Lance Xavier Guiseppe V.

Feliciano
III-3 RLE 4
I. Assessment:
Demographics
Hospital No: 13-05-22
Admission No: 14I00457
Name: Cristina Carreon Alvaaz
Age: 60
Sex: F Civil Status: Single
Date of Birth: 07-07-56
Nationality: Filipino
Religion: Roman-Catholic
Address: 1317 Miguelin Street, Sampaloc, Manila
Date of Admission: 09-23-14 Time: 1:29pm
Attending Physician: Dr. R. Montenegro
Resident in Charge: Dr. Bueno / Dr. Lajom
Chief Complaint: Supraclavicular Mass
History
Patient is diagnosed with follicular CA or thyroid s/p right lobectomy with isthmusectomy in 2010. Patient was
asymptomatic with no signs of hypothyroidism or hyperthyroidism during the interval. She did not follow up
and no meds were taken. 8 months PTA, patient noticed a 0.5 cm in diameter mass in the supraclavicular area.
Mass was slowly enlarging, non painful and there were no symptoms associated. FNAB was done in which
showed cytomorphologic finding suspicion for papillary thyroid carcinoma and thyroid function tests showed
normal results. She was advised operation in another tertiary institution. 6 mos PTA, she was given
levothyroxine 50 mg OD and was scheduled for surgery but was deferred due to incidence of hypertension. 3
mos PTA, surgery was again deferred due to hyperthyroidism in which intake of levothyroxine was
discontinued. Thyroid function test during this time was Low TSH and High FT4. She complained of easy
fatigability and choking sensation without palpitation, tremors, cold/heat intolerance, changes in bowel
movement and insomnia. 2 mos PTA, she consulted to our institution and PE during this time was 3x1 cm firm
non-tender fixed mass on right supraclaviclular area and 2x2cm non-tender soft lymph nodes on right
supraclavicular area. UTZ done small right thyroid with diffused parenchymal disease, solid nodule, right
supraclavicular consider lymph node. FT4 and TSH was normal. She was hence scheduled for completion
thyroidectomy.
Admitting Diagnosis: Papillary Thyroid Carcinoma
PCR format on assessment (Review of Systems)
General Survey (-)general weight loss (-) fever (-) sweats (-)insomnia
Cutaneous (-) pruritus
HEENT (+) Occasional dysphagia solid foods
Musculoskeletal (+)Right Knee Pain on Walking

Assessment
Vital Signs
BP: 160/110 ( ) Lying (/) Sitting ( ) Standing
(/) RUE ( ) LUE ( ) LLE ( ) RLE
Rested? (/) Yes ( ) No

Respiratory
Within Normal Limits/No problems noted
Rhythm/effort: ( ) Irregular ( ) Shallow ( ) Deep (
) Retractions
Chest shape: ( ) Barrel ( ) Pigeon ( ) Funnel
Expansion: ( ) Asymmetrical

PR: 89 ( ) Apical (/) RUE ( ) LUE ( ) LLE ( ) RLE

RR: 18 Temp: ___ ( ) Oral ( ) Axillary
( ) Tympanic
Pain Rate: ( ) Yes (/) No
Lung sounds: ( ) Crackles ( ) Fine ( ) Coarse
At rest:
With activity:
Location:
( ) Numeric Scale
( ) Other scale: specify
( ) Wheeze: ( ) Inhalation

Pain onset:
Quality:
Location:
Radiates ( ) Yes; where?

( ) No

What aggravates?
What relieves?
On pain medications? ( ) Yes
Specify
Comments:

(/) No;

Positioning
( ) Sitting (/) Supine ( ) Prone ( ) Side-Lying; location
; HOB: degree
Comments:
Psychosocial

( ) Exhalation
Location:
( ) Rhonchi Location:
( ) Diminished Location:
( ) Absent Location:
Cough: ( ) Yes
(/) No
( ) Nonproductive/Dry
( ) Productive
Sputum: Color
Amount
Consistency
Able to expectorate sputum? ( ) Yes ( ) No
Suctioning? ( ) Oral ( ) Trach ( ) ET
( ) Nasopharyngeal
Specify usual time of occurrence of coughing:
Nasal discharge? ( ) Yes (/) No
Color:
Amount:
( ) Thick consistency ( ) Thin consistency
( ) O2 Inhalation: ( ) NC ( ) Mask ( ) Others;
specify
Regulation:
mL/min;
O2
Humidifier in use? ( ) Yes ( ) No
Comments:

