About
Removal of cervical lymph nodes , muscles, and internal jugular vein in the neck area which may include reconstruction with a flap.
Assess
Surgical incision, range of motion of neck, understanding of procedure, pain, vitals, respiratory status.
Complications
Nerve damage, Infection, hemorrhage, impaired communication, fistula, respiratory compromise.
Diagnosis
- Knowledge deficit related to surgical procedure.
- Ineffective airway clearance related to surgical procedure.
- Impaired verbal communication related to surgical intervention.
- Acute pain related to actual tissue damage from surgical procedure.
- Risk for infection related to surgical procedure.
- Nutrition less than body requirements related to impaired oral intake.
Goals
- The client will maintain a patent airway.
- The client will remain free from infection.
- The client will state understanding of pre-, intra-, and post-operative plan of care
- The client will correctly perform coughing and deep breathing exercises.
- The client will be able to identify alternative ways to communicate during the post-operative period.
- The client will indicate a pain level less than 4 on a 0-10 scale.
Interventions
- Assess respiratory status including lung sounds, pulse-ox, and ventilation settings as indicated.
- Monitor for stridor, which could indicate severe respiratory compromise.
- Maintain suction equipment at the bedside and perform suctioning frequently to remove excess secretions.
- Monitor pain levels, surgical incision site ( color, pallor, warmth, capillary refill) for infection and signs of impaired circulation.
- Administer pain medications as prescribed.
- Encourage communication via alternative methods if patient unable to speak.
- Maintain patient on aspiration precautions.
- Teach client methods to improve mobility, facilitate coughing, enhance communication, and reduce pain.
- Monitor drainage containers and record output.
- Initiate and maintain nutritional support.
- Report any signs or symptoms of complications immediately to physician.
ليست هناك تعليقات:
إرسال تعليق