Hyperthyroidism

CHAPTER I INTRODUCTION Hyperthyroidism, a term for overactive tissue within the thyroid gland, resulting in overproduction and thus an excess of circulating free thyroid hormones: thyroxine (T4), triiodothyronine (T3) or both. Thyroid hormone is important at a cellular level, affecting nearly every type of tissue in the body. It functions as a stimulus to metabolism, and is critical to normal function of the cell. Hyperthyroidism, considered as the second most common endocrine disorder. It results from an excessive output of thyroid hormones due to abnormal stimulation of the thyroid gland by circulating immunoglobulin. This disorder affects women eight times more frequently than men and peaks between the second and fourth decades of life. It generally occurs between 20 and 40 years old and is more common in females. Weight loss, exopthalmos (protrusion of the eyeballs), hypertension, and heat intolerance: these are some of the signs and symptoms of Hyperthyroidism. Neurological manifestations can include tremors, irritability and restlessness. Hyperthyroidism is the most common endocrine disorder that’s why we choose this as our case study because of its relevance to our concept about disturbance in metabolism and endocrine. Since metabolism is all the chemical and physical processes which occur in living organisms and that maintain life and growth, endocrine is specifically producing secretions that are distributed in the body by the blood stream. Like with our patient with hyperthyroidism, there is an excess T4 (thyroxine) and T3 (triiodothyronine) and decreased of TSH (Thyroid Stimulating Hormone) that affects his metabolism (Medical surgical Nursing; Joyce Young Johnson).

ANATOMY AND PHYSIOLOGY Thyroid Gland The thyroid is one of the largest endocrine glands in the body. This gland is found in the neck inferior to (below) the thyroid cartilage (also known as the Adam's apple in men) and at approximately the same level as the cricoid cartilage. The thyroid controls how quickly the body burns energy, makes proteins, and how sensitive the body should be to other hormones. The thyroid participates in these processes by producing thyroid hormones, principally thyroxine (T4) and triiodothyronine (T3). These hormones regulate the rate of metabolism and affect the growth and rate of function of many other systems in the body. Iodine is an essential component of both T3 and T4. The thyroid also produces the hormone calcitonin, which plays a role in calcium homeostasis. The thyroid is controlled by the hypothalamus and pituitary. The gland gets its name from the Greek word for "shield", after the shape of the related thyroid cartilage. Hyperthyroidism (overactive thyroid) and hypothyroidism (underactive thyroid) are the most common problems of the thyroid gland.

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Anatomy The thyroid gland is butterfly-shaped organ and is composed of two cone-like lobes or wings: lobus dexter (right lobe) and lobus sinister (left lobe), connected with the isthmus. The organ is situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the oesophagus and carotid sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the laryngeal prominence or Adam's apple) and extends inferiorly to the fourth to sixth tracheal ring. It is difficult to demarcate the gland's upper and lower border with vertebral levels as it moves position in relation to these during swallowing. The thyroid gland is covered by a fibrous sheath, the capsula glandulae thyroidea, composed of an internal and external layer. The external layer is anteriorly continuous with the lamina pretrachealis fasciae cervicalis and posteriorolaterally continuous with the carotid sheath. The gland is covered anteriorly with infrahyoid muscles and laterally with the sternocleidomastoid muscle. Posteriorly, the gland is fixed to the cricoid and tracheal cartilage and cricopharyngeus muscle by a thickening of the fascia to form the posterior suspensory ligament of Berry. In variable extent, Zuckerkandl's tubercle, a pyramidal extension of the thyroid lobe, is present at the most posterior side of the lobe. In this region the recurrent laryngeal nerve and the inferior thyroid artery pass next to or in the ligament and tubercle. Between the two layers of the capsule and on the posterior side of the lobes there are on each side two parathyroid glands. The thyroid isthmus is variable in presence and size, and can encompass a cranially extending pyramid lobe (lobus pyramidalis or processus pyramidalis), remnant of the thyroglossal duct. The thyroid is one of the larger endocrine glands, weighing 2-3 grams in neonates and 18-60 grams in adults, and is increased in pregnancy