Cardiovascular
Within Normal Limits/No problems noted
Heart rhythm/quality: ( ) Irregular ( ) Regularly
Irregular ( ) Irregularly Irregular
( ) Weak/Thready ( ) Bounding

Mood: (/) Pleasant ( ) Sad

( ) Flat/Indifferent
( ) Anxious ( ) Calm (/) Cooperates with Care
( ) Murmurs: Location
( ) Fearful thoughts ( ) Irritability
Neck/Jugular Vein Distention? ( ) Yes (/) No
Comments: Patient is pleasant during interview as well Peripheral Pulses: ( ) Absent ( ) Unequal
as cooperative with health care providers
( ) Weak; Location:
Capillary Refill: (/) Fingernail ( ) Toenail;
( ) Delayed: < 2secs (site):
Peripheral Vascular (legs): ( ) Pallor ( ) Increased
warmth ( ) Ulcers ( ) Redness
( ) Increased coolness ;
( ) RLE ( ) LLE
Edema: ( ) Non-pitting: Location ( ) Pitting:
( )+1 ( )+2 ( )+3 ( )+4 Location
( ) Peripheral IV Line: ( ) Central IV Line ;
Location
Type

Neurology
Within Normal Limits/No problems noted

Gauge #
Date Inserted:
tubing was changed:
Presence of s/s of: ( ) Infiltration
( ) Inflammation ( ) Infection
Comments:

Date IV

LOC: (/) Alert ( ) Lethargic ( ) Comatose GCS Total:

15 (E=4, V=5, M=6)
Orientation: (/) Person (/) Place (/) Time
(/) Reasoning
Pupils: ( ) Reactive ( ) Non-reactive ( ) Brisk
( ) Sluggish ( ) R ( ) L ( ) Bilateral
Pupillary Size: ( ) Pinpoint ( ) Dilated ; Size: 2mm ( ) R
Gastrointestinal
( ) L (/) Bilateral
Aphasia: ( ) Receptive ( ) Expressive
Within Normal Limits/No problems noted
( ) Both/Global
Coherence of thought processes? (/) Yes ( ) No
Abdomen contour: (/) Round ( ) Flat
( ) Protuberant ( ) Scaphoid
Extremity Weakness: ( ) RUE ( ) LUE ( ) RLE
Bowel sounds x 4 quadrants: ( ) Hypoactive
( ) LLE
( ) Hyperactive ( ) Absent; Location
Extremity Paralysis: ( ) RUE ( ) LUE ( ) RLE
( ) Abdominal Tenderness: Location
( ) LLE
( ) Abdominal Rigidity: Location
Tremors: ( ) Rue ( ) LUE ( ) RLE ( ) LLE
Bowel Movement: date of last
BM:
usual pattern:
Vertigo: ( ) Yes
( ) No
Numbness? Location:
Stool: consistency
color
amount
Comments:
( ) Nausea; frequency
; timing
( ) Vomiting frequency
; amount
color
timing
Presence of abdominal mass? ( ) Yes (/) No
Location:
Comments:
Occasional Dysphagia with solid foods
Eyes and Ears
Within Normal Limits/No problems noted
(
)
Scleral
discoloration?
color:
Genitourinary & Gynecology
location:
( ) Eye drainage? color
amount
odor Within Normal Limits/No problems noted
location
( ) Blurring of vision; location:
Bladder: ( ) Distended ( ) Tender
( ) Eyeglasses ( ) Contact lens
( ) Nystagmus; location:
Strabismus: ( )convergent Kidney: ( ) flank pain
( ) Left ( ) Right
( )divergent ; location:
( ) Hearing difficulty? location:
Urine: color
( )cloudy ( )blood
( )burning ( )diminished stream ( ) incontinent
( ) Ear drainage? color:
( ) Foley Catheter ( ) Condom Catheter
amount:
odor:
location:
( ) Peritoneal ( ) Hemodialysis
Comments:
( ) Cystostomy Tube?
Location:
Discharge from genitalia? ( ) Yes (/) No color
amount
For Female Patient only:
Last Menstrual Period (LMP) date:
(/ ) Menopausal ( ) Pregnancy
Comments:
Musculoskeletal
Within Normal Limits/No problems noted

