Republic of the Philippines

NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY Old Sagay, Sagay City, Negros Occidental

(034)722-4120/www.nonescost.edu.ph

Northern Negros State College of Science and Technology

Sagay City, Negros Occidental

Graduate School

Masters in Nursing

In Partial Fulfillment of the Requirements in

NED 105 Research Process

CLINICAL RESEARCH PROPOSAL:

CARE OF PATIENT WITH HYPERTHYROIDISM

Presented To:

Atty. Joseph Gedeoni C. Valencia R.N., M.N., Ph.D.

Submitted By:

Jastine Joy V. Beltran, R.N.

January 10, 2016

Chapter I

INTRODUCTION

Background of the Study

The thyroid gland is a butterfly-shaped endocrine gland that is normally

located in the lower front of the neck. The thyroid’s job is to make thyroid

hormones, which are secreted into the blood and then carried to every tissue

in the body. Thyroid hormone helps the body use energy, stay warm and keep

the brain, heart, muscles, and other organs working as they should. The term

hyperthyroidism refers to any condition in which there is too much thyroid

hormone produced in the body. In other words, the thyroid gland is

overactive. Another term that you might hear for this problem is

thyrotoxicosis, which refers to high thyroid hormone levels in the blood

stream, irrespective of their source. Thyroid hormone plays a significant role in

the pace of many processes in the body. These processes are called your

metabolism. If there is too much thyroid hormone, every function of the body

tends to speed up. It is not surprising then that some of the symptoms of

hyperthyroidism are nervousness, irritability, increased perspiration, heart

racing, hand tremors, anxiety, difficulty sleeping, thinning of your skin, fine

brittle hair and weakness in your muscles—especially in the upper arms and

thighs. You may have more frequent bowel movements, but diarrhea is

uncommon. You may lose weight despite a good appetite and, for women,

menstrual flow may lighten and menstrual periods may occur less often. Since

hyperthyroidism increases your metabolism, many individuals initially have a

lot of energy. However, as the hyperthyroidism continues, the body tends to

break down, so being tired is very common. Hyperthyroidism usually begins

slowly but in some young patients these changes can be very abrupt. At first,

the symptoms may be mistaken for simple nervousness due to stress. If you

have been trying to lose weight by dieting, you may be pleased with your

success until the hyperthyroidism, which has quickened the weight loss,

causes other problems. In Graves’ disease, which is the most common form of

hyperthyroidism, the eyes may look enlarged because the upper lids are

elevated. Sometimes, one or both eyes may bulge. Some patients have

swelling of the front of the neck from an enlarged thyroid gland (a goiter).

The most common cause (in more than 70% of people) is

overproduction of thyroid hormone by the entire thyroid gland. This condition

is also known as Graves’ disease (American Thyroid Association). Graves’

disease is caused by antibodies in the blood that turn on the thyroid and

cause it to grow and secrete too much thyroid hormone. This type of

hyperthyroidism tends to run in families and it occurs more often in young

women. Little is known about why specific individuals get this disease.

Another type of hyperthyroidism is characterized by one or more nodules or

lumps in the thyroid that may gradually grow and increase their activity so

that the total output of thyroid hormone into the blood is greater than normal.

This condition is known as toxic nodular or multinodular goiter. Also, people

may temporarily have symptoms of hyperthyroidism if they have a condition

called thyroiditis. This condition is caused by a problem with the immune

system or a viral infection that causes the gland to leak stored thyroid

hormone. The same symptoms can also be caused by taking too much thyroid

hormone in tablet form. These last two forms of excess thyroid hormone are

only called thyrotoxicosis, since the thyroid is not overactive.

Diagnosis is usually a simple matter. A physical examination usually

detects an enlarged thyroid gland and a rapid pulse. The physician will also

look for moist, smooth skin and a tremor of your fingertips. Your reflexes are

likely to be fast, and your eyes may have some abnormalities if you have

Graves’ disease. The diagnosis of hyperthyroidism will be confirmed by

laboratory tests that measure the amount of thyroid hormones— thyroxine

(T4) and triiodothyronine (T3)—and thyroid-stimulating hormone (TSH) in

your blood. A high level of thyroid hormone in the blood plus a low level of

TSH is common with an overactive thyroid gland. If blood tests show that your

thyroid is overactive, your doctor may want to obtain a picture of your thyroid

(a thyroid scan). The scan will find out if your entire thyroid gland is

overactive or whether you have a toxic nodular goiter or thyroiditis (thyroid

inflammation). A test that measures the ability of the gland to collect iodine (a

thyroid uptake) may be done at the same time.

