Nursing Skills Archives - Page 6 of 18

Gynaecological Nursing

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Gynaecological nursing focuses on diseases and disorders primarily or uniquely found in women.

Warning Signs

Unusual Vaginal Discharge – yellow, green, or grey discharge accompanied by a foul odour
Abnormal Vaginal Bleeding – possibly caused by pregnancy, hormonal imbalance, or fibroids
Discomfort Whilst Urinating – damaged or weakened pelvic floor tissue
Pelvic Pain – sharp pain may be an indication of infection, ruptured ovarian cyst, or an ectopic pregnancy, while constant pain may be caused by uterine fibroids
Constant Fatigue – possibly caused by endometriosis, which is a condition in which tissue similar to the womb lining grows in other areas eg. the ovaries and the fallopian tubes
Pain During Intercourse – may present as deep pelvic pain or soreness in the genital area, possibly due to vaginal dryness, uterine fibroids, or infections
Unexplained Weight Loss – possible cancer sign
Leg Pain – ovarian cancer causes swelling due to fluid build-up produced by the tumour

gynaecological nursing — Retrieved from https://www.sunrisehospitals.in/watch-out-for-these-10-signs-of-cervical-cancer/ on 4th June 2022

Treatment Indications

Uterine fibroids a.k.a. leiomyomas are non-cancerous growths of the uterus, usually appearing during childbearing years. Fibroids tend to shrink during menopause.

(Image retrieved from https://www.uclahealth.org/fibroids/what-are-fibroids on 4th June 2022)

Cervical polyps are reddish, purplish, or greyish growths commonly shaped like a finger, bulb or stem, that can be found on the cervical canal. Polyps typically measure between a few millimeters to several centimeters.

(Image retrieved from https://www.healthnavigator.org.nz/health-a-z/c/cervical-polyps/ on 4th June 2022)

Endometriosis is a chronic inflammatory oestrogen-dependent condition in which the presence of endometrial glandular tissue can be found outside the uterus.

(Image retrieved from https://nitubajekal.com/endometriosis/ on 4th June 2022)

In Adenomyosis, endometrial tissue grows into the uterine muscular wall, acting normally during each menstrual cycle. Adenomyosis however causes the uterus to enlarge, often causing excrutiating pain and heavy periods.

(Image retrieved from https://www.cloudninefertility.com/blog/symptoms-causes-and-treatment-for-adenomyosis on 4th June 2022)

Cancer of the Uterus, Ovary, Cervix, or Endometrium.

(Image retrieved from http://www.humanillnesses.com/original/U-Z/Uterine-and-Cervical-Cancer.html on 4th June 2022)

In an Ectopic Pregnancy, the fertilized egg does not reach the uterus as it normally does. Instead, it gets attached to the cervix, abdominal cavity or fallopian tube.

(Image retrieved from https://www.kjkhospital.com/ectopic-pregnancy/ on 4th June 2022)

Intrauterine Adhesions are bands of fibrous tissue which form in the endometrial cavity, usually following a uterine procedure. They are often associated with menstrual abnormalities as well as infertility.

(Image retrieved from http://nezhat.org/treatment-of-infertility/infertility-determining-a-diagnosis/ on 4th June 2022)

Ovarian Cysts are fluid-filled sacs in an ovary or on its surface.

(Image retrieved from https://www.kjkhospital.com/ovarian-cysts/ on 4th June 2022)

Medical Management of certain Gynaecological Issues

Uterine Bleeding can be managed medically by use of an IUD (Intrauterine Device), hormonal medications such as oestrogen, progesterone, and oral contraceptives, and non-hormonal medications such as NSAIDs.
Pelvic Organ Prolapse can be medically managed by pelvic floor muscle training, vaginal pessaries, and adopting a healthy lifestyle which includes smoking cessation and maintaining an ideal body weight.
Fibroids can be medically managed through watchful waiting – an ideal approach for asymptomatic women where they are required to track any symptoms and undergo regular pelvic exams to monitor fibroids, until the menopause period where these usually shrink.
Endometriosis can be medically managed through over-the counter pain medications.

Gynaecological Procedures

Hysteroscopy

Hysteroscopy is a surgical procedure which allows the examination of the uterine cavity. A hysteroscope is inserted into the uterus through the vagina and cervix. Indications for a hysteroscopy include:

Symptom Investigation – heavy periods, post-menopause bleeding, pelvic pain
Diagnosis – to enable the diagnosis of polyps, fibroids and other possible issues
Treatment – removal of polyps, displaced IUDs, intrauterine adhesions, and fibroids through a myomectomy.

UFE – Uterine Artery/Fibroid Embolisation

Uterine Fibroid Embolisation (UFE) is a minimally invasive procedure commonly performed by a radiologist, used to treat fibroid tumors of the uterus that may cause heavy menstrual bleeding, pain, and pressure on the bladder or on the bowels. UFE uses fluoroscopy to guide the delivery of embolic agents to the uterus and fibroids to block the arteries which provide blood to the fibroids. Lack of bloodflow to the fibroids causes them to shrink. It promotes preservation of the uterus.

Laparoscopy

Uterine Laparoscopy is a diagnostic method used in the case of unexplained pelvic pain, unexplained infertility, or a history of pelvic infection. Alternatively, Laparoscopy can also provide treatment through the removal of ovaries and ovarian cysts, adhesions, fibroids, and uterus. It can also provide endometrial tissue ablation to help lessen menstrual flow. Laparoscopy can be used to treat uterine prolapse, blood flow blocking in the case of fibroids, and ectopic pregnancies.

Pelvic Floor Surgery

In a vaginal prolapse, muscles supporting the organs in a woman’s pelvis weaken, causing the uterus, urethra, bladder or rectum to droop down into the vagina. In certain cases, organs may actually protrude out of the vagina. Physiotherapy may help in certain cases, however, sometimes surgery may be required so the pelvic organs are put back in place. This is done through the vagina or through laparoscopy.

Retrieved from https://www.kegel8.co.uk/articles/pelvic-surgery/prolapse-surgery.html on 4th June 2022

Hysterectomy

A hysterectomy is a surgical procedure in which a woman’s uterus (or part of) is removed. Connected organs such as the fallopian tubes, ovaries, and cervix may also be removed during the same procedure. Hysterectomies are considered to be major surgeries and so are carried out electively through the abdomen, vagina, or laparoscopically.

Perioperative Gynaecological Nursing Care

Perioperative Gynaecological Nursing Care refers to patient care in the preoperative, intraoperative and postoperative period. Perioperative care should be based on the nursing process framework.

