NURSING CARE PLAN

CUES DIAGNOSIS INFERENCE PLAN OF CARE INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain Thyroglossal Within the 4 hours, the 1. VS taken and recorded 1. Serves as The goal was
Medyo related to post- duct cyst client will report pain is baseline data met. After the 4
masakit yung surgical relieved or controlled hours, the client
nasa leeg ko. incision AEB 2. Obtain assessment of 2. To rule out have reported
As verbalized Removal of cyst pain and investigate worsening of relief of pain
by the patient Verbalization of changes from previous underlying AEB:
relief of pain reports condition/develop
Objective Surgical ment of Di ko na
Cues: Insicion Pain scale of 0-3 out complications masyadong
of 10 where 0-nopain, nararamdama
Pain scale of 1-4- mild pain, 5-7- 3. Accept clients 3. Pain is subjective n ung sakit
4 out of 10 moderate pain, 8-10- description of pain experience and As verbalized
where 0- Damage to skin severe pain cannot be felt by by the patient
nopain, 1-4- tissue others.
mild pain, 5- (-) difficulty in Pain scale of 2
7- moderate swallowing 4. Provide quiet 4. To promote out of 10
pain, 8-10- Inflammatory environment nonpharmacologi where 0-
severe pain process cal pain nopain, 1-4-
With management mild pain, 5-7-
dressing on moderate pain,
neck, dry Acute pain 5. Encourage diversional 5. To distract 8-10- severe
and intact activities attention and pain
(+) difficulty reduce tension
in
swallowing 6. Administer Tramadol as
per doctors order. 6. To maintain
acceptable level
of pain
 CUES DIAGNOSIS INFERENCE PLAN OF CARE INTERVENTION RATIONALE EVALUATION

Subjective: Nausea r/t Within the 2 hours, the 1. Assess other causes of 1. To determine The goal was
Para akong effect of Thyroglossal duct client will be free of nausea. other causes to met.
nasusuka, anesthesia 2o cyst nausea AEB: be managed. After 2 hours,
tsaka nahihilo surgical the client have
ako As removal of Verbalization of been free of
verbalized by thyroglossal Removal of cyst feeling ease from 2. Instruct patient to 2. To prevent nausea
the patient cyst nausea avoid any food and aspiration
fluids until nausea Ok na ako.
Objective: General Normal salivation subside. Hindi na ako
Increase Anesthesia 3. To prevent nasusuka. As
salivation 3. Provide quite stimulation or verbalized by
environment. worsening of the patient.
Nausea nausea

4. To promote
4. Encourage deep, slow relaxation
breathing
5. To limit dwelling
5. Use distraction with on unpleasant
chatting with family. sensation
 CUES DIAGNOSIS INFERENCE PLAN OF CARE INTERVENTION RATIONALE EVALUATION

Subjective: Risk for injury Within the shift, the 1. Assess patients 1. To identify risk The goal was
Medyo r/t general Thyroglossal duct client will be free of muscle strength, gross for falls met.
nahihilo ako anesthesia cyst injury AEB: and fine motor After the shift,
As verbalized effects 2o coordination. the client have
by the patient surgical Verbalization of been free of
removal of Removal of cyst feeling ease from 2. Put side rails up 2. To provide injury
Objective: thyroglossal dizziness protection from
(+) weakness duct cyst falls. Hindi na ako
General (-) weakness nahihilo. As
Anesthesia 3. Provide quite 3. To promote rest verbalized by
environment. and relieve the patient.
weakness
Dizziness
4. Provide clean and 4. To further
hazard free prevent injuries.
Risk for Injury environment.

5. Assist patient in 5. To prevent

activities as tolerated injuries at the
same time
establishing self-
care.