Since no single treatment is best for all patients with hyperthyroidism.

The appropriate choice of treatment will be influenced by your age, the type

of hyperthyroidism that you have, the severity of your hyperthyroidism, other

medical conditions that may be affecting your health, and your own

preference. It may be a good idea to consult with an endocrinologist who is

experienced in the treatment of hyperthyroid patients. If you are unconvinced

or unclear about any thyroid treatment plan, a second opinion is a good idea.

Drugs known as antithyroid agents—methimazole (Tapazole®) or in rare

instances propylthiouracil (PTU)—may be prescribed if your doctor chooses to

treat the hyperthyroidism by blocking the thyroid gland’s ability to make new

thyroid hormone. Methimazole is presently the preferred one due to less

severe side-effects. These drugs work well to control the overactive thyroid,

bring quick control of hyperthyroidism and do not cause permanent damage

to the thyroid gland. In about 20% to 30% of patients with Graves’ disease,

treatment with antithyroid drugs for a period of 12 to 18 months will result in

prolonged remission of the disease. For patients with toxic nodular or

multinodular goiter, antithyroid drugs are sometimes used in preparation for

either radioiodine treatment or surgery.

Antithyroid drugs cause allergic reactions in about 5% of patients who

take them. Common minor reactions are red skin rashes, hives, and

occasionally fever and joint pains. A rarer (occurring in 1 of 500 patients), but

more serious side effect is a decrease in the number of white blood cells. Such

a decrease can lower your resistance to infection. Very rarely, these white

blood cells disappear completely, producing a condition known as

agranulocytosis, a potentially fatal problem if a serious infection occurs. If you

are taking one of these drugs and get an infection such as a fever or sore

throat, you should stop the drug immediately and have a white blood cell

count that day. Even if the drug has lowered your white blood cell count, the

count will return to normal if the drug is stopped immediately. But if you

continue to take one of these drugs in spite of a low white blood cell count,

there is a risk of a more serious, even life-threatening infection. Liver damage

is another very rare side effect. A very serious liver problem can occur with

PTU use which is why this medication should not generally be. Another way to

treat hyperthyroidism is to damage or destroy the thyroid cells that make

thyroid hormone. Because these cells need iodine to make thyroid hormone,

they will take up any form of iodine in your blood stream, whether it is

radioactive or not.

The radioactive iodine used in this treatment is administered by mouth,

usually in a small capsule that is taken just once. Once swallowed, the

radioactive iodine gets into your blood stream and quickly is taken up by the

overactive thyroid cells. The radioactive iodine that is not taken up by the

thyroid cells disappears from the body within days. Over a period of several

weeks to several months (during which time drug treatment may be used to

control hyperthyroid symptoms), radioactive iodine destroys the cells that

have taken it up. The result is that the thyroid or thyroid nodules shrink in

size, and the level of thyroid hormone in the blood returns to normal.

Sometimes patients will remain hyperthyroid, but usually to a lesser degree

than before. For them, a second radioiodine treatment can be given if needed.

More often, hypothyroidism (an underactive thyroid) occurs after a few

months and lasts lifelong, requiring treatment. In fact, when patients have

Graves’ disease, a dose of radioactive iodine is chosen with the goal of making

the patient hypothyroid so that the hyperthyroidism does not return in the

future. Hypothyroidism can easily be treated with a thyroid hormone

supplement taken once a dayprescribed. You should stop either methimazole

or PTU if you develop yellow eyes, dark urine, severe fatigue, or abdominal

pain. Because hyperthyroidism, especially Graves’ disease, may run in families,

examinations of the members of your family may reveal other individuals with

thyroid problems. (American Thyroid Association).

Statement of the Problem

How can a client with endocrine problem (hyperthyroidism) be assisted

in attaining a higher level of met needs utilizing Orlando’s interactive theory in

the nursing process?

Significance of the Study

The study is of great relevance in the care of the client with

Hyperthyroidism. Nursing Interventions are focused on the patient’s needs or

responses to the environment. It enables the nurse to determine the

effectiveness of interventions utilizing Ida Jean Orlando’s Theory as a guide in

nursing practice and render quality nursing care.

