1. PRE-OPERATIVE <br />Alteration in emotional status: Anxiety related to surgical procedure.<br />POST-OPERATIVE <br />Alteration in comfort : Pain related to post surgical intervention, Total thyoridectomy Thyroidectomy.<br />Potential bleeding related to surgical intervention : Total Thyroidectomy.<br />Alteration in nutritional status : Difficulty to swallowing related to post Total Thyroidectomy.<br />Potential infection at wound incision related to Total Thyroidectomy.<br />Self-esteem disturbance related to scar of surgical procedure.<br />Knowledge deficit related to self care management<br />Ncp 1<br />Date : 28/11/2010 <br />Time : 1500 hours <br /> <br />Nursing problem : <br />Alteration in emotional status: Anxiety related to surgery ( total thyroidectomy)<br /> <br />Supporting data : <br />Patient verbalized that she was anxious with the surgical procedure. <br />Patient asking more about surgery.<br />Patient facial expression looked worry. <br />Goal<br />Patient anxiety will be reduce and will be understand for the whole procedure and healing process at least 3-4 hours after nursing intervention given and during hospitalization.<br />Nursing intervention : <br />1) Assess patient level of anxiety by observe patient facial expression and verbalization also knowledge pertaining the disease and complication of surgery.<br />® As a baseline data to plan for future nursing intervention.<br /><ul><li>I- I looked patient facial expression and found that she develop minor anxious and asking many of question regarding surgery procedure
2. 2) Monitor patient vital sign especially blood pressure and pulse.
3. ® Increase blood pressure and pulse may indicate patient was in anxiety.
4. I- Observation was done on my patient and the reading is blood pressure- 137/93 mmHg, pulse- 76 beat/minute.
5. 3) Re-inforce doctor explanation using a simple language without medical jargon.
6. ® To increase patient understanding regarding surgical procedure and to gain a good coorperation from patient while doing nursing procedure.
7. I- With staff nurse helps, I re-explain to patient about the surgical procedure using a simple word.
8. 4) Encourage patient to verbalized her feeling and ask question regarding surgical procedure.
9. ® To gain patient knowledge and patient cooperation also reduce the anxiety.</li></ul>1-I encourage patient to ask any question regarding a procedure and try to explain and answer he clearly.<br /><ul><li>5) Encourage family member’s give support and be with patient during doctor explanation and involve in nursing care.
10. ® To provide moral support to the patient.
11. I- I encourage Mrs. A family member’s and his wife to accompany his and give moral support.
12. 6) Encourage patient to do divertional therapy. Eg : deep breathing exercise, watching television.
13. ® To divert patient mind from keep thinking about surgery and give relaxation</li></ul>I-I teach patient to do deep breathing exercise which can divert her mind and can give relaxation to the patient. <br /><ul><li>7) Provide condusive environment with a good ventilation and quite environment.
14. ® To encourage rest and relaxation which calm the mind. </li></ul>I-I draw patient curtain, provide a conducive environment and asked his to rest in bed. <br /><ul><li>8. Explain to patient the outcome of the post surgery
15. Patient will have mini below
16. Avoid coughing or sneeze which increase the pressure.
17. To provide more information about the procedure and surgery to reduce the anxiety.</li></ul>Date : 28/11/2010 <br />Time : 1900 hours<br />Evaluation : <br />Patient anxiety has reduce after 4 hours nursing intervention given and during hospitalization. <br /> <br />Supporting data : <br />Patient verbalize that she was not anxious anymore. <br />Patient give a good cooperation while nursing procedure performed. <br />Re-evaluation <br />Date @time : 28/11/2010 @ 2100<br />Patient look no more anxiety after nursing intervention given and he look calm and more relax.<br /><ul><li>Ncp 2
18. Date : 1/12/2010
19. Time : 0800 hours
21. Nursing problem :
22. Alteration in comfort : Pain related to post surgical intervention.
29. Patient will verbalize reduce of pains within one hour after nursing intervention given and during hospitalization.
31. Nursing intervention :
32. Assess patient general condition for severity of pain, location of pain and level of pain using pain scale..
33. ® As a baseline data to plan for future nursing intervention.
