Republic of the Philippines

NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY

Old Sagay, Sagay City, Negros Occidental
(034)722-4120/www.nonescost.edu.ph

Northern Negros State College of Science and Technology

Sagay City, Negros Occidental
Graduate School
Masters in Nursing

In Partial Fulfillment of the Requirements in

NED 105 Research Process
CLINICAL RESEARCH PROPOSAL:
CARE OF PATIENT WITH HYPERTHYROIDISM

Presented To:
Atty. Joseph Gedeoni C. Valencia R.N., M.N., Ph.D.
Submitted By:
Jastine Joy V. Beltran, R.N.

January 10, 2016

Chapter I
INTRODUCTION

Background of the Study

The thyroid gland is a butterfly-shaped endocrine gland that is normally

located in the lower front of the neck. The thyroids job is to make thyroid
hormones, which are secreted into the blood and then carried to every tissue
in the body. Thyroid hormone helps the body use energy, stay warm and keep
the brain, heart, muscles, and other organs working as they should. The term
hyperthyroidism refers to any condition in which there is too much thyroid
hormone produced in the body. In other words, the thyroid gland is
overactive. Another term that you might hear for this problem is
thyrotoxicosis, which refers to high thyroid hormone levels in the blood
stream, irrespective of their source. Thyroid hormone plays a significant role in
the pace of many processes in the body. These processes are called your
metabolism. If there is too much thyroid hormone, every function of the body
tends to speed up. It is not surprising then that some of the symptoms of
hyperthyroidism are nervousness, irritability, increased perspiration, heart
racing, hand tremors, anxiety, difficulty sleeping, thinning of your skin, fine
brittle hair and weakness in your musclesespecially in the upper arms and
thighs. You may have more frequent bowel movements, but diarrhea is
uncommon. You may lose weight despite a good appetite and, for women,
menstrual flow may lighten and menstrual periods may occur less often. Since
hyperthyroidism increases your metabolism, many individuals initially have a
lot of energy. However, as the hyperthyroidism continues, the body tends to

break down, so being tired is very common. Hyperthyroidism usually begins

slowly but in some young patients these changes can be very abrupt. At first,
the symptoms may be mistaken for simple nervousness due to stress. If you
have been trying to lose weight by dieting, you may be pleased with your
success until the hyperthyroidism, which has quickened the weight loss,
causes other problems. In Graves disease, which is the most common form of
hyperthyroidism, the eyes may look enlarged because the upper lids are
elevated. Sometimes, one or both eyes may bulge. Some patients have
swelling of the front of the neck from an enlarged thyroid gland (a goiter).

The most common cause (in more than 70% of people) is

overproduction of thyroid hormone by the entire thyroid gland. This condition
is also known as Graves disease (American Thyroid Association). Graves
disease is caused by antibodies in the blood that turn on the thyroid and
cause it to grow and secrete too much thyroid hormone. This type of
hyperthyroidism tends to run in families and it occurs more often in young
women. Little is known about why specific individuals get this disease.
Another type of hyperthyroidism is characterized by one or more nodules or
lumps in the thyroid that may gradually grow and increase their activity so
that the total output of thyroid hormone into the blood is greater than normal.
This condition is known as toxic nodular or multinodular goiter. Also, people
may temporarily have symptoms of hyperthyroidism if they have a condition
called thyroiditis. This condition is caused by a problem with the immune
system or a viral infection that causes the gland to leak stored thyroid
hormone. The same symptoms can also be caused by taking too much thyroid
hormone in tablet form. These last two forms of excess thyroid hormone are

only called thyrotoxicosis, since the thyroid is not overactive.

Diagnosis is usually a simple matter. A physical examination usually

detects an enlarged thyroid gland and a rapid pulse. The physician will also
look for moist, smooth skin and a tremor of your fingertips. Your reflexes are
likely to be fast, and your eyes may have some abnormalities if you have
Graves disease. The diagnosis of hyperthyroidism will be confirmed by
laboratory tests that measure the amount of thyroid hormones thyroxine
(T4) and triiodothyronine (T3)and thyroid-stimulating hormone (TSH) in
your blood. A high level of thyroid hormone in the blood plus a low level of
TSH is common with an overactive thyroid gland. If blood tests show that your
thyroid is overactive, your doctor may want to obtain a picture of your thyroid
(a thyroid scan). The scan will find out if your entire thyroid gland is
overactive or whether you have a toxic nodular goiter or thyroiditis (thyroid
inflammation). A test that measures the ability of the gland to collect iodine (a
thyroid uptake) may be done at the same time.

