Case study - Hypothyroidism: Nursing

Nurse Kyle works at a family practice clinic and is caring for Amara, a 54-year-old female who presents for a follow-up appointment after being prescribed levothyroxine 3 months ago for newly diagnosed hypothyroidism.

After settling Amara in her room, Nurse Kyle goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Amara’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

Nurse Kyle recognizes important cues, including Amara’s report of fatigue and constipation. He also notes that Amara shivers and pulls her jacket around her shoulders.

Nurse Kyle: Amara, tell me about what’s been going on since your last appointment. Amara: A lot of the same things, like I still feel tired and cold.

But my main issue is that I’m really constipated and it's making my stomach hurt. Next, Nurse Kyle analyzes these cues.

He reviews the electronic health record, or EHR, and notes that Amara started levothyroxine 3 months ago. He also notes her labs today show an elevated thyroid stimulating hormone, or TSH, and low free T4.

Nurse Kyle realizes that since Amara is not yet therapeutic on her medication, she is still experiencing symptoms of hypothyroidism.

Now, using the information he’s gathered, along with Amara’s medical history, Nurse Kyle chooses a priority hypothesis of constipation.

Then, he generates solutions to address Amara’s complaint of constipation that will include pharmacologic and nonpharmacologic interventions.

Nurse Kyle establishes the expected outcome that after intervening, Amara will have one bowel movement each day by the time she has her next follow-up in 6 weeks.

Nurse Kyle then takes action to implement these solutions. He knows that although Amara started on levothyroxine 3 months ago, it can take time for the medication to correct her thyroid hormone level, so she may still experience symptoms of hypothyroidism.

He also recognizes that Amara needs support to relieve her constipation, so he steps out of the exam room to collaborate with the health care provider.

Nurse Kyle explains Amara’s symptoms and the health care provider prescribes docusate tablets for Amara and increases her current dose of levothyroxine.

Nurse Kyle then re-enters Amara’s exam room. Nurse Kyle: Your health care provider increased your levothyroxine dose, since your labs and continued symptoms, like fatigue and constipation, mean you're still having hypothyroid problems.

Continuing to take your levothyroxine as prescribed will help normalize your thyroid hormone levels, which will help relieve constipation long-term.

They also ordered stool softener called docusate, which can help with constipation right now. Amara: That’s great, I hope it helps.

Is there anything else I can do? Nurse Kyle: Some other things that will help constipation include drinking more water, increasing the amount of fiber in your diet, and gradually increasing your daily activities.

Amara: Okay, I can do that. Nurse Kyle: Great!

Also, since we’re changing your levothyroxine dose, it’s important you follow-up as scheduled because we’ll need to monitor your symptoms and thyroid hormone levels.

Amara: Okay, I will. Six weeks later, Amara returns to the office for a follow-up appointment and Nurse Kyle evaluates the outcome of his actions.

Amara states she's feeling much better. When asked about constipation, Amara reports having a soft, easy-to-pass bowel movement daily for the past four weeks since increasing dietary fiber, being more active, and taking docusate.

She also reports that her hypothyroid symptoms are more under control, and she doesn’t feel as tired or cold. Nurse Kyle reviews her lab results and notes her TSH and free T4 are now within the normal range.

Alright, as a quick recap...Nurse Kyle recognized and analyzed cues related to Amara’s constipation, prioritized hypotheses, and generated solutions to address this problem.

He then implemented pharmacologic and nonpharmacologic interventions to address Amara’s constipation, evaluated Amara’s outcomes, and compared them to the expected outcome.

Since Amara had a bowel movement each day,