The thyroid is supplied with arterial blood from the superior thyroid artery, a branch of the external carotid artery, and the inferior thyroid artery, a branch of the thyrocervical trunk, and sometimes by the thyroid ima artery, branching directly from the aortic arch. The venous blood is drained via superior thyroid veins, draining in the internal

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jugular vein, and via inferior thyroid veins, draining via the plexus thyroideus impar in the left brachiocephalic vein. Lymphatic drainage passes frequently the lateral deep cervical lymph nodes and the pre- and parathracheal lymph nodes. The gland is supplied by sympathetic nerve input from the superior cervical ganglion and the cervicothoracic ganglion of the sympathetic trunk, and by parasympathetic nerve input from the superior laryngeal nerve and the recurrent laryngeal nerve..

Physiology The primary function of the thyroid is production of the hormones thyroxine (T4), triiodothyronine (T3), and calcitonin. Up to 80% of the T4 is converted to T3 by peripheral organs such as the liver, kidney and spleen. T3 is about ten times more active than T4. T3 and T4 production and action Thyroxine (T4) is synthesised by the follicular cells from free tyrosine and on the tyrosine residues of the protein called thyroglobulin (TG). Iodine is captured with the "iodine trap" by the hydrogen peroxide generated by the enzyme thyroid peroxidase (TPO) and linked to the 3' and 5' sites of the benzene ring of the tyrosine residues on TG, and on free tyrosine. Upon stimulation by the thyroid-stimulating hormone (TSH), the follicular cells reabsorb TG and proteolytically cleave the iodinated tyrosines from TG, forming T4 and T3 (in T3, one iodine is absent compared to T4), and releasing them into the blood. Deiodinase enzymes convert T4 to T3. Thyroid hormone that is secreted from the gland is about 90% T4 and about 10% T3. Cells of the brain are a major target for the thyroid hormones T3 and T4. Thyroid hormones play a particularly crucial role in brain maturation during fetal development. A transport protein (OATP1C1) has been identified that seems to be important for T4 transport across the blood brain barrier. A second transport protein (MCT8) is important for T3 transport across brain cell membranes. In the blood, T4 and T3 are partially bound to thyroxine-binding globulin, transthyretin and albumin. Only a very small fraction of the circulating hormone is free (unbound) - T4 0.03% and T3 0.3%. Only the free fraction has hormonal activity. As with the steroid hormones and retinoic acid, thyroid hormones cross the cell membrane and bind to intracellular receptors (α1, α2, β1 and β2), which act alone, in pairs or together with the retinoid X-receptor as transcription factors to modulate DNA transcription.

T3 and T4 regulation The production of thyroxine and triiodothyronine is regulated by thyroid-stimulating hormone (TSH), released by the anterior pituitary (that is in turn released as a result of TRH release by the hypothalamus). The thyroid and thyrotropes form a negative feedback loop: TSH production is suppressed when the T4 levels are high, and vice versa. The TSH production itself is modulated by thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus and secreted at an increased rate in situations such as cold (in which an accelerated metabolism

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would generate more heat). TSH production is blunted by somatostatin (SRIH), rising levels of glucocorticoids and sex hormones (estrogen and testosterone), and excessively high blood iodide concentration. Calcitonin An additional hormone produced by the thyroid contributes to the regulation of blood calcium levels. Parafollicular cells produce calcitonin in response to hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition to the effects of parathyroid hormone (PTH). However, calcitonin seems far less essential than PTH, as calcium metabolism remains clinically normal after removal of the thyroid, but not the parathyroids.

