instructor
2 November 2009 CHAPTER I. I. II.
Introduction Objectives a. general b. specific c. nurse-centered III. Patient Profile IV. Past Medical History V. Present Medical History VI. Patient Family History VII. Activities of Daily Living and other factors VIII. Physical Examination CHAPTER II. I. II. III. IV. V. VI. VII. VIII.
Definition Classification Anatomy and Physiology Pathophysiology Risk factors Signs and Symptoms Treatment – Prevention Diagnostic Tests
CHAPTER III. Collaborative Problems Nursing Diagnoses Indicators Collaborative Interventions Nursing Care Plan Recommendation Evaluation
3
I. INTRODUCTION Hyperthyroidism is the second most prevalent endocrine disorder after diabetes mellitus. The most common type of hyperthyroidism results from an excessive output of thyroid hormones caused by abnormal stimulation of thyroid gland by circulating immunoglobulins. It affects women eight times more frequently than men, with onset usually between the second and fourth decades. It may appear after an emotional shock, stress, or an infection, but the exact significance
4 of
these
relationships
is
not
understood.
5
II. OBJECTIVES
GENERAL OBJECTIVES To improve our ability to become an effective health care provider in preventing potential complications especially in clients having hyperthyroidism.
SPECIFIC OBJECTIVES Client-Centered At the end of our Intensive Care Practicum, the client would be able to: 1. Know the importance of having knowledge regarding her disease; 2. Know the importance of seeking medical treatment and or consultation with regards the improvement of her health status.
Student-Centered At the end of our Intensive Care Practicum, we would be able to: 1. Provide effective nursing intervention to the client regarding the disease, in home basis. 2. Improve our student nurse abilities, skills, knowledge and attitude in dealing with community clients who have this diagnosis.
6
III. PATIENT PROFILE
Name (Initial): Address:
Mrs. M.A. Purok 3, Barangay Singalat, Palayan City, Nueva Ecija
Birth date:
May 21, 1972
Age:
37 years old
Sex:
Female
Height:
5 feet and 2 inches
Weight:
46.3 kilograms
Civil Status: Religion:
Married Roman Catholic
Nationality:
Filipino
No. of Children: Five (5) OB Score:
G11P5
7
IV. PAST HISTORY 1991 – When Mrs. M.A. was at 19th year of age, she was been confirmed pregnant for the first time and had check-up on Dr. PJGMRMC (Cabanatuan City). Upon medical laboratories done, it revealed that it was a stillbirth. Another sequence of laboratories were ordered/done and her physician explains Hyperthyroidism – Goiter is the reason why her first pregnancy failed; thus, diagnosis of Hyperthyroidism had been made. She has been prescribed to have Propylthiouracil (PTU) and metoprolol. 1992 – Mrs. M.A. had undergone X-ray and ECG as follow-up laboratory/check-up and revealed an enlarged heart (cardiomegaly) as a result of her hyperthyroidism.
V. PRESENT HISTORY OF ILLNESS Mrs. M.A. had complaints of changes in bowel frequency and her menstrual cycle. She is disturbed by her goiter (feels like there’s consistent phlegm upon gulping), increased appetite but still does not gain weight. For all these symptoms and ailments, she still has not consulted to a physician regarding her disease.
VI. FAMILY HISTORY OF ILLNESS
8 The patient’s mother had hypertension and died because of Stroke at 81st year of age. His father has bronchial asthma. There was no
other
history
of
illness
on
the
family
identified
by
the
interviewers/observers upon actual series of interviews.
VII. ACTIVITIES OF DAILY LIVING AND OTHER FACTORS
HEALTH PERCEPTION/HEALTH
Non-compliance
MANAGEMENT
medication
with regimen
the after
completed the first prescription. “Eh
pagtapos
nung
sampong
piraso, di ko na tinuloy.” Pag may sumasakit o nilalagnat, ayon, bumibili lang ako ng gamut sa tindahan.” Breakfast: Bread and coffee NUTRITIONAL/METABOLIC
Lunch: Rice and vegetable
PATTERN
Supper: Rice and Fish Food Restrictions: None Usual fluid intake: 8-10 glasses (160cc x 8-10 = 1280 – 1600cc) per day
9 Any food supplement: None
BLADDER: ELIMINATION PATTERN
Usual Frequency: 4-5 times per day BOWEL: Usual Pattern per day: Time: Morning and night Frequency: Twice a day, once or none Color: Brownish Consistency: Semi-formed to formed Usual daily activities: walking
ACTIVITY-EXERCISE PATTERN
every morning at the front of their house Doing household chores, keeping her children Limitations to physical activities: None. The patient stated: “Wala
COGNITIVE-PERCEPTUAL
namang problema sa pagbabasa
PATTERN
ko, walang nanlalabo.” The patient is alert.
