CARE PLAN ON HYPOTHYROIDISM Subject:- Medical … on thyroid.pdf · Vertigo, malaise, headache,...
Transcript of CARE PLAN ON HYPOTHYROIDISM Subject:- Medical … on thyroid.pdf · Vertigo, malaise, headache,...
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CARE PLAN
ON
HYPOTHYROIDISM
Subject:- Medical Surgical Nursing-I
SUBMITTED TO: SUBMITTED BY:
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SUBMITTED ON: 15/01/2010
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CASE PRESENTATION
1. BIOGRAPHIC DATA:
Name : Mr. Mari Gowda
Age : 60 years
Sex : male
Address : #1 5, 1stcross,
batrayanpura, deepanjali Nagar
Bengaluru- 76
MRD No. : 223553
Education : Illiterate
Occupation : nil
Income : Rs. 2500 per month
Marital Status : Married
Religion : Hindu
Mother tongue : Kannada
Language known : Kannada, and telgu.
Ward : Medical ward
Date of admission : 14.01.2010
Diagnosis : Hypothyroidism.
2. HISTORY COLLECTION:
Chief complaints:-
Altered sensorium- 1 day
Anasarca (generalised edema) - 2 weeks
Generalised fatigue.
Present history of illness:-
Medical- Client was normal till 14.1.2010, suddenly he fainted and
became unconscious. Due to this, the client was brought to the hospital and
got admitted for further treatment.
Surgical- Nothing significant
Past history of illness:-
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Medical- Client is a known case of hypertension since 4 years back
and is on treatment. Client is also a known case of hyperthyroidism since 3
year back and is on tab Eltroxin.
Surgical- there is no history of any surgery done till date.
Personal Habits:-
Habits – he smokes and drinks alchohol.
Diet- he takes a mix diet, and usually eats two meals per day.
Sleeping habits- he sleeps atleast 5-6 hours per day, but not able to
sleep well the last 3-4 days due to weakness and joint
pains.
Hobby- his hobby is talking with people and .
Bowel and Bladder habits- he urinates atleast 4-5 times per day, and
his bowel pattern is regular, but for the
last 4-5 days her bowel pattern is
irregular.
Socialization- he socialises well with people and is a loving person.
Family history:-
There are four members in their family, his wife and two son. The
elder son is married and the younger son stays with him. There is no any
family history of DM, epilepsy or seizures
52 yrs
Sl
no.
Name Age Qualification/
Occupation
Relation to
Mr.marigowda.
Health status
1. Mr. Mari Gowda 6o yrs Illiterate. Client. Unhealthy
2. Mrs. Thayamma 52 yrs Illiterate wife healthy
3. Mr. Anand Gowda 38 yrs Class 8/ Autodriver Son Healthy
6o
yrs
38yrs 34 yrs
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4. Mr. Moti Gowda 34 yrs Class 9/ autodriver Son Healthy
Socio- economic status:-
Condition of the house- the client lives in there own house with his son,
which is pucca and concrete with single rooms including the kitchen. They used gas stove for
cooking. The house is supplied with electricity.
Water supply- water supply is from the corporation.
Drainage system- closed drainage system.
Surrounding environment- their surrounding environment is clean.
3. PHYSICAL EXAMINATION:
Vital signs:-
Temperature : 98.20 F
Pulse : 88 beat per minute
Respiration : 20 per minute
Blood Pressure: 160/100 mmHg
Height and weight:-
Height: 166 cm
Weight: 92 kg
General appearance:-
Constitution : obese
State of nutrition : Good
Personal appearance: Normal
Posture : Normal
Skin and hair : Fair complexion
Emotional state : Anxious
Co-cooperativeness: cooperative
HEAD TO FOOT EXAMINATION:-
Head:
Skull - has no abnormalities noted.
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Hair - grey hair, hair distribution normal
Movement of head- has full range of movement
Fore head - no scar or lesion noted
Face - facial puffiness present.
Eyes:
Eye brows- equal and even distribution
Eye lids- no lesion or scar noted.
