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I.

Introduction This is a case of a 22 year old male with a chief complaint of anterior neck enlargement associated with lower extremity weakness , occasional palpitation, increased perspiration, feeling of warmth and difficulty swallowing. Went to the hospital for scheduled surgical operation. Vital signs taken will a result of BP-140/90 mmHg, PR- 90 bpm ,RR- 21 bpm , temperature- 37 degrees Celsius. Hyperthyroidism is excessive thyroid hormone secretion from the thyroid gland .The manifestations of hyperthyroidism is called thyrotoxicosis, regardless of the origin of the thyroid hormone. Thyroid hormones affect metabolism in all body organs .The excessive thyroid hormones stimulates most body systems, causing hypermetabolism and increased sympathetic nervous system activity. Many of the manifestations are caused by the bodys response to the demands of hypermetabolism like increased systolic blood pressure, cardiac output , blood flow caused by increased heart rate and stroke volume. ( Workman, Ignativicius Medical Surgical Nursing 6th Edition ,Volume 2 )

The student nurses chose this case because they find it interesting .Also in the exposure in the Surgical Ward most of the scheduled operation were thyroidectomy. And the student nurses became interested because according to statistics it is diagnosed most often to women about ten times more often than men, but in this case the patient was a male. The student nurses also want to apply and

appreciate the nursing process especially the assessments. Not only theoretically, but also to apply nursing care such as infection control, alleviating anxiety and pain management .After this case study, the student nurses will be able to understand the pathophysiology of hyperthyroidism and to know the correlation of each drug to the case.

II.DEMOGRAPHIC DATA Name: E. A. P. Age: 22 years old Date of Birth: June 11, 1990 Address: B6L1-b Model Community Quezon St., Tondo Manila Marital Status: Single Religion: Roman Catholic

III. NURSING HISTORY The history was obtained from the patient. History of Present Illness Before admission, November 2011 the patient noticed he noticed anterior neck enlargement , occasional palpitation, and feeling of warmth. The patient self medicated with

medications recommended by neighbors but there was no improvement and the patient cant recall the name of the medication. May 2012, the patient noticed the mass became larger and it was accompanied by lower extremity weakness, palpitation, feeling of warmth and increase in perspiration .The patient also experienced occasional difficulty swallowing. The patient Self medicated with methimazole with different frequency. June 2012, patient had persistent lower extremity weakness. The patient consulted at MJH ER and was admitted for four days with the diagnosis of toxic goiter. August 2012 The patient had follow up check- up and was advised for admission at surgical unit and was scheduled for operation. Past Medical History This was the clients first hospitalization and operation. Family History With History of Allergy to Drugs Tapdin With History of Allergy on unknown Cause

Social History Smoker for five years, consumed six sticks a day Occasional alcoholic beverage drinker Out of school youth

IV. GORDONDS FUNCTIONAL HEALTH PATTERN 1. Health Perception Health Management Pattern Para sa akin masasabing malusog ang tao kapag wala siyang nararamdamang kakaiba at kapag nagagawa niya ng maayos ang mga gawain niya sa araw-araw Nahihirapan na ako dahil dito sa kondisyon ko ang pakiramdam ko ang bigat ng leeg ko. Madalas din akong nanghihina, pinagpapawisan at bumibilis tibok ng puso ko Do not take vitamin C.

2.Nutritional Metabolic Pattern Mahilig ako sa mga seafoods dati at sa mga inihaw na binebenta sa labas Siguro nakakaanim na baso ako ng tubig sa isang araw, minsan nagsosoftdrinks ako Medyo humina akong kumain kasi nitong mga nakaraang buwan nahihirapan akong lumunok

3.Elimination Pattern

Normal naman iyong pag-ihi ko , pero napansin ko napadalas iyong pagdumi ko kesa dati.Kung dati isang bese lang sa isang araw nagyon dalawa hanggang tatlong bese na Napansin ko din mas pawisin ako kesa dati. Kahit hindi naman masyadomg mainit ako pawis na pawis

4. Activity-Exercise Pattern Sa bahay lang ako o kaya naman sa bahay ng barkada hindi na kasi ako nag aaral. Siguro ang exercise ko na iyong paglalakad kapag minsan pumupunta ako sa tindahan.

5.Sleep and Rest Pattern Mga 11 ng gabi tulog na ako tapos ang gising ko na mga 8 na ng umaga Minsan kapag wala akong ginagawa natututlog ako ng tanghali matapos kumain

6. Cognitive-Perceptual Pattern Malinaw pa mata ko at maayos pa din pandinig ko The patient was slightly anxious because of his upcoming operation Can speak Filipino and English

7. Self Perception/Self-Concept Ang nagpapalungkot lang sa akin itong kondisyon ko at iyong nakaraan kong relationship Medyo mahiyain ako, ayokong nagsasalita sa harap ng madaming tao

8.Role-Relationship Pattern Kasama ko mama at papa ko sa bahay pero hindi kami masyadong close, hindi kasi ako masyadong nag oopen sa kanila Hindi ako nagtatrabaho ngayon baka bumalik ako sa pag aaral ko kapag mabuti na iyong kalagayan ko

9.Sexuality-Reproductive Hindi ako nagpapaexam katulad ng testicular Iyon kagagaling ko lang sa relationship ang madalas kong kasama mga lalaki, lalaki mga barkada ko eh

10. Coping Stress Tolerance Pattern Iyong sa past relationship ko ang sobrang nagbigay ng stress sa akin sobrang magulo kasi Minsan iniinom ko nalang para makalimutan ko, minsan yosi o di kaya matutulog ako

