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Nursing diagnosis CA posterior cricoid - Coggle Diagram
Nursing diagnosis CA posterior cricoid
Risk of airway obstruction due to cricoid have mucus
Pathophysiology
The patient has a lump on the left side, making it difficult for the person to breathe and also have thick mucus. and he was unable to cough herself because he was weak and exhausted.
Data support
S:
O: Observe the patient's breathing sounding full of mucus.
The patient said she could not breathe.
Goal
To allow the patient to breathe more efficiently
Evaluation criteria
Hb Hct normal
Consciousness does not decrease
Capillary refill < 2 s.
Oxygen Saturation between 95-100%
No symptoms of restlessness, rapid breathing, shortness of breath
blood pressure 100/60-120/80 millimeter of mercury
Vital signs: 60-100 pulses/min, 16-22 breaths/min.
Nursing intervention
Observers breathing, oxygen saturation
Measure 02 saturation every 4 hours to see the oxygen saturation in Ignoring symptoms of restlessness, confusion, rapid breathing, faster heartbeats, notice.
Assess the general condition, vital signs every 4 hours for assessment and surveillance.change of patient
Set up a 30-degree head lying position to promote the expansion of the exchange area. efficiently change the gas in the lungs
Take care of Suction to expel phlegm and secretions and help
effective breathing
Pain at the right arm to the shoulder due to physical illness
Goal
The patient had reduced pain.
Data support
S: The patient said she has pain
O: Observer the patient's discomfort from the pain
Evaluation criteria
The patient has a brighter face. more comfortable
No symptoms of pain, such as restlessness fast pulse sweat a lot
Vital signs: 60-100 pulses/min, 16-22 breaths/min,
Blood pressure 100/60-120/80 millimeter of mercury
Nursing intervention
Take care to receive painkillers tamol 50 mg prn q 6hrs accordingly.
Treatment plan and symptom monitoring It is an opioid drug. (Non-narcotic) analgesic action inhibits pain signals that enter the brain to bind to the opioid.
receptor to suppress pain After the patient has received the drug, the rate should be assessed.
Breathe if the respiratory rate is <16 breaths/minute and consciousness
Assess the level of pain. by looking at facial expressions movement
of the body, the contraction of the muscles from the stretching and bending of the arms, breathing
Provide an environment that is conducive to relaxation, quiet, without excessive noise.
Go, don't turn on the light too bright. so that the patient gets a restful sleep
enough
Assess vital signs every 4 hours to assess and monitor the level of
severity of pain
Take care of patients with Absolute bed rest to prevent pain stimulation.
Pathophysiology
Myocardial ischemia is perhaps the best known example of interstitial pain. It can be uncomfortable above your chest, pain in your shoulder, in your arm, or even your left hand.
3.Malnrutrition
Evaluation criteria
The patient received food according to the treatment guidelines.
No complications
Goal
Improved nutrition
Data support
S: -
O: observed the skinny patient
Nursing intervention
Check the abdominal tube feeding plan.
Assess for pain around the feeding tube, if severe pain, report to doctor for analgesic treatment.
Wash your hands thoroughly or use Waterless for 20-30 seconds and wear gloves.
Keep the posture in a comfortable position. Keep your head elevated at least 45 degrees.
BD 1.5:1 600ml x 4feed
Check food residues by using a Syringe irrigate size 50 ml. connected to the feeding tube. Gently pull the cylinder to suck out the gastric content, if more than 100 ml, feeding time should be delayed 1-2 hours.
When the food runs out Add about 30-50 cc of water or according to treatment guidelines.
Clean and keep the equipment tidy.
Wash hands thoroughly or use Waterless for 20-30 minutes.
Position the patient in a comfortable position.
Record I/O
Take care around the feeding hose.
Thai female age 60 year-old
CC: Refer from Chonburi Hospital for RT.
PI:
3-month PTA the patient go to Laemchabang Hospital are lumps and intermittent pain of Lt neck anterior
At Laemchabang Hospital the patient CT neck with contrast suspected thickening size 1.6x1.5 cm at posterior false vocal cord could be mass then was refer Chonburi Hospital
At Chonburi Hospital biopsy Lt. neck mass found that squamous cell carcinoma, non-keratinizing, moderately it deafferented then refer to Chonburi Cancer Hospital
At Chonburi Cancer Hospital FOL mass at posterior cricoid size 2-3cm
PH: U/D HT treatment with medication amlodipine 10mg 1 tap after meal 1time per day.