Muscle tone: ( ) Flaccid/Paralyzed ( ) Atrophy

Location:
Strength: (/) UE (/) LE ( ) Weak ( ) Paralysis ;
Location:
Range of Motion (ROM): ( ) Limited ; Location:
Gait: ( ) Unsteady ( ) Other: specify
( ) Assistive Device: specify
Activity assistance level: ( ) Dependent 100% ( )
Maximal 75% ( ) Moderate 50%
( ) Minimal 25% ( ) Supervision/ Stand-by assist;
no touching of patient
( ) Modified Independence; uses assistive devices
independently plus no touching of patient by others
(/) Independent; no assistive device in use plus no
assistance from others
Comments:
Pain in right knee upon walking
Integumentary
Within Normal Limits/No problems noted
Skin color: ( ) Pale ( ) Jaundice ( ) Cyanotic
Temp/texture/moisture: ( ) Cool ( ) Rough ( ) Moist
( ) Dry
( ) Sweating ( ) Oily
Presence of rash? ( ) Yes (/) No
Location:
Size (cm): length
depth
width
Wound bed color
characteristics
( ) moist ( ) dry
Presence of Wound? ( ) Yes (/) No ;
Location:
Size (cm): length
depth
width
Drainage
; wound bed color
; odor
Dressing, if any:
Presence of Pressure Sore? ( ) Yes (/) No ;
Location:
Stage: ( ) 1 ( ) 2 ( ) 3 ( ) 4;
Eschar? ( ) Yes
( ) No
Size (cm): length
depth
width
Drainage
; wound bed color
; odor
Dressing, if any:
Presence if Incision Site: ( ) Yes (/) No ; Location:
Size (cm): length
depth
width
Drainage
; wound bed color
; odor
Presence of: ( ) Staples ( ) Sutures ( )

Dermabond
Dressing, if any
Comments:
Presence of a Scar on neck. Scar was due to lobectomy
and isthmusectomy last 2010.
Please use drawing below for additional information:
Presence of several palpable mass numbering 4
around the neck

Past Medical History:

(+)HPN (2007)
(+)Arthritis on right knee (2013)
(+)Follicular CA of the thyroid s/p right lobectomy with isthmusectomy (2010)
(-)DM (-) Asthma (-) Allergies

Personal History
1.5 years smoking history
Not an alcoholic beverage drinker
Reports that she has no history on illicit drug use
Family History: (+) Stroke (Mother)
Social History: Occupation: Part time at printing press
Source of Income: Siblings (/) and Self (/)
Primary Care taker: Self and Care giver
Family relationships: Lives with care giver. No close relationship with relatives
Significant Lab and Diagnostic Exams
(June 11, 2014) Thyroid Fuunction via ELISA Method
TEST
Result
Reference Range
TSH
0.10
0.4-5.5
FT4
3.41
0.8-2.0
***TSH levels are within normal levels however FT4 levels are elevated indicating that the patient has possible
hyperthyroidism
.

(July 14, 2014) Ultrasound (outside institution)

Impression:
s/p subtotal thyroidectomy, right
small right thyroid with diffused parenchymal disease
solid nodules, left thyroid and isthmus
solid nodule, right supraclavicular consider lymph node
(Sept. 1, 2014) Ultrasound (UST)
Impression:
There is history of thyroid surgery (s/p lobectomy R)
Confluent solid nodules are seen at the right thyroid bed measuring 0.6x0.6x0.6cm, 0.7x0.7x0.6cm &
0.6x0.5x0.7 cm. Color doppler shows no intralesional blood flow.
Left lobe of the thyroid gland measures 5.3x1.3x1.9 cm with a volume of 6.9 cc. There are multiple
solid nodules seen.
s/p lobectomy right
solid nodules right thyroid bed which may represent residual thyroid or lymph node
Multiple lymph node both cervical and Right Supraclavicular regions
***both ultrasound results indicate a history of past lobectomy, and subtotal thyroidectomy as evidenced by
decreased sized of the remaining thyroid; however,there are of nodules present around the remaining portion of
the thyroid gland and the surrounding tissue. The nodules observed in the ultrasound are possibly the cancer
tumors growing around the thyroid.
Cytopathologic Report
Diagnosis: Anterior neck mass (subcutaneous nodules), fine needle aspiration Biopsy cytomorphology findings
suspicious for papillary thyroid carcinoma
Remarks: Noted history of a solid thyroid nodule on the right lower pole
Suggest Tissue Biopsy for confirmation
***The Cytopathology report suspects that the nodes are most likely papillary thyroid carcinoma but suggest
tissue biopsy for a more definitive result.
Blood 9-24-14
ABO/RH
O POSITIVE
***Blood type is shown to be O+
Immunology 9-13-14
TSH (ECLIA)
1.620 UIU/ml
NOTE:
Specimen Rechecked, results verified
***Within Normal Range