Iyong mama ko alam niya iyong problema ko medyo nagbigay siya ng advice

11. Value-Belief Pattern Minsan nalang ako magsimba kapag maisipan ko Roman Catholic

V.Physical Assesment Pre-Operative: Skin Eyes Mouth Pulmonary Occasional shortness of breath Rapid, shallow respirations (RR-21bpm) Difficulty in swallowing noted Slight exophthalmos Eyelid lag Wide-eyed appearance Diaphoretic Smooth, warm moist skin

Cardiovascular Increased systolic blood pressure (150/90 mmHg) Occasional tachycardia Neck Thyroid enlargement noted upon palpation Bruits (turbulence from blood flow ) noted upon auscultation

Lower Extremities Weakened lower extremities Psychosocial

Decreased attention span Irritable Restless

Post-Operative: Skin Eyes Mouth Pulmonary Cardiovascular Neck Clear breath sounds upon auscultation RR- 20 bpm BP- 140/90 mmHg With dry and intact post-operative dressing Hesitant to move the neck With guarding behaviour on neck Difficulty in swallowing noted Dry and pale lips Slight exophthalmos Eyelid lag Wide-eyed appearance Smooth, warm moist skin

Psychosocial Slightly irritable due to post-operative pain Gastrointestinal Hesitant to eat

X. Course in the Ward Pre-Operative ( August 03, 2012) For total thyroidectomy at 1 PM With consent secured and OR awared Cefazoline 1gm TIV given as pre-op medication Post-Operative With #1 D5LR 1l x 8 hours inserted at right metacarpal vein With SD #1 D5W 250 ml + Ketorolac 90 mg x 10 mcgtts/min at 150 cc level With post-operative dressing dry and intact; with cigarette drain on post-operative site Reminded on NPO status

Nursing Care Plan #1 Assessment Subjective: Msakit pa iyong opera ko , ang pakiramdam ko ang bigat ng leeg ko, as stated Pain scale rate of 7 where 10 is the highest and 1 is the lowest Objective: With guarding behaviour on neck Hesitant to move and speak With facial grimacing Hesitant to eat With post operative dressing on neck dry and intact Diagnosis Acute pain related to posy operative incision Planning At the end of the 8-hour duty the clients pain will decrease as manifested by: __ Pain scale rate of 5 __ Patient will speak and move __ Absence of facial grimacing __ Patient will consume food as tolerated Interventions 1. Encouraged to do deep breathing exercises. R: The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications. 2. Assisted in sitting. R: The client was hesitant to move, assisting him may decrease his hesitation to sit. And sitting will also promote good blood circulation to different parts of the body. 3. Instructed to eat food as tolerated. R: Since the client is on NPO status before the operation he must eat to sustain the energy needed by his body. And his operation is total thyroidectomy, eating is not contraindicated to his condition. 4. Encouraged to ambulate. R: This will promote good blood circulation. 5. Encouraged to change position at least every 2 hours. R: Turning will prevent bedsores and acquiring pneumonia. This will also promote good blood circulation. 6. Provided enough rest. R: This promotes healing by reducing basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth, healing and regeneration.

Evaluation: At the end of 8-hour duty the clients pain decreased as manifested by: Pain scale rate of 5 Patient was able to move and speak Absence of facial grimacing Patient consumed food as tolerated (mamon and ice cream) Goal Met!

Nursing Care Plan Assessment Subjective: Medyo kinakabahan ako, first time ko kasi maoperahan , as stated Objective: Slightly irritable Limited answers to questions With poor eye contact Restless

Diagnosis Moderate anxiety related to upcoming surgical procedure Planning At the end of 8-hour duty the client will decrease his anxiety as manifested by: __ Verbalization of relaxation __ Maintain eye contact __ Answers question comprehendly __ Decrease restlessness

Interventions

1. The student nurse introduced herself. R: Introducing yourself will lessen the anxiety of the patient since it was his first time to meet the student nurse. 2. Established rapport. R: Establishing rapport will gain the clients trust. 3. Provided information about the upcoming surgery. R: Explaining the procedure can develop clients understanding. And to know his own perception about the upcoming operation. 4. Identify the clients perception about the upcoming surgery. R: It can point the clients level of anxiety. 5. Prayed with the client. R: To ask Gods guidance during the operation. And for the client to know that God will be with him during the operation. 6.Provided pre-operative teaching.( Instructed the client to perform coughing and deep breathing exercises .Taught the client how to support the neck when coughing or moving .Placing both hands behind the neck when moving reduces the strain on the suture line .Explained that hoarseness may be present for a few days as a result of endotracheal tube placement during surgery. R: These teachings will decrease the anxiety of the client because he had simple knowledge on what to happen after the operation and what are the things that he should do. Evaluation At the end of the 8-hour duty the clients anxiety decreased as manifested by: Verbalization of feelings Maintained eye contact Comprehend answers to question Decreased restlessness

Goal Met! XIV. Health Teachings 1. Review to the client the manifestations of hyperthyroidism and instruct him to report an increase or recurrence of symptoms. 2. Instructed the client to inspect the incision area and to report redness , tenderness , drainage , or swelling to the health care provider. 3. The discharged client may continue to have mood changes as a result of hyperthyroidism. Explain the reason for mood swings to the client and family and reassure them that it will decrease with continued treatment. 4. Provided health teachings about the negative effects of smoking to ones health.