Problem #1: Acute Pain related to presence of surgical incision on the mandibular area Assessment S> O> the

patient manifested: - Guarding behavior - Expressive Behavior - Distraction behavior - Protective Gestures - Observed evidence of pain Nursing Diagnosis Acute Pain related to presence of surgical incision on the mandibular area as evidenced by guarding, expressive and distraction behavior, protective gestures and observed evidence of pain Scientific Explanation In performing Parotidectomy, surgical incision is expeted. By which, the incision itself causes direct irritation to the nerve endings by chemical mediators released at the site such as bradykinin. This irritation will send signal to the cortex and thalamus of the brain to produce pain perception. Planning Short Term: After 2 -4 hours of nursing interventions the patient will be able to verbalize nonpharmalogic methods in relieving pain Long Term: After 2 4 days of nursing interventions the patient will be able to demonstrate use of relaxation techniques, skills and diversional activities as indicated for individual situation Interventions Rationale Expected Outcome

Short Term: Independent: Independent: The patient shall 1. Establish Rapport 1. To gain the trust have able to verbalize and cooperation nonpharmalogic methods in relieving pain 2. Assess patient s general 2. To know and condition determine Long Term: The patient shall patient s needs have able to demonstrate use of relaxation 3. To obtain techniques, skills baseline data for and diversional future activities as indicated for 4. To determine individual situation the source/origin of pain for necessary interventions

3.

Monitor and record

Vital Signs 4. Determine the presence of possible pathophysiological/physical cause of pain

May Manifest: - Change in muscle tone - Diaphoresis - Changes in Vitals Signs

5. Note client s locus of 5. Individual s with external locus of control control may take little or no responsibility for pain management

6. Use pain rating scale 6. To evaluate the appropriate for age. severity of pain 7. Observe signs of nonverbal cues/pain behaviors and other defining characteristics as noted 8. Note when pain occurs 7. May be only indicator present when the client is unable to verbalize

8. To mediate prophylactically, as appropriate

9. Provide comfort 9. To promote non measures, quiet pharmalogical pain environment and calm management activities 10. Instruct/encourage to 10. to distract use relaxation techniques attention and reduce tentsion 11. Review procedures and 11. to reduce tell the client when treated concern of the may cause pain unknown and associated muscle tension 12. Encourage adequate rest periods 12. To prevent fatigue

13. Discuss with SO ways 13. To prevent in which they can assist the reoccurrence of client and reduce the condition

precipitating factors Dependent: 14. Administer analgesics, 14. To maintain acceptable level as indicated of pain.

Problem #2: Impaired Skin Integrity r/t mechanical factors like surgery secondary to Parotidectomy Assessment S- O>patient manifested: >post-operative incision near at the side of the ear down to the neck patient may manifest: >disruption of skin surface and layers >invasion of body structures >presence of edema, tenderness, redness, and discharges >altered sensation Nursing Diagnosis Impaired Skin Integrity r/t mechanical factors like surgery secondary to Parotidectomy Scientific Explanation Surgical incision of the incision near at the side of the ear down to the neck secondary to parotidectomy brings about the disruption of skin layers, altering its normal structure, making it vulnerable to pain upon any untoward movement and possible entry of foreign microorganisms. Planning Short-term: After 2-3h of nursing interventions, the patient will participate in preventive measures and treatment regimen. Long-term: After 3 days of nursing interventions, the patient will demonstrate behaviors to promote healing and to prevent further tissue injury. 4. provide care AM Interventions 1. establish rapport 2. assess patient s condition Rationale Expected Outcome 1. to gain trust Short-term: of the patient The patient shall have able to in 2. to note any participate abnormaliti preventive and es within measures treatment regimen. the patient Long-term: 3. to obtain The patient shall baseline have demonstrated data behaviors to promote healing and to prevent 4. to promote further tissue injury. comfort and prevent contaminati on 5. to prevent infection

3. monitor & recorded v/s

5. keep the area clean and dry 6. remove wet lines promptly 7. instruct the SO/patient to eat foods rich in CHONs such as steamed fish and legumes when patient is on

6. to provide comfort

7. for

faster

DAT diet

wound healing 8. to obtain pharmacolo gical benefits 9. to prevent excessive fluid loss

8. encourage SO/patient to follow medical regimens 9. regulate IVF

10. due given

meds

10. to provide pharmacolo gical pain managemen t 11. to satisfy the needs of the patient

11. attend needs of the patient

Problem #3: Disturbed sensory perception related to altered status of sense organ as evidenced by ingestion of anesthesia secondary to parotidectomy Assessment Nursing Diagnosis Disturbed sensory perception related to altered status of sense organ as evidenced by ingestion of anesthesia secondary to parotidectomy Scientific Explanation General anesthesia refers to inhibition of sensory, motor and sympathetic nerve transmission at the level of the brain, resulting in unconsciousness and lack of sensation. Change in the amount or patterning of incoming stimuli accompanied by diminished, exaggerated, distorted, or impaired response to such stimuli Planning Short term: After 2- 4 hours of nursing interventions the patient will be able to use resources effectively and appropriately Long term: After 2 4 days of nursing interventions the patient will be able to be free of injury Interventions Rationale Expected Outcome

