Assessment

Nursing diagnosis

Rationale

Goals & objectives

Nursing intervention Independent Minimize patients risk of infection by: Washing hands before and after providing care.

Rationale

Evaluation

February 3, 2009 7:00 pm Subjective:

risk for infection related to decrease in effectiveness of the bodys physical barriers associated with an open wound and bilateral removal of tonsils

Objective: Temp: 37C s/p tonsillectomy

Intact skin and mucous membrane are the bodys first line of defense against microorganisms. Bacteria can penetrate can cause the infection when the skin becomes crack and broken (e.g. surgery) furthermore the tonsils act as part of the immune system to help protect against infection. In particular, they are believe to be involves in helping fight off pharyngeal and upper respiratory tract infections that is why removal of tonsils decreases the power of immune system and allows the person to be more susceptible to infection.

After 8 hours of nursing intervention the patient will be able to remain free from signs and symptoms of infection as evidenced by: 1. patients temperature within normal range 2. Absence of signs of infection like swelling, increased pain or purulent drainage.

Hand washing is the single best way to avoid spreading pathogens.

After 8 hours of nursing intervention, GOAL WAS MET. The patient remained free from signs and symptoms of infection as evidenced by: 1. 37C 2. Absence of signs of infection like swelling, increased pain or purulent drainage.

Wearing gloves to

maintain asepsis when providing direct care. Monitor temperature at least every 4 hours and record. Report elevation immediately.

Gloves offer protection when handling wound dressing or carrying out various treatments. Sustained temperature elevation after surgery may signal onset of pulmonary complications, wound infection or dehiscence.

Factors that increases risk of infection - Crowded places - Eating raw foods Dependent:

These measures allow patient to participate in care and help patient modify lifestyle to maintain optimum health.

Administer antibiotics
Fundamentals of Nursing by Kozhier and Erbs volume 1 8th edition

as ordered by the physician each patient about

To prevent transmission of infection.

 Instruct patient will take Augmentin 625 mg per cap T.I.D as prescribed by the physician

Assessment February 3, 2009 3:00 pm Subjective: After operation masakit at saka uncomfortable yung pakamdam, as written by the patient. Objective: Pain characteristics: Quality- aching Severity- 7/10 (scale of 0-10, with 10 being the most severe) -Facial grimace -Dysphagia -Reluctance to move and staying flat on bed

Nursing diagnosis Acute pain related to surgical procedure (post-operative Bilateral tonsillectomy)

Rationale Acute pain is directly related to tissue injury and resolves when tissue heals. It may be caused by a stimulus such as trauma to body tissues that directly irritates the pain receptors causing inflammation (e.g. surgery).

Goals & objectives After 8 hours of nursing intervention, the patient will manifest increased level of comfort as evidenced by the ff: 1.pain scale will be reduced from 7/10 to less than 4/10 2. absence of facial grimace 3. patient will be able to rest comfortably.

Nursing intervention Independent 1. Instruct patient not to eat rough and spicy foods such as rice, pepper, peas, corn, nuts., seasonings, foods with garlic pepper or chili. 2. Instruct patient to refrain - talking - coughing

Rationale

Evaluation

It can cause vasodilation that could lead to bleeding. Talking and coughing can cause great pressure on the area which can lead to bleeding. This helps stimulate closure of gating mechanism in the spinal cord and blocks the transmission of pain impulses. It also decreases pain by promoting relaxation. Fatigue can decrease the clients threshold and tolerance for pain and thereby heighten the perception of pain. If the client is well-rested, she after experiences decrease pain and increase effectiveness of pain management measures.

After 8 hours of nursing intervention. GOAL was MET, patient manifest increased level of comfort as evidenced by the ff: -pain scale of 2 -absence of facial grimace -patient was able to rest comfortably

Fundamentals of Nursing by Kozier and Erb 8th edition Vol. 2 pp.11901191

3. Encourage use of relaxation techniques : - low rhythmic breathing, - back rubs - repositioning.

4. Minimize environmental activity and noise to promote rest. - proper lighting - quite environment - cool ventilation

Analgesics are thought to interfere with the

transmission of pain impulses by inhibiting prostaglandin synthes. Dependent 1. Administer analgesics arcoxia 125mg D.O. PRN as ordered.

Nursing diagnosis

Rationale

Goals & objectives

Nursing intervention

Rationale

Evaluation

Assessment February 2, 2009 7:00 pm Subjective: Natatakot ako para bukas kasi hindi naman natin alam kung magiging maayos lahat Objective: -scheduled OR on February 3,2009 at 10:00 am -decreased concentration -dysphagia Fundamentals of Nursing by Kozier and Erb 8th edition Vol. 2 p. 1004 Fear related to surgical procedure and anticipated post operative discomforts and complications Fear is an emotional response to threats or danger. It is a basic survival mechanism occurring in response to a specific stimulus such as pain or the threat of pain. After 3 hours of patient teaching and nursing intervention, client will: 1.patient will be aware about the procedures and is ready to go through it. 2. share her thoughts and feelings about the impending surgery and its anticipates effects such as post-operative pain, halitosis, and inflammation. 3. verbalize an understanding of the possible complication of surgery such as bleeding and infection as well as the management to prevent these to occur. Independent 1. Establish rapport. To gain clients trust and cooperation. After 3 hours of patient teaching and nursing intervention, GOAL WAS MET, client: 1. Told the nurse she fully understood the surgical procedure and is ready to go through it.. 2. Shared her thoughts and feelings about the impending surgery and its anticipates effects such as post-operative pain, halitosis, and inflammation. 3. Verbalized an understanding of the possible complication of surgery such as bleeding and infection as well as the management to prevent these to occur.

