care plan on hypothyroidism subject:- medical … on thyroid.pdf · vertigo, malaise, headache,...

A COMPLETE COACHING FOR THE PREPARATION OF STAFF NURSE/AIIMS/PGI/RPSC/ B.Sc NURSING.

/M/Sc.NURSING BY SAHU SIR-894787914

CARE PLAN

ON

HYPOTHYROIDISM

Subject:- Medical Surgical Nursing-I

SUBMITTED TO: SUBMITTED BY:

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SUBMITTED ON: 15/01/2010

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CASE PRESENTATION

1. BIOGRAPHIC DATA:

Name : Mr. Mari Gowda

Age : 60 years

Sex : male

Address : #1 5, 1stcross,

batrayanpura, deepanjali Nagar

Bengaluru- 76

MRD No. : 223553

Education : Illiterate

Occupation : nil

Income : Rs. 2500 per month

Marital Status : Married

Religion : Hindu

Mother tongue : Kannada

Language known : Kannada, and telgu.

Ward : Medical ward

Date of admission : 14.01.2010

Diagnosis : Hypothyroidism.

2. HISTORY COLLECTION:

Chief complaints:-

Altered sensorium- 1 day

Anasarca (generalised edema) - 2 weeks

Generalised fatigue.

Present history of illness:-

Medical- Client was normal till 14.1.2010, suddenly he fainted and

became unconscious. Due to this, the client was brought to the hospital and

got admitted for further treatment.

Surgical- Nothing significant

Past history of illness:-



Medical- Client is a known case of hypertension since 4 years back

and is on treatment. Client is also a known case of hyperthyroidism since 3

year back and is on tab Eltroxin.

Surgical- there is no history of any surgery done till date.

Personal Habits:-

Habits – he smokes and drinks alchohol.

Diet- he takes a mix diet, and usually eats two meals per day.

Sleeping habits- he sleeps atleast 5-6 hours per day, but not able to

sleep well the last 3-4 days due to weakness and joint

pains.

Hobby- his hobby is talking with people and .

Bowel and Bladder habits- he urinates atleast 4-5 times per day, and

his bowel pattern is regular, but for the

last 4-5 days her bowel pattern is

irregular.

Socialization- he socialises well with people and is a loving person.

Family history:-

There are four members in their family, his wife and two son. The

elder son is married and the younger son stays with him. There is no any

family history of DM, epilepsy or seizures

52 yrs

Sl

no.

Name Age Qualification/

Occupation

Relation to

Mr.marigowda.

Health status

1. Mr. Mari Gowda 6o yrs Illiterate. Client. Unhealthy

2. Mrs. Thayamma 52 yrs Illiterate wife healthy

3. Mr. Anand Gowda 38 yrs Class 8/ Autodriver Son Healthy

6o

yrs

38yrs 34 yrs



4. Mr. Moti Gowda 34 yrs Class 9/ autodriver Son Healthy

Socio- economic status:-

Condition of the house- the client lives in there own house with his son,

which is pucca and concrete with single rooms including the kitchen. They used gas stove for

cooking. The house is supplied with electricity.

Water supply- water supply is from the corporation.

Drainage system- closed drainage system.

Surrounding environment- their surrounding environment is clean.

3. PHYSICAL EXAMINATION:

Vital signs:-

Temperature : 98.20 F

Pulse : 88 beat per minute

Respiration : 20 per minute

Blood Pressure: 160/100 mmHg

Height and weight:-

Height: 166 cm

Weight: 92 kg

General appearance:-

Constitution : obese

State of nutrition : Good

Personal appearance: Normal

Posture : Normal

Skin and hair : Fair complexion

Emotional state : Anxious

Co-cooperativeness: cooperative

HEAD TO FOOT EXAMINATION:-

Head:

Skull - has no abnormalities noted.



Hair - grey hair, hair distribution normal

Movement of head- has full range of movement

Fore head - no scar or lesion noted

Face - facial puffiness present.

Eyes:

Eye brows- equal and even distribution

Eye lids- no lesion or scar noted.

