Introduction

Hyperthyroidism is a pathology that occurs mainly in the female sex, a situation that, if not treated during pregnancy, can trigger thyrotoxicosis and even in its most serious form “thyroid storm” where the life of the mother and the mother and her child may be at potential risk ¹. In the world, the prevalence of thyroid diseases until 2022 was 10 %, and the presence in the female population is ten times more frequent ², they become manifest in around 4 % of pregnancies, situation that is part of the 75 % of deaths in women of reproductive age, according to the World Health Organization (WHO) 2019 ³.

In Mexico, the presence of problems related to the thyroid gland was detected in at least 1.4% of women of reproductive age ^3-4). Women with hyperthyroidism during pregnancy are at greater risk of loss of maternal-fetal well-being. Some body functions are altered as a result of the hormonal storm that a pregnancy produces (thyrotoxicosis). Thyrotoxicosis is evidenced by hypermetabolism and hyperactivity produced by elevated serum concentrations of free thyroxine (T4L by its acronym in Spanish) and/or free triiodothyronine (T3L by its acronym in Spanish) and its prevalence is found in 1 to 4 of every 1000 pregnancies ^5,6.

At the beginning of pregnancy, the diagnosis of thyrotoxicosis is differentiated from severe hyperthyroidism. The clinical manifestations in both are the following: palpitations, anxiety, tremors and heat intolerance. A complete history (anamnesis) and physical examination are required to establish the cause ⁷. From the above, the risks can lead to abortion before week 12, and before week 32, premature birth, premature placental detachment, preeclampsia, high blood pressure and heart failure for the mother, and in the fetus disorders such as low birth weight and fetal hyperthyroidism, the latter may be present, even if the mother is euthyroideal ⁸.

Maternal characteristics considered in the reproduction stage such as age, ethnicity, number of pregnancies, physical condition, nutritional status, and comorbidities, in addition to external aspects such as access to health services and prenatal control, are determinants of maternal-fetal health. ^3,9,10. In 2016, the WHO restructured the number of consultations suggested during pregnancy, increasing the steps from four to eight, having to be carried out in a sequence starting from the 12^th week of gestation as the first contact, and the subsequent ones every 4 weeks from the 20^th, until the 34^th week, then every 2 weeks until the 40^th week, which marks the end of the pregnancy ¹¹.

The discipline of nursing is recognized from its beginnings as a social process linked to the art of caring, it responds to the need to help people when they do not have sufficient capacity to care for themselves, it identifies the real and/or potential needs of the person who demands care, generates autonomy or dependency as a consequence of the activities assumed by the nurse ¹². The above gives direction for the use of the nursing care process (PAE by its acronym in Spanish) and the nursing taxonomy that allows providing quality care with the standardization of nursing care such as the North American Nursing Diagnosis Association (NANDA), the classification of nursing results (NOC) and the nursing intervention classification (NIC) ^13-15.

Dorothea Orem's General Theory of Self-Care Deficit in nursing focuses attention on the person being cared for, seeking to identify to what extent such person assumes responsibility for its own care ¹⁶, the nursing professional has five methods of helping relationship or substitute that he/she can use according to the need that the person under his/her care presents, which are: in a compensatory way according to the deficit, he/she can also assume a role to support, guide, teach and provide conditions in the environment that allows the development of such person ^16,17. The purpose of this work was to develop a PAE for a pregnant woman who suffered from hyperthyroidism using the NANDA, NOC and NIC taxonomies with a focus on Orem's theory.

Methodology

The present research refers to a descriptive case study of a pregnant woman with hyperthyroidism, admitted to a second level care public hospital in the city of Los Mochis, in Sinaloa, Mexico. To this effect, the stages included in the PAE were followed, which are: assessment, diagnosis, planning, execution, and evaluation. For the assessment stage, the observation of subjective and objective data was carried out from the physical examination in a cephalocaudal manner, the registration was carried out in an assessment guide based on the General Theory of Self-Care Deficit by Dorothea Orem ¹⁷; in addition, information was indirectly available through the clinical record. For which reason elements proposed by Orem were rescued where the theory is constituted by three theories implicit and related to each other, which are: self-care theory, self-care deficit theory and the nursing system theory, it is a theory that it can be applied to various fields, which has come to be considered of great scope due to its scientific foundation ^16,18.