Since no single treatment is best for all patients with hyperthyroidism.

The appropriate choice of treatment will be influenced by your age, the type
of hyperthyroidism that you have, the severity of your hyperthyroidism, other
medical conditions that may be affecting your health, and your own
preference. It may be a good idea to consult with an endocrinologist who is
experienced in the treatment of hyperthyroid patients. If you are unconvinced
or unclear about any thyroid treatment plan, a second opinion is a good idea.
Drugs known as antithyroid agentsmethimazole (Tapazole) or in rare
instances propylthiouracil (PTU)may be prescribed if your doctor chooses to

treat the hyperthyroidism by blocking the thyroid glands ability to make new
thyroid hormone. Methimazole is presently the preferred one due to less
severe side-effects. These drugs work well to control the overactive thyroid,
bring quick control of hyperthyroidism and do not cause permanent damage
to the thyroid gland. In about 20% to 30% of patients with Graves disease,
treatment with antithyroid drugs for a period of 12 to 18 months will result in
prolonged remission of the disease. For patients with toxic nodular or
multinodular goiter, antithyroid drugs are sometimes used in preparation for
either radioiodine treatment or surgery.

Antithyroid drugs cause allergic reactions in about 5% of patients who

take them. Common minor reactions are red skin rashes, hives, and
occasionally fever and joint pains. A rarer (occurring in 1 of 500 patients), but
more serious side effect is a decrease in the number of white blood cells. Such
a decrease can lower your resistance to infection. Very rarely, these white
blood cells disappear completely, producing a condition known as
agranulocytosis, a potentially fatal problem if a serious infection occurs. If you
are taking one of these drugs and get an infection such as a fever or sore
throat, you should stop the drug immediately and have a white blood cell
count that day. Even if the drug has lowered your white blood cell count, the
count will return to normal if the drug is stopped immediately. But if you
continue to take one of these drugs in spite of a low white blood cell count,
there is a risk of a more serious, even life-threatening infection. Liver damage
is another very rare side effect. A very serious liver problem can occur with
PTU use which is why this medication should not generally be. Another way to
treat hyperthyroidism is to damage or destroy the thyroid cells that make

thyroid hormone. Because these cells need iodine to make thyroid hormone,
they will take up any form of iodine in your blood stream, whether it is
radioactive or not.
The radioactive iodine used in this treatment is administered by mouth,
usually in a small capsule that is taken just once. Once swallowed, the
radioactive iodine gets into your blood stream and quickly is taken up by the
overactive thyroid cells. The radioactive iodine that is not taken up by the
thyroid cells disappears from the body within days. Over a period of several
weeks to several months (during which time drug treatment may be used to
control hyperthyroid symptoms), radioactive iodine destroys the cells that
have taken it up. The result is that the thyroid or thyroid nodules shrink in
size, and the level of thyroid hormone in the blood returns to normal.
Sometimes patients will remain hyperthyroid, but usually to a lesser degree
than before. For them, a second radioiodine treatment can be given if needed.
More often, hypothyroidism (an underactive thyroid) occurs after a few
months and lasts lifelong, requiring treatment. In fact, when patients have
Graves disease, a dose of radioactive iodine is chosen with the goal of making
the patient hypothyroid so that the hyperthyroidism does not return in the
future. Hypothyroidism can easily be treated with a thyroid hormone
supplement taken once a dayprescribed. You should stop either methimazole
or PTU if you develop yellow eyes, dark urine, severe fatigue, or abdominal
pain. Because hyperthyroidism, especially Graves disease, may run in families,
examinations of the members of your family may reveal other individuals with
thyroid problems. (American Thyroid Association).

Statement of the Problem

How can a client with endocrine problem (hyperthyroidism) be assisted

in attaining a higher level of met needs utilizing Orlandos interactive theory in
the nursing process?