Lacrimation- clear fluid expression

Conjunctiva- appears pale and clear

Sclera - appears white

Cornea - appears moist

Irish pupil - appears round and central in the sclera.

Pupil - PERRLA

Ears:

Appearance- no mass or lesion noted

Discharge - None

Hearing - normal

Lesion - none

Nose:

Appearance - no septum deviation

Discharge - none

Patency -both nostrils are patent

Sense of smell- good

Mouth and throat:

Lips - dry

Tongue - coated tongue

Teeth - molar and pre-molar absent in both sides

Gums - black

Buccal mucosa- no lesion and ulceration

Tonsil - not palpable

Taste - normal

Neck:

General appearance- normal

Lymph nodes - not palpable

Thyroid glands - not palpable

Cysts and tumour - absent



Chest:

Inspection- size and shape are normal

Palpation- no local swelling noted

Auscultation- bilateral crepts present

Abdomen:

Inspection- normal in shape, no abnormalities

Palpation- no organomegally

Percussion- no fluid filled spaces found

Auscultation- peristalsis movement present, bowel sound absent.

Spine and back:

Spine and curvature- no lordosis or kyphosis noted.

Movement - all movement are normal

Tenderness - no tenderness noted

Genitalia:

No discharge noted, normal.

Upper and lower extremities:

Upper- normal movement, no lymph node enlargement noted

Lower- normal anatomically. Bilateral pitting pedal edema present.

Skin:

Colour of skin- fair complexion

Edema- generalised edema present

Moisture- dry

Turgor- moderate

SYSTEMIC ASSESSMENT:-

Nervous system:

Conscious- client is conscious

Orientation- oriented

Obeys commands- yes, client obeys commands.

Altered sensorium – no.

Cardiovascular system:

S1- present



S2- present

S3- absent

S4- absent

Murmur- present (mild)

Respiratory system:

Inspiration & expiration- present

Respiration rate- 20 per minute

Ronchi/ wheezing- present

Gastro-intestinal system:

Peristalsis movement- absent

Bowel pattern- irregular

Organomegally- absent

Urinary system:

Frequency- 5 to 6 times per day normally

Burning micturation- absent

Catheterization- present; Input = 1000ml, Output = 800ml

Urine colour- dark straw colour

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4. INVESTIGATION:

Sl

no.

Investigation Patient’s value Impressi

-on

Normal value

1.

2.

3.

4.

Thyroid Profile

Liver Function

Test (LFT)

USG abdomen

Echocardiography

28/12/2009

T3= 64.21 ng/dl

T4= 7.57 g/dl

TSH= o.3 µU/ml

12/01/2010

T3= 56.10 ng/dl

T4= 6.56 ng/dl

TSH= 0.377 µU/ml

28/12/2009

Total Bil.= 1.1mg/dl

Direct Bil.=0.5 mg/dl

SGOT (AST)=62 IU

SGPT (ALT)=35 IU

Serum Alkaline phosphate= 268

Serum Total protein= 5.5 g/dl

Serum Albumin=2 g/dl

28/12/2009

Normal

28/12/2009

Sclerotic aortic valve

Mild MR

Normal chambers

Low

Normal

Low.

Low

Normal

Normal

Normal

Normal

High

Normal

High

Normal

Normal

-

Sclerotic

aortic

valve

and mild

T3= 75-195 ng/dl

T4= 4- 12µg/dl

TSH= 0.5-5.0 µU/ml

Total Bil.= upto 1mg/dl

Direct Bil= upto 0.4 mg/dl

SGOT= 8-40 IU

SGPT= 8-40 IU

S. Alkaline phosphate= upto

104 U/L

S. Total protein= 6.0-8.4 g/dl

Serum albumin=3.5-5.0 g/dl

-

-



5.

Complete Blood

Count Test

Normal LV function

Large left Pleural effusion

28/12/2010

Hb. = 8.1 gm/dl

Total WBC= 4,700 c/cmm

Neutrophil= 69%

Lymphocytes= 27%

Eosinophils= 02%

Monophil= 02%

Basophil= 00%

ESR= 40 mm/hr

MR.

