The main nursing problems in thyroid diseases. Nursing Process

Nursing process in diffuse toxic goiter. Diffuse toxic goiter (Graves' disease, thyrotoxicosis) - a disease characterized by increased secretion of hormones thyroid gland.
The main importance in the etiology of the disease is given to hereditary predisposition. In the occurrence of the disease are also important: trauma, infection (tonsillitis, influenza, rheumatism). solar radiation, pregnancy and childbirth, organic lesions of the central nervous system(CNS), diseases of other endocrine glands.
The main clinical manifestations of the disease are: an increase in the thyroid gland, increased excitability, irritability. tearfulness. The behavior of the patient, his character changes: fussiness, haste, resentment, hand tremor appear.
Complaints and anamnesis during questioning are presented by the patient poorly, often he fixes attention on trifles and misses important symptoms. Patients often complain of excessive sweating, poor heat tolerance, subfebrile temperature, trembling of the extremities, and sometimes of the whole body, sleep disturbance. significant and rapid weight loss good appetite. There are often changes from of cardio-vascular system: palpitations, shortness of breath, aggravated by physical exertion, interruptions in the region of the heart. Women often have a disorder menstrual cycle. Draws attention on examination appearance patient: facial expression often takes on an "angry" or "frightened" look due to eye symptoms and primarily due to exophthalmos (bulging eyes) and rare blinking. Greffe's symptom appears (lag of the upper eyelid when the eyes are lowered, while a white strip of sclera is visible) and Moebius's symptom (loss of the ability to fix objects at close range), eye shine and lacrimation. Patients may complain of pain in the eyes, sensations of sand, foreign body, double vision. On the part of the cardiovascular system, there is a pronounced tachycardia up to 120 beats. min, possible atrial fibrillation, increased blood pressure.

Nursing process in diffuse toxic goiter:
Patient problems:
A. Existing (real):
- irritability;
- tearfulness:
- resentment:
- palpitations, interruptions in the region of the heart:
- shortness of breath; pain in the eyes;
- weight loss:
- increased sweating;
- trembling of the limbs;
- weakness, fatigue;
- sleep disturbance;
- poor heat tolerance.
B. Potential:
- the risk of developing a "thyrotoxic crisis";
- "thyrotoxic heart" with symptoms of circulatory failure;
- fear of the possibility of surgical treatment or treatment with radioactive iodine.
Collection of information during the initial examination:
Collecting information from a patient with diffuse toxic goiter sometimes causes difficulties due to the peculiarities in her behavior and requires tact and patience from the nurse when talking with him.
A. Questioning the patient about:
- the presence of diseases of the thyroid gland in the next of kin;
- previous diseases, traumas of the central nervous system; features professional activity; connection of the disease with psychotrauma;
- the patient's attitude to sun exposure, tanning:
- the duration of the disease;
- observation by an endocrinologist and the duration of the examination, its results (when and where was the last examination);
- medicines used by the patient (vine, regularity and duration of administration, tolerability);
- for women, find out if the manifestation of the disease is associated with pregnancy or childbirth, and if there are any menstrual irregularities;
- complaints of the patient at the time of the examination.
B. Examination of the patient:
- pay attention to the appearance of the patient, the presence of eye symptoms, tremor of the hands, body;
- inspect the neck area;
- assess the condition skin;
- measure body temperature;
- determine the pulse and give it a characteristic;
- measure blood pressure;
- determine body weight.
Nursing interventions, including work with the patient's family:
1. Provide physical and mental rest to the patient (it is desirable to place him in a separate room).
2. Eliminate annoying factors - bright light, noise, etc.
3. Observe deontological principles when communicating with a patient.
4. Have a conversation about the essence of the disease and its causes.
5. Recommend a full-fledged diet with a high content of protein and vitamins, with a restriction of coffee, strong tea. chocolate, alcohol.
6. Recommend wearing lighter and looser clothing.
7. Ensure regular ventilation of the room.
8. Inform about the medicines prescribed by the doctor (dose, features of administration, side effects, portability).
9. Control:
- adherence to the regimen and diet;
- body weight;
- frequency and rhythm of the pulse;
- arterial pressure;
- body temperature;
- the condition of the skin;
- reception medicines prescribed by the doctor.
10. Ensure patient preparation for additional methods research biochemical analysis blood, a test for the accumulation of radioactive iodine by the thyroid gland, scintigraphy. ultrasound.
11. Conduct a conversation with the patient's relatives, explaining to them the reasons for the changes in the patient's behavior, reassure them, recommend being more attentive and tolerant with the patient.

Topic: "Nursing care for thyroid diseases:

diffuse toxic goiter, hypothyroidism"

Diffuse toxic goiter (DTG)- a disease caused by excessive secretion of thyroid hormones (thyroxine and triiodothyronine) by the tissue of the thyroid gland, leading to dysfunction of various organs and systems. DTG is a genetically determined autoimmune disease caused by the formation of specific thyroid antibodies that have a stimulating effect on the function of thyroid cells.

Causes:

mental trauma
dysfunction of the pituitary gland
hereditary predisposition

Complaints:

From the CNS : tremor of the fingers, a feeling of internal trembling, sleep disturbance, irritability, tearfulness, conflict in the family and at work
From the side CCC: palpitations, heart pain, shortness of breath on exertion
From the side of digestive system: increased appetite, increased stool (up to 3-4 times a day), weight loss,
From the side of eye: a feeling of feeling sand”, lacrimation, decreased visual acuity.
From the endocrine system:feeling of pressure in the neck, difficulty in swallowing, menstrual irregularities.