34. I assess patient level of pain using pain scale and ask patient to choose within 1-5 which indicate 1: mild pain and 5: severe pain. Patient choose 4 which is consider as severe pain at the surgery site.
35. Monitor patient vital sign especially blood pressure and pulse.
36. ® High blood pressure and pulse indicate that patient having a pain.</li></ul>I-Observation was done on my patient and my patient blood pressure is 134/98 mmHg pulse is 84 beat/minute.<br /><ul><li>Administer IM Pethadine 25 mg as ordered by doctor.
37. ® To relieve pain.
38. I- I prepare the medication IM Pethadine 25 mg with staff nurses supervision. The medication was given by staff nurse.
39. Position patient in semi fowlers (45 degree)
40. ® To promote comfort to patient.
41. I- I assist patient to lying in semi fowlers position.
42. Encourage patient to maintain head/neck in neutral position and support the neck during movement
43. To avoid hypertension of neck and prevent stress on the suture line</li></ul>I – I instruct patient to use hand to support the neck.<br /><ul><li>Teach and encourage patient to do a deep breathing exercise.
44. ® For muscle relaxation and reduce pain.
45. I- I advice patient to take a deep breath exercise by inhale through his nose and hole 10 second and exhale through purse lip.
46. Encourage patient to rest in bed.
47. ® To minimize patient movement. Extra movement will trigger more pain.
48. I- I told patient to have a rest in bed.
49. Provide conducive environment to patient such as silent and restrict visitor.
50. To reduce pain and promote comfort to patient.
51. I – I told Mr.A to restrict visitor and there is no people except his wife only.
52. Keep call bell near to the patient
53. To easy reach aln limit stretching, muscle strain in operative area
54. I – I keep call bell near to patient
55. Provide cool liquid or soft diet such as ice cream and porridge.
56. Soft diet will prevent from pain if patient experience difficulty swallowing.</li></ul>Evaluation <br />Date @time ; <br /><ul><li>Supporting data :
57. Patient verbalize that her pain was reduced.
58. Patient choose number 2 from the scale which is considered as mild pain
59. .Patient blood pressure was in a normal range 126/60mmHg.
60. Ncp 3
61. Date : 31/12/2009
62. Time : 1500 hours
64. Nursing problem :
65. Potential bleeding related to surgical intervention, Left Thyroidectomy.
66. Goal :
67. Patient will not have any sign and symptoms of bleeding after nursing intervention given during hospitalization.
68. Supporting data :
69. Patient was undergone thyroid surgery ( Left Thyroidectomy ).
70. Patient have incision wound at the neck.
71. Patient have drain at left side of neck.
72. Nursing intervention :
73. 1) Assess patients general condition for sign and symptoms of bleeding : patient look pale and lethargic.
74. ® Act as a baseline data to carry out appropriate nursing intervention.
75. I- I assessed patient general condition. Patient was not pale and patient was active.
76. 2) Monitor patient vital sign every one hour followed by four hourly observation.
77. ® To detect any abnormalities and early sign and symptoms of bleeding. Low blood pressure, tachycardia may indicate that patient having bleeding.
78. I- I do observation on patient hourly and followed by four hourly observation. The reading is blood pressure (100/70-140/90 mmhg) and pulse rate is (50-85 beat/minute).
80. 3) Position as patient comfort : not hyperextend the neck.
81. ® To minimize pressure at the post-op site thath will increase potential bleeding.
82. I- I position patient recumbent without pillow for first 2 hour.
83. Date : 01/01/2010
84. Time : 1500 hours
86. Evaluation :
87. Patient do not experience any sign and symptom of bleeding for the first 24 hours after nursing intervention given.
89. Supporting data :
90. Patient blood pressure was in a normal range ( 114/76 mmHg ).
91. Patient wound site is dry and intact.
92. Ncp 4
93. Date : 31/12/2010
94. Time : 1500 hours
96. Nursing problems :
97. Alteration in nutrirional status : Difficulty to swallowing related to post Thyroidectomy.
99. Supporting data :
100. Patient complain of difficulty to swallowing after post Thyroidectomy.
101. Patient verbalized she difficult to swallowed with solid diet.
102. Goal :
103. Patient dysphagia problem will be less after nursing intervention given and during hospitalization.
105. Nursing intervention :
106. 1) Assess patient ability in swallowing food, amount of food that can be taken in every meals and how much frequent she take a meals.
