THYROIDECTOMY GENERAL HOSPITAL Age: 29 years old Sex: Male ASSESSMENT Subjective Data Objective Data Diagnosis Vital

l signs: Nahihirapan Impaired swallowing T:37C akong PR:76bpm lumunok, as verbalized by RR:18cpm the patient. BP:120/80
mmHg With difficulty of swallowing. Limitation of food volume.

Date: 07-22-xxxx

Plan After 5 hours of nurse-patient intervention, the patient will be able to:
Verbalize understanding of causative or contributing factors. Promote intake.

Interventions

Evaluation Take and record After rendering vital signs. nursing Interventions, Provide patient was able to cognitive cues Demonstrate feeding (e.g., remind methods patient to chew appropriately to the of swallow as patients situation.
indicated. Focus attention on feeding/ swallowing activity and decreasing environmental stimuli.

Second day post thyroidectomy.

Pass food from mouth to stomach easily.

Place food midway in oral cavity and provide mediumsized bite.

2 THYROIDECTOMY GENERAL HOSPITAL Age: 29 years old Sex: Male ASSESSMENT Subjective Data Objective Data Diagnosis Nahihirapan Vital signs: Impaired verbal akong T:36C communication magsalita, as PR:80bpm verbalized by RR:21cpm the patient. BP:120/80mmHg
Speak or verbalized with difficulty. Difficulty of forming words or sentences. Use of non-verbal cues.

Date: 07-22-xxxx

Second day post thyroidectomy

Plan After 8 hours of nurse-patient intervention, the patient will be able to: Establish methods of communication in which needs can be expressed. Participate in therapeutic communication. Demonstrate congruent verbal or non-verbal communication.

Interventions
Maintain a clam unhurried manner. Provide sufficient time for client to respond. Use confrontation skills, when appropriate, within an established nurse-client relationship. Use and assist client/SO(s) to learn therapeutic communication skills of acknowledgeme nt, active listening, and Imessage.

Evaluation After rendering nursing Interventions, patient was able to express and demonstrate communication methods appropriately verbal and non-verbal relative to therapy

Involves family and SO(s) in plan of care as much as possible.

3 THYROIDECTOMY GENERAL HOSPITAL Age: 29 years old Sex: Male ASSESSMENT Subjective Data Objective Data Diagnosis Nahihilo ako, Vital signs: Impaired physical as verbalized mobility T:36.7C by the patient. PR:74bpm RR:21cpm BP:130/90 mmHg Intoleranc e to activity. Decrease strength and endurance Limited range of motion. Difficulty turning. Date: 07-22-xxxx

Plan After 3 hours of nurse-patient intervention, the patient will be able to: Demonstrate techniques/beha viour that enables resumption of activities. Maintain/increase strength.

Evaluation Observe movement After rendering when the client is nursing Interventions, unaware of patient was able to observation. verbalize Encourage understanding of adequate intake of situation/risk factors fluid/nutritious and individual foods. treatment regimen Instruct to place pillows on the side. and safety measures Also was able to Encourage clients maintain and increase involvement in decision making as strength.
much as possible.

Interventions