1. Case Study 3 Group 6 Michelle French, Lauren Kasparian, Kimberly McGinness, Emily Parsons 1

2. Background  Olivia Johnson is a 40 year old, single mother of two children. She works as a high school counselor and is a member of the city council.  She sees her family physician annually and presented no signs or symptoms of illness until eight months ago. 2

3. 3Symptoms Ms. Johnson has noticed a general feeling of nervousness, irritability, and pounding heartbeat. She has noticed that she is less tolerant of the summer heat, and is eating more than usual but losing weight. Upon examination, she complains of slight shortness of breath with exertion, blood pressure of 180/92, warm flushed skin, thin, friable nails, elevated thyroid levels, an elevated BMR, and a height of 5’4’’ and weight of 105 lbs. Giving her a BMI of 18.

4. 4 Medical Diagnosis   The client was diagnosed with hyperthyroidism (Grave’s Disease).   Hyperthyroidism is caused by autoimmune antibodies binding to the thyroid stimulating the production of thyroid stimulating hormone( TSH).   This stimulation causes uncontrolled and excessive production of TSH, increasing the creation and secretion of the thyroid hormones T4 and T3. Thus causing hypermetabolism.

5. 5 Gordon’s Functional Health Patterns –Health Perception/Health Management: Risk for Injury of the Eye related to exopthalmos –Activity-Exercise: Activity Intolerance related to exertional dyspnea –Cognitive-Perceptional: Readiness for enhanced Knowledge

6. 6 Gordon’s Functional Health Patterns -Self-Perception/Self Concept: Anxiety related to change in health status -Role-Relationship: Interrupted Family Processes related to a shift in the health status of a family member

7. 7 Holistic Care Elimination 1. What is your normal bowel movement and voiding pattern? 2. Do you take laxatives or diuretics? 3. Is there any pain on urination or defecation? Filling in the gaps; finding the missing FHP’s Sleep-Rest 1.How much sleep do you normally get a day? 2. Do you feel like you have adequate energy for daily tasks? 3.Do you use any sleep aids including herbals?

8. 8 Value/Belief 1. How do you perceive your spirituality? 2. What do you value in life? 3. Would you consider your beliefs to be a positive force in your life? Coping/Stress Tolerance 1. What do you feel are stressors in your life? 2. How do you normally deal with stress? 3. How would you describe your support system? Sexuality-Reproductive 1. What is your perception of your sexual health? 2. Do you practice safe sex? 3. Are you satisfied with your sex life? Holistic Care

9. 9 Nursing Diagnosis Nutritional-Metabolic: Imbalanced Nutrition; Less than the Body Needs related to hypermetabolism S/S-  Nervousness, less tolerance for summer heat, Irritability, loss of weight with adequate food intake, restlessness, skin is warm and flushed, nails are thin and friable, she is 5’4’’ and 105 lbs.

10. Planning  Progressively gaining weight until it is within the normal range for her height and age, (114-154 lbs).  Identify nutritional requirements.  Consume a nutritionally balanced diet containing sufficient calories to prevent further weight lose. 10

11. 11 Interventions  See a dietician to establish a diet based upon needs related to clients hypermetabolism.  Client should monitor signs of malnutrition  Recent excessive weight loss > 10lbs.  BMI less than 20  Daily weighing

12. 12 Outcomes and Evaluation  Evaluating if weight and lab values have increased or decreased.  Continuing to evaluate with a holistic approach will look at the client’s over all being to ensure a positive progression. It is important to evaluate the plan of care as a whole because the client’s total health is priority, rather than success or failure of individual interventions.

13. 13 Diagnosis Impaired Nutrition related to hypermetabolism Critical Steps- diagnostic reasoning using assessment data; data clustering to find patterns; identify defining characteristics that support NANDA nursing diagnoses. Diagnosis Impaired Nutrition related to hypermetabolism Critical Steps- diagnostic reasoning using assessment data; data clustering to find patterns; identify defining characteristics that support NANDA nursing diagnoses. Assessment Data- nervousness, irritability, restless, less tolerance for summer heat, eating more but losing weight, skin is warm and flushed, nails are thin and friable, 5’4” and 105lbs, BMI of 18 Organize Data-gather objective data through initial and ongoing assessments and subjective data from therapeutic interaction Assessment Data- nervousness, irritability, restless, less tolerance for summer heat, eating more but losing weight, skin is warm and flushed, nails are thin and friable, 5’4” and 105lbs, BMI of 18 Organize Data-gather objective data through initial and ongoing assessments and subjective data from therapeutic interaction Implementation -Refer to a dietician to establish a diet based upon needs related to clients hyper metabolism. -Client should monitor signs of malnutrition *Recent excessive weight loss >10lb *BMI less than 20 -Daily weighing Skills that framed the case: each implementation we used critical thinking to evaluate the possible consequences of each intervention & decide if consequences out way benefits Implementation -Refer to a dietician to establish a diet based upon needs related to clients hyper metabolism. -Client should monitor signs of malnutrition *Recent excessive weight loss >10lb *BMI less than 20 -Daily weighing Skills that framed the case: each implementation we used critical thinking to evaluate the possible consequences of each intervention & decide if consequences out way benefits Planning - Progressively Gain weight until within normal range (114-154 lbs) - Identify nutritional requirements - Consume a nutritionally balanced diet to prevent further weight loss -Be free of signs of malnutrition - Recognize factors contributing to underweight - Consume adequate nourishment -Meet with a dietician to establish a nutritional plan and establish a time frame. Planning - Progressively Gain weight until within normal range (114-154 lbs) - Identify nutritional requirements - Consume a nutritionally balanced diet to prevent further weight loss -Be free of signs of malnutrition - Recognize factors contributing to underweight - Consume adequate nourishment -Meet with a dietician to establish a nutritional plan and establish a time frame. Evaluation -Evaluate if weight and lab values have increased or decreased -Ongoing evaluation with a holistic approach and look at the client’s over all well being to ensure a positive progression -Critically evaluate and revise therapy until you and client resolve problems as defined by nursing diagnosis Evaluation -Evaluate if weight and lab values have increased or decreased -Ongoing evaluation with a holistic approach and look at the client’s over all well being to ensure a positive progression -Critically evaluate and revise therapy until you and client resolve problems as defined by nursing diagnosis 40y/o mother of t Patient: Olivia Johnson 40y/o mother of two Diagnosed with hyperthyroidism

14. Reflection  As a group we initially tried to divide up the work. Realizing the topics all overlapped we rerouted the plan and worked collaboratively to formulate a congruent plan of care and nursing process.  If the project was to be redone we would establish this in the beginning and set times focused on selective areas to better time management. 14

15. References  Ackley, B. J., & Ladwig, G. B. (2007). Mosby's Guide to Nursing Diagnosis. St Louis,Missouri: Mosby.  Bahn, R. (2003). Pathophysiology of Graves? Ophthalmopathy: The Cycle of Disease. The Journal of Clinical Endocrinology and Metabolism, 88(5). Retrieved April 20, 2009.  Loeb, S. (1994). Handbook of Medical-Surgical Nursing. Springhouse: Springhouse Corporation.  Perry, A. G., & Potter, P. A. (2008). Fundamentals of Nursing (Fundamentals of Nursing (Potter & Perry). St Louis, Missouri: Mosby.  Tracy, S. (Director) (2009, February 5). Functional Health Patterns., University Of New Hampshire, Durham.  Williams, M. (2002). Nutrition For Health, Fitness and Sport, 6th Edition, pb, 2002. New York: Mcgraw Hill. 15