The Orem assessment guide was used as an instrument, which is segmented into two sections, the basic conditioning factors, and the universal requirements, which in turn has three subsections called universal, development and health deviation. The response options are open, multiple, and dichotomous ¹⁷. Based on the data obtained and by using clinical judgment, the diagnostic stage was completed, where the NANDA ¹³ was used, which allowed the NOC ¹⁴⁾ to be proposed. For the third stage, it was approached from the NIC ¹⁵, for which independent and interdependent interventions were established, as part of the individualized nursing care plans PLACE ¹⁹.

Corresponding to the fourth stage, which is execution, this allowed the PLACE to be implemented in search of achieving the proposed results following three phases: preparation, execution, and documentation. With this, it was possible to complete the fifth stage, which was the evaluation according to the applicability of the PLACE, as suggested by the nursing care model that is part of the National Nursing Program, which is aimed at improving technical quality and comprehensive care coverage at all levels of care in order to guarantee patient safety and apply a systematized practice of nursing care ⁽²⁰⁾. The application of the guide and the implementation of the PLACE by the current director of the Hospital was authorized, in the period of 2021. The present investigation was carried out in accordance with the general health regulations regarding research for health and in regard to the recovery of the care person's data, articles 16, 20 and 21 were specifically provided for the protection of the person's privacy and authorization through informed consent ²¹.

Case presentation

In basic conditioning factors, JLAL is pregnant, 19 years old, single, resident of a rural area of the municipality of Ahome, Sinaloa. At the time of her assessment, her weight was 75 kg and her height was 1.62 cm, her body mass index (BMI) was calculated at 27.5. She mentioned being a housewife and living with her parents, she played the role of caregiver for her parents who covered their needs, which was reflected in the good communication she maintained with them, she denied belonging to any religion, she had incomplete high school education. She had been known to have hypothyroidism since childhood and had been under treatment since then. She had all the public services at her home and expressed the hope that her health and that of her baby would improve.

The assessment according to the General Theory of Self-Care Deficit, in relation to the self-care requirements: Universal, identified a pregnant woman at 31.2 weeks of gestation who attended the gynecological emergency service referred from her health center due to thyroid dysfunction. Upon her arrival at the service, the patient expressed feeling “nervous”, she denied drug addictions and allergies. The measurement of vital signs in the blood pressure figures were found to be elevated (150/100 mmHg), heart rate of 130 per minute, oxygen saturation of 97 % and respiratory rate of 24 per minute. She denied any other symptoms. She was in her first pregnancy and reported experiencing active fetal movements and cramping.

During the nursing intervention, a peripheral line was placed for the administration of crystalloid solutions, laboratory studies and thyroid function tests were requested (T3 5.5 nmol/L, TSH-S 0.01 mIU/L, free T3 15.23 nmol/L, T4 total 24.8 nmol/L), toxemic and preoperative profile (glucose 79 mg/dL, creatinine 0.20 mg/dL, uric acid 4.6 mg/dL, Glutamic Oxaloacetic Transaminase 9.9 U/L, Glutamic Pyruvic Transaminase 6.4 U/L, Total Bilirubin 0.38 mg/dL, Direct bilirubin 0.21 mg/dL, Indirect bilirubin 0.2 mg/dL, Prothrombin times 2.9 seconds, Partial thromboplastin time 26.5 seconds, Hemoglobin 8.4 g/dL, Platelets 400 10˄3/μl, leukocytes 9.4 10˄3 /μl, urine collection was started within 24 hours (hrs). Interconsultation with the endocrinology service was also requested. The patient remained fasting, starting treatment with intravenous hydralazine 5 mg at a response dose to improve blood pressure levels, after administration of antihypertensives, her figures remained within the therapeutic objective. The process of fetal lung maturation began with the administration of betamethasone intramuscularly at 12 mg every 24 hours for three doses.

Subsequently, supplemental oxygen was provided through a nasal prong device providing oxygen at 3 liters (lts) per minute due to the presence of fetal tachycardia. She is questioned about her treatment, to which she responds as not maintaining basic treatment for her disease, for which levothyroxine 100 mcg per day was indicated; however, she expressed having suspended the treatment at the beginning of pregnancy due to fear that it could be affected by the medication, which is why she stopped attending her endocrinology check-up appointment. Her gynecological or prenatal check-ups, she reported that they were carried out irregularly, since she was not informed of the importance of this care. A reassessment was performed with the laboratory results, which highlighted the following: normal toxemic profile, glucose 79 mg/dl, creatinine 0.20 mg/dL, uric acid 4.6 mg/dL, hemoglobin 8.4 g/dL, platelets 400 10˄3/μl, leukocytes 9.4 x103 µL, abnormal thyroid profile (Total Triiodothyronine (T3): 3.4 nmol/L, TSH-S 0.01 mIU/L, Free T3: 6.6 nmol/L, Free Tetraiodothyronine (T4): 3.03 nmol/L, Total Tetraiodothyronine : 23.17 nmol/L, positive hemotype O and general urine test with leukocytes of 25/uL, bacterial flora of 1000/uL, positive crystals, yellow color, Ph of 6, erythrocytes <1.00/uL, pathological urine culture, contained proteins of 12.5 mg/dL in 24-hour urine.

