ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATION RATIONALE Evaluation
S: “I feel palpitations Decreased cardiac Patient diagnosed After 45 mins of Independent After 45 mins of
and tightness output related to with Grave disease in nursing intervention, nursing interven
during activity.” As uncontrolled pregnancy with the patient is -Assess patient’s -To provide baseline the patient was
verbalized by the hyperthyroidism impending thyroid expected to: vital sign data to
patient and altered heart storm. Thyroid storm Exhibit Exhibit
rate is a life-threatening eupnea and - Auscultate heart - Prominent S1 and eupnea
O: health condition that remain free sounds, noting extra murmurs are remain
- Tachycardia, is associated with of side heart sounds, associated with of side
PR: 148bpm untreated or effects from development of forceful cardiac effects f
- BP: undertreated the gallops and systolic output of the
197/97mmHg hyperthyroidism. An medications murmurs. hypermetabolic medicati
- Patient’s excess of thyroid used to state; development used to
history of hormones increases achieve of S3 may warn of achieve
Grave's disease cardiac contractility adequate impending cardiac adequa
for the past 10 and resting heart rate cardiac - Monitor ECG, failure. cardiac
years and has leading to inadequate output noting rate/rhythm. - Tachycardia may output
not been blood pumped by the After 8 hours of Document reflect direct After 8 hours of
treated for a heart to meet the nursing intervention, dysrhythmias. myocardial nursing interven
year. metabolic demands the patient is stimulation by the patient was
- Increase in FT4 of the body. expected to: thyroid hormone. to:
levels of 75.62 Dysrhythmias often
pmol / L Maintain occur and may Maintai
- Low TSHs levels adequate -Auscultate breath compromise cardiac adequa
of 0.005 µIU / cardiac sounds. Note function/output. cardiac
mL. output for adventitious sounds. output
- Wayne Index tissue needs -Early sign of tissue n
with a value of as evidenced pulmonary as
23 by stable - Monitor congestion, evidenc
- Burch vital signs, temperature; reflecting by stabl
Wartofsky scale palpable provide cool developing cardiac vital sig
with a value of peripheral environment, limit failure. BP – 12
45 pulses, good bed linens/clothes, PR- 80b
- Impending capillary administer tepid - Fever (may exceed Eupnea
thyroid storm refill, and sponge baths 104°F) may occur as palpabl
clear lung a result of excessive periphe
sounds hormone levels and pulses,
can aggravate capillary
diuresis/dehydration refill, an
- Observe and cause increased clear lun
signs/symptoms of peripheral sounds
severe thirst, dry vasodilation, venous
mucous membranes, pooling, and
weak/thready pulse, hypotension.
poor capillary refill,
decreased urinary - Rapid dehydration
output, and can occur, which
hypotension. reduces circulating
volume and
- Closely monitor for compromises
symptoms of heart cardiac output
failure and
decreased cardiac
output, including
diminished quality of - As these symptoms
peripheral pulses, of heart failure
cold and clammy progress, cardiac
skin and extremities, output declines.
increased respiratory
rate, presence of
paroxysmal
nocturnal dyspnea or
orthopnea,
increased heart rate,
neck vein distention,
decreased level of
consciousness, and
presence of edema.
-Indicates need for
-Observe for adverse reduction or
side effects of discontinuation of
adrenergic therapy.
antagonists: severe
decrease in pulse,
BP; signs of vascular
congestion/HF; -It is necessary for
cardiac arrest. the nurse to assess
how well the patient
-Monitor blood is tolerating current
pressure, pulse, and medications before
condition before administering
administering cardiac medications
cardiac medications
Collaborative - Rapid fluid
replacement may be
- Administer IV fluids necessary to
as indicated improve circulating
volume but must be
balanced against
signs of cardiac
failure/need for
- Provide inotropic support.
supplemental O2 as - May be necessary
indicated to support increased
metabolic
demands/O2
- Administer consumption.
medications as
indicated - Given to control
thyrotoxic effects of
tachycardia,
tremors, and
Thyroid hormone nervousness and is
antagonist, first drug of choice
methimazole 30mg, for acute storm.
twice daily
- Blocks thyroid
hormone synthesis
and inhibits
-Beta-blockers, peripheral
Propranalol conversion of T4 to
30mg twice daily T3.
- Decreases heart
- Strong iodine rate/cardiac work by
solution (Lugol’s blocking [beta]-
solution) 5 drops per adrenergic receptor
6hrs sites and blocking
conversion of T4 to
T3.
- Acts to prevent
release of thyroid
hormone into
circulation by
increasing the
amount of thyroid
hormone stored
within the gland
