NURSING CARE PLAN
ASSESSMENT
Subjective: “Madali akong mapagod, pakiramdam ko hinag hina ako (I
get tired easily and I feel very weak)” as
DIAGNOSIS
Fatigue related to hypermetabolic state with increased energy requirements.
INFERENCE
Hyperthyroidism is an over production of thyroid hormone, which creates far reaching metabolic effects. Hypertrophy and hyperplasia of the thyroid gland occur with increased vascularity. Most of the clinical manifestations result from increased metabolic rate, excessive heat production, increase neuromuscular and cardiovascular activity, and hyperactivity of the sympathetic nervous system. The condition is more often in women than men and occurs in several form.
PLANNING
After 8 hours of nursing interventions, the patient will display improved ability to participate in desired activities.
INTERVENTION
Independent: • Monitor vital signs, noting pulse rate at rest and when active. •
RATIONALE
Pulse is typically elevated and, even at rest, tachycardia (up to 160 beats/min) may be noted. Oxygen demand and consumption are increased in hypermetabolic state, potential risk of hypoxia with activity. Reduces stimuli that may aggravate agitation, hyperactivity and insomnia. Help counteract effects of increased metabolism. May decrease nervous energy, promoting relaxation. Increased irritability of the CNS may cause patient to be easily excited,
EVALUATION
After 8 hours of nursing interventions, the patient was able to display improved ability to participate in desired activities.
verbalized by patient. Objective: • • • • Decreased performance. Jittery behavior. Irritability V/S taken as follows: T: 37.1 P: 108 R: 22 Bp: 120/80
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Note development of tachypnea, dyspnea, pallor, and cyanosis.
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Provide quiet environment, cool room, decreased sensory stimuli, soothing colors, quiet music. Encourage patient to restrict activity and rest in bed as much as possible. Provide comfort measures like judicious touch and cool showers. Avoid topics that irritate or upset the patient. Discuss ways to respond to these feelings.
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agitated, and prone to emotional outburst. Collaborative: • Administer medications as indicated like sedatives. •
To combat nervousness, hyperactivity, and insomnia.