Reference
0.27-4.20

Nurses Notes
9/24/14
8am Pre-Op Care D
A
R

For Completion Thyroidectomy with Bilateral Modified lateral

Neck Dissection tomorrow 7am
Encourage to verbalize thoughts, secure consent as well was
consent for anesthesia.
Patient Amenable

10am Procedure

D
A

11am
R
10pm Pre-Op Care D
A

9/25/14
8am Health-Teaching

For Chest X-Ray

Coordinate with Radiology. Transferred safely.
X-ray Done. Transferred back to FSW safely.
Amenable
For Completion Thyroidectomy with Bilateral Modified lateral
Neck Dissection tomorrow 7am
Started D5NR IL @ 30 gtts/min
NPO @ 12am
asked to wear gown
Secured all consents on the chart
Informed about in-availability of blood reservation
Amenable

D
A
R

For Completion Thyroidectomy with Bilateral Modified lateral

Neck Dissection tomorrow 7am
Maintained on NPO
Encourage deep breathing exercises and verbalize feelings
Amenable

10am-6am

OR Completion Thyroidectomy
with Modified Radical
Neck Dissection

11:10pm

s/p completion thyroidectomy post op ------ Please See PACU Monitoring Sheet
D
Recieved Patient from PACU CD Post-Op
A
Encourage to deep breathe
kept on NPO
Placed on Modified High Back Rest
Monitored for signs of Hypocalcemia, bleeding, infection
R
Amenable

9/26/14
9am

SICU Please see Attached Checklist

Post-Op Care D s/p completion thyroidectomy with bilateral modified radical

neck dissection type III
A
Encourage deep breathing exercises
turn from side to side, reinforce proper body hygiene &
wound care and watched out for untoward signs and
symptoms
R
Amenable

12pm Risk for hypocalcemia D

A

s/p completion thyroidectomy with bilateral modified

radical neck dissection type III
Encouraged to deep breathe and increase calcium intake
& report signs of numbness, check signs and other wound
signs and symptoms

9/27/14
8am Enhanced Nutrition

Amenable

s/p completion thyroidectomy with bilateral modified

radical neck dissection type III
Encouraged to eat prescribed diet, increase Calcium intake
and increase fluid intake as tolerated
Amenable

A
R
10pm Risk for Infection

D
A

R
9/28/2014
8pm Risk for Infection

D
A

R
9/29/2014
8am Continuity of Care

D
A

s/p completion thyroidectomy with bilateral modified

radical neck dissection type III
Encouraged to increase fluid intake
Secured materials for change off dressing
Observed proper Handwashing
Watched out for signs and symptoms of infection
Amenable
s/p completion thyroidectomy with bilateral
modified radical neck dissection type III
Encouraged to increase fluid intake
Secured materials for change off dressing
Observed proper Hand washing
Watched out for signs and symptoms of infection
Amenable
s/p completion thyroidectomy with bilateral
modified radical neck dissection type III
Encouraged mass fluid intake and ambulation
Encouraged to eat prescribed diet and increase Calcium
intake
Instructed to report any untoward signs
Amenable