10 Usual sleep pattern on bedtime: SLEEP-REST PATTERN
8:00 pm Usual awakening time: 4:00 am Average hours slept: 8 hours Sleep routine: side-lying to semi fowlers position The patient is conscious about
SELF-PERCEPTION/SELF-
her goiter in her mid-twenties but
CONCEPT PATTERN
when she had children to rear, it became a normal perception to her that this is just a part of her body. She has little concern about her health. The patient verbalizes contentment on her health status, so she perceived medical checkup is of low concern. The patient has a good communication and relationship
ROLE-RELATIONSHIP
with her husband and children, also of her sisters. The patient verbalizes “Eh, talagang ganito, sanay na magalaga ng mga bata, eh minsan
11 nga pinapagalitan ko at makukulit.”
“Wala naman problema, Eh liban SEXUAL-REPRODUCTIVE
na lang kasi ilang beses na din akong nakunan,” as the patient verbalizes. “Kapag may dumadating na
COPING/STRESS TOLERANCE
problema, nakakayanan naman,
PATTERN
kaso dapat hinay-hinay lang kasi nga yung dibdib ko nga eh parang titibok ng malakas”, “minsan sinasabi ko sa asawa ko, nakakaluwag din ng loob,” as patient verbalizes. The patient verbalized:
VALUES-BELIEF PATTERN
“Nagdadasal din, at nagsisimba pag lingo, nagpapasalamat nga ako at may nakakain kami arawaraw.”
12
DATE
11-18-
HT.
5’2”
Weig ht
46.3 kg
Neck Circumfer ence
Blood Pressure
12 ½ in.
110/90
09
Temperat ure
Pulse rate
36.8⁰C
96 bpm
36.8⁰C
94 bpm
Respirat ory rate
21 cpm
mmHg
11-23-
5’2”
09
46.0 kg
12.7 in.
120/70
22 cpm
mmHg
BMI: 18.5 Weight: 46.0 kg (101.2 lbs.) Height: 5’2”
VIII. PHYSICAL EXAMINATION BODY PART
ACTUAL FINDING
NORMAL FINDINGS
SKULL
Round, normocephalic,
Round upon palpation,
Symmetrical with no
normocephalic and
palpable masses
symmetrical
13
HAIR
Normally distributed,
Evenly distributed upon
black in color
inspection
Thin in texture
FACE
Symmetrical, no
Inspection: symmetrical,
involuntary movements
facial expression is dependent on feeling and no involuntary muscle movement
EYES
Parallel and evenly placed
Inspection: parallel and
PERRLA, with slight
evenly placed,
redness and shiny
symmetrical, non-
bulbar conjunctivae
protruding, clear sclerae
VISUAL
No visual difficulties nor
No visual difficulties nor
EARS
blurring Skin color is same with
blurring Color is the same with
that of the face,
the face, symmetrically
symmetrical, flexible and
aligned. Auricle equally
with no discharges
in line with outer canthus of the eyes
14
NOSE
TONGUE
Symmetrical with no
Symmetrical and
discharges
straight, no nasal flaring
Moist, no lesion
Moist, no lesions, no swelling or lumps
NECK
No lesion, (-) CLAD, with
No abnormal swelling or
palpable bruit below
masses
thyroid cartilage, with pulsation BREAST
With no palpable masses
Uniform in color, no palpable masses and sign of tenderness
THORAX
Bronchovesicular
Bronchovesicular sounds between scapula and lateral to the sternum
HEART
97 beats per minute, no
HR: 60-100 bpm
presence of gallops UPPER
Complete digits, no
Equal in length, no
EXTREMITIES
deformities,
lesions, no area of deformity; complete
15 digits
LOWER
Complete digits, no
Equal in length, no
EXTREMITIES
deformities, with
lesions, no area of
obvious varicose veins
deformity; complete
on both posterior legs Dry, thin
digits
SKIN
NAILS
With slight clubbing,
Symmetrical and
pale
straight
16
CHAPTER II. CASE DISCUSSION I. DEFINITION
GOITER, HYPERTHYROIDISM (GRAVES DISEASE) A goitre (BrE), or goiter (AmE) (Latin gutteria, struma), also called a bronchocele, is a swelling in the thyroid gland, which can lead to a swelling of the neck or larynx (voice box). Goitre usually occurs when the thyroid gland is not functioning properly.
Hyperthyroidism is the 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. Thyroid hormone functions as a stimulus to metabolism and is critical to normal function of the cell. In excess, it both overstimulates metabolism and exacerbates the effect of the sympathetic nervous system, causing "speeding up" of various body systems and symptoms resembling an overdose of epinephrine (adrenaline). These include fast heart beat and symptoms of palpitations, nervous system tremor and
17 anxiety symptoms, digestive system hypermotility (diarrhea), and weight loss. Graves' disease is a thyroid-specific autoimmune disorder in which the body makes antibodies to the thyroid-stimulating hormone receptor (TSHR), leading to hyperthyroidism, or an abnormally strong release of hormones from the thyroid gland. Normally, the release of thyroid hormones is mediated by thyroid-stimulating hormone (TSH), a hormone secreted by the pituitary gland that binds to TSHR to stimulate the thyroid to release thyroid hormones. This normal cycle is self-regulating: the hormones secreted by the thyroid keep more TSH from
being
produced
(Janeway,
2001).
