PHYSICAL ASSESSMENT

VITAL SIGNS: RESPIRATORY

BP – 120/70 -(-) Cough
PR – 58 -(-) Difficulty of
RR – 21 breathing
Temp. – 370C -Symmetrical chest
expansion
CARDIOVASCULAR-Clear breath sounds
-(-) Chest pain
-(-) Hypertension MUSCULOSKELETAL
- (-) Tremors
- (-) Trousseau’s sign
NEUROLOGICAL
-PERRLA
-LOC: Alert
-Strong reflexes

INTEGUMENTARY
-Skin color: Pale -Warm to
touch
-Good skin turgor -Dry skin

NUTRITIONAL/METABOLIC
positive Dysphagia
(-) N&V
GASTROINTESTINAL
TRACT
-Present BM

GENITOURINARY
TRACT
-Clear urine color

OVER ALL
APPEARANCE
-With wound dressing
on neck
 Thyroid Gland Increase energetic exchange of
the calorie gene

Increase need of TSH

Compensated increase hormonal production

Hyperplasia into local follicles

Enlarged thyroid / nodular goiter

Compression of trachea and

esophagus
Difficulty Difficulty of Subtotal Thyroidectomy
in swallowing breathing
Date Doctor’s Order Rationale
2/8/200
Please admit to -for further management of
8
2:00 PM surgery.
Secure consent patient
-to protect client from having
for any surgical procedure they do
management. not want/do not understand
and protects also the hospital
  TPR every shift -for
and monitoring and recording
health personnel
  NPO v/s avoid
-to every aspiration
shift and as a
preparation for surgery.
Date Doctor’s Order Rationale

IVF on OR day -to replace body fluids lost

either before or during
For elective surgery
-to remove the part
Subtotal affected by the nodule
thyroidectomy
Notify -to inform the physician
COC/ROD/OR
Refer ROD for -for management of
scheduling operation
Date Doctor’s Order Rationale

2/9/200 O2 inhalation at 3 -to increase oxygen supply

8
LPM via nasal
cannula while
  Monitor patient
patient is asleep -to determine sudden
every 15 minutes changes in patient’s
till stable, q 1˚x1, condition
q 2˚x1, q 4˚ &
Date Doctor’s Order Rationale

  IVF: Decrease to  
KVO while on BT.
  D5 LR 1L x 30 -adequate nutrition that

gtts/min. provide tissue repair

  D5 NR 1L x8 -for adequate hydration

hours. and nutrition that promotes

healing
 D
Doctor’s Order Rationale
ate

  Left arm, BT of FWB -to replace blood loss post-

500 ml x 25 gtts/min op
  (save BT Hgb
Post-BT, line)and Hct -to monitor blood chemistry
6 hours after
  Meds:  
  Tramadol 50 mg -to relieve pain of patient,
slow IV push every 6 post-op
hours x dose ANST
 D
Doctor’s Order Rationale
ate

  Ketorolac 30 mg, IV, -to relieve pain of patient,

every 6 hours x 6 post-op
  doses ANST
Ranitidine 50( ).
mg, IV -to reduce the risk of
,every 8 hours by 2 hyperacidity due to NPO
  doses.
Cefazolin 1 gm, IV, status
-to reduce the incidence of
every 8 hours certain post-op infections
 Date Doctor’s Order Rationale

Moderate high back -to facilitate lung

rest
Monitor intake and expansion
-to check for fluid
output every 2 balance
hours and record
02/10/20
Clear
pleaseliquid to - for gradual orientation of
08
general liquid diet. diet post-op
Date Doctor’s Order Rationale

  IVF PNSS 1L x 16 - for adequate hydration

hours. and nutrition that

  Continue meds. -for continuous
promotes healing
pharmacologic
  CWD( change wound -management
to prevent infection and
dressing ) to protect from bacterial
contamination.
Date Doctor’s Order Rationale

Increase Cefazolin - to reduce the incidence

to 1 gm, IV, every of certain post-op infection
8 hours 1 tab BID
Caltrate - to prevent and treat
calcium deficiency due to
thyroid d/o
Date Doctor’s Order Rationale

