Risk for Impaired Tissue Integrity related to Graves' Disease

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.

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Fatigue related to Graves' Disease

Nursing Care Plan for Graves' Disease


Nursing Diagnosis : Fatigue related to hypermetabolic with increased energy needs; sensitive stimulation of nerves in connection with disorders of body chemistry.

Supporting Data: reveal very lack of energy to maintain the usual routine, decreased performance, lability / emotional stimuli sensitive, nervous, tense, agitated behavior, damage the ability to concentrate.

Goal: verbally disclose about an increase in energy levels, showed improvement in the ability to participate in the activity.

Nursing Intervention:

Independent:

1. Monitor vital signs and record pulse both at rest and during activity.
R /: pulse widely increased and even at rest, tachycardia (above 160 times / min) may be found.

2. Note the development of tachypnea, dyspnea, pallor and cyanosis.
R /: Needs and oxygen consumption will be increased on a hypermetabolic state, which is potentially hypoxia while doing the activity.

3. Provide / create a quiet environment, cold room, lower sensory stimulation, the colors are cool and relaxing music (calm).
R /: Lowering stimulation is likely to cause agitation, hyperactivity and insomnia.

4. Advise the patient to reduce the activity and increase bed rest as much as possible whenever possible.
R /: Helps combat the effects of increased metabolism.

5. Give the act of making the patient comfortable, such as: touch / massage, powder cool.
R /: Can lose energy in the nerves which further enhances relaxation.

6. Provide alternate activities fun and quiet, like reading, listening to the radio and watching television.
R /: Allows for the use of energy in a constructive way and probably will also reduce anxiety.

7. Avoid talking about a topic that is annoying or threatening the patient, discuss how to respond to these feelings.
R /: Increased sensitivity of the central nervous system can cause the patient easily aroused, agitation and excessive emotion.

8. Discuss with the people in a state of fatigue and emotional unstable.
R /: Understand that the physical behavior improve coping with the current state of encouragement and advice of people nearby to respond positively and provide support to the patient.

Collaboration:
9. Give the drug as indicated.
R /: To cope with the situation (nervous), hyperactivity and insomnia.

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