ATENEO DE NAGA UNIVERSITY

COLLEGE OF NURSING
S/Y 2020-2021

A CASE STUDY ON

GRAVES DISEASE

SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR MEDICAL

SURGICAL NURSING– RLE

By:

Julius Robert Ables

Kristeen Joyce Alaurin

Alyanah Penelope Canlas

Ma. Ericka Enciso

Aibee Pacis

April Joyce Rendor

Renie Augustine Serano

Christine Valledor

RLE GROUP 1 – RR32

 INTRODUCTION

The thyroid gland at the front of your neck is a tiny, butterfly-shaped

gland. Thyroid hormones determine how energy is used by your body, so they
influence practically every organ in your body, including the way your heart
beats. Hormones are directly secreted into the bloodstream, where they travel
to different parts of the body. Graves' disease is an autoimmune condition that
induces hyperthyroidism, or overactive thyroid. Your immune system is
targeting the thyroid with this disease which causes it to produce more thyroid
hormone than your body requires and often the skin and eyes are affected. It
is characterized by abnormal thyroid enlargement and elevated thyroid
hormone production (hyperthyroidism). Thyroid hormones are associated with
many different body systems and, thus, the particular symptoms and signs of
Graves' disease can vary greatly.

Another medical term used to describe and call Graves’ disease is toxic
diffuse goiter. It affects females by a ratio of 5-10 to 1. more frequently than
males. The disease normally occurs with a peak prevalence of 40-60 around
middle age, but can also affect infants, teenagers, and the elderly. In nearly
every area of the planet, Graves' disease exists. It is estimated that Graves'
disease affects 2 percent -3 percent of the general population. It is the most
common cause of hyperthyroidism in the United States. The disease affects
about 1 in 200 people. The most frequent cause of hyperthyroidism is Graves'
disease.

Hyperthyroidism can cause serious problems with the heart, bones,

muscles, menstrual cycle, and fertility if left unchecked. Untreated
hyperthyroidism can lead to health complications for the mother and baby during
pregnancy. For in pregnancy, thyroid hormone levels that are only a little
elevated are typically not a concern. More extreme hyperthyroidism that is not
treated, though, will affect the mother as well as the infant. Before getting
pregnant, make sure the hyperthyroidism is under control if you have Graves'
disease.

DEFINITION OF TERMS

● Burch Wartofsky Scale – It is a point scale that helps to assess of the

probability of thyrotoxicosis independently from the level of thyroid
hormones. It is solely based on clinical and physical criteria.
● Exophthalmos – Describes a condition where the eyeball protrudes from
the eye socket, making it appear to bulge. It can affect one or both eyes.
● Fetal Movements – It refers to motion of a fetus caused by its own
muscle activity.
● Fatigue – A term used to describe an overall feeling of tiredness or lack
of energy.
● Gestation – It is defined as the time between conception and birth.
● IUFD – Stands for intrauterine fetal demise that is fetal death that occurs
after 20 weeks of gestation before birth.
● Postpartum – It is commonly defined as the six weeks after childbirth.
● Pregnancy – Pregnancy occurs when a sperm fertilizes an egg after it’s
released from the ovary during ovulation.
● Pulmonary edema – It is a condition caused by excess fluid in the
lungs.
● Wayne Index Scale – It is a clinical score that may be used in the
clinical diagnosis of thyrotoxicosis. It is a diagnostic index that scores the
presence or absence of various signs and symptoms of hyperthyroidism
for the purpose of establishing a diagnosis.
 NURSING HEALTH HISTORY

Patient X, a 35 years old pregnant woman admitted in the hospital because of

the complaint of diminished fetal movement since a day ago upon admission.
Patient X, is six months pregnant with her third baby.

Chief Complaint
The patient complained of absence of fetal movement upon admission.

History of the Present Illness

Characteristics: Patient X complains of palpitation and tightness during activity.

She also verbalized a feeling of fatigue.
Onset: It all started during pregnancy.
Location: Lower pelvis
Duration: The patient experiences palpitation and tightness during engagement
to activity.
Severity: (no data present)
Pattern: Every engagement to activity palpitation and tightness occur.
Associating Factors: Feeling of fatigue and palpitations

Past History
Patient X has a history of normal labor from her previous delivery with a healthy
baby and hasn't experienced bleeding and trauma before. She also has a history
of Grave's disease for the past ten years and it has not been treated for a year.
Physical Examination