Chapter II

THEORETICAL FRAMEWORK

Review of Literature

According to Journal of the ASEAN Federation of Endocrine

Societies (JAFES) on their study on Prevalence of Thyroid Disorders among

Adults in the Philippines last 2012 the frequency of thyroid disorders varies in

different countries. A national prevalence study among the Filipino adult

population using thyroid function tests will give us information vital to public

health. Data on thyroid disorders, which include both overt and subclinical

forms can provide estimates of the national burden of this illness. Distribution

by age can help us formulate focused strategies and guidelines for improving

medical care in thyroid disorders among subsets of Filipinos.

The national prevalence of goiter was first reported in 1987. Clinical

examination for the presence of goiter was undertaken during the 1987 and

1993 National Nutrition Surveys allowing comparisons. There appeared to be

an increase in the prevalence of goiter during this six-year period, with the

initial rate in 1987 of 3.7% to 6.7% in 1993. 6. The data studied both non-

pregnant and pregnant adults with the highest prevalence seen among

pregnant women aged 13 to 20 years at 27.4%.

To determine the latest prevalence of various categories of abnormal

thyroid dysfunction among the Filipino non-pregnant adult population and to

describe the prevalence of thyroid enlargement in the Philippines in relation to

thyroid dysfunction status. They covered all 17 regions and 80 provinces of

the Philippines. It included all Filipino adults 20 years and older, who are non-

pregnant and non-lactating. A standard questionnaire was used to collect data

on previous diagnosis and current treatment for thyroid disorders, and neck

examination by trained field personnel was done to assess the presence of

goiter. Blood was extracted, processed and sent to an accredited laboratory

for free T4 and TSH testing using micro-particle enzyme immunoassay.

A total of 4897 persons had thyroid function tests. Of these, 417

(8.53%) had thyroid function abnormalities with the most common

abnormality being subclinical hyperthyroidism occurring in 5.33%. The other

categories had the following prevalence: true hyperthyroidism 0.61% ; true

hypothyroidism 0.41%; and subclinical hypothyroidism 2.18% . Majority of the

population 4480 (91.47%) had normal thyroid function tests. Of those with

subclinical hyperthyroidism, 55% are females with mean age of 48 years

(95% CI 45.9-50.1 years) compared with the volunteers with normal thyroid

function who were younger (mean age of 43.1, 95% CI 42.5-43.6 years). Out

of the 7,227 volunteers who responded to the survey and clinical examination,

a total of 674 (8.9%) had goiters. Out of the 674 subjects with goiters, 379

had diffuse enlargement (56%) while the rest had nodular goiter (44%).

Among the sub-population (n= 4897) who underwent thyroid function testing,

9% of those with normal thyroid function tests have goiters.

They concluded that the prevalence of thyroid function abnormalities in

the Philippines is 8.53% with the greatest proportion of volunteers having

subclinical thyroid disease. There is a low prevalence of both true or overt

hyperthyroidism and hypothyroidism. In the larger survey, it was found that

8.9% of volunteers who were examined had goiters. The etiology of these

goiters will need to be ascertained in future studies.

The symptoms may include enlarged thyroid gland, nervousness,

irritability, insomnia, diarrhea, heart palpitation, unexpected weight loss

despite increased appetite, heat intolerance, increased in bowel movements.

There may be puffiness around the eyes and a characteristic stare due to

elevation of upper eyelids. Advanced symptoms are easily detected, but early

symptoms especially in elderly , may be quite suspicious.

(http://www.medicinenet.com/hyperthyroidism)

The most common method used to diagnose thyroid disorders,

is through blood testing. Blood is drawn and lab-tested to see if the thyroid’s

hormone levels are in the normal range. If they are outside of the normal

reference range, on the high end, this would indicate an over-active thyroid

gland, “hyperthyroidism”. The treatment for hyperthyroidism is also by oral

medication but in this case, medications called “Thyroid Hormone

Replacement Medications” are used to supplement the thyroid’s

underproduction of thyroid hormones. (Disease and Disorders: A Nursing

Therapeutic Manual. 3rd Edition. 2007)

And on the Epidemiological survey on the relationship between

different Iodine intakes and prevalence of Hyperthyroidism conducted by F.