The autoantibodies produced in Graves' disease are not subject to negative feedback, so they continue to be produced and bind to TSHR even when thyroid hormone levels rise too high. These antibodies act as agonists, stimulating more hormones to be released and thus leading to hyperthyroidism.
II. CLASSIFICATION Goiter •
I - palpation struma - in normal posture of head it cannot be seen. Only found when palpating.
•
II - struma is palpative and can be easily seen.
18 •
III - struma is very big and is retrosternal. Pressure and compression marks.
Types of hyperthyroidism: •
Graves' disease (diffuse toxic goiter) Graves' disease is most often associated with hyperthyroidism. Researchers believe Graves' disease is caused by an antibody which stimulates the thyroid too much, in turn causing the excess production of thyroid hormone. Graves' disease is categorized as an autoimmune disorder (a dysfunction of the body's immune system). The disease is most common in young to middle-aged women and tends to run in families. Symptoms of Graves' disease are identical to hyperthyroidism, with the addition of three other symptoms. However, each individual may experience symptoms differently. The three additional symptoms include:
o
goiter (enlarged thyroid which may cause a bulge in the neck)
o
bulging eyes (exophthalmos)
o
thickened skin over the shin area
19 Classification of Graves Eye Disease Mnemonic: "NO SPECS" Class 0: No signs or symptoms Class 1: Only signs (limited to upper lid retraction and stare, with or without lid lag) Class 2: Soft tissue involvement (oedema of conjunctivae and lids, conjunctival injection, etc) Class 3: Proptosis Class 4: Extraocular muscle involvement (usually with diplopia) Class 5: Corneal involvement (primarily due to lagophthalmos) Class 6: Sight loss (due to optic nerve involvement) •
Toxic Nodular Goiter (also called multinodular goiter) Hyperthyroidism caused by toxic nodular goiter is a condition in which one or more nodules of the thyroid becomes overactive. The overactive nodules actually act as benign thyroid tumors. Symptoms of toxic nodular goiter do not include bulging eyes or skin problems, as in Graves' disease. The cause of toxic nodular goiter is not known.
20 •
Thyroiditis Thyroiditis causes temporary hyperthyroidism, usually followed with hypothyroidism (an underactive thyroid). Thyroiditis is an inflammation of the thyroid gland. There are three types of thyroiditis: o
Hashimoto's thyroiditis
o
Subacute Granulomatous Thyroiditis
o
Silent Lymphocytic Thyroiditis
Hypothyroidism is the disease state in humans caused by insufficient production of thyroid hormone by the thyroid gland. Cretinism is a form of hypothyroidism found in infants.
Causes About three percent of the general population is hypothyroidic. Factors such as iodine deficiency or exposure to Iodine-131 (I-131) can increase that risk. There are a number of causes for hypothyroidism. Historically, and still in many developing countries, iodine deficiency is the most common cause of hypothyroidism worldwide. In iodinereplete individuals, hypothyroidism is mostly caused by Hashimoto's
21 thyroiditis, or by a lack of the thyroid gland or a deficiency of hormones from either the hypothalamus or the pituitary. Hypothyroidism can result from postpartum thyroiditis, a condition that affects about 5% of all women within a year after giving birth. The first phase is typically hyperthyroidism. Then, the thyroid either returns to normal or a woman develops hypothyroidism. Of those women who experience hypothyroidism associated with postpartum thyroiditis, one in five will develop permanent hypothyroidism requiring life-long treatment. Hypothyroidism can also result from sporadic inheritance, sometimes autosomal recessive. Hypothyroidism is also a relatively common disease in domestic dogs, with some specific breeds having a definite predisposition. Temporary hypothyroidism can be due to the Wolff-Chaikoff effect. A very high intake of iodine can be used to temporarily treat hyperthyroidism, especially in an emergency situation. Although iodine is substrate for thyroid hormones, high levels prompt the thyroid gland to take in less of the iodine that is eaten, reducing hormone production. Hypothyroidism is often classified by the organ of origin:
22
Symptoms In adults, hypothyroidism is associated with the following symptoms:[5] [7][8]
Early symptoms •
Poor muscle tone (muscle hypotonia)
•
Fatigue
•
Cold intolerance, increased sensitivity to
•
Goiter
•
Thin, brittle fingernails
•
Thin, brittle hair
•
Paleness
•
Decreased sweating
•
Dry, itchy skin
•
Weight gain and water
cold •
Depression
•
Muscle cramps and joint
retention •
rate – less than sixty beats
pain •
Carpal Tunnel Syndrome
Bradycardia (low heart
per minute) •
Constipation
Late symptoms •
Slow speech and a hoarse, breaking voice – deepening of the voice can also be noticed
•
Dry puffy skin, especially on the face
•
Thinning of the outer third of the eyebrows (sign of Hertoghe)
•
Abnormal menstrual cycles
23 •
Low basal body temperature
Less common symptoms •
Impaired memory
•
Impaired cognitive function (brain fog) and inattentiveness
•
A slow heart rate with ECG changes including low voltage signals. Diminished cardiac output and decreased contractility.
