Concept Map
Student Name:
Instructor:
Erickson’s Developmental Stage Related to pt. & Cite
References (1)
Patient Education (In Pt.) & Discharge Planning (home needs)
History of Present Illness (HPI), Pathophysiology of Admitting Dx
(Cite References) Medical, Surgical, Social History (1).
Medical History
Cultural considerations, ethnicity, occupation, religion,
family support, insurance. (1) (14)
Surgical History
Social History
Chief Complaint
Patient Information
(1)
Name:
Age:
Gender:
Code Status:
DPOA:
Living Will:
Diagnostic Test/ Lab Results with dates
and Normal Ranges (3)
Test
Norms
Date
Current
Value
Admitting Diagnosis
Medical Management/ Orders/ Medications & Allergies (2)
Name
Dose
RT
Freq.
MOA
RN
Considerations
Onset/Peak/
Duration
(Insulin)
Priority nursing diagnosis #1
Vital Signs (4)
Neurological (5)
Cardiovascular (6)
Respiratory (7)
Nutrition/Hydration
(8)
GI (9)
GU (10)
Rest/ Exercise (11)
Outcome/Goal #1
Outcome/Goal #2
Integumentary (12)
Endocrine (13)
Psychosocial (14)
Misc. (Ht/Wt)
Interventions # 2
Interventions #1
Assessment/ Evaluation #2
Assessment/ Evaluation #1
PC Outcomes/Goal
Potential Complications/ at
risk for
Priority nursing diagnosis #2
PC Interventions
PC Evaluation Plan
Hyperthyroidism
Overview
Hyperthyroidism is hyperactivity of the thyroid with sustained increase in synthesis and release of
thyroid hormones. It is characterized by a state of hypermetabolism. The most common form of
hyperthyroidism is Graves’ disease. Other causes include toxic nodular goiter, thyroiditis, excess iodine
intake, pituitary tumors, and thyroid cancer.
Graves’ disease is an autoimmune disorder in which antibodies to the TSH receptor develop and
stimulate the thyroid gland to release triiodothyronine (T3), thyroxine (T4), or both. The excessive
release of thyroid hormones leads to the clinical manifestations associated with thyrotoxicosis.
The goal of management of hyperthyroidism is directed toward blocking the adverse effects of excessive
thyroid hormone, suppressing oversecretion of thyroid hormone, and preventing complications.
Treatment options include antithyroid medications, radioactive iodine therapy, and surgical
intervention.
Meet your Patient
J.P., age 38, is a real estate agent who comes to the urgent care center after several days of experiencing
what she thinks is viral gastroenteritis. J.P. complains of shortness of breath on exertion, insomnia,
nervousness, and fatigue. She has had diarrhea for the last 3 days.
She recently separated from her husband, and she and her two school-age children have been living
with her parents. She reports that she had a total hysterectomy for fibroids 2 years ago, and she had
similar symptoms at that time, but they finally went away. She feels exhausted all the time, but
attributes her fatigue to a demanding work schedule and the care of her children.
Assessment findings are as follows: blood pressure 148/92 mm Hg, heart rate 98 beats/minute and
bounding, respiratory rate 22 breaths/minute, and temperature 101.2° F (38.4° C); height 5 ft 4 in,
weight 102 lb; S1 and S2 heart sounds loud with grade II systolic murmur noted; lungs clear in all fields;
bowel sounds hyperactive in all quadrants; skin is warm, smooth, and moist.
Her general appearance is restless and anxious with a fine tremor of her fingers. She has a mild
protrusion of the eyeballs, but can close her eyelids over her eyes. She denies any specific pain, but says
she feels as if she is about to explode.
The health care provider detects a goiter while palpating J.P.’s thyroid gland and orders laboratory tests:
? Total T4 18 mcg/dL
? Free T3 280 ng/dL
? TSH 0.05 µU/mL
The health care provider orders a radioactive iodine uptake (RAIU) test to determine the cause of J.P.’s
hyperthyroidism. When explaining this test to J.P., you understand that a(n) increased uptake is
indicative of Graves’ disease as a cause of hyperthyroidism.
