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) Monitor patient vital sign especially blood pressure and pulse.
® Increase blood pressure and pulse may indicate patient was in anxiety.
I- Observation was done on my patient and the reading is blood pressure- 137/93 mmHg, pulse- 76 beat/minute.
3) Re-inforce doctor explanation using a simple language without medical jargon.
® To increase patient understanding regarding surgical procedure and to gain a good coorperation from patient while doing nursing procedure.
I- With staff nurse helps, I re-explain to patient about the surgical procedure using a simple word.
4) Encourage patient to verbalized her feeling and ask question regarding surgical procedure.
® 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.
Avoid coughing or sneeze which increase the pressure.
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 />
Assess patient general condition for severity of pain, location of pain and level of pain using pain scale..
® As a baseline data to plan for future nursing intervention.
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.
Monitor patient vital sign especially blood pressure and pulse.
® 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.