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Nursing Care Plan

Nursing Diagnosis and Interventions

Decreased Cardiac Output related to Cardiogenic Shock

Friday, April 24, 2015

Nursing Care Plan for Cardiogenic Shock

Nuyrsing Diagnosis : Decreased cardiac output related to changes in myocardial contractility / inotropic changes.

Characterized by:
Systolic arterial pressure less than 90 mmHg (absolute hypotension) or at least 60 mm Hg under basal pressure (relative hypotension), postural changes were recorded from the bed to sitting up, rapid pulse is not strong or weak, irregular, extra heart sound S3 or S4 may indicate heart failure or lowering an ventricular contractility, symptoms of skin tissue hypoperfusion; diaphoresis (moist skin), pale, cold acral, cyanosis, veins on the backs of the hands and feet collapse, mental function disorders, anxiety, revolt, apathy, confusion, decreased consciousness and coma, urine output of less than 30 ml / h (oliguria).


1. Auscultation BP. Compare both hands and measure with sleeping, sitting, standing, if possible.
Rational: Hypotension may occur in connection with ventricular dysfunction, myocardial hypoperfusion and vagal stimulation. However, hypertension is also a common phenomenon, possibly related to pain, anxiety, catecholamine expenses, and or previous vascular problems. Orthostatic hypotension (postural) may be associated with complications of infarction.

2. Evaluation of the quality of the pulse as indicated.
Decreased cardiac output causes decreased weakness / strength of the pulse. Suspected irregularity dysrhythmias, which require further evaluation.

3. Record the sound S3, S4
S3 occurs in CHF but also looks at the failed mitral (regurgitation) and left ventricular work overload accompanied by severe infarction. S4 may be associated with myocardial ischemia, ventricular stiffness, and pulmonary or systemic hypertension.

4. Record the voice murmur / friction.
Shows disruption of normal blood flow in the heart, is not a good example valves, damage to the septum, or papillary muscle vibration / chordae tendineae. Friction with infarction is also associated with inflammation, examples of pericardial effusion and pericarditis.

5. Monitor heart rate and rhythm. Record dysrhythmias via telemetry.
Frequency and heart rhythm that responds to medication and activities in accordance with the occurrence of complications / dysrhythmias (premature ventricular contraction particular or heart block), which affects the function of the heart or increase ischemic damage. Beats / fibrillation acute or chronic coronary artery may look at or involvement valve and possibly a pathological condition.

6. Provide tools and emergency medicine.
Coronary occlusions sudden, lethal dysrhythmias, infarct expansion and worsening conditions of shock is a condition that trigger cardiac arrest, which require immediate life-saving therapy.

7. Collaboration in the provision of supplemental oxygen, as indicated.
Increase the amount of oxygen preparations for myocardial demand.

8. Collaboration to maintain the way in IV as indicated.
Track patents essential to the delivery of emergency medicine at the dysrhythmias and chest pain.

9. Collaboration on re-examination of the ECG, chest x-ray, laboratory data examination (cardiac enzymes, GDA, electrolytes).
ECG may provide information with respect to the progress / improvement of cardiogenic shock, ventricular function status, electrolyte balance and the effects of the drug.
Chest x-ray may show pulmonary edema in connection with ventricular dysfunction.
Cardiac enzymes Events can monitor the progress of the patient, presence of hypoxia showed the need for additional oxygen, electrolyte balance exemplarily hypo- / hyperkalemia very large effect on heart rhythms and contractions.

10. Collaboration in the provision of anti dysrhythmias as indicated, and when used in the installation of aids / maintain pacemaker.
Dysrhythmias, usually on the basis symptomatic except for PCV, which often threaten prophylactically.
Pacemaker is a temporary support measures during the acute phase / required permanently on condition that heavy damage conduction system (Such as: Cardiogenic Shock)

Cardiogenic Shock - 6 Nursing Diagnosis

Nursing Care Plan for Cardiogenic Shock


Cardiogenic shock is a clinical syndrome in which the heart is unable to pump blood adequately to meet the metabolic needs of the body due to dysfunction of the heart muscle.

