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Submitted to:
Asst. Prof. Osel Sherwin Melad
Submitted by:
Angel Clyla Amit
COLLEGE OF NURSING
Silliman University
Dumaguete City
Vision
A leading Christian institution committed to total human development for the well-being of society and environment.
Mission
Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian fellowship and
relationship can be nurtured and promoted.
Provide opportunities for growth and excellence in every dimension of the University life in order to strengthen character, competence and faith.
Instill in all members of the University community an enlightened social consciousness and a deep sense of justice and compassion.
Promote unity among peoples and contribute to national development.
Goals
Silliman aims to have…
A quality and diverse body of students;
A holistic and responsive educational program with a Christian orientation;
A quality faculty comparable to Asian standards;
A quality support staff;
Adequate facilities and administrative systems
A supportive and involved alumni; and
A long-term financial viability.
Institutional Graduate Outcomes
Attributes Indicators
1. Creative Critical Thinker 1.1 Asks pertinent questions, reflecting a heightened consciousness
and curiosity
1.2 Perceives the world in a correct and creative way
1.3 Is a problem-solver
2. Transformative Christian Witness 2.1 Influences society and impact the environment
2.2 Serves the others with compassion
2.3 Leads an exemplary life
2.4 Discerns (and acts on) what is right and wrong
2.5 Discerns (and acts on) what is good and bad
2.6 Sees the Divine in all that is in the world
2.7 Lives out the Via, Veritas, Vita- and becomes an image of
God’s justice and love to others
3. Effective communicator 3.1 Participates actively in social discourse
3.2 Expresses ideas and feelings accurately and in a clearly
organized manner- both in writing and speaking
3.3 Listens attentively and empathetically
3.4 Discerns and processes information objectively
3.5 Exchanges opinions rationally, assertively but not arrogantly,
respecting other’s opinions
3.6 Demonstrates appreciation of ethical and moral standards of
effective communication and practices them
4. Independent, Reflective Life-long Learner 4.1 Updates abilities, knowledge, skills, and qualifications
4.2 Values all forms of learning
4.3 Strives for excellence, always
4.4 Transcends challenges that are yet to be known in the
“laboratory of possibilities”
Programs Outcomes:
G01: Applying the knowledge of physical, social, natural, and health sciences and humanities in the practices of nursing.
G02: Perform safe, appropriate, and holistic care to individuals, families, population groups and communities utilising the nursing process.
G03: Apply guidelines and principles of evidence-based practice in the delivery of care.
G04: Practice nursing in accordance with the existing laws, legal, ethnical, and moral principles.
G05: Communicate effectively in speaking, writing, and presenting using culturally appropriate language.
G07: Collaborate effectively with the inter, intra, and multi-disciplinary and multi-cultural terms.
G08: Practice beginning management and leadership skills using systems approach in the delivery of client care.
G10: Engage in lifelong learning with a passion to keep current with national and global developments in general and nursing and health developments in particular.
Question and
I. Hyperthyroidisms answer
1. State accurately Socialized
what is a. Definition of hyperthyroidism Discussion
Lecture with Power 3 minutes
hyperthyroidism, is hyperactivity of the thyroid gland with
sustained increase in synthesis and release of Point Presentation
its different key
concepts and type thyroid hormones. Hyperthyroidism occurs in
and determine women more than men, with the highest
what causes it to frequency in persons 20 to 40 years old. The most
happen. common form of hyperthyroidism is Graves’
disease. Other causes include toxic nodular
2. Determine some goiter, thyroiditis, excess iodine intake, pituitary
clinical tumors, and thyroid cancer. The term
thyrotoxicosis refers to the physiologic effects or
manifestation clinical syndrome of hypermetabolism that results
associated with from excess circulating levels of T4, T3, or both.
hyperthyroidism Hyperthyroidism and thyrotoxicosis usually occur
together, as seen in Graves’ disease.
c. Clinical manifestations
Clinical manifestations of hyperthyroidism are Lecture with Power 10
related to the effect of excess circulating thyroid Point Presentation minutes
hormone. It directly increases metabolism and
tissue sensitivity to stimulation by the
6. State accurately sympathetic nervous system.
what is
hypothyroidism, Palpation of the thyroid gland may reveal a
its different key goiter. When the thyroid gland is excessively
concepts and type large, a goiter may be noted on inspection.
and determine Auscultation of the thyroid gland may reveal
what causes it to bruits, a reflection of increased blood supply.
happen. Another common finding is ophthalmopathy, a
term used to describe abnormal eye appearance or
function. A classic finding in Graves’ disease is
exophthalmos, a protrusion of the eyeballs from
the orbits that is usually bilateral . Exophthalmos
results from increased fat deposits and fluid
(edema) in the orbital tissues and ocular muscles.
