uScenario
K.B. is a 65-year-old man admitted to the hospital after a 5-day episode of the flu with complaints of dyspnea on exertion, palpitations, chest pain, insomnia, and fatigue. K.B. was diagnosed with Graves disease
6 months ago and placed on methimazole (Tapazole) 15mg/day. His other past medical history includes
heart failure and hypertension requiring antihypertensive medications; however, he states that he has
not been taking these medications on a regular basis. Vital signs (VS) are: 150/90, 124 irregular, 20, 100.2
F (37.9 C). Admission assessment findings are: height 5ft, 8 in; Weight 132lb; appears anxious and restless; loud heart sounds; 1+ pitting edema noted in bilateral lower extremities; diminished breath sounds
with fine crackles in the posterior bases. K.B. begins to cry when he tells you he recently lost his wife; you
notice someone has punched several more holes in his belt so he could tighten it.
Chart View
Laboratory Test Results
Hemoglobin (Hgb) 11.8g/dL
Hematocrit (Hct) 36%
Erythrocyte sedimentation rate (ESR) 48mm/hr
Sodium 141mmol/L
Potassium 4.7mmol/L
Chloride 101mmol/L
Blood urea nitrogen (BUN) 33mg/dL
Creatinine 1.9mg/dL
Free thyroxine (T4
) 14.0ng/dL
Triiodothyronine (T3
) 230ng/dL
1. Which of K.B.’s assessment findings represent manifestations of hypermetabolism?
Anxiety, restlessness, insomnia, increased systolic blood pressure (BP), palpitations, dysrhythmias,
tachycardia, dyspnea, elevated temperature, low weight-to-height ratio.
2. Interpret K.B.’s laboratory results.
K.B.’s higher-than-normal levels of T4
and T3
indicate hyperthyroid states. His elevated BUN level is
most likely caused by dehydration secondary to his hypermetabolic state. K.B.’s ESR is elevated; this
is associated with infection, inflammation, and tissue necrosis or infarction. His low Hgb and Hct
levels could be caused by his hypermetabolic state, as well as reflecting anemia caused by chronic
disease and possible dietary deficiency.
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372 Copyright 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
7 Endocrine Disorders
3. You go to assess K.B. What additional data do you need to obtain because he has Graves
disease?
Perform an in depth assessment of each of his presenting symptoms, including fatigue, insomnia,
chest pain, dyspnea, and palpitations.
Explore whether he has experienced any difficulty concentrating, irritability, photophobia,
emotional lability, changes in appetite, changes in bowel habits, heat intolerance.
Assess him for additional signs and symptoms of excess thyroid hormone: increased deep tendon
reflexes, tetany, tremor, ophthalmopathy (exophthalmos, periorbital edema, periorbital and
conjunctival inflammation, decreased extraocular muscle movement, corneal injury, blurred
vision, eye pain, photophobia, and diplopia), diaphoresis, and changes in hair, skin, or nails.
Chart View
Physician’s Orders
Propranolol (Inderal) 20mg PO q6h
Dexamethasone (Decadron) 10mg IV q6h
Verapamil (Calan SR) 120mg/day PO
Furosemide (Lasix) 80mg IV push now, then 40mg/day IVP
Diet as tolerated
STAT ECG and echocardiogram
Up ad lib
IV of D5W at 125mL/hr
Daily weights with intake and output (I&O)
4. The physician writes these admission orders. Which will you question, and why?
The beta-adrenergic blocker propranolol (Inderal) and calcium-channel blocker verapamil (Calan)
should not be prescribed for patients with a history of heart failure; the negative inotropic side
effects can diminish cardiac output and worsen heart failure. If K.B. had an elevated BP, the
physician should initiate therapy with other beta-blockers with greater cardiac benefits.
Given K.B.’s history of hyperthyroidism, irregular heart rate, elevated temperature, chest pain,
and heart failure, the activity order should be questioned; decreased activity would decrease
myocardial oxygen consumption and metabolic activity.
Because of the possibility of heart failure, infusing D5W at 125mL/hr could contribute to volume
overload and a worsening of cardiac status.
5. Describe four priority problems related to K.B.’s nursing care.
Decreased cardiac output from dysrhythmias and possible heart failure
Potential for hyperthermia from increased heat production
Inadequate oxygenation from hypermetabolism
Dehydration and inadequate nutrition from inadequate intake to meet increased metabolic needs
Altered elimination; diarrhea with potential fluid and electrolyte imbalances
Inability to tolerate activity because of increased metabolism, fatigue, weakness, heart failure
Need for education about Graves disease and medical therapy
Case Study Progress
Later on your shift, you note that K.B. is extremely restless and disoriented to person, place, and time. VS
are 174/82, 180 and irregular, 32 and labored, 104 F (40 C). His electrocardiogram (ECG) shows atrial
fibrillation.