Yang, et. al., wherein they made a comparative cross-sectional and

longitudinal survey conducted in three areas with borderline iodine deficiency,

mild iodine excess (previously mild iodine deficiency) and severe iodine

excess. Universal salt iodization had been introduced 3 years previously except

in the area with borderline iodine deficiency. In total 16 287 inhabitants from

three areas answered a questionnaire concerning the history of thyroid

disease. Among them 3761 unselected subjects received further investigations

including thyroid function, thyroid autoantibodies, thyroid ultrasonography and

urinary iodine excretion. RESULTS: Among areas with median urinary iodine

excretion of 103 microg/l, 375 microg/l and 615 microg/l (P<0.05), the

prevalence of hyperthyroidism did not differ significantly (1.6%, 2% and

1.2%). The prevalence of subclinical hyperthyroidism was higher in areas with

borderline iodine deficiency and mild iodine excess than in the area with

severe excess iodine intake (3.7%, 3.9% and 1.1%, P<0.001). The

prevalence of Graves' disease and its proportion in hyperthyroidism did n

ot differ among areas. The incidence of hyperthyroidism did not significantly

increase after the introduction of universal salt iodization. They concluded that

different iodine intakes under a certain range do not affect the prevalence and

type of hyperthyroidism. Subclinical hyperthyroidism is more prevalent in the

iodine deficient area than in the severe iodine excessive area. In the area with

mild iodine deficiency, the introduction of universal salt iodization may not be

accompanied by an increased incidence of hyperthyroidism.

Theoretical Source

Ida Jean Orlando was the first nurse to develop her theory from

actual nurse-patient situations. She used a qualitative method to obtain data

from which she developed her theory. She describes her model as revolving

around five major interrelated concepts; the function of professional nursing;

the presenting behavior of the patient; the immediate response of the nurse;

the nursing process discipline and improvement. Orlando views the

professional function of nursing as finding out and meeting the patient’s

immediate need for help. Orlando’s theory focuses on how to produce

improvement in the patient’s behavior. According to Orlando, a person

becomes a patient requiring nursing care when he or she has needs for help

that cannot be met independently because he or she has physical limitations,

has negative reaction to an environment, or has experience that prevents the

patient from communicating his or her needs. When the nurse acts, an action

process transpires. This action process by the nurse in a nurse-patient contact

is called nursing process. Orlando’s theory is specific in nurse-patient

interaction. The goal of the nurse is to determine and meet patient’s

immediate need. The role of the nurse is to find out and meet the patient's

immediate need for help. The patient's presenting behavior may be a plea for

help; however, the help needed may not be what it appears to be.

Therefore, nurses need to use their perception, thoughts about

the perception, or the feeling engendered from their thoughts to explore with

patients the meaning of their behavior. This process helps nurse find out the

nature of the distress and what help the patient needs. Orlando's theory

remains one the of the most effective practice theories available. The use of

her theory keeps the nurse's focus on the patient. The strength of the theory

is that it is clear, concise, and easy to use. While providing the overall

framework for nursing, the use of her theory does not exclude nurses from

using other theories while caring for the patient. Professional nursing is

conceptualized as finding out and meeting the client’s immediate need for

help. This framework will be important for Nurses who are assigned in special

clinical areas that require quick decision making & critical thinking skills. If the

patient’s condition improved, then the intervention is effective and the patient

moves on to new problems.

Orlando’s major assumption about Nursing is that it is a distinct

profession "Providing direct assistance to individuals in whatever setting they

are found for he purpose of avoiding, relieving, diminishing, or curing the

individual's sense of helplessness" .

Orlando assumes that a Human/Person is an individual in need. Unique

individual behaving verbally or nonverbally. Assumption is that individuals are

at times able to meet their own needs and at other times unable to do so.

Orlando assumes that Health that freedom from mental or physical

discomfort and feelings of adequacy and well being contribute to health. She

also noted that repeated experiences of having been helped undoubtedly

culminate over periods of time in greater degrees of improvement

Orlando assumes Environment is a nursing situation that occurs

when there is a nurse-patient contact and that both nurse and patient

perceive, think, feel and act in the immediate situation. any aspect of the

environment, even though its designed for therapeutic and helpful purposes,

can cause the patient to become distressed. She stressed out that when a

nurse observes a patient behavior, it should be perceived as a signal of

distress. (Parker, Marilyn. Nursing Theories and Nursing Practice. FA Davis

Company. 2005

Conceptual Framework

Figure1. The Nursing Process Flowchart

The above figure illustrates the nursing care approach in assisting the client

with need for help. The assessment Phase focuses on the client with need.