The increased pressure forces the eyeballs
7. Determine some outward. The upper lids are usually retracted and
clinical elevated, with the sclera visible above the iris.
manifestation When the eyelids do not close completely, the
associated with exposed corneal surfaces become dry and
hypothyroidism irritated. Serious consequences, such as corneal
ulcers and eventual loss of vision, can occur. The
changes in the ocular muscles result in muscle
weakness, causing diplopia.
e. Diagnostic studies
The two primary laboratory findings used to
confirm the diagnosis of hyperthyroidism are
decreased TSH levels and elevated free thyroxine
(free T4) levels. Total T3 and T4 levels may also
be assessed, but they are not as definitive. Total
T3 and T4 determine both free and bound (to
protein) hormone levels. The free hormone is the
only biologically active form of these hormones.
The RAIU test is used to differentiate Graves’
disease from other forms of thyroiditis. The
patient with Graves’ disease shows a diffuse,
homogeneous uptake of 35% to 95%, whereas the
patient with thyroiditis shows an uptake of less
than 2%. The person with a nodular goiter has an
uptake in the high normal range.
f. Collaborative care
The goal of management of hyperthyroidism is to block
the adverse effects of excessive thyroid hormone,
suppress oversecretion of thyroid hormone, and prevent
complications. There are several treatment options,
including antithyroid medications, radioactive iodine
therapy, and surgical intervention. The choice of
treatment is influenced by the patient’s age and
preferences, coexistence of other diseases, and pregnancy
status.
Drug herapy
Drugs used in the treatment of
hyperthyroidism include antithyroid drugs,
iodine, and β-adrenergic blockers. These
drugs are useful in the treatment of thyrotoxic
states, but they are not considered curative.
Radiation therapy or surgery may ultimately
be required.
Antithyroid drugs
The first-line antithyroid drugs are
propylthiouracil (PTU) and methimazole
(Tapazole). These drugs inhibit the
synthesis of thyroid hormones. Indications
for the use of antithyroid drugs include
Graves’ disease in the young patient,
hyperthyroidism during pregnancy, and
the need to achieve a euthyroid state
before surgery or radiation therapy. PTU
is generally used for patients who are in
their first trimester of pregnancy, have an
adverse reaction to methimazole, or
require a rapid reduction in symptoms.
PTU is also considered first line in
thyrotoxicosis, since it also blocks the
peripheral conversion of T4 to T3. The
advantage of PTU is that it achieves the
therapeutic goal of being euthyroid more
quickly, but it must be taken three times
per day. In contrast, methimazole is given
in a single daily dose.
Iodine
Iodine is used with other antithyroid drugs
to prepare the patient for thyroidectomy or
for treatment of thyrotoxicosis. The
administration of iodine in large doses
rapidly inhibits synthesis of T3 and T4
and blocks the release of these hormones
into circulation. It also decreases the
vascularity of the thyroid gland, making
surgery safer and easier. The maximal
effect of iodine is usually seen within 1 to
2 weeks. Because of a reduction in the
therapeutic effect, long-term iodine
therapy is not effective in controlling
hyperthyroidism. Iodine is available in the
form of saturated solution of potassium
iodine (SSKI) and Lugol’s solution.
B-adrenergic Blockers
β-Adrenergic blockers are used for
symptomatic relief of thyrotoxicosis.
These drugs block the effects of
sympathetic nervous stimulation, thereby
decreasing tachycardia, nervousness,
irritability, and tremors. Propranolol is
usually administered with other
antithyroid agents. Atenolol is the
preferred β-adrenergic blocker for use in
the hyperthyroid patient with asthma or
heart disease.
Surgical therapy
Thyroidectomy
is indicated for individuals who have (1) a
large goiter causing tracheal compression,
(2) been unresponsive to antithyroid
therapy, or (3) thyroid cancer.
Additionally, surgery may be done when
an individual is not a candidate for RAI.