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PATHOPHYSIOLOGY HYPERTHYROIDISM Modifiable

Non-modifiable

Diet

Age

Lifestyle

• •

Heavy drinker Navy

Gender

Occupation

Health History

Increase TSH stimulation to the Pituitary Gland

Stimulation of Thyroid Hormone Increase in T3 and T4

Hormonal Imbalance Multi-system Changes

Physical

Enlarge Thyroid gland

Eyes

CV HR BP Respiratory System

Nutrition

Weight Loss Appetite

Musculoskeletal System

Psychological

Integumentary

Neurological

Sweating

Irritability

Anxiety Restless Fine Tremors

Insomnia Heat Intolerance

Exopthalmos RR

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CHAPTER IV PRESENTATION AND ANALIZATION OF DATA

DEMOGRAPHIC PROFILE Patient’s name: Mr. Bean Age: 28 yrs old Gender: Male Address: Habay Bacoor, Cavite Educational Attainment: College Graduate ( Nautical Engineering) Employment: Navy History of Present illness: Few months PTA the pt increased his appetite but he didn’t gain weight instead he lost some weight. He usually had an insomnia and restless on the rest of the day. He also experienced occasionally palpitation and fine tremors. Few days PTA the pt vomits all the foods he ate and experiencing fine tremors in his extremities. On the day of his admission he experience severe palpitation/ tachycardia and he felt lightheadedness and loss his consciousness that’s prompted his admission in one of the Tertiary Hospital in Cavite City.

History of Past Medical History The patient was a fully immunized child except measles and chickenpox and no allergy in any medicines. Patient had a primary KOCH’s during his childhood years but treated at 7 years old. The patient had different diseases during his childhood he had measles and chickenpox which prompted his several admissions to hospital.

Family History of

Mother Side: Hypertension and Diabetes Mellitus Father Side: Hypertension

Personal/ Social History He usually had sedentary lifestyle. He likes to eat cabbage very often and he did’t usually eat fish. He is an heavy alcohol drinker since he was in high school. He can drink up to 2 long necks of hard drinks like emperador.

Patient Clinical Record

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Final Diagnosis: Hyperthyroidism Chief Complain: Loss of consciousness Reason for Admission: For evaluation and management Date of Admission: November 20, 2008 Weight: BEFORE 60 kg

Height: 5’ 6”

AFTER 52 kg

BMI= wt. in kg/ (ht. in m)² General survey Receive patient alert, conscious, restless and coherent.

Review of System and Physical Examination

Dec. 3, 2008 Pulse: 120 bpm BP: 140/90 mmHg Temp: 36.5 ˚C RR: 27 cpm

Physical Assessment SKIN HAIR Areas to assess Characteristics

Findings Resilient, silky hair

SCALP Areas to assess

Findings

Characteristics

Shiny and smooth without lesions, masses or

Deformities

mumps No trauma deformities

Redness or scaliness

No redness or scaliness

SKULL

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Areas to assess

Findings

Characteristics

Rounded and smooth skull contour without any

Symmetry of facial features and movement

sings of enlargement. Symmetrical in facial features and movement

EYES Areas to assess

Findings

Characteristics

Pink conjunctiva, anicteric sclera

Symmetry of eye features and movement

Bilateral Exopthalmus; [+] PERRLA

NECK Areas to assess Symmetry

Findings Enlarged and palpable mass on anterior portion of the neck

Thyroid gland

Presence of mass during palpitation

Nails Areas to assess Capillary refill

Findings [-] slow capillary refill, [-] crushing pain

LUNGS Areas to assess Characteristics

Findings [-] wheezes, [-] masses, [-] cough.

Musculoskeletal Areas to assess Characteristics

Findings Fine tremors

Neurologic

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Areas to assess Characteristics

Findings Irritable and restless

ABDOMEN Areas to assess

Findings

Characteristics

[+] symmetrical, [-] bruit sound, [-] pain.

After physical assessment there was no abnormalities expect for resilient and silky hair, bilateral exopthalmus of his eyes, excessive sweating of his skin, enlarged and palpable mass on the anterior portion of the neck, fine tremors, irritable and restless.

