NCP for Graves' Disease - Risk for Impaired Tissue Integrity

Graves' disease is an autoimmune disease. It most commonly affects the thyroid, frequently causing it to enlarge to twice its size or more (goiter), become overactive, with related hyperthyroid symptoms such as increased heartbeat, muscle weakness, disturbed sleep, and irritability. It can also affect the eyes, causing bulging eyes (exophthalmos). It affects other systems of the body, including the skin, heart, circulation and nervous system.


The signs and symptoms of Graves' disease virtually all result from the direct and indirect effects of hyperthyroidism, with main exceptions being Graves' ophthalmopathy, goitre, and pretibial myxedema (which are caused by the autoimmune processes of the disease). Symptoms of the resultant hyperthyroidism are mainly insomnia, hand tremor, hyperactivity, hair loss, excessive sweating, shaking hands, itching, heat intolerance, weight loss despite increased appetite, diarrhea, frequent defecation, palpitations, muscle weakness, and skin warmth and moistness. Further signs that may be seen on physical examination are most commonly a diffusely enlarged (usually symmetric), nontender thyroid, lid lag, excessive lacrimation due to Graves' ophthalmopathy, arrhythmias of the heart, such as sinus tachycardia, atrial fibrillation, and premature ventricular contractions, and hypertension. People with hyperthyroidism may experience behavioral and personality changes including: psychosis, mania, anxiety, agitation, and depression.


Nursing Diagnosis for Graves' Disease : related to changes in the mechanism of protection of the eyes; damage eyelid closure / exophthalmos.


Goal: Being able to identify measures to provide protection to the eyes and prevention of complications.


Nursing Interventions:


Independent:


1. Observation periorbital edema, eyelid closure disorders, narrow field of vision, excessive tears. Note the presence of photophobia, taste any thing beyond the eyes and eye pain.

R /: general manifestations of excessive adrenergic stimulation associated with thyrotoxicosis who require support to the resolution of crisis intervention can eliminate symptomatology.


2. Evaluation of the sharpness of the eyes, report the presence of blurred vision or double vision (diplopia).

R /: Infiltrative ophthalmopathy (Graves' disease) is the result of an increase in the retro-orbital tissue, which creates exophthalmos and lymphocyte infiltration of the extraocular muscles that cause fatigue. The emergence of visual impairment can worsen or improve the independence of therapy and clinical course of the disease.


3. Instruct the patient to use sunglasses when the patient woke up and cover with a blindfold during sleep as needed.

R /: Protecting corneal damage if the patient can not close their eyes to perfect as edema or fibrosis pads as fat.


4. The head of the bed elevated and limit the use of salt if indicated.

R /: Lowering tissue edema when there are complications such as CHF which can aggravate exophthalmos.


5. Instruct the patient that the extraocular eye muscles if possible.

R /: Improving circulation and maintain eye movements.


6. Give the patient the opportunity to discuss their feelings about the picture changes, body size or shape to improve self-image.

R /: Eyeball rather prominent cause someone unattractive, it can be reduced by using makeup, wearing glasses.


Collaboration:

1. Give the medicine according to the indication.

R /: Awarded to reduce inflammation that develops rapidly.


2. Antithyroid drugs

Can reduce signs / symptoms or prevent the situation getting worse.


3. Diuretics

Can reduce edema in the soft state.


Source :


http://nursing-care-plan.blogspot.com/2014/12/risk-for-impaired-tissue-integrity.html