University:
College
Course:
College Nursing
Academic year:

2023
Views:

398

Pages:

1
Author:

zabunama7llw

A 40-year-old female client is admitted to a medical-surgical unit for management of severe hyperthyroidism. She has no know history of any other health problems. On admission she is hypertensive, tachycardic, and has a core body temperature of 101° F (38.3° C). Select the nursing action that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or is Nonessential (makes no difference or not necessary) for the client's care at this time. Rationale: The client is at high risk for developing thyroid storm, a life-threatening exacerbation of hyperthyroidism that can rapidly lead to seizures, stroke, and myocardial infarction. This problem is characterized with overstimulation of the nervous and cardiac systems. Indicated Vital signs, especially temperature and blood pressure, must be monitored closely. Rising core body temperature and more severe hypertension are hallmarks of impending thyroid storm. Applying a cooling blanket helps prevent further elevation of temperature. Keeping the room lighting helps prevent overstimulation of the nervous system, which could increase the rate of progression of the client's condition to thyroid storm. Asking whether there is any possibility of pregnancy because some of the drugs used to manage hyperthyroidism are teratogenic and can cause birth defects. A 72-year-old female client is brought to the emergency department by her family who found her vomiting from eating food that had been sitting on the stove for about 3 days. She is somewhat confused and keeps stating that she "just wants to go to bed." Although she has always been independent in all activities, her family says over the past 2 months she has lost interest in visiting, eating out, or even going to church. She has a history of hypothyroidism and hypertension, both of which have been controlled by medication for many years. Her current vital signs are: Temperature = 96.8° F (36° C) Blood pressure = 88/56 Pulse = 56 beats/min Respirations = 10 breaths/min, shallow Choose the most likely options for the information missing by selecting from the list of options provided. Note that not all options will be used. Rationale: A) The client is most immediately at risk for respiratory failure (the most common cause of death in clients with severe hypothyroidism) and dehydration. The respiratory failure is related to the slow, shallow respiratory rate and poor perfusion from with decreased cardiac output as evidenced by the low blood pressure and heart rate. B) The client remains at risk for falls and pressure injury throughout her hospital stay. The confusion may cause her to attempt to toilet without assistance because she has always been independent. The skin changes brought on by hypothyroidism along with the poor perfusion and gas exchange increase the risk for pressure injury.