Preoperative care

GOALS

Preoperative care should aim to:

reduce surgical morbidity
minimise delays and cancellations
assess and optimise the patient’s health and fitness status
anticipate possible complications and prepare for their eventuality
facilitate anaesthesia planning
reduce patient anxiety by providing related information, answering any related questions, and address any concerns that the patient may have about perioperative care

PATIENT HISTORY

compile the patient’s medical history, including personal and family diseases, allergies, health-related habits, socioeconomic status, and past hospitalisation experiences
compile the patient’s surgical history, including information about previous operations and anaesthetic tolerance
compile gynaecologic and obstetric history, including current issue complaints, information about the menstrual cycle, past pregnancies, use of birth control, sexual history, smear test, infections, and breast diseases

EXAMINATION

Physical examination of the patient in the preoperative period helps to establish whether the current disease or issue is causing the patient to be instable or experience exacerbations. A preoperative physical examination should include:

vital signs
physical observation
airway and lung auscultation
cardiac auscultation (including rhythm determination)
neurologic condition
abdominal and pelvic examination

GYNAECOLOGIC EXAMINATION

breast, abdomen and pelvic organ examination, all of which can be supplemented by detailed assessment of the uterus via an ultrasound scan
endometrial sampling in women with abnormal uterine bleeding or abnormal endometrial imaging
cervical cancer screening
pregnancy test for women in childbearing age

PSYCHOLOGIC CONSIDERATIONS

feeling vulnerable may cause women to experience negative feelings which include fear of the unknown, fear of pain, and fear of the illness itself
provide a relaxed and private setting
ask open-ended questions in a non-judgemental way
do not make assumptions about the patient, including assumptions related to patient sexuality
ensure all questions the patient may have are answered clearly and understood well

INVESTIGATIONS

blood tests should include CBC, fasting and blood glucose, kidney function, serum electrolytes, blood group, liver function test, INR
ECG and stress test
chest x-ray
ultrasound
CT scan
MRI

PREOPERATIVE GYNAECOLOGICAL NURSING CARE

gain informed consent
review pre-op physical preparation eg. skin, bowels, NBM, cessation of medications, use of drugs, alcohol and smoking
explain what happens in the operating theatre
discuss post-operative routines such as routines related to respiratory care (coughing exercises), leg exercises (promoting venous return), early ambulation, pain control, fluids and nutrition
ensure patient has allergy and ID bracelets on
record baseline vital signs prior to transfer to the operating theatre
ensure jewellery and valuables are removed prior to transfer
ensure nail polish and makeup are removed prior to transfer
ask about any dentures and loose teeth, hearing aids etc – ensure their safety prior to transfer
ensure patient is put NBM at the right time
administer thromboprophylactic treatment
ensure patient has a bath or shower with antimicrobial soap
ensure hair removal is done – avoid abrasions by using hair clipping rather than shaving
ensure patient relatives know about the approximate length of surgery waiting time
ensure administration of prophylactic antibiotic 30 minutes prior to surgery

Intraoperative Care

The intraoperative period covers the time from when a patient is transferred to the operating room until being admitted to the post-anaesthesia care unit. During this period, the nurse acts as the patient’s main advocate.

In intraoperative care, the following should be ensured:

safe patient care
safe environment
limited traffic in and out of the operating theatre
correct use of surgical attire to promote staff safety, maintain sterility and cleanliness
correct patient positioning to reduce unnecessary injury due to prolonged surgery time
adherence to surgical count policy
adherence to sterility so as to reduce the risk of wound contamination and possible post-op surgical site infections
bladder catheterisation through the use of an intermittent stainless steel catheter may be needed (based on surgeon’s preference); catheterisation is carried out when the patient is asleep but before the first incision is made
draping serves as a barrier to endogenous and exogenous sources of contamination, thus reducing the risk of SSIs, as well as extends the sterile field for the placing of sterile instruments and supplies

WHO SURGICAL SAFETY CHECKLIST

PATIENT POSITIONING

Lithotomy positioning allows optimum exposure and surgical access to the perineum for vaginal surgeries. Potential issues with Lithotomy positioning include skin breakdown, nerve damage, musculoskeletal injury, and circulatory compromise.

Supine positioning is ideal for pelvic surgeries such as in open hysterectomy. Potential issues with Supine Positioning include skin breakdown, lumbar strain, nerve injury, and circulatory compromise.

NOTE: If the patient is put in the Trendelenburg Position, the patient may also be at risk of respiratory compromise.

Retrieved from https://nurseslabs.com/patient-positioning/ on 5th June 2022

Retrieved from https://slidetodoc.com/patient-positioning-rachel-brightthomas-consultant-surgeon-wahnhst-r/ on 5th June 2022

ELECTROCAUTERY

Electrocautery is a procedure which uses heat from an electric current to destroy abnormal tissue eg. tumors or lesions. It may also be used to control bleeding during surgery or after an injury.

Retrieved from https://www.itcindia.org/high-frequency-surgical-equipment/ on 5th June 2022

DIATHERMY BURN

Diathermy is a surgical technique which uses heat generated by an electrical current to cut tissue or seal blood vessels. Accidental diathermy burns can cause unsightly scarring which may limit motion in affected joints or function of other tissues.

INTRAOPERATIVE HYPOTHERMIA PREVENTION

Under surgical conditions, the body becomes at risk of hypothermia due to exposure and impairment of the body’s normal thermoregulatory response. This results in accelerated heat loss.

An individual with hypothermia experiences drug metabolism impairment, coagulation, increased bleeding, and wound infection.

Methods to maintain normothermia under intraoperative circumstances include warming through forced air blanket, and administration of warmed IV fluids.

OPEN SURGERY VS LAPAROSCOPY

Type of surgery and incision made for gynaecological issues depend on:

uterine size
possible required exploration of the upper abdomen
past incisions
cosmetic considerations

Open Surgery Approach

Advantages	Disadvantages
uterine size, fibroid size and extensive adhesions do not pose any limiting issues	longer recovery and rehabilitation period
promotes prolapse repair if required	increased risk of bleeding and infection
enables extensive exploration if needed	usually more painful

Laparoscopic Approach

Advantages	Disadvantages
shorter inpatient treatment duration	increased length of surgery
quicker return to normal activities	increased risk of bladder or ureter injury
associated with long term better quality of life	requires high laparoscopic surgical skills
enables diagnosis and treatment of additional pelvic diseases	use of carbon dioxide gas for abdomen inflation causes pain in the lower chest and up into the shoulder area post-op
reduced bleeding and infection risk

Vaginal Approach

Advantages	Disadvantages
shortest operation time	limited by uterine size, presence of pelvic adhesions, and previous surgeries
short recovery period and quicker discharge from hospital	limited ability to examine the fallopian tubes and ovaries
lowest cost
no scarring
reduced need for pain medication

Postoperative Care

Postoperative care is the management of a patient following a surgical intervention. Postoperative care extends from the immediate postoperative period in the operating room and post-anasthaesia care unit, to the days following surgery.

Postoperative care aims to prevent complications eg. infection, promote healing, and rehabilitation of the patient towards better quality of life. Postoperative care should be managed through the use of the nursing process. The extent of this period depends on the patient’s pre-surgical health status, type of surgery performed, and whether the surgical procedure was performed in a day-surgery setting or in the hospital.

Discharge Criteria

PATIENT CONDITION

stable vital signs
conscious state (same as pre-anaesthesia)
pain control
mobility (same as pre-anaesthesia)
manageable nausea, vomiting or dizziness
oral food and drink tolerance
passing of urine / urinary catheter in situ
discharge authorised by a member of the medical team
responsible adult availability to transport patient and accompany home in a suitable vehicle

PATIENT MONITORING & EDUCATION

vaginal flow monitoring – brownish discharge may be present for a few weeks
incision should be kept clean and dry to avoid it becoming infected
soft loose-fitting clothes should be worn due to incision tenderness
deep breathing exercises
leg exercises
flatus should be tackled with walking and warm fluid intake
prevention of constipation through dietary fibre intake
straining avoidance (including for bowel movement purposes)
avoidance of sexual intercourse for 4-6 weeks
avoid inserting items in the vagina

HOSPITAL DISCHARGE REQUIREMENTS

provide the patient with written and verbal instructions about post-op care
provide the patient with advice on resumption of regular medication
provide the patient with information on when to resume normal daily activities
provide the patient with a contact place and telephone number in the case of emergency care need

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The Nursing Process

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The nursing process is a systematic guide to patient-centered care through 5 sequential steps: assessment, diagnosis, planning, implementation, and evaluation.

