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NURSING DIAGNOSIS: Tissue Integrity, risk for impaired
Risk factors may include
- Alterations of protective mechanisms of eye: impaired closure of eyelid/exophthalmos
Possibly evidenced by
- [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Desired Outcomes
Tissue Integrity: Skin & Mucous Membranes (NOC)
- Maintain moist eye membranes, free of ulcerations.
Risk Control (NOC)
- Identify measures to provide protection for eyes and prevent complications.
7 Hyperthyroidism Nursing Care Plan (NCP)
- Decreased Cardiac Output — Hyperthyroidism Nursing Care Plan (NCP)
- Fatigue — Hyperthyroidism Nursing Care Plan (NCP)
- Disturbed Thought Processes — Hyperthyroidism Nursing Care Plan (NCP)
- Imbalanced Nutrition — Hyperthyroidism Nursing Care Plan (NCP)
- Anxiety — Hyperthyroidism Nursing Care Plan (NCP)
- Impaired Tissue Integrity — Hyperthyroidism Nursing Care Plan (NCP)
- Knowledge Deficit — Hyperthyroidism Nursing Care Plan (NCP)
Hyperthyroidism Nursing Care Plans Nursing Interventions & Rationale
| Nursing Interventions | Rationale |
| Encourage use of dark glasses when awake and taping the eyelids shut during sleep as needed. | Protects exposed cornea if patient is unable to close eyelids completely because of edema/fibrosis of fat pads. |
| Elevate the head of the bed and restrict salt intake if indicated. | Decreases tissue edema when appropriate, e.g., HF, which can aggravate existing exophthalmos. |
| Instruct patient in extraocular muscle exercises if appropriate. | Improves circulation and maintains mobility of the eyelids. |
| Provide opportunity for patient to discuss feelings about altered appearance and measures to enhance self-image. | Protruding eyes may be viewed as unattractive. Appearance can be enhanced with proper use of makeup, overall grooming, and use of shaded glasses. |
| Administer medications as indicated:Methylcellulose drops; Adrenocorticotropic hormone (ACTH), prednisone;
Antithyroid drugs;
Diuretics. | Lubricates the eyes, reducing risk of lesion formation.Given to decrease rapidly progressive and marked inflammation.
May decrease signs/symptoms or prevent worsening of the condition.
Can decrease edema in mild involvement. |
| Prepare for surgery as indicated. | Eyelids may need to be sutured shut temporarily to protect the corneas until edema resolves (rare) or increasing space within sinus cavity and adjusting musculature may return eye to a more normal position. |
Found through:
impaired tissue integrity signs and symptoms, knowledge deficit as evidenced by aids