An endocrinology consultation is requested for J.P. The health care provider discusses treatment options
for Graves’ disease and recommends radioactive iodine (RAI) therapy. However, J.P. does not want to
deal with the risk of hypothyroidism that frequently occurs following RAI and chooses a subtotal
thyroidectomy.
Surgery is planned in 6 to 8 weeks, and as preparation, J.P. will take saturated solution of potassium
(SSKI), propranolol, and propylthiouracil (PTU):
Saturated solution of potassium (SSKI): Decreases the vascularity of the thyroid gland and inhibits
release and synthesis of thyroid hormones
Propranolol: Blocks the effects of sympathetic nervous system stimulation
Propylthiouracil (PTU): Inhibits synthesis of thyroid hormones and peripheral conversion of T4 to T3
Knowing that radioactive iodine therapy is the first-line treatment for hyperthyroidism, you recognize
that taking the patient’s preferences into account in choosing surgical intervention instead is an example
of evidence-based practice.
You teach J.P. how to care for her symptoms of hyperthyroidism until the medications become effective:
?
?
?
?
?
?
Ask for help in performing tasks requiring fine motor skills to avoid injury.
Avoid highly seasoned and high-fiber foods.
Bathe frequently and use powder lightly to keep the skin dry.
Sit upright as much as possible to decrease periorbital edema.
Eliminate caffeine from the diet.
Schedule daily rest periods and use relaxation techniques.
Seven weeks after her diagnosis, J.P. undergoes a subtotal thyroidectomy. In preparing for her return
from the postanesthesia care unit, you place a tracheostomy tray in the room and verify correct
functioning of the suction equipment and oxygen flow.
When J.P. is returned to her room, your priority nursing intervention will be to assess her for signs of
tracheal compression. Bleeding or swelling at the incision site can cause compression on the trachea,
obstructing the airway, and the patient must be monitored closely for this complication.
As you check J.P.’s vital signs on her first postoperative day, she states that the blood pressure cuff is too
tight and is hurting her arm. You note that she has a spasm in her hand and recognize this as a positive
Trousseau’s sign.
After checking the morning laboratory results, you notify the health care provider of this finding and
prepare to administer IV calcium gluconate.
J.P. asks you how taking out her thyroid gland can cause spasms in her hand. Your response is based on
knowledge that this reaction is a result of trauma to the parathyroid glands. Damage to the vascular
supply of the glands during neck surgery (e.g., thyroidectomy, radical neck surgery) can cause iatrogenic
hypoparathyroidism. Trousseau’s sign is a clinical manifestation of hypoparathyroidism.
To promote comfort and return of normal neck motion after her thyroidectomy, you teach J.P. to move
her head to flex, extend, rotate, and laterally bend her neck. The neck will be stiff and sore following a
thyroidectomy, and active range-of-motion exercises should be performed for all motions of the neck to
promote return of full range of motion. Supporting her head with her hands while moving will help
prevent wound dehiscence but has no effect on return of normal neck motion.
J.P. is prepared for discharge on the third postoperative day. Following discharge instructions, you know
additional teaching is needed when J.P. says “If I develop symptoms of hypothyroidism right away, I will
have to take thyroid preparations for the rest of my life.”
Most patients experience a period of relative hypothyroidism soon after surgery because of the
substantial reduction in the size of the thyroid. At this time the administration of thyroid hormone is
avoided because the use of exogenous hormone inhibits pituitary production of TSH and delays or
prevents the restoration of normal thyroid gland function and tissue regeneration.
You also recognize the importance of teaching J.P. to avoid excessive iodine ingestion and high
environmental temperature. Adequate iodine is necessary to promote thyroid function, but excesses
can inhibit the thyroid gland. Exposure to high environmental temperature can also inhibit thyroid
regeneration.