2/11/0 General to Soft - for gradual orientation of

8  diet
Continue present -diet
for post-op
continuous
meds. pharmacologic
  IVF D5 NM 1L x 16 -management
for adequate hydration

hours. and nutrition that

  CWD (Clean - to prevent infection and
promotes healing
Wound Dressing) to protect from bacterial
contamination
 Date Doctor’s Order Rationale

Give Cotalbex 1 - treatment and prevention

ampoule, IV OD. of vitamin B deficiency
Give Ponser 50 diseases
-to relieve pain of the
02/12/0 DAT
mg, TID. -patient
adequate nutrition that
8
provide needed tissue
repair
Date Doctor’s Order Rationale

  For serum Ionized - to monitor calcium

calcium test. concentration in the blood
  IVF D5 NM 1L x 16 - for adequate hydration

hours. and nutrition that

  CWD -promotes
to prevent infection and
healing
to protect from bacterial
contamination
 Date Doctor’s Order Rationale

02/13/ Continue present - for continuous

08 meds. pharmacologic
  IVF D5 NM 1L x 16 -management
for adequate hydration

hours. and nutrition that

  CWD -promotes
to prevent infection and
healing
to protect from bacterial
contamination
 Date Doctor’s Order Rationale

02/14/08 Nevramin 1 -for neural disturbances

  tablet, BID
Thyrax 500 gm 1 -to increase level of TSH
tablet, BID
  Caltrate 1 tab BID - to treat calcium
deficiency
 Date Doctor’s Order Rationale

2/15/0 Insert IVF PNSS1L x - for adequate hydration

8 KVO. and nutrition that
  Calcium gluconate -to reversehealing
promotes
drip 2 ampoules in hypermagnesemia due
  250 cc D5W
Increase Caltrate
x 8˚ 1 -totoovercorrection
treat calcium
tab BID deficiency
Date Doctor’s Order Rationale

2/16/0 Continue present - for continuous

8 meds. pharmacologic
  Continue -management
to reverse
gluconate drip 2 hypermagnesemia due to
ampoule, IV, in overcorrection
250 cc D5W x 8
hours.
Date Doctor’s Order Rationale

2/17/08 Continue present - for continuous

meds. pharmacologic
  Follow up serum -management
to monitor calcium
Ionized calcium concentration in the blood
02/18/0 Continue
test. present - for continuous
8
meds. pharmacologic
management
 11.20.07

Macroscopic & Microscopic Examination

Cytology reveals islands of dishesive cells w/

moderate anisonucleosis. The individual cells have
round nuclei surrounded by scant cytoplasm. Some
cells have rounded intranuclear inclusions. The
cluster of cells shows anatomic borders of
palisading cuboidal cells. The background shows
moderate lymphocytes, hemosiderophages & red
blood cells.
 11.20.07

NORMAL VALUES RESULTS JUSTIFICA

T3 0.6 – 1.8 1.23 Normal
TION
T4 ug/ml
4.8 -12.0 11.04 Normal
TSH 0.4 – 6.0
ug/dl 0.56 Normal
uIu/ml
 CLINICAL
CHEMISTRY
02.01.08
COMPONENTS & SI RESULTS JUSTIFICATION
Hemoglo
VALUES
12-16 g/dl 13.3 g/dl Within normal
Hematoc
bin .40-0.54 0.40 g/dl Within
value
normal
rit g/dl Decreased
value
WBC 5.0-10.0 x 4.3 x 109/L level:Hematopoiet
109/L ic disease, Viral
infections,
agranulocytosis,
Anti-thyroid drugs.
 CBC

COMPONENTS & SI RESULTS JUSTIFICATI

BT VALUES
1-7 minutes 1’ 30” Normal
ON
Cirrhosis,
BUN 10-18 mg/dl 8 mg/dl malnutrition,
nephrosis
Chronic
Creatinine 0.6-1.2 1.3 mg/dl glomerulonep
mg/dl hritis,
nephritis,
CHF, muscle
 01.08.08

ECG interpretation: Norma Sinus rhythm at 98/min

RR interval: 0.16 seconds
QRS: 0.06 seconds
QT interval: interval 0.32 seconds
Chest X- Ray: Normal PA View
 01.08.08