General complaints : increased sweating, fever to subfebrile numbers, constant feeling of heat, muscle weakness.

Objective research methods:

The patient has a youthful appearance,

Neck deformity (enlargement of the thyroid gland).

The skin is moist, warm, velvety to the touch

Reduction of the subcutaneous fat layer (weight loss)

Increase in body temperature.

Eye symptoms:

eye glitter
Shtelvig's symptom - a wide opening of the palpebral fissure (a close, "angry" look)
Mobius sign - violation of the convergence of the eyeballs
Graefe's symptom - the appearance of a white stripe when moving eyeball down between the edge of the upper eyelid and the edge of the cornea

CCC - tachycardia, atrial fibrillation; increased blood pressure (systolic)

CNS - tremor of fingers

Laboratory methods:

Clinical blood test (hypochromic anemia, leukopenia)
Blood test for thyroid hormones (increased levels of hormones T3 and T4, decreased levels of TSH)
Biochemical blood test (cholesterol level is lowered)
Blood sugar test (hyperglycemia)

Instrumental Methods:

131
Thyroid ultrasound

Treatment:

1. Hospitalization for moderate and severe thyrotoxicosis

2. Diet number 15 with a high content of protein and vitamins

3. Drug therapy:

Basic therapy - drugs from the group of thyreostatics - Mercazolil at a dose of 20-30 mg

per day (under the control clinical analysis blood)

Symptomatic therapy:

sedatives - valerian tincture, motherwort tincture,
small tranquilizers phenazepam, seduxen, etc.
cardiac glycosides - korglukon, strophanthin (with heart failure and atrial fibrillation).
- adrenergic blockers (anaprilin, obzidan) to normalize blood pressure and pulse rate

4. Surgical methods treatment - subtotal resection of the thyroid gland.

Complications:

thyrotoxic crisis,
exophthalmos, prolapse of the eyeball, clouding and ulceration of the cornea,
compression of the neck organs by an enlarged thyroid gland.

Disrupted satisfaction of needs:eat, drink, breathe, sleep, be clean, maintain body temperature, communicate, work.

Patient problems:

Irritability,
Tearfulness
heartbeat
Sleep disturbance
Increased stool
sweating
Conflict in the family and at work

Nursing care:

recommendations on the mode of work and rest
nutritional advice - inclusion in the diet of foods rich in protein and vitamins
psychological support for patients.
regular walks before going to bed, airing the room.
monitor heart rate, blood pressure, body weight
educate the patient about skin care.
change of underwear and bed linen
with exophthalmos recommend wearing dark glasses on sunny days
talk with the patient about the need to take thyreostatic drugs
teach relatives how to create a psychological climate in the family
teach relatives the rules for counting heart rate, respiratory rate, measuring blood pressure, weighing, thermometry

Medical examination:

Observation at the endocrinologist (control turnout as prescribed by the endocrinologist)
Examination by an ophthalmologist once every six months
ECG monitoring once every six months
Clinical blood test
Blood for sugar.
Control of blood pressure, pulse rate.

Hypothyroidism.

Hypothyroidism - a disease caused by a decrease in thyroid function or its complete loss.

Causes:

autoimmune thyroiditis
congenital aplasia of the thyroid gland
surgical treatment (subtotal resection of the thyroid gland)
drug exposure (mercasolil overdose)

Patient complaints:

lethargy, weakness, drowsiness
fatigue
memory loss
chilliness
aching pain in the heart, shortness of breath
muscle pain
hoarseness
hair loss
constipation
weight gain
in women, menstrual irregularities (may be infertile)
in men, decreased libido

Objective examination:

Appearance - adynamia, facial expressions are poor, speech is slowed down
Puffy face
The palpebral fissures are narrowed, the eyelids are swollen
Hoarseness of voice
The skin is dry, cold to the touch, dense swelling of the feet and legs (there is no fossa when pressed)
Body temperature is reduced
Weight gain
decrease in blood pressure,
The decrease in heart rate - less than 60 beats. per minute (bradycardia)

Laboratory and instrumental research methods

Laboratory methods:

Clinical blood test (anemia)

Blood chemistry:

Determination of the level of thyroid hormones (T3, T4 - the level is reduced)
Level thyroid-stimulating hormone(TSH) increased
The level of antibodies to thyroid tissue
Cholesterol level - hypercholesterolemia

Instrumental Methods:

Absorption of radioactive iodine J 131 thyroid gland (examination of thyroid function)
Thyroid Scan
Thyroid ultrasound

Treatment:

Diet number 10 (eliminate foods rich in cholesterol, reduce the energy value of food, recommend foods containing fiber)
Drug Therapy: Substitution hormone therapy: thyroxine, L-thyroxine

Complications :

1. Decrease in intelligence,

Need Disorders: eat, excrete, maintain body temperature, be clean, dress, undress, work.

Patient problems:

muscle weakness
chilliness
Decreased memory
constipation
Increase in body weight.

Nursing care:

Give recommendations on diet therapy (exclude foods containing animal fats, include foods rich in fiber - bran bread, raw vegetables and fruits, limit carbohydrate intake).
Control of frequency, pulse, blood pressure, weight control, stool frequency,
Teach the patient about personal hygiene.
Teach relatives how to communicate with patients
Train relatives in patient care.
Recommend wearing warm clothes during the cold season.
Follow doctor's orders.

