aLlenL's lnlLlals Address Age Clvll SLaLus ulagnosls

ASSESSMENT
NURSING
DIAGNOSIS
INFERENCE GOALS
NURSINGINTERVENTIO
NS
RATIONALE EVALUATION

Subjective:
"Madali akong
mapagod,
pakiramdam ko
hinag hina ako "
verbalized by
patient.

Objective:

ODecreased
performance.

OJittery
behavior.

Orritability

OV/S taken as
follows:
T: 37.1
P: 108
R: 22
Bp: 120/80













Fatigue related
to hypermetabolic
state with
increased
energy
requirements.

Hyperthyroidism or
Thyrotoxicosis
(Grave's Disease) is
an over production of
thyroid hormone,
which creates far
reaching metabolic
effects.

Hypertrophy and
hyperplasia of the
thyroid gland
occur with increased
vascularity.

Most of the clinical
manifestations result
from increased
metabolic rate,
excessive heat
production, increase
neuromuscular and
cardiovascular
activity, and
hyperactivity of the
sympathetic nervous
system. The
condition is more
often in women than
men and occurs in
several form.

After 8 hours
of nursing
interventions,
the patient will
display
improved
ability to
participate in
desired
activities.
Independent:

OMonitor vital signs,
noting pulse rate at rest
and when
active.

ONote development of
tachypnea, dyspnea,
pallor,
and cyanosis.



OProvide quiet
environment, cool room,
decreased sensory
stimuli, soothing colors,
quiet music.

OEncourage patient to
restrict activity and rest in
bed as much as possible.

OProvide comfort
measures like judicious
touch and
cool showers.

OAvoid topics that irritate
or upset the patient.
Discuss
ways to respond to
these feelings.

4,-47,tive:

OAdminister
medications as
indicated like
sedatives

OPulse is typically
elevated and, even at
rest,
tachycardia (up
to 160 beats/min) may
be noted.

OOxygen demand and
consumption are
increased in
hypermetabolic state,
potential risk of
hypoxia with activity.

OReduces stimuli
that may aggravate
agitation, hyperactivity
and insomnia.

OHelp counteract
effects of increased
metabolism.

OMay decrease
nervous energy,
promoting relaxation.


Oncreased irritability
of the CNS may ause
patient to be easily
excited, agitated, and
prone to emotional
outburst.

OTo combat
nervousness,
hyperactivity,
and insomnia
After 8 hours of
nursing
interventions,
the patient was
able to display
improved ability
to participate in
desired
activities.