Which nursing diagnosis takes highest priority for a female client with hyperthyroidism?
A. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess.
B. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing.
C. Body image disturbance related to weight gain and edema.
D. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess.
Correct Answer: D. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis. Options B and C may be appropriate for a client with hypothyroidism, which slows the metabolic rate.
Option A: Monitor daily food intake. Weigh daily and report losses. Continued weight loss in the face of adequate caloric intake may indicate failure of antithyroid therapy. Encourage the patient to eat and increase the number of meals and snacks. Give or suggest high-calorie foods that are easily digested.
Option B: Elevate the head of the bed and restrict salt intake if indicated. Decreases tissue edema when appropriate: HF, which can aggravate existing exophthalmos. Instruct the patient in extraocular muscle exercises if appropriate. Improves circulation and maintains mobility of the eyelids.
Option C: Provide an opportunity for the 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.
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