Cardiogenic shock is a syndrome of severe pathophysiological disorders related to abnormal cellular metabolism, which is generally caused by poor tissue perfusion. Also known as peripheral circulatory failure thorough with inadequate tissue perfusion (Tjokronegoro, A., et al, 2003).


Cardiogenic shock is usually caused by a sudden interruption in the function of the heart or as a result of a decrease in contractile function of chronic heart.
such as:
  • Acute myocardial infarction with all its complications.
  • Acute myocarditis.
  • Acute cardiac tamponade.
  • Infective endocarditis.
  • Trauma heart.
  • Spontaneous rupture of chordae tendineae.
  • Cardiomyopathy in the final level.
  • Severe valvular stenosis.
  • Acute valvular regurgitation.
  • Left atrial myxoma.
  • Complications of cardiac surgery.

Predisposing factors

From several studies reported any factors predisposing the onset of cardiogenic shock, such as:
  • Relatively older age (over 60 years).
  • A history of heart trouble.
  • Infarction old and new.
  • AMI progressively widespread.
  • Mechanical complications of AMI (septum torn, mitral insufficiency, ventricular dyssynergy).
  • Myocardial extra factor: drugs penyabab hypotension or hypovolemia.

Clinical manifestations

Main complaints of Cardiogenic Shock:
  • Oliguria (urine less than 20 ml / h).
  • There may be a relationship with AMI (acute myocardial infarction).
  • Substernal pain such as AMI.
Important sign of Cardiogenic Shock:
  • Blood pressure: down less than 80-90 mmHg.
  • Tachypnea and inside.
  • Tachycardia.
  • Rapid pulse, unless there is a block of A-V.
  • Signs of lung dam: wet crackles in both lung bases.
  • Very weak heart sounds, heart sounds often heard III.
  • Cyanosis.
  • Diaphoresis (sweating).
  • Cold extremities.
  • Mental changes.

  • Cardiopulmonary arrest.
  • Dysrhythmias.
  • Multisystem organ fails.
  • Stroke.
  • Thromboembolism.

Nursing Diagnosis for Cardiogenic Shock
  1. Decreased cardiac output related to changes in myocardial contractility / inotropic changes.
  2. Impaired gas exchange related to changes in alveolar-capillary membrane.
  3. Excess fluid volume related to a decrease in renal organ perfusion, increased sodium / water, hydrostatic pressure increase or decrease plasma proteins (absorbs water in the interstitial area / tissue).
  4. Ineffective tissue perfusion related to reduction / cessation of blood flow.
  5. Acute pain is related to ischemic tissues secondary to blockage or narrowing of coronary arteries.
  6. Activity intolerance related to imbalance between the oxygen supply and needs, the ischemic / necrotic myocardial tissue.

Risk for Decreased cardiac output related to Graves' Disease

Saturday, December 6, 2014

Nursing Care Plan for Graves' Disease

Risk for Decreased cardiac output related to uncontrolled hyperthyroidism, hypermetabolism circumstances; increase in workload of the heart; , Changes in venous return flow and systemic vascular resistant; changes in the frequency, rhythm and conduction of the heart.

  • Maintain adequate cardiac output in accordance with the needs of the body,
characterized by;
  • stable vital signs,
  • normal peripheral pulses,
  • normal capillary filling,
  • good mental status,
  • no dysrhythmias.
Nursing Interventions :


1. Monitor blood pressure at rest position, sitting and standing, if possible. Consider the magnitude of the pressure pulse.
R /: Orthostatic hypotension is common or may occur as a result of excessive peripheral vasodilation and decrease in circulating volume. The amount of compensation pulse pressure is a reflection of the increase in stroke volume and a decrease in custody vascular system.

2. Monitor CVP if the patient used.
R /: Provides direct measure circulating volume and more accurately and directly measure cardiac function.