Significance of the Study

The study is of great relevance in the care of the client with

Hyperthyroidism. Nursing Interventions are focused on the patients needs or
responses to the environment. It enables the nurse to determine the
effectiveness of interventions utilizing Ida Jean Orlandos Theory as a guide in
nursing practice and render quality nursing care.

Chapter II

THEORETICAL FRAMEWORK

Review of Literature

According to Journal of the ASEAN Federation of Endocrine

Societies (JAFES) on their study on Prevalence of Thyroid Disorders among
Adults in the Philippines last 2012 the frequency of thyroid disorders varies in
different countries. A national prevalence study among the Filipino adult
population using thyroid function tests will give us information vital to public
health. Data on thyroid disorders, which include both overt and subclinical
forms can provide estimates of the national burden of this illness. Distribution

by age can help us formulate focused strategies and guidelines for improving
medical care in thyroid disorders among subsets of Filipinos.
The national prevalence of goiter was first reported in 1987. Clinical
examination for the presence of goiter was undertaken during the 1987 and
1993 National Nutrition Surveys allowing comparisons. There appeared to be
an increase in the prevalence of goiter during this six-year period, with the
initial rate in 1987 of 3.7% to 6.7% in 1993.

6.

The data studied both non-

pregnant and pregnant adults with the highest prevalence seen among
pregnant women aged 13 to 20 years at 27.4%.
To determine the latest prevalence of various categories of abnormal
thyroid dysfunction among the Filipino non-pregnant adult population and to
describe the prevalence of thyroid enlargement in the Philippines in relation to
thyroid dysfunction status. They covered all 17 regions and 80 provinces of
the Philippines. It included all Filipino adults 20 years and older, who are nonpregnant and non-lactating. A standard questionnaire was used to collect data
on previous diagnosis and current treatment for thyroid disorders, and neck
examination by trained field personnel was done to assess the presence of
goiter. Blood was extracted, processed and sent to an accredited laboratory
for free T4 and TSH testing using micro-particle enzyme immunoassay.

A total of 4897 persons had thyroid function tests. Of these, 417

(8.53%) had thyroid function abnormalities with the most common
abnormality being subclinical hyperthyroidism occurring in 5.33%. The other
categories had the following prevalence: true hyperthyroidism 0.61% ; true
hypothyroidism 0.41%; and subclinical hypothyroidism 2.18% . Majority of the
population 4480 (91.47%) had normal thyroid function tests. Of those with
subclinical hyperthyroidism, 55% are females with mean age of 48 years

(95% CI 45.9-50.1 years) compared with the volunteers with normal thyroid
function who were younger (mean age of 43.1, 95% CI 42.5-43.6 years). Out
of the 7,227 volunteers who responded to the survey and clinical examination,
a total of 674 (8.9%) had goiters. Out of the 674 subjects with goiters, 379
had diffuse enlargement (56%) while the rest had nodular goiter (44%).
Among the sub-population (n= 4897) who underwent thyroid function testing,
9% of those with normal thyroid function tests have goiters.

They concluded that the prevalence of thyroid function abnormalities in

the Philippines is 8.53% with the greatest proportion of volunteers having
subclinical thyroid disease. There is a low prevalence of both true or overt
hyperthyroidism and hypothyroidism. In the larger survey, it was found that
8.9% of volunteers who were examined had goiters. The etiology of these
goiters will need to be ascertained in future studies.

The symptoms may include enlarged thyroid gland, nervousness,

irritability, insomnia, diarrhea, heart palpitation, unexpected weight loss
despite increased appetite, heat intolerance, increased in bowel movements.
There may be puffiness around the eyes and a characteristic stare due to
elevation of upper eyelids. Advanced symptoms are easily detected, but early
symptoms especially in elderly , may be quite suspicious.
(http://www.medicinenet.com/hyperthyroidism)

The most common method used to diagnose thyroid disorders,

is through blood testing. Blood is drawn and lab-tested to see if the thyroids
hormone levels are in the normal range. If they are outside of the normal
reference range, on the high end, this would indicate an over-active thyroid

gland, hyperthyroidism. The treatment for hyperthyroidism is also by oral

medication but in this case, medications called Thyroid Hormone
Replacement Medications are used to supplement the thyroids
underproduction of thyroid hormones. (Disease and Disorders: A Nursing
Therapeutic Manual. 3rd Edition. 2007)