COMPONENTS & SI RESULTS JUSTIFICATION

Hemoglob
VALUES
12-16 g/dl 13.3 g/dl Within normal
Hematocri
in .40-0.54 0.40 g/dl Within
value
normal
RBC
t 4-5.5
g/dl x 4.4 x 1012/L Withinvalue
normal
1012/L value
Decreased
WBC 5.0-10.0 x 4.3 x 109/L level:Hematopo
109/L ietic disease,
Viral infections,
agranulocytosis,
Platelets 150-400 x 223 x 109/L Anti-thyroid
Within normal
109/L drugs.value.
 01.08.08

Differential Count RESULT JUSTIFICATION

Neutrophil 50-70% 61%
S Normal
Eosinophil
s 1-3% 1% Normal
Lymphocy
s 25-35% 31% Normal
tes
Monocytes 4-6% 7% Normal
 02.09.08

NORMAL VALUES RESULT JUSTIFICATION

T3 0,6 – 1.8 S
1.03 Normal
T4 4.8 -12.0
ug/ml 9.54 Normal
TSH ug/dl
0.4 – 6.0 0.49 Normal
uIu/ml
 02.17.08

NORMAL VALUES RESULT JUSTIFICATION

S Decreased level:
Calcium 8.5 – 10.4 6.0 mg/dl diarrhea, mal
mg/dl absorption of
calcium from GIT,
hypoparathyroidism
, alcoholism
 Generic Name:
Cefalozin Sodium
Brand Name:
Cefradine
Dosage: 1gm IV q8
Classification
Antibiotic
Cephalosporin
(1st Generation)
 Indication
Susceptible infections and prophylaxis of infections
during surgical operations
Mechanism of Action
Bactericidal: inhibits synthesis of bacterial cell wall
and causes cell death.
Contraindication
Hypersensitivity to Cephalosporin and penicillin
Use cautiously with renal failure, lactation, and
pregnancy.
 Side Effects/ Adverse Effects
Nausea, diarrhea, vomiting, abdominal pain,
headache, restlessness, rash.
GU: Nephrotoxic
Nursing Consideration
>History of penicillin and cephalosporin allergy.
>Have vit. K available in case hypoprothrombinemia
occur.
>Do not use alcohol while taking this drug for 3 days
because severe reactions occur.
>Report severe diarrhea, DOB , unusual tiredness,
 Generic Name: Calcium Salts
Brand Name: Caltrate
Dosage: 1 tab BID

Classification
Antacid
Electrolyte
Indication
Hypocalcemic tetany or hyperkalemia and
parathyroid tetany.
Necessary for proper nerves and muscle function,
blood clot, normal cardiac function.
 Mechanism of Action
Essential element of the body, helps maintain the
functional integrity of the nervous and muscular
system, an enzyme co-factor and affects the
secretory activity of the endocrine and exocrine
glands.
Contraindication
Hypersensitivity to salmon calcitonin or fish
products, lactation.
Use cautiously with renal insufficiency,
osteoporosis, pernicious anemia.
 Side Effects / Adverse Effects
CV: slowed heart rate, tingling ( rapid IV
administration)
Peripheral vasodilation, drop in BP
Nursing Consideration
>Asses for hypersensitivity to salmom calcitonin or
fish products, lactation, osteoporosis, pernicious
anemia, renal disease
>Asses for physical: skin lesions muscle tone,
urinalysis, serum calcium
>Report twitching, muscle spasm, dark urine, rash
Generic Name: Tramadol Hydrochloride
Brand Name: Ultram
Dosage: 50mg IV q6 x 2 doses

Classification
Analgesic, centrally acting

.ModerateIndication
to severe acute or
chronic pain and in painful
diagnostic measure and
surgery.
 Mechanism
A centrally of Action
acting analgesic not related
chemically to opiates. Precise mechanism is
not known. The analgesic effect is only
partially antagonized by the antagonist
naloxone.
Contraindication
Hypersensitivity to tramadol. Acute
intoxication with alcohol, hypnotics, centrally
acting analgesics, opiates, or psychotrpic
Side
Malaise, Effectsdrugs.
anxiety, / Adverse Effects
confusion, coordination
disturbance, euphoria, nervousness, sleep d/o,
abdominal pain, anorexia, urinary retention,
dizziness, vertigo, headache, N&V,
constipation.
 Nursing Consideration
>If client is on a Diuretic, discontinue 2
to 3 days prior to beginning therapy
with trandolapril to reduce likehood of
hypotension
>Monitor BP, cardiac status, CBC,
electrolytes, liver and renal function,
>Take only as directed.
>May experience cough , dizziness, and
diarrhea. Report if persistent.
Generic Name: Ketorolac tromethamine
Brand Name: Toradol
Dosage: 30 mg IV q6 x 6 doses