Lacrimation- clear fluid expression
Conjunctiva- appears pale and clear
Sclera - appears white
Cornea - appears moist
Irish pupil - appears round and central in the sclera.
Pupil - PERRLA
Ears:
Appearance- no mass or lesion noted
Discharge - None
Hearing - normal
Lesion - none
Nose:
Appearance - no septum deviation
Discharge - none
Patency -both nostrils are patent
Sense of smell- good
Mouth and throat:
Lips - dry
Tongue - coated tongue
Teeth - molar and pre-molar absent in both sides
Gums - black
Buccal mucosa- no lesion and ulceration
Tonsil - not palpable
Taste - normal
Neck:
General appearance- normal
Lymph nodes - not palpable
Thyroid glands - not palpable
Cysts and tumour - absent
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Chest:
Inspection- size and shape are normal
Palpation- no local swelling noted
Auscultation- bilateral crepts present
Abdomen:
Inspection- normal in shape, no abnormalities
Palpation- no organomegally
Percussion- no fluid filled spaces found
Auscultation- peristalsis movement present, bowel sound absent.
Spine and back:
Spine and curvature- no lordosis or kyphosis noted.
Movement - all movement are normal
Tenderness - no tenderness noted
Genitalia:
No discharge noted, normal.
Upper and lower extremities:
Upper- normal movement, no lymph node enlargement noted
Lower- normal anatomically. Bilateral pitting pedal edema present.
Skin:
Colour of skin- fair complexion
Edema- generalised edema present
Moisture- dry
Turgor- moderate
SYSTEMIC ASSESSMENT:-
Nervous system:
Conscious- client is conscious
Orientation- oriented
Obeys commands- yes, client obeys commands.
Altered sensorium – no.
Cardiovascular system:
S1- present
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S2- present
S3- absent
S4- absent
Murmur- present (mild)
Respiratory system:
Inspiration & expiration- present
Respiration rate- 20 per minute
Ronchi/ wheezing- present
Gastro-intestinal system:
Peristalsis movement- absent
Bowel pattern- irregular
Organomegally- absent
Urinary system:
Frequency- 5 to 6 times per day normally
Burning micturation- absent
Catheterization- present; Input = 1000ml, Output = 800ml
Urine colour- dark straw colour
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4. INVESTIGATION:
Sl
no.
Investigation Patient’s value Impressi
-on
Normal value
1.
2.
3.
4.
Thyroid Profile
Liver Function
Test (LFT)
USG abdomen
Echocardiography
28/12/2009
T3= 64.21 ng/dl
T4= 7.57 g/dl
TSH= o.3 µU/ml
12/01/2010
T3= 56.10 ng/dl
T4= 6.56 ng/dl
TSH= 0.377 µU/ml
28/12/2009
Total Bil.= 1.1mg/dl
Direct Bil.=0.5 mg/dl
SGOT (AST)=62 IU
SGPT (ALT)=35 IU
Serum Alkaline phosphate= 268
Serum Total protein= 5.5 g/dl
Serum Albumin=2 g/dl
28/12/2009
Normal
28/12/2009
Sclerotic aortic valve
Mild MR
Normal chambers
Low
Normal
Low.
Low
Normal
Normal
Normal
Normal
High
Normal
High
Normal
Normal
-
Sclerotic
aortic
valve
and mild
T3= 75-195 ng/dl
T4= 4- 12µg/dl
TSH= 0.5-5.0 µU/ml
Total Bil.= upto 1mg/dl
Direct Bil= upto 0.4 mg/dl
SGOT= 8-40 IU
SGPT= 8-40 IU
S. Alkaline phosphate= upto
104 U/L
S. Total protein= 6.0-8.4 g/dl
Serum albumin=3.5-5.0 g/dl
-
-
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5.
Complete Blood
Count Test
Normal LV function
Large left Pleural effusion
28/12/2010
Hb. = 8.1 gm/dl
Total WBC= 4,700 c/cmm
Neutrophil= 69%
Lymphocytes= 27%
Eosinophils= 02%
Monophil= 02%
Basophil= 00%
ESR= 40 mm/hr
MR.