And on the Epidemiological survey on the relationship between

different Iodine intakes and prevalence of Hyperthyroidism conducted by F.
Yang, et. al., wherein they made a comparative cross-sectional and
longitudinal survey conducted in three areas with borderline iodine deficiency,
mild iodine excess (previously mild iodine deficiency) and severe iodine
excess. Universal salt iodization had been introduced 3 years previously except
in the area with borderline iodine deficiency. In total 16 287 inhabitants from
three areas answered a questionnaire concerning the history of thyroid
disease. Among them 3761 unselected subjects received further investigations
including thyroid function, thyroid autoantibodies, thyroid ultrasonography and
urinary iodine excretion. RESULTS: Among areas with median urinary iodine
excretion of 103 microg/l, 375 microg/l and 615 microg/l (P<0.05), the
prevalence of hyperthyroidism did not differ significantly (1.6%, 2% and
1.2%). The prevalence of subclinical hyperthyroidism was higher in areas with
borderline iodine deficiency and mild iodine excess than in the area with
severe excess iodine intake (3.7%, 3.9% and 1.1%, P<0.001). The
prevalence of Graves' disease and its proportion in hyperthyroidism did n
ot differ among areas. The incidence of hyperthyroidism did not significantly
increase after the introduction of universal salt iodization. They concluded that
different iodine intakes under a certain range do not affect the prevalence and
type of hyperthyroidism. Subclinical hyperthyroidism is more prevalent in the

iodine deficient area than in the severe iodine excessive area. In the area with
mild iodine deficiency, the introduction of universal salt iodization may not be
accompanied by an increased incidence of hyperthyroidism.

Theoretical Source

Ida Jean Orlando was the first nurse to develop her theory from
actual nurse-patient situations. She used a qualitative method to obtain data
from which she developed her theory. She describes her model as revolving
around five major interrelated concepts; the function of professional nursing;
the presenting behavior of the patient; the immediate response of the nurse;
the nursing process discipline and improvement. Orlando views the
professional function of nursing as finding out and meeting the patients
immediate need for help. Orlandos theory focuses on how to produce
improvement in the patients behavior. According to Orlando, a person
becomes a patient requiring nursing care when he or she has needs for help
that cannot be met independently because he or she has physical limitations,
has negative reaction to an environment, or has experience that prevents the
patient from communicating his or her needs. When the nurse acts, an action
process transpires. This action process by the nurse in a nurse-patient contact
is called nursing process. Orlandos theory is specific in nurse-patient
interaction. The goal of the nurse is to determine and meet patients
immediate need. The role of the nurse is to find out and meet the patient's
immediate need for help. The patient's presenting behavior may be a plea for
help; however, the help needed may not be what it appears to be.

Therefore, nurses need to use their perception, thoughts about

the perception, or the feeling engendered from their thoughts to explore with
patients the meaning of their behavior. This process helps nurse find out the
nature of the distress and what help the patient needs. Orlando's theory
remains one the of the most effective practice theories available. The use of
her theory keeps the nurse's focus on the patient. The strength of the theory
is that it is clear, concise, and easy to use. While providing the overall
framework for nursing, the use of her theory does not exclude nurses from
using other theories while caring for the patient. Professional nursing is
conceptualized as finding out and meeting the clients immediate need for
help. This framework will be important for Nurses who are assigned in special
clinical areas that require quick decision making & critical thinking skills. If the
patients condition improved, then the intervention is effective and the patient
moves on to new problems.

Orlandos major assumption about Nursing is that it is a distinct

profession "Providing direct assistance to individuals in whatever setting they
are found for he purpose of avoiding, relieving, diminishing, or curing the
individual's sense of helplessness" .

Orlando assumes that a Human/Person is an individual in need. Unique

individual behaving verbally or nonverbally. Assumption is that individuals are
at times able to meet their own needs and at other times unable to do so.