Diagnostic Test Results Date: November 29, 2008 Examination/s Requested T3 T4 TSH

Results 7.98 33.81 0.04

Normal Values 2.2-6.8 pmol/L 10.3-25.74 pmol/L 0.3-5.0Uiu/ML

Interpretation Increased Increased Decreased

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Date: December 9, 2008 Examination/s Requested T3 T4 TSH

Results 7.7 29.8 0.1

Normal Values 2.2-6.8 pmol/L 10.3-25.74 pmol/L 0.3-5.0Uiu/ML

Interpretation Increased Increased Decreased

Results 7 26 0.2

Normal Values 2.2-6.8 pmol/L 10.3-25.74 pmol/L 0.3-5.0Uiu/ML

Interpretation Increased Increased Decreased

Date: January 15, 2009 Examination/s Requested T3 T4 TSH Interpretation The diagnostic result was increased T3 AND T4 this result indicate that the patient has a hyperthyroidism. TSH is low it also an indicative of hyperthyroidism.

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CONCEPT MAP

1.) Increase cardiac workload related to hypermetabolic state

6.) Disturbed body image related to disease process (hyperthyroidism)

5.) Disturbed sleep pattern related to daytime activity pattern

Patient’s name: Mr. Bean Age: 28 yrs old Gender: Male Increased appetite Heat tolerance Fatigue Anxiety Insomnia Bilateral exopthalmos Weight loss Restless Tremors (fine) Increase sweating Irritability Silky resilient hair Vital signs: PR: 120 bpm BP: 140/90 mmHg Temp: 36.5 °C RR: 27 cpm

2.) Imbalanced nutrition: less than body requirements related to hyper metabolic state secondary to excessive thyroid hormone secretion

3.) Anxiety (mild) related to increased stimulation secondary to excessive thyroid hormone secretion

4.) Fatigue related to increased energy requirements secondary to hypermetabolic state

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Interpretation of Concept Map 1.) The first priority nursing diagnosis is cardiac output; risk for decrease. Because of the heart inadequately pump blood to meet metabolic demands of the body. It should be prioritized based on the ABC principle (Airway, Breathing and Circulation). The heart inadequately pumped blood it results to inadequate oxygenation of the body. Which manifest the patient to restlessness, irritability, fatigue and with vital signs of BP 140/90 mmHg, PR 120 bpm and RR 27 cpm. Appropriate nursing interventions should be done for the patient to have adequate cardiac output (Blood pressure, pulse rate and respiratory rate) within normal parameters.

2.) The second priority nursing is imbalanced nutrition: less than body requirements. Because the patients body is having intake of nutrients insufficient to meet the metabolic needs of the body; which is cause by hyper metabolic state secondary to excessive thyroid hormone secretion. Nursing interventions needs to be formulated for the patient, to be able to consume adequate nourishment needed by the body based to patient’s weight age and height.

3.) The third priority nursing diagnosis is anxiety. Patient is irritable, has insomnia, intolerance to heat, restless, fatigue, has fine tremors, increased sweating, and has a respiratory rate of 27 cpm. Anxiety is an alerting signal that warns of impending danger and because of the formulated nursing interventions the patient will be able to take the verbalized feeling of anxiety and measures to deal with it.

4.) The fourth priority nursing diagnosis is fatigue. Based on the assessment done the patient is manifesting fine tremors, anxiety, increased sweating and verbalizing lack of energy with vital signs of pulse rate 129 bpm, blood pressure 140/90 mmHg and respiratory rate 27 cpm. Appropriate nursing interventions are necessary to increase energy and improved well-being of the patient. Because fatigue is an overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.

5.) The fifth priority nursing diagnosis is disturbed sleep pattern. Patient is verbally complaining of difficulty falling asleep and based on the assessment done he is irritable, have fine tremors and unilateral exopthalmos. Time- limited disruption of sleep this is what the patient experiencing. Which can affect the recovery of the patient that is, why necessary nursing interventions should be done.

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6.) The last priority nursing diagnosis disturbed body image. Disturbed body image means confusion in mental picture of one’s physical self. The patient is manifesting weight loss, unilateral exopthalmos, silky resilient hair and he is shy at first. That’s why necessary nursing interventions should be done for the patient to accept the change or loss and change in his lifestyle.

