Hyperthermia and Imbalanced Nutrition related to Hyperthyroidism

Assessment

1. Activity / Rest
Symptoms : Insomnia, increased sensitivity ; muscle weakness, impaired coordination ; Severe fatigue.
Signs : muscle atrophy.

2. Circulation
Symptoms : Palpitations, chest pain (angina).
Signs : dysrhythmias (atrial fibrillation), gallop rhythm, murmurs ; Increased blood pressure with a heavy tone pressure, tachycardia ; Circulatory collapse, shock (crisis thyrotoxicosis)

3· Ego Integrity
Symptoms : Experiencing severe stress both emotionally and physically.
Signs : Emotions labile (euphoria moderate to delirium), depression.


Physical Examination (ROS : Review of Systems)

1. Respiratory B1 (breath)
circulatory collapse, shock (crisis thyrotoxicosis), increased respiratory rate, dyspnea, and pulmonary edema.

2. Cardiovascular B2 (blood)
Hypertension, arrhythmia, palpitations, heart failure, lymphocytosis, anemia, splenomegaly, enlarged neck.

3. Nerves B3 (Brain)
Rapid and guttural speech, impaired mental status and behavior, such as confusion, disorientation, anxiety, sensitive excitatory, delirium, psychosis, stupor, coma, tremors smooth on hands, without purpose, some parts jerky, hyperactive deep tendon reflexes.

4. Urinary B4 (bladder)
Oligomenorrhea, amenorrhea, down libido, infertility, gynekomastia.

5. Digestive B5 (bowel)
Sudden weight loss, increased appetite, eat a lot, eat often, thirst, nausea and vomiting.

6. Musculoskeletal / integument B6 (bone)
Weakness, fatigue.


Nursing Diagnosis for Hyperthyroidism

Nursing Diagnosis : Hyperthermia related to inflammatory processes.

Goal : Normal body temperature.

Outcomes :

• No signs of dehydration,
• Lips moist.

Intervention :
1. Give warm water compress as needed.
R / : Can help decrease heat experienced by the patient.

2. Encourage clients to use clothes that can absorb sweat.
R / : Due to the humid conditions of the body triggers the growth of fungi that cause risk of complications.

3. Maintain a cool environment.
R / : To help maintain the body temperature of the patient to be in a normal state.

4. Collaboration with the medical team in drug delivery.
R / : Helps reduce body temperature of the patient.


Nursing Diagnosis : Imbalanced nutrition : less than body requirements related to the inability to absorb nutrients.

Goal : Nutritional needs fulfilled.

Outcomes :

• Return to normal eating,
• Normal weight,
• Normal laboratory examination,
• Showed no signs of malnutrition,
• Not nausea,
• Not vomiting.

Intervention :
1. Supervise dietary supply, give eat little but often.
R / : To avoid nausea and vomiting and nutritional needs of patients.

2. Encourage the patient to eat little but often.
R / : Increased appetite.

3. Provide information about the importance of nutrition for the body.
R / : Improving patients' knowledge about nutrition.

4. Collaboration with the medical team in drug delivery.
R / : To provide appropriate therapy for patients.