•
Reactive (or post-prandial) hypoglycemia
•
Sluggish reflexes
•
Hair loss
Diagnostic testing To diagnose primary hypothyroidism, many doctors simply measure the amount of thyroid-stimulating hormone (TSH) being produced by the pituitary gland. High levels of TSH indicate that the thyroid is not producing sufficient levels of thyroid hormone (mainly as thyroxine (T4) and smaller amounts of triiodothyronine (T3)). However, measuring just TSH fails to diagnose secondary and tertiary hypothyroidism, thus leading to the following suggested blood testing if the TSH is normal and hypothyroidism is still suspected: •
Free triiodothyronine (fT3)
•
Free levothyroxine (fT4)
24 •
Total T3
•
Total T4
Additionally, the following measurements may be needed: •
24 hour urine free T3[17]
•
Antithyroid antibodies — for evidence of autoimmune diseases that may be damaging the thyroid gland
•
Serum cholesterol — which may be elevated in hypothyroidism
•
Prolactin — as a widely available test of pituitary function
•
Testing for anemia, including ferritin
•
Basal body temperature
III. ANATOMY AND PHYSIOLOGY
25
The thyroid gland is a butterfly-shaped organ and is composed of two cone-like lobes or wings: lobus dexter (right lobe) and lobus sinister (left lobe), and is also connected with the isthmus. The organ is situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the esophagus and carotid sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the laryngeal prominence or Adam's apple) and extends inferiorly to the fifth or sixth tracheal ring. It is difficult to demarcate the gland's upper and lower border with vertebral levels because it moves position in relation to these during swallowing.
26 At the microscopic level, there are three primary features of the thyroid: Feature
Description The thyroid is composed of spherical follicles that selectively absorb iodine (as iodide ions, I-) from the blood for production of thyroid hormones. Twentyfive percent of all the body's iodide ions are in the
Follicles
thyroid gland. Inside the follicles, colloid serves as a reservoir
of
materials
for
thyroid
hormone
production and, to a lesser extent, act as a reservoir for the hormones themselves. Colloid is rich in a protein called thyroglobulin. The follicles are surrounded by a single layer of Thyroid epithelial c thyroid epithelial cells, which secrete T3 and T4. ells
When the gland is not secreting T3/T4 (inactive), the
(or "follicular
epithelial cells range from low columnar to cuboidal
cells")
cells. When active, the epithelial cells become tall columnar cells. Scattered among follicular cells and in spaces
Parafollicular cells between the spherical follicles is another type of (or "C cells")
thyroid
cell,
calcitonin.
parafollicular
cells,
which
secrete
27
IV. PATHOPHYSIOLOGY
28
CTLA-4A T-cells/B-cells produce antibodies Anti-TSRH antibodies
Destruction/ TSRH
TSH binding FREE T3 T4
SHBG
Cell metabolism/activity
Calcitonin release
Thyroid gland activity Hypertrophy
Estradiol concentration
hypocalcemia SNS activity
Goiter
LH
Amenorrhea/ oligomenorrhea
Changes in bowel
BMR
Muscular activity fatigue tremors
cardiomegaly palpitations
Ca, P loss
Osteoclast activity
Cardiac decompensation
Tissue perfusion hypercalcemia
Susceptibility to Fx and Osteoporosis
Brittle hair
dyspnea
Pathophysiogic paradigm HYPERTHYROIDISM
O2 demand
pallor
Appetite despite wt.
hyperhidrosis
29
V. RISK FACTORS AGE The riskiest age for developing Graves' disease and hyperthyroidism is between 20 and 40. -------------------------------------------------------------------HISTORY Having any past history of thyroid problems, autoimmune disease, or endocrine disease yourself or in your family puts you at greater risk for developing Graves' disease and hyperthyroidism. --------------------------------------------------------------GENDER Graves' disease and hyperthyroidism affect women 8 times more often than men. --------------------------------------------------------------PREGNANCY Pregnancy and the year after childbirth are both times of greater risk for Graves' disease and hyperthyroidism
30 EXPOSURE TO OR EXCESS OF IODINE/IODINE DRUGS Being exposed to or ingesting an excess of iodine, whether through medical tests, topical exposure, or ingesting of iodine or supplements containing iodine can trigger hyperthyroidism. --------------------------------------------------------------TRAUMA TO THE THYROID Thyroid trauma can trigger hyperthyroidism in some people. The types of trauma include vigorous manipulation or palpation of the thyroid; surgery to the thyroid, parathyroids, or the area surrounding the thyroid; injection to the thyroid; biopsy of the thyroid; and neck injury, i.e., whiplash, or from an automobile seat belt after a crash ---------------------------------------------------------------
MAJOR STRESS
31 Stress is a factor that appears to trigger the onset of Graves' disease in some patients. Researchers have documented a definite connection between major life stressors -- i.e., death of a spouse, divorce or separation, loss of a job, death of close family member, major accident/personal injury, moving, marriage -- and the onset of Graves' disease. --------------------------------------------------------------SMOKING There is an increased risk of Graves' disease in smokers. Smokers with Graves' ophthalmopathy tend to have more severe symptoms that are more resistant to treatment. --------------------------------------------------------------EXCESSIVE INTAKE OF THYROID HORMONE Taking too much prescription thyroid hormone -- whether by accident or by deliberate self-medication can cause hyperthyroidism.