Retrieved from https://nurseslabs.com/nursing-diagnosis/ on 7th November 2021

Characteristics of the Nursing Process

Dynamic & Cyclic – a process in which each phase interacts with and is influenced by the other phases
Open & Flexible – easily adaptable to different circumstances and emergencies
Universally Acceptable – allows nurses to practice nursing with all individuals within any type of practice setting
Patient Centered -the nursing process approach requires care respectful of and responsive to the individual patient’s needs, preferences, and values; the nurse functions as a patient advocate, enables the patient to make informed decisions, and maintains patient-centered engagement within the healthcare setting
Problem Oriented – aims to tackle arising and possible problems
Interpersonal & Collaborative – provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals, both of them learning and growing due to the interaction
Systematic – has an ordered sequence of activities, each of which depends on the accuracy of the activity that precedes it whilst influencing the activity following it
Goal Directed – the interaction between the nurse and the patient is based on a common goal
Planned – provides a basic structure on which nursing care can be provided
Holistic – takes into account all aspects of the patient

Benefits of the Nursing Process

Improves the patient’s quality of care
Promotes active patient participation in own health through continuous evaluation
Promotes nursing efficiency through better time and resource use
Saves time and energy through the creation of a care plan to follow up with
Reduces omissions and duplications
Acts as a guide outlining consistent and responsive care
Helps in identifying the patient’s goals and required strategies
Promotes collaboration in the management of the patient’s health-related problem
Promotes positive patient outcomes
Promotes patient safety
Promotes patient satisfaction

Step 1: Assessment

collect and document data on the patient’s health status
identify the patient’s strengths as well as limitations
repeat continuously throughout the nursing process

Step 2: Diagnosis & Planning

sort and analyze data collected on assessment
identify actual, potential, or health promotion nursing diagnosis
put together a nursing care plan tackling identified diagnosis

Step 3: Implementation

implement the nursing care plan with the aim of achieving the required goals and outcomes
continue carrying out assessments evaluating the patient’s response to treatment and care
modify where necessary
document

Step 4: Evaluation

perform at specific intervals and continue until patient achieves health goals or is discharged
target the restoration of self-care abilities if required
assess the client’s response to the carried out nursing interventions
assess response to goals and/or planned outcome criteria documented in the Diagnosis phase
determine the patient’s progress towards aimed goals and the effectiveness of the nursing care plan being carried out

Nursing Care Plan Example…

Retrieved from https://www.pinterest.ph/pin/611222980657579285/ on 7th November 2021

Nursing Care Plan Template…

Retrieved from https://www.pinterest.com/pin/732679433111887637/ on 7th November 2021

NOTE: While it is still being barely done, it is a great idea to implement the Nursing Process into your nursing documentation, including the words Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Nursing Plan Examples based on the Nursing Process

Scenario: Patient Presenting with Hypothyroidism

Risk of Malnutrition

ASSESSMENT:

assess how hypothyroidism is currently being controlled
assess patient’s weight
assess whether the patient is taking enough fibre in her dietary intake so as to prevent constipation
check BMI and assess whether patient is at risk of obesity
ask about daily caloric intake

DIAGNOSIS:

imbalanced nutrition

PLANNING:

aim for more nutritious lower caloric intake and weightloss or weight maintenance, depending on the patient’s current weight status

IMPLEMENTATION:

educate patient about the risk of obesity which comes with hypothyroidism
teach patient the importance of planning meals beforehand
teach patient the importance of taking frequent smaller meals rather than a big meal
encourage patient to keep a food diary so all nutritional and caloric intake can be monitored and adjustments may be made
involve dietitian if necessary, who can help provide meal plans to prevent over-eating
encourage exercising
encourage fluid intake
ensure the patient has a good support system through family or friends who can help by offering support

EVALUATION:

compare patient weight with previous weight readings
maintain fluid intake and output charting
review food diary
review care plan

Risk of Constipation

ASSESSMENT:

ask patient how much stools are being passed and whether constipation is being experienced

DIAGNOSIS:

constipation

PLANNING:

aim to reduce constipation, which is a side effect of hypothyroidism

IMPLEMENTATION:

encourage patient to drink more water
encourage exercise
encourage increased fibre intake
if necessary, a stool softener such as Movicol may be recommended

EVALUATION:

review situation with the patient
review care plan

Possible Lack of Health Literacy about Hypothyroidism

ASSESSMENT:

talk to the patient and assess health literacy in general and about hypothyroidism

DIAGNOSIS:

lack of health literacy

PLANNING:

teach patient about the condition and the importance of medicine compliance for life

IMPLEMENTATION:

explain in simple terms what hypothyroidism is
explain that since her body is not producing enough thyroid hormone, this needs to be taken orally
explain that thyroxine needs to be taken for life, and that it shouldn’t be stopped even if one is feeling well
explain that follow-ups are very important since clinicians need to ensure that a therapeutic dose of thyroxine is achieved and maintained

EVALUATION:

question the patient about the information you have relayed, and ensure that adequate knowledge has been grasped
re-explain where needed

Possibility of Fatigue

ASSESSMENT:

assess patient for fatigue
if fatigue is being experienced, explain that it is one of the side-effects of hypothyroidism

DIAGNOSIS:

fatigue

PLANNING:

aim for better performance during the day and adequate rest during the night

IMPLEMENTATION:

encourage patient to rest frequently, spacing daily activities throughout the day
encourage patient to notice at what times it feels easier to maintain activities, so that better day planning can be implemented according to their energy levels
reassure patient and encourage not to push themselves too much, but to go along with their capabilities
teach patient that exercise, although may feel too tiring, helps in muscle build-up and strength

EVALUATION:

assess if patient is feeling better with regards to fatigue
re-evaluate care plan and adjust where necessary

Patient Prone To Feeling Cold

ASSESSMENT:

ask if patient is feeling cold often, and check whether any skin issues are arising due to coldness

DIAGNOSIS:

patient feeling cold

PLANNING:

aim for better clothing options/planning and advise regarding skin breakdown

IMPLEMENTATION:

encourage patient to always carry with an extra jumper or jersey, and to avoid going out when it is very cold or late in the evening if possible
teach patient to prevent skin breakdown by encouraging use of soap for sensitive skin and adequate skin care

EVALUATION:

re-assess situation
re-evaluate care plan and adjust if necessary

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Nursing Diagnosis

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Nursing diagnosis is the nurse’s clinical judgment about a patient’s response to actual or potential health conditions or needs.

Medical Diagnosis vs Nursing Diagnosis

*Medical Diagnosis*…	Nursing Diagnosis…
points to a particular disease or medical condition	focuses on the patient’s needs
is based on the physiological or medical condition	focuses on the patient’s physiological and/or psychological response to changes in health
is also concerned with the aetiology of the disease	addresses potential problems

Types of diagnosis include:

Actual Diagnosis – diagnosis of the problem/s present at the time of patient assessment
Potential Diagnosis – diagnosis of a potential problem which may arise from the patient’s actual diagnosis
Health Promotion Diagnosis – diagnosis in relation to altered behaviours towards healthy living

NANDA’s Nursing Diagnoses

NANDA International, officially founded in 1982 and previously known as the North American Nursing Diagnosis Association, is a professional organisation of nurses aiming to standardise nursing terminology.

The current structure of NANDA’s nursing diagnoses is referred to as Taxonomy II and has three levels: Domains (13), Classes (47) and Diagnoses (237) (Herdman & Kamitsuru, 2018).

