THYROID PAPILLARY CANCER

A Case Study Rizal Medical Center

NURSING CARE PLAN NO.1 ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION

S: Hirap lang ako lumunok. as pt. verbalized. O: >with post-surgical incision @ both sides of anterior neck >with 2 Jackson-Pratt drains @ each side of the neck @50cc level >body weakness >with non-productive cough noted >with hoarseness of voice noted >difficulty in swallowing noted NURSING DIAGNOSIS RISK FOR ASPIRATION related to post-surgical incision @ anterior neck secondary to the presence of solid nodules

short-term goal partially compensatory At the end of 3 hours of NI, the patient will be able to swallow well.

focus on raising upper extremities with head slightly flexed forward when eating. focus on encouraging a rest period before meals focus on providing warm liquids

to prevent foods/liquids from entering the lungs thus preventing aspiration giving ample time on eating prevents fatigue to activate temperature receptors in the mouth partly responsible for swallowing to prevent nausea and vomiting or back flowing to prevent mouth overload or assess if foods cant be swallowed to prevent back flowing and foe easy digestion and absorption

Patients condition prevented.

facilitate on instructing small, frequent feedings focus on having patient check around cheeks with tongue after each bite focus on maintaining an upright position for 30 minute after feeding depend on administration of Tramadol 1oomg TIV Q8

binds to opiate receptors in the CNS causing inhibition of ascending pain pathways

THYROID PAPILLARY CANCER

A Case Study Rizal Medical Center

NURSING CARE PLAN NO. 2 ASSESSMENT S: Ang laki ng tahi niya. as pt.s wife verbalized. O: >with post-surgical incision @ anterior neck >with dry and intact dressings >with 2 Jackson-Pratt drains @ each sides of incision site @ 50cc level >body weakness >with guarding behavior >with non-productive cough noted >less movement exerted on upper extremities >difficulty turning the neck >limited ROM PLANNING Long-term goal Partially compensatory At the end of 5 hours of NI, the patients . INTERVENTIONS Facilitate on inspecting skin, describing wounds and changes observed Focus on monitoring for signs of complications in wound healing Focus on keeping: -area clean and dry -dressings intact Facilitate on using support on affected area by placing pillows behind the head Focus on providing wellbalanced diet especially protein-rich and vitamin Ccontaining foods Depend on administration of medication: - Cefuroxime sodium 1g TIV every 8 hours as ordered RATIONALE to prevent the occurrence of infections EVALUATION Patients condition maintained.

to detect presence of further sequelae

to prevent the risk for infection

to prevent exertion of pressure on the affected area

NURSING DIAGNOSIS
IMPAIRED SKIN INTEGRITY related to post-surgical incision @ both sides of anterior neck secondary to the presence of solid nodules

to provide tissue repair and collagen formation to fasten wound healing

inhibits cell wall synthesis; promoting osmotic instability usually bactericidal

THYROID PAPILLARY CANCER

A Case Study Rizal Medical Center

NURSING CARE PLAN NO. 3 ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION

S: Nahihirapan ako igalaw leeg ko. as patient verbalized. O: >seen in Semi-fowlers position >with post-surgical incision along the anterior neck >with dry and intact dressing >body weakness >requesting assistance from others when reaching an object >slowed movement >difficulty turning his neck >limited ROM NURSING DIAGNOSIS IMPAIRED PHYSICAL MOBILITY related to incision at the neck secondary to post-surgical procedure (Total thyroidectomy with MRMD)

Short-term goal Partially compensatory At the end of 3 hours of nursing intervention, the patient will resume activities of daily living.

Facilitate in use of side To provide comfort and prevent rails and any safety fall measures Facilitate in support of To maintain position of function affected body part and reduce risk of developing pressure ulcers Focus on encouraging To enhance sense of participation in self-care independence and diversional activities Focus in identifying energy-conserving To limit fatigue and maximize techniques for ADLs. participation Facilitate on encouraging adequate intake of fluids To maximize energy production and nutritious foods Depend on administration: -Tramadol 100mg every 8 hours Inhibits prostaglandin synthesis TIV thus alleviating pain

Patients condition improved.

THYROID PAPILLARY CANCER

A Case Study Rizal Medical Center

NURSING CARE PLAN NO. 4 ASSESSMENT S:Magpepeklat na to di ba? as patients verbalized. O: > PLANNING Long-term goal Partially compensatory At the end ofNI, patient and family will adapt to altered body image. INTERVENTIONS Facilitate on assessing ability to adjust to altered body image Focus on providing opportunities for patient and family to discuss feelings of altered body image Focus on emphasizing that disease and surgery have no effect on patients masculinity Facilitate on reassuring patient of ability to continue roles and relationships with family and friends. Focus on arranging for him to talk with someone who has had surgery for cancer RATIONALE EVALUATION Patients condition

NURSING DIAGNOSIS
Body image disturbance related to post-surgical incision at the anterior neck secondary to cancer diagnosis

THYROID PAPILLARY CANCER

A Case Study Rizal Medical Center

Focus on referring family to support or self-help group if appropriate.

THYROID PAPILLARY CANCER

A Case Study Rizal Medical Center