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nursing care plan for post thyroidectomy and cholecystectomy

nursing care plan for post thyroidectomy and cholecystectomy

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Published by irish m magracia

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Categories:Types, Research, Science
Published by: irish m magracia on Mar 08, 2010
Copyright:Attribution Non-commercial

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08/16/2013

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Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
“Nahihirapanakong lumunok”, asverbalized by thepatient.
Objective:
Vital signs: T:37°CPR:76bpmRR:18cpmBP:120/80mmHg
Withdifficulty of swallowing.
Limitation of food volume.
Second daypostthyroidectomy.ImpairedswallowingAfter 5 hours of nurse-patientintervention, thepatient will beable to:
Verbalizeunderstanding of causativeorcontributing factors.
Promoteintake.
Pass foodfrommouth tostomacheasily.
 Take andrecordvitalsigns.
Providecognitivecues (e.g.,remindpatient tochew of swallowasindicated.
Focusattentiononfeeding/swallowing activityanddecreasingenvironmentalstimuli.
Establishesbaseline forassessingimprovement orchanges.
 To enhanceconcentration andperformance of swallowingsequence.
 To avoiddestructionduringfeeding.
 Toadequatelytrigger theswallowing
Demonstratefeedingmethodsappropriatelyto thepatient’ssituation.
 
Place foodmidway inoralcavity andprovidemedium-sized bite.reflex.
Assessment DiagnosisPlanning Intervention Rationale Evaluation
Subjective:
“Nahihilo ako”, asverbalized by thepatient.
Objective:
Vital signs: T:36.7°CPR:74bpmRR:21cpmBP:130/90mmHg
Intoleranceto activity.
Decreasestrength andImpairedphysicalmobilityAfter 3 hours of nurse-patient intervention, thepatient will be able to:
Demonstratetechniques/behaviour that enablesresumption of activities.
Maintain/increasestrength.
Observemovementwhen theclient isunaware of observation.
Encourageadequateintake of fluid/nutritious foods.
Instruct toplacepillows on
 To noteincongruencies withreports of ability.
Promotewell-beingandmaximizesenergyproduction.
 To providesafety tothe
Verbalizeunderstanding of situation/risk factorsandindividualtreatmentregimenand safetymeasures.
Maintainandincreasestrength.
 
endurance.
Limitedrange of motion.
Difficultyturning.the side.
Encourageclient’s/SO’sinvolvement indecisionmaking asmuch aspossible.patient.
Enhancestocommitment to plan,optimizingoutcomes.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
“Nahihirapanakong magsalita”,as verbalized by thepatient.
Objective:
Vital signs: T:36°CPR:80bpmRR:21cpmImpairedverbalcommunicationAfter 8 hours of nurse-patientintervention, thepatient will be ableto:
Establishmethods of communication in whichneeds can beexpressed.
Maintain aclamunhurriedmanner.Providesufficienttime forclient torespond.
Individualswithexpressiveaphasiamay talkmore easilywhen theyare restedand relaxedand whenthey are

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