Download ppt - Nodular Thyroid Goiter

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 - (-) Trousseaus sign

NEUROLOGICAL -PERRLA -LOC: Alert -Strong reflexes INTEGUMENTARY -Skin color: Pale touch -Good skin turgor -Warm to -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 of Difficulty breathing in swallowing

Subtotal Thyroidectomy

Date2/8/200 8 2:00 PM

Doctors Order

Rationale

Please admit to -for further management of surgery. Secure consent for management. patient -to protect client from having any surgical procedure they do not want/do not understand and protects also the hospital -for health personnel and monitoring and recording v/s avoid aspiration and as a -to every shift preparation for surgery.

TPR every shift NPO

Date

Doctors Order

Rationale

IVF on OR day For elective Subtotal Notify thyroidectomy COC/ROD/OR Refer ROD for scheduling

-to replace body fluids lost either before or during -to remove the part surgery affected by the nodule -to inform the physician -for management of operation

Date

Doctors Order

Rationale

2/9/200 8

O2 inhalation at 3 LPM via nasal cannula while Monitor is asleep patient patient every 15 minutes till stable, q 1x1, q 2x1, q 4 &

-to increase oxygen supply

-to determine sudden changes in patients condition

Date

Doctors Order

Rationale

IVF: Decrease to KVO while on BT. D5 LR gtts/min. D5 NR hours.1L 1L

-adequate nutrition that provide tissue repair -for adequate hydration and nutrition that promotes healing

x 30 x8

D ate

Doctors Order

Rationale

Left arm, BT of FWB

-to replace blood loss post-

500 ml x 25 gtts/min op Post-BT, line) (save BT Hgb and Hct -to monitor blood chemistry 6 hours after Meds: Tramadol 50 mg hours x dose ANST -to relieve pain of patient,

slow IV push every 6 post-op

D ate

Doctors Order

Rationale

Ketorolac 30 mg, IV, -to relieve pain of patient, every 6 hours x 6 ,every 8 hours by 2 Cefazolin 1 gm, IV, doses. every 8 hours post-op hyperacidity due to NPO -to reduce the incidence of status certain post-op infections Ranitidine 50 mg, IV -to reduce the risk of doses ANST ( ).

Date

Doctors Order

Rationale

Moderate high back -to facilitate lung Monitor intake and rest output every 2 hours and record02/10/20 08

-to check for expansion fluid balance - for gradual orientation of diet post-op

Clear pleaseliquid to general liquid diet.

Date

Doctors Order

Rationale

IVF PNSS hours.

1L

x 16

- for adequate hydration and nutrition that -for continuous promotes healing pharmacologic

Continue meds.

CWD( change wound management - to prevent infection and dressing ) to protect from bacterial contamination.

Date

Doctors Order

Rationale

Increase Cefazolin - to reduce the incidence to 1 gm, IV, every Caltrate 8 hours 1 tab BID of certain post-op infection - to prevent and treat calcium deficiency due to thyroid d/o

Date

Doctors Order

Rationale - for gradual orientation of - for continuous diet post-op pharmacologic - for adequate management hydration and nutrition that - to prevent infection and promotes healing to protect from bacterial contamination

2/11/0 General to Soft 8 Continue present diet meds. IVF D5 NM1L

x 16

hours. CWD (Clean Wound Dressing)

Date

Doctors Order

Rationale

Give Cotalbex 1 ampoule, IV OD. Give Ponser 5002/12/0 8

- treatment and prevention of vitamin B deficiency -to relieve diseases pain of the - adequate nutrition that patient provide needed tissue repair

DAT mg, TID.