32
VI. SIGNS AND SYPMTOMS BY THE BOOK: Nervousness
Fatigability
Irritability
Amenorrhea/menstrual
Palpitations
disturbance
Heat intolerance
Change in bowel
Increased perspiration
Cardiac decompensation
Flushed skin
Osteoporosis
Exophthalmos/Eye
Tremors
symptoms
Goiter
Increased appetite Weight loss BY THE PATIENT: Palpitations Increased appetite Change in bowel frequency Amenorrhea Goiter
Heart enlargement
Erythema and edema of eyelids (bulbar conjunctivae)
33
VII. TREATMENT THYROSTATICS Thyrostatics are drugs that inhibit the production of thyroid hormones, such as carbimazole (used in UK) and methimazole (used in US), and propylthiouracil. Thyrostatics are believed to work by inhibiting the iodination of thyroglobulin by thyroperoxidase, and thus, the formation of tetra-iodothyronine (T4). Propylthiouracil also works outside the thyroid gland, preventing conversion of (mostly inactive) T4 to the active form T3. Because thyroid tissue usually contains a substantial reserve of thyroid hormone, thyrostatics can take weeks to become effective, and the dose often needs to be carefully titrated over a period of months. A very high dose is often needed early in treatment, but if too high a dose is used persistently, patients can develop symptoms of hypothyroidism. BETA-BLOCKERS Many of the common symptoms of hyperthyroidism such as palpitations, trembling, and anxiety are mediated by increases in beta adrenergic receptors on cell surfaces. Beta blockers are a class of drug
34 which offset this effect, reducing rapid pulse associated with the sensation of palpitations, and decreasing tremor and anxiety. This doesn't help the underlying problem of excess thyroid hormone, but makes
the
symptoms
much
more
manageable,
particularly
as
definitive treatment with thryostatic drugs can take a number of months to work. Propranolol in the US, and Metoprolol in the UK, are most frequently used to augment treatment for hyperthyroid patients. Permanent treatments SURGERY Surgery (to remove the whole thyroid or a part of it) is not extensively used because most common forms of hyperthyroidism are quite effectively treated by the radioactive iodine method, and because there is a risk of also removing the parathyroid glands, and of cutting the recurrent laryngeal nerve, making swallowing difficult. However,
some
Graves'
disease
patients
who
cannot
tolerate
medicines for one reason or another, patients who are allergic to iodine, or patients who refuse radioiodine opt for surgical intervention. Also, some surgeons believe that radioiodine treatment is unsafe in patients with unusually large gland, or those whose eyes have begun to bulge from their sockets, claiming that the massive dose of iodine needed will only exacerbate the patient's symptoms.
35 RADIOIODINE In iodine-131 (Radioiodine) radioisotope therapy, radioactive iodine-131 is given orally (either by pill or liquid) on a one-time basis to destroy the function of a hyperactive gland. Patients who do not respond to the first dose are sometimes given an additional radioactive iodine treatment in a larger dose. The iodine given for ablative treatment is different from the iodine used in a scan. Radioactive iodine is given after a routine iodine scan, and uptake of the iodine is determined to confirm hyperthyroidism. The radioactive iodine is picked up by the active cells in the thyroid and destroys them. Since iodine is only picked up by thyroid cells (and picked up more readily by over-active thyroid cells), the destruction is local, and there are no widespread side effects with this therapy. Radioactive iodine ablation has been safely used for over 50 years, and the only major reasons for not using it are pregnancy and breast-feeding. A common outcome following radioiodine is a swing to the easily treatable hypothyroidism, and this occurs in 78% of those treated for Graves' thyrotoxicosis and in 40% of those with toxic multinodular goiter or solitary toxic adenoma. Use of higher doses of radioiodine reduces the incidence of treatment failure, with the higher response to treatment consisting mostly of higher rates of hypothyroidism. There is increased sensitivity to radioiodine therapy in thyroids appearing on
36 ultrasound scans as more uniform (hypoechogenic), due to densely packed large cells, with 81% later becoming hypothyroid, compared to just
37%
in
those
with
more
normal
scan
appearances
(normoechogenic).
PREVENTION Detecting the early warning signs and symptoms of Graves’ disease and take charge of health, rather than wait until it (or the drugs used to treat Graves’ disease) has ravaged your health, making it more difficult to heal is the only known prevention for it is an autoimmune disorder.