Classification
Nonsteroidal anti-inflammatory
drug
Indication
Short term (up to 5 days)
management of severe, acute
pain that requires analgesia at the
opiate level.
 Mechanism of Action
Possesses anti-inflammatory, analgesic, and
antipyretic effects. Over 99% is bound to plasma
proteins. Metabolized in the liver with over 90%
excreted in the urine and the remainder excreted in
the feces.
Hypersensitivity Contraindication
to the drug or allergic symptoms
(angioedema, bronchospasm) to aspirin or other
NSAIDs.
As prophylactic analgesic before any major surgery
or intraoperatively when hemostasis is critical due
to increased risk of bleeding.
 Side Effects / Adverse Effects
Pallor, GI pain, peptic ulcers, nausea,
dyspepsia, stomatitis, excessive thirst, GI
bleeding, headache.
>Correct hypovolemia prior to administering.
Nursing Consideration
>Note any previous experience with NSAIDs
and the results.
>Determine any liver and renal dysfunction;
assess hydration.
>Drug may cause drowsiness and dizziness
avoid activities that require mental alertness.
>Avoid, alcohol, ASA, and all OTC agents
 Generic Name: Aeknil
Brand Name: Paracetamol
Dosage: IV stat

Classification
Analgesic/ antipyretic

Relieve mild to Indication

moderate pain due to
things such as headache, muscle
and joint pain, backache and period
pains. It is also used to bring down a
high temperature.
 Reduces the production of prostaglandins, pro-
Mechanism
inflammatory chemicals ofproduction
the Action of which is
also inhibited by aspirin, but unlike aspirin,
paracetamol does not have much anti-
inflammatory action. Aspirin inhibits the production
of the pro-clotting chemicals thromboxanes,
paracetamol does not. Aspirin is known to inhibit
the cyclooxygenase (COX) family of enzymes, and
because of paracetamol's partial similarity of
aspirin's action, much research has focused on
Contraindication
whether paracetamol also inhibits COX.
Hypersensitivity to drug
 Side Effects / Adverse Effects
> Rarely causes gastrointestinal
problems or allergic skin reactions

Nursing Consideration

Assess for hypersensitivity reaction

Generic Name: Levothyroxine Sodium
Brand Name: Eltroxin
Dosage:50 ugm 1 tab BID

Classification
Hormone & synthetic substitutes;
thyroid agent
Indication
Specific hormonal replacement
therapy in the presence of
hypothyroidism of an etiology.
 Mechanism of Action
Synthetically prepared monosodium salt and levo-
isomer of thyroxine, with similar actions and uses
(thyroxine, principal component of thyroid gland
secretions, determines normal thyroid function).
Contraindication
Patient’s with hypersensitivity to any ingredient of the
tablets and patients with thyrotoxicosis, AMI or
uncorrected adrenal insufficiency.
 Side Effects
CNS: Irritability, / Adverse
nervousness, Effects headache
insomnia,
(pseudotumor cerebri in children), tremors,
craniosynostosis (excessive doses in children). CV:
Palpitations, tachycardia, arrhythmias, angina pectoris,
hypertension. GI: Nausea, diarrhea, change in
appetite. Urogenital: Menstrual irregularities. Body
as a Whole: Weight loss, heat intolerance, sweating,
fever, leg cramps, temporary hair loss (children).
 Thyroid replacement therapy is usually lifelong.
Nursing Consideration
Learn how to self-monitor pulse rate. Notify physician if
rate begins to increase above 100 or if rhythm changes
are noted.
Notify physician immediately of signs of toxicity (e.g.,
chest pain, palpitations, nervousness).
Monitor pulse before each dose during dose
adjustment. If rate is >100, consult physician.
Monitor for adverse effects during early adjustment. If
metabolism increases too rapidly, especially in older
adults and heart disease patients, symptoms of angina
or cardiac failure may appear.
Note: Levothyroxine may aggravate severity of
previously obscured symptoms of diabetes mellitus,
 Generic Name: Dopamine hydrochloride
Brand Name: Dopastat, Intropin, Revimine
Dosage: 50mg cap TID pc

