Nursing Care Plan for Goiter - Assessment and Diagnosis

Nursing Assessment and Nursing Diagnosis for Goiter

Goiter (struma), is a swelling of the thyroid gland, which can lead to a swelling of the neck or larynx (voice box). Goitre is a term that refers to an enlargement of the thyroid (thyromegaly) and can be associated with a thyroid gland that is functioning properly or not.

A person with goiter can have normal levels of thyroid hormone (euthyroidism), excessive levels (hyperthyroidism) or levels that are too low (hypothyroidism).

A symptom is something the patient feels or reports, while a sign is something other people, including the doctor detects. For example, a headache may be a symptom while a rash may be a sign.

Some patients may have goiter and not know it because they have no symptoms.

The main symptom for a person with goiter is swelling of the thyroid gland. This may eventually become a noticeable lump in the throat. The patient may be more aware of it - a visible swelling at the base of the neck - when looking in the mirror and shaving or putting on makeup.

The following symptoms may also exist when a person has goiter:
  • Hoarseness (voice)
  • Coughing more frequently than usual
  • A feeling of tightness in the throat
  • Swallowing difficulties (less common)
  • Breathing difficulties (less common)
Nursing Care Plan for Goiter

Nursing Care Plan for Goiter - Assessment and Diagnosis

In implementing the nursing care, the authors use the guidelines as a basis for solving the nursing care of patient problems scientifically and systematically, which includes the step of assessment, nursing diagnosis, nursing Interventions and evaluation.


Assessment

Assessment is the first step in the nursing process as a whole in order to get the data or information needed to determine the health problems faced by patients through interviews, observation, and physical examination include:

a. Activity / rest
Subjective data: insomnia, muscle weakness, impaired coordination, severe fatigue.
Objective data: muscle atrophy.

b. Elimination
Subjective data: urine in large amounts, changes in the faeces, diarrhea.

c. Ego integrity
Subjective data: experiencing severe stress both emotionally and physically.
Objective data: emotional instability, depression.

d. Food / fluid
Subjective data: sudden weight loss, increased appetite, eat a lot, eat often, thirst, nausea and vomiting.
Objective data: thyroid enlargement, goiter.

e. The pain / comfort
Subjective data: orbital pain, photophobia.

f. Breathing
Subjective data: increased respiratory frequency, tachypnea, dyspnea, pulmonary edema (the crisis thyrotoxicosis).

g. Security
Subjective data: intolerance to heat, excessive sweating, allergic to iodine (may be used in the examination).
Objective data: the temperature rises above 37.40 C, diaphoresis, smooth skin, warm and reddish, thin hair, shiny and straight, eksoptamus: retraction, conjunctival irritation and watery, pruritus, erythema lesion (common in pretibial) is a very severe.

h. Sexuality
Data subyktif: decreased libido, bleeding slightly or not at all, impotence.


After all the data collected, further divided into two groups:

a. subjective data
Subjective data include: coordination disorder insomnia, changes in the pattern of elimination, the ability to handle the pressure (stress), weight loss, increased appetite, orbital pain, respiratory frequency increases, the power adjustment to heat and cold, decreased libido.

b. objective data
It is characterized by muscle atrophy, emotional instability, depression, thyroid enlargement, goiter, increased temperatures above 37.40 C, diaphoresis, nature and characteristics of the body, including hair quality situation and the state of the eye.


The next step is determining the nursing diagnosis is a statement and a real or potential problem, based on the data collected.


Nursing Diagnosis for Goiter

Nursing diagnosis in patients with goitre especially post surgery can be formulated as follows:

1. Risk for Ineffective Airway Clearance related to obstruction of the trachea, swelling, bleeding and laryngeal spasm,
characterized by:
Subjective data: pain swallowing, painful wound.
Objective data: breathing fast and deep, there are secretions / mucus.

2. Impaired Verbal Communication related to vocal cord injury / damage to the larynx, tissue edema, pain, discomfort,
characterized by:
Subjective data: swelling of the throat tissues, pain in the wound, the patient does not feel comfortable, pain swallowing.

3. Risk for Injury / tetany related to the surgery, stimulation of the central nervous system,
characterized by:
Subjective data: rapid breathing (tachypnea), wound pain.
Objective data: increased body temperature, tachycardia, cyanosis, convulsions, numbness, and infection of the surgical wound.

4. Acute Pain related to the surgery of the tissue / muscle and postoperative edema,
characterized by:
Subjective data: ask, ask for information, statements misconceptions.
Objective data: do not follow the instructions / complications that can be prevented.

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