 Pain
o Do you feel any pain? If yes, rate from 1-10, with 10 being the most
painful.
 o Where do you feel the pain? How will you describe the pain? How
many times do you feel the pain? For how long? When did this pain
started to occur? What provokes this pain? What relieves it?
 HEENT
o Head
 The patient has a fine, thin, black hair that is equally distributed
on her scalp. No swelling, lumps, or masses palpated.
o Eyes
 The patient has bulging eyes and normal vision.
o Mouth
 The patient’s lips are moist and pinkish with no lesion. There
are also no lesions nor sores in the mucous membrane.
o Throat
 The thyroid gland feel soft in the neck without pain.
 Respiratory System
o Chest movement is symmetrical. No mass palpated. No dull sounds
upon percussion. No abnormal breath sounds upon auscultation. The
patient does not use accessory muscles during respiration.
 Cardiovascular System
o Patient is tachycardic. Pulses are palpable and has normal rhythm. No
edema on the extremeties. Capillary refill less than 3 seconds.
 GIT
o Normal abdominal sounds upon auscultation.
 Integumentary system
o Skin is moist. No scars, wound, or edema, observed.
 Musculoskeletal
o Patient can do physical motion as command.

Mental Status Examination

Level of Consciousness

The patient is conscious with a Glasgow coma scale score of 15, wherein she has
spontaneous eye opening response, orientation to time, person, and place, and
moves according to what she is commanded to do.
Appearance

Upon entering the hospital, the patient appeared well dressed, well groomed,
and with good posture.

Behavior/Mood and Affect

During the assessment, the patient appeared relax and was not nervous, and
trembling was not observed. She maintains eye contact during the interview. She
was also cooperative and was able to answer the nurse’s questions.

Speech

The patient talks at a rate that is not too slow or too fast. She has a well-
modulated voice, and answers the questions clearly.

Thought Content

The patient does not hallucinate. She reports that she has no phobias. And she
does not have any thoughts of harming herself.
 PATTERNS OF HEALTH CARE

Health Perception Health Management Pattern

Before Hospitalization:
The patient reported that her general health has been well that she does
not usually get sick. She was then diagnosed with goiter 10 years ago, and to
keep herself healthy, she adheres to her therapeutic regimen. However, she also
reported that she has not continued her treatment for a year. Whenever she
catches a cold, she uses Vicks vaporub or liniment oil to relieve the symptoms.
She also reported that she does not smoke or drink, and that she has never been
involved in any accidents. She already gave birth to two children via normal
spontaneous delivery. On her third pregnancy, she became anxious and worried
because she was not feeling any fetal movements, hence she sought care in the
hospital.
During Hospitalization:
The patient’s general condition appeared weak with a BP - 197/87 mmHg
and PR - 148 bpm. The patient's physical examination, the exophthalmos, and
the thyroid gland feel soft in the neck. The patient was given Methimazole 30 mg
twice daily, propranolol 30 mg twice daily, and Lugol 5 drops per 6 hours from
the endocrine section. She was also administered oxytocin postpartum and
advised giving diuretics and vasodilators for pulmonary edema. Nitroglycerin at a
dose of 5 meq per hour and furosemide 30 mg per hour intravenously to improve
the condition of pulmonary edema.

Nutritional Metabolic Pattern

Before Hospitalization

The patient reported that she usually eats 3 meals a day and snacks in
between meals. She stated that their usual meal is chicken, and that she is also
fond of eating cabbage and potatoes. When she was diagnosed with goiter, she
was encourage to have a diet rich in iodine, however she finds it hard to adhere
to this since most of their household members are allergic to seafood. She also
reported that she takes vitamin C supplements, and that she usually consumes
8-10 glasses of water. When eating, she sometimes finds it hard to swallow her
food because she feels there’s a blockage in her throat. She stated that she does
not gain any weight despite having a good appetite. She weighs 56 kg, with a
height of 5 ft, and her temperature is 37.2 C.

For her skin assessment, she reported that she easily sweat and feel hot.
Her skin is moist, and she reported that it does not take too long for her wounds
to heal.
During Hospitalization
Her diet was changed, which made her more adherent to her
recommended diet. She remains to have a good appetite but was not gaining
weight. Although she did lose some after she delivered her baby. She now
weighs 53 kg, and her skin is intact.

Elimination Pattern
Before Hospitalization
The patient reported that she usually defecate 2 times a day, one at the
morning, and on the afternoon. She describes her stool as soft and watery most
of the time. She usually urinates 5 times a day, and describes her urine as
yellowish in color. She also easily sweats.
During Hospitalization
During her stay, her bowel elimination pattern and urinary elimination
pattern is the same with before she was admitted.
Activity-Exercise pattern
Before Hospitalization
The patient does not engage in any physical exercises and she only
engages in physical activities through household chores. However, she reports
that she easily gets tired when doing chores. Although she can perform activities
of daily living independently, there are some tasks that she needs assistance,
such as buying groceries. On her leisure, she usually watches television.
She has a slightly slow-paced gait, and her lower back curve is slightly
increased. She can perform range of motion completely.