II. Anatomy and Physiology

Thyroid Gland
The thyroid gland is an H shaped or butterfly shaped gland located in the lower neck in front of the trachea and
between the carotid arteries.
It has two lobes (rounded tissue parts) connected by an isthmus (bridge of tissue) with a rich blood. Parathyroid
glands, which are brownish-yellow bodies of endocrine tissue, are located behind the thyroid gland. The nerves
that supply the voice box (recurrent laryngeal nerve) run behind the thyroid gland in the groove between the
trachea and esophagus (tube between the mouth and stomach. Being an endocrine gland, the thyroid gland does
not have any ducts to carry away the thyroid hormone. The hormone enters the blood stream directly.
The thyroid gland produces and stores the iodine containing thyroid hormone, which helps to regulate:
Body metabolism
Heart rate
Blood pressure
Temperature
Growth and development

Menstrual periods
Muscle and nerve activity

III.Pathophysiology
Papillary carcinoma develops in cells that produce thyroid hormone. It is usually well differentiated (looks like
normal thyroid cells and grows slowly), but tends to be multifocal in nature, that is, occurs in more than one site
in the gland. Papillary carcinoma accounts for about 80% of thyroid cancer. It tends to spread locally into lymph
nodes and adjacent structures. It is important to note that thyroid cancer can produce signs and symptoms
similar to hyperthryoidism.
Cause is unknown but associated with heredity, exposure to chemicals, radiation, iodine, surgery and even
thyroid diseases. It can occur in patients that are euthyroid (no thyroid problems) similar to our patient. The
malignacny enlarges, causes infiltration of the outlying lymph nodes and hypertrophies leading to enlargement
and compression of the throat. This is manifested by palpable nodes and masses on the neck and dysphagia due
to compression. The cancer also displaces and destroys normally functioning thyroid cells this leads to
hyperactivity and abnormal functioning. The abnormality manifested as elevated FT4 and low to normal TSH
indicating Hyperthyroidism. This explains the manifestations of tremors, heat/cold intolerance, insomnia due to
hyperactivity and hyper production of thyroid hormones.
-Signs and Symptoms
easy fatigablity
tremors
occasional dysphagia
heat/cold intolerance
changes in bowel movement
insomnia
palpable nodule on neck

FLOW CHART

IV. Discussion of the OR Procedure

Surgery Performed: Completion Thyroidectomy with Bilateral Modified Radical Neck Dissection Type III
Surgery was performed to remove the remaining thyroid tissue after patient had a partial thyroidectomy back in
2010. Based on the diagnosis the patient has a papillary thyroid carcinoma, the reason the entire thyroid was
removed was to remove cancerous nodules on the thyroid and surrounding tissue. It was not only the thyroid
gland that was removed but subsequent tissue that have been affected by the carcinoma. Lymph nodes were also
excised and all benign nodules that were seen during the operation were also removed.
Hockey Stick Incision

Positive and Negative aspects related to the Surgery

Positive effects of the Surgery include removal of malignant tumors reducing risk of further development and
metastasis, dysfunctional thyroid gland is also removed alleviating symptoms of increased thyroid hormone
levels. There will also be relief of symptoms.
Negative effects of the surgery include hypothyroidism due to the lack of a functional thyroid gland, risk for
shock due to the amount of blood loss that is why patient needs to be on IVF or with Blood Transfusion,
cancerous tumors may not be completely excised and there is still a risk of a remission. In the case of the patient
there was an apparent recurrence of the cancer just four years after the first surgery.
OR Technique with significant discussion
1. GETA
patient was given general anesthesia through an endotracheal tube. Anesthetic agent (Sevorane)
was administered and patient was slowly sedated.
2. Asepsis & Antisepsis
skin preparation was done to sterilize area and prepare it for incision. This is also to prevent
infection.
3. Sterile Drapes
patient was draped properly only exposing site for operation and to avoid contact with other nonsterile areas.
4. Bilateral hockey stick incision
An incision was made on the neck resembling a U shape.
5. creation of superior and inferior platysmal flaps
Flaps help in reconstruction and better wound healing after the skin has been closed after
suturing. This method provides a reliable and easy way to repair the soft tissue defect over the
trachea and revise the scarring deformity left by tracheostomy
6. Midline division of strap muscles followed by dissection of left thyroid lobe
7. Isolation and ligation of left middle thyroid vein
8. Isolation and ligation of left superior thyroid vessel