At the time of the physical assessment, the patient was conscious, with adequate coloring and hydration of the skin and in teguments, she presented edema in the lower extremities, referring to "not having noticed it before", she was questioned about her diet to which she responded that she generally consumed enough water, and the foods she frequently consumed were red meat, jam, coffee and sausages. During her pregnancy, at the time of assessment she had gained 5 kg.

Regarding elimination, she mentioned urinating 10 times a day (frequency) and evacuations regularly and spontaneously, without presenting dependency to move around or do daily tasks, given that she had sufficient energy and participation in her self-care.

Regarding psychosocial status, she was recognized as a sociable person, she accepted herself physically, emotionally, and socially. Regarding family history, she had sick relatives who had died from systemic arterial hypertension; in the case of her mother, she mentioned that she also suffered from hypothyroidism. Regarding her development as a person, she was in the adolescent stage; she had her menarche at the age of 15 and began her sexual life at the age of 17; she complied with the vaccination schedule, including the anti-COVID 19 vaccine with 3 doses of 3 and influenza.

She was evaluated by an endocrinologist who mentioned that at the time she had clinical signs of thyrotoxicosis, presence of exophthalmos, fine tremor, tachycardia 138-140 per minute, hyperreflexia, blood pressure monitoring was indicated since upon admission she had high systolic pressures of up to 150-160 mmhg, she was kept under observation and surveillance in the hospital, with vital signs taken 2 times per shift, monitoring of fetal focus. She was considered a patient at high risk of complications; family members and the patient were talked to about the disease, consequences, and risks that she presented. A new free T4 laboratory was requested in one week to observe changes after treatment for thyrotoxicosis, which included antithyroid medication and beta blocker to control the disease and symptoms such as: propranolol 40 mg every 12 hours, thiamazole 10 mg every 12 hours.

On the 2nd day of her hospital stay, she developed the following diagnoses: pregnancy at 31.4 weeks of gestation by ultrasound, hyperthyroidism, gestational hypertension and grade 2 anemia. A blood transfusion of 1 red blood cell package was performed, improving conditions (9.5 g/dL), and continuing with established medical management. After completing 48 hours of maternal-fetal surveillance, with treatment adjustment, complying with the fetal lung maturation scheme, and not presenting symptoms for more than 24 hours, the medical area personnel indicated hospital discharge with an open appointment for an outpatient consultation of endocrinology and gynecology.

Results

Regarding the assessment of JLAL according to the significant data found and clinical reasoning, the following NANDA labels were identified: Risk of alteration of the maternal-fetal dyad (00209), Willingness to improve self-care (00182), Willingness to improve knowledge (00161), Willingness to improve the childbearing process (00208), Poor knowledge (00126), Risk of ineffective peripheral tissue perfusion, (00228), Risk of decreased cardiac tissue perfusion (00200), ineffective childbearing process (00221), and ineffective self-management of health (00276), the latter two were developed as individualized PLACE and executed in order to make efficient the interventions required by the woman in a health situation.

The PLACE of the ineffective maternity process (00221), allowed the establishment of the NIC high-risk pregnancy care and the administration of blood products, which resulted in the execution of activities for the identification of medical factors related to poor outcomes during pregnancy , the above allows us to know risk factors by reviewing the obstetric history and determining the pregnant woman's understanding of them, thereby allowing the pregnant woman to be guided on self-care techniques, use of prescribed drugs and monitoring compliance with medical treatment and self-care exercised for the healthy development of pregnancy.

Regarding the second intervention within the PLACE, corresponding to the Administration of blood products, the activities consisted of verifying the medical indications, which requires knowing the pregnant woman's history of transfusions, making authorization through informed consent necessary for the supply of erythrocyte concentrate. The nursing personnel carried out and applied the protocol for supplying the blood product, mentioning the pregnant woman for the timely report in case of a transfusion reaction (pruritus, dizziness, dyspnea, and chest pain). Likewise, the final disposition of the transfusion is fulfilled, (Table 1).

