NU272 HESI Case Study: Thyroid Disorders (week 4)

The client's dose of levothyroxine is increased, and arrangements are made for a home health nurse to assess her weekly for 4 weeks. During one of the home visits, the client talks with the nurse about her dietary intake. She said she has been reading online about her diagnosis. The client asks the nurse if she should take supplemental iodine tablets as a preventive measure for her hypothyroidism.

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With early recognition and intervention, the client only spends two nights in the hospital and recovers quickly, but she is concerned about this event occurring again. She asks what causes this condition.

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Prior to the administration of each dose of levothyroxine, it is important to obtain which assessments? (Select all that apply. One, some, or all options may be correct.)

Administer the medication prior to eating breakfast. (The medication should be administered on an empty stomach prior to breakfast.) Ensure that the heart rate is less than 100.(If the heart rate is 100 or greater, the medication should be held and the HCP should be notified.)

The client reports to the nurse that she took an antidepressant for several months and because of how she's feeling, she'd like to restart her medication. Which is the most important advice by the nurse?

Advise her to check with the HCP first. - Sedatives can increase the sensitivity to hormone replacement therapy. These medications should only be used if approved by the HCP.

The client also panics and admits to the nurse that she can't remember if she took her pill this morning. It is about 2 pm in the afternoon. Which information is important for the nurse to provide to the client?

Advise the client that she will notify the HCP to call her with further instruction.

The client asks the nurse how she got this disease. Which explanation by the nurse is accurate?

An autoimmune dysfunction causes thyroid dysfunction. The most common cause of hypothyroidism in adults is autoimmune thyroiditis (Hashimoto's disease) in which the immune system attacks the thyroid. More than 95% of clients either have primary or thyroidal hypothyroidism which refers to dysfunction of the thyroid itself.

Which information in the client's history would be of concern to the nurse related to the use of levothyroxine?

The client takes a daily calcium supplement. - Calcium should be taken at least four hours after the Levothyroxine dose to prevent interference with absorption.

Meet the Client

The client works full time as a high school math teacher. She is currently working on a specialist degree, taking night classes at one of the local colleges. She noticed that she is more sluggish than normal. She doesn't have the energy for girls' nights out anymore, and for the past 4 months, she has not attended her exercise classes. The client gained 10 pounds in the past 4 to 6 months. Her friends say she acts depressed and encouraged her to see a healthcare provider (HCP) so she makes an appointment with the HCP.

Home Health Care/Nursing Diagnoses

The home health nurse is developing a plan of care with the client until the new dose of levothyroxine controls her symptoms.

Which is the best response for the nurse when instructing the client about the use of supplemental iodine?

The use of salt with iodine and a well-balanced diet should provide adequate iodine. - Moderate salt intake with a proper diet provides adequate iodine intake.

The client tells the nurse she has a hard time taking medications regularly. She asks how long she will need to take the Levothyroxine. What is the nurse's best response?

You will need to take this medication for the remainder of your life.

What information should the nurse provide as a potential cause of a myxedema crisis?

Contracting the flu. - Viral infections can be a trigger for a myxedema crisis. Other triggers include the use of drugs (such as opioids, tranquilizers and barbiturates), exposure to cold, and trauma.

Which diagnosis would be included in the plan of care?

Decreased cardiac output. - Decreased heart rate and force of contraction can lead to symptoms of diminished cardiac output.

At the two week visit, the client and the nurse have more discussions about her dietary intake. The nurse knows that the client understands her dietary needs when she makes which statement?

"Foods that I should include in my diet include tuna, yogurt, and macaroni." - All of these foods are good sources of iodine.

The client's presenting vital signs: Temperature: 96.0° F (36.0° C) Pulse: 52 beats/minute Respirations: 18 breaths/minute Blood pressure: 140/80 mmHg Given the initial history and vital signs, what other questions should the nurse ask? (Select all that apply. One, some, or all options may be correct.)

"Have you had any changes in your bowel habits?" "Do you still feel sleepy when you wake up in the mornings despite getting a good night's sleep?" "Have you noticed any changes in your hair or nails?" - Hypothyroidism can cause constipation.Hypothyroidism can cause sleep disturbances.Hypothyroidism can cause hair loss and brittle nails.

Which is the best response by the nurse?

"It sounds like that was a very frightening experience for you." - The best response is to acknowledge and support Eugena's fears and concerns. This is an open-ended statement that will encourage Eugena to continue to express her fears. Submit

What is the client'sdaily dose of medication? (Enter numerical value only. If rounding is necessary, round to the hundredth.)

150 lbs = 68.18 kg 68.18 x 1.7 mcg = 115.9 115.9 mcg/1000 = 0.115 mg

Based on the client's history and presenting symptoms, which additional diagnostic tests does the nurse anticipate the HCP to order?(Select all that apply. One, some, or all options may be correct.)

CBC with differential. (The HCP needs to rule out other possible causes of the client's symptoms which could include anemia or an infection.) Blood Chemistries.(Chemistries would be needed to evaluate the client's electrolyte and fluid status.) TSH and free T4. (These indicate the functioning or non-functioning of the thyroid gland.)

Diagnostic Tests

The client is scheduled for a radioactive iodine uptake test. This test is used to measure the rate of iodine uptake by the thyroid gland. She is also scheduled for a thyroid scan.

The client has signed the consent for the radioactive iodine uptake test. What are the most important assessments for the nurse to obtain prior to the test? (Select all that apply. One, some, or all options may be correct.)

Ask if the client has been taking any OTC medications such as cough syrups? (Many OTC cough medications contain some iodine. There may not be enough to interfere with the test results, but the information needs to be assessed.) Investigate the client's use of over the counter (OTC) multivitamin and herbal products.(Many OTC multivitamins contain some iodine. There may not be enough to interfere with the test results, but the information needs to be assessed.) Find out if the client has ever had a reaction to a bee sting.(Allergic reactions to bee stings and shell fish should be assessed.)

