79731886 NCPs for Parotidectomy

7/31/2019 79731886 NCPs for Parotidectomy

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Problem #1:Acute Pain related to presence of surgical incision on the mandibular area

Assessment Nursing

Diagnosis

Scientific

Explanation

Planning Interventions Rationale Expected Outcome

S>

O> the patient

manifested:

- Guardingbehavior

- ExpressiveBehavior

- Distractionbehavior

- ProtectiveGestures

- Observedevidence of

pain

May Manifest:

- Change inmuscle tone

- Diaphoresis- Changes in

Vitals Signs

Acute Pain

related to

presence of

surgical incision

on the

mandibular area

as evidenced by

guarding,

expressive and

distraction

behavior,

protective

gestures and

observedevidence of pain

In performing

Parotidectomy,

surgical incision is

expeted. By which,

the incision itself

causes direct

irritation to the

nerve endings by

chemical mediators

released at the site

such as bradykinin.

This irritation will

send signal to the

cortex andthalamus of the

brain to produce

pain perception.

Short Term:

After 2 -4 hours of

nursing

interventions the

patient will be able

to verbalize

nonpharmalogic

methods in

relieving pain

Long Term:

After 2 4 days of

nursing

interventions thepatient will be able

to demonstrate

use of relaxation

techniques, skills

and diversional

activities as

indicated for

individual situation

Independent:

1. Establish Rapport

2. Assess patients general

condition

3. Monitor and recordVital Signs

4. Determine the presence

of possible

pathophysiological/physical

cause of pain

5. Note clients locus of

control

6. Use pain rating scale

appropriate for age.

Independent:

1. To gain the trust

and cooperation

2. To know and

determine

patients needs

3. To obtain

baseline data for

future

4. To determine

the source/origin

of pain for

necessary

interventions

5. Individuals with

external locus of

control may take

little or no

responsibility for

pain management

6. To evaluate the

severity of pain

7. May be only

indicator present

when the client is

unable to verbalize

Short Term:

The patient shall

have able to

verbalize

nonpharmalogic

methods in

relieving pain

Long Term:

The patient shall

have able to

demonstrate use

of relaxation

techniques, skillsand diversional

activities as

indicated for

individual situation


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7. Observe signs of

nonverbal cues/pain

behaviors and other

defining characteristics as

noted

8. Note when pain occurs9. Provide comfort

measures, quiet

environment and calm

activities

10. Instruct/encourage to

use relaxation techniques

11. Review procedures and

tell the client when treated

may cause pain

12. Encourage adequate

rest periods

13. Discuss with SO ways

in which they can assist the

client and reduce

precipitating factors

Dependent:

14. Administer analgesics,as indicated

8. To mediate

prophylactically, as

appropriate

9. To promote nonpharmalogical pain

management

10. to distract

attention and

reduce tentsion

11. to reduce

concern of the

unknown and

associated muscle

tension

12. To prevent

fatigue

13. To prevent

reoccurrence of

the condition

14. To maintainacceptable level

of pain.

Problem #2: Impaired Skin Integrity r/t mechanical factors like surgery secondary to Parotidectomy

Assessment Nursing Diagnosis Scientific Explanation Planning Interventions Rationale Expected Outcome


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S-

O>patient

manifested:

>post-operative

incision near at the

side of the ear down

to the neck

patient may

manifest:

>disruption of skin

surface and layers

>invasion of body

structures

>presence of

edema, tenderness,

redness, anddischarges

>altered sensation

Impaired Skin

Integrity r/t

mechanical factors

like surgery

secondary to

Parotidectomy

Surgical incision of

the incision near at

the side of the ear

down to the neck

secondary to

parotidectomy brings

about the disruption

of skin layers, altering

its normal structure,

making it vulnerable

to pain upon any

untoward movement

and possible entry of

foreign

microorganisms.

Short-term:

After 2-3h of

nursing

interventions, the

patient will

participate in

preventive

measures and

treatment regimen.

Long-term:

After 3 days of

nursing

interventions, the

patient will

demonstratebehaviors to

promote healing

and to prevent

further tissue injury.

