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					                    Student Nurses’ Community

                                                                                                             NURSING CARE PLAN – Thyroidectomy
ASSESSMENT           DIAGNOSIS           INFERENCE              PLANNING              INTERVENTION              RATIONALE           EVALUATION
SUBJECTIVE:         Risk for           Thyroidectomy is      After 1 hour of      Independent                                      After 1 hour of
                    ineffective        the removal of all    nursing               Monitor respiratory       Respirations may    nursing
“Nahihirapan ako    airway             or a portion of the   interventions, the      rate, depth, and           remain rapid       interventions, the
lumunok at          clearance. Risk    thyroid gland. The    patient will            work of breathing.         because of         patient was able
huminga” (I'm       factor may         procedure is          maintain patent                                    hyperthyroid       to maintain patent
having trouble      include tracheal   usually performed     airway, with                                       state, but         airway, with
swallowing and      obstruction;       to treat various      aspirations                                                           aspirations
                                                                                                                development of
breathing) as
                    swelling,          disease of the        prevented.                                         respiratory        prevented.
verbalized by the   bleeding, and      thyroid gland that                                                       distress is
patient.            laryngeal          may not be                                                               indicative of
                    spasms.            treated effectively                                                      tracheal
                                       by chemotherapy                                                          compression
                                       or medication. A                                                         from edema or
OBJECTIVE:                             total                                                                    hemorrhage.
                                       thyroidectomy is                              Auscultate breath       Rhonchi may
   Irritability                       indicated for                                  sounds, noting            indicate airway
   Restlessness                       certain                                        presence of rhonchi.      obstruction and
   Difficulty of                      carcinomas and                                                           accumulation of
    communicati                        to relieve tracheal                                                      copius thick
    ng                                 or esophageal                                                            secretions.
   V/S taken as                       compression.                                  Assess for dyspnea,     Indicators of
    follows                                                                           stridor, “crowning”       tracheal
                                                                                      and cyanosis.             obstruction or
    T: 36.9˚C                                                                                                   laryngeal spasm.
    P: 80                                                                            Keep head of the        Enhances
    R: 20                                                                             bed elevated 30 to        breathing and
    BP: 110/ 80                                                                       45 degrees.               reduces
                                                                                                                likelihood of
                                                                                                                tension on
                                                                                                                surgical wound.
                                                                                     Assist in               Maintain clear
                                                                                      repositioning, deep       airway and
                                                                                      breathing exercises,      ventilation.
                                                                                      and coughing, as
                                                                                      indicated.
                                                                                     Ascertain that          Edema and pain
Student Nurses’ Community

                                suction equipment is   may impair
                                functioning and        patient’s ability to
                                available.             clear airway.
                               Check dressing        Anterior dressing
                                frequently.            may appear dry
                                                       because blood
                                                       pools
                                                       dependently.
                               Investigate reports   May indicate
                                of difficulty          edema and
                                swallowing and         sequestered
                                drooling of oral       bleeding in
                                secretions.            tissues
                                                       surrounding
                                                       operative site.
                               Keep tracheostomy  Compromised
                                tray at bedside.       airway may
                                                       create a life-
                                                       threatening
                                                       situation
                                                       requiring
                                                       emergency
                                                       procedure.

                            Collaborative
                             Provide stream            Reduces
                                inhalation; humidify     discomfort of
                                room air.                sore throat and
                                                         tissue edema
                                                         and promotes
                                                         expectoration of
                                                         secretions.

				
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posted:9/14/2011
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