Low
High
Hb. =12-16 g/dl
Total WBC= 5-10,000 c/cmm
Neutrophil=
Lymphocytes=
Eosinophils=
Monophil=
Basophil=
ESR= 1-2 mm/hr
Sl
no.
Investigation Patient’s value Impressi
-on
Normal value
6.
7.
8.
Haemogram
Biochemistry
Haematology
peripheral smear
PCV= 26%
RBC= 3.9million/cmm
Platelet count= 1.7 lac/ cmm
MCV= 66 fl
MCH= 21 pg
MCHC= 32%
FBS= 99 mg/dl
PPBS= 121 mg/dl
BUN= 7.9 mg/dl
S. Creatinine= 0.7 mg/dl
Erythrocytes- are microcytic
hypochromic cells with
macrocytes and good number of
target cells. No evidence of
haemolysis.
Leucocytes- normal in number,
morphology and distribution.
Thrombocytes- normal in
number and morphology. No
hemoparasites found.
Normal
Low
Normal
Normal
Normal
Normal
Microlyti
c
hypochro
mic
anaemia
PCV= 40-50%
RBC= 4.5-6.5million/cmm
Platelet count=1.5-3.5 lac/cmm
MCV= 86-98 fl
MCH= 27-32 pg
MCHC= 32-36%
FBS= 110-126mg/dl
PPBS= <200mg/dl
BUN= 8-25 mg/dl
S.Creatinine= 0.6-1.5 mg/dl
-
5. MEDICATION:
Sl
no
Medication Dose,
route &
time
Action of drug Side effect Nursing
responsibility
1. Tab. Eltroxin 100 mg Stimulates metabolism Insomnia,
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2.
3.
4.
5.
6.
7.
Inj.
hydrocortisone
Inj.
Ceftriaxone
Inj. Rantac
Inj. Metrogyl
Tab. Avas
Tab. Telma
Orally
OD
100 mg
IV
BD
1 gm
IV
BD
100 mg
IV
BD
100 ml
IV
TDS
10 mg
Orally
OD
40 mg
Orally
OD
of all body tissues by
accelerating rate of
cellular oxidation.
Decreased
inflammation. mainly
by stabilising leukocyte
lysomal membranes;
suppresses immune
response, stimulates
bone marrow and
influence protein, fat
and CHO metabolism
A 3rd generation
cephalosporin that
inhibits cell wall
synthesis, promoting
osmotic instability,
usually bactericidal.
Competitively inhibits
action of histamine on
the H2 at receptor sites
of parietal cells
decreasing gastric acid
secretion.
A direct acting
trichomonocide and
amebicide that works at
both intestinal and
extra intestinal sites.
Inhibits calcium ion
influx across cardiac
and smooth muscle
cells, thus decreasing
myocardial contractility
and oxygen demand.
Blocks the
vasoconstricting and
aldosterone secreting
effects of angiotensin II
by selectively blocking
the binding of
tachycardia,
palpation, diarrhoea,
vomiting,
arrhythmias, cardiac
arrest.
Headache, vertigo,
edema, arrhythmias,
glucoma, GI
irritation, easy
bruising,
hypocalcaemia,
muscle weakness,
skin eruption.
Thrombophlebitis,
anorexia, vomiting,
thrombocytopenia,
pain at the injection
site, anaemia.
Vertigo, malaise,
headache, blurred
vision, jaundice,
burning and itching
at the injection site.
Headache, vertigo,
seizures, abdominal
cramping, nausea,
rash, constipation,
anorexia.
Headache, fatigue,
flushing, nausea,
abdominal pain,
dyspnoea, rash,
pruritis.
Dizziness, pain,
fatigue, headache,
nausea, UTI, back
pain, flu like
symptoms.
- check vital signs.
- follow strictly the
five rights.
- monitor closely the
patient for any side
effect of the drugs
given.
-observe the site of
injection carefully.
check vital signs.
- follow strictly the
five rights.
- monitor closely the
patient for any side
effect of the drugs
given.
check vital signs.
- follow strictly the
five rights.
- monitor closely the
patient for any side
effect of the drugs
given.
check vital signs.
- follow strictly the
five rights.