Upon admission, the nurse should give the highest priority to meeting which need of a client who is brought to the ED with Myxedema crisis? (Select all that apply. One, some, or all options may be correct.)

Assess cardiac system.(Myxedema crisis is life threatening. It is imperative to monitor for circulatory collapse.) Start an IV of Normal Saline at prescribed rate. (This action is priority to prevent circulatory collapse.) Cover the client with warm blankets.(Hypothermia is a common symptom with myxedema crisis.)

The client has been doing well with her medication regimen at home. She has been on the levothyroxine about 3 weeks, and she is continuing to work and trying to finish the current semester of school. She has a follow up appointment in 6 weeks with her HCP.

During week four, the client begins to feel bad. She has a cough and a low grade fever. She treats her symptoms with an OTC medication, but her symptoms worsen. She is diagnosed with the flu and after 3 days she still feels bad. She calls a colleague to take her to the local emergency department (ED). Upon arrival, she is lethargic but arousable. She tells the nurse she was recently diagnosed with hypothyroidism.

Which behavior indicates to the nurse that the client understands the instructions related to the new medication?

Eugena states that she will need to notify the HCP of any chest pain. - Chest pain can indicate a problem with the cardiovascular system. Clients should be instructed to monitor their pulse and to report tachycardia, an irregular pulse, or palpitations to the HCP.

Other therapies for myxedema crisis include maintaining a patent airway, administration of IV levothyroxine sodium, IV glucose, and IV corticosteroids. Nurses should continue to monitor the vital signs, especially the blood pressure, heart rate and temperature hourly until stable.

Eugena's blood gases are as follows: pH: 7.33 pCO2: 50 PaO2: 99 HCO3: 24

Thyroid scans are one means of evaluating the thyroid gland for presence of a nodule. Scanning also demonstrates the size, shape, function, and position of the thyroid gland. Radioactive iodine is administered PO or parenterally, and the uptake of the iodine by the thyroid gland is measured. Clients with hypothyroidism will demonstrate a decreased uptake of the radioactive iodine.

Further physical examination reveals a slight obesity with a BMI of 27. While assessing the thyroid gland, the nurse finds a goiter. Goiter is the term for an enlarged thyroid gland. Depending on the cause of the hypothyroidism, the client may have a goiter. A goiter can also be present with hyperthyroidism. Lab results indicate mild anemia and a TSH that is 20 (normal is 0.5 to 5.0 microunits/mL).

At her six week appointment, The client reports of fatigue, some increasing constipation, and weight gain. Her serum TSH level is still elevated. Based on the clinical manifestations and lab results, what change in medication should the nurse anticipate?

Increase her dose of levothyroxine. - The client is still exhibiting symptoms of hypothyroidism, which will require an increase in her dose of levothyroxine. Her dose will be increased as needed.

Which approach by the nurse describes the action of the levothyroxine?

Increases fat, protein, carbohydrate metabolism. - The action of levothyroxine is the same as endogenous thyroid hormone. The drug increases the metabolic rate (increased oxygen consumption, respiration and heart rate) and increases the rate of fat, protein, and carbohydrate metabolism. It promotes growth and maturation.

Pharmacologic Management

Medical treatment for hypothyroidism is based on replacement therapy. The HCP will monitor the client's goiter for now. The primary medication used to treat hypothyroidism is levothyroxine sodium. The HCP prescribes 1.7 mcg/kg body weight/day. The client weights 150 lbs.

Based on the diagnosis of hypothyroidism, what condition does the nurses suspect the client is experiencing?

Myxedema crisis. - Myxedema is a rare life threatening condition that is a decompensated state of severe hypothyroidism.

Based on the nurse's assessment of these labs which finding accurately describes the results?

Respiratory acidosis.

Which symptoms are the client with hypothyroidism most likely to exhibit? (Select all that apply. One, some, or all options may be correct.)

Somnolence and fatigue. (Hypothyroidism generally causes an individual to have decreased initiative, somnolence, slowed speech, fatigue and lethargy.) Coarse dry skin. Somnolence and cold intolerance.

On the fourth week visit, the nurse recognizes that the client is improving when she assesses which of the following? (Select all that apply. One, some, or all options may be correct.)

The client has lost 5 pounds. (Weight gain is a symptom of hypothyroidism. Weight loss is a sign of improvement of thyroid function.) The client reports that she has begun walking around the track twice a week.(Increased energy level is sign of improved thyroid function. Hypothyroidism causes decreased energy levels.) The client reports that her bowel habits have returned to normal.(Hypothyroidism causes constipation. As the thyroid improves, bowel habits should return to the client's baseline.)

Which instructions should the nurse include when teaching the client about levothyroxine sodium? (Select all that apply. One, some, or all options may be correct.)

This medication requires periodic lab work to monitor levels. (This is a true statement. TSH levels are monitored periodically (usually every 4 to 6 weeks) to monitor levels and adjust medication dose accordingly.) Report chest pain, a rapid heartbeat, or increased nervousness to the HCP. (These are signs/symptoms that should be reported to the HCP. These are symptoms that could indicate an adverse reaction.) Wear a medical alert bracelet. (This is an important safety factor for the client.)

Based on the health care provider's (HCP) assessment and interpretation of the diagnostics, the client is diagnosed with hypothyroidism. Which other lab should be monitored after the diagnosis of hypothyroidism is confirmed?

Triglycerides and cholesterol. Hypothyroidism can cause increased triglyceride and cholesterol levels, leading to coronary atherosclerosis.