23 December 2011

Nursing Diagnosis Nursing Intervention Thyroid Cancer

Thyroid cancer is a malignancy of the thyroid, which has 4 types, namely: papillary, follicular, anaplastic and medullary. Thyroid cancer rarely causes enlargement of the gland, more often causes a small growth (nodules) in the gland. Most thyroid nodules are benign, thyroid cancer is usually curable.

Thyroid cancer often limits the ability to absorb iodine, and limit the ability to produce thyroid hormone, but sometimes produce enough thyroid hormone, causing hyperthyroidism.

Nursing Diagnosis for Patient with Thyroid Cancer
Commong Nursing Diagnosis That Could Be Found In Patient With Thyroid Cancer:

  • Fear/Anxiety [specify level]
  • Acute/chronic Pain
  • Risk for ineffective Airway Clearance
  • Impaired verbal Communication
  • Risk for Injury, [tetany, thyroid storm]
  • Deficient Knowledge [Learning Need] regarding Condition, prognosis, treatment, self-care, and Discharge needs

1. Acute Pain

Related to:
pressure / swelling of the tumor nodule

Possible evidenced by:

  • The existence of the neck pain may spread to the orbital area.
  • Pain scale of 0-10
  • Looks withstand pain
  • There is pain in swallowing, and difficulty swallowing

Expected results:

  • Pain reported lost / reduced
  • Pain scale of 0-2
  • Looks relaxed
  • No complaints when swallowing
  • Nursing Interventions :
  • Observe for signs of pain both verbal and nonverbal
  • Teach and encourage patients to use relaxation techniques
  • Collaboration of analgesic

2. Ineffective airway clearance

Related to:

  • Tracheal obstruction due to tumor mass pressure
  • Laryngeal spasm
  • Accumulation of secretions

Possible evidenced by:

  • Difficulty breathing
  • Difficulty of removing secret
  • Complained of shortness of breath
  • Above normal respiration

Expected results:

  • There is no difficulty breathing
  • Secret easy exit
  • Do not complain shortness of breath
  • Respiration in the normal range (16-20)
  • Nursing Intervention :
  • Monitor respiratory frequency, depth of breathing
  • Auscultation of breath sounds, record a Ronchi
  • Assess the dyspneu, stridor and cianosis
  • Note the quality of the respiratory
  • Practice deep breathing or coughing and effective as indicated
  • Investigate the secret accumulation and exploitation done with caution as indicated
  • Collaboration of Ogsigen therapy if necessary

3. Impaired Verbal Communication

Related to:
Injury to vocal cords
Laryngeal nerve damage
Tissue edema
Possible evidenced by:
Talk husky / can not speak

Expected results:

  • Being able to create a method of communication in which needs can be understood
  • Nursing Interventions :
  • Periodically examine the function of speech
  • Keep communication simple
  • Provide a suitable alternative method of communication
  • Anticipation of needs as possible