Skip to main content

Risk for Impaired Skin Integrity - Graves' Disease

Many factors are thought to play a role in getting Graves' disease. These might include:

  • Genes. Some people are prone to Graves' disease because of their genes. Researchers are working to find the gene or genes involved.
  • Gender. Sex hormones might play a role, and might explain why Graves' disease affects more women than men.
  • Stress. Severe emotional stress or trauma might trigger the onset of Graves' disease in people who are prone to getting it.
  • Pregnancy. Pregnancy affects the thyroid. As many as 30 percent of young women who get Graves' disease have been pregnant in the 12 months prior to the onset of symptoms. This suggests that pregnancy might trigger Graves' disease in some women.
  • Infection. Infection might play a role in the onset of Graves' disease, but no studies have shown infection to directly cause Graves' disease.

Graves disease is an autoimmune disorder that leads to overactivity of the thyroid gland (hyperthyroidism). The thyroid is a small gland in the front of the neck. It makes hormones called T3 and T4 that regulate how the body uses energy. Thyroid hormone levels are controlled by the pituitary, which is a pea-sized gland in the brain. It makes thyroid stimulating hormone (TSH), which triggers the thyroid to make thyroid hormone.

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

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

Interventions and Rationale:

Independent:

1. Observation periorbital edema, impaired eyelid closure, narrow field of vision, excessive tears. Note the presence of photophobia, taste any thing outside the eye and pain in the eyes.
Rationale: common manifestation of excessive adrenergic stimulation associated with thyrotoxicosis who require support to a resolution of the crisis intervention can eliminate symptomatology.

2. Evaluation of visual acuity, report any blurred vision or double vision (diplopia).
Rational: Oftalmopati infiltrative (Graves disease) is the result of an increase in retro-orbital tissue, which creates exophthalmos and lymphocyte infiltration of extra-ocular muscles that cause fatigue. The emergence of visual impairment, can worsen or improve independence therapy and clinical course of disease.

3. Instruct the patient to use dark glasses, when awake and closed with a blindfold over sleep as needed.
Rationale: Protecting corneal damage if the patient can not turn a blind eye to perfect as edema or fibrosis due to fat pad.

4. The head of the bed elevated and limit the use of salt if indicated.
Rationale: Reducing tissue edema when there are complications such as chronic heart failure which can aggravate exophthalmos.

5. Instruct the patient to exercise extra-ocular eye muscles if possible.
Rationale: Improve circulation and maintain eye movements.

6. Give the patient the opportunity to discuss their feelings about the changes in the size or shape of body image to improve the self-image.
Rationale: The ball slightly bulging eyes, causing a person is not attractive, it can be reduced by wearing makeup, wearing glasses.

Source :

http://nandabooks.blogspot.com

Popular posts from this blog

NANDA Ineffective Health Maintenance

NANDA Definition: The inability to identify, manage, or seek out help to maintain health Defining Characteristics: History of lack of health-seeking behavior;  reported or observed lack of equipment, financial, and/or other resources;  reported or observed impairment of personal support systems;  expressed interest in improving health behaviors;  demonstrated lack of knowledge regarding basic health practices;  demonstrated lack of adaptive behaviors to internal and external environmental changes;  reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas Related Factors: Disabled family coping, perceptual-cognitive impairment (complete or partial lack of gross or fine motor skills);  lack of or significant alteration in communication skills (written, verbal, or gestural);  unachieved developmental tasks;  lack of material resources;  dysfunctional grieving;  disabling spiritual distress;  inabi

Sleep Pattern Disturbance

Sleep Pattern Disturbance Related To Impaired oxygen transport Impaired elimination Impaired metabolism Immobility Medication Hospitalization Lack of exercise Anxiety response Life-style disruptions As evidenced by Major : Difficulty falling or remaining a sleep Minor : Fatigue on awakening or during the day Dozing during the day Agitation Mood alterations Outcome : The patient will: Demonstrate an optimal balance of rest and activity A.E.B. ___ hours of uninterrupted sleep at night. Remain awake during the day. Nursing Interventions Explore with patient potential contributing factors. Maintain bedtime routine per patient preference. Takes sleeping pill as ordered by a physician. Provide comfort measures to induce sleep: Void before retiring. Coordinate treatment/meds to limit interruptions during sleep period. Limit the amount and length of daytime sleeping Increase daytime activity

Ineffective Breastfeeding NANDA Definition

NANDA Definition: Dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process Defining Characteristics: Unsatisfactory breastfeeding process;  nonsustained suckling at the breast;  resisting latching on;  unresponsive to comfort measures;  persistence of sore nipples beyond first week of breastfeeding;  observable signs of inadequate infant intake; insufficient emptying of each breast per feeding;  infant inability to latch on to maternal breast correctly;  infant arching and crying at the breast; infant exhibiting fussiness and crying within the first hour after breastfeeding;  actual or perceived inadequate milk supply;  no observable signs of oxytocin release;  insufficient opportunity for suckling at the breast Related Factors: Nonsupportive partner/family;  previous breast surgery;  infant receiving supplemental feedings with artificial nipple;  prematurity;  previous history of breastfeeding failure;  poor infant