Risk for Impaired Tissue Integrity | NCP Hyperthyroidism

Nursing diagnosis: risk for impaired Tissue Integrity

Risk factors may include
Alterations of protective mechanisms of eye—impaired closure of eyelid.

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Tissue Integrity: Skin and Mucous Membranes
Maintain moist eye membranes, free of ulcerations.
Risk Control
Identify measures to provide protection for eyes and prevent complications.

Nursing intervention with rationale:
1. Encourage use of dark glasses when awake and taping the eyelids shut during sleep, as needed.
Rationale: Protects exposed cornea if client is unable to close eyelids completely because of edema and fibrosis of fat pads.

2. Elevate the head of the bed and restrict salt intake, if indicated.
Rationale: Decreases tissue edema when appropriate.

3. Instruct client in extraocular muscle exercises, if appropriate.
Rationale: Improves circulation and maintains mobility of the eyelids.

4. Provide opportunity for client to discuss feelings about altered appearance and measures to enhance self-image.
Rationale: Protruding eyes may be viewed as unattractive. Appearance can be enhanced with proper use of makeup, overall grooming, and use of shaded glasses.

5. Administer medications, as indicated, for example: Methylcellulose drops and artificial tears
Rationale: Lubricates the eyes, reducing risk of lesion formation.

6. Adrenocorticotropic hormone (ACTH) and prednisone
Rationale: Given to decrease rapidly progressive and marked inflammation
(AACE, 2006).

7. Antithyroid drugs
Rationale: May decrease signs and symptoms or prevent worsening of the condition.

8. Diuretics
Rationale: Can decrease edema in mild involvement.

9. Prepare for surgery, as indicated.
Rationale: 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 (AACE, 2006).