Intrauterine growth restriction
Allison is a 35-year-old G2P1 F who is currently 6 weeks postpartum. She was induced for intrauterine growth restriction (IUGR delivered vaginally without complications. This morning, her husband found her difficult to rouse and confused so he called EMS.
The husband states she has been anxious since the birth of her child, but believes this is expected because the baby was small at birth and pediatricians are concerned about his growth.
Allison had nausea, vomiting and diarrhea for two days prior. Her milk supply has diminished and she has now switched to formula feeding.
The husband states they have not traveled recently and have no sick contacts.
Allison is still on maternity leave so she has been home caring for the infant. The husband has returned to work.
What additional history questions should we ask the husband at this time? Let’s come up with ten.
What initial nursing assessments should be performed?
Upon further questioning you learn:
PMH vitilaigo, hyperlipidemia, asthma
PSH none
SH: Allison works as a CRNA at a local hospital where she has been employed for 9 years. She walks for exercise but has been exercising less since the birth of the baby. She does not smoke or drink alcohol. She follows a vegan diet. She has been married to her husband Chad for 4 years. The couple recently purchased a new home right next to Allison’s mother which has been both a source of support but also stress at times.
ALL None
Meds simvastatin 10 mg daily, albuterol inhaler PRN
At this time, Allison is only minimally responsive to painful stimuli. She is unable to answer orientation questions and just keeps repeating her husband’s name. The nurse notes redness to her eyes and swelling around her eyelids. She has thyromegaly with +bruit and +thrill. There are no palpable nodules. Heart rate is rapid and irregular. Lungs have diffuse crackles bilaterally. Vital signs are as follows:
HR 145 bpm
BP 120/76 mmHg
RR 32 bpm
Temp 101°F
SpO2 89% on 4L nasal cannula
What should the nurse’s first action be?
What diagnostic tests do you anticipate will be ordered?
Her HR goes up to 155. AN EKG demonstrates atrial fibrilation. The patient becomes even less responsive and she is intubated for airway protection. She is transferred to the ICU. Her lab results are below:
Na 144 pH 7.33 TSH <0.005 (0.2-4.2 is normal)
K 5.0 pCO2 48 WBC 14K
Mg 1.0 HCO3- 24 Hgb 12.5
BUN 11 pO2 190 Hct 38%
Cr 0.7 Lactate 3.2 Plt 450K
What is going on with Allison?
She is treated with IV fluids, a beta blocker, and methimazole 20 mg PO BID. She starts doing much better clinically, she is in normal sinus rhythm and she is able to be extubated. She is transferred to the floor on hospital day 4 and now has the following test results: TSH <0.005, T4 9.0 (normal)
Thyrotrophin receptor antibody (TRAb) 30 (high)
ALT 150 U/L (normal is up to 42)
AST 102 u/L (normal is up to 37)
Alk phos 306 U/l (60-306)
Nuc med thyroid scan demonstrates diffuse increased uptake equal throughout the thyroid gland with no areas suggestive of a hot or cold nodule.
Thyroid sono demonstrates enlarged, hypervascular thyroid with no discrete nodules
What is concerning about her laboratory results and what could be causing it?
What do you think is the etiology of her thyroid condition?
What are her treatment options?
Allison opts to proceed with a total thyroidectomy. Post operatively, she complains of pins and needles in her hands and on exam, you note a positive Chvostek’s sign and positive Trousseau’s sign.
What surgical complication might Allison be experiencing?
What treatment should be ordered?
What patient counseling should be provided to a patient who has just undergone a total thyroidectomy? Any other meds we need to discuss?
Allison’s surgical pathology returns as follows:
Enlarged thyroid gland
R lobe tumor 0.5 papillary thyroid cancer, encapsulated, no lymphatic or angioinvasion.
Central neck lymph nodes 1/11 positive for papillary thyroid cancer. The tumor focus is 0.5 mm.
WHAT DO WE DO NOW!??!??