During Hospitalization
In the ward, she the nurse assists her in doing ROM exercises to stretch
her muscles. She also needs assistance for dressing and toileting.

Sleep Rest Pattern

Before Hospitalization
The patient reported that she usually has 4-5 hours of interrupted sleep.
She usually falls asleep at 10 or 11 pm and wakes up 3 or 5 am. She takes a rest
whenever she feels tired.

During Hospitalization
She reported that she can sleep for 6-8 hours without interruptions. She
starts falling asleep at 9 or 10 pm and wakes up at 4 or 5 am. She also reported
that she is well-rested.

Cognitive-Perceptual Pattern
Before Hospitalization:
 The patient doesn’t experience any difficulty with hearing. She is sensitive
to light and she reports a slight pain and pressure in her eyes. Exophthalmos is
evident. She also reported that she has poor memory.
During Hospitalization:
During the assessment, the patient is conscious with GCS score of 15. She
was oriented with time, place and person. She is sensitive to lights and
exophthalmos is evident.

Role-Relationship Pattern
Before Hospitalization:
The patient lives in a house with 4 members, she, her husband, and their
two children. They share a good relationship, and they don’t have a problem with
their community. Their income comes from her husband, and she reported that it
is enough for all of their expenses. They also support her sister financially with
some of her needs.

During Hospitalization:
“When I knew I was ill and pregnant, I got so worried. My family needs
me and my husband is working also. Now, I feel helpless here in the hospital” as
verbalized by the patient, indicating that they became short with their income.
She also reported that their relatives were also worried of her condition.

Self-Perception Self Concept Pattern

Before Hospitalization:
When her disease started to manifest in her physical appearance (eyes
started to bulge, can’t gain weight, etc.), she was unhappy with these changes
as she became different from how she looked before having the disease. She
also experienced some judgment from her neighbors as they usually ask her why
does she look different and why are her eyes bulging. This furthered the
decrease in her self-esteem.
During Hospitalization:
The patient stated she felt helpless to her family in the hospital. She was
still unhappy about herself and has poor self-esteem. She blames herself by
wondering if her baby could have been saved if she did not stop her treatment.
The patient complained of shortness of breath and anxiety after two hours
postpartum.

Sexuality-Reproductive Pattern
Before Hospitalization
The patient is not sexually active due to her decreased libido. Her
husband has been understanding of her situation, and they decided that they
don’t want another pregnancy. She also reported that before getting pregnant,
she has an irregular menstrual cycle.

During Hospitalization
The patient is amenorrheic, and she reported that there are no abnormal
discharges from her vagina.

Coping-Stress Tolerance Pattern

Before Hospitalization
The patient considered having goiter as the biggest challenge she faced,
and she copes from this by going out most of the time. Whenever their family
faces a problem, she and her husband usually talk about it and come up with a
solution. She also stated that prayers can help her cope with her problems.
During Hospitalization
 Her greatest challenge right now is her current condition, and she faces
this with the support of her husband, and through prayers.

Value-Belief Pattern
Before Hospitalization
The patient is a roman catholic who believes that her religion is important
as this helps her face the adversaries of life. She shared that prayer gives her
strength to deal with the problems she encounter in life.
During Hospitalization
The patient remains faithful to her religion. She also reported that being
admitted to the hospital does not interfere with her religious practices, rather, it
made her faith stronger as she faces her current condition.
 ANATOMY AND PHYSIOLOGY