Orlando assumes that Health that freedom from mental or physical

discomfort and feelings of adequacy and well being contribute to health. She
also noted that repeated experiences of having been helped undoubtedly
culminate over periods of time in greater degrees of improvement

Orlando assumes Environment is a nursing situation that occurs

when there is a nurse-patient contact and that both nurse and patient
perceive, think, feel and act in the immediate situation. any aspect of the
environment, even though its designed for therapeutic and helpful purposes,
can cause the patient to become distressed. She stressed out that when a
nurse observes a patient behavior, it should be perceived as a signal of
distress. (Parker, Marilyn. Nursing Theories and Nursing Practice. FA Davis
Company. 2005

Conceptual Framework

Assessment

Level of Met
Needs
utilizing
Orlandos
Theory

Goals of
Nursing
Action

Planning /
Implementation

Levels of
Met
Needs

Evaluation

Figure1. The Nursing Process Flowchart

The above figure illustrates the nursing care approach in assisting the client
with need for help. The assessment Phase focuses on the client with need.

The planning/implementation Phase directs to setting up of goals and

objectives, and identifying and carrying out of the nursing actions. The
Evaluation phase focuses on validating the effectiveness of the met needs.

Definition of Terms

Met Needs. Needs presented as behaviors that the client is able to meet
whether independently, with minimum assistance or solely with assistance.

Level of Met Needs. Needs that presented as behaviors that are classified
according to how the client is able to perform them and is categorized as high,
average, below average, and low level of adaptation.

High Level of Met Needs. Client is able to meet needs independently

without the help, aid or support which has the mean score range of 3.1 4.

Average Level of Met Needs. Client is able to meet needs with a little
help, aid or support in the form of nursing care. Success in meeting the
particular need is high without assistance which has the mean score range of
2.1 3.
Below Average Level of Met Needs. Client is able to meet needs solely
with the help, aid or support in the form of nursing care. Success in meeting
the human needs is low without assistance which has the mean score range of
1.1 2.

Low Level of Met Needs. Clients needs that are barely met or not met at
all which has the score range of 0 1.

Observed Behavioral Response. These are the frequency of indicators in

each category.

Code

Description

Always

Behavior observed all the time rated as 4.

Most of the time

Behavior observed frequently rated as 3.

Sometimes

Behavior observed occasionally rated as 2.

Rarely

Behavior observed once in a while rated as 1.

Chapter III

APPLICATION OF THE NURSING THEORY

CLIENTS PROFILE

Name:

Patient X

Address:

Prk. Kabutongan, Brgy. Vista Alegre, Bacolod City

Age:

40

Sex:

Male

Status:

Married

Height:

58

Weight:

60 kgs

Occupation:

Farmer

Educational Attainment:

High School Graduate

Dialect/Language Spoken: Tagalog and Ilonggo

Chief Complaints:
and Mouth

Sudden Lost of Weight, On and Off Fever, Sore Throat,

Sores for 2 weeks

Medical Impression:

Hyperthyroidism

CLINICAL HISTORY

Patient X was diagnosed of Hyperthyroidism 5 years ago. For the past 5 years,
he doesnt have any complaints regarding hyperthyroidism. And he hasnt
done laboratory tests for his condition as he should like the T3, TSH, and T4.
He hasnt monitored his blood since then. He experienced simple cough, fever,

or flu-like symptoms for the past years. Patient X was admitted due to
decrease of WBC related to anti-thyroid drug side effects.

Last June 26, 2014 Patient X consulted an Endocrinologist and instructed him
to do some laboratory tests such as T3, T4, TSH, CBC and SGPT. When they
went back to the Endocrinologist, the doctor was alarmed since his WBC was
only 3.5K/uL and his SGPT were so high to 144U/L. He instructed the patient
that she cant treat his Hyperthyroidism unless his blood levels were normal.
His Endocrinologist, prescribed patient X to continue drinking the Carbimazole
5mg and Indural 10mg to minimize his hyperthyroidism symptoms like
palpitations, sweating, and insomnia. The Doctor advised him to watch out
signs like mouth sores, sore throat, and fever. After a month, he went back to
the doctor and consulted, after the laboratory tests done. The Doctor
maintained a low dose of Carbimazole and to continue the Indural 10mg, TID.
and follow-up after 6 weeks.

ASSESSMENT TOOL

The assessment tool was constructed based on the concept presented in the
theory of Ida Jean Orlando categorized into four assessment parameters
which are Physiological, Social, Psychological and Spiritual and subcategorized to areas to which Orlandos Theory wants to focus. These areas
assessed in accordance with the clients ability to meet own needs. This
assessment serves as a basis for nursing actions.