Medical examination:

Regular follow-up visits to the endocrinologist.
Control of the level of thyroid hormones, cholesterol levels.
ECG monitoring once every six months.
Body weight control.

Test questions:

Define diffuse toxic goiter.
The main causes of the development of diffuse toxic goiter.
The main complaints in thyrotoxicosis.
The main eye symptoms in thyrotoxicosis.
Definition of hypothyroidism
Main clinical manifestations hypothyroidism

MOTIVATION

Thymus gland (thymus) located in the upper part of the anterior mediastinum and is the central organ of the immune system.

The thymus produces T-lymphocytes, hormones that regulate their maturation and differentiation (thymosin, thymopoietin, thymic factor, etc.), as well as insulin-like and calcitonin-like factors and growth factor.

The thymus gland reaches its maximum development in the early childhood, and from the age of 2, its involution begins.

adrenal glands located in the retroperitoneal tissue above the upper poles of the kidneys at the level of the XI-XII thoracic vertebrae. The adrenal glands are composed of the cortex and the medulla. The cortical substance produces more than 60 biologically active substances and hormones that affect metabolic processes. The main hormones are: glucocorticoids (regulate carbohydrate metabolism, have anti-inflammatory and desensitizing effects), mineralocorticoids (involved in the regulation of water-salt metabolism and carbohydrate metabolism), androgens and estrogens. The hormones of the medulla - adrenaline and norepinephrine - affect the level of blood pressure.

Pancreas located behind the stomach at the level of I-II lumbar vertebrae and has exocrine and intrasecretory functions.

Pancreatic hormones are synthesized in the islets of Langerhans: β-cells produce insulin, α-cells produce glucagon. Pancreatic hormones regulate carbohydrate metabolism, affect fat and protein metabolism.

By the time of the birth of a child, the hormonal apparatus of the pancreas is anatomically developed and has sufficient secretory activity. Insufficient production of insulin leads to the development of diabetes mellitus.

sex glands: ovaries girls, testicles in boys. The sex glands are already formed at birth, but begin to function intensively only by puberty. The hormones produced by them affect the growth and development of the body as a whole, determine the male or female type of body formation, character, and behavior. In girls, puberty begins at around 10 years of age, and in boys at around 11 years of age.
Nursing care for thyroid disorders
Hypothyroidism
Hypothyroidism- a disease characterized by reduced secretion of thyroid hormones as a result of direct damage to the thyroid gland (primary hypothyroidism) or dysregulation of its function by the hypothalamic-pituitary system (secondary hypothyroidism).

One of the most common causes of hypothyroidism in children is a congenital malformation of the thyroid gland. The frequency of congenital hypothyroidism is 1:4000-1:5000 among all newborns. Among children with congenital hypothyroidism, there are 2 times more girls than boys.

Causes of congenital (primary) hypothyroidism:

absence of the thyroid gland (agenesis);
its insufficient development in the process of embryogenesis (hypoplasia);
genetically determined defect in the synthesis of thyroid hormones;
autoimmune thyroiditis in the mother (damage to the gland by antithyroid antibodies);
x-ray or radioactive exposure;
insufficient intake of iodine in the body.

Acquired hypothyroidism is less common and occurs, as a rule, after a certain period of normal development of the child.

Causes of acquired (secondary) hypothyroidism:

violation of the hypothalamic-pituitary system, due to reduced production of thyroid-stimulating hormone (a hormone that stimulates the activity of the thyroid gland);
immunopathological lesion of the thyroid gland (autoimmune thyroiditis).

The mechanism of development of hypothyroidism.

Thyroid hormones are stimulants of metabolism, growth and development. They directly affect normal growth, the development of skin and skeleton structures, the maturation of the central nervous system, and carbohydrate and protein metabolism. Deficiency of thyroid hormones (T3-thyroxine and T4-triiodothyronine) leads to significant disturbances in the body's vital functions. In addition, intermediate products of the breakdown of substances accumulate in the body (in the integumentary tissues - mucinous substance, skeletal and cardiac muscles - creatinine), leading to degenerative changes in the body.

There are three clinical forms of hypothyroidism according to the severity of the course of the disease:

Light form.
Medium form.
Severe form (myxedema).

Congenital and acquired hypothyroidism in children has a similar clinical picture, in both cases, the processes of inhibition of all body functions predominate - a delay in the physical, mental and sexual development of the child. In this case, the changes are sharper, the earlier the disease occurs.

The main clinical manifestations of congenital hypothyroidism:

The disease usually manifests itself during the first weeks of the neonatal period. At the same time, all children suffering from a severe form are similar to each other:

large body weight at birth;
the face is unattractive, inexpressive, puffy, pale with an icteric tinge, the nose is large, the eyes are widely spaced, the palpebral fissures are narrow, the large, swollen tongue does not fit in the mouth, the mouth is half open;
the neck is short, thick, the hands are wide, the fingers are thick, short;
the skin is dry, edematous, with a yellowish tint, marbling and acrocyanosis are pronounced;
the hair is coarse, brittle, dry and sparse, the hairline on the forehead is down, the forehead is wrinkled, especially when the child cries, the voice is rough and low;

Puffiness of the face and trunk, large tongue, umbilical hernia in congenital hypothyroidism

supraclavicular fossae filled with myxedematous tissue, in addition, it is expressed on the back surfaces of the hands, eyelids, genitals;
the child is lethargic, drowsy, indifferent, sucks poorly, but there is an increase in body weight;
shortness of breath is expressed, breathing is noisy, stridor, there may be episodic respiratory arrests;
muffled heart sounds, bradycardia, arterial hypotension;
the abdomen is enlarged, there is often a delay in the fall of the umbilical cord residue for more than 3-4 days, later - umbilical hernia, flatulence, constipation (disorder of absorption and excretory function);

child with athyreosis

growth retardation gradually forms, maturation slows down bone tissue(seams, fontanel close late, teeth erupt);
in the absence of timely treatment, brain function is impaired, mental and physical development is delayed.