S> O> The patiend manifested: - Change in response to stimuli - Restlessness - Changed in sensory acuity - Altered sense of balance

Short term: Independent: Independent: The patient shall 1. Establish Rapport 1. To gain the trust have able to use and cooperation resources effectively and 2. Assess patient s 2. To know and appropriately general condition determine patient s needs Long term: The patient shall 3. Monitor and 3. To obtain baseline have able to be free record Vital Signs data for future of injury 4. To assess client s 4. identify client sensation status with condition that can affect sensing, interpreting stimuli 5. To note whether 5. Determine response is response to painful appropriate to stimuli stimulus, immediate or delayed 6. To relax the patient giving calm 6. Provide safety environment measures as needed 7. To determine

7. Describe where affected areas of the body are when moving client

necessary intervention when affected area is located 8. Enhances commitment to abd continuation of plan, optimizing outcomes

8. Provide explanations of the plan care with the client, involving SO as much as possible

Dependent: Dependent 9. To identify 9. Monitor drug medications with regimen effects or drug interactions that may cause/exacerbate perceptual problems 10. Discuss drug regimen, noting possible toxic side effects of both prescription and OTC drugs 10. Prompt recognition of side effects allows for timely intervention/change in drug regimen

Problem #5: Risk for Infection related to surgical incision near the at side of the ear down to the neck secondary to parotidectomy Assessment S> O>the patient manifested: Surgical incision sited at the side of the ear down to the neck Tissue destruction With increased exposure to environmen tal pathogens Nursing Diagnosis Risk for Infection related to surgical incision near the at side of the ear down to the neck secondary to parotidectomy Scientific Explanation With the presence of surgical incision leading to tissue damage, it can lead to certain amounts that can expose a part of the incision site making the microorganisms open to lead inside the tissue or organ. This then gives potential risk to the patient leading to growth of microorganisms and then tangles with the body s defense and immune stimulation, then after all complications, it then leads to infection. Planning Short term: After 2 3 hours of nursing interventions the patient will be able to verbalize understanding of individual s causative/risk factors Expected Outcome Short term: Independent: Independent: The patient shall 1. Establish Rapport 1. To gain the trust have able to and cooperation verbalize understanding of 2. Assess patient s 2. To know and individual s general condition determine patient s causative/risk needs factors Interventions Rationale

3. Monitor and 3. To obtain baseline Long term: record Vital Signs data for future The patient shall Long term: have able to achieve After 2 3 days of 4. Note risk factors 4. For occurrence of timely wound nursing infection healing interventions the patient will be able 5. Observe for 5. To assess and to achieve timely localized signs of locate the possible wound healing infection at insertion origin of infection sites of invasive lines, sutures, surgical incisions/wounds 6. Stress proper hand hygiene by all caregivers between therapy 7. Provide isolation, indicated 6. To give first line of defense when giving care to the client

for 7. Reduces risk of as cross contamination

8. Maintain sterile 8. To prevent technique for all infection or invasive procedures contamination of the wound 9. Change surgical/other wound dressings, as indicated 9. For proper wound hygiene to fasten the healing period prevent potential grown of pathogens 10. To meet the metabolic need of the client for better wound healing and resistance to infection

10. Review individual nutritional needs, appropriate exercise program and need for rest

Problem #4: Risk for Imbalanced Body Temperature related to post anesthesia effect

Assessment

Nursing Diagnosis Risk for Imbalanced Body Temperature related to post anesthesia effect

S> O>the patient manifested: post operational anesthesia effect altered metabolic rate

>may manifest hyperthermia hypothermia

Scientific Explanation In susceptible individuals, these drugs can induce a drastic and uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if not treated quickly. Malignant hyperthermia (MH) or malignant hyperpyrexia is a rare life-threatening condition that is usually triggered by exposure to certain drugs used for general anesthesia; specifically, the

Planning Short Term: After 2 4 hours of nursing interventions the patient will be able to maintain body temperature within normal range Long Term: After 2 4 days of nursing interventions the patient will be able to demonstrate behaviors monitoring and maintaining appropriate body temperature

Interventions

Rationale

Expected Outcome

Independent: 1. Establish Rapport

2. Assess patient s general condition

3. Monitor and record Vital Signs 4. Determine if present illness/condition results to exposure to environmental factors, surgery trauma 5. Assess nutritional status

Independent: Short Term: 1. To gain the trust The patient shall have able to and cooperation maintain body 2. To know and temperature within determine patient s normal range needs Long Term: 3. To obtain The patient Shall baseline data for have able to demonstrate future behaviors monitoring and 4. Helps to maintaining determine the appropriate body scope of temperature intervention that may be needed

6. Monitor/maintain

5. To determine metabolism effect on the body temperature and to identify foods or nutrient deficits that affect

volatile anesthetic agents and the neuromuscular blocking agent, succinylcholine. In susceptible individuals, these drugs can induce a drastic and uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if not treated quickly.

comfortable ambient environment 7. Monitor core body temperature

metabolism 6. To relax the patient for normal core temperature monitoring 7. For assessment and to establish necessary interventions 8. To prevent reoccurrence

8. Discuss potential problem/individual risk factors with client 9. Instruct in appropriate self care measures

9. To be self reliant and knowledgeable in existing condition