J T  is a 28-year-old female patient who is visiting her nurse practitioner for her yearly physical examination. During the assessment, the practitioner notices significant swelling in the front of the patient's neck. The nurse practitioner orders laboratory studies, ultrasonography, and a computed tomography (CT) scan of the thyroid. The patient is diagnosed with thyroid cancer, and a total thyroidectomy is performed. On the first operative day, J.T. says she feels tingling around her mouth and in her fingers. She feels like her heart is "skipping beats."

1. What would the nurse recognize the problem J.T. is having and what would be the nursing considerations?
2. The patient is beginning thyroid hormone replacement with levothyroxine (Synthroid), and she has some questions for the nurse. J.T. asks how long she will need to take levothyroxine. How will the nurse respond?
3. J.T. would like to know if there are any adverse effects associated with this medication. How will the nurse respond?

 

N.B., who has type 2 diabetes, is 26 weeks pregnant and placed on insulin therapy during pregnancy. She asks about why she is unable to take her oral medication as usual.1. The patient asks how a pill will lower his blood sugar. How will the nurse respond?

1. What is the nurse's best response?
2. N.B. is concerned about how her diabetes can affect her baby. What teaching points would the nurse provide?
3. N.B. asks why her insulin dose continues to increase after 20 weeks of gestation and is worried something is wrong. What information should be provided to N.B.?

Case 1

1. What would the nurse recognize the problem J.T. is having and what would be the nursing considerations?
2. The patient is beginning thyroid hormone replacement with levothyroxine (Synthroid), and she has some questions for the nurse. J.T. asks how long she will need to take levothyroxine. How will the nurse respond?
3. J.T. would like to know if there are any adverse effects associated with this medication. How will the nurse respond?

Case 2

1. What is the nurse's best response?
2. N.B. is concerned about how her diabetes can affect her baby. What teaching points would the nurse provide?
3. N.B. asks why her insulin dose continues to increase after 20 weeks of gestation and is worried something is wrong. What information should be provided to N.B.?

Answers:

Case 1

1. The patient might be expeciencing Hypocalcemia which may be most commonly caused by Hypoparathyroidism brought about by the Total Thyroidectomy. The patient shows signs of Chvostek's sign (tingling around the mouth), Trousseau's sign (tingling of the fingers), and palpitations described by the patient as Skip beats. If the patient is symptomatic, IV calcium gluconate ! ampule in 500ml D5W should be administered for 5 hours intravenously. The nurse should give the patient 3g of elemental calcium by mouth as soon as patient is able to swallow. The ionized calcium should also be monitored every 8 hours after thyroidectomy. If calcium values are decreasing, increase dosage to 4g per day. If calcium is stable or increasing, titrate calcium to 1g TID for a week, then 1g BID for a week, then 1g QID for week until discontinue by the doctor.
2. The nurse will inform the patient that she will need to take Levothyroxine for the rest of her life. Levothyroxine would serve as synthetic thyroid hormones which is important for the body's metabolism. Inform patient to not stop taking Levothyroxine without talking to the doctor.
3. Inform the patient that the medication has adverse effects. These include angina, arthralgia, congestive heart failure, flushing, increased pulse, myocardial infarction, palpitations, arrhythmias, cramps, diarrhea, nervousness, anxiety, headache, heat intolerance, insomnia, myasthenia, pseudomotor cerebri, alopecia, weight loss, infertility, dysphagia, fever, tachycardia, tremor, decreased bone mineral density, muscle weakness, muscle spasm, hair loss, and rashes.

Sources:

• Medscape
• https://medicine.uiowa.edu/iowaprotocols/calcium-management-thyroidectomy-patients-hypocalcemia

Case 2

1. Patient is not able to take her usual oral medication because oral hypoglycemics are not taken during pregnancy because these are teratogenic and may have hypoglycemic effect to the fetus. These medications have different subclasses and work in various ways. One example would be the Sulfonylureas which stimulate the beta cells of the pancreas to produce insulin which lower blood sugar levels by allowing them glucose to enter the cells.
2. Diabetes can affect the baby in many ways. Babies of diabetic mothers have a higher chance of developing obesity and diabetes in the future. These can also result in Neonatal hypoglycemia, Macrosomia (Large baby), Jaundice, Stillbirth, Miscarriage, Birth defects, Fetal growth restriction, and Respiratory distress.
3. It is normal that the insulin dose increases because of the increasing demand of the fetus for glucose and the continuous lowering of maternal fasting and blood sugar levels in between meals to prevent hypoglycemia. This is done to control post-prandial surges in glucose.

Sources:

• Medscape