- monitor closely the
patient for any side
effect of the drugs
given.
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Nursing diagnosis
(Problem identified)
1. Activity intolerance related to weakness and apathy secondary to a
decreased metabolic rate.
2. Constipation related to decreased peristalsis secondary to slowed
metabolic rate and activity intolerance.
3. Skin integrity, risk for impaired related to edema and dryness
secondary to infiltration of fluid into interstitial spaces.
4. Knowledge deficit regarding disease condition related to lack of
exposure.
8.
Cap. Becosule
1 cap
Orally
OD
angiotensin II to the
angiotensin I receptor
in many tissues.
Multi-vitamins.
-
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APPLICATION OF THEORY
Name : Mr. Mari Gowda
Age : 60yrs
Sex : male
Ward : Medical ward
Present complaints : altered sensorium and decreased physical activity
Diagnosis : Hypothyroidism
Theories applicable:
i) Dorothy E. Johnson Behavioural System Model
ii) Sister Callista Roy Adaptation Model
iii) Orems self care deficit theory
iv) Martha Rogers Unitary Human Model
In this case i am going to give care according to the Betty Neumann theory.
BETTY NEUMANN MODEL
This theory offers a holistic view of the client system including system
including the concept of open system, environment, stressors, prevention and reconstitution.
Nursing is concerned with whole person and dyanamic composes of relationship between
physiological, psychological, sociocultural, developmental, spiritual, and variables. The client
is view as aopen system in interaction with environment.
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MAJOR CONCEPTS AND DEFINITIONS
The major concepts plentified in the model are holistic client approach open system, basic
structure, environment, created environment, stressors, lines of stressors, lines of defence and
resistance, degree of reaction, prevention, reconstruction, content, negenetrophy, entrophy,
stability, and wellness and illness.
PREVENTION AS INTERVENTION
Intervention is a purposeful action to help client to retain or maintain system stability. It can
occur before or after resistance of lines are penetrated both reaction and reconstitution phases.
Intervention are based on the possible or actual degree of reaction, resource goal, and the
anticipated outcome. Neumann identifies three level of prevention such as primary,
secondary and tertiary.
PRIMARY PREVENTION
Primary prevention is carried out when stressors is suspected or identified. A reaction has not
yet occurred or intervention would perhaps attempt to reduce possibility of the individual
encounter with the stressor or in the same way to attempt to strengthen the individual.
Flexible line of the defence internal lines of defence. Strengthen the individual. Flexible lines
of resistance to decrease the possibility of the reaction.
SECONDARY PREVENTION
Involves intervention or treatment after symptoms from stressors from stresses have accured.
Both the clients internal and external sources used towards stabilization to strengthen the
internal lines of resistance, redujce the reaction, reduce the reaction and increase the
resistance factors.
TERTIARY PREVENTION
A primary goal is to strengthen resistance to stressors by reduction to have prevent recurrence
or regression.
NURSING CARE OF MR. MARIGOWDA WITH NEUMANNS MODEL
Assessment data
The case history is considered in the neumanns model according to five client variable.
Physiological variables
This variables are described hypothyroidism, which is congenital heart diseases. This also
describes the hypertention with obesity.
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Temperature 990F
Pulse 74 b/min
Respiratory rate 32 breaths/min
Blood pressure 170/110
S1 and S2 sounds are heard.
Abdomen: No organomegaly, no fluid accumulation found. Amd peristalysis sounds heard.
Upper extremities and lower extrimities are normal, no edema.
Nervous system; conscious, orientation to time place and person is good.
Investigation revealed normalicity.
Physiological variables
These variables paint a picture of very anxious aged man concerned about his future and he
know that he has very little time left. His family is worried about his illness but never tried to
reveal it out.
Sociocultural pattern
Mr.marigowda has a formal up to 5th std and having good relationship with his family
members. Family is fully supporting his in unhealthy condition and also psychologically.
Developmental variables
Mr.marigowda 60 yr old man and is a father and also a grandfather. he has left her grand
children at home and is worried about them.
Spiritual variables
Mr.marigowda is a God fearing man, he does puja regularly and also visits temple regulary
before when he was well. he believes that illness is a punishment from God and it is due to
sin.
