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.]
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.
- 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
|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;
|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.|