37
VIII. DIAGNOSTIC EXAMINATION Thyroid hormone blood tests: Thyroid-stimulating hormone (TSH): Test first done to evaluate thyroid function and considered a reliable method of detecting a thyroid problem. TSH is suppressed in hyperthyroidism to < 0.1 μU /mL (except when etiology is a TSH-secreting pituitary tumor or pituitary resistant to thyroid hormone). Hyperthyroidism is indicated if TSH fails to rise after administration of thyrotropin-releasing hormone (TRH). (Normal TSH is 0.4-4.5 rnilli-intemational units/liter.) Thyroxine (T4): Produced by the thyroid gland when the pituitary gland releases TSH. Free T4 can be measured directly (FT) or calculated by index (FTI). Total T4 measures both bound and free T4. Triiodothyronine (T3): Small amount produced directly by thyroid gland. Most T3 is made by other tissues that convert T4 into T3. T4 has a greater effect on metabolism than T3 even though T3 is normally present in lower amounts than T4. Total T3 measures both bound and free T3 (FT3). (Normal total T3 is 70-195 [nanograms per deciliter].) Both T3 and T4 are increased in hyperthyroidism; however, T3 appears to be the more accurate diagnostic indicator of hyperthyroidism than T4.
38 Triiodothyronine uptake (T3U): An indirect measurement of the amount of the protein thyroxine-binding globulin (TBG) that can bind T3 and T4. A high T4 value combined with a high T3U value usually confirms the presence of hyperthyroidism. Thyroid scan: Differentiates between Graves' disease and Plummer's disease, both of which result in hyperthyroidism. Needle or open biopsy: May be done to determine cause of hyperthyroidism, differentiate cysts or tumors, diagnose enlargement of thyroid gland. ECG: Atrial fibrillations, shorter systole time, cardiomegaly, heart enlarged with fibrosis and necrosis (late signs or in elderly with masked hyperthyroidism). Serum glucose: Elevated (related to adrenal involvement). Alkaline phosphatase and serum calcium: Increased. Electrolytes: Hyponatremia may reflect adrenal response or dilutional effect in fluid replacement therapy. Hypokalemia occurs because of GI losses and diuresis. Urine creatinine: Increased.
39
THYROIDECTOMY Nursing Interventions
• Preoperative 1. Informed Consent 2. Deep Breathing exercises 3. Leg exercises 4. Support head 5. ROM exercises of neck 6. Instructing patient to lessen talking after surgery 7. Positioning the patient: neck slightly extended Nursing Interventions
• Post operative 1. O2, suction equipment, tracheostomy tray 2. Calcium carbonate at bedside 3. Assess for hematoma formation 4. Assess laryngeal stridor during respirations 5. Assess chvostek and trosseau’s sign, hyperactive DTR – report if seen/observed. 6. Semi-Fowler’s position/pillow-lubricate neck incision 7. NPO on the day of surgery 8. Blood transfusion can be ordered; nursing responsibilities in administering BT:
40 The nurse has to get consent forms signed by the patient or a qualified
-
representative of the patient, except in the cases of trauma or life saving situations if the patient is unable to make that decision; The nurse is responsible for insuring that the right unit of blood is to be
-
administered to the right patient after typing and cross-matching by the lab. This is done by checking the lot, serial numbers, blood type, and expiration date with another nurse or qualified lab personnel; -
The nurse has to take a complete set of vital signs for a baseline data;
-
After starting the transfusion, the vital signs must be checked after 15 minutes, then 30 minutes from then, then at one hour. Then vital signs must be checked every hour, according to hospital protocol; The vital signs are checked this often to monitor for a reaction to the blood. If
-
a reaction occurs, then the transfusion must be stopped immediately and normal saline infused; The nurse should monitor if the patient took the pre-Blood Transfusion
-
medications if then ordered 9. Monitor VS including pain control (Fever at 3rd day indicates infection) 10.
Sutures are usually removed at 5th day post surgery
Patient Teaching •
Caloric intake
•
Adequate iodine intake
•
Regular exercise
•
If complete thyroidectomy will need life long pharmocologigic thyroid replacement therapy
41 POST OPERATIVE ADVICE for the Patient: Following your surgery 1. Your wound will not be covered with a dressing. This allows the nursing staff to check your neck for bleeding or swelling. 2. Your observations will be checked post operatively for the first 4 hours. Blood pressure and pulse. 3. It is quite normal to notice some bruising around the site. You may also experience some numbness and/ or tingling. The initial redness of the scar will gradually fade over the next 6 months until it becomes a pale white line. 4. You may experience some mild to moderate pain, which can be relieved by taking the painkillers. 5. You are advised to avoid any heavy lifting or contact sports for 4 weeks.
42
CHAPTER III:
NURSING CARE PLAN
I. COLLABORATIVE PROBLEMS 1. HYPOTHYROIDISM Hypothyroidism occurs when the thyroid gland does not produce enough thyroid hormone to meet the body’s needs. Without enough thyroid hormone, many of the body’s functions slow down.