NANDA nursing diagnosis — Retrieved from https://en.wikipedia.org/wiki/NANDA_International on 1st June 2022

Models of Nursing Care

Activities of Daily Living
Adaptation
Self Care
Goal Attainment

Activities of Daily Living

nursing diagnosis adl's — Retrieved from https://info.eugeria.ca/en/have-you-heard-of-adls/ on 1st June 2022

Roy’s Adaptation Model

nursing diagnosis — Retrieved from https://schoolworkhelper.net/the-roy-adaptation-model-health-environmentsociety-nursing/ on 1st June 2022

Orem’s Theory of Self Care

Retrieved from https://www.pinterest.com/pin/443886107007181690/ on 1st June 2022

King’s Goal Attainment Model

Retrieved from https://pmhealthnp.com/kings-goal-attainment/ on 1st June 2022

Nursing Diagnosis Care Plan – Based on the ADL

Activities of Daily Living	Assessment	Diagnosis	Implementation	Evaluation
Maintaining a safe environment
Communication
Breathing
Eating & Drinking
Elimination
Washing & Dressing
Controlling Temperature
Mobilisation
Working & Playing
Sexuality
Sleeping
Death
Education
Discharge

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Patient Hospital Admission

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Patient hospital admission refers to the admission and acceptance of a patient into a health facility with the aim of staying under observation, undergoing necessary diagnostic investigations, and receiving required medical or surgical treatment. Patient hospital admission can be either elective – where a procedure is planned beforehand, or an emergency.

Elective Admission

In an elective patient hospital admission, a healthcare professional agrees with the patient on a convenient date for admission. This enables the patient to prepare in advance for the procedure.

Emergency Admission

In an emergency patient hospital admission, the patient is usually brought in by relatives or friends in a critical condition. In such an admission, the patient is usually transported by a wheelchair or a stretcher to an adequate ward for immediate evaluation and treatment.

Elective Patient Hospital Admission Procedure

Welcome the patient and any accompanying relatives to the ward and introduce yourself and any other present HCPs
Gather all required documents such as admission papers and other important information or documentation from the accompanying nurse
Confirm patient identity through given details
Ensure that the patient and accompanying relatives feel welcomed and comfortable
Gather any additional required information by the patient and/or the accompanying relatives
Provide a hospital bed located at an ideal room for the patient in question, based on the patient’s health requirements and condition
Provide assistance to the patient to change into pyjamas or hospital gown and ensure identification bracelet and any other required tags eg. allergy bracelet is provided
Take baseline vital signs and document
Collect any required specimens if needed
Administer any urgent medications
Ensure patient valuables are taken care of
Ensure informed consent is obtained, signed by the patient
Inform relatives about visiting hours and about anything that they may need to bring in for the patient on their next visit
Following relatives’ departure from the ward, orient patient to the ward and to the surrounding environment
Provide nursing care based on The Nursing Process
Input the patient’s particulars in the admission and discharge book
Document admission into the patient’s nursing documentation sheet
Input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system

Emergency Patient Hospital Admission Procedure

Perform hand hygiene
Gather emergency equipment– vital signs apparatus, resuscitation trolley, oxygen, venepuncture equipment, suction apparatus, and an adequate bed in a suitable location based on the patient’s condition
Welcome the patient and accompanying relatives to the ward and introduce yourself and any other present HCPs
Gather all required documents such as admission papers and other important information or documentation from the accompanying nurse
Confirm patient identity through given details
Assess patient’s overall condition efficiently
Receive patient into a previously prepared bed, keeping the patient’s current condition in mind
Provide assistance to the patient to change into pyjamas or hospital gown and ensure identification bracelet and any other required tags eg. allergy bracelet is provided
Take baseline vital signs and observe further the patient’s overall appearance and reaction, level of consciousness, skin integrity, pain, breathing pattern, and any other complaints, and document
Collect relevant history from the patient or accompanying relatives
Ensure informed consent is obtained, signed by the patient (include detailed information about required emergency procedures is given to ensure informed consent)
Ensure patient valuables are taken care of
Inform relatives about visiting hours and about anything that they may need to bring in for the patient on their next visit
Following relatives’ departure from the ward, orient patient to the ward and to the surrounding environment
Collect any required specimens if needed
Administer prescribed medications
Input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system
Document admission into the patient’s nursing documentation sheet

The Nurse’s Role in the Admission Process

Ensure the patient’s physical and emotional needs are met
Ensure the patient is assigned to a bed adequate to his/her personal needs and condition
Ensure that the patient’s admission report is completed
Ensure the patient is assessed using The Nursing Process
Provide a holistic approach to patient care based on the Activities of Daily Living guide whilst considering the patient’s psychological, social, spiritual, and cultural needs
Ensure the patient’s comfort and aim to reduce anxiety in both the patient and accompanying relatives

Patient Hospital Admission — Retrieved from https://nurseslabs.com/nursing-diagnosis/ on 7th November 2021

Transferring the Patient

During a hospital stay, the patient may require transferring from one ward to another within the same healthcare facility.

Transfer in

In a Transfer-In, a patient is moved from one unit to another, eg. from a medical to a surgical ward.

When a patient is being transferred in:

ensure a suitable bed is available to receive the patient
ensure all necessary equipment depending on the patient’s condition is readily available
ensure the patient, accompanying nurse, and any accompanying relatives are received warmly
ensure correct handover, transfer of notes, and any patient personal belongings are received from the accompanying nurse
confirm patient identity with accompanying nurse
clarify any queries pertaining to the patient’s condition
introduce yourself and other present HCPs to the patient and accompanying relatives
assess patient’s overall condition efficiently
ensure the patient is assessed using The Nursing Process
orient patient and relatives to the ward and to the surrounding environment
input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system, including time of admission
document transfer into the patient’s nursing documentation sheet

Transfer Out

In a Transfer-Out, the patient can be transferred from one ward to another, or from one facility to another.

When transferring a patient out:

confirm transfer with receiving unit
assess the patient’s condition
arrange for a nurse to accompany the patient
plan for an appropriate transferring vehicle if required
collect all patient data
reduce the patient’s and accompanying relatives’ anxiety by explaining reason for transfer
obtain informed written consent for transfer
assist in the packing of the patient’s personal belongings
ensure patient’s medication, diagnostic results, and transfer notes, are all compiled as required
assist patient in dressing up adequately for the transfer
assist patient into a wheelchair or stretcher, and into an ambulance, if required
ensure patient’s notes and belongings are handed over to the accompanying nurse
input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system, including time of transfer
document transfer into the patient’s nursing documentation sheet

Discharging the Patient from the Hospital

Discharge planning should start shortly after the patient is admitted, and is usually done at the discretion of the medical team, based on the patient’s overall health condition, or if the patient requests to be discharged. The patient and his/her relatives should always be informed about intended discharge plans.

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Haemostasis ~ The Blood Clotting Process

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Haemostasis

Haemostasis is the process by which blood loss is prevented. This happens through three basic mechanisms:

Vascular Spasm – blood vessel damage stimulates pain receptors to cause immediate smooth muscle contraction within its wall; this reduces blood loss rate for up to 30 minutes, during which other haemostatic mechanisms are triggered.
Platelet Plug Formation – platelets which come into contact with damaged blood vessel parts begin to enlarge, become irregular, sticky, and start adhering to collagen fibres; ADP (adenosine diphosphate) and enzyme synthesis triggers the formation of other substances, activating more platelets to adhere to the original platelets, forming a platelet plug, which is then reinforced by fibrin threads.
Blood Coagulation a.k.a. Blood Clotting -whilst blood within the vessels maintains its liquid state, blood outside the vessels thickens and forms a gel (serum) which separates from the liquid. Blood serum is blood plasma without its clotting proteins, whilst the gel is the clot, which contains insoluble fibres that trap the cellular components of the blood.