THE ENDOCRINE SYSTEM

The endocrine system is one of the major organ systems in the body
which plays a vital role in orchestrating cellular interactions, metabolism, growth,
reproduction, aging, and response to adverse conditions (Porth, 2015). It is
composed of interconnected networks of glands which are linked with the
nervous and immune system. Chemicals such as neurotransmitters released by
the nervous system can also function as hormones when required. Whereas the
immune system responds to the introduction of foreign agents by means of
chemical messengers (cytokines) and is also subject to regulation by adrenal
corticosteroid hormones (Porth, 2015). This organ system specifically involves
the production and release of hormones. These chemical transmitter substances
are produced by endocrine glands but can also be produced by specialized
tissues found in GIT, kidney, and white blood cells.
 The thyroid gland is the largest endocrine gland in the body. It is a
butterfly-shaped organ located in the lower neck, anterior to the trachea. It
weighs around 30 g and is about 5 cm long and 3 cm wide. This secretes thyroid
hormone and calcitonin. Th4 thyroid hormone consists of T4 and T3, containing
4 and 3 iodine molecules respectively. These are synthesized and stored on the
protein of cells of thyroid gland and are released when necessary to the
bloodstream. For the thyroid gland to synthesize thyroid hormones, iodine is
needed and important. The thyroid stimulating hormone also called thyrotropin
controls the secretion of T3 and T4. The thyroid hormone controls the body’s
cellular metabolic activities by increasing the level of specific enzymes that
contribute to consumption of oxygen. Thyroid hormones also affect the
replication of cells for brain development. The thyroid gland influences the major
organ systems in the body including the basal metabolic rate, thermogenesis,
serum cholesterol levels, and vascular resistance (Porth, 2015).

Major Action and Source of Selected Hormones

SOURCE HORMONE MAJOR ACTION
CRH, TRH, GHRH, Controls the release of pituitary hormones
GnRH
Hypothalamus Somatostatin Inhibits GH and TSH
Inhibits prolactin release from the pituitary,
Dopamine
inhibits FSH and FSH
Stimulates growth of bone and muscle,
promotes protein synthesis and fat
GH
metabolism, decreases carbohydrate
metabolism.
Stimulates synthesis and secretion of
Anterior ACTH
adrenal cortical hormones
Pituitary
Stimulates synthesis and secretion of thyroid
TSH
hormone
Male: stimulates sperm production
FSH Female: stimulate growth of ovarian follicle,
ovulation
 Male: stimulates secretion of testosterone,
development of interstitial tissue of testes.
LH Female: stimulates development of corpus
luteum, release of oocyte, production of
estrogen and testosterone.
ADH Increase water reabsorption by kidney
Posterior
Stimulates contraction of pregnant uterus,
Pituitary Oxytocin
milk ejection from breasts after childbirth.
Increase sodium absorption, potassium loss
Mineralocorticoids
by kidney.
Affects metabolism of all nutrients, regulates
Adrenal blood glucose levels, affects growth, has
Glucocorticoids
Pituitary anti-inflammatory action, and decreases
effects of stress.
Adrenal Have minimal intrinsic androgenic activity.
Androgens
Adrenal Epinephrine Serves as a neurotransmitter for
Medulla Norepinephrine sympathetic nervous systems.
Thyroid Increase the metabolic rate, increase
Thyroid Gland Hormones protein, and bone turnover
Calcitonin Lowers blood calcium and phosphate levels.
Parathyroid Parathyroid Regulates serum calcium
Gland Hormone
Insulin Lowers blood glucose level
Pancreatic
Glucagon Increase blood glucose level
islet cells
Somatostatin Delays intestinal absorption of glucose.
1,25-Dihydroxy Stimulates calcium absorption of glucose.
Kidney
vitamin D
Affects development of female sex organs
Estrogen
and secondary sex characteristics.
Ovaries Influences the menstrual cycle, stimulates
Progesterone growth of the uterine wall, and maintains
pregnancy.
Affect development of male sex organs and
Testes Androgens secondary sex characteristics; aid in sperm
production.
PATHOPHYSIOLOGY
 DIAGNOSTIC TEST

A. Thyroid Function Studies (date)

TEST NAME RESULTS REFERENCE INTERPRETATION

RANGE
Serum Thyroid –Stimulating Tests
Thyroid- 0.005 Women: 4-5 Decreased TSH is a
stimulating µIU/mL µIU/mL normal response of the
hormone brain for too much thyroid
(thyrotropin) hormone produced by the
thyroid gland
Serum T₃, T₄ and FT₄
Triiodothyronine 4.6 nmol/L Pregnancy: Increased T₃ levels usually
(T₃) 1.1-2.8 suggest hyperthyroidism
nmol/L and Grave’s disease
Thyroxine (T₄) 219.5 Pregnancy: T₄ levels is often slightly
nmol/L 128.7-219 elevated during pregnancy
nmol/L due to high TBG (thyroid
binding globulin) proteins
Thyroxine, free 75.62 Women: 13- Increased FT₄ usually
(FT₄) pmol/L 26 pmol/L suggest hyperthyroidism
and Grave’s disease
 DRUG STUDY