Table 1. Assessment Tool

Direction: Put a check mark () on the scale corresponding to the observed
behavioral response coded and described as follows: 4 Always; 3 Most of
the time; 2 Sometimes; 1 Rarely.

ASSESSMENT PARAMETERS
PHYSIOLOGIC NEEDS
Oxygenation
Manifests clear breath sounds and effortless breathing
Demonstrates normal breathing pattern (16 20 breaths per minute)
Manifests normal pulse rate (60 100 beats per minute)
Manifests promptly capillary refill of fingernail beds (around 3
seconds)
Manifests normal Blood Pressure (100 120 / 60 80 mmHg)
Nutrition
Eats well balanced diet during regular meals.
Eats regularly at least three times a day
Drinks Sufficient amount of water at least 6 8 glasses (2000ml) per
day
Takes nutritional supplement like multivitamins
Exhibits ideal Body weight for height and age
Elimination
Moves bowel with normal consistency and without difficulty.
Voids painlessly approximately 5 8 times daily (800 1000cc)
Sleep and Rest
Sleeps at least 6 8 hours at night without interruption

4 3 2 1

Takes adequate amount of rest at daytime

Exercise and Activity
Performs activities of daily living independently
Takes a bath independently at least once daily
Practices good dental hygiene at least once daily
Grooms fingernails and toenails regularly
Wears neat, clean, appropriate clothing
Dresses and undresses independently
Exercise at least 15-30 minutes a day such as brisk walking & deep
breathing, especially in early morning.
PSYCHOLOGICAL NEEDS
Self- Concept
Expresses fears about the nature of disease
Identifies feelings & concerns about physical ailment
Verbalizes understanding and acceptance of present condition
Self Esteem
Provides financial needs of the family
Works with a sense of accomplishment
Shows ability to work with dedication
Complies with the therapeutic regimen
SOCIAL NEEDS
Interpersonal Relationship
Demonstrates harmonious relationship with parents
Mingles with friends and relatives
Community Resources
Utilizes health facilities (like health center, hospital) appropriately

Participates in learning activities or opportunities for learning

SPIRITUAL NEEDS
Devotes regular worship time
Expresses gratification with compatibility of spiritual belief and daily
living,
Practices spiritual belief that strengthen hope and comfort in facing
life.
TOTAL

The Evaluation Scale

To get the clients level of Met Needs, statistical procedure for getting the
Mean Score from each category is computed to determine which category is
greatly affected in order to prioritize nursing intervention. The formula is as
follows:

Clients Score
Mean Score (X) = ---------------------Number of Items

To come up with Over All Mean Score and to describe the clients level of
Met Needs in 2 categories, the formula to be used is:

Clients Score in all categories

Over All Mean Score (OSM) = ---------------------------------------Number of Items in all categories

Scale
0
4

LOW

BELOW AVERAGE

AVERAGE

HIGH

Figure 2. The Evaluative Scale of clients met needs

D. Nursing Process

Assessment Phase

Table 2. Initial Assessment of Patient X

CATEGORY

No.
of

Perfe
ct

Clien
t

Mea
n

Items

Score Score Scor

e

PHYSIOLOGIC NEEDS

Rank

Description

Oxygenation

20

12

2.4

Average

Nutrition

20

1.8

Below
Average

Elimination

2.5

4.5

Low Average

Sleep and Rest

Below
Average

Exercise and Activity

24

15

2.5

4.5

Average

Sub Total

20

80

43

2.15

PSYCHOLOGICAL NEEDS

Self- Concept

12

1.3

Below
Average

Self Esteem

16

Below
Average

Sub Total

28

12

1.7

SOCIAL NEEDS

Interpersonal Relationship

Average

Community Resources

1.5

Below
Average

Sub Total

16

2.25

SPIRITUAL NEEDS

12

Average

TOTAL

34

136

73

2.14

Average

X = 2.14

Scale
0
4

LOW

BELOW AVERAGE

AVERAGE

HIGH

Figure 3. The Evaluative Scale of the level of met needs based on the initial
assessment of Patient X

Interpretation
The initial assessment of Patient X has a total score of 73. The mean score
were added and divided by the total number of categories is equal to 2.14 as
an overall mean score described as an Average level of met needs as
demonstrated on the scale.