Date

Doctors Order

Rationale

For serum Ionized calcium test. IVF D5 NM hours. CWD1L

- to monitor calcium concentration in the blood - for adequate hydration and nutrition that - to prevent infection and promotes healing to protect from bacterial contamination

x 16

Date

Doctors Order

Rationale

02/13/ 08

Continue present meds. IVF D5 NM hours. CWD1L

- for continuous pharmacologic - for adequate management hydration and nutrition that - to prevent infection and promotes healing to protect from bacterial contamination

x 16

Date

Doctors Order

Rationale

02/14/08

Nevramin 1 Thyrax 500 tablet, BID gm 1 tablet, BID

-for neural disturbances -to increase level of TSH

Caltrate 1 tab BID - to treat calcium deficiency

Date

Doctors Order

Rationale

2/15/0 Insert IVF PNSS1L x 8 KVO. Calcium gluconate drip 2 ampoules in Increase Caltrate 250 cc D5W x 8 1 tab BID

- for adequate hydration and nutrition that -to reverse promotes healing hypermagnesemia due - to treat calcium to overcorrection deficiency

Date

Doctors Order

Rationale

2/16/0 Continue present 8 meds. Continue gluconate drip 2 ampoule, IV, in 250 cc D5W x 8 hours.

- for continuous pharmacologic - to reverse management hypermagnesemia due to overcorrection

Date

Doctors Order

Rationale

2/17/08

Continue present meds. Follow up serum Ionized calcium Continue present test. meds.

- for continuous pharmacologic - to monitor calcium management concentration in the blood - for continuous pharmacologic management

02/18/0 8

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 T3 T4 TSH VALUES 0.6 1.8 ug/ml 4.8 -12.0 0.4 6.0 ug/dl uIu/ml RESULTS 1.23 11.04 0.56 JUSTIFICA Normal TION Normal Normal

CLINICAL CHEMISTRY 02.01.08 COMPONENTS & SI Hemoglo 12-16 g/dl VALUES Hematoc .40-0.54 bin rit g/dl WBC 5.0-10.0 x 109/L JUSTIFICATION Within normal Within normal value Decreased value 4.3 x 109/L level:Hematopoiet ic disease, Viral infections, agranulocytosis, Anti-thyroid drugs. RESULTS 13.3 g/dl 0.40 g/dl

CBC COMPONENTS & SI BT VALUES minutes 1-7 BUN 10-18 mg/dl RESULTS 1 30 8 mg/dl JUSTIFICATI Normal ON Cirrhosis, malnutrition, nephrosis Chronic glomerulonep hritis, nephritis, CHF, muscle

Creatinine

0.6-1.2 mg/dl

1.3 mg/dl

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

Platelets

150-400 x 109/L

01.08.08 Differential Count Neutrophil 50-70% Eosinophil s 1-3% Lymphocy 25-35% s tes Monocytes 4-6% RESULT 61% S 1% 31% 7% JUSTIFICATION Normal Normal Normal Normal

02.09.08 NORMAL T3 T4 TSH VALUES 0,6 1.8 4.8 -12.0 ug/ml ug/dl 0.4 6.0 uIu/ml RESULT S 1.03 9.54 0.49 JUSTIFICATION Normal Normal Normal

02.17.08 NORMAL VALUES Calcium JUSTIFICATION Decreased level: diarrhea, mal 8.5 10.4 6.0 mg/dl absorption of mg/dl calcium from GIT, hypoparathyroidism , alcoholism RESULT S

Generic Name: Cefalozin Sodium Brand Name: Cefradine Dosage: 1gm IV q8Classification 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 Indication .Moderate to severe acute or chronic pain and in painful diagnostic measure and surgery.

Mechanism of Action A centrally 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 Effectsconfusion, Effects / Adverse coordination Malaise, anxiety, drugs. 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 Indication Relieve mild to 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, proMechanism of Action inflammatory chemicals the production of which is also inhibited by aspirin, but unlike aspirin, paracetamol does not have much antiinflammatory 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 levoisomer of thyroxine, with similar actions and uses (thyroxine, principal component of thyroid gland secretions, determines normal thyroid function). Contraindication Patients with hypersensitivity to any ingredient of the tablets and patients with thyrotoxicosis, AMI or uncorrected adrenal insufficiency.