DRUG NAME MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE NURSING

(GENERIC/BRAND ACTION S EFFECT CONSIDERATI
NAME) ON
GENERIC: Is used to treat -In patients Contraindicated in the CNS: Patients who
METHIMAZOLE overactive with Graves’ presence of drowsiness, receive
thyroid disease with hypersensitivity to the headache, methimazole
(hyperthyroidis hyperthyroidis drug or any of the anxiety should be
BRAND NAME: m). It works by m other product under close
TAPAZOLE stopping the -To ameliorate components. GI: surveillance
thyroid gland symptoms of constipation, and should be
ROUTE: ORAL from making too hyperthyroidis nausea and cautioned to
much thyroid m vomiting, report
CLASSIFICATIO hormone. epigastric immediately
N: distress, salivar any evidence
ANTI-THYROID gland of illness. If
DRUG enlargement this occurred
stop giving
DOSAGE: 30mg HEMATOLOGIC: the drug and
BID Agranulocytis, notify the
aplastic anemia, physician
thrombocytopen
ia

METABOLIC:
hypothyroidism
 SKIN: rash, skin
discoloration

PREGNANCY:
maternal heart
failure,
spontaneous
abortion,
preterm birth,
stillbirth and
fetal or
neonatal
hyperthyroidism
.

Dermatologic: -Report to
It is used along It is a Known Urticaria, physician
GENERIC: with antithyroid medication hypersensitivity to angioedema, promptly the
POTASSIUM medicines to and iodine; hyperkalemia, cutaneous occurrence of
IODIDE prepare the disinfectant.To pulmonary edema hemorrhage GI bleeding,
thyroid gland for treat abdominal
surgical removal thyrotoxicosis Endocrine & pain,
BRAND NAME: and to treat until surgery metabolic: distension,
LUGOL certain can be carried hypothyroidism nausea, or
overactive out, protect vomiting.
thyroid the thyroid Gastrointestinal: -Report
CLASSIFICATIO conditions gland from Metallic taste, clinical S&S of
N: (hyperthyroidis radioactive GI upset, iodism.
Anti-thyroid m, thyroid iodine, and to soreness of Usually,
drug storm). It works treat iodine teeth and gums symptoms will
by shrinking the deficiency. subside with
ROUTE: ORAL size of the Miscellaneous: dose
thyroid gland Lymph node reduction and
DOSAGE: and by enlargement lengthened
5gtts/6hrs decreasing the intervals
amount of between
thyroid doses.
hormones the -Keep
body makes. physician
informed
about
characteristics
of sputum:
quantity,
consistency,
color.

In patients with
-prevention of hypersensitive to
chronic nitrates and in those CNS: dizziness,
GENERIC: Reduces cardiac anginal with early MI, severe headache,
NITROGLYCERI oxygen demand attacks anemia, increased throbbing, -assess
N by decreasing Acute angina ICP, cardiac weakness patient’s
left ventricular pectoris: to tamponade, condition
BRAND NAME: end-diastolic prevent or restrictive CV: fainting, before
 pressure and to minimize cardiomyopaty, flushing, starting drug
ROUTE: IV a lesser extent, anginal constrictive orthostatic therapy
systemic attacks when pericarditis hypotension, -monitor vital
CLASSIFICATIO vascular taken palpitations, signs and
N: NITRATE, resistance. immediately tachycardia drug response
ANTIANGINAL, before -check BP
VASODILATOR Therapeutic: stressful GI: Nausea and every
prevents or events vomiting 5minutes at
DOSAGE: relieves acute start of
5meq/hr angina, lowers SKIN: rash, infusion and
blood pressure, cutaneous every 15mins
and helps minize vasodilation after
heart failure -if severe
caused by MI hypotension
occurs, stop
infusion.
Reverse the
effects of
drug quickly
and notify the
physician
GENERIC: Inhibits sodium Indicated to Contraindicated to CNS: Dizziness, -assess
FUROSEMIDE and chloride patients with patients with fever, patient’s
reabsorption at acute hypersensitive headache, underlying
BRAND NAME: proximal and pulmonary reaction to drug restlessness, condition
LASIX distal tubule and edema, heart components and in vertigo, before
ascending loop failure those with anuria. weakness. starting
CLASSIFICATIO of henle therapy.
N: DIURETIC, CV: orthostatic -be alert for
ANTIHYPERTEN Therapeutic: hypotension, adverse
SIVE promotes water thrombophlebiti reaction and
and sodium s, dehydration drug
ROUTE: IV excretion interactions
DOSAGE: GI: abdominal
30mg/hr discomfort,
anorexia,
constipation,
diarrhea,
nausea,
vomiting