Retrieved from https://quizlet.com/185065266/hemostasis-vs-anticoagulation-and-thrombolysis-flash-cards/ on 22nd May 2022

Blood Coagulation

Blood coagulation is the process of clot formation – a process which involves various chemicals referred to as coagulation factors.

haemostasis coagulation factors — Retrieved from https://www.vetfolio.com/learn/article/hemostasis on 22nd May 2022

There are 3 basic stages for coagulation…

Stage 1: Formation of Prothrombin Activator

Stage 1 involves the formation of prothrombin activator, initiated by the extrinsic and intrinsic pathway of blood clotting.

Stage 2: Conversion of Prothrombin into Thrombin

Following the formation of prothrombin activator, it binds to Ca²⁺ ions (Calcium Ions), causing the conversion of prothrombin into thrombin.

Stage 3: Conversion of Fibrinogen into Fibrin

Thrombin and Ca²⁺ ions trigger the conversion of Fibrinogen (soluble) to Fibrin (insoluble).

Thrombin activates Factor XIII (Antihemophilic Factor) which strengthens and stabilises the fibrin clot.

Through a positive feedback effect, Thrombin accelerates the formation of prothrombin activator through Factor V (Proaccelerin), which further accelerates the production of more Thrombin.

The formed clot plugs the ruptured area of the blood vessel, preventing haemorrhage. This is followed by permanent repair of the blood vessel.

Additional Factors related to Haemostasis

Vitamin K

Efficient clotting requires Calcium as well as Vitamin K, which is required for prothrombin formation and other coagulation factors by the liver. Vitamin K is formed by the human intestinal bacteria, and can also be found in foods such as spinach, cabbage, cauliflower, and liver.

Thrombosis

Thrombosis is the formation of a clot (thrombus) within an intact blood vessel. Thrombosis is caused within blood vessels containing sluggish blood flow, and when platelets stick to fatty deposits on the blood vessels’ inner surface. A thrombus can either dissolve or else grow and eventually block the blood vessel.

Embolism

Embolism happens when a part of the thrombus breaks off from its original site forming an embolus, moves along the blood stream until it reaches a small blood vessel and blocks it.

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Blood Disorders

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Blood disorders have an impact on the main components of the blood – red blood cells, which carry oxygen throughout the body; white blood cells, which fight infection; and platelets, which help through their blood clotting mechanism. Some blood disorders are caused by genes. However, blood disorders can also result from other diseases, medications, or lack of nutritional intake.

Diagnostic Tests for Blood Disorders

CBC (Complete Blood Count) – haemoglobin, haematocrit, reticulocyte count, red blood cell indices, MCV (mean corpuscular volume i.e. RBC size), and RDW (RBC distribution width)
Blood Chemistry Tests – Electrolytes, Fats, Proteins, and Glucose
Blood Enzyme Tests – Myoglobin, Troponin, and Creatine-Kinase
Blood Clotting Tests – PT (Prothrombin Time), aPTT (activated partial thromboplastin time), TT (Thrombin Time)
Serum Vitamin B12 and folate levels, haptoglobin, erythropoietin levels
Bone Marrow aspiration

Anaemia

Anaemia is a blood disorder in which there is a deficiency in erythrocytes or haemoglobin, leading to tissue oxygen deprivation.

Causes

bleeding (eg. menstruation, childbirth, NSAIDs overuse [may cause ulcers and gastritis], GI conditions [ulcers, haemorrhoids, gastritis and cancer]
decreased or abnormal RBC production (eg. sickle-cell anaemia, iron-deficiency anaemia, vitamin deficiency, problems related to the bone marrow and/or stem cells)
premature RBC destruction (RBCs inability to withstand circulation stress, leading to premature rupture, causing haemolytic anaemia)

Possible complications

Confusion
Parathesias (a burning or prickling sensation usually felt in the hands, arms, legs, or feet, but can also extend to other body parts)
Congestive Heart Failure
Death

1. Iron-Deficiency Anaemia

Iron-Deficiency Anaemia is a type of anaemia in which there is lack of iron in the body. Iron is required for the production of haemoglobin for red blood cells to carry oxygen throughout the body.

2. Pernicious Anaemia

Pernicious Anaemia is a type of anaemia in which the intrinsic factor is missing. This results in lack of Vitamin B12 absorption. While Pernicious Anaemia is very common in older individuals and individuals who have had a gastric resection, it may also result from malnutrition in which B12 intake is low, such as in vegetarian diets or lack of dairy products intake.

3. Aplastic Anaemia

Aplastic Anaemia is caused by a deficiency of all blood cell types due to bone marrow development failure. Aplastic Anaemia is considered to be a rare disease.

4. Thalassemia

The term ‘Thalassemia’ refers to a group of hereditary disorders in which there is defective haemoglobin-chain synthesis. In Thalassemia there is an abnormal decrease in RBCs’ haemoglobin (hypochromia), small RBCs (microcytosis), blood element destruction (haemolysis) and anaemia.

Anaemia Clinical Manifestations

Retrieved from https://medlineplus.gov/genetics/condition/iron-refractory-iron-deficiency-anemia/ on 19th May 2022

Retrieved from https://www.kindpng.com/imgv/hiRwoTJ_symptoms-of-anaemia-symptoms-of-anemia-hd-png/ on 19th May 2022

Anaemia Nursing Care

Assessment

What type of anaemia is involved?
What symptoms is it exhibiting, and to what extent?
How are these symptoms leaving an impact on the patient’s daily life?
What medication has the patient been on – past and present? Was the patient on medications which may have caused a reduction in bone marrow activity, caused haemolysis, or affected folate metabolism?

Diagnosis

Fatigue (due to haemoglobin decrease i.e. reduced oxygen saturation)
Malnutrition (lack of required nutrition and nutrient intake)
Decreased Tissue Perfusion (due to reduced blood volume – hematocrit)
Poor Medication Compliance

Implementation

ensure adequate rest to reduce fatigue along with periods of feasible activities to promote physical activity, whilst also assessing for other conditions such as pain, depression, and insomnia, which may further exacerbate fatigue
encourage and/or ensure adequate nutritional intake through a healthy diet comprising of adequate iron, vitamin B12, folic acid, and protein intake (if required supplements may be recommended), whilst avoiding alcohol
ensure adequate tissue perfusion through blood transfusions, IV fluids, and if required supplemental oxygen (monitor vital signs and SPO2)
educate about the importance of medication compliance and management of side effects
promote complication avoidance by assessing for heart failure, assessing the patient neurologically, evaluating the patient’s gait and balance, and complaints of parathesias

Evaluation

assess for signs and symptoms of heart failure
measure and document the patient’s weight on a daily basis
intake and output charting
assess for possible need of diuretics in the case of fluid retention

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Blood Groups and Blood Transfusions

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Blood Groups

Erythrocytes contain antigens called agglutinogens or isoantigens which are genetically determined. At least, 300 blood group systems may be detected on red blood cells’ surface. However, the focus is on 2 major classifications of blood groups, namely the ABO Blood Grouping System and the Rhesus System.

ABO Blood Grouping System

there are 2 types of agglutinogens: Agglutinogen A and Agglutinogen B
individuals with red blood cells containing Agglutinogen A have a Blood Type A
individuals with red blood cells containing Agglutinogen B have a Blood Type B
individuals with red blood cells containing both Agglutinogen A and B have Blood Type AB
individuals with red blood cells containing NO Agglutinogen A and NO Agglutinogen B have Blood Type O

The BLOOD PLASMA contains antibodies called agglutinins or isoantibodies.

