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Combating the beta-adrenergic effects of thyroid storm such as tachycardia, tremors, and restlessness involves the administration of a beta blocker. The nurse should expect to administer Propanolol 60-120mg I.V. every 6 hours. The patient should have continuous cardiac monitoring. Propanolol is the drug of choice because it not only has beta blocking properties to reduce heart rate, but it also blocks conversion of T4 to T3, thereby decreasing the overall thyroid hormone levels. Propanolol should not be used in patients with chronic lung disease due the potential for bronchospasm. In that case, a beta-1 selective blocker would be a better choice. (Dahlen, 2002; Dulak, 2005; Kaplow & Hardin, 2007). The critical care nurse can provide additional supportive care measures during thyroid storm. Interventions for alleviating the high fever associated with thyroid storm include use of a cooling blanket, ice packs, and fans. Shivering should be avoided as this can increase body temperature. Acetaminophen is the anti-pyretic of choice because aspirin or salicylates can increase the circulating levels of thyroid hormone. Treat dehydration and electrolyte imbalance with I.V. fluids, typically those containing dextrose to replace hepatic stores of glycogen depleted during thyroid storm. The patient should receive continuous cardiac monitoring to watch for life-threatening dysrhythmias and other interventions such as vagal maneuvers may be indicated to decrease heart rate. Insertion of a pulmonary artery catheter may be needed for hemodynamic monitoring for those patients who develop congestive heart failure (Dahlen, 2002; Dulak, 2005). Finally, once the patient is stabilized, the precipitating event for thyroid storm should be treated aggressively. This event may include severe infection in which case antibiotics will be administered. Most commonly the event is an undiagnosed hyperthyroid condition such as Grave’s disease. Treatments for Grave’s disease include radioactive iodine, anti-thyroid medications, or thyroidectomy (Dahlen, 2002; Dulak, 2005). Application of the Synergy Model Patient Characteristics The Synergy Model describes eight patient characteristics that provide a common ground for assessing each unique patient’s needs along a continuum from health to illness (Curley, 1998). These characteristics are resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability. The patient’s characteristics may fluctuate as the patient’s condition changes over time. Recognizing these changes allows the nurse with the appropriate competencies to be better matched with patient to synergize the best patient outcomes (Hardin & Hussey, 2003) In the case study, Rachel can be described as being resilient because she is young and strong with high endurance and is able to mount a response to her illness. She is vulnerable to the various stressors thyroid storm presents and her condition is presently unstable. Rachel’s case is complex because several body systems are entangled, namely the cardiovascular system and the endocrine system. She has moderate resource availability as evidenced by lack of health care insurance, but a strong family and social support system. Rachel is able to participate in her care at a moderate level, but still requires assistance from her family and nursing staff. Rachel is limited in her decision making ability at the present time due to her course of illness and depends on her family to make decisions regarding her care. Finally, Rachel’s case is moderately unpredictable as there is an expected course of events; however, these events may waver or change with time. The holistic view of Rachel’s characteristics aids in the development of a care plan that can match the nurse with appropriate competencies to care for Rachel’s complex needs. Nurse Competencies Nursing competencies capitalize on the strengths and skills of individual nurses and exist on a continuum from novice to expert. Matching nurses’ compentencies to particular patient needs and characteristics will result in synergistic care and outcomes. Nurse competencies within the Synergy Model are clinical judgment, advocacy and moral agency, caring practices, collaboration, systems thinking, response to diversity, facilitator of learning, and clinical inquiry (Curley, 1998). After evaluating Rachel’s patient characteristics, the nursing competencies that will be a priority are clinical judgment, collaboration, systems thinking, facilitation of learning, and clinical inquiry. The nurse caring for Rachel will need to be an expert in these competencies. The critical care nurse will use clinical judgment to synthesize and interpret Rachel’s assessment results and make decisions about her care. She will look at Rachel’s overall needs and collaborate with the multi-disciplinary team. Collaboration will take place with the social worker to help Rachel and her family work through issues such as lack of health insurance and need for regular medical follow-up. The critical care nurse would need to be proficient in systems thinking. A holistic view of the patient would be necessary to integrate and apply a variety of strategies related to patient care. For example in thyroid storm, the nurse would need to implement a variety of strategies to decrease Rachel’s high fever: acetaminophen, cooling blanket, and ice packs to the groins. In addition, the nurse would need to be monitoring the cardiovascular system and administering medication for tachycardia and arrhythmias.
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