GU: frequent
urinations,
oliguria,
polyuria

HEMA: anemia,
agranulocytosis

MUSCULOSKELE
 TAL: muscle
spasm

GENERIC: Pitocin (oxytocin Indicated for -Where there is redness or Be aware of

OXYTOCIN injection) is a the initiation significant irritation at the purpose and
natural hormone or cephalopelvic injection site, anticipated
BRAND: that causes the improvement disproportion loss of appetite, effect of
PITOCIN uterus to of uterine -In obstetrical nausea, oxytocin.
contract used to contractions, emergencies where vomiting, Report
CLASSIFICATIO induce labor, where this is the benefit-to-risk cramping, sudden,
N: OXYTOCIC strengthen labor desirable and ratio for either the stomach pain, severe
AGENT contractions considered fetus or the mother more intense or headache
during suitable for favors surgical more frequent immediately
ROUTE: IV childbirth, reasons of intervention; contractions to healthcare
control bleeding fetal or -Where adequate (this is an providers.
after childbirth, maternal uterine activity fails to expected effect
or to induce an concern, in achieve satisfactory of oxytocin),
abortion. order to progress; sinus irritation.
achieve
vaginal
delivery.
 COURSE IN THE WARD

TIME
(2/10/21) DOCTOR’S SURGICAL NURSING ACTION
ORDER PERFORMED
6:00 AM Joined the endorsement
and the nurses' rounds.
Received patient at the
endocrine section lying on
bed, awake and with IV
line.
7:00 AM Administer Monitored and recorded
Methimazole 30 mg initial vital signs of T:
twice daily, 36.5ᵒC, PR: 148 bpm, RR:
Propranolol 30 mg 18 breaths/min, BP:
twice daily, and 197/87 mmHg.
Lugol 5 drops per 6
hours. Medication was given.
8:00 AM Reviewed the patient's
chart, medication orders,
past health history and
laboratory analysis.
9:00 AM Terminate
pregnancy through Pregnancy was terminated.
vaginal delivery and Medication was given.
administration of
oxytocin
postpartum.
10:00 AM Conducted complete head-
to-toe assessment and
interviewed using Gordon's
11 Functional Health
Patterns.
11:00 AM Documented patient’s
complaint of shortness of
breath and anxiety.
12:00 NN Administer Monitored and recorded
nitroglycerin 5 latest vital signs of T: 36ᵒC,
meq/hour and PR: 110 bpm, RR: 18
furosemide 30 breaths/min, BP: 130/9
mg/hour mmHg.
intravenously. Medication was given.
1:00 PM Constructed a sample chart
for the patient. Initiated
case presentation.
 NURSING CARE PLAN 1

ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATION RATIONALE Evaluation

S: “I feel Decreased Patient

palpitations cardiac diagnosed Short Term Independent Short Term
and tightness output with Grave
during activity.” disease in After 45 mins -Assess patient’s -To provide After 45 mins
related to
As pregnancy of nursing vital sign baseline data of nursing
verbalized by the uncontrolled with intervention, intervention,
patient hyperthyroi impending the patient is - Auscultate heart - Prominent the patient
dism and thyroid expected to: sounds, noting S1 and was able to
O: altered storm.  Exhibit extra heart murmurs are  Exhibit
- Tachycar heart rate Thyroid eupne sounds, associated eupnea
dia, PR: as storm is a a and development of with forceful and
148bpm life- remain gallops and cardiac remain
manifested
- BP: threatening free of systolic murmurs. output of free of
197/97m by health side hypermetabo side
mHg palpitations, condition effects lic state; effects
- Patient’s chest that is from development from
history of tightness, associated the of S3 may the
Grave's tachycardia with medic warn of medicat
disease and untreated or ations impending ions
for the undertreated used cardiac used to
elevated BP.
past 10 hyperthyroidi to failure. achieve
years and sm. An achiev adequa
has not excess of e - Monitor ECG, - Tachycardia te
been thyroid adequ noting may reflect cardiac
treated hormones ate rate/rhythm. direct Output
for a increases cardia Document myocardial
year. cardiac c dysrhythmias. stimulation □ Goal Met
- Increase contractility output by thyroid □ Goal
in FT4 and resting hormone. Partially
levels of heart rate Long Term Dysrhythmias Met
75.62 leading to often occur □ Goal
pmol / L inadequate After 8 hours and may
Unmet
- Low blood of nursing compromise
TSHs pumped by intervention, cardiac
Long Term
levels of the heart to the patient is function/outp
0.005 meet the expected to: ut.
After 8 hours
µIU / mL. metabolic
of nursing
- Wayne demands  Mainta -Auscultate breath -Early sign of
intervention,
Index of the body. in sounds. Note pulmonary
the patient
with a adequ adventitious congestion,
was able to:
value of ate sounds. reflecting
23 cardia developing
 Maintai
- Burch c cardiac
n
Wartofsk output failure.
adequa
y scale for
te
with a tissue - Monitor - Fever (may
cardiac
value of needs temperature; exceed
output
45 as provide cool 104°F) may
for
- Impendin eviden environment, limit occur as a
tissue
g thyroid ced by bed linens/clothes, result of
needs
storm stable administer tepid excessive
as
vital sponge baths hormone
evidenc
signs, levels and
ed by
palpab can
stable
le aggravate
vital
periph diuresis/dehy
signs,
eral dration and
BP –
pulses, cause
120/80
good increased
PR-
capilla peripheral 80bpm
ry vasodilation, Eupnea
refill, venous ,
and pooling, and palpabl
clear hypotension. e
lung periphe
sounds - Observe - Rapid ral
signs/symptoms of dehydration pulses,
severe thirst, dry can occur, good
mucous which capillar
membranes, reduces y refill,
weak/thready circulating and
pulse, poor volume and clear
capillary refill, compromises lung
decreased urinary cardiac sounds
output, and output
hypotension.
□ Goal Met
□ Goal
- Closely monitor - As these Partially
for symptoms of symptoms of Met
heart failure and heart failure □ Goal
decreased cardiac progress,
Unmet
output, including cardiac
diminished quality output
of peripheral declines.
pulses, cold and
clammy skin and
extremities,
increased
respiratory rate,
presence of
paroxysmal
nocturnal dyspnea
or orthopnea,
increased heart
rate, neck vein
distention,
decreased level of
consciousness,
and presence of
edema.