Classification
Autonomic nervous system agent
(sympathomimetic); alpha- and beta-
adrenergic agonist

Indication imbalance in
To correct hemodynamic
shock syndrome due to MI
(cardiogenic shock), trauma,
endotoxic septicemia (septic shock),
open heart surgery, and CHF.
 Mechanism of Action
Naturally occurring neurotransmitter and immediate
precursor of norepinephrine. Major cardiovascular
effects produced by direct action on alpha- and beta-
adrenergic receptors and on specific dopaminergic
receptors in mesenteric and renal vascular beds.
Contraindication
Pheochromocytoma; tachyarrhythmias or ventricular
fibrillation. Safe use during pregnancy (category C),
lactation, or children is not established
 CV: Hypotension, ectopic beats,
Side Effects
tachycardia, / Adverse
anginal Effects
pain, palpitation,
vasoconstriction (indicated by
disproportionate rise in diastolic
pressure), cold extremities; less
frequent: aberrant conduction,
bradycardia, widening of QRS
complex, elevated blood pressure. GI:
Nausea, vomiting. CNS: Headache.
Skin: Necrosis, tissue sloughing with
extravasation, gangrene, piloerection.
Other: Azotemia, dyspnea, dilated
pupils (high doses).
Monitor blood pressure, pulse, peripheral pulses, and
urinary output at intervals prescribed by physician.
Precise measurements
Nursing Consideration
are essential for accurate
titration of dosage.
Report the following indicators promptly to physician
for use in decreasing or temporarily suspending dose:
Reduced urine flow rate in absence of hypotension;
ascending tachycardia; dysrhythmias;
disproportionate rise in diastolic pressure (marked
decrease in pulse pressure); signs of peripheral
ischemia (pallor, cyanosis, mottling, coldness,
complaints of tenderness, pain, numbness, or burning
sensation).
Monitor therapeutic effectiveness. In addition to
improvement in vital signs and urine flow, other
indices of adequate dosage and perfusion of vital
 Brand Name: Cotalbex
Dosage: 1 amp OD
Classification

Vitamin B's/with C
1 amp OD

Indication
Prevention & treatment of vit B
deficiency.
 Mechanism of Action
> water soluble vitamin that combines with ATP in
liver, kidney, and leukocytes to form thiamine

Contraindication
> hypersensitvity

Side Effects / Adverse Effects

Anaphylactic reactions.
 Nursing Consideration
>monitor vital signs
>monitor patients ECG
>assess for signs of and symptoms of improvement
>observe the patient for reversal of deficiency
symptoms
 Generic Name: Nevramin
Dosage: 1tab BID

Classification
Vit. B12 Fulsurtiamine

Indication
Neural disturbances & anemic
conditions.
 Mechanism of Action
> water soluble vitamin that combines with ATP in
liver, kidney, and leukocytes to form thiamine

Contraindication
> hypersensitvity

Side Effects / Adverse Effects

Anaphylactic reactions.
 Medical diagnosis
Nodular Thyroid Goiter

Nursing diagnosis
Alteration in comfort: acute pain related
to postoperative surgical procedure.
Long-term Goal
The patient will be free from pain before
discharge.
Short-term Goal
After my nursing intervention the patient will
reduce pain from pain scale of 6/10 to 3/10.
 Objective Cues
RR: 21 cpm
Temp: 37.1 Degree Celsius
(+)guarding behavior in the
incision site.
(+) facial grimace.
7/10 pain scale by sign
language.
 Nursing problem
Pain at incision site
Scientific Reason
A state in which an individual experiences and
report the presence of severe discomfort or an
uncomfortable sensation.
SOURCE:
Nurses pocket guide: Nursing diagnosis with
interventions 4th edition by Marilynn
E.Doenges and Mary Frances Moorhouse
 Nursing Interventions Rationale
Assess for Pain may be
presence or routine
description of pain. postoperative
surgical discomfort
or may result from
pressure of an
 Assess patient’s expanding
position. hematoma.
Improper
positioning can
 Nursing Interventions Rationale
Assess neck Early
incision for identification of
approximated skin complications
edges, redness, allows prompt
swelling, and treatment.
drainage.
Use relaxation These techniques
techniques as lessen difficulty in
appropriate. swallowing.
Administer cool
 Nursing Interventions Rationale
 Protect the neck
incision by
instructing Neck flexion
patient to: compresses the
 Avoid neck trachea.
flexion/hypextentio Hyperextension
n. causes
pulling/tension on
the incision line.
 Avoid rapid head This prevents
 Nursing Interventions Rationale