9. Isolation and ligation of left inferior thyroid vessels followed by identification of recurrent laryngeal
nerve left.
To cut blood supply and prevent bleeding before cutting of the thyroid gland. The thryoid gland
is highly vascular so in order to prevent further loss of blood by ligating instead of immediately
cutting then clamping. This also prevents damage to the laryngeal nerve.
10. Dissection of left thyroid lobe off trachea
The remaining thyroid lobe was removed from it's attachment on the trachea.
11. Excision of Right supraclavicular lymph node on surface of SCM, right
Lymph node resting on the surface of the supraclavicular muscle was removed.
12. Opening of right SCM and transection of Right omohyoid muscle
Supraclavicular Muscle was opened and the right omohyoid muscle was transected in order to
expose underlying tissue (specifically the clavicular lymph nodes).
13. Dissection of level II, III, IV, and V CLN off right IJV
Clavicular lymph node II-IV were removed
Post-op Diagnosis:
Papillary Thyroid carcinoma Stage IVA (T4aN1b(MO)
s/p right lobectomy & isthmusectomy (2010) s/p FNAB (2014)

V. Drug Analysis
Name
Esomeprazole

Mechanism of Action
Anti-ulcer/ proton Proton pump inhibitor
pump inhibitor
that suppresses gastric
acid secretion by specific
inhibition of the H+/K+ATPase in the gastric
parietal cell. The S- and
R-isomers of
esomeprazole are
protonated and converted
in the acidic
compartment of the
parietal cell forming the
active inhibitor, the
achiral sulphenamide. By
acting specifically on the
proton pump,
esomeprazole blocks the
final step in acid
production, thus reducing
gastric acidity. This
effect is dose-related up
to a daily dose of 20 to
40 mg and leads to
inhibition of gastric acid
secretion.

Indication and why was

it given
It was given since the
patient is on an NSAID
therapy of 3 different
drugs. PPI's are also
given to relieve GI
irritation caused by use of
NSAIDs

Relevant and significant

Nursing Care Measures
rash
itching
difficulty breathing or
swallowing
swelling of the face, throat,
tongue, lips, eyes, hands, feet,
ankles, or lower legs
hoarseness
irregular, fast, or pounding
heartbeat
dizziness
muscle spasms
uncontrollable shaking of a part
of the body
seizures
severe diarrhea with watery
stools
stomach pain
fever

Amlodipine

Ciprofloxacin 500

Parecoxib

Calcium Channel
Blocker/Antihypertensive

Antibiotics/
fluoroquinolones

NSAID

Amlodipine is a
dihydropyridine calcium
antagonist (calcium ion
antagonist or slowchannel blocker) that
inhibits the
transmembrane influx of
calcium ions into
vascular smooth muscle
and cardiac muscle.

Patient is a known
Hypotension
hypertensive. Amlodipine
was given to help control Nausea
blood pressure
Dizziness

The bactericidal action of

ciprofloxacin results
from inhibition of the
enzymes topoisomerase
II (DNA gyrase) and
topoisomerase IV, which
are required for bacterial
DNA replication,
transcription, repair,
strand supercoiling
repair, and
recombination.

To prevent infection this

medication was given as
a prophylactic antibiotic
prior to surgery

Cox-2 inhibitor
anti-inflammatory,

Pain management given

via IV for patients who

Bradycardia

Pruritus
Superinfection
Difficulty Breathing
Nausea & Vomiting
GI irritation
fever
GI irritation, bleeding and
perforation

antipyretic and analgesic are unable to take oral

effects is the inhibition of pain medications
Myocardial infraction
prostaglandin synthesis
immediately after surgery
by blocking of the
Stroke
enzyme cyclooxygenase2 (COX-2)
Nausea
Vomiting
Pruritus
Difficulty of Breathing

shortness of breath
chest pains or ankle
swelling appear or worsen
Celecoxib

NSAID

Cox-2 inhibitor
anti-inflammatory,
antipyretic and analgesic
effects is the inhibition of
prostaglandin synthesis
by blocking of the
enzyme cyclooxygenase2 (COX-2)