2. Maintain a calm, supportive, confident manner when interacting with the client. . 3. Encourage questions and clarification of information provided. 4. Instruct client in relaxation techniques and encourage participation in diversional activities such as: -deep breathing -pursed lipsing -games -listening to music

Sense of abandonment can exacerbate fear.

To help reduce clients anxiety. To promote relaxation technique and to help reduce clients anxiety.

Nursing Care Planning Guides by Susan Puderbaugh Ulrich 6th edition

Assessment February 4, 2009 10:00 am Subjective: Gusto ko pa matuto tungkol sa sakit ko at operasyon para matulungan ko sarili ko as verbalized by the patient Objective: -exhibited enthusiasm in listening

Nursing diagnosis

Rationale Presence of cognitive information related to a specific topic sufficient for meeting health related goals and can be strengthened

Goals & objectives After 8 hours of patient teaching and nursing intervention the patient will be able to have additional knowledge as manifested by: 1. Exhibit responsibility for own learning and seek answers to questions 2. Verbalize understanding of information to develop individual plan to meet health care needs/goals 3. Verbalize post operative tonsillectomy care

Nursing intervention Independent 1. Verify clients level of knowledge about post operative care

Rationale

Evaluation After 3 hours of patient teaching and nursing intervention, GOAL WAS MET, client was able to have additional knowledge as evidenced by: 1. Exhibited responsibility for own learning and seek answers to questions 2. Verbalized understanding of information to develop individual plan to meet health care needs/goals 3. Verbalized post operative tonsillectomy care

Post op care and treatment, readiness for enhanced knowledge related to removal of bilateral tonsils

2. Ascertain preferred
methods of learning -auditory -visual -interactive 3. provide health teaching:

1. Provides opportunity to assure accuracy and completeness of knowledge base for future learning 2. Identifies best approaches to facilitate learning process 3. To enhance patients knowledge about proper post operative care

1. Do not use aspirincontaining medication for 14 days after surgery. Do not use any medications during the 10- to 14-day post-op period that the physician did not prescribe. Many medications will contain aspirin, ibuprofen, or related

compounds that can cause bleeding because of their effects on blood clotting. It increases your chances of bleeding. 2. Avoid acidic beverages such as citrus drinks and tomato juice for up to two weeks post-op. 3. Adults should avoid alcohol for 10 days post-op. It can cause bleeding, pain, and dehydration. 4. At discharge, prescription will be given: a. ANTIBIOTIC S -Take them until they are GONE. They will help decrease pain, mouth odor, fever and the chances of bleeding. b. PAIN MEDICATIO N - Don't be exceptionall y brave. You are given

the medication for a tease it hurts to have surgery. 5. Avoid frequent coughing and clearing of the throat. It can cause bleeding. 6. It is common for there to be a bad breath-odor after tonsillectomy. This can be decreased by abundant fluid intake. 7. If you look in the back of your throat after surgery, you will see white material in the location where your tonsils were. It looks like a bad infection. This is expected. Think of it like a scab soaked in saliva. Also, you may notice a little numbness of the tongue for awhile after surgery. This will go away. 8. It is common for the pain in the throat to be also referred to the ears. Do not be

4. For additional information and for patients satisfaction

misled into thinking this represents an ear infection - it does not. 9. Fever is a common sequelae to tonsillectomy. You will be on antibiotics already. There is Arcoxia in the pain medication. Make sure that you continue to take lots of clear fluids. If the fever remains high for several hours, watch for signs of dehydration. 10. It is common to have an increase in pain after 4- to-6-days following surgery. Don't be concerned, it doesn't mean something is wrong. Treat it with pain medication. 4. Provide sources/ references about post operative tonsillectomy care

Assessment

Nursing Diagnosis

Rationale

Goals and Objective

Nursing Intervention

Rationale

Evaluation

February 3, 2009 8:00 pm Subjective: Hirap ako lumunok dahil sa opera ako as written by the patient. Objective: Observed evidence of difficulty in swallowing Hyperextension of the head during and after meals

Impaired swallowing related to removal of bilateral tonsils

Deficit in oropharyngeal structure or function provide abnormal functioning of the swallowing mechanism p. 538 NANDA p.599-600 medical and surgical nursing 11th edition

After 8 hours of nursing interventions the client will be able to swallow effectively as evidence by:

Verbalize understanding of causative/ contributing factors Demonstrate feeding methods appropriate to the individual situation like soft cold diet Maintain adequate hydration as evidence by moist mucous membranes and individually appropriate urine output.

Independent: Inspect oropharyngeal cavity for edema, inflammation, alter integrity of oral mucosa, adequacy of oral hygiene Record current weight/ recent changes Suction oral cavity Encourage rest period before meals Avoid milk products and chocolate

To prevent further complication

After doing the 8 hours of nursing intervention the client was able to swallow effectively as evidenced by: Verbalized oropharyngeal cavity for edema, inflammation, altered integrity or oral mucosa and adequacy of oral hygiene Demonstrated feeding methods appropriate to the individual situation like soft cold diet Maintained adequate hydration as evidenced by moist mucous membranes and individually appropriate urine output.

To prevent aspiration To removed excessive secretions To minimize fatigue Which may thicken oral secretions To enhance comfort To prevent infections

Dependent: Provide analgesics prior to feeding Give antibiotics

Nurses Pocket Guide

by Doenges, Moorehouse, Murr 9th edition pg.512-514