Side Effects / Adverse Effects CNS: Irritability, nervousness, insomnia, headache (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 betaadrenergic agonist Indication To correct hemodynamic imbalance in 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 betaadrenergic 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 / Adverse Effects tachycardia, anginal 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 are essential for accurate Nursing Consideration 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 GoiterNursing 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 siteScientific 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 presence or description of pain.

Assess patients position.

Pain may be routine postoperative surgical discomfort or may result from pressure of an expanding hematoma. Improper positioning can


Rationale

Assess neck incision for approximated skin edges, redness, swelling, and drainage. Use relaxation techniques as appropriate. Administer cool

Early identification of complications allows prompt treatment. These techniques lessen difficulty in swallowing.


Rationale

Protect the neck incision by instructing patient to: Avoid neck flexion/hypextentio n. Avoid rapid head

Neck flexion compresses the trachea. Hyperextension causes pulling/tension on the incision line. This prevents


Rationale

Administer analgesic, throat sprays/lozenges as needed.

To prevent unnecessary pain.

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


Risk for Fluid Volume loss: Bleeding R/T postLong-term surgery neck GoalAfter 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 serosanguinous discharge. BP -120/70 HR - 58 bpm

Nursing problem

Risk for bleedingScientific ReasonHemorrhage 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


Rationale

Assess for signs For early and symptoms of detection and bleeding. prevention of complication To detect if Observe the theres already sides and the back of the neck an actual bleeding. for pooling of


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


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


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 (-) Trousseaus sign. (-) Chvosteks sign. Body malaise

Nursing problem

Risk for tetanyScientific 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.


Rationale

Monitor v/s, noting elevating temperature, tachycardia (140200bpm), dysrrhythmias, respiratory distress, cyanosis(developi

Manipulation of gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm.


Rationale

Evaluate reflexes periodically. Observe for neuromuscular irritability.

Hypocalcemia with tetany (usually transient) may occur 1-7 days post op and indicates hypoparathyroidism , which can occur as a result in advertent trauma to/ partial to removal of


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 generally require calcium levels. replacement


Rationale

Administer medications as indicated: -Calcium (Gluconate)

-Corrects

-Anticonvulsant

deficiency which is usually temporary but maybe permanent. - Controls seizure activity until


Goal met. Client did not develop injury/tetany during my shift as evidenced by (-) Trousseaus and (-) Chvosteks sign. Goal partially met. Client did not developed tetany but there was presence of body malaise, (-) Trousseaus and (-) Chvosteks sign. Goal not met. Client developed tetany within my shift as

Medical 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 InfectionScientific 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


Rationale

Monitor the following for signs of infection: Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, and exit sites of tubes, drains, or catheters.

Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified at culture.


Rationale

Elevated temperature.

Fever of up to 38 C (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


Rationale

Assess nutritional status, including weight, history of weight loss, and serum albumin.

Stressed proper handwashing

Patients with poor nutritional status may be anergic, or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection. Prevent


Rationale

Include information in preoperative teaching about ways to reduce potential for postoperative infection. Monitor white blood count (WBC).

The client will be knowledgeable about preventing infection by her self. Rising WBC indicates bodys effort to combat pathogens. Very low WBC indicates


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


Risk For Altered Body Nutrition: Less than body requirements R/T Inability to ingest 2o to post - neck surgery. Long-term 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 NutritionScientific ReasonCertain 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:


Rationale

Assess patient condition. Provide food preference with the patients tolerance.

To provide a baseline data for necessary nursing interventions. To increase patients interest with food


Rationale

Assess patients ability to swallow and her eating habits.

Provide small and frequent feedings. Feed patients slowly with water to follow.

To gather info regarding the extent of swallowing that the patient can tolerate and if foods taken are nutritious. To decrease gastric motility that causes clients to feel full thus reducing intake To gradually exercise


Rationale

Promote a pleasant environment for eating. Weigh patient regularly.

Appetite may improve if environment is conducive to eating. Monitor nutritional state and effectiveness


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:

Patients Profile Anatomy & Physiology Pathophysiology Medical Management Laboratory Results Drug Study Nursing Care Plan