Scenario

K.B. is a 65-year-old man admitted to the hospital after a 5-day episode of “the flu” with
complaints of dyspnea on exertion, palpitations, chest pain, insomnia, and fatigue. K.B. was
diagnosed with Graves’ disease 6 months ago and placed on methimazole (Tapazole) 15mg/day.
His other past medical history includes heart failure and hypertension requiring
antihypertensive medications; however, he states that he has not been taking these medications
on a regular basis. Vital signs (VS) are: 150/90, 124 irregular, 20, 100.2 °F (37.9° C). Admission
assessment findings are: height 5ft, 8 in; weight 132lb; appears anxious and restless; loud heart
sounds; 1+ pitting edema noted in bilateral lower extremities; diminished breath sounds with
fine crackles in the posterior bases. K.B. begins to cry when he tells you he recently lost his wife;
you notice someone has punched several more holes in his belt so he could tighten it.

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1. Which of K.B.'s assessment findings represent manifestations of hypermetabolism?

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Bp pulse, high temp, tachypnea, anxiety, insomnia restlessness,

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2. Interpret K.B.'s laboratory results.

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T3 and T4 are elevated

BUN- elevated, impaired kidney function from dehydration from increased metabolic state
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ESR- elevated from inflammation for infection or tissue necrosis

HGB, HCT low caused by hypermetabolic state

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 3. You go to assess K.B. What additional data do you need to obtain because he has Graves’
disease?
Goiter
N/V- nutritional status
Ask about chest pain or feeling palpitations
SOB?

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Changes in bowel habits?

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Increased DTR

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Tremors

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Bulging eyes, blurred vision rs e
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Diaphoresis
Changes in hair skin and nails
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Th
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 4. The physician writes these admission orders. Which will you question, and why?

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Why are we giving lasix if he is dehydrated?- because of his heart failure

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We want on bedrest to decreases his metabolic demand

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Fluids going at 125/hr is fast for someone with heart failure
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Propranolol and verapamil will worsen his heart failure
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5. Describe four priority problems related to K.B.'s nursing care.

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Weight gain
Arrhythmias
Hyponatremia
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Decreased CO
Inadequate oxygenation
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Activity intolerance
Th
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 Case Study Progress
Later on your shift, you note that K.B. is extremely restless and disoriented to person, place, and
time. VS are 174/82, 180 and irregular, 32 and labored, 104° F (40° C). His electrocardiogram
(ECG) shows atrial fibrillation.
6. What is likely happening with K.B.? State your rationale.
Thyroid crisis/storm because of his metabolic demand is increased

7. What will you do first?

Call RRT and put oxygen

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8. You need to call the physician regarding K.B.'s status. Using SBAR, what will you report to
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the physician?
Vitals are 174/82, pulse is 180 and irregular, ECG show A fib, temp of 104. Patient came in with
graves’ disease and is presenting with thyroid storm symptoms. Can we get something to lower
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heart rate and blood pressure. Can you come assess the patient.
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Case Study Progress

The physician evaluates K.B. and determines he is in thyroid crisis. The physician's orders are
shown in the chart.
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9. Describe how you would care for K.B. in the next hour

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Give Tylenol, give the digoxin, watch oxygen saturation, watch heart rate while giving Cardizem,
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initiate bedrest immediately.
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10. The label on the vial of diltiazem (Cardizem) states that there are 5mg/mL. How many total
milliliters will you administer for the first dose? How many for the second (if needed)?
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3 mL
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11. Describe how to safely administer Lugol’s solution.

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Use straw to avoid teeth

Dilute in water or juice to disguise the taste

12. What is your primary nursing goal at this time?

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 Decrease the effects of thyroid storm while promoting cardiac function

13. Describe six interventions you will perform over the next few hours for K.B. based on this
Priority
- Monitor heart and blood pressure
- Monitor temp
- Monitor neuro status
- Administer pain medication
- Increase fluids
- Monitor labs

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14. Why was K.B. at risk for developing thyroid storm?
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Wasn’t taking medication

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Has been sick lately

Suffered from the death of his wife (stress)
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15. Identify three outcomes that you expect for K.B. as a result of your interventions.
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Pain controlled
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Vitals stable
Maintain cardiac output
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Edema absent
Lung clear

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 Case Study Progress
After several hours of treatment, K.B.'s condition stabilizes. The physician discusses two
treatment options with K.B. and his family: radioactive iodine (RAI) therapy, also known as I-
131, and subtotal thyroidectomy.
16. K.B. is fearful of radiation treatment and asks you for your opinion. How would you
respond?
You should not make a recommendation, ask them to share their fears and clarify any
misconception, provide accurate information. Educate but don’t sway.

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17. K.B. decides to receive RAI. During pretreatment instructions, the family asks whether he
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will be radioactive and what precautions they should take. Outline important guidelines for
instructing K.B. and his family regarding home precautions.
He won’t be radioactive for 48-72 hours but his secretions and bodily fluids will be, avoid close
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contact, don’t share utensils, do laundry separately, flush toilet twice after each use for 48
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hours, don’t kiss or hold baby for up to 72 hours.

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18. In the midst of all this, you remain concerned over K.B.'s bereavement after the loss of his
wife. How would you address this issue?

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 Group therapies or support group
Find activities that he is interested
Help identify coping mechanisms

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19. K.B. does have some exophthalmos and is experiencing periodic photophobia and dry eyes.

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What should you include in teaching him how to manage these problems? Select all that apply.

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a. Wear sunglasses at all times when outside.

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b. Report any changes in vision to the physician.
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c. Use artificial tears to provide moisture as needed.
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d. Tape the eyes closed at night with nonallergenic tape.
e. Apply warm compresses to the eyes if they are irritated. (cold not warm)
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20. Which statement indicates K.B. understands the discharge instructions?

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a. “I will take this medication on a full stomach.”

b. “If I get a sore throat, ice chips should help me feel better.”
c. “I should see an improvement in my symptoms by tomorrow.”
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d. “I will follow the precautions for 2 weeks to keep my family safe.”

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Case Study Outcome

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Six months later, K.B.'s heart rate, blood pressure, and thyroid hormone levels are within normal
limits. He has gained 14 pounds and has started walking in the mornings without any dyspnea.
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He says he has started to do woodworking and has been doing some volunteer work at the
senior center.
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