Assessment

Planning /

Implementation

Evaluation

Goals of

Nursing

Action

Levels of

Met

Needs

Level of Met Needs

utilizing Orlando’s

Theory

The planning/implementation Phase directs to setting up of goals and

objectives, and identifying and carrying out of the nursing actions. The

Evaluation phase focuses on validating the effectiveness of the met needs.

Definition of Terms

Met Needs. Needs presented as behaviors that the client is able to meet

whether independently, with minimum assistance or solely with assistance.

Level of Met Needs. Needs that presented as behaviors that are classified

according to how the client is able to perform them and is categorized as high,

average, below average, and low level of adaptation.

High Level of Met Needs. Client is able to meet needs independently

without the help, aid or support which has the mean score range of 3.1 – 4.

Average Level of Met Needs. Client is able to meet needs with a little

help, aid or support in the form of nursing care. Success in meeting the

particular need is high without assistance which has the mean score range of

2.1 – 3.

Below Average Level of Met Needs. Client is able to meet needs solely

with the help, aid or support in the form of nursing care. Success in meeting

the human needs is low without assistance which has the mean score range of

1.1 – 2.

Low Level of Met Needs. Client’s needs that are barely met or not met at

all which has the score range of 0 – 1.

Observed Behavioral Response. These are the frequency of indicators in

each category.

Code Description

Always Behavior observed all the time rated as 4.

Most of the time Behavior observed frequently rated as 3.

Sometimes Behavior observed occasionally rated as 2.

Rarely Behavior observed once in a while rated as 1.

Chapter III

APPLICATION OF THE NURSING THEORY

CLIENTS PROFILE

Name: Patient X

Address: Prk. Kabutongan, Brgy. Vista Alegre, Bacolod City

Age: 40

Sex: Male

Status: Married

Height: 5’8’’

Weight: 60 kgs

Occupation: Farmer

Educational Attainment: High School Graduate

Dialect/Language Spoken: Tagalog and Ilonggo

Chief Complaints: Sudden Lost of Weight, On and Off Fever, Sore Throat, and Mouth Sores for 2 weeks

Medical Impression: Hyperthyroidism

CLINICAL HISTORY

Patient X was diagnosed of Hyperthyroidism 5 years ago. For the past 5 years,

he doesn’t have any complaints regarding hyperthyroidism. And he hasn’t

done laboratory tests for his condition as he should like the T3, TSH, and T4.

He hasn’t monitored his blood since then. He experienced simple cough, fever,

or flu-like symptoms for the past years. Patient X was admitted due to

decrease of WBC related to anti-thyroid drug side effects.

Last June 26, 2014 Patient X consulted an Endocrinologist and instructed him

to do some laboratory tests such as T3, T4, TSH, CBC and SGPT. When they

went back to the Endocrinologist, the doctor was alarmed since his WBC was

only 3.5K/uL and his SGPT were so high to 144U/L. He instructed the patient

that she can’t treat his Hyperthyroidism unless his blood levels were normal.

His Endocrinologist, prescribed patient X to continue drinking the Carbimazole

5mg and Indural 10mg to minimize his hyperthyroidism symptoms like

palpitations, sweating, and insomnia. The Doctor advised him to watch out

signs like mouth sores, sore throat, and fever. After a month, he went back to

the doctor and consulted, after the laboratory tests done. The Doctor

maintained a low dose of Carbimazole and to continue the Indural 10mg, TID.

and follow-up after 6 weeks.

ASSESSMENT TOOL

The assessment tool was constructed based on the concept presented in the

theory of Ida Jean Orlando categorized into four assessment parameters

which are Physiological, Social, Psychological and Spiritual and sub-

categorized to areas to which Orlando’s Theory wants to focus. These areas

assessed in accordance with the client’s ability to meet own needs. This

assessment serves as a basis for nursing actions.

Table 1. Assessment Tool

Direction: Put a check mark (√) on the scale corresponding to the observed

behavioral response coded and described as follows: 4 – Always; 3 – Most of

the time; 2 – Sometimes; 1 – Rarely.

