Name: ABC Age/Gender: 57/ F Room & Bed #: ICU Room no.

11
Chief Complaint: Hot flashes Attending physician: Dr. Tutu, B.
Diagnosis: Thyroid crisis/ Thyroid storm

Date/Time Cues Need Nursing Objectives of care Nursing Intervention Implementation Evaluation
Diagnosis
A Decreased cardiac Wi th i n 8 h ou rs o f August 25, 2021
Objective: output related to n u rsi n g @ 3PM
A C
 SpO2 of 89% increased workload i n te rven ti o n , 1.) Administer medication
“Goal partially
U  O2 @ 15L/min T of the heart as p a ti en t wi l l be ab l e as ordered: propranolol, 1
met”
via mask evidenced by: to : methimazole, iodine.
G  CRT of 5 I R: A variety of
 SpO2 of 89% a ) De mo n stra te
U seconds V medications may
 O2 @ 15L/min vi ta l si g n s Within 8 hours of
 GCS: 3/15 prevent damage in the
S I via mask wi th i n nursing
 Thyroid blood vessels and
 CRT of 5 man a g ea b le intervention, the
T Function tests: T complications that may
seconds le ve l . patient was able
lead to heart attack and
Y  GCS: 3/15 to:
• T3: 250 ng/dl b ) Man i fe st CR T o f lowers thyroid hormone.
 Thyroid
2 (elevated) <2 se co n d s 2.) Monitor Glasgow coma a) Latest vital
Function tests:
• T4: 16 μg/dL scale and other neurologic signs:
5, (elevated) A c) In crea se assessment every hour 2
• T3: 250 ng/dl gl a sgo w co ma T-
• Free T4: 3 ng/dl N and compare findings and
(elevated) scal e fro m 3 to 37.2C
(elevated) report for any changes.
2 D • T4: 16 μg/dL 9. CR-
• TSH: 0.34 R: This is critical for
(elevated) 140 bpm
mIU/L identifying early signs of
0 • Free T4: 3 ng/dl PR-
(decreased) deterioration in patient's
(elevated) 132 bpm
2 E level of consciousness.
• TSH: 0.34 RR-
 Ultrasound: To identify changes or
1 X mIU/L 28 cpm
thyroid improvement in the
(decreased) BP- 140/90
enlarged @ E patient’s condition
8cm (enlarged) particularly the level mmHg
@ R  Ultrasound:
 ECG of consciousness. b) Develop
thyroid
7 interpretation: C 3.) Assess cardiovascular 3 CRT of 1.5
enlarged @
Atrial fibrillation status, an extra hearts
A  Vital signs as of I 8cm (enlarged) sounds, complaints of seconds.
7am:  ECG orthopnea or dyspnea
M S c) Glasgow
T-40 C interpretation: on exertion.
coma scale
CR- E Atrial fibrillation R: Prominent S1 and
of 6 and
180 bpm  Vital signs as murmurs are associated
remains
PR- of 7am: with forceful cardiac
below than
175 bpm T-40 C output of hypermetabolic
normal
RR- 33 CR- state; development of
range.
cpm 180 bpm S3 may warn of
BP- PR- impending cardiac
160/100 175 bpm failure.
mmHg RR- 33 4.) In cardiac arrest, call a 4
cpm code blue. Start Jessel D. Yu,
BP- compression. St.N
160/100 R: This helps keep
mmHg oxygenated blood
flowing to the brain and
other crucial organs
Rationale: until normal heart
The hemodynamic rhythm is restored.
alterations due to 5.) Regulate oxygen as 5
thyroid storm ordered by the
decrease physician
myocardial R: To ensure adequate
contractile reserve, oxygenation and avoid
precluding further hypoxia.
increases in 6.) Continuously monitor
ejection fraction ECG and ST segment.
and cardiac output R: To prevent changes 6
on exertion. in the ECG that can
adversely affect cardiac
output and ST segment
Reference: changes indicative of
myocardial ischemia.
7.) Monitor and record 7
Misra, M., MD.
changes in the vital
signs.
(2021b, April 2). R: Vital signs may be
elevated because of
Thyroid Storm: increased SVR.
8.) Place in a high fowler’s 8
Practice Essentials, position.
R: Elevating the head of
Pathophysiology,
the bed promotes
proper respiration and
Etiology. Thyroid
ventilation.
Storm. 9.) Check for calf
tenderness, swelling,
https://emedicine.m local redness, or pallor 9
of extremity.
edscape.com/articl R: Reduced cardiac
output, venous stasis,
e/925147- and enforced bed rest
increases risk of
overview#a5 thrombophlebitis. 10
10.) Monitor I&O.
R: Kidneys repond to
Herdman, T. H., &
reduced cardiac output
Kamitsuru, S.
by retaining water and
(2018). Nanda
sodium.
nursing diagnoses:
11.) Perform tepid sponge
definitions &
bath, provide cool
classification 2018-
environment, limit bed
2020. New York:
linens and clothes.
Thieme.
R: Fever may occur as a
result of excessive
hormone levels and can
aggravate diuresis and
dehydration and cause
increased peripheral
vasodilation and venous
.
References:

Effects of trunk posture in

Fowler’s position on

hemodynamics. (2016,

May 1). ScienceDirect.

https://www.sciencedire

ct.com/science/article/pii

/S156607021500003X

GP. (2016, June 9).