107. ® Act as baseline data to carry out appropriate nursing intervention.
108. I- I assess patient’s problem by asking her about having a pain or not and how to frequent she take a meals.She verbalized is difficulty to swallowed a meals.
109. 2) Provide a soft diet to the patient during hospitalization.
110. ® To ensure patient easier to swallowing.
111. I- I inform to dietitian to give a soft diet to my patient.
113. 3) Encourage patient to eat in a small diet amount but frequently.
114. ® To fulfill patient body requirement of nutritional and it will enhance patient intake.
115. I -I advise patient to take a small amount of food every time she take a meals but make sure take it frequently.
116. 4)Encourage patient to take more fluids of water.
117. ® To maintain body fluid and built energy for patient.
118. I- I told patient that she must take more water as substitute intolerate with diet.
119. 5) Monitor patient intake and output chart.
120. ® To detect patient intake and output and to see whether it is balance or not.
121. I- I record my patient intake and output during my shift.
122. 6) Inform doctor if patient still complaining of difficulty to swallowing.
123. ® To get further management.
124. I- Doctor was informed regarding patient progress.
125. Date : 31/12/2009
126. Time : 2100 hours
128. Evaluation :
129. Patient feel more comfortable and more tolerate her meals after nursing intervention given.
131. Supporting data :
132. Patient verbalized that can take more amount of food and more tolerate than previous.
133. Patient feel more comfortable when taken her meals.
134. Ncp 5
135. Date : 31/12/2009
136. Time : 1500 hours
138. Nursing problem :
139. Potential infection at surgical incision related to post surgery : Left Thyroidectomy.
141. Supporting data :
142. Patient have drain at left sided of neck.
143. Patient got incision at the neck.
144. Goal :
145. Patient will not experience of any sign and symptoms of infection after nursing intervention given and during hospitalization.
146. Nursing intervention :
147. 1) Assess patient general condition for any sign and symptoms of infection such as redness, swelling, pain, warm.
148. ® Act as baseline data to carry out appropriate nursing intervention.</li></ul>I assess patient surgical site. There are no sign and symptom of infection. Dressing is clean, dry and intact.<br /><ul><li>2) Monitor patient vital sign especially body temperature 4 hourly observation.
149. ® Increasing in body temperature may indicate that patient having infection.
150. I- I monitor patient body temperature every 4 hourly observation. Patient body temperature was in normal range 36.2-37.4 C.
152. 3) Maintain good hand washing before and after handling patient.
153. ® To prevent infection.
154. I-I make sure that I wash my hand every time before and after handling patient.
155. 4) Maintain aseptic technique while doing dressing.
156. ® To prevent wound contamination.
157. I- I assist doctor while doing dressing. The dressing was done using a aseptic technique.
159. 5) Advise patient not to touch dressing site if unnecessary.
160. ® To prevent transmission of microorganism.</li></ul>I advise patient not to touch the dressing site and also told the complication by doing it.<br /><ul><li>6) Observe patient drain output, observe for color of drain.
161. ® Abnormal color (brownish) may indicate that patient having infection.
162. I- Patient drain output was observed every time when I do the observation. It was red in color.
163. 7) Teach patient about sign and symptoms of infection, such as itchiness, pain, warmth, redness or swelling.
164. ® patient will be aware sign of infection and will be able to inform nurses if there was any changes.
165. I- I teach patient regarding sign and symptom of infection and advise patient to inform nurses or doctor if any abnormalities detected.
166. 8)Advise patient to maintain her own personel hygiene.
167. ® To minimize the risk of getting infection.
168. I-I advise patient to make that she maintain her personal hygiene well such as always hand washing before and after take meals.
169. 9) Encourage patient to take high protein diet and hugh vitamin C diet in their meals.
170. ® To promote wound healing and increase body resistance.</li></ul>I told patient about the advantage of taking protein and vitamin c in meal.<br /><ul><li>Date : 01/01/2010