Francisco, Krisianne Mae L.

BSN III B (group B3)

Hypothyroidism

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Independent  
“Hindi naman po ako Imbalanced After 4 hours of  Monitor daily food intake. Weigh  To attain baseline data After 4 hours of nursing
malakas kumain ang nutrition: More nursing daily. and determine changes. intervention, the client
ko pero napapansin ko than body intervention, the demonstrated
po nadadagdagan ang requirement client will interventions and lifestyle
aking timbang related to greater demonstrate  Provide assistance and  Due to a decrease in changes to improved
Objective intake than interventions and encouragement as needed during energy levels, the client nutritional status as
 progressive weight metabolic needs lifestyle changes to mealtime. will need support to evidenced by eating six
gain of 20 pounds in 1 as evidenced by improved nutritional ensure the adequate small meals, eating foods
year progressive status. intake of essential rich in fiber and
 puffy face weight gain and Dependent nutrients. maintaining low-
 thyroid gland is not decreased cholesterol, low-calorie,
palpable appetite.  Administer medications as  For the medical low-saturated-fat diet.
 constipation indicated: Levothyroxine 50mg tab management of Goal met.
OD  hypothyroidism.
Vital signs:
 BP: 110/60 mmHg Collaborative  Teaching the client and
 PR: 58 bpm  Educate the client and family family will make them
 Temperature: 96.8oF regarding body weight changes in understand the opposite
Laboratory result hypothyroidism. relationship between
 Decreased serum T4 appetite and weight
concentration (3.8 gain in hypothyroidism.
ug/dl)
 Increased TSerum  Collaborate with a dietician to  The dietician can
Cholesterol (255 determine client’s caloric needs. calculate the
mg/dl)
 Encourage the relatives to provide
client six small meals throughout
the day.
 Advise the intake of foods rich in
fiber.
 Instruct the client and the family
members to follow a low-
cholesterol, low-calorie, low-
saturated-fat diet.
appropriate caloric
requirements to
maintain nutrient intake
and achieve a stable
weight.
 This will make sure that
the client has an
adequate intake of
nutrients in the client
with decreased energy
levels.
 Hypothyroidism slows
the action of the
digestive tract
causing constipation.
 When thyroid hormone
levels are low, the body
doesn’t break down and
remove bad cholesterol
as efficiently as usual;
And, since the client
has a slow metabolism,
he/she requires fewer
calories to support the
metabolic need
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Independent  
“Nanghihina po ako” Fatigue related to After 4 hours of  Assess the client’s ability to  The client may After 4 hours of nursing
Objective impaired nursing perform activities of daily living experience fatigue with intervention, client
 postural dizziness metabolic state as intervention, client (ADLs). minimal exertion due to verbalized a reduction of
 slow speech evidence by will verbalize a a slow metabolic rate. fatigue as evidenced by
 deep tendon reflex postural dizziness reduction of fatigue. This symptom hinders normal posture. Goal met.
time is delayed and slow speech. the client’s ability to
 pale, cool, dry, and perform daily activities.
thick skin
 thyroid gland is not  Assess the client’s energy level  A slow metabolism can
palpable and muscle strength and muscle result in decreased
tone. energy levels. The
Vital signs: muscle may be weaker
 BP: 110/60 mmHg and joints stiffer due to
 PR: 58 bpm mucin deposits in joints
 Temperature: 96.8oF and interstitial spaces.
Laboratory result This type of cellular
 Decreased serum T4 edema may contribute
concentration (3.8 to delayed muscle
ug/dl) contraction
 Increased TSerum and relaxation. The
Cholesterol (255 client may report
mg/dl) generalized weakness
and muscle pain.

Dependent
  Administer medications as
indicated: Levothyroxine 50mg tab
OD  hypothyroidism.
Collaborative
 Educate the client and family
regarding body weight changes in
hypothyroidism.
 Collaborate with a dietician to
determine client’s caloric needs.
 Encourage the relatives to provide
client six small meals throughout
the day.
 Advise the intake of foods rich in
fiber.
 Instruct the client and the family
 For the medical
management of
 Teaching the client and
family will make them
understand the opposite
relationship between
appetite and weight
gain in hypothyroidism.
 The dietician can
calculate the
appropriate caloric
requirements to
maintain nutrient intake
and achieve a stable
weight.
 This will make sure that
the client has an
adequate intake of
nutrients in the client
with decreased energy
levels.
 Hypothyroidism slows
the action of the
digestive tract
causing constipation.
 When thyroid hormone
members to follow a low-
cholesterol, low-calorie, low-
saturated-fat diet.
levels are low, the body
doesn’t break down and
remove bad cholesterol
as efficiently as usual;
And, since the client
has a slow metabolism,
he/she requires fewer
calories to support the
metabolic need