2. THYROTOXICOSIS, THYROID STORM (THYROTOXIC CRISIS) Thyrotoxicosis (hyperthyroidism, Graves' disease) is a condition in which the thyroid gland produces excess thyroid hormone (thyroxine) which results in effects on the whole body.
3. FRACTURES Hyperthyroidism interferes with your normal metabolism. This can lead to a loss of bone mass and even osteoporosis. In severe cases of osteoporosis, compression fractures can result. A compression fracture occurs when the vertebrae are jarred hard enough to cause one or more to break. Normally, it takes a powerful jolt to cause a compression fracture, but if the bones are brittle from osteoporosis, even everyday activities can cause a break.
43
II. NURSING CARE PLANS 1. Risk for decreased Cardiac Output 2. Fatigue 3. Risk for disturbed Thought Process 4. Deficient Knowledge/Knowledge deficit
III. NURSING GOAL -
The patient will be free from complications of Hyperthyroidism
IV. INDICATORS 1.
(Body Mass Index) BMI: (Wt. 46 kg; Ht. 5’2”) 27.5 and above - high risk 23-27.4 - moderate risk 18.5 - 22.9 - low risk below 18.5 - risk of nutritional deficiency diseases
2.
BP - <120 mmHg systolic - <80 diastolic mmHg
3.
Pulse rate – 60 -100 bpm
4.
Respiratory rate – 12-20 cpm
5.
Palpitations
6.
Increased appetite
7.
Change in bowel frequency
8.
Amenorrhea
9.
Goiter
10.
Heart enlargement
44 11.
Erythema and edema of eyelids (bulbar conjunctivae)
COLLABORATIVE PROBLEMS 1. HYPOTHYROIDISM Monitor patient for signs of increasing severity of signs and symptoms of hypothyroidism a. decreased level of consciousness b. decreased vital signs
Extreme hypothyroidism may lead to myedema, myedema coma, slowing of all body systems if left untreated
c. increasing difficulty in awakening or arousing patient Monitor respiratory rate, depth, pattern, pulse oximetry, and ABG
Identifies patient’s baseline to monitor further changes and evaluate effectiveness of interventions
Explain rationale for thyroid hormone replacement
Provides rationale for patient to use thyroid hormone replacement as prescribed
Encourage increased fluid intake and intake of high fiber foods
Hypothyroidism can result in constipation due to decrease in peristalsis, increasing the bulk of stools promotes passage of soft stools
Provide extra layer of clothing
Hypothyroidism results cold intolerance due to hypoactive cell metabolism and heat production; minimizes heat loss
Promote independence in self care activities.
Encouragement needed in fatigued, often depressed patient
a. space activities to promote rest a. encourages activities while
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and exercise as tolerated.
allowing time for adequate rest
b. assist woth self-care activities when patient is fatigued.
b. permits patient to participate to the extent possible in self-care activities
c. provide stimulation through conversation and non-stressful activities.
c. promotes interest without overly stressing the patient.
d. monitor patient’s response to increasing activities.
d. guards against over and under exertion by the patient.
Monitor for signs of fracture, pin sites for areas of increased pain/burning sensation, or presence of edema, foul odor and discharge
May indicate onset of local infection and can lead to other bone diseases
Assess for muscle tone, reflexes
Muscle rigidity, tonic spasms may reflect development of tetanus
Monitor vital signs. Note presence of chills, fever, malaise and changes in sensation
Hypotension, tachycardia, chills and fever may reflect development of serious complications
Assess degree of immobility produced by injury/treatment and patient’s perception of immobility
Patient may be restricted by selfview, self-perception with actual physical limitations, requiring information/intervention to promote progress towards wellness
Encourage participation in diversional activities. Maintain stimulating environment
Provides opportunity for release of energy, refocuses attention, enhancing pt. sense of self-control and decreases social isolation
Encourage isometric exercises starting with unaffected site/limb
Isometric exercises contract muscles without bending joints and help maintain muscle strength
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Assist with or encourage self-care activities
Improves muscle strength and circulation; enhances self-control in situation and promotes selfdirected wellness
Encourage to increase oral fluid intake to 2000-3000 ml per day (within cardiac tolerance)
Keeps the body well-hydrated. Decreases the risk of urinary infection, constipation
Provide diet high in protein, carbohydrates, vitamins and minerals
In the presence of musculoskeletal injuries, nutrients are required for healing are rapidly depleted, often results in weight loss as much as 20-30 lb
2. THYROTOXIC CRISIS Monitor for signs of thyrotoxic crisis (High fever, extreme tachycardia, altered neurologic or mental state)
Severe action of cell metabolism exaggerates disturbances on major systems such as cardiovascular and neurologic which can cause serious complications (coma – death)
Humidified oxygen is administered
Oxygen is administered to meet and improve high metabolic demands.