-Observe for -Indicates

adverse side need for
effects of reduction or
adrenergic discontinuati
antagonists: on of
severe decrease in therapy.
pulse, BP; signs of
vascular
congestion/HF;
cardiac arrest.
-It is
-Monitor blood necessary for
pressure, pulse, the nurse to
and condition assess how
before well the
administering patient is
cardiac tolerating
medications current
medications
before
administering
 cardiac
medications
Dependent/
Collaborative

- Administer IV - Rapid fluid

fluids as indicated replacement
may be
necessary to
improve
circulating
volume but
must be
balanced
against signs
of cardiac
failure/need
for inotropic
support.

- Provide - May be
supplemental O2 necessary to
as indicated support
increased
metabolic
demands/O2
consumption.

- Administer - Given to
medications as control
indicated thyrotoxic
 effects of
tachycardia,
tremors, and
nervousness
and is first
drug of
choice for
acute storm.

Thyroid hormone - Blocks

antagonist, thyroid
methimazole hormone
30mg, twice daily synthesis
and inhibits
peripheral
conversion of
T4 to T3.

-Beta-blockers, - Decreases
Propranalol heart
30mg twice daily rate/cardiac
work by
blocking
[beta]-
adrenergic
receptor sites
and blocking
conversion of
T4 to T3.

- Strong iodine - Acts to

solution (Lugol’s prevent
solution) 5 drops release of
per 6hrs thyroid
hormone into
circulation by
increasing
the amount
of thyroid
hormone
stored within
the gland
 NURSING CARE PLAN 2

ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Ineffective Abnormally Short Term: Independent: Short Term:

breathing high blood
“nahihirapan pattern pressure After 45 - Obtain and - Provides After 45
akong related to and pulse minutes of monitor client’s baseline minutes of
huminga” as pulmonary rate lead to nursing vital status data nursing
verbalized by edema as exacerbatio intervention, intervention, a
the patient manifested n of a normal and - Obtain client’s - To assess normal and
by shortness tachycardia effective health and causative effective
Objective: of breath. and high respiratory medical history and risk respiratory
blood pattern will factor pattern will be
BP – pressure be established,
197/87mmHg during established, which will be
PR – 148 delivery, which will be - Auscultate and - to evaluate evidenced by
bpm which evidenced by percuss chest the client’s report
✔ Fatigue resulted in client’s and take note of presence of relief in
✔ anxiety pulmonary report of rate and depth and breathing
✔ shortness edema, relief in of respirations characteristi
of breath which breathing. cs of breath □ Goal Met
causes the sounds and □ Goal
shortness of Long Term: secretions Partially
breath and Met
anxiety. After 8 hours - elevate the head - to promote □ Goal
of nursing of the bed maximal Unmet
intervention inspiration
a normal and
effective
respiratory Long Term:
pattern will - assist client with - to help the
be breathing client cope After 8 hours
maintained, retraining with of nursing
which will be difficulty in intervention a
evidenced by breathing normal and
absence of effective
cyanosis and - teach client - to help respiratory
other signs about relaxation client cope pattern will be
of hypoxia. techniques with DOB maintained,
The patient which will be
will also be evidenced by
able to - Encourage - to limit absence of
demonstrate adequate rest fatigue cyanosis and
at least 2 period other signs of
coping hypoxia. The
behaviors to patient will
maintain an - Provide a calm - promote also be able
effective environment rest to
respiratory and demonstrate
pattern. at least 2
- close monitoring - to assess coping
of patient the effect of behaviors to
treatment maintain an
to the effective
patient’s respiratory
condition pattern.
Dependent: □ Goal Met
□ Goal
- Administer - To relieve Partially
prescribed breathing Met
medications by treating □ Goal
o diuretics pulmonary Unmet
o vasodilators edema