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Flexible line of defence normal line of defence
Line of defence
Basic Structure - Mr. mari gowda
60years old - male - Dependent - Hypothyroidism
Nursing diagnosis
- Activity intolerance related to weakness and apathy secondary to a decreased metabolic rate.
- Constipation related to decreased peristalsis secondary to slowed metabolic rate and activity intolerance.
- Skin integrity, risk for impaired related to edema and dryness secondary to infiltration of fluid into interstitial spaces.
- Knowledge deficit regarding disease condition related to lack of exposure.
Intervention
Primary intervention Reduce the possibility of becoming depressed by increasing dependence and assistance to feed her Secondary prevention proper treatment of hypothyroidism tertiary prevention facilitate Mrs. Nagamma to adapt with stress
Evaluation
Mr.mari gowda
adapt with stress
and accept her
present condition
and treatment
regimen
Interpersonal Mr. mari gowda is afflicted with hypothyroidism Intrapersonal he is with his family members Extrapersonal Unable to do any physical activity
Physiological
Hypothyroidism and
hypertension with obesity
Psychological- anxious
Sociocultural- diminished
socialization
Developmental- 60 year old
unable to adjust hospitalisation
Basic structure
Energy sources
Basic structure
Energy source
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Nursing diagnosis
(problems identified)
1. Activity intolerance related to weakness and apathy secondary to a decreased metabolic rate.
2. Constipation related to decreased peristalsis secondary to slowed metabolic rate and activity intolerance.
3. Skin integrity, risk for impaired related to edema and dryness secondary to infiltration of fluid into interstitial spaces.
4. nutrition Imbalanced more than body requirements related to calorie intake in excess of metabolic rate as evidenced by
hypometabolism and weight gain
5.Therapeutic regimen management ineffective related to lack of knowledge regarding medication as manifested by questioning
of long term effects.
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Nursing theory
applied
Subjective and
objective data
Nursing
diagnosis
Goal Planning Implementation Evaluation
Betty neuman
theory
The clients line
of resistance is
broken and she is
in secondary
prevention stage
as the treatment
initiated after the
symptoms from
stress have
occurred. The
stressors are
interpersonal and
the physiological
variable is
affected
Sub: how will I reduce
my weight
Obj: the weight of the
patient has increased to
92 kgs, recommeneded
to reduce the weight
Imbalanced
nutrition more
than body
requirements
related to calorie
intake in excess
of metabolic rate
as evidenced by
hypometabolism
and weight gain
To maintain and meet
nutritional needs
-determine patients
desire and
motivation in weight
reduction
- Plan an exercise
program taking into
patients limitations
- Chart progress
towards reaching a
final goal and post a
strategic location
- encourage use of
internal reward
system when goals
are accomplished.
- determine the goals
to attain the
nutritional level by
collaborating with
the dietician
- monitor the intake
and output chart
Weight the patient
regularly and
accordingly give the
nutritional needs.
-Determined the
desire of the
patient
-Planned an
exercise to be done
every day to
reduce weight
- charted the
progress
-Encouraged the
internal reward
system when the
goal was
accomplished
- determined the
nutritional level be
collaborating the
dietician
- monitored the
intake and output
chart.
- weighed the
patient regularly.
Maintained
and
achieved
optimum
wiegth
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Nursing theory
applied
Subjective and
objective data
Nursing
diagnosis
Goal Planning Implementation Evaluation
Betty neuman
theory
The clients line
of resistance is
broken and she is
in secondary
prevention stage
as the treatment
initiated after the
symptoms from
stress have
occurred. The
stressors are
interpersonal and
the physiological
variable is
affected
Sub: I cannot pass
motion for last 3 days
Obj: no bowel sounds
heard during purcussion
Constipation
related to
gastrointestinal
hypomotility as
evidenced by
irregular hard
stools
Experience regular
and soft stools to
pass
-Encourage
increased fluid
intake to maintain
soft stools
- Instruct the patient
on high fibre diet to
increase knowledge
regarding of to
increase fecal mass
- monitor bowel
movements
including frequency,
consistency, shape
and volume
- suggest to the
physician to
laxatives and stool
softners to stimulate
GI motility.
