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  • 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 />
    • 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.
    1-I encourage patient to ask any question regarding a procedure and try to explain and answer he clearly.<br />
    • 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
    I-I teach patient to do deep breathing exercise which can divert her mind and can give relaxation to the patient. <br />
    • 7) Provide condusive environment with a good ventilation and quite environment.
    • 14. ® To encourage rest and relaxation which calm the mind.
    I-I draw patient curtain, provide a conducive environment and asked his to rest in bed. <br />
    • 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.
    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 />
    • Ncp 2
    • 18. Date : 1/12/2010
    • 19. Time : 0800 hours
    • 20.  
    • 21. Nursing problem :
    • 22. Alteration in comfort : Pain related to post surgical intervention.
    • 23.  
    • 24. Supporting data :
    • 25. Patient done total thyroidectomy on 30/11/10
    • 26. Patient complain of pain at surgical incision
    • 27. Patient blood pressure-142/99 mmHg, pulse-99 beat/minute.
    • 28. Goal :
    • 29. Patient will verbalize reduce of pains within one hour after nursing intervention given and during hospitalization.
    • 30.  
    • 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.
    I-Observation was done on my patient and my patient blood pressure is 134/98 mmHg pulse is 84 beat/minute.<br />
    • 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
    I – I instruct patient to use hand to support the neck.<br />
    • 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.
    Evaluation <br />Date @time ; <br />
    • 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
    • 63.  
    • 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).
    • 79.  
    • 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
    • 85.  
    • 86. Evaluation :
    • 87. Patient do not experience any sign and symptom of bleeding for the first 24 hours after nursing intervention given.
    • 88.  
    • 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
    • 95.  
    • 96. Nursing problems :
    • 97. Alteration in nutrirional status : Difficulty to swallowing related to post Thyroidectomy.
    • 98.  
    • 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.
    • 104.  
    • 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.
    • 112.  
    • 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
    • 127.  
    • 128. Evaluation :
    • 129. Patient feel more comfortable and more tolerate her meals after nursing intervention given.
    • 130.  
    • 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
    • 137.  
    • 138. Nursing problem :
    • 139. Potential infection at surgical incision related to post surgery : Left Thyroidectomy.
    • 140.  
    • 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.
    I assess patient surgical site. There are no sign and symptom of infection. Dressing is clean, dry and intact.<br />
    • 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.
    • 151.  
    • 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.
    • 158.  
    • 159. 5) Advise patient not to touch dressing site if unnecessary.
    • 160. ® To prevent transmission of microorganism.
    I advise patient not to touch the dressing site and also told the complication by doing it.<br />
    • 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.
    I told patient about the advantage of taking protein and vitamin c in meal.<br />
    • Date : 01/01/2010
    • 171. Time : 1500 hours