Collaborative:
- to
- Consult determine
cardiology cause of
division SOB
 NURSING CARE PLAN 3

ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATIO RATIONALE EVALUATION

N
S: “I’m having a Fatigue Over time,  Short Independent
feeling of fatigue” related to Hyperthyroi term After 1 hour
as verbalized by hypermetaboli dism goal: - Note - O2 of nursing
the patient. c state with increase in Within 1 development of demand interventions
increased metabolism hour of tachypnea, and , the client
energy can break nursing dyspnea, pallor, consumptio identified
requirements the body interventi and cyanosis. n are basis of
O: as evidenced down and ons, the increased in fatigue.
- Nervousness by can cause client will hypermetab
- Tension verbalization tiredness identify olic state, After 8 hours
- PR: 148 bpm of and fatigue basis of potentiating of nursing
- BP: overwhelming fatigue. risk of interventions
197/87mmHg lack of energy hypoxia , the client
 Long term with reported
Fatigue goal: activity. improved
related to Within 8 sense of
physiological hours of - Provide for - Reduces energy.
factor: nursing quiet stimuli that
Pregnancy interventi environment; may
ons, the cool room, aggravate
client will decreased agitation,
report sensory stimuli, hyperactivit
improved soothing colors, y, and
sense of quiet music. insomnia.
energy

- Encourage - Helps
patient to restrict counteract
activity and rest effects of
in bed as much increased
as possible. metabolism

- Provide for - Allows for

diversional use of
activities that are nervous
calming, e.g., energy in a
reading, radio, constructive
television manner and
may reduce
anxiety.

- Assist the - A plan

patient to that
develop a balances
schedule for periods of
daily activity and activity with
rest periods of
rest can
help the
patient
complete
desired
activities
without
adding to
levels of
fatigue

- Avoid topics - Increased

that irritate or irritability of
upset patient. the CNS
Discuss ways to may cause
respond to these patient to
feelings. be easily
excited,
agitated,
and prone
to
emotional
 outbursts.

- Educate the -
patient and Organizatio
family about task n and
organization managemen
methods and t of time
time organization can assist
methods. the patient
save energy
and avoid
fatigue.

-Discuss with SO -
reasons for Understandi
fatigue and ng that the
emotional behavior is
lability. physically
based may
enhance
coping with
current
situation
and
encourage
SO to
respond
positively
and provide
support for
patient.
 DISCHARGE PLAN

Medications ● Emphasize to patient the

importance of adhering to the
prescribed therapeutic regimen
(anti-thyroid therapy and beta-
blockers)
Exercise ● Advise the patient to gradually
resume to usual activities as
tolerated
● Advise to schedule periods of
uninterrupted rest
Treatment ● Teach patient about proper
wound care of the incision and
proper washing/cleaning of the
perineum
Health Teaching ● Educate patient to observe lochia
(normal characteristics)
● Advise the patient to call a
healthcare professional when
experiencing serious side effects
and postpartum complications.
Out-patient ● Advise patient to return to
hospital or clinic at least once a
month for monitoring of thyroid
function.
● Refer patient to social services
and support groups that could
 assist her financially and
psychologically
Diet ● Discourage highly seasoned
foods and food that irritate the
GI tract such as coffee, tea, and
alcohol
● Encourage food high in calories
and proteins
● Instruct patient to record and
monitor daily weight and dietary
intake
Spirituality ● Advise the patient to attend
mass every Sunday and find time
to pray.
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VanPutte, C., Regan, J., & Russo, A. (2018). Seeley's Essential of Anatomy and
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