Start Intravenous fluids containing Sugar-containing intravenous dextrose fluids are administered to replace liver glycogen stores that have been decreased in hyperthyroid client Monitor vital signs. Continuous Tepid sponge bath for patients experiencing fever. Note for increasing fever
Independent nursing actions are needed in times of fever, tepid sponge bath lowers body heat by means of evaporation of surface heat produced by increased metabolism of the body
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Administer PTU or methimazole
PTU and methimazole impede formation of thyroid hormone and block conversion of T4 to T3, the more active form of thyroid hormone
3. FRACTURES Monitor for signs of fracture, pin sites for areas of increased pain/burning sensation, or presence of edema, foul odor and discharge
May indicate onset of local infection and can lead to other bone diseases
Assess for muscle tone, reflexes
Muscle rigidity, tonic spasms may reflect development of tetanus
Monitor vital signs. Note presence of chills, fever, malaise and changes in sensation
Hypotension, tachycardia, chills and fever may reflect development of serious complications
Assess degree of immobility produced by injury/treatment and patient’s perception of immobility
Patient may be restricted by selfview, self-perception with actual physical limitations, requiring information/intervention to promote progress towards wellness
Encourage participation in diversional activities. Maintain stimulating environment
Provides opportunity for release of energy, refocuses attention, enhancing pt. sense of self-control and decreases social isolation
Encourage isometric exercises starting with unaffected site/limb
Isometric exercises contract muscles without bending joints and help maintain muscle strength
Assist with or encourage self-care activities
Improves muscle strength and circulation; enhances self-control in situation and promotes selfdirected wellness
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Encourage to increase oral fluid intake to 2000-3000 ml per day (within cardiac tolerance)
Keeps the body well-hydrated. Decreases the risk of urinary infection, constipation
Provide diet high in protein, carbohydrates, vitamins and minerals
In the presence of musculoskeletal injuries, nutrients are required for healing are rapidly depleted, often results in weight loss as much as 20-30 lb
NURSING CARE PLAN NURSING DIAGNOSIS: risk for decreased Cardiac Output INTERVENTION Monitor BP lying, sitting, and standing, if able. Note widened pulse pressure.
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RATIONALE General/objective hypotension may occur as a result of excessive peripheral vasodilation and decreased circulating volume. Widened pulse pressure reflects compensatory increase in stroke volume and decreased systematic vascular resistance.
Investigate reports of chest pain or angina
May reflect increased myocardial oxygen demands/ischemia
Auscultate heart sounds, noting extra heart sounds, development of gallops and systolic murmurs
Prominent S1 and murmurs are associated with forceful cardiac output of hyper metabolic state; development of S3 may warn an impending cardiac failure.
Monitor electrocardiogram (ECG), noting rate/rhythm. Document dysrhythmias
Tachycardia may reflect direct myocardial stimulation by thyroid hormone. Dysrhythmias often occur and compromise cardiac output/function.
Auscultate breath sounds, noting adventitious sounds
Early sign of pulmonary congestion, reflecting developing cardiac failure.
Monitor temperature, provide cool environment, limit bed linens/clothes, and administer tepid sponge baths.
Fever (may exceed 100 F) can occur as a result of excessive hormone levels increasing diuresis/dehydration, causing increased peripheral vasodilation, venous pooling, and hypotension
Observe signs/symptoms of Rapid dehydration can occur, severe thirst, dry mucous which reduces circulating volume membranes, weak, thready pulse, and compromises cardiac output. poor capillary refill, decreased urinary output, and hypotension Weigh daily. Encourage chair rest/bedrest; limit non-essential activity
Activity increases metabolic/circulatory demands, which may potentiate cardiac failure
Provide supplemental oxygen as indicated.
May be necessary to support increased metabolic demand / oxygen consumption.
Provide hypothermia blanket as indicated.
Occasionally used to lower uncontrolled hyperthermia (104F and higher) to reduce metabolic
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RECOMMENDATION A simple mnemonics for Hyperthyroidism (Graves Disease)
H eat intolerance, provide cool environment Y
ou should increase fluid intake
P
TU, methimazole, (Thyrostatics)
E
ducation about the disease
R
adioiodine
T
hyroidectomy
H ave pt. properly referred to an endocrinologist Y
ield for proper treatment regimen
R
est when symptoms exacerbates
O bserve weight, report increasing losses I
nstruct self-care remedies
D iscuss to SOs in case of emotional lability
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I nstruct importance of managing S/Sx S ymptomatic treatment such as βblockers M onitor BP, HR/PR, ECG
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EVALUATION At the end of our group exposure to the community setting for Intensive Care Practicum (ICP), our client will knowledgably understand the disease that she has. By giving her certain important health teachings and encouraging her for proper referral, she will manage her disease and maintain her wellness thru application of nursing intervention regarding hyperthyroidism. At the end of the group exposure, we had learned the gravity of having a case study in community setting, perhaps, different from hospital, it still had inculcated our skills towards nursing interventions, knowledge about certain diseases and application of appropriate attitude in dealing with patients in the community. -Nicanor M. Domingo III Ethel Joy F. Fabros NEUST BSN IV-A 2010 Barangay Singalat, City of Palayan To: HEIDI FAJARDO, R.N. LORY CRISANTO, R.N., M.A.N. Critiques/Panel of Evaluators