One advantage that thyroidectomy has
over RAI is a more rapid reduction in T3
and T4 levels.
Subtotal thyroidectomy
is often the preferred surgical procedure
and involves the removal of a significant
portion (90%) of the thyroid gland.
Endoscopic thyroidectomy
is a minimally invasive procedure. Several
small incisions are made, and a scope is
inserted. Instruments are passed through
the scope to remove thyroid tissue or
nodules. Endoscopic thyroidectomy is an
appropriate procedure for patients with
small nodules (less than 3 cm) and no
evidence of malignancy. Advantages of
endoscopic thyroidectomy over open
thyroidectomy include less scarring, less
pain, and a faster return to normal
activity.
Nutritional therapy
With the increased metabolic rate in hyperthyroid
patients, there is a high potential for the patient to
have a nutritional deficit. A high-calorie diet
(4000 to 5000 cal/day) may be ordered to satisfy
hunger, prevent tissue breakdown, and decrease
weight loss. This can be accomplished with six
full meals a day and snacks high in protein,
carbohydrates, minerals, and vitamins. The
protein content should be 1 to 2 g/kg of ideal
body weight. Increase carbohydrate intake to
compensate for increased metabolism.
Carbohydrates provide energy and decrease the
use of body-stored protein. Teach the patient to
avoid highly seasoned and high-fiber foods
because these foods can further stimulate the
already hyperactive GI tract. Instruct the patient
to avoid caffeine-containing liquids such as
coffee, tea, and cola to decrease the restlessness
and sleep disturbances associated with these
fluids. Refer the patient to a dietitian for help in
meeting individual nutritional needs. Socialized discussion 15
g. Nursing Management minutes
Nursing Diagnosis
Nursing diagnoses for the patient with
hyperthyroidism include, but are not limited to,
the following:
Activity intolerance related to fatigue and
heat intolerance
Imbalanced nutrition: less than body
requirements related to hypermetabolism
and inadequate food intake
Planning
The overall goals are that the patient with
hyperthyroidism will (1) experience relief of
symptoms, (2) have no serious complications
related to the disease or treatment, (3) maintain
nutritional balance, and (4) cooperate with the
therapeutic plan.
Nursing implementation
Acute thyrotoxicosis is a systemic syndrome that
requires aggressive treatment, often in an
intensive care unit. Administer medications
(previously discussed) that block thyroid
hormone production and the sympathetic nervous
system. Provide supportive therapy, including
monitoring for cardiac dysrhythmias and
decompensation, ensuring adequate oxygenation,
and administering IV fluids to replace fluid and
electrolyte losses. This is especially important in
the patient who experiences fluid losses due to
vomiting and diarrhea. Ensuring adequate rest
may be a challenge because of the patient’s
irritability and restlessness. Provide a calm, quiet
room because increased metabolism and
sensitivity of the sympathetic nervous system
causes sleep disturbances. Other interventions
may include (1) placing the patient in a cool room
away from very ill patients and noisy, high-traffic
areas; (2) using light bed coverings and changing
the linen frequently if the patient is diaphoretic;
and (3) encouraging and assisting with exercise
involving large muscle groups (tremors can
interfere with small-muscle coordination) to
allow the release of nervous tension and
restlessness. It is important to establish a
supportive, trusting relationship to facilitate
coping by a patient who is irritable, restless, and
anxious. If exophthalmos is present, there is a
potential for corneal injury related to irritation
and dryness. The patient may have orbital pain.
Nursing interventions to relieve eye discomfort
and prevent corneal ulceration include applying
artificial tears to soothe and moisten conjunctival
membranes. Salt restriction may help reduce
periorbital edema. Elevate the patient’s head to
promote fluid drainage from the periorbital area.
The patient should sit upright as much as
possible. Dark glasses reduce glare and prevent
irritation from smoke, air currents, dust, and dirt.
If the eyelids cannot be closed, lightly tape them
shut for sleep. To maintain flexibility, teach the
patient to exercise the intraocular muscles several
times a day by turning the eyes in the complete
range of motion. Good grooming can help reduce
the loss of self-esteem from an altered body
image. If the exophthalmos is severe, treatment
options include corticosteroids, radiation of
retroorbital tissues, orbital decompression, or
corrective lid or muscle surgery.
II. Hypothyroidism
Primary hypothyroidism
is caused by destruction of thyroid tissue or
defective hormone synthesis.