Agglutinin A attacks Agglutinogen A
Agglutinin B attacks Agglutinogen B

Retrieved from https://cbm.msoe.edu/crest/ePosters/a16gtaBloodType.html on 14th May 2022

Rhesus (Rh) System

the Rh system is based on the presence (or lack of) of agglutinogens which can be found on the surfaces of erythrocytes
individuals with red blood cells containing Rh agglutinogens are said to be Rh+
individuals with red blood cells containing NO Rh agglutinogens are said to be Rh-

Retrieved from https://www.scienceabc.com/humans/is-it-important-to-compare-blood-groups-with-your-partner.html on 14th May 2022

Blood Transfusions

Blood transfusions are commonly indicated for circulatory shock, anaemia (lack of healthy red blood cells leading to inadequate oxygen distribution to the body’s tissues), haemophilia (bleeding disorder, usually inherited, with an improper blood clotting mechanism), and haemolytic disease of the newborn (a disease in which there is fast destruction of red blood cells).

Incompatible blood transfusions may cause very bad consequences such as kidney damage, brain damage, and even death.

Further Information…

Red Cell Concentrates – indicated for anaemia and acute blood loss: help increase oxygen carrying capacity through raising haemoglobin concentration in the patient. Can be stored in a temperature of 4 +/-2°C for 42 days (or for 28 days if irradiated). If unused or left for more than 30 minutes in the transport box, Red Cell Concentrates should be returned to the Blood Bank to minimise the risk of bacterial growth.

CMV (CytoMegaloVirus) Negative Blood: indicated for intrauterine transfusions, neonate transfusion (28 days post EDD) and pregnant women transfusion.

Irradiated Blood: indicated for intrauterine transfusion, BM/ stem cell transplantation, Hodgkin’s disease, etc.

For more details on the administration of blood and blood components click here.

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Blood Components and Functions

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The internal environment of the human organism is made up of blood within the blood vessels, interstitial fluid surrounding the body cells, and lymph inside the lymph vessels.

The blood is able to pick up:

nutrients (from the digestive tract)
oxygen (from the lungs)
hormones (from the endocrine glands)
enzymes (from multiple body sites)

The blood can also act as a transportation means for disease-causing organisms. For this reason, the lymphatic system helps in picking up wastes from the interstitial fluid, cleansing them of bacteria, and returning them bacteria-free into the blood.

Physical Characteristics of the Blood

blood components — Retrieved from https://quizlet.com/96941163/56-what-is-the-normal-ph-of-blood-181b-physical-characteristics-of-blood-flash-cards/ on 12th May 2022

Blood Functions

1. Transportation

Blood helps in the transportation of:

Oxygen (from the lungs to the body’s cells)
Carbon Dioxide (from the cells to the lungs)
Nutrients (from the digestive organs to the cells)
Waste Products (from the cells to the kidneys, lungs, and sweat glands)
Hormones (from the endocrine glands to the cells)
Enzymes (to various cells)

2. Regulation

Blood helps in the regulation of:

pH (through buffers)
Body Temperature (through heat-absorbing and coolant properties of its water content)
Water within the Cells (mainly through dissolved sodium ions)

3. Protection

Blood helps in protecting the body against:

Blood Loss (through the blood clotting mechanism)
Toxins and Foreign Microbes (through special combat-unit cells such as white blood cells)

Blood Composition

Blood is made up of 2 portions:

1. Formed Elements

make up 45% of the total blood volume
include Red Blood Cells, White Blood Cells (Granular – neutrophils, eosinophils & basinophils; and Agranular – lymphocytes & monocytes), and Platelets.

2. Plasma

makes up 55% of the total blood volume
water (91.5% of total plasma)
proteins (7% of total plasma)
other solutes (1.5% of total plasma)

Haematopoiesis – Blood Cell Formation

Haematopoiesis a.k.a. blood cell formation takes place within the Red Bone Marrow (myeloid tissue in the humerus, femur, sternum, ribs, vertebrae & pelvis) and Lymphoid Tissue (in the spleen, tonsils & lymph nodes).

Red Blood Cells, Leucocytes & Platelets are produced within the Bone Marrow.
Agranular Leucocytes (lymphocytes & monocytes) are produced by the Bone Marrow and the Lymphoid Tissue.

Red Blood Cells a.k.a. Erythrocytes

do not contain a nucleus
cannot reproduce
cannot carry on extensive metabolic activities
plasma membrane is selectively permeable
plasma membrane encloses cytoplasm and haemoglobin
have a biconcave shape which promotes increased surface area for diffusion purposes
contain a lot of haemoglobin molecules which increase their capacity for oxygen transportation
allow transportation of a small amount of carbon dioxide along with haemoglobin

Normal Haemoglobin Values

Infants	14-20gm/dl
Adult Females	12-15gm/dl
Adult Males	14-16.5gm/dl

Erythropoiesis – Erythrocyte Production

erythropoiesis and erythrocyte destruction usually proceed at the same pace
if the balance between erythropoiesis and erythrocyte destruction is disrupted, a homeostatic mechanism is initiated to promote erythrocyte production
in oxygen deficiency, particular kidney cells release the enzyme Renal Erythropoietic Factor which converts plasma protein into the hormone erythropoietin, which, when reaching the red bone marrow, stimulates haemocytoblasts to develop into red cells

NOTE: Blast is a short name for an immature WBC, such as a lymphoblast or myeloblast. In normal circumstances, less than 5% of the cells in healthy bone marrow at any one time are blasts. Within the bone marrow, normal blasts develop into mature, functioning blood cells and are then released into the bloodstream.

Retrieved from https://labpedia.net/erythropoiesis-rbc-maturation-rbc-counting-procedure/ on 12th May 2022

Haemoglobin in Erythrocytes

erythrocyte life span is around 120 days long
the plasma membrane of depleted cells are removed from the circulation by macrophages in the spleen, liver, and bone marrow
haemoglobin is broken down into Haemosiderin (iron-containing pigment which is stored or used in the bone marrow for the production of new haemoglobin for new RBCs), Bilirubin (pigment secreted by the liver into bile) and Globin (protein metabolised in the liver).

White Blood Cells a.k.a. Leucocytes

there is a much lesser amount of WBCs than RBCs in the human body: 700 RBCs per 1 WBC
leucocytes contain nuclei
leucocytes do NOT contain haemoglobin
leucocytes have surface proteins called Human Leucocyte Associated Antigens (HLA) which are unique to each and every person

There are 2 types of WBCs:

GRANULAR LEUCOCYTES:

NEUTROPHILS (POLYMORPHS) – make up the biggest amount of total leucocytes; involved in phagocytosis of bacterial pathogens and the release of antimicrobial chemicals
EOSINOPHILS – involved in phagocytosis of antigen-antibody complexes, allergens and inflammatory chemicals, and the release of enzymes which help weaken or destroy parasites
BASOPHILS – involved in the secretion of histamine which promotes blood flow to a particular tissue, and the secretion of heparin which promotes mobility of other WBCs by clotting prevention
develop from red bone marrow
have granules in the cytoplasm
have a lobed nuclei

AGRANULAR LEUCOCYTES:

MONOCYTES – turn into macrophages; phagocytise pathogens, dead neutrophils, and dead cells debris; and present antigens that activate other cells within the immune system
LYMPHOCYTES – assist with immune memory, secrete antibodies, present antigens for the activation of other cells within the immune system, and help in destroying cancer cells, virus-infected cells, and foreign cells
develop from lymphoid and myeloid tissue
do not have granules in the cytoplasm

Retrieved from https://www.pinterest.com/pin/452752568781425426/ on 13th May 2022