Low

High

Hb. =12-16 g/dl

Total WBC= 5-10,000 c/cmm

Neutrophil=

Lymphocytes=

Eosinophils=

Monophil=

Basophil=

ESR= 1-2 mm/hr

Sl

no.

Investigation Patient’s value Impressi

-on

Normal value

6.

7.

8.

Haemogram

Biochemistry

Haematology

peripheral smear

PCV= 26%

RBC= 3.9million/cmm

Platelet count= 1.7 lac/ cmm

MCV= 66 fl

MCH= 21 pg

MCHC= 32%

FBS= 99 mg/dl

PPBS= 121 mg/dl

BUN= 7.9 mg/dl

S. Creatinine= 0.7 mg/dl

Erythrocytes- are microcytic

hypochromic cells with

macrocytes and good number of

target cells. No evidence of

haemolysis.

Leucocytes- normal in number,

morphology and distribution.

Thrombocytes- normal in

number and morphology. No

hemoparasites found.

Normal

Low

Normal

Normal

Normal

Normal

Microlyti

c

hypochro

mic

anaemia

PCV= 40-50%

RBC= 4.5-6.5million/cmm

Platelet count=1.5-3.5 lac/cmm

MCV= 86-98 fl

MCH= 27-32 pg

MCHC= 32-36%

FBS= 110-126mg/dl

PPBS= <200mg/dl

BUN= 8-25 mg/dl

S.Creatinine= 0.6-1.5 mg/dl

-

5. MEDICATION:

Sl

no

Medication Dose,

route &

time

Action of drug Side effect Nursing

responsibility

1. Tab. Eltroxin 100 mg Stimulates metabolism Insomnia,



2.

3.

4.

5.

6.

7.

Inj.

hydrocortisone

Inj.

Ceftriaxone

Inj. Rantac

Inj. Metrogyl

Tab. Avas

Tab. Telma

Orally

OD

100 mg

IV

BD

1 gm

IV

BD

100 mg

IV

BD

100 ml

IV

TDS

10 mg

Orally

OD

40 mg

Orally

OD

of all body tissues by

accelerating rate of

cellular oxidation.

Decreased

inflammation. mainly

by stabilising leukocyte

lysomal membranes;

suppresses immune

response, stimulates

bone marrow and

influence protein, fat

and CHO metabolism

A 3rd generation

cephalosporin that

inhibits cell wall

synthesis, promoting

osmotic instability,

usually bactericidal.

Competitively inhibits

action of histamine on

the H2 at receptor sites

of parietal cells

decreasing gastric acid

secretion.

A direct acting

trichomonocide and

amebicide that works at

both intestinal and

extra intestinal sites.

Inhibits calcium ion

influx across cardiac

and smooth muscle

cells, thus decreasing

myocardial contractility

and oxygen demand.

Blocks the

vasoconstricting and

aldosterone secreting

effects of angiotensin II

by selectively blocking

the binding of

tachycardia,

palpation, diarrhoea,

vomiting,

arrhythmias, cardiac

arrest.

Headache, vertigo,

edema, arrhythmias,

glucoma, GI

irritation, easy

bruising,

hypocalcaemia,

muscle weakness,

skin eruption.

Thrombophlebitis,

anorexia, vomiting,

thrombocytopenia,

pain at the injection

site, anaemia.

Vertigo, malaise,

headache, blurred

vision, jaundice,

burning and itching

at the injection site.

Headache, vertigo,

seizures, abdominal

cramping, nausea,

rash, constipation,

anorexia.

Headache, fatigue,

flushing, nausea,

abdominal pain,

dyspnoea, rash,

pruritis.

Dizziness, pain,

fatigue, headache,

nausea, UTI, back

pain, flu like

symptoms.

- check vital signs.

- follow strictly the

five rights.

- monitor closely the

patient for any side

effect of the drugs

given.

-observe the site of

injection carefully.

check vital signs.


five rights.



effect of the drugs

given.

check vital signs.


five rights.



effect of the drugs

given.

check vital signs.


five rights.



effect of the drugs

given.



