Student Nurses’ Community
NURSING CARE PLAN – Thyroidectomy ASSESSMENT SUBJECTIVE: “Nahihirapan ako lumunok at huminga” (I'm
having trouble swallowing and breathing) as
DIAGNOSIS Risk for ineffective airway clearance. Risk factor may include tracheal obstruction; swelling, bleeding, and laryngeal spasms.
INFERENCE Thyroidectomy is the removal of all or a portion of the thyroid gland. The procedure is usually performed to treat various disease of the thyroid gland that may not be treated effectively by chemotherapy or medication. A total thyroidectomy is indicated for certain carcinomas and to relieve tracheal or esophageal compression.
PLANNING After 1 hour of nursing interventions, the patient will maintain patent airway, with aspirations prevented.
INTERVENTION Independent • Monitor respiratory rate, depth, and work of breathing.
RATIONALE • Respirations may remain rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage. • Rhonchi may indicate airway obstruction and accumulation of copius thick secretions. • Indicators of tracheal obstruction or laryngeal spasm. • Enhances breathing and reduces likelihood of tension on surgical wound. • Maintain clear airway and ventilation. • Edema and pain
EVALUATION After 1 hour of nursing interventions, the patient was able to maintain patent airway, with aspirations prevented.
verbalized by the patient.
OBJECTIVE: • • • • Irritability Restlessness Difficulty of communicati ng V/S taken as follows T: 36.9˚C P: 80 R: 20 BP: 110/ 80
Auscultate breath sounds, noting presence of rhonchi.
Assess for dyspnea, stridor, “crowning” and cyanosis. Keep head of the bed elevated 30 to 45 degrees.
Assist in repositioning, deep breathing exercises, and coughing, as indicated. Ascertain that
Check dressing • Anterior dressing frequently. humidify room air. airway may create a lifethreatening situation requiring emergency procedure. may appear dry because blood pools dependently. Investigate reports • May indicate of difficulty edema and swallowing and sequestered drooling of oral bleeding in secretions.
. clear airway. Keep tracheostomy • Compromised tray at bedside. • Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions.Student Nurses’ Community
suction equipment is may impair functioning and patient’s ability to available. tissues surrounding operative site.
Collaborative • Provide stream inhalation.