1. establish rapport2. assess patients

condition

3. monitor &recorded v/s

4. provide AM care5. keep the area

clean and dry

6. remove wet linespromptly

7. instruct theSO/patient to eat

foods rich in

CHONs such as

steamed fish and

legumes when

patient is on DAT

diet8. encourage

SO/patient to

follow medical

regimens

9. regulate IVF10.due meds given11.attend needs of

the patient

1. to gain trust ofthe patient

2. to note anyabnormalities

within the

patient

3. to obtainbaseline data

4. to promotecomfort and

prevent

contamination

5. to preventinfection

6. to providecomfort

7. for fasterwound healing

8. to obtainpharmacologic

al benefits

9. to preventexcessive fluid

loss

10. to providepharmacologic

al pain

management

11. to satisfy theneeds of the

patient

Short-term:

The patient shall

have able to

participate in

preventive

measures and

treatment regimen.

Long-term:

The patient shall

have demonstrated

behaviors to

promote healing

and to prevent

further tissue injury.

Problem #3: Disturbed sensory perception related to altered status of sense organ as evidenced by ingestion of anesthesia secondary to parotidectomy

Assessment Nursing Diagnosis Scientific

Explanation



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S>

O> The patiend

manifested:

- Change inresponse to

stimuli

- Restlessness- Changed in

sensory acuity

- Altered sense ofbalance

Disturbed sensory

perception related

to altered status of

sense organ as

evidenced by

ingestion of

anesthesia

secondary to

parotidectomy

General anesthesia

refers to inhibition of

sensory, motor and

sympathetic nerve

transmission at the

level of the brain,

resulting in

unconsciousness and

lack of sensation.

Change in the

amount or

patterning of

incoming stimuli

accompanied by

diminished,

exaggerated,

distorted, or

impaired response tosuch stimuli

Short term:

After 2- 4 hours of

nursing

interventions the


to use resources

effectively and

appropriately

Long term:

After 2 4 days of

nursing

interventions the


to be free of injury

Independent:


2. Assess patients

general condition

3. Monitor and

record Vital Signs

4. identify client

with condition that

can affect sensing,

interpreting stimuli

5. Determine

response to painful

stimuli

6. Provide safety

measures as

needed

7. Describe where

affected areas of

the body are when

moving client

8. Provide

Independent:


and cooperation

2. To know and

determine patients

needs

3. To obtain baseline

data for future

4. To assess clients

sensation status

5. To note whetherresponse is

appropriate to

stimulus, immediate

or delayed

6. To relax the

patient giving calm

environment

7. To determine

necessary

intervention when

affected area is

located

8. Enhances

commitment to abd

Short term:

The patient shall

have able to use

resources

effectively and

appropriately

Long term:

The patient shall

have able to be free

of injury


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explanations of the

plan care with the

client, involving SO

as much as possible

Dependent

9. Monitor drug

regimen

10. Discuss drug

regimen, noting

possible toxic side

effects of both

prescription andOTC drugs

continuation of plan,

optimizing

outcomes

Dependent:

9. To identify

medications with

effects or drug

interactions that

may

cause/exacerbate

perceptual problems

10. Prompt

recognition of side

effects allows for

timely

intervention/changein drug regimen


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Problem #5: Risk for Infection related to surgical incision near the at side of the ear down to the neck secondary to parotidectomy

Assessment Nursing Diagnosis Scientific Explanation Planning Interventions Rationale Expected Outcome

S>

O>the patient

manifested:

- Surgicalincision

sited at the

side of the

ear down to

the neck

- Tissuedestruction

- Withincreased

exposure to

environmen

tal

pathogens

Risk for Infection

related to surgical

incision near the at

side of the ear

down to the neck

secondary to

parotidectomy

With the presence of

surgical incision

leading to tissue

damage, it can lead to

certain amounts that

can expose a part of

the incision site

making the

microorganisms open

to lead inside the

tissue or organ. This

then gives potential

risk to the patient

leading to growth of

microorganisms andthen tangles with the

bodys defense and

immune stimulation,

then after all

complications, it then

leads to infection.

