Question

25-year-old female client is being admitted to the postanesthesia care unit (PACU)
following a thyroidectomy for hyperthyroidism. The client had undergone three
months of preoperative treatment with antithyroid medications and iodine
preparations to establish euthyroid status prior to her surgery. At the client's bedside
the nurse has set up a tracheostomy set, endotracheal tube, laryngoscope, and suction
equipment. There are ampules of calcium gluconate on hand. The nurse places the
client in a semi-Fowler's position, and is supporting her head and neck with pillows
and sandbags. The nurse frequently checks the client's vital signs, and assesses her
suture line for strain or bleeding. Once the immediate postoperative period has passed,
the client will be transferred to the surgical ward where she will recuperate and learn
about lifelong thyroid replacement therapy.
a. Why is it important to support the client's head and neck with sandbags and
pillows?
b. Develop a plan of care for this patient including 2 actual and 2 potential

Answer 1

#Answer A#

Client 39 had gone under Thyroidectomy.Place in semi-Fowler's position and support head and neck with sandbags or small pillows.It Prevents hyperextension of the neck and protects the integrity of the suture line.

#Answer B#

@Care plan 1@

Assessment:-

Subjective data:- pt complains of pain at surgical site

Objective data:-

• Reports of pain
• Narrowed focus; guarding behavior; restlessness

Nursing Diagnosis:-

Acute pain Related to Surgical interruption and manipulation of tissues or muscles.

Intervention And Rational:-

A.Assess verbal and nonverbal reports of pain, noting location, intensity (0–10 scale), and duration.

Useful in evaluating pain, choice of interventions, the effectiveness of therapy.

B.Place in semi-Fowler’s position and support head and neck with sandbags or small pillows.

Prevents hyperextension of the neck and protects the integrity of the suture line.

C.Maintain head and neck in a neutral position and support during position changes. Instruct patient to use hands to support the neck during movement and to avoid hyperextension of the neck.

It Prevents stress on the suture line and reduces muscle tension.

D.Keep call bell and frequently needed items within easy reach.

Limits stretching, muscle strain in the operative area.

E.Give cool liquids or soft foods, such as ice cream or popsicles.

Although both may be soothing to sore throat, soft foods may be tolerated better than liquids if patient experiences difficulty swallowing.

F.Administer analgesics and/or analgesic throat sprays and lozenges as necessary.

It Reduces pain and discomfort; enhances rest.

Outcomes:-

Client Reports control of pain.

@Care plan 2@

Nursing Diagnosis:-

• Risk for Ineffective Airway Clearance Realted to Tracheal obstruction; swelling, bleeding, laryngeal spasms.

Interventions and Rational:-

A.Monitor respiratory rate, depth, and work of breathing.

Respirations may remain somewhat rapid, but the development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.

B.Auscultate breath sounds, noting the presence of rhonchi.

Rhonchi may indicate airway obstruction and accumulation of copious thick secretions.

C.Caution patient to avoid bending neck; support head with pillows.

Reduces the likelihood of tension on the surgical wound.

D.Assist with repositioning, deep breathing exercises, and/or coughing as indicated.

Maintains clear airway and ventilation. Although “routine” coughing is not encouraged and may be painful, it may be needed to clear secretions.

E.Suction mouth and trachea as indicated, noting color and characteristics of sputum.

Edema and pain may impair the patient’s ability to clear own airway.

F. Check dressing frequently, especially the posterior portion.

If bleeding occurs, the anterior dressing may appear dry because bloodpools dependently.

G.Keep tracheostomy tray at the bedside.

Compromised airway may create a life-threatening situation requiring an emergency procedure.

H.Provide steam inhalation; humidify room air.

It Reduces the discomfort of sore throat and tissue edema and promotes expectoration of secretions.

Outcomes:-

• Client maintained a patent airway, with aspiration prevented.

@Care plan 3@

Assessmemt:-

Subjective data:-

Patient complains of unability to speaking.

Objective data:-

• Impaired articulation
• use of nonverbal cues such as gestures.

Nursing Diagnosis:-

• Impaired Verbal Communication related to tissue edema ,pain or discomfort.

Nursing Interventions:-

A.Keep communication simple. Ask yes or no questions.

Reduces demand for response and promotes voice rest.

B.Provide alternative methods of communication as appropriate: slate board, picture board. Place IV line to minimize interference with written communication.

It Facilitates the expression of needs.

C.Anticipate needs as possible. Visit patient frequently.

It Reduces anxietyand patient’s need to communicate.

D.Post notice of the patient’s voice limitations at central station and answer call bell promptly.

Prevents patient from straining voice to make needs known or summon assistance.

E.Maintain a quiet environment.

It Enhances ability to hear whispered communication and reduces the necessity for the patient to raise or strain voice to be heard.

Otcomes:-

• Client established a method of communication in which needs can be understood.