Nursing diagnosis

(Problem identified)

1. Activity intolerance related to weakness and apathy secondary to a

decreased metabolic rate.

2. Constipation related to decreased peristalsis secondary to slowed

metabolic rate and activity intolerance.

3. Skin integrity, risk for impaired related to edema and dryness

secondary to infiltration of fluid into interstitial spaces.

4. Knowledge deficit regarding disease condition related to lack of

exposure.

8.

Cap. Becosule

1 cap

Orally

OD

angiotensin II to the

angiotensin I receptor

in many tissues.

Multi-vitamins.

-



APPLICATION OF THEORY

Name : Mr. Mari Gowda

Age : 60yrs

Sex : male

Ward : Medical ward

Present complaints : altered sensorium and decreased physical activity

Diagnosis : Hypothyroidism

Theories applicable:

i) Dorothy E. Johnson Behavioural System Model

ii) Sister Callista Roy Adaptation Model

iii) Orems self care deficit theory

iv) Martha Rogers Unitary Human Model

In this case i am going to give care according to the Betty Neumann theory.

BETTY NEUMANN MODEL

This theory offers a holistic view of the client system including system

including the concept of open system, environment, stressors, prevention and reconstitution.

Nursing is concerned with whole person and dyanamic composes of relationship between

physiological, psychological, sociocultural, developmental, spiritual, and variables. The client

is view as aopen system in interaction with environment.



MAJOR CONCEPTS AND DEFINITIONS

The major concepts plentified in the model are holistic client approach open system, basic

structure, environment, created environment, stressors, lines of stressors, lines of defence and

resistance, degree of reaction, prevention, reconstruction, content, negenetrophy, entrophy,

stability, and wellness and illness.

PREVENTION AS INTERVENTION

Intervention is a purposeful action to help client to retain or maintain system stability. It can

occur before or after resistance of lines are penetrated both reaction and reconstitution phases.

Intervention are based on the possible or actual degree of reaction, resource goal, and the

anticipated outcome. Neumann identifies three level of prevention such as primary,

secondary and tertiary.

PRIMARY PREVENTION

Primary prevention is carried out when stressors is suspected or identified. A reaction has not

yet occurred or intervention would perhaps attempt to reduce possibility of the individual

encounter with the stressor or in the same way to attempt to strengthen the individual.

Flexible line of the defence internal lines of defence. Strengthen the individual. Flexible lines

of resistance to decrease the possibility of the reaction.

SECONDARY PREVENTION

Involves intervention or treatment after symptoms from stressors from stresses have accured.

Both the clients internal and external sources used towards stabilization to strengthen the

internal lines of resistance, redujce the reaction, reduce the reaction and increase the

resistance factors.

TERTIARY PREVENTION

A primary goal is to strengthen resistance to stressors by reduction to have prevent recurrence

or regression.

NURSING CARE OF MR. MARIGOWDA WITH NEUMANNS MODEL

Assessment data

The case history is considered in the neumanns model according to five client variable.

Physiological variables

This variables are described hypothyroidism, which is congenital heart diseases. This also

describes the hypertention with obesity.



Temperature 990F

Pulse 74 b/min

Respiratory rate 32 breaths/min

Blood pressure 170/110

S1 and S2 sounds are heard.

Abdomen: No organomegaly, no fluid accumulation found. Amd peristalysis sounds heard.

Upper extremities and lower extrimities are normal, no edema.

Nervous system; conscious, orientation to time place and person is good.

Investigation revealed normalicity.

Physiological variables

These variables paint a picture of very anxious aged man concerned about his future and he

know that he has very little time left. His family is worried about his illness but never tried to

reveal it out.

Sociocultural pattern

Mr.marigowda has a formal up to 5th std and having good relationship with his family

members. Family is fully supporting his in unhealthy condition and also psychologically.

Developmental variables

Mr.marigowda 60 yr old man and is a father and also a grandfather. he has left her grand

children at home and is worried about them.

Spiritual variables

Mr.marigowda is a God fearing man, he does puja regularly and also visits temple regulary

before when he was well. he believes that illness is a punishment from God and it is due to

sin.