J.P. is discharged home with written instructions regarding signs and symptoms to monitor for
hypothyroidism, as well as dietary needs. She has a scheduled follow-up appointment with her health
care provider for 2 weeks from the date of discharge. Although she is not happy with the appearance of
her neck incision, she is relieved by your explanation that the scar will fade and eventually resemble a
neck wrinkle.
NANDA Nursing Diagnoses for Hyperthyroidism
?
?
?
?
Hyperthermia
Activity intolerance
Imbalanced nutrition: Less than body requirements
Disturbed thought processes
Complication of hyperthyroidism= Thyroid Storm
NANDA Nursing Diagnoses after Thyroidectomy
? Risk for injury
? Ineffective airway clearance
? Knowledge deficit
6/25/2020
MIA_NURS211L_202006SUI_E-03
Name
NURSING CONCEPT MAP RUBRIC
Description
Rubric Detail
Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
History of
Present
Illness
100.00 %
76.00 %
50.00 %
25.00 %
HPI explained in detail
with accurate and indepth understanding of
chief complaint and
supported by evidence
based citations.
HPI explained in
some detail with
moderate
understanding of
chief complaint or
no support from
evidence based
citations.
HPI explained in limited
detail with marginal
understanding of chief
complaint and no
support from evidence
based citations.
HPI details limited with
poor understanding of
chief complaint and no
evidence based citations
to support.
100.00 %
76.00 %
50.00 %
25.00 %
Identi es
comprehensive
assessments
parameters relevant to
medical diagnoses with
relevant diagnostic
procedures supported
by evidence based
citations.
Identi es most
relevant
assessments
parameters relevant
to medical diagnosis
with relevant
diagnostic
procedures
supported by
evidence based
citations.
Identi es limited
relevant assessments
parameters relevant to
medical diagnosis,
relevant diagnostic
procedures and vaguely
supported by evidence
based citations.
Fails to identify relevant
assessments parameters
relevant to medical
diagnoses, relevant
diagnostic procedures or
not supported by
evidence based citations.
Weight
8.00%
Physical
Assessment, &
Diagnostic tests/
procedures
Weight
8.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Past Medical &
Surgical History,
Pathophysiology
100.00 %
76.00 %
50.00 %
25.00 %
Past medical/surgical
history detailed with full
explanation of
Pathophysiology for
each diagnosis &
accurate details with
speci c detail related to
the client’s history and
symptoms and
supported by evidence
based citations.
Past medical/surgical
history given with
partial explanation
of identi ed
preexisting medical
diagnoses &
explanation accurate
with some detail
related to the client’s
history and
symptoms.
supported by
evidence based
citations.
Past medical/surgical
history given with
minimal explanation of
identi ed preexisting
medical diagnoses & few
details related to the
client’s history and
symptoms or not
supported by evidence
based citations.
No past medical/surgical
history given without
explanation; no preexisting medical diagnosis
identi ed or explanations
inaccurate and not
related to the client’s
history and symptoms
without evidence.
100.00 %
76.00 %
50.00 %
25.00 %
Identi es and de nes
correct stage with
examples of
meeting/not meeting
tasks supported by
evidence based
citations.
Identi es and
de nes correct stage
with examples of
meeting/not meeting
tasks supported by
evidence based
citations.
Identi es correct stage
without adequate
de nition or example of
meeting/not meeting
tasks without evidence
based citations.
Identi es incorrect stage
without de nition or
inappropriate examples
given, not supported by
evidence based citations.
Weight
8.00%
Erikson’s
Developmental
Stages
Weight
8.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Socioeconomic/
Psychosocial
Assessment
100.00 %
76.00 %
50.00 %
25.00 %
Describes
socioeconomic and
cultural background in
complete detail with
references; Identi es 3
psychosocial concerns.
Describes
socioeconomic and
cultural background
in some detail with
references; Identi es
2 psychosocial
concerns.
Describes
socioeconomic and
cultural background in
vague detail without
references; Identi es 1
psychosocial concern.
Describes socioeconomic
and cultural background
with no detail without
references; Identi es no
psychosocial concerns.