Patient is diagnosed with GI irritation, bleeding and

arthritis this medication perforation
is given for relief of pain
due to arthritis.
Myocardial infraction
Stroke
Nausea
Vomiting
Pruritus
Difficulty of Breathing

shortness of breath
chest pains or ankle
swelling appear or worsen
Arcoxia

NSAID

Cox-2 inhibitor
For pain due to
anti-inflammatory,
ostheoarthritis
antipyretic and analgesic
effects is the inhibition of
prostaglandin synthesis
by blocking of the
enzyme cyclooxygenase2 (COX-2)

GI irritation, bleeding and

perforation
Myocardial infraction
Stroke
Nausea
Vomiting
Pruritus
Difficulty of Breathing

shortness of breath
chest pains or ankle
swelling appear or worsen

VI. Nursing Care Plans

Pre-Op
Cues and Clues

Nur Dx

Analysis

Goals

Restless

Anxiety
secondary to
impending
surgical
procedure

Patient may be
anxious of the
outcome of the
surgery and the
dangers that
might happen
during the
procedure. This
may be due to
problems in
understanding the
operation or
simply fear of
possible
complications.

Lessen anxiety

Cold hands
pallor in hands

Implementation

Ask patient to
verbalize fears
Patient verbalizes and concerns
fears and
concerns

Listen to
concerns

Use therapeutic
communication

Provide calm
peaceful setting

Risk Factors:
Transportation on
stretcher
Valuables given
to relatives
ID band in place

Risk for injury

Injury to the
patient may
occur during
transfer. The
patient might
accidentally fall
off the stretcher
due to anxiety
and moving
about. Some
patient may slip
inside the OR
items that can
cause
electrocution
such as jewelry,
etc. Worse is
wrong patient
underwent a
wrong operation.

No incidence of
falls

Secure bed rails

Right procedure
and care rendered
to patient
Check chart,
proper
patient id and
endorsement and confirm identity
sign in procedure of patient

Rationale

Evaluation

Allowing patient
to verbalize
concerns can help
them express
their grievances
and relieve their
anxiety

Patient able to
express concerns
Patient calm and
relaxed

Nurses and
health care
providers must
listen and address
concerns
Using proper
communication
and supportive
attitude help
clients cope with
stress and
anxiety.
A noisy
environment will
only agitate the
patient, thus we
need to provide a
soothing and
relaxing
environment in
order to help
calm down the
patient.
This will prevent
incidence of falls
during transport
from Ward to OR
suite

Endorsement and
sign in done

This will ensure

that we have the
right patient
going for the
right procedure

The right patient

was transferred
and prepared for
the right
procedure.

Ensure that all

valuable are
secured by
significant others

This prevents
incidence of loss
items and prevent
injury from
electrocution or
even sepsis
(especially with
jewelry)

Receive

Obtaining

No incidence of
falls

endorsement
from ward nurse

endorsement
from the nurse in
charge of the
initial care of the
patient will
inform you of
any special
needs, treatment
and specific
concerns the
patient may have.

Implementation

Rationale

Evaluation

Operating
sponges or even
hemostat clamps
that accidentally
fell should
immediately be
discarded since
they could carry
microorganisms
that can
contaminate the
sterile field and
cause infection if
introduced into
the patient.

Maintain sterility
of the field and
instruments

Intra-Op
Cues and Clues

Nur Dx

Risk factors

Risk for infection Possible

contamination of
the sterile field
and instruments
by improper
aseptic technique
such as not
reporting fallen
instruments,
sponges or use of
contaminated
instruments,
sutures and
needles could
cause infection.

Instruments
inserted inside
patient
Instruments fell
from the sterile
field
Personnel
moving and
coming in
contact with
sterile area

Risk factors
Long Operation
time

Packing of
Operating

Goals

Maintain sterility Discard

of the field and
contaminated
instruments
materials
No contaminated
materials
introduced to
patient
Prevent infection

No contaminated
materials
introduced to
patient
No incidence of
infection
Asepsis
maintained

Risk for
thrombus
formation

Due to long
No incidence of
periods of time
embolism
without
ambulation and
the possibility of
stasis, blood may
pool and start to
form clots inside
the deep veins of
the legs. When
they are
dislodged as an
embolism they
may cause
obstruction or
worse an
infarction leading
to severe injury
to the patient.