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Flexible line of defence normal line of defence

Line of defence

Basic Structure - Mr. mari gowda

60years old - male - Dependent - Hypothyroidism

Nursing diagnosis

- Activity intolerance related to weakness and apathy secondary to a decreased metabolic rate.

- Constipation related to decreased peristalsis secondary to slowed metabolic rate and activity intolerance.

- Skin integrity, risk for impaired related to edema and dryness secondary to infiltration of fluid into interstitial spaces.

- Knowledge deficit regarding disease condition related to lack of exposure.

Intervention

Primary intervention Reduce the possibility of becoming depressed by increasing dependence and assistance to feed her Secondary prevention proper treatment of hypothyroidism tertiary prevention facilitate Mrs. Nagamma to adapt with stress

Evaluation

Mr.mari gowda

adapt with stress

and accept her

present condition

and treatment

regimen

Interpersonal Mr. mari gowda is afflicted with hypothyroidism Intrapersonal he is with his family members Extrapersonal Unable to do any physical activity

Physiological

Hypothyroidism and

hypertension with obesity

Psychological- anxious

Sociocultural- diminished

socialization

Developmental- 60 year old

unable to adjust hospitalisation

Basic structure

Energy sources

Basic structure

Energy source


Nursing diagnosis

(problems identified)

1. Activity intolerance related to weakness and apathy secondary to a decreased metabolic rate.

2. Constipation related to decreased peristalsis secondary to slowed metabolic rate and activity intolerance.

3. Skin integrity, risk for impaired related to edema and dryness secondary to infiltration of fluid into interstitial spaces.

4. nutrition Imbalanced more than body requirements related to calorie intake in excess of metabolic rate as evidenced by

hypometabolism and weight gain

5.Therapeutic regimen management ineffective related to lack of knowledge regarding medication as manifested by questioning

of long term effects.


Nursing theory

applied

Subjective and

objective data

Nursing

diagnosis

Goal Planning Implementation Evaluation

Betty neuman

theory

The clients line

of resistance is

broken and she is

in secondary

prevention stage

as the treatment

initiated after the

symptoms from

stress have

occurred. The

stressors are

interpersonal and

the physiological

variable is

affected

Sub: how will I reduce

my weight

Obj: the weight of the

patient has increased to

92 kgs, recommeneded

to reduce the weight

Imbalanced

nutrition more

than body

requirements

related to calorie

intake in excess

of metabolic rate

as evidenced by

hypometabolism

and weight gain

To maintain and meet

nutritional needs

-determine patients

desire and

motivation in weight

reduction

- Plan an exercise

program taking into

patients limitations

- Chart progress

towards reaching a

final goal and post a

strategic location

- encourage use of

internal reward

system when goals

are accomplished.

- determine the goals

to attain the

nutritional level by

collaborating with

the dietician

- monitor the intake

and output chart

Weight the patient

regularly and

accordingly give the

nutritional needs.

-Determined the

desire of the

patient

-Planned an

exercise to be done

every day to

reduce weight

- charted the

progress

-Encouraged the

internal reward

system when the

goal was

accomplished

- determined the

nutritional level be

collaborating the

dietician

- monitored the

intake and output

chart.

- weighed the

patient regularly.

Maintained

and

achieved

optimum

wiegth


Nursing theory

applied

Subjective and

objective data

Nursing

diagnosis


Betty neuman

theory

The clients line

of resistance is

broken and she is

in secondary

prevention stage

as the treatment

initiated after the

symptoms from

stress have

occurred. The

stressors are

interpersonal and

the physiological

variable is

affected

Sub: I cannot pass

motion for last 3 days

Obj: no bowel sounds

heard during purcussion

Constipation

related to

gastrointestinal

hypomotility as

evidenced by

irregular hard

stools

Experience regular

and soft stools to

pass

-Encourage

increased fluid

intake to maintain

soft stools

- Instruct the patient

on high fibre diet to

increase knowledge

regarding of to

increase fecal mass

- monitor bowel

movements

including frequency,

consistency, shape

and volume

- suggest to the

physician to

laxatives and stool

softners to stimulate

GI motility.