100.00 %
76.00 %
50.00 %
25.00 %
Weight
8.00%
Lists 3 or more
appropriate
collaborative
issues/concerns;
Rationale demonstrates
excellent understanding
of consults and
interventions.
Lists 2 appropriate
collaborative
issues/concerns;
Rationale
demonstrates
satisfactory
understanding of
consults and
interventions.
Lists 1 appropriate
collaborative
issue/concern; Rationale
demonstrates vague
understanding of
consults and
interventions.
Lists inappropriate
collaborative
issues/concerns;
Rationale demonstrates
unsatisfactory
understanding of consults
and interventions.
Potential Health
Deviations
100.00 %
76.00 %
50.00 %
25.00 %
Identi es TWO
prioritized risk factors in
proper format; Writes 3
independent nursing
interventions.
Identi es 1
prioritized risk factor
in proper format;
Writes 2
independent nursing
interventions.
Identi es 2 prioritized
risk factors but not in
proper format; Writes 1
independent pertinent
nursing intervention.
Does not identify
prioritized risk factors;
Writes 0-1 independent
nursing intervention not
pertinent to the
diagnosis.
Weight
8.00%
Interprofessional
Consults &
Discharge
Referrals
Weight
8.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Priority
Nursing
Diagnosis
100.00 %
76.00 %
50.00 %
25.00 %
TWO (2) prioritized
diagnoses written
correctly with proper
format with proper
etiology with su cient
data to support the
diagnosis.
One (1) prioritized
diagnoses written
correctly with proper
format with proper
etiology with
su cient data to
support the
diagnosis. Written
correctly without
su cient data to
support diagnosis.
Written incorrectly with
su cient data to
support diagnosis, not a
priority.
Written incorrectly, not in
correct format, or without
su cient data to support
diagnosis.
Weight
8.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Implementation
and
Rationale
100.00 %
76.00 %
50.00 %
25.00 %
Identi es 4
comprehensive nursing
interventions which
support each SMART
goal and nursing
diagnoses. Nursing
interventions are
appropriate and safe
and demonstrates
clinical reasoning.
Includes nursing and
pharmacological
interventions. Includes
at least 1 health
teaching intervention
that considers health
literacy level and needs
of patient/family.
Includes psychosocial,
spiritual, and cultural
needs. Each is
supported with scienti c
rationale using textbook
or EBP.
Identi es 3 nursing
interventions which
support each SMART
goal and nursing
diagnoses. Nursing
interventions are
appropriate and safe
and demonstrate
clinical reasoning.
Involved some
independent nursing
and pharmacological
actions. Incomplete
health teaching
activities. Incomplete
psychosocial,
spiritual, and
cultural needs
addressed. Each is
supported with
scienti c rationale
using textbook or
EBP.
Identi es 2 nursing
interventions which
support each SMART
goal and nursing
diagnoses. Nursing
interventions are
inappropriate, but safe
and demonstrates poor
clinical reasoning.
Interventions were
appropriate for the
condition, but did not
take into consideration
the patient’s individual’s
unique needs. Irrelevant
health teaching
activities. Does not
individualize
psychosocial, spiritual,
and cultural needs. Each
is supported with
scienti c rationale using
textbook or EBP.
Identi es 1 independent
intervtion with teaching
Nursing interventions do
not support each SMART
goal and nursing
diagnoses. Does not
demonstrate clinical
reasoning, were
inappropriate or
contraindicated the
nursing diagnosis.
Focused solely on
physician orders and
monitoring and did not
include nursing actions .
Did not mention health
teaching activities. Does
not include psychosocial,
spiritual, and cultural
needs. Are not supported
with scienti c rationale
using textbook or EBP.
Weight
9.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Planning/Goals &
Evaluation
100.00 %
76.00 %
50.00 %
25.00 %
Goal is measureable,
realistic, related to the
problem; Data supports
if goal is met, not met
with appropriate
revisions.
Goal is not
measureable,
realistic, related to
the problem; Data
somewhat supports
if goal is met, not
met with
appropriate
revisions.