If possible, ask
medical
personnel to
avoid moving
around
unnecessarily

Some providers No incidence of

are moving
embolism
around the
operating room
suite, this can
lead them to
touch unsterilized
or contaminated
areas and could
cause a breech in
the sterility of the
incision,
instruments, etc.
In order to
prevent this, ask
them to remain in
position unless
necessary. If need
to move, they
may go backback of each
other and observe
asepsis.

Risk for injury

During surgery,
instruments,
sutures and
sponges are

Do instrument
counting

Instruement
counting during
the prepping of
the patient and

Prolonged lying
on the OR Table

Risk factors:

Analysis

No instruments,
sponge, sharps
left inside

No instruments,
sponge, sharps
left inside

Sponge inside

inserted within
the patient, when
left or attention
was drawn away
from them, they
may be forgotten
and would be left
inside when the
incision is finally
closed. This
could lead to
internal trauma,
sepsis and the
like.

use of blades,
needles and small
other instruments
Use of Cautery
Machine

all instruments all

accounted for

initial and final

counts provide a
tally of
instruments and
materials used.
This prevents
incidence of
leaving
instruments
inside.

no incidence of
electrical injury

Observe for
where sponges,
are inserted or
placed

During surgery,
the scrub nurse
should observe
where sponges,
hemoclips,
clamps are place
because they may
be forgotten and
accidentally left
inside during
closing.

note fallen
instruments

Accounting and
discarding of
downed
instruments keep
the tally and
maintain sterility
of items used in
the surgery

use grounding
pad

During the
procedure there is
an evident use of
a cautery
machine. The use
of grounding pad
provides
protection from
possible
electrical injury.

all instruments all

accounted for
no incidence of
electrical injury

Post-Op
Cues and Clues

Nur Dx

Secretions
Risk for
forming in mouth aspiration
secondary to
Absent gag reflex sedation
Effects of
Sedation
Pulse oximetry
95%

Analysis

Goals

Implementation

Rationale

Evaluation

Due to effects of
the narcotic agent
used to place the
client in a
sedated state,
there is a
possibility that
secretions may
be aspirated due
to
unconsciousness
and apparent
absence of the

No incidence of
aspiration

Suction
secretions

Since patient is
still unable to
swallow or is still
under the effects
of anesthesia,
suctioning
secretions would
prevent incidence
of aspiration and
depression of
breathing.

No incidence of
aspiration

maintian
adequate
oxgenation
Limit incidence
of nausea and
vomiting

Pulse oximeter
100%
No incidence of
post-operative
nausea and
vomiting

gag reflex

Evaluate return
of gag reflex

Once patient is
already awake
and gag reflex
returns aspiration
is less likely to
occur since
patient is already
conscious and
can swallow
rather than retain
saliva or
secretions in the
airway.

Give anti-emetics Giving

prophylactic antiemetics can help
prevent incidence
of vomiting.
Give NSAIDS, or
corticosteroids
for pain relief
instead of opioids

PostThyroidectomy
and BMRND
Difficulty
speaking/
inability to
modulate speech

Impaired verbal
communication
secondary to
thyroidectomy.

Surgical
procedure has left
subsequent
trauma over the
adjacent areas
such as the voice
box. This causes
problems in voice
articulation
especially in the
immediate postoperative phase.
Presence of a
penrose drain
within the neck
also contributes
to the problem

Assist client in
establishing a
method of
communication
Client is able to
communicate
needs

Opioid
medications
cause severe cns
depression which
could lead to
further incidence
of nausea and
vomiting which
could eventually
lead to aspiration.

Inform client that Client may be

impairment is
anxious because
only temporary
prior to the
operation she
was able to speak
now she isn't.
The health
professionals
must inform the
patient that this is
a temporary
effect of the
surgery and
would improve
with time.
Provide pen and
paper

In order to
facilitate
communication
in case the
patient needs
something, being
resourceful like
giving a pen and
paper or a board
could help
facilitate
communication
for the moment.

Client was able to

choose and
establish a means
of
communication
Client able to
communicate
needs

VII. References

Perioperative nursing: principles practice

Brunner and Suddarth's Textbook of Medical-Surgical Nursing
Mosby's Pocket Dictionary 6th Edition
Davis' Drug Guide for Nurses
Nurse's Pocket Guide Diagnoses, Prioritized Interventions and Rationales