Nursing Interventions for Graves' Disease - Risk for Impaired Skin Integrity

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.

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. 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.

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.

Risk for Impaired Skin Integrity - NCP Guillain-Barre syndrome

Nursing Diagnosis Risk for Impaired Skin Integrity - Nursing Care Plan for Guillain-Barre Syndrome

Guillain-Barre syndrome is a serious disorder that occurs when the body's defense (immune) system mistakenly attacks part of the nervous system. This leads to nerve inflammation that causes muscle weakness and other symptoms.

Symptoms of Guillain-Barre syndrome include:

•     Numbness or tingling in your hands and feet and sometimes around the mouth and lips.
•     Muscle weakness in your legs and arms and the sides of your face.
•     Trouble speaking, chewing, and swallowing.
•     Not being able to move your eyes.
•     Back pain.

Symptoms usually start with numbness or tingling in the fingers and toes. Over several days, muscle weakness in the legs and arms develops. After about 4 weeks, most people begin to get better.

You may need to be treated in the hospital for the first few weeks. This is because GBS can be deadly if weakness spreads to muscles that control breathing, heart rate, and blood pressure.

Signs and tests

A history of increasing muscle weakness and paralysis may be a sign of Guillain-Barre syndrome, especially if there was a recent illness.

A medical exam may show muscle weakness and problems with involuntary (autonomic) body functions, such as blood pressure and heart rate. The examination will also show that reflexes, such as the "ankle or knee jerk," are decreased or missing.

There may be signs of decreased breathing caused by paralysis of the breathing muscles.

The following tests may be ordered:

•     Cerebrospinal fluid sample ("spinal tap")
•     ECG
•     Electromyography (EMG) tests the electrical activity in muscles
•     Nerve conduction velocity test
•     Pulmonary function tests

Nursing Diagnosis : Risk for Impaired Skin Integrity : dekubitus related to kelemahan otot, paralisis, gangguan sensasi, perubahan nutrisi, inkontinensia.

Expected outcomes:

• Patients retain the skin remains dry and intact.
• Maintaining depressed area remains dry and intact, free of pressure sores.

Intervention:

1. Assess motor function and sensation every 4 hours.
R /: muscle paralysis can occur quickly with a pattern that has been rising.

2. Assess the patient's degree of dependence.
R /: To identify patients in need of ADL ability.

3 . Monitor depressed area.
R /: Identifying early signs of pressure sores.

4. Keep the bed, lake remains clean, tight and dry.
R /: Laken, wet, dirty, matted facilitate the occurrence of pressure sores.

5. Monitor intake and output of nutrients.
R /: inadequate nutrition reduce the risk of pressure sores.

6. Perform over the position every 2 hours.
R /: Smooth distressed parts of blood flow.

7. Perform ROM.
R /: Preventing atrophy.