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Chapter: Medical Surgical Nursing: Assessment and Management of Patients With Endocrine Disorders

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Nursing Process: The Patient With Hyperthyroidism

The health history and examination focus on symptoms related to accelerated or exaggerated metabolism.

NURSING PROCESS:THE PATIENT WITH HYPERTHYROIDISM

Assessment

The health history and examination focus on symptoms related to accelerated or exaggerated metabolism. These include the pa-tient’s and family’s report of irritability and increased emotional reaction and the impact these changes have had on the patient’s interaction with family, friends, and coworkers. The history in-cludes other stressors and the patient’s ability to cope with stress.

 

The nurse assesses the patient’s nutritional status and the pres-ence of symptoms. Symptoms related to excessive nervous system output and changes in vision and appearance of the eyes are noted. The nurse periodically assesses and monitors the patient’s cardiac status, including heart rate, blood pressure, heart sounds, and peripheral pulses.

 

Because emotional changes are associated with hyperthyroid-ism, the patient’s emotional state and psychological status areevaluated, as are such symptoms as irritability, anxiety, sleep dis-turbances, apathy, and lethargy, all of which may occur with hyper-thyroidism. The family may also provide information about recent changes in the patient’s emotional status.

Diagnosis

 

NURSING DIAGNOSES

 

Based on all the assessment data, the major nursing diagnoses of the patient with hyperthyroidism include the following:

 

·      Imbalanced nutrition, less than body requirements, related to exaggerated metabolic rate, excessive appetite, and in-creased gastrointestinal activity

 

·       Ineffective coping related to irritability, hyperexcitability, apprehension, and emotional instability

 

·      Low self-esteem related to changes in appearance, excessive appetite, and weight loss

 

·      Altered body temperature

 

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Based on assessment data, potential complications may include the following:

 

·      Thyrotoxicosis or thyroid storm

 

·       Hypothyroidism

 

Planning and Goals

 

The goals for the patient may be improved nutritional status, im-proved coping ability, improved self-esteem, maintenance of nor-mal body temperature, and absence of complications.

Nursing Interventions

 

IMPROVING NUTRITIONAL STATUS

 Hyperthyroidism affects all body systems, including the gastro-intestinal system. The appetite is increased but may be satisfied by several well-balanced meals of small size, even up to six meals a day. Foods and fluids are selected to replace fluid lost through diarrhea and diaphoresis and to control the diarrhea that results from increased peristalsis. Rapid movement of food through the gastrointestinal tract may result in nutritional imbalance and fur-ther weight loss. To reduce diarrhea, highly seasoned foods and stimulants such as coffee, tea, cola, and alcohol are discouraged. High-calorie, high-protein foods are encouraged. A quiet atmo-sphere during mealtime may aid digestion. Weight and dietary intake are recorded to monitor nutritional status.

 

ENHANCING COPING MEASURES

 

The patient with hyperthyroidism needs reassurance that the emotional reactions being experienced are a result of the disorder and that with effective treatment those symptoms will be con-trolled. Because of the negative effect these symptoms have on family and friends, they too need reassurance that these symp-toms are expected to disappear with treatment.

It is important to use a calm, unhurried approach with the patient. Stressful experiences are minimized; therefore, if hospi-talized, the patient is not placed in a room with very ill or talka-tive patients. The environment is kept quiet and uncluttered. Noises, such as loud music, conversation, and equipment alarms, are minimized. The nurse encourages relaxing activities if they do not overstimulate the patient.

If thyroidectomy is planned, the patient needs to know that pharmacologic therapy is necessary to prepare the thyroid gland for surgical treatment. The nurse instructs and reminds the patient to take the medications as prescribed. Because of hyperexcitability and shortened attention span, the patient may require repetition of this information and written instructions.

 

IMPROVING SELF-ESTEEM

 

The hyperthyroid patient is likely to experience changes in ap-pearance, appetite, and weight. These factors, along with the pa-tient’s inability to cope well with family and the illness, may result in loss of self-esteem. The nurse conveys an understanding of the patient’s concern about these problems and assists the patient to develop effective coping strategies. The patient and family need to know that these changes are a result of the thyroid dysfunction and are, in fact, out of the patient’s control.

 

If changes in appearance are very disturbing to the patient, mirrors may be covered or removed. In addition, the nurse re-minds family members and personnel to avoid bringing these changes to the patient’s attention. The nurse explains to the pa-tient and family that most of these changes are expected to dis-appear with effective treatment.