The main clinical manifestations of acquired hypothyroidism.

The disease develops, as a rule, after a period of normal development of the child. Gradually developing hypofunction of the thyroid gland noticeably changes the appearance of the child:

speech and movements slow down, the voice becomes rough, memory is disturbed, school performance worsens, indifference and lack of interest in the environment appear;
puffiness of the face is expressed, the skin becomes pale and dry, the hair is brittle and dry, chilliness, hypothermia;
muscle tone is reduced despite hypertrophy of the muscular system (due to interstitial edema and mucin deposition);
anemia associated with impaired absorption of vitamin B12 (due to insufficient secretion of gastromucoprotein) is detected;
growth is low, there is a lag in bone age (ossification nuclei appear late), body proportions are violated (if treatment is not carried out in a timely manner, dwarfism may develop);
sexual development slows down;
often there is a lack of independent stool.

Examination of the spectrum of thyroid hormones (decrease in the level of hormones - T3 and T4 and an increase in the blood content of the pituitary thyroid-stimulating hormone - TSH in primary hypothyroidism; a decrease in TSH - in secondary);
X-ray of the hand (delayed rate of ossification in the wrist joints in children older than 3-4 months);
Ultrasound of the thyroid gland (tissue hypoplasia).

Prevention.

Registration and monitoring of pregnant women with an unfavorable history of thyroid diseases or living in areas endemic for goiter.
Timely identification of children at risk for the development of hypothyroidism (children born to mothers with thyroid pathology, from regions of the country endemic for goiter, exposed to ionizing radiation, with thyroid hypoplasia, suffering from vegetovascular dystonia).
Holding replacement therapy with hypothyroidism throughout life.

Basic principles of treatment of hypothyroidism.

Replacement therapy should begin as early as possible, as a rule, combined synthetic thyroid drugs are prescribed - thyreotome, thyreocomb.
Additionally, vitamins A, group B are prescribed.
Neurotrophic drugs - piracetam, encephabol, cerebrolysin, pantogam.
Rehabilitation activities: massage, physiotherapy exercises, classes with a speech therapist.

Forecast.

With adequate replacement therapy for mild forms of congenital and acquired hypothyroidism, the prognosis is favorable. When treatment for congenital hypothyroidism is started after 2 months of age, the prognosis for normal mental development is uncertain.

Hyperthyroidism
Hyperthyroidism- a disease characterized by an increased content of active thyroid hormones in the blood, due to its dysfunction.

It is less common in children than in adults.

It is customary to single out:

Diffuse toxic goiter (Graves' disease, Graves' disease).
Diffuse non-toxic goiter (endemic goiter).

Risk factors for developing hyperthyroidism:

family-hereditary factor (presence among family members of patients with hyperthyroidism);
chronic foci of infection, reinfection;
adverse factors external environment(environmental, radiation pollution);
imbalance of trace elements in the diet;
exposure to various groups of drugs (especially with uncontrolled intake of thyroidin);
mental trauma, etc.

The mechanism of development of diffuse toxic goiter.

A disease of an autoimmune nature, based on a genetically determined defect in immunity with a predominant lesion of T-lymphocytes (suppressors). Dysfunction of T-lymphocytes leads to the production of thyroid-stimulating antibodies (TS-lg), which have the ability to stimulate the functional activity and reproduction of thyrocytes. As a result, there is an increased release of thyroid hormones into the bloodstream.

The mechanism of development of diffuse non-toxic goiter.

The disease occurs due to insufficient intake of iodine, which, as a rule, causes a compensatory increase in the production of biologically active triiodothyronine. According to the feedback mechanism, the production of thyroid-stimulating hormone (TSH) by the pituitary gland increases, and subsequently an increased sensitivity of thyrocytes to TSH is formed. The consequence of hyperproduction of thyroid hormones are violations of energy metabolism (decrease in ATP synthesis), tissue respiration, and metabolic processes.

There are several degrees of enlargement of the thyroid gland:

I degree - there is no visible increase in the gland.

II degree - the gland is visible when swallowing.

III degree - the gland fills the neck area between the sternocleidomastoid muscles.

IV-V degree - very large iron.
The main clinical manifestations of diffuse toxic goiter:

The disease is manifested, as a rule, by thyrotoxicosis:

the behavior and character of the child changes, excitability and emotional instability increase, unreasonable anger, sleep disturbance are noted;
typical symptoms of thyrotoxicosis are expressed: eye glitter, rare blinking, exophthalmos, lacrimation, tremor of the upper extremities;
warm skin, increased sweating hyperhidrosis), palms are wet, areas of hyperpigmentation appear;
changes in the cardiovascular system: pain in the heart, palpitations, tachycardia, which is stable;
the thyroid gland is enlarged (goiter);
weight loss is noted increased appetite and increased growth, especially in the initial period of the disease, accelerated maturation of bones and teeth;

exophthalmos, thyroid enlargement

glands in a 12-year-old patient with thyrotoxicosis

dyspeptic phenomena (loose stools) are often noted;
there may be a delay in pubertal development (with severe hyperthyroidism).