- prescribe better
nutrition for the
patient.
-Encouraged the
patient to increase
the fluid
-Instructed the
patient on high
fibre diet
-Monitored the
bowel movements
regularly
-Suggested the
physician for the
stool softners and
dulcolex was given
-Prescribed needed
nutrition for the
patient
Now the
patient has
no
constipation
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Nursing theory
applied
Subjective data and
objective data
Nursing
diagnosis
Goal Planning Implementation Evaluation
Betty Neumann
theory
The clients line
of resistance is
broken and she is
in secondary
prevention stage
as the treatment
initiated after the
symptoms from
stress have
occurred. The
stressors are
interpersonal and
the physiological
variable is
affected
Sub: I cannot do my own
works, I am feeling
fatigue
Obj: patient is seen very
weak, needed ssome rest
Acivity
intolerance
related to
decreased
metabolic rate
and mucin
deposits in joints
and interstitial
space as
evidenced by
generalized
weakness and
muscle and joint
stiffness
To participate in self
care in daily living
Determine the
patients physical ,
social and
psychologic
capabilities
-Monitor the patient
for evidence of
excess physical and
emotional fatigue
-Monitor patients
oxygen response
with the vital signs
regularly
-Promote bed rest
and activity
limitation
-Plan activities for
periods when the
patient has the most
energy to allow
maximum
participation.
-Dtermined the
patients
capabilities
-Monitored the
patient for physical
and emotional
fatigueness
-Monitored
patients oxygen
response with the
vital signs
-Promoted bed rest
and activity was
limited
-Planned activities
when the patient
had most of the
energy
The patient
is able to
participate I
self care and
in daily
living
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Nursing theory Subjective and objective
data
Nursing
diagnosis
Planning or goal. Intervention. Implementation Evaluation.
Betty neuman
theory
The clients line
of resistance is
broken and she is
in secondary
prevention stage
as the treatment
initiated after the
symptoms from
stress have
occurred. The
stressors are
interpersonal and
the physiological
variable is
affected
Subjective data.
Patient says that he
doesn’t know about
medications and has
plenty of doubts about
his condition.
Objective data:
On observation he asks
many questions and does
things unconvincingly.
.
therapeutic
regimen
management
ineffective related
to lack of
knowledge
regarding
medication and
diet as manifested
by questioning of
long term effects.
To improve the
knowledge of the
patient about his
condition ,.
Asses the knowledge
level of the patient .
Explain factors that
contribute to disease
factor.
Instruct patient on
home care measures
related to excercise ,
and prevention of
complication .
Provide written
instruction s of
prescribed
medication.
Advice him for the
regular follow up.
Assessed the
knowledge of
patient to know
his level of
knowledge about
his condition.
Explained factors
that contribute to
disease condition.
Instructed patient
on home care
measures about
excersice and
prevetion of
complication.
Every thing which
is related to his
health is given in
written format to
help in improving
his knowledge.
Adviced patient to
come for regular
follow up.
knowledge
of the
patient
about his
condition
,exercises,
and the
treatment
regimen is
improved to
some
extent.
A COMPLETE COACHING FOR THE PREPARATION OF STAFF NURSE/AIIMS/PGI/RPSC/ B.Sc NURSING.
/M/Sc.NURSING BY SAHU SIR-894787914
Conclusion.
Patien named marigowda admitted with altered sensorium, fatigue, generalised edema and he
was diagnosed has hypothyroidism, and he was treated now he is improving gradually, his
consiousness is improving and edema is reducing.
Bibliography.
Lewis SM,Heitkemper MM,Dirksen SR.medical surgical nursing,assessment and management of clinical problems.6th ed.missouri:mosby;2004.p.1319-22.
Suzane cs,Brenda gb,jonice lh, Textbook of Medical-Surgical Nursing.10th ed.wolters klwwer; 2004.p1215-21.
Silverstri LA..comprehensive review of nclex.rn.examination .3rd ed.pennylvania:saunders;2006.p.637-37
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