Nursing Assessment
Preoperative
1. Activity / exercise
Insomnia, increased sensitivity, muscle weakness, impaired coordination, severe fatigue, muscle atrophy, increased respiratory frequency, tachypnea, dyspnea
2. Elimination
Urine in large amounts, diarrhea.
3. Coping / self defense
Experiencing severe anxiety and stress, both emotional and physical, emotional instability, depression.
4. Nutrition and metabolic
Nausea and vomiting, the temperature rises above 37.4 º C. Enlargement of the thyroid, non-pitting edema, especially in the pretibial, diarrhea or constipation.
5. Cognitive and sensory
Talk fast and raucous, confusion, restlessness, coma, tremors of the hands, hyperactive deep tendon reflexes, orbital pain, photophobia, palpitations, chest pain (angina).
6. Reproductive / sexual
Decreased libido, hypomenorrhea, menorea and impotent.
Postoperative
1. Basic assessment data
- The pattern of activity / rest: insomnia, severe weakness, impaired coordination
- Neuro-sensory patterns: impaired mental status and behavior, such as confusion, disorientation, anxiety, sensitive to stimuli, hyperactive deep tendon reflexes.
- Returns the status of hyperthyroidism with preoperative
- Preventing complications
- Eliminating pain
- Provide information on procedures
- Complications can be prevented or reduced
- Pain disappeared
- Surgical procedure / prognosis and treatment can be understood
- May need assistance in treatment techniques partially or completely,
- Daily activities, maintaining the house chores.
Nursing Diagnosis and Interventions for Thyroidectomy - Preoperative
1. Imbalanced Nutrition, Less Than Body Requirements related to the inability of clients to enter or swallow food.
Goal:
Expected levels of available nutrients to meet metabolic demands.
Expected outcomes:
- Fulfilled food intake, fluid and nutrients
- Tolerance to the recommended diet
- Maintain body mass and body weight within normal limits
- Reported adequacy energy level
1. Auscultation of bowel sounds
Rational: hyperactive bowel sounds reflecting an increase in the lower stomach motalitas or alter the function of absorption.
2. Monitor food intake every day. And weights every day and report a decrease.
Rational: weight loss continuously in a state of sufficient caloric intake is an indication of the failure of antithyroid therapy.
3. Avoid feeding can increase the peristaltic bowel.
Rationale: increased motalitas gut can cause diarrhea and absorption of necessary nutrients.
4. Collaborate with doctors medicinal drugs or vitamins that are needed to meet the nutritional needs of clients.
Evaluation:
The level of nutrients available to the client able to meet the metabolic needs.
Nursing Diagnosis and Interventions for Thyroidectomy - Postoperative
1. Ineffective airway clearance related to airway obstruction (airway spasm).
Goal:
Kepatenan maintain airway.
Expected outcomes:
- Demonstrate effective airway clearance evidenced by gas exchange and ventilation harmless.
- Easy to breathe.
- No: restlessness, cyanosis, and dyspnea.
- Oxygen saturation in the normal range.
1. Monitor respiratory rate, depth, and the work of breathing.
Rational: normal breathing sometimes quickly, but development of respiratory distress is indicative of tracheal compression due to edema or hemorrhage.
2. Auscultation breath sounds, record a voice crackles.
Rational: rhonchi is indicative of obstruction / laryngeal spasm which require rapid evaluation and intervention.
3. Check the neck bandage every hour on the initial postoperative period, and then every 4 hours.
Rationale: Surgical neck region can cause airway obstruction due to postoperative edema.
2. Acute pain related to postoperative edema
Goal:
Expected to control pain and can be reduced.
Expected outcomes:
- No moans
- Relaxed facial expression
- Reported pain may be reduced or lost, from the scale of 7 is reduced to 2.
1. Assess for signs of pain in both verbal and nonverbal, note the location, intensity (scale of 0-10), and duration.
Rationale: useful in evaluating pain, choice determine the effectiveness of therapeutic interventions.
2. Provides patient in semi-Fowler position, and chock the head / neck with a small pillow.
Rational: to prevent hyperextension neck and protect the integrity of the suture line
3. Instruct the patient to use relaxation techniques, such as imagination, soft music, progressive relaxation.
Rational: help untyuk refocus attention and help patients to cope with pain / discomfort more effectively.
4. Give analgesics prescribed and evaluation of effectiveness.
Rational: analgesics in severe pain may need to block pain.
Evaluation:
Pain on the client can be reduced