 

If the patient experiences eye changes secondary to hyper-thyroidism, eye care and protection may become necessary. The patient may need instructions about instillation of eye drops or ointment prescribed to soothe the eyes and protect the exposed cornea.

 

The patient may be embarrassed by the need to eat large meals. Therefore, the nurse arranges for the patient to eat alone if desired and avoids commenting on the patient’s large dietary intake while making sure that the patient receives sufficient food.

 

MAINTAINING NORMAL BODY TEMPERATURE

 

The patient with hyperthyroidism frequently finds a normal room temperature too warm because of an exaggerated metabolic rate and increased heat production. The nurse maintains the en-vironment at a cool, comfortable temperature and changes bed-ding and clothing as needed. Cool baths and cool or cold fluids may provide relief. The reason for the patient’s discomfort and the importance of providing a cool environment are explained to the family and staff.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

The nurse closely monitors the patient with hyperthyroidism for signs and symptoms that may be indicative of thyroid storm. Car-diac and respiratory function are assessed by measuring vital signs and cardiac output, ECG monitoring, arterial blood gases, and pulse oximetry. Assessment continues when treatment is initiated because of the potential side effects on cardiac function. Oxygen is administered to prevent hypoxia, to improve tissue oxygena-tion, and to meet the high metabolic demands. Intravenous flu-ids may be necessary to maintain blood glucose levels and to replace lost fluids. Antithyroid medications (PTU or methima-zole) may be prescribed to reduce thyroid hormone levels. In ad-dition, propranolol and digitalis may be prescribed to treat cardiac symptoms. If shock develops, treatment strategies must be implemented.

 

Hypothyroidism is likely to occur with any of the treatments used to treat hyperthyroidism. Therefore, the nurse periodically monitors the patient. Most patients report a greatly improved sense of well-being after treatment of hyperthyroidism, and some fail to continue to take prescribed thyroid replacement therapy. Therefore, part of patient and family teaching is instruction about the importance of continuing therapy indefinitely after discharge and a discussion of the consequences of failing to take medication.

 

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

The nurse teaches the patient with hyperthyroidism how and when to take prescribed medication, and provides instruction about the essential role of the medication in the broader thera-peutic plan. Because of the hyperexcitability and decreased at-tention span associated with hyperthyroidism, the nurse provides a written plan for the patient to use at home. The type and amount of information given depend on the patient’s stress and anxiety levels. The patient and family members receive verbal and writ-ten information about the actions and possible side effects of the medications. The nurse identifies adverse effects that should be reported if they occur (Chart 42-5).


 

If a total or subtotal thyroidectomy is anticipated, the patient needs information about what to expect. This information is re-peated as the time of surgery approaches. The nurse also advises

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the patient to avoid stressful situations that may precipitate thy-roid storm.

 

Continuing Care

 

Referral for home care, if indicated, allows the home care nurse to assess the home and family environment and the patient’s and family’s understanding of the importance of adhering to the ther-apeutic regimen and the recommended follow-up monitoring. The nurse reinforces to the patient and family the importance of long-term follow-up because of the risk for hypothyroidism after thyroidectomy or treatment with antithyroid medications or ra-dioactive iodine. The nurse also assesses the patient for changes indicating return to normal thyroid function and signs and symp-toms of hyperthyroidism and hypothyroidism. Further, the nurse reminds the patient and family about the importance of health promotion activities and recommended health screening.

 

Evaluation

 

EXPECTED PATIENT OUTCOMES

 

Expected patient outcomes may include:

 

1)    Improves nutritional status

a)     Reports adequate dietary intake and decreased hunger

b)    Identifies high-calorie, high-protein foods; identifies foods to be avoided

c)     Avoids use of alcohol and other stimulants

d)    Reports decreased episodes of diarrhea

2)    Demonstrates effective coping methods in dealing with family, friends, and coworkers

a)     Explains reasons for irritability and emotional instability

b)    Avoids stressful situations, events, and people

c)     Participates in relaxing, nonstressful activities

3)    Achieves increased self-esteem

a)     Verbalizes feelings about self and illness

b)    Describes feelings of frustration and loss of control to others

c)     Describes reasons for increased appetite

4)    Maintains normal body temperature

5)    Absence of complications

a)     Serum thyroid hormone and TSH levels are within normal limits

b)    Identifies signs and symptoms of thyroid storm and hypo-thyroidism

c)     Vital signs and results of ECG, arterial blood gases, and pulse oximetry are within normal limits

 

d)    States importance of regular follow-up and lifelong maintenance of prescribed therapy

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