There are mild, moderate and severe forms of hyperthyroidism, usually independent of the size of the gland.

Diffuse non-toxic goiter can remain without clinical changes for many years while maintaining the euthyroid state.

Laboratory and instrumental diagnostics:

Study of the spectrum of thyroid hormones (with diffuse toxic goiter, the levels of T3 and T4 are increased, the level of TSH is normal or reduced, and with diffuse non-toxic goiter, the levels of T3 and T4 are normal or moderately reduced, and the content of TSH is increased).
X-ray of the hand (determination of bone age).
Ultrasound of the thyroid gland (various degrees of enlargement, the presence of cysts).

Basic principles of treatment.

At diffuse toxic goiter children are hospitalized.
Drugs with a thyrotoxic effect are prescribed - mercazolil or propylthiouracil for 2-6 weeks at the rate of 0.5-1 mg / kg for 3 doses per day, then the dose is reduced every 1-2 weeks by 5-10 mg to the maintenance dose, which is 2, 5-5 mg, it is given for 6-12 months, under the control of clinical indicators and the level of hormones in the blood.
In case of allergic reactions or large goiter, surgical treatment is indicated.
At diffuse non-toxic goiter, proceeding with an increase in the thyroid gland more than II degree and an increase in the level of TSH - long-term therapy with the maximum tolerated doses of thyroid hormones is indicated: L-thyroxine, thyroidin until the size of the gland normalizes, followed by gradual withdrawal of drugs.

Forecast.

Properly performed treatment for diffuse toxic goiter in many patients leads to recovery. With the ineffectiveness of conservative therapy resort to surgical intervention. Subtotal removal of the thyroid gland can be the cause of the development of hypothyroidism, which requires lifelong replacement therapy.

endemic goiter
endemic goiter- enlargement of the thyroid gland, which develops when iodine enters the body below daily requirement. The disease occurs, as a rule, in people living in endemic goiter areas. An area is considered endemic if the prevalence of an enlarged thyroid gland in children and adolescents reaches more than 5%, among adults more than 30%.

Etiology. The main role in the development of endemic goiter is given to iodine deficiency: iodine deficiency in the atmosphere, intake of iodine in an inaccessible form for absorption, hereditary disorders of iodine metabolism. The manifestation of iodine deficiency can contribute to concomitant diseases and physiological conditions (puberty, lactation). The living conditions, the cultural and social level of the population, the amount of microelements taken with food matter.

clinical picture. Clinical manifestations of the disease are determined by the functional state of the thyroid gland, its shape and size. The functional state of the thyroid gland in most cases is euthyroid. Preservation of the function of the gland is ensured by its compensatory increase. Long-term illness can lead to a decrease in thyroid function and the development of hypothyroidism.

Complications of endemic goiter are thyroiditis, malignancy is possible.

Treatment. In the case of diffuse endemic goiter with a slight degree of enlargement of the thyroid gland, iodine preparations are effective. In the absence of effect, as well as in the hypothyroid course, therapy with thyroid hormones and thyroid preparations is indicated. At increased function thyreostatic drugs are used. Indications for surgical treatment are nodular, mixed and diffuse forms of goiter IV-V degrees, accompanied by compression of the neck organs, atypical location of the thyroid gland, goiter with severe destructive changes.

Prevention. For prophylaxis in goiter-endemic areas, iodized table salt is used (group prophylaxis) or taking one antistrumine tablet once a week (individual prophylaxis).
Nursing care for congenital and acquired thyroid diseases.

To give truthful information to parents about the causes of thyroid diseases, their course and the prospects for the development of the child.

To identify real and potential problems in a timely manner and meet the vital needs of the child and his parents.

Possible problems for the child:

malnutrition;
violation of the function of vital organs;
high risk of concomitant infections (due to reduced immunity);
lag in physical, mental and mental development;
violation of self-care due to mental and mental retardation;
suffering about appearance;
lack of communication;
lack of family support.

Possible problems for parents:

stress, psychological discomfort;
feeling of guilt towards the child;
lack of knowledge about the disease and its causes;
difficulties in caring for a child, feeding, raising, teaching;
situational crisis in the family (material difficulties, job loss, the need for constant care for a problem child, etc.);
search for professionals who modern methods treatment and rehabilitation, etc.

Nursing intervention.

Support parents at all stages of realizing reality. Convince parents of the need for long-term replacement and maintenance therapy, monitor the effectiveness of ongoing therapy, when side effects notify the doctor.

Advise parents on the organization of nutrition of the child, adequate to his condition and age.

To help parents correctly assess the abilities and capabilities of the child, to teach them to control the level of their intellectual development. Encourage your child to be active. Advise to conduct classes with specialists (psychologist, speech therapist, etc.).

Teach parents to carry out the prevention of intercurrent diseases (avoid contact with sick children and adults, conduct general strengthening activities, massage, physiotherapy exercises).

To convince parents after discharge from the hospital of the need for dynamic monitoring of the child by doctors - a pediatrician, endocrinologist, neurologist, psychoneurologist, speech therapist and other specialists according to indications: up to 3 years of age quarterly, up to seven years - 1 time in 6 months, then annually up to 14 years. Every 6 months, it is necessary to carry out radiography of the hands (to track the bone age) until it matches the real age of the child.

To help families with children with hypothyroidism unite in a parent support group to jointly address issues of upbringing, education and social adaptation.