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Assessment

Subjective: “ madali nga ako mapagod” as verbalized by the patient Objective: -

Restless Irritability fatigue

Vital Signs:

-

BP: 140/90 mmHg

-

PR: 120 bpm RR: 27 cpm

Nursing Diagnosis Increased cardiac workload related to hypermetabolic as evidenced by increase blood pressure, pulse rate and respiratory rate

Planning

At 4 hours of nursing intervention the patient will be able to maintain adequate cardiac output as evidence by stable vital signs as follows blood pressure (from 140/90 to 120/80) , pulse rate (120- 60-100 bpm) and respiratory rate (2720bpm).

Intervention

Independent: • Monitor vital signs especially blood pressure •

Place the client in semiFowler’s position or position of comfort • Provide restful environment Dependent: • Maintain adequate nutrition and fluid balance as ordered by the physician ( low iodine and low root crops foods) Collaborative: • Administer Beta Blockers (Propanolol) Inderal as ordered).

Rationale

•

• •

May indicate compensatory changes in stroke volume Elevating the head may decrease cardiac work load Rest periods decrease oxygen consumption

•

To provide proper nourishment to the patient

•

Decreases heart rate/ cardiac work by blocking conversion of T3 to T4.

Evaluation

After 4 hours of rendering nursing intervention the patient was able to maintain adequate cardiac output as evidence by stable vital signs as follows blood pressure (120/80) , pulse rate (110 bpm) and respiratory rate (24bpm)

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Assessment

Subjective: “Pumayat talaga ako, maski malakas ako kumain, ganito siguro talaga pag may goiter” as verbalized by the patient Objective: -

Increased appetite Weight loss

(Weight before: 60 kg) (Weight now: 52 kg) -

Restless Irritability

Nursing Diagnosis

Planning

Imbalanced nutrition: less than body requirements related to hyper metabolic state secondary to excessive thyroid hormone secretion as evidenced by weight loss, restlessness and irritability.

At 4 hours of nursing intervention the patient will be able to consume adequate nourishment.

Intervention Independent: • Provided good oral hygiene before and after meals • Monitor food intake • Encourage patient to eat and increase meals and snaks with high calorie that are easily digested

•

Instruct the patient to avoid foods that increased peristalsis (eg. Tea. Coffee, fibrous and highly seasoned foods) and fluids that causes diarrhea (eg. Apple/ prune juice). • Provide relaxing and pleasant environment Dependent: • Determine healthy body weight for age and height

Rationale

•

To enhance client’s appetite and ability to eat

•

Continued weight loss in face of adequate caloric intake may indicate failure of antithyroid therapy. Keeping enough caloric intake aids in hypermetabolic state

•

•

It is increased GI motility may result in diarrhea and impair absorption of needed nutrients

•

To enhance the intake ability

•

To provide patient the appropriate diet

•

To meet energy requirements

Evaluation

After 4 hours of rendering nursing intervention the patient was able to consume adequate nourishment.

Collaborative: • Administer medication indicated

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(vitamin B complex)

Assessment

Nursing Diagnosis

Planning

Anxiety (mild) related to increased stimulation secondary to excessive thyroid hormone secretion as evidenced by irritability, insomnia, restlessness, tremors( fine), increased sweating, and increased respiration

At 8hours of nursing intervention the patient will be able to verbalize feelings of anxiety

Intervention

Rationale

Evaluation

Independent: Subjective: “ naiinip na ako dito” as verbalized by the patient Objective: Irritability Restless Fatigue Tremors (fine) Increased sweating Increased respiration (RR 27 cpm) -

• Observe behavior indicative of level of anxiety

•

Mild anxiety is manifested by irritability and insomnia

• Establish therapeutic relationship

• To have an open communication

• Stay with patient, maintaining calm manner. • Speak in brief statements, using simple words.

• To establish rapport.