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7 Endocrine Disorders
6. What is likely happening with K.B.? State your rationale.
The elevated BP, tachycardia, temperature, and respirations and the onset of atrial fibrillation are
consistent with thyroid storm or thyrotoxic crisis.
7. What will you do first?
Because this is a medical emergency, call the rapid response team and physician. Place him on
oxygen therapy per protocol.
8. You need to call the physician regarding K.B.’s status. Using SBAR, what will you report to
the physician?
You would first need to identify yourself and the patient. Then describe the situation, focusing on
the VS and new onset of confusion and atrial fibrillation. Relate the earlier assessment findings:
1+ bilateral lower extremity pitting edema and diminished breath sounds with fine crackles in
the posterior bases. State how many hours it has been since he was admitted, and review the
interventions you performed, including whether you placed K.B. on oxygen. You would conclude
your remarks with the belief that he is experiencing thyroid storm and that the physician needs to
see K.B.
Case Study Progress
The physician evaluates K.B. and determines he is in thyroid crisis. The physician’s orders are shown in the
chart.
Chart View
Physician’s Orders
Oxygen at 2L per nasal cannula
STAT arterial blood gases, brain natriuretic peptide (BNP), and cardiac enzymes
Digoxin (Lanoxin) 0.25mg IV push now, then 0.125mg IVP q8h2 doses
Diltiazem (Cardizem) bolus dose of 0.25mg/kg IV; after 15 minutes, give a second dose of
0.35mg/kg IV for heart rate greater than 140
Increase methimazole (Tapazole) to 15mg PO q6h
Lugol’s solution 10 drops PO tid: start 1 hour after first methimazole dose
Hydrocortisone (HydroCort) 50mg IVP q6h
Absolute bed rest
Acetaminophen (Tylenol) 650mg PO q6h prn for temp over 100 F (37.8 C)
9. Describe how you would care for K.B. in the next hour.
If not already done, place K.B. on oxygen with oxygen saturation monitoring. Assess heart and lung
sounds and jugular venous distention for signs of heart failure. Administer the intravenous (IV)
diltiazem then the digoxin and hydrocortisone. Administer the acetaminophen for his temperature
and the increased dose of methimazole, noting the time so that the Lugols solution can be started
60 minutes later. Obtain the arterial blood gases, BNP, and cardiac enzymes. If 15 minutes have
elapsed and K.B.’s heart rate remains elevated, administer the second dose of diltiazem. Maintain
K.B. on bed rest throughout this period. If the heart rate remains elevated 15 minutes after the
second dose of diltiazem, notify the physician.
Part 1 Medical-Surgical Cases
374 Copyright 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
7 Endocrine Disorders
10. The label on the vial of diltiazem (Cardizem) states that there are 5mg/mL. How many total
milliliters will you administer for the first dose? How many for the second (if needed)?
132lb/2.2lb/kg=60kg
First dose: 600.25mg=15mg
5mg/1mL: 15mg/x
x=3mL
Second dose: 600.35mg=21mg
5mg/1mL: 21mg/ x
x=4.2mL
11. Describe how to safely administer Lugols solution.
K.B. needs to have the medication given in water or juice to mask its strong, unpleasant taste. He
should drink it through a straw to avoid discoloration of the teeth.
12. What is your primary nursing goal at this time?
The primary nursing goal is to decrease the effects of the excess hormone while supporting
cardiovascular function and maintaining a safe patient environment.
13. Describe six interventions you will perform over the next few hours for K.B. based on this
priority.
Monitor BP, temperature, and neurologic status.
Maintain ECG and oxygen saturation monitoring.
Auscultate lung sounds frequently.
Titrate oxygen per protocol.
Administer IV fluids and medications as prescribed.
Because of increased cardiac workload, assess for chest pain, development of an S3
sound, and
presence of jugular venous distention (JVD) and edema, and monitor urine output in addition
to VS.
Promote reduction in body temperature by administering the as-needed acetaminophen and
maintaining a cool environmental temperature.
Maintain I&O. Monitor laboratory values as available.
Maintain a safe, calm environment; implement seizure precautions.
