Alert Oriented to place & person Very scared Visual and auditory hallucinations (1 month PTA)

Face covered with a mask that appeared in front of him from time to time male voice (he will be harmed) house possessed by demons that are coming to get him suspicious of family members someone was doing witchcraft on him

 (-) Psychotic symptoms/psychiatric treatment (+) learning disability in reading & math special educ. until 10th grade (-) psychotropic medications (-) recent or past alcohol/drug abuse

 Bilateral proptosis Diplopia on superior and lateral gaze Minimal lid lag Conjunctival injection bilaterally, no ulceration

 Thyroid gland visibly, palpably enlarged 3 fold, smooth, symmetrical, nontender Bruit right lobe of the thyroid gland

 3 months PTA Graves disease with hyperthyroidism (+) weight loss of 20-25 lbs. in 2 mos.

 Is an autoimmune disorder that leads to overactivity of the thyroid gland (hyperthyroidism).

 The thyroid is a small gland in the front of the neck. It makes hormones called T3 and T4 that regulate how the body uses energy. Thyroid hormone levels are controlled by the pituitary, which is a pea-sized gland in the brain. It makes thyroid stimulating hormone (TSH), which triggers the thyroid to make thyroid hormone.

 With Graves' disease, the immune system makes antibodies that act like TSH, causing the thyroid to make more thyroid hormone than your body needs. This is called an overactive thyroid or hyperthyroidism. An overactive thyroid causes every function of the body to speed up, such as heart rate and the rate your body turns food into energy. Graves' disease is one cause of overactive thyroid

Goiter Weight Changes Temperature Problems Heart and Blood Pressure Changes Gastrointestinal Problems Skin Changes Graves' Dermopathy/ Pretibial Myxedema

Changes to Hair / Nails / Hands

Eye Problems Thinking/Cognition Problems Mood Problems Panic and Anxiety Reflex/Movement Issues Sleep Problems

Gender History Age Pregnancy Smoking Intake of too much thyroid hormone Exposure to or Excess of Iodine/Iodine Drugs Certain Medical Treatments and Drugs Trauma to the Thyroid Major Stress

Blood Test A diagnosis can be confirmed with blood tests that measure the levels of thyroxine and TSH in your blood. High levels of thyroxine and low or nonexistent amounts of TSH indicate an overactive thyroid. The amount of TSH is important because it's the hormone that signals your thyroid gland to produce more thyroxine. These tests are particularly necessary for older adults, who may not have classic symptoms of hyperthyroidism.

 (-) Thyroid dysfunction treatment (-) History of radiation to the head & neck (-) Use of goitrogens (-) History of psychiatric illness or thyroid diseases.

Thyroid Blood Tests Thyroxine (T4) Triiodothyronine (T3) Thyrotropin(TSH) Free Thyroxine (FT4)

Result 11.3 ug/d 35% 0.006 mIU/mL 2.4 ng/dL

Reference 5.0 11.5 ug/dL 24% - 35% 0.4 -5.0 mIU/mL 0.8 -1.8 ng/dL

Interpretation: A high level of T4 confirms hyperthyroidism. Total triiodothyronine (Total T3) is generally elevated in hyperthyroidism and decreased in hypothyroidism. Thyroid-stimulating Hormone (TSH, thyrotropin) is generally elevated in hyperthyroidism. Free thyroxine (Free T4) is generally elevated in hyperthyroidism.

 Start of Risperidone and thyroid medications. No auditory and visual hallucinations or paranoid ideas

 Psychosis secondary to uncontrolled hyperthyroidism

 Included psychotic disorder not otherwise specified (DSM IV) probably secondary to uncontrolled hyperthyroidism. DSM IV schizophreniform disorder was included in differential diagnosis.

ASSESSMENT OBJECTIVE: - Weight loss of 2025 lb over a 2-month period.

NURSING DIAGNOSIS Imbalanced nutrition: Less than body requirements related to weight loss of 2025 lbs as manifested by signs of Graves Disease.

BACKGROUND KNOWLEDE Graves' disease stops your body from absorbing maximum nutrients from your food. Eating a highfat diet will slow down your digestion process and will allow your body to pull more nutrients from your foods. This may also help with any hunger you may experience as a result of the disease. Foods that may help your condition include lean meats, grains, fruits and vegetables. Graves' disease may cause weight loss. Increasing your daily caloric intake and eating foods with higher fat content can help you gain weight. Once your disease is under control, you should return to your previous calorie intake. Treatment of Graves' disease can also lead to weight gain. If you should experience this side effect, alter your diet so that you are eating fewer calories but are also eating nutrientrich foods. This will ensure that your body

PLANNING After 2 weeks of nursing interventions the patient will gain 1 lb.

INTERVENTION INDEPENDENT: -Monitor daily food intake. Weight daily

RATIONALE

EVALUATION After 2 weeks of Nursing Interventions the patient was able to gain 1 lb.

-Monitoring the weight of the patient will be the baseline of the caloric intake is effective or not

-Do health teachings about foods that good for his case like: >Encourage the patient to eat and increase number of meals and snacks, using high-caloric foods that are easily digested >Encourage the patient to eat gluten free foods (e.g lean meat, fish, and chicken or turkey. Beans, corn, rice, milk, unprocessed cheeses, and fresh or frozen fruits or vegetables) >Encourage the patient to eat Goitrogenic foods (e.g Brussel sprouts, cauliflower, broccoli, cabbage, turnips, and the like) - Increased Nutrients as part of a wellbalanced diet are necessary to meet metabolic demands.

- eating gluten causes celiac disease, an intestinal condition characterized by the inability to absorb nutrients from food.

- Goitrogens are thyroid antagonists; create less toxicity when cooked

ASSESSMENT

NURSING DIAGNOSIS

BACKGROUND KNOWLEDE gets all its necessary nutrients while lowering your risk for weight gain. The hypermetabolic state causes gastrointestinal hypermotility, with nausea, vomiting,diarrhea, and abdominal pain. Although, the client may have an increased appetite and eat more than usual, weight loss continues.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

-Avoid foods that increases peristalsis (e.g tea, coffee,apple, etc.,)

-Increased motility of GIT may result in diarrhea and impair absorption of needed nutrients)

COLLABORATIVE: -Consult with dietician to provide diet high in calories, Protein,Carbohydrates, Vitamins A,B,C,D,E and Zinc and Selenium - Vitamins C and E should also be taken for proper thyroid function. - Vit B important for developing the immune system and for the proper functioning of thyroid gland -Vit D for proper absorption of calcium in the body, supplemented to avoid osteoporosis and promote good bone health - Mineral supplements like zinc and selenium are also required for their antioxidant properties and development of immune system.

Naldo, Bridget Parayaoan, Ericka Judith Pascual, Anne Janelle Punzalan, Irene Quibod, Cristina Santos, Aiza Teodoro, Michelle Ann