• Provide comfort measures (putting up the bed siderails and don’t leave the client alone at bedside) • Encourage client to express feelings • Provide accurate information about the situation Dependent: • Review coping strategies or mechanism

After 8 hours of rendering nursing intervention the patient was able to verbalized feelings of anxiety

• Attention span may be shortened, concentration reduced, limiting ability to assimilate information. • To promote clients safety. • To know the coping strategy of the client • Helps the patient to know the realit • To determine those that might be helpful to the current situation of the patient

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Assessment Subjective: “eto madali ako mapagod” as verbalized by the patient Objective: -

Tremors (fine) Heat intolerance Restless Increased sweating

Nursing Diagnosis

Planning

Fatigue related to hypermetabolic state with increases energy requirements as evidenced by fine tremors, anxiety, incresed sweating with vital signs of pulse rate 120 bpm, blood pressure of 140,90 mmHg and respiratory rate of 27 cpm

At 8 hours of nursing intervention the patient will be able to verbalize increased energy and improve well-being

Intervention Independent: •

Monitor vital signs (especially pulse rate)

•

Provide quiet environment

•

Encourage patient to restrict activity and rest as much as possible

•

Provide diversional activities (e.g reading, radio, television)

Vital signs: PR: 120 bpm BP: 140/90 mmHg RR: 27 cpm

Rationale

• Evaluate need for assistance or assistive devices • Assist with self care needs; keep bed in low position and travel ways clear of furniture

•

To note if there is tachycardia or incresed in pulse rate

•

Reduces stimuli that may aggravate hyperactivity or to relief fatigue

•

Helps to counteract effects of increased metabolism

•

May reduce anxiety

•

To know what are the needs of the patient

•

For easy access and to avoid accidents

Evaluation After 8 hours of rendering nursing intervention the patient was able to verbalized increased energy and improved well-being

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Assessment

Subjective: “Hindi ako masyado nakatulog kagabi, kumakabog yung dibdib ko” as verbalized by the patient Objective: -

Irritability fatigue tremors (fine) Presence of eyebags on. Frequent yawning.

Nursing Diagnosis

Disturbed sleep pattern related to daytime activity pattern as evidenced by irritability tremors (fine) Presence of eye bags. Frequent yawning.

Planning Long Term: After 24 hours of nursing intervention the patient will be able to identify the different measures how to obtain a normal sleeping pattern evidenced by non- irritable, relax, and absence of eye bags, and no frequent yawning.

Intervention

Rationale

Independent: •

Provided quiet environment and comfort measures (e.g backrub, washing hands and face, cleaning and straitening sheets) in preparation to sleep.

•

To enhance client ability to fall asleep.

•

Recommended limiting intake of chocolate and caffeine/alcoholic beverages esp. prior to bedtime

•

Caffeine increases awaking time during the night. A full stomach interferes with sleep

•

Encourage the client to develop a bedtime ritual that includes quiet activities such as reading pocketbooks or watching television

•

Effective in inducing and maintaining sleep

•

To monitor clients sleeping pattern.

Evaluation Long Term: After 24 hours of rendering nursing intervention the patient was be able to obtained the different measures of an 8 hours normal sleeping pattern as evidenced by (-) irritability, relax, and minimal yawning.

Dependent: •

Obtain history including bed time routines

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Assessment Subjective: “Para nga ko si Garfield yung dalawa kong mata, ang laki.” As verbalized by the patient Objective: -

Bilateral exopthalmos Silky resilient hair Shy at first Weight loss

(Weight before: 60 kg) (Weight now: 52 kg)

Nursing Diagnosis Disturbed body image related to disease process (hyperthyroidism) as evidence by, bilateral exopthalmos.

Planning Long Term: After 2 days of nursing intervention the patient will be able to demonstrate acceptance of self image as evidence by interact with the nurse on duty, and student nurses

Intervention

Rationale

Independent: •

Encourage client to make own decisions and accept both inadequacies and strengths

•

Assess for and promote good nutrition and sleep patterns

•

Acknowledge coping mechanisms as a normal feelings when adjusting to changes in body and lifestyle

•

Encourage client to verbalize feelings

Dependent: •

•

•

For support to patient about his illness

•

Good nutrition and sleep patters promote faster healing and better coping

•

Assist the client to coping to renewed sense of well-being & increases trust between the nurse and patient.