Goal is not measureable,
not realistic, related to
the problem; Data
vaguely supports if goal
is met, not met with
inappropriate revisions.
Goal is not measureable,
not realistic, not related
to the problem; Data
does not support if goal is
met, not met with
inappropriate revisions.
Medications
100.00 %
76.00 %
50.00 %
25.00 %
Weight
9.00%
Lists all MAR
medications with
relevant side e ects and
nursing considerations
speci c to patient and
reasons why patient is
receiving drug. Shows
safe ranges by weight
for infants and children
or gives a rationale if it is
out of range.
Lists all MAR
medications but
does not include
relevant side e ects
and nursing
considerations
speci c to patient
and why patient is
receiving drug.
Shows safe ranges
by weight for infants
and children or gives
a rationale if it is out
of range.
Lists most of the MAR
medications with
relevant side e ects and
nursing considerations
speci c to patient and
why patient is receiving
drug. Shows safe ranges
by weight for infants and
children or gives a
rationale if it is out of
range.
Lists some MAR
medications but does not
include relevant side
e ects and nursing
considerations speci c to
patient. Safe dosages by
weight for infants and
children are missing or
incorrect.
Weight
9.00%
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MIA_NURS211L_202006SUI_E-03
Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
General
Organization
100.00 %
76.00 %
50.00 %
25.00 %
Accurate APA format;
Appropriate citations &
references; No spelling
or grammar errors.
1-2 APA format
errors; Some
citations, references
are appropriate;
Minimal spelling or
grammar errors.
Many APA format errors;
Inappropriate citations
or references; Many
spelling or grammar
errors.
No APA formatting; No
citations or references
included; Many spelling
or grammar errors.
Weight
9.00%
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Concept Map
Student Name:
Instructor:
Erickson’s Developmental Stage Related to
pt. & Cite References (1) = 8%
Patient Education (In Pt.) & Discharge Planning (home
needs) = 8%
Identifies and defines correct stage with
examples of meeting/not meeting tasks
supported by evidence-based citations.
Education during hospitalization.
Education at discharge (before going home). When to call
911.
Lists 3 or more appropriate collaborative issues/concerns;
Rationale demonstrates excellent understanding of consults
and interventions.
Cultural considerations, ethnicity, occupation,
religion, family support, insurance. = 8%
Describes socioeconomic and cultural
background in complete detail with references;
Identifies Three psychosocial concerns.
Diagnostic Test/ Lab Results
with dates and Normal Ranges
(3)
Test
Norms
Date
Current
Value
Chief Complaint
a BRIEF statement identifying why the
patient is here – in the patient’s own
words – for instance “headache”, NOT
“bad headache for 3 days”.
Patient Information
(1)
Name:
Age:
Gender:
Code Status:
DPOA:
Living Will:
Dose
RT
Pathophysiology of Admitting Dx (References) = 8%
Admitting Diagnosis
Medical History
Medical Management/ Orders/ Medications & Allergies = 9%
Lists all MAR medications with relevant side effects and nursing
considerations specific to patient and reasons why patient is receiving drug.
Shows safe ranges by weight for infants and children or gives a rationale if it
is out of range.
Name
History of Present Illness (HPI) = 8%
Explained in detail with accurate and in-depth
understanding of chief complaint and supported by
evidence-based citations.
Information regarding the CC using the OLDCART
format. If the CC was “Unintentional weight loss”, the
OLDCART for the HPI might look like the following
example:
Onset: 2 months ago
Location: Generalized
Duration: Steady weight loss, 3-5 pounds per week
Characteristics: Associated with feeling tired, poor
appetite, and occasional nausea without vomiting
Aggravating Factors: Food smells increase the frequency
of nausea
Relieving Factors: Small, bland meals are better tolerated
Treatment: None reported
Freq.
MOA
RN
Considerations
Onset/Peak/
Duration
(Insulin)
Past medical/surgical history detailed with full
explanation of Pathophysiology for each diagnosis &
accurate detail with specific detail related to the client’s
history and symptoms and supported by evidence-based
citations.