14. Why was K.B. at risk for developing thyroid storm?
Thyroid crisis may be precipitated by a major stressor such as an infection (K.B. had the flu) and the
recent loss of his wife. K.B. might have stopped taking his antithyroid therapy (the history indicates
he does not take antihypertensive medication regularly).
15. Identify three outcomes that you expect for K.B. as a result of your interventions.
Temperature, BP, heart rate, and respiratory rate will return to his baseline range.
K.B. will be oriented to person, place, and time.
Lung sounds will be clear; peripheral edema will be absent.
ECG will show sinus rhythm.
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7 Endocrine Disorders
Case Study Progress
After several hours of treatment, K.B.’s condition stabilizes. The physician discusses two treatment options
with K.B. and his family: radioactive iodine (RAI) therapy, also known as I-131, and subtotal thyroidectomy.
16. K.B. is fearful of radiation treatment and asks you for your opinion. How would you
respond?
Clarify with K.B. and his family what they know about the risks and benefits of each therapy option.
Ask K.B. and his family to explain their fears related to radiotherapy. Clarify any misconceptions, and
provide accurate information regarding radiation. Facilitate the decision-making process, but do not
influence their decision. K.B. needs to understand that if he chooses the RAI or I-131 option, he will
most likely have to take a pill every day for the rest of his life to maintain a normal thyroid level. He
does not have a good track record with taking pills.
17. K.B. decides to receive RAI. During pretreatment instructions, the family asks whether he
will be radioactive and what precautions they should take. Outline important guidelines for
instructing K.B. and his family regarding home precautions.
Precautions are dose dependent, but the dose typically used to treat hyperthyroidism is generally
low enough to allow for outpatient administration.
Urine, saliva, sweat, and feces will contain RAI, but K.B. will not be radioactive.
Home instructions should include increasing oral intake to enhance excretion, cleaning the tub
after each use, and using individual eating utensils. K.B. should be instructed to flush the toilet
twice after each use for 24 to 48 hours after returning home from treatment.
Even though the amount of radiation in K.B.’s body is minimal, he should be instructed to avoid
kissing or holding a child or baby for 48 to 72 hours.
18. In the midst of all this, you remain concerned over K.B.’s bereavement after the loss of his
wife. How would you address this issue?
Encourage K.B. to verbalize his feelings over the loss of his wife. Acknowledge the pain he is
experiencing, and reinforce his normal feelings of grief. Explore with K.B. how he has coped with
previous losses, and help him identify expressions of grief that may help him. Encourage him to talk
about his spouse and participate in his usual day-to-day activities and spiritual practices. Help him
to identify those around him who can support him best; friends, family, clergy, and grief support
groups are all sources of support.
19. K.B. does have some exophthalmos and is experiencing periodic photophobia and dry eyes.
What should you include in teaching him how to manage these problems? Select all that
apply.
a. Wear sunglasses at all times when outside.
b. Report any changes in vision to the physician.
c. Use artificial tears to provide moisture as needed.
d. Tape the eyes closed at night with nonallergenic tape.
e. Apply warm compresses to the eyes if they are irritated.
Answers: a, b, c, d
Patients need to wear sunglasses or glasses with tinted lenses when they are outside. He can
use artificial tears to provide moisture and cool, not warm, compresses to relieve discomfort. If his
eyes do not close completely, taping them closed at night can decrease the risk of corneal injury. He
should report any vision changes to the physician promptly and have an annual eye examination.
Part 1 Medical-Surgical Cases
376 Copyright 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
7 Endocrine Disorders
20. Which statement indicates K.B. understands the discharge instructions?
a. I will take this medication on a full stomach.
b. If I get a sore throat, ice chips should help me feel better.
c. I should see an improvement in my symptoms by tomorrow.
d. I will follow the precautions for 2 weeks to keep my family safe.
Answer: b
K.B. should be instructed that radiation thyroiditis is possible and might cause dryness and
irritation of the mouth and throat. Relief can be obtained with frequent sips of water, ice chips, or the
use of a salt-and-soda gargle three or four times per day. The maximum effects of RAI might take 2
to 3 months to be fully realized. After a treatment, K.B. should follow routine safety precautions for
48 to 72 hours. RAI is best administered on an empty stomach (i.e., 2 hours before or 2 hours after
eating) because of the risk of vomiting.
Case Study Outcome
Six months later, K.B.’s heart rate, blood pressure, and thyroid hormone levels are within normal limits.
He has gained 14 pounds and has started walking in the mornings without any dyspnea. He says he has
started to do woodworking and has been doing some volunteer work at the senior center
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