3. Check for chest pain experienced by the patient or the patient complained of angina.
R /: It is a sign of the increased oxygen demand by the heart muscle or ischemia.

4. Assess pulse or heart rate while the patient is sleeping.
R /: Gives a more accurate assessment of the tachycardia.

5. Auscultation of heart sounds, note the presence of an extra heart sounds, the presence of a gallop rhythm and systolic murmur.

6. Monitor ECG, record and note the speed or rhythm of the heart and the presence of dysrhythmias.
R /: Tachycardia is a direct reflection of the heart muscle stimulation by thyroid hormone, dysrhythmias often occurs and can harm the function of the heart or cardiac output.

7. Auscultation of breath sounds, note the presence of abnormal noise.
R /: Early signs of pulmonary congestion associated with the onset of heart failure.

8. Monitor the temperature, provide a cool environment, limit the use of linen / clothing, compress with warm water.
R /: Fever occurs as a result of excessive hormone levels and may increase diuresis / dehydration and cause an increase in peripheral vasodilatation, venous buildup and hypotension.

9. Observe the signs and symptoms of severe thirst, dry mucous membranes, weak pulse, slow capillary filling, decreased urine output, and hypotension.
R /: Fast dehydration can occur which would decrease the volume of circulation and decrease cardiac output.

10. Record the input and output, urine specific gravity record.
R /: Losing a lot of fluids (through vomiting, diarrhea, diuresis, diaphoresis) can lead to severe dehydration, concentrated urine and body weight decreased.

11. Measure weight every day, recommend bed rest, limit unnecessary activity.
R /: Activities will increase the metabolic needs / circulation potentially cause heart failure.

12. Note the presence of a history of asthma / bronchoconstriction, pregnancy, sinus bradycardia / heart block progress to heart failure.
R /: This condition affects the choice of therapy (eg, the use of beta-adrenergic blockers are contraindicated).

13. Observation of antagois adrenergic side effects, such as a decrease in pulse and blood pressure dramatically, signs of vascular congestion / CHF, or cardiac arrest.
R /: One indication to reduce or stop the therapy.

1. Give IV fluids as indicated.
R /: Iv fluid administration through quickly need to improve circulation volume but must be balanced with attention to signs of heart failure / requirement for inotropic agent administration.

2. Give O2 as indicated.
R /: It may also be required to meet the increased metabolic needs / requirements for the oxygen.

4 Nursing Diagnosis for Graves' Disease

Nursing Care Plan for Graves' Disease

Graves' disease is an autoimmune disease in which the thyroid is overactive, producing excessive amounts of thyroid hormone (serious metabolic imbalance known as hyperthyroidism and thyrotoxicosis) and disorder can be on the eyes and skin. Graves' disease is the most common form of thyrotoxicosis common and can occur at any age, is more common in women than men. This syndrome consists of one or more of the picture thyrotoxicosis, goitre, ophtalmopathy (exopthalmus), dermopathy (pretibial myxedema).

Signs and Symptoms:
  • Weight loss.
  • Dyspnea.
  • Exophthalmos.
  • Sweating.
  • Palpitations, tachycardia.
  • Diarrhea.
  • Increased appetite.
  • Muscle fatigue.
  • Tremor (fingers and toes)
  • Oligomenorrhea / amenorrhea.
  • Palms hot and humid.
  • Tachycardia, irregular pulse sometimes because of atrial fibrillation, pulsus celer.
  • Nervous, easily aroused, anxiety, mood changes, insomnia.
  • Mumps (possibly accompanied by the sound pulse and vibration).


Graves' disease therapy directed at the control stage of thyrotoxicosis with antithyroid administration as propylthiouracil (PTU) or Carbimazole. The definitive treatment can be selected between the long-term antithyroid medication, radioactive iodine or detachments with bilateral subtotal thyroidectomy.
The indications for surgery are:
  • Need to achieve definitive results fast.
  • Multinodular goitre with hyperthyroidism.
  • Objections to antithyroid.
  • Solitary toxic nodule.
  • Reduction with antithyroid unsatisfactory.

