Abbreviation | Descriptor | Client Data |
|---|---|---|
| C | Character | Rough and dry Skin Loss of hair Constipation |
O | Onset | The symptoms started one month ago and got worse for the last two weeks. |
L | Location | Pains denies feeling any pain. |
D | Duration | The roughness and drying of skin started four months ago, but it subsided after two weeks. |
E | Exacerbation | The patients reports that her condition is not subsiding this time. |
| Radiation | The patient denies feeling pain. | |
R | Relief | A warm bath helps to relieve the skin of the patient. |
A | Antecedent | The cousin of the patient passed away four months ago and she was going through grief, however, she is not grieving now. |
A | Associated | The patient reports fatigue, and an effect on her elimination process. |
HPI: History of Present Illness
The patient shows signs of rough and dry skin and loss of hair. Also, she denies feeling pain in her body. However, she has reported having fatigue, and normal elimination in her body has been interfered with. The patient also reported that the itchiness and roughness on her skin started four months ago, but it subsided after two weeks. Every time the patient takes a warm bath, the discomfort in her skin lessens. The patient reported having lost a cousin four months ago; this caused her stress. However, she ascertained that she was not grieving anymore.
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Nursing Diagnosis
The patient will go through blood tests; since diagnosing hypothyroidism is determined by the results obtained from blood tests. The blood tests will ascertain the level of TSH and thyroid hormone thyroxin (Mayoclinic.org, 2020). When levels of thyroxin are low, and the TSH level is high; it illustrates that the patient is suffering from hypothyroidism. This condition occurs when there is an increased production of TSH, which tries to arouse the thyroid gland to release high levels thyroid hormone.
SMART Goal
For the patient to get better, she needs to use synthetic thyroid hormone daily. This medication helps to restore the level of hormones, thus reversing the symptoms of hypothyroidism (Mayoclinic.org, 2020). After the patients start their medication, they are likely to start feeling better since the medication will lower the levels of cholesterol and prevent weight gain. The levothyroxine is a lifelong treatment, but the dosage a patient requires might change, and the TSH level will be checked every year.
Intervention with Rationale
Besides medication, a patient should be advised to protect themselves against cold; since the symptoms of the disease worsens when they are exposed to cold (Nurseslabs, 2020). The patient should also include diets that are high in fibre to their meals; this will help to control bowel movement, thus reducing constipation and prevent weight gain.
References
Mayoclinic.org. (2020). Hypothyroidism - Diagnosis and treatment - Mayo Clinic . Mayoclinic.org. Retrieved 23 May 2020, from https://www.mayoclinic.org/diseases-conditions/hypothyroidism/diagnosis-treatment/drc-20350289.
Nurseslabs. (2020). Hypothyroidism Nursing Care Management: A Study Guide . Nurseslabs. Retrieved 23 May 2020, from https://nurseslabs.com/hypothyroidism/.