Administer To prevent

analgesic, throat unnecessary
sprays/lozenges pain.
as needed.
 Possible Evaluations

Goal met.
Patient pain scale decreased from 6/10
to 4/10 by sign language.
Goal partially met.
Patient pain scale decreased from 6/10
to 5/10 by sign language.
Goal not met.
Patient was not able to reduce pain felt.
 Medical diagnosis
Nodular Thyroid Goiter
Nursing diagnosis
Risk for Fluid Volume loss: Bleeding R/T
postLong-term
– neck surgery
Goal
After hospitalization patient will still be free
from manifestations of an impending bleeding
and other post – operative complications.
Short-term Goal
At the end of my shift patient will be able
to manifest no signs and symptoms of
 Objective Cues

With wound dressing to

penrose drain with sero-
sanguinous discharge.
BP -120/70
HR - 58 bpm
 Nursing problem
Risk for bleeding

Scientific Reason
Hemorrhage is a serious complication of
surgery that can result to death. It can present
insidiously or emergently at any time in the
immediate post-operative period or up to
several days after surgery.
Sources: Med – Surg. Nursing. Smeltzer & Bare
Vol.1 p. 970
 Nursing Interventions Rationale

Assess for signs For early

and symptoms of detection and
bleeding. prevention of
complication
Observe the To detect if
sides and the there’s already
back of the neck an actual
for pooling of bleeding.
 Nursing Interventions Rationale
Teach patient For the awareness
about signs and of the patient that
symptoms of complications may
complications to occur and that
look out for within a consultation is
day or two. necessary right
away.
Advise the patient straining places
to just rest and not tension on the
sutures that may
 Possible Evaluations

Goal met.
Patient was able to manifest no
signs and symptoms of bleeding.
Goal not met.
Patient manifest signs and
symptoms of bleeding as evidenced
by frequent swallowing, tachycardia
and hypotension.
 Medical diagnosis
Nodular Thyroid Goiter
Nursing diagnosis
Risk for injury: Tetany related to
possible stimulation of parathyroid
gland.
Long-term Goal
Client will be free from injury until
discharge.
Short-term Goal
At the end of my shift, client will
demonstrate absence of injury with
 Objective Cues
Serum Ca = 6.0 mg/dL
(-) Trousseau’s sign.
(-) Chvostek’s sign.
Body malaise
 Nursing problem
Risk for tetany
Scientific Reason
Tetany is the most characteristic
manifestation of hypocalcemia. Tetany
refers to the entire symptom complex
induce by increase neural excitability. This
symptoms are due to spontaneous
discharges of both sensory and motor fibers
in peripheral nerves.
 Nursing Interventions Rationale