Differential Blood Count

*Type of White Blood Cell*	*Normal Differential Count*	*High WBC Count Implication*
Neutrophils	60% – 70%	damage caused by invading bacteria
Eosinophils	2% – 4%	allergic reaction
Basophils	0.5% – 1%	allergic reaction
Lymphocytes	20% – 25%	antigen-antibody reaction
Monocytes	3% – 8%	chronic infection

Life Span of Leucocytes

leucocytes can live from just a few days to a few months, depending on what type of leucocytes they are
during infection, white blood cells become very active, usually living for only a few hours

Platelets

platelets contain no nucleus
platelets have a life span of between 5 to 9 days
platelets help prevent fluid loss through a chain of reaction leading in blood clotting
stem cell development from haemocytoblast to platelets takes place in the red bone marrow

Stem cell developmental pathway. Retrieved from https://slideplayer.com/slide/12774626/ on 14th May 2022

Plasma

Plasma is made up of:

WATER – 90% of total amount of water in plasma is derived from the GI tract; 10% is derived from cellular respiration; water absorbs heat and acts as a solvent and suspending medium for the blood’s solid components
SOLUTES – makes up 8.5% of the total plasma volume
PROTEINS – ALBUMINS (55% of plasma proteins) are produced by the liver; provide viscosity in the blood which helps maintain blood pressure; exert osmotic pressure to help in maintaining water balance between the blood and the tissues; help regulate blood volume; GLOBULINS (38% of plasma proteins) a.k.a. antibodies; FIBRINOGEN (7% of plasma proteins) is produced by the liver; it helps in the blood clotting process

blood plasma components — Retrieved from https://www.austincc.edu/apreview/PhysText/Blood.htm on 14th May 2022

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Thyroid Disease & Patient Education Based on NICE Guidelines

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The phrase thyroid disease refers to medical conditions which affect the way the thyroid gland works. The thyroid gland typically produces an amount of hormones which help the body to function well. Too much thyroid hormone production is referred to as hyperthyroidism, whilst too little thyroid hormone production is referred to as hypothyroidism.

Retrieved from https://www.easyyogasan.com/thyroid-test-t3-t4-tsh-normal-range/ on 10th May 2022

Hyperthyroidism usually causes tachycardia, weight loss, and nervousness. On the other hand, hypothyroidism may cause lethargy, weight gain, and cold intolerance.

Retrieved from https://terrainwellness.com/symptoms-of-hashimotos-flare-up/ on 29th April 2022

Thyroid Disease Risk Factors

family history of thyroid disease
medical conditions eg. type 1 diabetes and rheumatoid arthritis)
high iodine-containing medication eg. amiodarone
increased age
past thyroidectomy
past radiation

Hyperthyroidism Causes

Graves’ Disease
Nodules
Thyroiditis
Excessive iodine intake

Symptoms

anxiety
irritability
nervousness
heat sensitivity
insomnia
vision problems
eye irritation
goitre
tremors.
irregular periods
period cessation
shortness of breath – patient has high metabolism, muscle wasting, leading to exhaustion and fatigue, all of which can cause shortness of breath
weight loss – imbalanced nutrition due to high metabolic rate (adequate food intake needs to be ensured)
muscle weakness – in case of inadequate food intake, if no carbs or glucose are available to be broken down, the body turns to protein breakdown, leading to muscle wasting

Hypothyroidism Causes

Thyroiditis
Hashimoto’s Thyroiditis
Post-Partum Thyroiditis (usually temporary)
Iodine Deficiency
Non-Functioning Thyroid Gland

Symptoms

cold sensitivity
memory problems
voice hoarseness
hair dryness and coarseness
fatigue
weight gain
frequent and heavy periods

Thyroid Disease Diagnostic Tests

TFTs (TSH, T⁴ and T³ levels) – to check the amount of thyroid stimulating hormone (TSH) and circulating thyroid hormones in serum, so thyroid gland’s thyroid hormone production and regulation ability is assessed
CBC – to check amount of red blood cells in the blood (to rule out anaemia)
Renal Profile – to determine the kidneys’ health by evaluating parameters such as proteins, electrolytes, and minerals

Subclinical Thyroid Dysfunction

Subclinical Thyroid Dysfunction is a biochemical diagnosis in which TSH levels are outside the reference range, and circulating T₄ and T₃ are within the reference range.

Subclinical Thyroid Dysfunction is most commonly detected incidentally. However, in certain cases, individuals may exhibit symptoms of hypothyroidism or hyperthyroidism. Studies related to long-term consequences of subclinical thyroid dysfunction indicate increased cardiovascular morbidity and mortality, increased risk of osteoporosis, and possible links to dementia.

Thyroid Disease Patient Education – Based On NICE Guidelines (2019)

Ensure that information is presented to facilitate shared decision making…

Explain to people with thyroid disease who need treatment, and their family or carers…that:
– Thyroid disease usually responds well to treatment.
– The goal of treatment is to alleviate symptoms and align thyroid function tests within or close to the reference range.
– People may feel well even when their thyroid function tests are outside the reference range.
– Even when there are no symptoms, treatment may be advised to reduce the risk of long-term complications.
– Even when thyroid function tests are within the reference range, changes to treatment may improve symptoms for some people.
– Symptoms may lag behind treatment changes for several weeks to months.
– Day-to-day changes in unexplained symptoms are unlikely to be due to underlying thyroid disease because the body has a large reservoir of thyroxine.

Provide people with thyroid disease, and their family or carers…with written and verbal information on:
– their underlying condition, including the role and function of the thyroid gland and what the thyroid function tests mean
– risks of over-and under-treatment
-their medicines
-need for and frequency of monitoring
– when to seek advice from a healthcare professional
– how thyroid disease and medicines may affect pregnancy and fertility

Provide people with hypothyroidism, and their family…with written and verbal information on:
– possible drug interactions of thyroid hormone replacements, including interactions with over-the-counter medicines
– how and when to take levothyroxine
NICE Guidelines, 2019

Patients with thyroid disease need to have a clear understanding on the disease, treatment goals, and connection between thyroid function tests and symptoms. Medication (Levothyroxine) is frequently taken incorrectly, possibly leading to suboptimal treatment.

Patient information and support on thyroid disease help patients make informed decisions on the management of their condition.

A complete drug history of the patient helps determine if Levothyroxine may interfere with other medications currently being taken, in which case, the patient may be recommended to take Levothyroxine earlier or half hour before food and other medications.

Review of other drug intake should be made so if needed, changes may be made to drug prescription. Example: Iodine may cause toxicity problems with the thyroid gland and may lead to hypothyroidism. Example: Lithium use blocks thyroid hormone production.

The patient needs to be made aware that any side effects experienced may be due to thyroid disease, and that, if kept under control, such side effects may be reduced. Constipation, which is one of the side effects of hypothyroidism, may subside following regular use of Levothyroxine. However, if it persists, increasing high fibre intake and more fluids should help further. Movicol may also be prescribed to help with constipation (if other methods fail to help).

Regular exercise needs to be encouraged, starting slowly, and increasing gradually. This is because patients with thyroid disease such as hypothyroidism tend to gain weight. If necessary, patient may be referred to a dietitian.

Medication compliance is very important with regards to Levothyroxine. The patient needs to be educated about the condition – that it is a lifelong condition which needs to be controlled by medication. It is a chronic disease. Thus, Levothyroxine should not be stopped, even if patient feels well.

Patient should be encouraged to attend all follow-ups so as to ensure that the right dose has been prescribed. It may take a couple of follow-ups until the right dose is achieved. The patient should be instructed that in case of palpitations, chest pain, and tachycardia, contact should be made with clinician so as to ensure she is not going into hyperthyroidism instead.