Patients in hypothyroid coma should be admitted to the intensive care unit or intensive care unit.

It is necessary to immediately take blood for the content of thyroid hormones, blood pH, glucose, sodium, chlorides, acid-base balance, record an ECG, perform catheterization Bladder. A progressive decrease in body temperature worsens the prognosis. To warm the patient, it is necessary to wrap the patient in blankets, gradually increase the room temperature. Heating pads, bottles with hot water use for warming is not recommended, as peripheral vasodilation appears, impairing blood flow internal organs(danger of collapse).

In a specialized hospital, the patient will be given IV L-thyroxine, IV glucocorticoids, to eliminate hypoglycemia - 40% glucose solution IV and 5% solution IV drip, to combat collapse - rheopolyglucin, 10% albumin solution, to increase blood pressure - angiotensinamide, with heart failure - cardiac glycosides (in a small dosage, since the myocardium in hypothyroidism is highly sensitive to glycosides), to improve metabolism in the myocardium - pyridoxal phosphate, lipoic acid, riboxin, cocarboxylase.

Urgent care in hypothyroid coma

General activities include: slow gradual warming of the patient is not higher than one degree per hour during hypothermia, hydrocortisone is administered intravenously (50-100 mg, daily dose up to 200 mg), prescribe thyroxine (daily dose of 400-500 mcg) as a slow infusion.

Along with this, oxygen therapy is carried out in combination with artificial ventilation of the lungs. Blood transfusion is indicated to treat anemia erythrocyte mass(the latter is preferred). Infusion therapy is carried out with great care, at the same time glucocorticoids are administered.

Vigorous antibiotic therapy is mandatory to suppress co-infection or prevent an outbreak of a dormant infection. In patients in a coma, atony of the bladder is constantly noted, therefore, a permanent urinary catheter is placed.

NURSING ACTIVITY IN HYPOTHYROISIS

Nursing uses a variety of theories and knowledge. This knowledge is used by the sister in informing the patient, teaching him and guiding him or guiding him.

Currently, the theory of Virginia Henderson is being applied. Within the framework of this theory, Henderson tried to highlight the basic human needs, the satisfaction of which should be aimed at patient care. These needs include:

1. Breath

2. Nutrition and fluid intake

3. Physiological functions

4. Motor activity

5. Sleep and rest

6. Ability to dress and undress independently

7. Maintenance of body temperature and the possibility of its regulation

8. Personal hygiene

9. Ensuring your own safety

10. Communication with other people, the ability to express their emotions and opinions

11. Ability to observe customs and rituals according to religions

12. Being able to do what you love

13. Recreation and entertainment

14. Need for information

Henderson is also known for her definition of nursing: “The unique function of the nurse is to assist the individual, sick or well, in carrying out such activities that contribute to the preservation or restoration of health, which he could provide for himself if he had the necessary strength, will and knowledge

Nursing Process- a scientific method of organizing and providing nursing care, implementing a plan for caring for therapeutic patients, based on the specific situation in which the patient and nurse.

The Purpose of the Nursing Process:

Ø identify real and potential problems in a timely manner;

Ø meet the violated vital needs of the patient;

Ø provide psychological support to the patient;

Ø Maintain and restore the patient's independence in meeting the daily needs of his daily activities.

Nursing process in hypothyroidism

Stage I: nursing examination (collection of information)

When questioning the patient: the nurse finds out

ü Increased fatigue

o hair loss

Stage II: identification of disturbed needs and problems of the patient

Possible violated needs:

physiological:

muscle pain

· hair loss

increase in body weight

Possible patient problems:

ü Aching pain in the heart, shortness of breath

ü in women, menstrual irregularities (may be infertile)

in men, decreased libido

lethargy, weakness, drowsiness

ü chilliness

ü memory loss

psychological:

Depression due to an acquired disease;

Fear of instability of life;

Underestimation of the severity of the condition;

Lack of knowledge about the disease;

Lack of self-service;

Care in sickness;

Lifestyle change

social:

Disability,

Financial difficulties in connection with a decrease in working capacity;

social isolation.

spiritual:

Lack of spiritual participation.

priority:

aching pain in the heart, shortness of breath

potential:

risk of developing complications.

Stage III: nursing intervention planning

The nurse, together with the patient and his relatives, formulates goals and plans nursing interventions for a priority problem.

The goal of nursing interventions is to promote recovery, prevent the development of complications and the transition to a more severe course.

IV stage: implementation of nursing interventions

Nursing interventions:

Dependent (performed as prescribed by a doctor): ensuring the intake of medications, performing injections, etc.;

Independent (performed by a nurse without the doctor's permission): recommendations on diet, measurement of blood pressure, pulse, respiratory rate, organization of the patient's leisure and others;

Interdependent (performed by a medical team): providing advice from narrow specialists, ensuring research.

Stage V: evaluation of the effectiveness of nursing interventions

The nurse evaluates the result of interventions, the patient's response to measures of assistance and care. If the set goals are not achieved, the nurse adjusts the nursing intervention plan

Manipulations performed by a nurse

BP measurement

Target: diagnostic.

Indications: doctor's appointment, preventive examinations.

Equipment: tonometer, phonendoscope, alcohol, tampon (napkin), pen, temperature sheet.

