Scenario You are working in a community outpatient clinic where you perform the

Question

Scenario
You are working in a community outpatient clinic where you perform the intake assessment on R.M., a
38-year-old woman who is attending graduate school and is very sedentary. Her chief complaint is overwhelming
fatigue that is not relieved by rest. She is so exhausted that she has difficulty walking to classes
and trouble concentrating when studying. She reports a recent weight gain of 15 pounds over 2 months
without clear changes in her dietary habits. Her face looks puffy, she has experienced excessive hair loss,
and her skin is dry and pale. She complains of generalized body aches and pains with frequent muscle
cramps and constipation. You notice she is dressed inappropriately warmly for the weather.

Chart View
Vital Signs (VS)
Blood pressure (BP) 142/84mm Hg
Heart rate 52 beats/min
Respiratory rate 12 breaths/min
Temperature 96.8° F (36° C)

Compare her VS with those of a healthy person her same age.

List eight general questions you might ask R.M. to assist in determining what is going on.

You know that potential causes for some of R.M.'s symptoms include depression,
hypothyroidism, anemia, cardiac disease, fluid and electrolyte imbalance, and allergies. As
part of your screening, describe how you would begin to investigate if any of these conditions
explain R.M.'s symptoms.

What diagnostic tests are the most appropriate for R.M., and why?

Chart View
Laboratory Test Results
Thyroid-stimulating hormone (TSH) 20.9mU/L (2-10mU/L)
Thyrotropin-releasing hormone (TRH) 18.8ng/dL (2-10ng/dL)
T3 24mU/L (70-205ng/dL)
Free T4 0.2ng/dL (0.8-2.4ng/dL)

5. Interpret R.M.'s laboratory results

6. The practitioner affirms a diagnosis of hypothyroidism. With this diagnosis, what other signs
and symptoms would you want to assess for in R.M.?

7. The practitioner prescribes levothyroxine (Synthroid) 1.7 mcg/kg body weight per day. At
this time, R.M. weighs 130 pounds. What should be her daily dose of levothyroxine in
milligrams? How would her prescription read?

8. What general teaching issues will you address with R.M. concerning hypothyroidism?

9. What teaching needs will you review with R.M. with regard to her medication?

10. What should you teach R.M. regarding prevention of myxedema coma?

11. Which statements indicate R.M. understands your teaching regarding hypothyroidism and
using Synthroid? Select all that apply.
a. “It may take several weeks before I feel better.”
b. “The best time to take my medicine is with breakfast.”
c. “If my heart rate is over 100, I will hold my medication until it is back below 100.”
d. “I will be able to discontinue my medication after the symptoms are under control.”
e. “I will come in when you need me to so my blood levels can be checked to make sure the
medicine is working.”

12. Before R.M. leaves the clinic, she asks how she will know whether the medication is “doing its
job.” Outline simple expected outcomes for R.M

13. A few weeks later, R.M. calls the clinic stating she cannot remember whether she took her
thyroid medication. What additional data should you obtain, and how would you advise her?

Case Study Outcome
R.M. comes in 2 months later for a follow-up visit. You cannot believe she is the same person. She looks
and walks as if she were 10 years younger. Her skin appears more radiant, and her hair looks much healthier.
“You can't believe how different I'm feeling,” she says. “I didn't know how bad off I was; I'm starting to
live again

Antithyroid/Throid Replacement Medications

Methimazole

Propylthiouracil

Levothyroxine

Liothyronine

Potassium Iodide (SSKI)

The Nursing Process

What nursing assessment will you perform regarding each medicaton?

What planning and implementation do you need to do for each medication?

How would you evaluate the effictiveness of each medication?

Explanation / Answer

Vital signs comparison

In normal adult,

BP average is 120 / 80, but for R. M systolic pressure is elevated.

Heart rate 60 - 100 is normal, itsi reduced for her.

Respiratory rate - 12 - 20(avg. 18) it falls under lower range of normal.

Temperature - 98.6 is normal orally. So she has lower body temperature

Eight general questions

Investigation and diagnostic tests relating to R.M complaints are complete blood count, thyroid function test. As the presenting complaints, age and gender of the patient supports more towards hypothyroidism.

5. Lab results show elevated TSH,TRH levels and reduced T3, T4 levels thus confirming hypothyroidism.

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