- prescribe better

nutrition for the

patient.

-Encouraged the

patient to increase

the fluid

-Instructed the

patient on high

fibre diet

-Monitored the

bowel movements

regularly

-Suggested the

physician for the

stool softners and

dulcolex was given

-Prescribed needed

nutrition for the

patient

Now the

patient has

no

constipation


Nursing theory

applied

Subjective data and

objective data

Nursing

diagnosis


Betty Neumann

theory

The clients line

of resistance is

broken and she is

in secondary

prevention stage

as the treatment

initiated after the

symptoms from

stress have

occurred. The

stressors are

interpersonal and

the physiological

variable is

affected

Sub: I cannot do my own

works, I am feeling

fatigue

Obj: patient is seen very

weak, needed ssome rest

Acivity

intolerance

related to

decreased

metabolic rate

and mucin

deposits in joints

and interstitial

space as

evidenced by

generalized

weakness and

muscle and joint

stiffness

To participate in self

care in daily living

Determine the

patients physical ,

social and

psychologic

capabilities

-Monitor the patient

for evidence of

excess physical and

emotional fatigue

-Monitor patients

oxygen response

with the vital signs

regularly

-Promote bed rest

and activity

limitation

-Plan activities for

periods when the

patient has the most

energy to allow

maximum

participation.

-Dtermined the

patients

capabilities

-Monitored the

patient for physical

and emotional

fatigueness

-Monitored

patients oxygen

response with the

vital signs

-Promoted bed rest

and activity was

limited

-Planned activities

when the patient

had most of the

energy

The patient

is able to

participate I

self care and

in daily

living


Nursing theory Subjective and objective

data

Nursing

diagnosis

Planning or goal. Intervention. Implementation Evaluation.

Betty neuman

theory

The clients line

of resistance is

broken and she is

in secondary

prevention stage

as the treatment

initiated after the

symptoms from

stress have

occurred. The

stressors are

interpersonal and

the physiological

variable is

affected

Subjective data.

Patient says that he

doesn’t know about

medications and has

plenty of doubts about

his condition.

Objective data:

On observation he asks

many questions and does

things unconvincingly.

.

therapeutic

regimen

management

ineffective related

to lack of

knowledge

regarding

medication and

diet as manifested

by questioning of

long term effects.

To improve the

knowledge of the

patient about his

condition ,.

Asses the knowledge

level of the patient .

Explain factors that

contribute to disease

factor.

Instruct patient on

home care measures

related to excercise ,

and prevention of

complication .

Provide written

instruction s of

prescribed

medication.

Advice him for the

regular follow up.

Assessed the

knowledge of

patient to know

his level of

knowledge about

his condition.

Explained factors

that contribute to

disease condition.

Instructed patient

on home care

measures about

excersice and

prevetion of

complication.

Every thing which

is related to his

health is given in

written format to

help in improving

his knowledge.

Adviced patient to

come for regular

follow up.

knowledge

of the

patient

about his

condition

,exercises,

and the

treatment

regimen is

improved to

some

extent.



Conclusion.

Patien named marigowda admitted with altered sensorium, fatigue, generalised edema and he

was diagnosed has hypothyroidism, and he was treated now he is improving gradually, his

consiousness is improving and edema is reducing.

Bibliography.

Lewis SM,Heitkemper MM,Dirksen SR.medical surgical nursing,assessment and management of clinical problems.6th ed.missouri:mosby;2004.p.1319-22.

Suzane cs,Brenda gb,jonice lh, Textbook of Medical-Surgical Nursing.10th ed.wolters klwwer; 2004.p1215-21.

Silverstri LA..comprehensive review of nclex.rn.examination .3rd ed.pennylvania:saunders;2006.p.637-37

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VISIT REGULAR:- www.mcinursing.com

CALL:- 8947879143 (SAHU SIR)



care plan on hypothyroidism subject:- medical … on thyroid.pdf · vertigo, malaise, headache,...

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