Stages	Rationale
I. Preparation for the procedure 1. Gather information about the patient. Kindly and respectfully introduce yourself to him. Clarify how to contact him if the nurse sees the patient for the first time	Establishing contact with the patient
2. Explain to the patient the purpose and sequence of the procedure	Psychological preparation for manipulation
3. Obtain consent to the procedure	Respect for patient rights
4. Warn the patient about the procedure 15 minutes before it starts, if the study is carried out as planned
5. Prepare the necessary equipment	Ensuring the effective implementation of the procedure
6. Wash and dry your hands
7. Connect the pressure gauge to the cuff and check the position of the pressure gauge needle relative to the zero mark of the scale	Checking the health and readiness of the device for operation
8. Treat the phonendoscope membrane with alcohol	Ensuring infectious safety
II. Performing the Procedure 1. Have the patient sit or lie down with the arm positioned so that the middle of the cuff is at heart level. Apply the cuff to the patient's bare shoulder 2-3 cm above the elbow (clothes should not squeeze the shoulder above the cuff); fasten the cuff so that 2 fingers fit between it and the upper arm (or 1 finger in children and adults with a small arm). Attention! Blood pressure should not be measured on the arm on the side of the mastectomy, on the weak arm of the patient after a stroke, on the paralyzed arm	Elimination of possible unreliability of the results (every 5 cm displacement of the middle of the cuff relative to the level of the heart leads to overestimation or underestimation of blood pressure by 4 mm Hg). Exclusion of lymphostasis that occurs when air is injected into the cuff and the vessels are clamped. Ensuring the reliability of the result
2. Invite the patient to put his hand correctly: in an extended position, palm up (if the patient is sitting, ask him to place a clenched fist of his free hand under his elbow)	Ensuring maximum extension of the limb
3. Find the place of pulsation of the brachial artery in the region of the cubital cavity and lightly press the membrane of the phonendoscope against the skin in this place (without effort).	Ensuring the reliability of the result
4. Close the valve on the "pear", turning it to the right, and inject air into the cuff under the control of a phonendoscope until the pressure in the cuff (according to the pressure gauge) does not exceed 30 mm Hg. the level at which the pulsation disappeared	Exclusion of discomfort associated with excessive clamping of the artery. Ensuring the reliability of the result
5. Turn the valve to the left and begin to release air from the cuff at a speed of 2-3 mm Hg / s, while maintaining the position of the phonendoscope. At the same time, listen to the tones on the brachial artery and monitor the readings on the manometer scale	Ensuring the reliability of the result
6. When the first sounds (Korotkov sounds) appear, “mark” the numbers on the pressure gauge scale and remember them - they correspond to the systolic pressure	Ensuring the reliability of the result. The systolic pressure values should match the readings on the manometer, at which the pulsation disappeared during the process of air injection into the cuff
7. Continuing to release air, note the diastolic pressure indicators corresponding to the weakening or complete disappearance of loud Korotkoff tones. Continue auscultation until the pressure in the cuff decreases by 15-20 mm Hg. relative to the last tone	Ensuring the reliability of the result
8. Round the measurement data to 0 or 5, record the result as a fraction (in the numerator - systolic pressure; in the denominator - diastolic), for example, 120/75 mm Hg. Deflate the cuff completely. Repeat the blood pressure measurement procedure two or three times with an interval of 2-3 minutes. Record averages	Ensuring a Reliable BP Measurement Result
9. Inform the patient of the measurement result. Attention! In the interests of the patient, reliable data obtained during the study are not always reported.	Ensuring the patient's right to information
III. Finishing the procedure 1. Treat the membrane of the phonendoscope with alcohol	Ensuring infectious safety
2. Wash and dry your hands	Ensuring infectious safety
3. Make a record, reflecting the results obtained and the patient's reaction in it	Ensuring continuity of observation

Note. At the first visit of the patient, the pressure on both hands should be measured, later on only on one, noting which one. If a stable significant asymmetry is detected, all subsequent measurements should be carried out on the arm with more high rates. Otherwise, measurements are carried out, as a rule, on the “non-working hand”.

The nursing process in hypothyroidism plays a very important role. The nurse is the doctor's right hand. She carries out all the appointments of the endocrinologist and makes sure that the patient of the hospital also clearly follows the instructions.

Being a paramedical staff, a nurse controls the work of nurses, nurses and nannies. The speed of recovery of a patient with hypothyroidism, his mental and physical condition upon discharge home depends on her professionalism and knowledge.

Hypothyroidism, or insufficiency of thyroid function, often becomes the cause of children or adults.

A hormonal disorder can be caused by a congenital or surgically acquired absence of the thyroid gland, a defect in the body's enzyme systems, pathogenic phenomena in the hypothalamus or pituitary gland.

Manifestations of hypothyroidism

Congenital pancreatic insufficiency is diagnosed immediately after the birth of a child. The pathology is characterized by a large weight of the baby, lethargy, drowsiness, a rough voice, a long torso and short limbs, dry, pale skin, a flat bridge of the nose and widely spaced eyes, and a voluminous stomach. At an older age, mental retardation, dystrophy, and disproportion of the skeleton are noted.

Acquired hormonal imbalance is manifested by:

pastosity of facial tissues;
memory impairment and lethargy;
thinning, brittleness and dryness of nails and hair;
cardiac arrhythmia, low blood pressure;
constant chilliness and constipation.

In severe cases, myxedema coma occurs.

Insufficiency of the thyroid gland is always difficult and requires not only specific treatment, but also all kinds of procedures to care for the patient. Often, patients are affected by the central nervous system, the neuropsychic state worsens, it becomes aggressive, capricious and irritable. Therefore, the nurse requires a lot of endurance, calmness and patience in relation to such patients.