Endocrinology - The

thyroid and the heart.

GPonline.

https://www.gponline.co

m/endocrinology-

thyroid-

heart/cardiovascular-

system/cardiovascular-

system/article/995935

Misra, M., MD. (2021, April 2).

 Thyroid Storm

Medication:

Antithyroids, Iodides,

Beta- blockers,

Glucocorticoids.

Https://Emedicine.Meds

cape.Com/Article/92514

7-Medication.

https://emedicine.medsc

ape.com/article/925147-

medication

Nayyar, M. (2019, February

11). Thyroid storm.

Cancer Therapy

Advisor.

https://www.cancerthera

pyadvisor.com/home/de

cision-support-in-

medicine/hospital-

medicine/thyroid-storm-
 3/

R. (2017, July 3).

Thyrotoxicosis (Thyroid

Storm) Nursing Care

Plan & Management.

RNpedia.

https://www.rnpedia.co

m/nursing-

notes/medical-surgical-

nursing-

notes/thyrotoxicosis-

thyroid-storm/

CLUSTERING

Health Nutritional- Metabolic Elimination Activity- Exercise Cognitive-perceptual Sleep-Rest

Perception/Health
Management
O Diagnosed with o “Sge lang ko ug libang
hyperthyroidism 2 o  Nausea ug suka nurse.      Pag o   “Luya ko pirme og  RLS/GCS: 3/14 o   Verbalization of
two years ago human nako kaon kay taud sakit akong dughan”  nods as an answer “Wa koy gana ilihok,
o   Thyroid Function taud makalibang nako” as verbalized by the  Shakey voice when answering permanente nalang
Medications: tests: As verbalized by the patient patient o Kinsa man tung sigi ug sulod?” kapoy kaayo akung
o Methimazole frequently verbalized by the lawas” during
o Propranolol T3: 250 ng/dl (elevated) o Mura man kog ga interview
o Changes in bowel habits patient.
T4: 16 μg/dL (elevated) palpitate kanang
(diarrhea) o asa ko?” frequently verbalized by
Free T4: 3 ng/dl nay ga toktok sa o   Droopy eyes and
the patient.
(elevated) akung heart” as dark circles
o Has vomited 3x since o “Asa akong mama?” verbalized by
TSH: 0.34 mIU/L verbalized
(decreased) 6am (300mL) the patient. o   Restless
Tremors o Disorientation to person, place
o Temp– 38.9 C o Hyperactive bowel and time
sounds SpO2 of 89% o Memory deficit, altered attention
o Ultrasound: thyroid span, and decreased ability to
enlarged @ 8cm o Intake and Output as of o   O2 @ 15L/min grasp ideas
(enlarged) 8am: via face mask o Impaired ability to make decisions
Intake: 500mL Output: and problem solve
o Food intake: 950mL o ECG o Disordered thought sequencing
consumed the entire o Vomitus= 300mL interpretation: Atrial
meal served o  Stool and urine = 650mL fibrillation o   (+) abdominal pain
o   Pain scale: 1/3 (mild) given that:
 With good appetite o   CRT >5 0= no pain felt
but assistance when seconds  1= mild pain
feeding is needed 2 =moderate pain
o   ECG 3= severe pain
o Weight loss of interpretation: Atrial
5kgs in a week fibrillation

o BMI as of today:  CR – 180 bpm

Height: 5 feet and 4  PR – 175 bpm
inches  RR – 33 cpm
Weight: 41kg 
 BP – 160/100
BMI:   16.02
(Underweight)
o Rapid, bounding
o “Pag -abot namu radial pulse felt
dinhi dong pirte naman
o  Fatigue
ana niyang inita
 hangtud karon wala pa
gihapon mahuwasi”, as
verbalized by the
watcher

o “Murag naa koy

kalintura kay init man
kaayo akong paminaw.
Wala ko kasabot sa
akong gibati. Basta init
jud kaayo.” as
verbalized by a 57
years old female
patient.

o Skin is hot to touch 

o Facial and chest

flushing

Values-Belief  Role Relationship Sexuality-Reproductive Coping/Stress Self-Perception/Self-concept

Tolerance
o “Kusog man ko mukaon nurse, naa
o  Irritable pud koy gana inig mukaon ko pero
grabe  jud akong pagpayat. Normal
o “Ngano nag sige pa ba ni nurse?” as verbalized by the
man lang mog sulod patient
diri? nikuha naman
mog bp ganiha” as
stated during VS
taking

 Over reaction