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On arrival to the hospital, Rachel’s vital signs are: temperature 104.5° F, blood pressure 144/68, pulse 158, and respiratory rate of 32. The cardiac monitor shows sinus tachycardia and oxygen saturation is 96%. The patient is restless with tremors noted. The following physical assessment information was obtained: pupils are equal, round, and reactive to light; skin is warm, moist, and face is flushed; mucus membranes are moist, no jugular vein distention, no lymphadenopathy, no nuchal rigidity, and a slightly enlarged palpable thyroid gland is noted. Lungs are clear to auscultation. Cardiac exam reveals tachycardia, but regular rhythm without murmur, rub or gallop. Abdomen is soft and non-tender. Bowel sounds are hyperactive. Pedal pulses present, no pedal edema noted. Social history includes that Rachel is single and lives with her roommate. She graduated from college 6 months ago and works as a waitress. The patient is presently without health insurance and family lives several hours away. Rachel’s family has been contacted by phone and they report no history of any health conditions. She takes no regular medications other than birth control. She denies use of illicit drugs, but does drink alcohol 2 to 3 drinks weekly. Her roommate reports the patient has been in good health until recently and has noticed a significant weight loss in Rachel over the past 2 months. Rachel’s family is supportive and on the way to the hospital. Differential diagnoses include sepsis, drug toxicity, meningitis, psychiatric disorder, and thyroid storm. Various lab studies such as CBC, CMP, Glucose, Liver enzymes, BUN, creatinine, serum calcium, CPK, Free T4, T3, and TSH were ordered. Blood and urine cultures were negative. Chest x-ray findings were normal. Electrocardiogram shows sinus tachycardia at rate of 158 without ischemic changes. A lumbar puncture was performed with normal glucose and protein without white blood cells. Based on these findings, sepsis and meningitis were ruled out. Urine and blood toxicity screens were negative ruling out drug toxicity. The etiology being related to a psychiatric disorder seemed unlikely with evidence of high fever. Refer to Table 1 for a listing of pertinent lab results. Based on the findings of low TSH in the face of elevated T3 and T4 and the patient’s clinical presentation, a diagnosis of thyroid storm was made. Nursing Interventions Critical care nurses should rely on the use of assessment skills to recognize the hypermetabolic state of thyroid storm so that treatment is not delayed. The cardinal signs of thyroid storm include high fever, marked tachycardia, atrial fibrillation, heart failure, neurological symptoms such as agitation and restlessness, and gastrointestinal symptoms such as nausea, vomiting, and diarrhea (Kaplow & Hardin, 2007). Early recognition of this myriad of signs can improve outcomes and decrease mortality with thyroid storm. The treatment goals of thyroid storm include: 1) blocking the production of thyroid hormones in the thyroid gland 2) inhibiting release of hormones from the thyroid gland 3) beta adrenergic blockade 4) identification of the precipitating event and 5) supportive therapy (Kaplow & Hardin, 2007). Once symptoms are recognized, treatment should begin immediately and should not be delayed waiting for the return of lab results (Dulak, 2005). The patient should be admitted to the critical care unit. Immediate nursing interventions for supportive care should include establishing intravenous (I.V.) access for hydration and replacement of fluid and electrolytes lost from vomiting and diarrhea. A nasogastric tube should be placed to administer anti-thyroid medication if the patient is unable to swallow as these medications do not come in an available I.V. form. Oxygenation is a priority and blood gases should be evaluated and oxygen therapy initiated (Dahlen, 2002; Dulak, 2005; Young, 1999). Critical care nurses should be familiar with the regimen of medications administered during thyroid storm. The first medication administered should be an anti-thyroid medication such as propylthiouracil (PTU) which blocks the synthesis of thyroid hormones and inhibits the peripheral conversion of T4 to T3. The dosage is 200-250mg every 4 hours orally or via gastric tube. The nurse should monitor for signs of bleeding and a decreased platelet count. Methimazole, another anti-thyroid medication does not work in the periphery as PTU does; therefore, PTU is the anti-thyroid medication of choice during thyroid storm (Dahlen, 2002; Dulak, 2005; Kaplow & Hardin, 2007). One to two hours later, a potassium iodide solution such as Lugol’s solution should be administered to prevent the release of stored thyroid hormone into the system. Timing of this medication is important as early administration of iodide may cause the body to synthesize more T4, worsening the toxic state. The dosage is 8 drops every 6 hours orally or via gastric tube (Dahlen, 2002; Dulak, 2005; Kaplow & Hardin, 2007). Hydrocortisone administration is useful as the thyrotoxic state depletes cortisol from the adrenal glands. The nurse should administer 100mg I.V. every 8 hours and monitor glucose and electrolytes as well as for signs of fluid overload (Dahlen, 2002; Dulak, 2005; Kaplow & Hardin, 2007).
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