To prevent ineffective self-management of health (00276), NICs teaching was established: disease process, Teaching: prescribed medications and Improving coping were established, for which the pregnant woman is presented with the characteristics of the disease and the importance of complying with the treatment, therefore, it was important to mention the need for changes in lifestyle in order to avoid future complications and/or control the disease process.

Likewise, when providing help to the pregnant woman initially, the appropriate short and long-term objectives are jointly established, by understanding the pregnant woman's capacity for decision-making, in search of problem resolution, providing objective information related to the diagnosis, treatment and prognosis, which allowed us to conclude with the evaluation of the pregnant woman's knowledge about the specific disease process, (Table 2).

In execution and evaluation, to meet the proposed objective, the results (NOC) were addressed interdependently (gynecologist, endocrinologist, chemist), developing the proposed interventions. From the clinical history, some risk factors were determined for the stage in which the pregnant woman was, such as the history of hyperthyroidism, which triggered in the patient a series of complications associated with a high-risk pregnancy. In relation to the history of not attending prenatal consultations, the pregnant woman was provided with information about the importance of complying with prenatal check-ups on a regular basis, which leads to the next point, which consisted of identifying compliance with treatment for the present thyroid disease, where a deficit in self-care was found when abandoning pharmacological treatment was detected, as expressed by the patient, for this reason it was insisted on carrying out safe control of her pregnancy in conjunction with her chronic illness. Regarding the medical professional, consultation with an endocrinologist specialist was requested, so that he/she would carry out a series of assessments and subsequently indicate new studies to be performed. She was kept under strict surveillance and the medical indications were followed in their entirety (pharmacological treatment, oxygen supply through nasal cannulae.

Laboratory studies showed low hemoglobin (8.4 mg/dL), for which the gynecologist indicated transfusion of blood products. Important information was collected prior to transfusion, such as the presence of allergies, which were denied, type of blood group, informed consent to transfuse, the number and date of the unit to be transfused, once the information is obtained, the protocol is followed: taking vital signs prior to placing the unit and every hour afterwards, monitoring the puncture site to rule out injuries or infiltration, monitoring the blood package and administration of saline solution at the end of the unit.

Discussion

Based on the objective of developing a PAE for a pregnant woman with thyroid disease, it was pertinent to build and implement two PLACES to encourage the responsibility of self-care on the part of the pregnant woman, planning: ineffective maternity process and ineffective self-management of health. In accordance with the PLACES, the prenatal maternal situation was considered, which was compromised due to the complications generated by the suspension of medical treatment for hypothyroidism prior to pregnancy that led to hyperthyroidism, situation that was addressed with multidisciplinary care of high-risk pregnancy, administration of treatment, blood products, office studies and health education.

Orem's theory has been applied in various studies, of which some have been recovered that have considered women in various stages of life as a subject of study. In the case of pregnant women with sexually transmitted infections, they represented a high incidence compared to other pathologies, so it is necessary for nursing personnel to participate with prevention and health promotion strategies, where the population behaves safely and responsibly toward sexual and reproductive health ²². Orem's theory allows us to understand the self-care actions that pregnant women develop ²³.

Moreover, some authors ²⁴ described in their study adverse events during pregnancy due to the omission of pharmacological treatment, likewise, previous studies ^5,25,26 mentioned complications in the newborn due to the thyroid disease during pregnancy, by focusing attention on prenatal care and risk prediction to intervene in a timely manner in the development of possible complications. Considering it is important to identify those pregnant women with a previous diagnosis of thyroid disease for their follow-up and control ¹⁰.

The limitation of this research work was the in-person follow-up with the study person, data was only obtained from the system 3 months after the application of the guide and the interventions. This did not allow us to expand the results objectively nor to evaluate the implemented activities in the long term.

Conclusions

The PAE in a pregnant woman with thyroid pathology exposed the context experienced by women who suffer from chronic diseases and are in risk situations where they do not usually foresee or separate their health conditions prior to pregnancy, and which lead to compromising maternal-fetal well-being. That said, nursing personnel have an important role in the first level of care for the timely detection of women of childbearing age with comorbidities. The application of tools is suggested, such as records of vital signs, somatometry and history of the beneficiaries, which will allow the identification of the female population at risk of a complicated pregnancy. This combined with the monitoring of each of the women of childbearing age with risk factors, which will allow an approach to provide them with education for preconception maternal health.

Conflict of interests

The authors declare that there is no conflict of interest.

Financing

The authors declare that there was no type of financing.