•

To enhance coping or handling his situation

•

Social support enhances both emotional and physical health

•

To have acceptance and not embarrassed the patient when his appearance is affected

Encourage significant other to offer support Alert staff or significant others to monitor facial expressions and nonverbal behaviors

Evaluation Long Term: After 2 days of rendering nursing intervention the patient was able to accept self image as evidenced by interaction with the student nurses

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DRUG STUDY Name

Generic Name: methimazole Brand Name: Tapazole 10 mg Dose: 10 mg Route: PO Frequency: q6

Mode of Action

Increases metabolic rate, cardiac output and protein synthesis. Useful for treating thyrotoxic crisis and in preparation for subtotal thyroidectomy.

Indications

For treating Hyperthyroidism

Contraindications

Thyrotoxicosis, myocardial infarction and severe renal disease

Adverse Effects

Side effects: Nausea and vomiting, diarrhea, cramps, tremors, nervousness, insomnia, headache and weight loss

Nursing Interventions



Instruct patient to take the drug with meals to decrease gastrointestinal symptoms



Advise patient about the effects of iodine and its presence in iodized salt, shellfish and OTC cough medicines



Emphasize the importance of drug compliance; abruptly stopping the antithyroid drug could bring on a thyroid crisis



Teach patient the signs and symptoms of hypothyroidism: lethargy, puffy eyelids and face, thick tongue, slow speech with hoarseness, lack of perspiration and slow pulse. Hypothyroidism may result to treatment of Hyperthyroidism

Adverse Effects: Tachycardia, hypertension and palpitations

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Name

Generic Name: propanolol Hcl Brand Name: Inderal 20 mg Dose: 20 mg Route: PO Frequency: OD

Mode of Action

Selectively blocks beta  - adrenergic receptor sites, decreases sympathetic outflow to the periphery, suppresses renninangiotensinaldosterone system

Indications

To control hypertension and management for thyrotoxicosis

Contraindications

Second and Third degree heart block, cardiogenic shock, CHF, sinus bradycardia Caution: Hepatic, renal or thyroid dysfunction; asthma; peripheral vascular disease; type 1 diabetes mellitus

Adverse Effects

Side Effects: Bradycardia, thrombocytopenia, drowsiness, dry mouth and dizziness

Nursing Interventions



Monitor vital signs especially blood pressure and pulse



Instruct patient to comply with drug regimen: abrupt discontinuation of antihypertensive drug may cause rebound hypertension



Advise patient that antihypertensives may cause dizziness resulting from orthostatic hypotension. Instruct patient to remain in a sitting position for several minutes before standing

Adverse Effects: Complete heart block, bronchospasm, agranulocytosis

Encourage patient to increase fluid intake Instruct client to avoid excessive intake of alcoholic beverages. Alcohol can cause vitamin B complex deficiencies 

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Name

Mode of Action

Indications

Generic Name: Vitamin B Complex

Water- soluble vitamins are not stored in the body and are readily excreted in the urine. Protein binding of water – soluble vitamins is minimal.

To treat peripheral neuritis, essential for building block of nucleic acids, red blood cell formation and synthesis of hemoglobin

Brand Name: Nevramin Route: PO Frequency: OD

Contraindications

Patient with liver dysfunction

Adverse Effects

GI irritation and vasodilation, resulting in flushing sensation

Nursing Interventions



Instruct client to take the prescribed amount of drug.



Advise client to check the expiration dates on vitamin containers before purchasing and taking them. Potency of the vitamin is reduced after the expiration date.



Advise client to eat a wellbalanced diet that includes the recommended amounts and types of food detailed in the food pyramid



Encourage patient to eat foods high in Vitamin B such as grains, cereal, bread and meats



Instruct client to avoid excessive intake of alcoholic beverages. Alcohol can cause vitamin B complex deficiencies

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