Responsibilities of a nurse

The nurse plays one of the main roles in the production medical care population and the effectiveness of the services provided. The functions of a nurse are varied. They affect not only diagnostic and therapeutic measures, but also directly relate to the care of patients with the aim of their speedy recovery.

For a good nurse, stress resistance, accuracy, diligence, cleanliness, attentive attitude to patients, and, of course, special knowledge are very important. Therefore, there are certain requirements for the training of nurses.

A nurse, working with patients with hypothyroidism, must be qualified to carry out the following procedures;

independently collect the patient's history and carry out some diagnostic measures;
work with documents, fill out and store medical records, submit discharge forms;
monitor the physical and emotional state of the patient;
each nurse should be able to provide first aid in the absence of a doctor;
carry out the nursing process - carry out the necessary procedures (droppers, dressings, injections), distribute dosed norms of medicines;
be interested in the well-being of patients, prepare patients for tests and take them, measure temperature and pressure;
quickly and accurately follow the orders of the doctor.

In addition, the nurse must be well versed in the causes and symptoms of the disease, know the methods of therapy and correctly apply them.

Goals of nursing care for hypothyroidism

Nursing process in hypothyroidism is the care of the patient, in which his psychological and physical needs are fully satisfied. Possessing the necessary knowledge and skills, the nurse must inform and educate the patient, guide him.

There are specific goals for the nursing process in caring for patients with hypothyroidism.

They are as follows:

Detect existing and potential problems in a timely manner.
Satisfy the needs of the patient, provide an acceptable quality of life.
Provide moral support to the patient, his family and friends, inform them about the state of health and the course of the disease.
Maintain and restore the patient's independence in meeting daily needs.

Based on these points, the tactics of the nursing process for patients with hypothyroidism are built. A single goal may include many activities that contribute to its successful implementation.

Nursing process in hypothyroidism

For patients admitted to the hospital with a diagnosis of hypothyroidism, a special tactic of the nursing process has been determined, consisting of several stages. All of them are interconnected. Each stage of nursing care is another step towards achieving the main goal of treatment - the complete recovery of the patient.

Stage I - collection of anamnesis

This period includes a survey of the patient. The nurse reveals:

lethargy, apathy, fatigue, lack of interest in life;
hair loss, thinning and brittle nails;
chest pain, shortness of breath and other symptoms of hypothyroidism.

All collected information is analyzed by a nurse, and based on it, the explicit and hidden needs of the patient are determined.

Stage II - identifying the patient's problems

After taking an anamnesis, a nursing diagnosis is made and impaired needs are identified.

The problems of a patient with hypothyroidism are conditionally divided into existing ones that are currently worrying and possible ones (may appear in the future).

A survey conducted by a nurse reveals existing difficulties. Among them, the most common are:

psychological (stress, immersion in illness, low self-esteem, fear of losing a job);
social (lack of funds due to illness and long-term disability);
spiritual.

In the future, a sharp increase in body weight, constipation is possible. In women, there is often a violation of the monthly cycle and infertility.

Stage III - strategy of nursing interventions

During this period, the nurse, together with the patient and his family, plans nursing activities. The main goal of the nursing process is to speed up the recovery of the patient and reduce the risk of possible complications.

The nursing intervention plan should include both short-term and long-term issues.

Stage IV - implementation of nursing interventions

At this stage, the nursing process is carried out according to a plan agreed with the leading doctor and the patient or his relatives.

Nursing interventions are:

Dependents. Produced only by order of the doctor (appointment medicines and procedures).
Independent. Performed by a nurse independently (measurement of blood pressure, setting droppers, injections).
Interdependent.

At this stage, the nurse performs direct care for patients with hypothyroidism. It consists in thoroughly cleansing, moisturizing and softening the skin, as the skin becomes rough, dry and flaky.

At nursing care for often chilly patients it is necessary to control the temperature environment. If necessary, the patient should be offered a heating pad or an extra blanket.

Since the body temperature in this pathology reflects the degree of development of the disease, it is advisable to carry out thermometry several times a day.

Patients with hypothyroidism often suffer from low blood pressure and bradycardia, so the nurse needs to monitor blood pressure, committing all changes. With angina attacks, measures generally accepted in such cases are carried out.

Replacement therapy involves taking hormonal drugs, which are dosed and issued by a nurse strictly on time. In addition to drug treatment, patients are prescribed compliance, which helps to reduce the symptoms of hypothyroidism. Diet control is also part of the nursing process.

If a patient develops a myxedema coma, the nurse should immediately notify the doctor and do a test for the content of thyroid hormones in the blood. Then take ECG readings, measure blood pressure, conduct a bladder catheterization and warm the patient with blankets and increase the temperature in the room.

After providing the first support, the duties of a nurse are supplemented by regular infusion of levothyroxine and oxygen therapy. In the event of a developed collapse, injections of prednisolone, dopamine or are necessary. The treatment regimen is prescribed by a doctor.

Stage V - assessment of the nursing process

If, after all nursing interventions, a patient with hypothyroidism has a persistent improvement in well-being, we can talk about the effectiveness of nursing care.

In case of failure of the measures taken, the nurse corrects the plan of nursing interventions, coordinating it with the endocrinologist.

Hypothyroidism is quite serious illness which can lead to serious complications. The patient needs constant therapy to alleviate the condition and maintain the quality of life, so the nurse can become his friend and assistant for many years.