ASSESSMENT PARAMETERS 4 3 2 1

PHYSIOLOGIC NEEDS

Oxygenation

Manifests clear breath sounds and effortless breathing

Demonstrates normal breathing pattern (16 – 20 breaths per minute)

Manifests normal pulse rate (60 – 100 beats per minute)

Manifests promptly capillary refill of fingernail beds (around 3 seconds)

Manifests normal Blood Pressure (100 – 120 / 60 – 80 mmHg)

Nutrition

Eats well balanced diet during regular meals.

Eats regularly at least three times a day

Drinks Sufficient amount of water at least 6 – 8 glasses (2000ml) per

day

Takes nutritional supplement like multivitamins

Exhibits ideal Body weight for height and age

Elimination

Moves bowel with normal consistency and without difficulty.

Voids painlessly approximately 5 – 8 times daily (800 – 1000cc)

Sleep and Rest

Sleeps at least 6 – 8 hours at night without interruption

Takes adequate amount of rest at daytime

Exercise and Activity

Performs activities of daily living independently

Takes a bath independently at least once daily

Practices good dental hygiene at least once daily

Grooms fingernails and toenails regularly

Wears neat, clean, appropriate clothing

Dresses and undresses independently

Exercise at least 15-30 minutes a day such as brisk walking & deep breathing, especially in early morning.

PSYCHOLOGICAL NEEDS

Self- Concept

Expresses fears about the nature of disease

Identifies feelings & concerns about physical ailment

Verbalizes understanding and acceptance of present condition

Self – Esteem

Provides financial needs of the family

Works with a sense of accomplishment

Shows ability to work with dedication

Complies with the therapeutic regimen

SOCIAL NEEDS

Interpersonal Relationship

Demonstrates harmonious relationship with parents

Mingles with friends and relatives

Community Resources

Utilizes health facilities (like health center, hospital) appropriately

Participates in learning activities or opportunities for learning

SPIRITUAL NEEDS

Devotes regular worship time

Expresses gratification with compatibility of spiritual belief and daily living,

Practices spiritual belief that strengthen hope and comfort in facing life.

TOTAL

The Evaluation Scale

To get the clients level of Met Needs, statistical procedure for getting the

Mean Score from each category is computed to determine which category is

greatly affected in order to prioritize nursing intervention. The formula is as

follows:

Client’s Score

Mean Score (X) = ----------------------

Number of Items

To come up with Over – All Mean Score and to describe the client’s level of

Met Needs in 2 categories, the formula to be used is:

Clients Score in all categories

Over – All Mean Score (OSM) = ----------------------------------------

Number of Items in all categories

Scale

0 1 2 3

4

LOW BELOW AVERAGE AVERAGE HIGH

Figure 2. The Evaluative Scale of client’s met needs

D. Nursing Process

Assessment Phase

Table 2. Initial Assessment of Patient X

CATEGORY

No.

of

Items

Perfe

ct

Score

Clien

t

Score

Mea

n

Scor

e

Rank Description

PHYSIOLOGIC NEEDS 2

Oxygenation 5 20 12 2.4 3 Average

Nutrition 5 20 9 1.8 2 Below

Average

Elimination 2 8 5 2.5 4.5 Low Average

Sleep and Rest 2 8 2 1 1 Below Average

Exercise and Activity 6 24 15 2.5 4.5 Average

Sub Total 20 80 43 2.15

PSYCHOLOGICAL NEEDS 1

Self- Concept 3 12 4 1.3 1 Below

Average

Self – Esteem 4 16 8 2 2 Below

Average

Sub Total 7 28 12 1.7

SOCIAL NEEDS 3

Interpersonal Relationship 2 8 6 3 2 Average

Community Resources 2 8 3 1.5 1 Below Average

Sub Total 4 16 9 2.25

SPIRITUAL NEEDS 3 12 9 3 4 Average

TOTAL 34 136 73 2.14 Average

Scale

0 1 2 3

4

LOW BELOW AVERAGE AVERAGE HIGH

Figure 3. The Evaluative Scale of the level of met needs based on the initial

assessment of Patient X

X = 2.14

Interpretation

The initial assessment of Patient X has a total score of 73. The mean score

were added and divided by the total number of categories is equal to 2.14 as

an overall mean score described as an Average level of met needs as

demonstrated on the scale.