Secondary hypothyroidism
is caused by pituitary disease with decreased TSH
secretion or hypothalamic dysfunction with
decreased thyrotropinreleasing hormone (TRH)
secretion. Hypothyroidism may also be transient
and related to thyroiditis or discontinuance of
thyroid hormone therapy.
d. Complications
The mental sluggishness, drowsiness, and lethargy of
hypothyroidism may progress gradually or suddenly to a
notable impairment of consciousness or coma. This
situation, termed myxedema coma, is a medical
emergency. Myxedema coma can be precipitated by
infection, drugs (especially opioids, tranquilizers, and
barbiturates), exposure to cold, and trauma. It is
characterized by subnormal temperature, hypotension,
and hypoventilation. Cardiovascular collapse can result
from hypoventilation, hyponatremia, hypoglycemia, and
lactic acidosis. For the patient to survive a myxedema
coma, vital functions must be supported and IV thyroid
hormone replacement administered.
e. Diagnostic studies
The most common and reliable laboratory tests for
thyroid function are TSH and free T4. These values,
correlated with symptoms gathered from the history and
physical examination, confirm the diagnosis of
hypothyroidism. Serum TSH levels help determine the
cause of hypothyroidism. Serum TSH is high when the
defect is in the thyroid and low when it is in the pituitary
or the hypothalamus. The presence of thyroid antibodies
suggests an autoimmune origin of the hypothyroidism.
Other abnormal laboratory findings are elevated
cholesterol and triglycerides, anemia, and increased
creatine kinase.
f. Collaborative Care
The treatment goal for a patient with hypothyroidism is
restoration of a euthyroid state as safely and rapidly as
possible with hormone therapy. A low-calorie diet is also
indicated to promote weight loss or prevent weight gain.
Nutritional therapy
Low-calorie diet
Drug therapy
Levothyroxine
Levothyroxine (Synthroid) is the drug of
choice to treat hypothyroidism. In the
young and otherwise healthy patient, the
maintenance replacement dosage is
adjusted according to the patient’s
response and laboratory findings. When
thyroid hormone therapy is initiated, the
initial dosages are low to avoid increases
in resting heart rate and BP. In the patient
with compromised cardiac status, careful
monitoring is needed when starting and
adjusting the dosage because the usual
dose may increase myocardial oxygen
demand. The increased oxygen demand
may cause angina and cardiac
dysrhythmias.
Liotrix
Liotrix is a synthetic mix of levothyroxine
(T4) and liothyronine (T3) in a 4 : 1
combination. Levothyroxine has a peak of
action of 1 to 3 weeks. In contrast, liotrix
has a faster onset of action with a peak of
2 to 3 days. Liotrix can be used in acutely
ill individuals with hypothyroidism
Nursing Diagnosis
Nursing diagnoses for the patient with
hypothyroidism may include, but are not limited
to, the following:
Imbalanced nutrition: more than body
requirements related to calorie intake in
excess of metabolic rate
Constipation related to GI hypomotility
Impaired memory related to
hypometabolism
Planning
The overall goals are that the patient with
hypothyroidism will (1) experience relief of
symptoms, (2) maintain a euthyroid state, (3)
maintain a positive self-image, and (4) comply
with lifelong thyroid therapy.
Nursing implementation
Administer thyroid hormone therapy and all other
medications IV because paralytic ileus may be
present in myxedema coma. Monitor the core
temperature because hypothermia often occurs in
myxedema coma. Use soap gently and moisturize
frequently to prevent skin breakdown. Frequent
changes in patient positioning and a low-pressure
mattress can also assist in maintaining skin
integrity.
References:
Bucher, Dirksen, Heitkemper, & Lewis. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed.). Missouri, USA: Mosby,
Elsevier Inc.
Ignativicus, D., & Workman, L. (2010). Medical surgical nursing: Patient-centered collaborative care (6th ed.). Missouri, USA: Saunders Elseviers.
Bare, B., et al. (2010). Brunner & suddarth’s textbook of medical-surgical nursing(12th ed,vol 2). Philadelphia, PA: Lippincott Williams & Wilkins.
Burcher, Dirksen, Heitkemper, Lewis, O’Brien. (2008). Medical -surgical nursing. 7 t h ed. Vol. 1. Elsevier : Philippines.