Surgical History:
Any history of surgeries.
Social History:
Include occupation and major hobbies, family status,
tobacco & alcohol use, any other pertinent data. Always
add some health promo question here – such as whether
they use seat belts all the time or whether they have
working smoke detectors in the house.
Priority nursing
diagnosis #1 = 8%
Prioritized, actual
(Problem-Focused)
diagnosis written
correctly with proper
format with proper
etiology with sufficient
data to support the
diagnosis. No risk
(potential) diagnosis
Outcome/Goal #1
SMART goal:
Specific, Measurable,
Achievable, Realistic,
Timely, and related to
the problem.
Interventions #1 = 9%
-FOUR comprehensive
nursing & pharmacological
interventions which support
each SMART goal and
nursing diagnosis.
-At least ONE health teaching
intervention.
-Explain your Scientific
Rationale for each
intervention using textbook or
EBP.
Potential Complications/ at
risk for = 8%
Identifies TWO prioritized risk
factors:
-Risk for decreased cardiac
output R/T ineffective
contractility of the heart.
-Risk for Cardiac Dysrhythmias
R/T cardiac ischemia/necrosis
Vital Signs (4)
Nutrition/Hydration
(8)
Neurological (5)
GI (9)
Cardiovascular (6)
GU (10)
Respiratory (7)
Rest/ Exercise (11)
Priority nursing
diagnosis #2
Acute Chest Pain R/T
myocardial
ischemia/infarction AEB
ST-segment
depression/elevation in
ECG, increased heart rate
and blood pressure, selfreport of acute chest pain,
shortness of breath;
diaphoresis, pallor,
weakness.
Outcome/Goal #2
Integumentary (12)
Endocrine (13)
Assessment/ Evaluation #1 = 9%
Identifies comprehensive assessments parameters
relevant to medical diagnoses with relevant
diagnostic procedures supported by evidencebased citations.
Data supporting if goal is met. If goal is not met,
then appropriate revisions.
PC Outcomes/Goal
Patient will maintain adequate
cardiac output, AEB strong
peripheral pulses, systolic BP
within 20 mm Hg of baseline,
HR 60 to 100 beats/min with
regular rhythm, urinary output
30 mL/hr or greater, warm and
dry skin, clear breath sounds,
good capillary refill.
Psychosocial (14)
Misc. (Ht/Wt)
Assessment/ Evaluation #2
-Assessment of chest pain using standardized
pain scale.
-Monitor change in physiological parameter such
as blood pressure, heart rate, respiratory rate,
and oxygen saturation.
-Monitor electrocardiogram (ECG) changes.
Goal met = patient expresses relief from acute
chest pain, vital signs within normal levels, and
no ECG changes.
PC Interventions
Writes Three independent nursing interventions to
prevent potential complications and achieve the
goal:
-Dysrhythmia Management
-Invasive Hemodynamic Regulation
-Cardiac Care: Acute
Within 30 minutes, patient
will verbalize satisfactory
pain control AEB selfreport of no pain, vital
signs within normal levels.
-Administer oxygen to help
reduce or reserve ischemia.
-Administer Nitroglycerine to
relax smooth muscles in the
vascular system, causing
peripheral arterial and venous
vasodilation.
-Administer morphine sulfate IV
to reduce anxiety and decrease
the patient’s perception of pain.
-Instruct patient on the
importance of reporting
changes in pain immediately to
provide prompt treatment and
prevent myocardial injury.
PC Evaluation Plan
Data supporting if goal is met. If goal is not met, then
appropriate revisions:
Goal met: Patient maintains adequate cardiac output
and absent of dysrhythmias, AEB strong peripheral
pulses, systolic BP within 20 mm Hg of baseline, HR
60 to 100 beats/min with regular rhythm, urinary
output 30 mL/hr or greater, warm and dry skin, clear
breath sounds, good capillary refill, and normal level
of consciousness.

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