References

Cleveland Clinic (2020). Thyroid Disease: Causes, Symptoms, Risk Factors, Testing & Treatment. Retrieved from https://my.clevelandclinic.org/health/diseases/8541-thyroid-disease on 5th May 2022

NICE Guidelines (2019). Thyroid Disease: assessment and management. Retrieved from https://www.nice.org.uk/guidance/ng145 on 5th May 2022

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Thyroidectomy Perioperative Nursing Care

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The thyroid gland plays a major role in the metabolism, growth and development of the human body, regulating body functions by constantly releasing a steady amount of thyroid hormones into the bloodstream. At times however, an individual may require a thyroidectomy, which is the surgical removal of all or part of the thyroid gland. This may happen due to thyroid-related conditions such as Goitre and Carcinomas.

Hypothyroidism vs Hyperthyroidism

In hypothyroidism, the thyroid gland is underactive, hence it doesn’t produce enough thyroid hormone. On the other hand, in hyperthyroidism, the thyroid gland is overactive, hence it produces too much thyroid hormone.

Thyroidectomy Perioperative Nursing Care — Retrieved from https://terrainwellness.com/symptoms-of-hashimotos-flare-up/ on 29th April 2022

Thyroidectomy Indications

Goitre

A goitre a.k.a. goiter refers to swelling of the thyroid gland which causes a lump located at the front of the neck which moves up and down with swallowing. Nodules are lumps located within the thyroid gland.

Solitary Nodular Goitre (single swelling) – most commonly benign, solitary nodular goitres are often left untreated. If upon examination cancer is not excluded, surgery is usually recommended. An overactive nodule a.k.a. hot nodule can be treated by pharmacological medication, radioactive iodine treatment, or surgery.
Multi-Nodular Goitre (multiple swellings) – common multiple swellings which usually do not require surgery unless breathing and/or swallowing become compromised, or in case of rapidly growing nodules, or the individual prefers to undergo surgery for aesthetic purposes (unsightly goitre).

Carcinoma

Thyroid cancer is a rare type of cancer affecting the thyroid gland. Types of thyroid cancers include:

papillary carcinoma – the most common type, affecting mostly females under 40; papillary carcinomas appear as irregular solid or cystic masses or nodules
follicular carcinoma – affecting mostly middle-aged females, these malignant epithelial tumors account for about 15% of malignant thyroid tumors
rare carcinomas – include thyroid teratomas, lymphomas, and squamous cell carcinomas.

Retrieved from https://basicmedicalkey.com/cancer-treatment-and-chemotherapy/ on 21st June 2022

Thyroidectomy Types

Hemi-Thyroidectomy – removal of half of the thyroid gland
Lobectomy – removal of either the right or the left thyroid gland lobe, commonly done in the case of solitary goitre
Total Thyroidectomy – removal of the whole thyroid gland, commonly done in cases of malignant thyroid tumors
Subtotal Thyroidectomy – removal of almost whole thyroid gland, commonly done in multi-nodular goitre (some thyroid tissue surrounding one parathyroid gland is preserved)
Near-Total Thyroidectomy – removal of almost whole thyroid gland, commonly done in multi-nodular goitre (some thyroid tissue surrounding one parathyroid gland is preserved)
Isthmusectomy – removal of the thyroid isthmus

Retrieved from https://cancer.ca/en/cancer-information/cancer-types/thyroid/treatment/surgery on 5th May 2022

Thyroidectomy Perioperative Nursing Care

Thyroidectomy Preoperative Care

BLOOD INVESTIGATIONS:

CBC
Urea, Electrolytes, & Creatinine
T₃, T₄, & TSH (Thyroid Stimulating Hormone)

SCANS:

Thyroid Gland ultrasound scan
Radio-Iodine Thyroid Scan
Neck X-ray
Chest X-ray

OTHER INVESTIGATIONS:

FNAC (Fine Needle Apiration Cytology) of thyroid nodule, if palpable
Indirect Laryngoscopy for pre-operative assessment of vocal cords functioning

CARE:

patient reassurance through answering of any questions in relation to surgery so as to help reduce patient anxiety and fear; this also helps in acquiring informed consent
patient education regarding neck support in preparation for post-operative self-care
administration of anti-thyroid medication eg. Methimazole to promote a euthyroid (normal thyroid function) state
preparation of Potassium Iodide (Iodine) which helps to decrease thyroid gland vascularity, thus reducing risk for haemorrhage
avoid prophylactic antibiotic administration in such a clean elective surgery unless indicated

Thyroidectomy Postoperative Care

PATIENT CARE ON DAY OF SURGERY:

monitor patient’s vital signs and document accordingly
keep patient NBM (nil-by-mouth)
administer between 2.5l-3l of supplemental IV fluid
administer analgesics as prescribed to reduce severe post-operative pain
in case of excessive blood loss during surgery, blood transfusion may be required

PATIENT CARE FROM DAY 2:

encourage initial sips of clear fluid; move on to free fluids, to a soft diet, and finally to a normal diet once each phase is tolerated
maintain vital signs monitoring – temperature rise following 3rd day of surgery indicates infection
monitor surgical site for signs of infection; change initial dressing after 48-72hrs following surgery (unless it’s soaked beforehand, in which case should be changed earlier); use dry dressings every alternate day if suture line is clean and dry; removal of sutures is recommended for the 5th day post-op to avoid scarring as much as possible
monitor daily output from Redivac Drain – remove drain after 48 hours OR when drainage is reduced to a few milliliters in a 24hr period
keep on administering prescribed analgesics, monitoring their effectiveness and taking necessary measures in case of inefficacy

Redivac Drain

Thyroidectomy Complications

haemorrhage – assess surgical wound area for drainage, monitor blood pressure and pulse to notice possible hypovolaemic shock earlier on; risk of haemorrhage is at its peak in the first 24 hours post-op
respiratory distress – assess respiratory rate, rhythm, depth, and strength; prepare suction equipment, oxygen, and tracheostomy set at hand since possible haemorrhage and oedema may result in tracheal compression
wound infection
voice hoarseness and aphonia (total vocal cord paralysis due to nerve damage which causes sounds to come out as just whispers) – assess speaking tone and ability; hoarseness, which eventually subsides, happens due to oedema or endotracheal tube used during surgery
hypocalcemic tetany (low calcium levels in the blood caused by accidental parathyroid glands removal in total thyroidectomy) – this complication may occur in up to 7 days post-op; signs and symptoms include tingling of toes, fingers, and lips; prepare calcium gluconate or calcium chloride in case it’s needed for IV use

Further Related Information

Graves’ Disease

Graves’ disease is an immune system disorder that causes overproduction of thyroid hormones a.k.a. hyperthyroidism. Signs and symptoms of Graves’ disease can be wide ranging.

Hashimoto’s Disease

Hashimoto’s Thyroiditis a.k.a. Hashimoto’s Disease is an autoimmune disease that causes the body to produce antibodies which attack thyroid cells, leading to the under-production of the thyroid hormone. Symptoms of Hashimoto’s Disease may include goitre, lethargy, weight gain, and muscle weakness.

Thyroid Storm

Thyroid storm a.k.a. thyrotoxic crisis is an acute, life-threatening, hypermetabolic state caused by excessive release of thyroid hormones in individuals with thyrotoxicosis. Thyroid storm may be the initial presentation of thyrotoxicosis in undiagnosed paediatric patients, especially neonates.

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Myxedema Coma

Myxedema coma, which is considered to be a medical emergency with a high mortality rate, is defined as severe hypothyroidism that causes decreased mental status, hypothermia, and other organs to slow down their functions.

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