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Thyroidectomy NCP

The patient, Anacleta Bacaron, has been diagnosed with a non-toxic goiter. She reported difficulty swallowing but could eat porridge. Her vital signs were stable and the dressing on her neck was dry and intact. The nurse's diagnosis was imbalanced nutrition due to inability to eat or swallow properly. The goal was for the patient to ingest enough food within 8 hours to meet nutritional needs. Nursing interventions included monitoring vitals and intake/output, promoting fluid intake, assessing swallowing ability, promoting rest, and giving anti-emetic drugs before meals. However, after 8 hours the patient still vomited despite an appetite and anti-emetic medication.

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2K views1 page

Thyroidectomy NCP

The patient, Anacleta Bacaron, has been diagnosed with a non-toxic goiter. She reported difficulty swallowing but could eat porridge. Her vital signs were stable and the dressing on her neck was dry and intact. The nurse's diagnosis was imbalanced nutrition due to inability to eat or swallow properly. The goal was for the patient to ingest enough food within 8 hours to meet nutritional needs. Nursing interventions included monitoring vitals and intake/output, promoting fluid intake, assessing swallowing ability, promoting rest, and giving anti-emetic drugs before meals. However, after 8 hours the patient still vomited despite an appetite and anti-emetic medication.

Uploaded by

kzbreakerr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Name of Pt: Bacaron, Anacleta

Diagnosis: Multiodular non toxic goiter


Time/Date Assessment Nsg. Diagnosis Goal of Care Nsg. Interventions Evaluation
August 29,
2014

7-3 shift
Subjective: medyo lisod
mulunok pero makaya man
nako mukaon basta lugaw






Objective:
BP: 120/80, temp: 36.6 C,
pulse: 81, RR: 18, with post
of dressing @ anterior
neck dry and intact.

Imbalanced
Nutrition: less than
body requirements
r/t inability of clients
to enter or swallow
food.
Within 8 hours of
nursing intervention,
the patient will be
able to ingest foods
in order to restore
optimum nutritional
status, to meet the
body requirements
and to promote
health.
1.) Monitor VS.

2.) Monitor
Intake and
Output.

3.) Promote
adequate fluid
intake.

4.) Determine
and evaluate
the ability to
chew and
swallow food.

5.) 6.) Promote
rest

6.) 7.) Administer
anti emetic
drugs or as
ordered by
the physician
before meal.
Within 8 hours of
nursing intervention,
the patient displayed
good appetite but
still vomited even
taking anti-emetic
drug.

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