Short term:

After 2 3 hours of

nursing

interventions the


to verbalize

understanding of

individuals

causative/risk

factors

Long term:

After 2 3 days of

nursing

interventions thepatient will be able

to achieve timely

wound healing

Independent:


2. Assess patients

general condition

3. Monitor and

record Vital Signs

4. Note risk factors

5. Observe for

localized signs of

infection at insertion

sites of invasive

lines, sutures,

surgical

incisions/wounds

6. Stress properhand hygiene by all

caregivers between

therapy

7. Provide for

isolation, as

indicated

8. Maintain sterile

technique for all

invasive procedures

9. Change

surgical/otherwound dressings, as

indicated

10. Review

individual nutritional

needs, appropriate

exercise program

and need for rest

Independent:


and cooperation

2. To know anddetermine patients

needs

3. To obtain baseline

data for future

4. For occurrence of

infection

5. To assess and

locate the possible

origin of infection

6. To give first line of

defense when giving

care to the client

7. Reduces risk of

cross

contamination

8. To prevent

infection or

contamination of the

wound

9. For proper wound

hygiene to fasten the

healing period

prevent potentialgrown of pathogens

10. To meet the

metabolic need of

the client for better

wound healing and

resistance to

infection

Short term:

The patient shall

have able to

verbalize

understanding of

individuals

causative/risk

factors

Long term:

The patient shall

have able to achieve

timely wound

healing


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Problem #4: Risk for Imbalanced Body Temperature related to post anesthesia effect

Assessment Nursing Diagnosis Scientific

Explanation


S>

O>the patient

manifested:

- post operationalanesthesia effect

- altered metabolicrate

>may manifest

- hyperthermia- hypothermia

Risk forImbalanced Body

Temperature

related to post

anesthesia effect

In susceptibleindividuals, these

drugs can induce a

drastic and

uncontrolled

increase in skeletal

muscle oxidative

metabolism, which

overwhelms the

body's capacity to

supply oxygen,

remove carbon

dioxide, and regulate

body temperature,

eventually leading to

circulatory collapse

and death if not

treated quickly.

Malignant

hyperthermia (MH)

or malignant

hyperpyrexia is a

rare life-threatening

condition that isusually triggered by

exposure to certain

drugs used for

general anesthesia;

specifically, the

volatile anesthetic

agents and the

neuromuscular

Short Term:After 2 4 hours of

nursing

interventions the


to maintain body

temperature within

normal range

Long Term:

After 2 4 days of

nursing

interventions the


to demonstrate

behaviors

monitoring and

maintaining

appropriate body

temperature

Independent:


2. Assess patients

general condition

3. Monitor and

record Vital Signs

4. Determine if

present

illness/condition

results to exposure

to environmental

factors, surgery

trauma

5. Assess nutritional

status

6. Monitor/maintain

comfortable

ambient

environment

Independent:


and cooperation

2. To know and

determine patients

needs

3. To obtain

baseline data for

future

4. Helps to

determine the

scope of

intervention that

may be needed

5. To determine

metabolism effecton the body

temperature and to

identify foods or

nutrient deficits

that affect

metabolism

6. To relax the

Short Term:

The patient shall

have able to

maintain body

temperature within

normal range

Long Term:

The patient Shall

have able to

demonstrate

behaviors

monitoring and

maintaining

appropriate body

temperature


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blocking agent,

succinylcholine. In

susceptible

individuals, these

drugs can induce a

drastic and

uncontrolled

increase in skeletal

muscle oxidative

metabolism, which

overwhelms the

body's capacity to

supply oxygen,

remove carbon

dioxide, and regulate

body temperature,

eventually leading to

circulatory collapseand death if not

treated quickly.

7. Monitor core

body temperature

8. Discuss potential

problem/individual

risk factors with

client

9. Instruct in

appropriate self

care measures

patient for normal

core temperature

monitoring

7. For assessment

and to establish

necessary

interventions

8. To prevent

reoccurrence

9. To be self reliant

and knowledgeable

in existing condition

Documents

79731886 NCPs for Parotidectomy