Nursing Care Plan for Morbus Basedow (Graves' Disease)

Definition

Basedow disease or also commonly known as Graves' disease is a disease that is often encountered in young people due to the increased production of thyroid is characterized by increased absorption of radioactive iodine by the thyroid gland.

Etiology

Presumably due to the role of increased production of antibodies against the thyroid and the presence of local thyroid adenoma (a tumor) that grows in the thyroid tissue and ensekresi will be a lot of thyroid hormone.

Pathophysiology


In most patients with hyperthyroidism, the thyroid gland enlarges two to three times its normal size, accompanied by many folds hyperplasia and follicle cells into the follicle, so the number of these cells further increased the number of times in comparison with enlarged glands. Each secretory cell increases the speed of several orders of magnitude.

Changes in the thyroid gland is similar to changes caused by excess TSH. In some patients found the presence of some material that has a way of working is similar to TSH in the blood. Usually these materials are immunoglobulin antibody that binds to membrane receptors, which together with the membrane receptors that bind TSH. The material is continuously stimulated activation of cAMP in the cell system, with the end result is hyperthyroidism.


Clinical Manifestation

• Weight loss
• Dyspnea
• Ecsoftalmus
• Sweat
• Palpitations, tachycardia
• iarrhea
• Increased appetite
• Muscle fatigue
• Tremor (fingers and toes)
• Oligomenorrhea / amenorrhea
• Palms hot and humid
• Tachycardia, irregular pulse sometimes due to atrial fibrillation, pulses Seler
• Nervousness, irritability, anxiety, emotional instability, insomnia.
• Mumps (possibly accompanied by the sound pulse and vibration).

Nursing Care Plan for Morbus Basedow (Graves' Disease)

Nursing Assessment for Morbus Basedow (Graves' Disease)

Basic data on the assessment of patients with Morbus Basedow (Graves' Disease) is:

1. Activity / rest
Symptoms: insomnia, increased sensitivity, muscle weakness, impaired coordination, severe fatigue.
Signs: muscle atrophy.

2. Circulation
Symptoms: palpitations, chest pain (angina).
Signs: dysrhythmia (atrial fibrillation), the rhythm gallops, murmurs, increased blood pressure with a heavy tone pressure, tachycardia at rest, circulatory collapse, shock (crisis thyrotoxicosis).

3. Elimination
Symptoms: urine in large amounts, changes in stool (diarrhea).

4. Ego integrity
Symptoms: Experiencing severe stress both emotionally and physically.
Signs: Emotions labile (euphoria moderate to delirium), depression.

5. Food / fluid
Symptoms: sudden weight loss, increased appetite, eat lots, eat often, thirst, nausea and vomiting.
Signs: Enlarged thyroid, goiter, non-pitting edema especially the pretibial area.

6. Neuro-sensory
Signs: rapid and raspy speech, impaired mental status and behavior, such as: confusion, disorientation, restlessness, sensitive excitatory, delirium, psychosis, stupor, coma, tremors of the hands smooth, without purpose, some parts of the jolt snapped, hyperactive deep tendon reflexes ( RTD).

7. Pain / comfort
Symptoms: orbital pain, photophobia.

8. Respiration
Signs: increased respiratory frequency, tachypnea, dyspnea, pulmonary edema (the crisis thyrotoxicosis).

9. Security
Symptoms: no tolerance to heat, excessive sweating, allergic to iodine (may be used in the examination).
Signs: the temperature rises above 37.40 C, diaphoresis, skin smooth, warm and reddish, thin hair, shiny, straight, eksoftalmus: retraction, irritation of the conjunctiva and aqueous, pruritus, erythema lesion (often occur in pretibial), which became very severe .

10. Sexuality
Signs: decreased libido, hipomenore, amenorrhea, and impotence.

11. Guidance / learning
Symptoms: a family history of thyroid problems, history of hypothyroidism, hormone therapy toroid or antithyroid medication, discontinued antithyroid treatment, partial thyroidectomy surgery, history of administration of insulin causes hypoglycemia, heart problems or heart surgery, a new disease occurred (pneumonia) , trauma, X-ray examination with contrast images.


 Nursing Diagnosis for Morbus Basedow (Graves' Disease)

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