Monitor v/s, Manipulation of

noting elevating gland during
temperature, subtotal
tachycardia (140- thyroidectomy
200bpm), may result in
dysrrhythmias, increased
respiratory hormone release,
distress, causing thyroid
cyanosis(developi storm.
 Nursing Interventions Rationale
Evaluate reflexes Hypocalcemia
periodically. with tetany (usually
Observe for transient) may
neuromuscular occur 1-7 days post
irritability. op and indicates
hypoparathyroidism
, which can occur as
a result in advertent
trauma to/ partial to
removal of
 Nursing Interventions Rationale
Keep side rails. Reduces potential
Raised / padded, for injury if seizures
bed in low position, occur.
and airway at
bedside. Avoid use
restraints.
Clients with levels
Monitor serum less than 8.5 mg/dL
calcium levels. generally require
replacement
 Nursing Interventions Rationale
Administer
medications as
indicated: -Corrects
-Calcium deficiency which is
(Gluconate) usually temporary
but maybe
permanent.
-Anticonvulsant - Controls seizure
activity until
 Possible Evaluations
Goal met.
Client did not develop injury/tetany during my
shift as evidenced by
(-) Trousseau’s and (-) Chvostek’s sign.
Goal partially met.
Client did not developed tetany but there was
presence of body malaise, (-) Trousseau’s and
(-) Chvostek’s sign.
Goal not met.
Client developed tetany within my shift as
 Medical diagnosis
Nodular Thyroid Goiter
Nursing diagnosis
Risk for infection related to
postoperative surgical incision.
Long-term Goal
The patient will remain free from
infection until discharge.
Short-term Goal
After my nursing intervention, patient
will remain free from infection, as
evidenced by normal vital signs and
 Objective Cues
BP: 120/ 70 mmHg
RR: 21 cpm
PR: 58 bpm
Temp: 37.1C
(+)sero-sanguinous, at
Jackson pratt.
 Dressing: dry/clean and
 Nursing problem
Risk for Infection
Scientific Reason
The state in which an individual is at
increased risk for being invaded by
pathogenic organisms.
SOURCE:
Nurses pocket guide: Nursing diagnosis
with interventions 4th edition by
Marilynn E. Doenges and Mary Frances
Moorhouse
 Nursing Interventions Rationale
Monitor the
following for signs
of infection: Any suspicious
Redness, swelling, drainage should be
increased pain, or cultured; antibiotic
purulent drainage therapy is
at incisions, injured determined by
sites, and exit sites pathogens
of tubes, drains, or identified at culture.
catheters.
Nursing Interventions Rationale
Elevated Fever of up to 38° C
temperature. (100.4° F) for 48 hours
after surgery is related to
surgical stress; after 48
hours, fever above 37.7 °
C (99.8° F) suggest
infection; fever spikes that
occur and subside are
indicative of wound
infection; very high fever
accompanied by sweating
 Nursing Interventions Rationale
 Assess nutritional Patients with poor
status, including nutritional status
weight, history of may be anergic, or
weight loss, and serum unable to muster a
albumin. cellular immune
response to
pathogens and are
therefore more
susceptible to
Stressed proper infection.
handwashing Prevent
 Nursing Interventions Rationale

Include information The client will be

in preoperative knowledgeable
teaching about ways about preventing
to reduce potential for infection by her
postoperative self.
infection.
Rising WBC
Monitor white blood indicates body’s
count (WBC). effort to combat
pathogens. Very
low WBC indicates
 Possible Evaluations

Goal met.
Patient vital signs are stable. No
signs of infection.
Goal not met.
Patient acquired infection as
evidenced by abnormal v/s and
presence of purulent discharge on
 Medical diagnosis
Nodular Thyroid Goiter
Nursing diagnosis
Risk For Altered Body Nutrition: Less than
body requirements R/T Inability to ingest
2o to post - neck
Long-term surgery.
Goal
After hospitalization patient will be able to
maintain normal weight without signs and
symptoms of deteriorating nutritional state.
Short-term Goal
At the end of my shift patient will be able to
swallow larger amounts of food.
 Objective Cues
Difficulty in swallowing.
Lack of interest in food
Pale looking
Dry skin
Weight = 50 kg.
DAT diet
 Nursing problem
Risk for Altered Body Nutrition

Scientific Reason
Certain signs that may appear to indicate
nutritional deficiency, may reflect other
systemic conditions (e.g. Endocrine d/o,
infectious dse.). Other may result from
impaired digestion, absorption excretion or
storage of nutrients in the body.
Sources:
 Nursing Interventions Rationale

Assess patient To provide a

condition. baseline data for
necessary
Provide food nursing
interventions.
preference with
the patients To increase
tolerance. patients interest
with food
 Nursing Interventions Rationale
Assess patient’s To gather info
ability to swallow and regarding the extent of
her eating habits. swallowing that the
patient can tolerate
and if foods taken are
Provide small and nutritious.
frequent feedings. To decrease gastric
motility that causes
Feed patients slowly clients to feel full thus
with water to follow. reducing intake
To gradually exercise
 Nursing Interventions Rationale

Promote a Appetite may

pleasant improve if
environment for environment is
eating. conducive to
eating.
Weigh patient Monitor
regularly. nutritional state
and effectiveness
 Possible Evaluations

Goal Met:
Patient was able to swallow larger than
her usual amount of food intake.
Goal Partially Met:
Patient manifested increase in appetite
but still having less tolerance due to
odynophagia.
Goal Not met:
 Patient’s Profile
Anatomy & Physiology
Pathophysiology
Medical Management
Laboratory Results
Drug Study
Nursing Care Plan