Nursing Diagnosis for Graves' Disease

1. Risk for decreased cardiac output
related to: uncontrolled hyperthyroidism, hypermetabolism circumstances; increase in workload of the heart; changes in venous return flow and systemic vascular resistant; changes in the frequency, rhythm and conduction of the heart.

2. Fatigue
related to: hypermetabolic with increased energy needs; sensitive stimulation of nerves in connection with disorders of body chemistry.
Supporting Data: reveal very lack of energy to maintain the usual routine, decreased performance, lability / emotional stimuli sensitive, nervous, tense, agitated behavior, damage the ability to concentrate.

3. Risk for imbalanced nutrition less than body requirements related to: increased metabolism (increased appetite / intake with weight loss); nausea, vomiting, diarrhea; relative insulin deficiency, hyperglycemia.

4. Risk for impaired tissue integrity
related to: changes in the mechanism of protection of the eyes; damage eyelid closure / exophthalmos.

Chronic Pain and Risk for Infection - NCP for Nasal Cavity Cancer

Nursing Care Plan for for Nasal Cavity Cancer

Nursing Diagnosis : Chronic Pain related to compression / nerve tissue destruction and inflammation.

Nursing Interventions :
  1. Perform basic comfort measures (repositioning, massage the back) and keep entertainment activities (newspapers, radio).
  2. Teach the client's pain management (relaxation techniques, deep breathing, visualization, guided imagery).
  3. Give appropriate analgesic therapy program.
  4. Evaluation of pain (scale, location, frequency, duration).
Rational :
  1. Increase relaxation and shift the focus of attention the client of pain.
  2. Increasing the participation of the client, actively in solving problems and increasing sense of self-control / autonomy.
  3. Analgesic reducing pain response.
  4. Assessing the development of the client's problem.

Nursing Diagnosis : Risk for infection related to the inadequate secondary defenses and immunosuppressive effects of radiotherapy / chemotherapy.

Nursing Interventions :
  1. Emphasize the importance of oral hygiene.
  2. Teach hand washing techniques to the client and family, emphasize to avoid scraping / touching the wound area in the nasal cavity (area of operation).
  3. Assess the results of laboratory tests which showed a decrease in immune function (leukocytes, erythrocytes, platelets, hemoglobin, plasma albumin).
  4. Give antibiotics according to the treatment program.
  5. Emphasize the importance of protein-rich nutrition in relation to the decrease in endurance.
  6. Assess vital signs and symptoms / signs of infection in the entire body system.
Rational :
  1. Infection of the nasal cavity can be sourced from the inadequate oral hygiene.
  2. Teaches preventive measures to avoid secondary infection.
  3. Assessing the development of cellular immunity / humoral.
  4. Antibiotics are used to treat infections or prophylaxis administered on the client with the risk of infection.
  5. Protein is necessary as a precursor formation of amino acids making antibodies.
  6. Immunosuppressive effects of radiation therapy and chemotherapy can facilitate the emergence of local and systemic infections.

Heart Failure - 5 Nursing Diagnosis and Intervention

Wednesday, November 12, 2014

Nursing Care Plan for Heart Failure 

Nursing Diagnosis : 

1. Impaired Gas Exchange related to changes in the alveolar capillary membrane.
characterized by; dyspnea, orthopneu.

Goal: more effective gas exchange, the results; analysis of blood gases within normal limits and the patient was free from respiratory distress.

Interventions :
  • Auscultation of breath sounds, crackles, wheezing.
  • Instruct the patient to cough effectively and breathe deeply.
  • Keep sitting or bed rest with semifowler position.
  • Collaboration to monitor blood gas analysis and pulse oximetry.
  • Collaboration for the provision of supplemental oxygen as indicated.
  • Collaboration for diuretics and bronchodilators.
Rationale :
  • Monitor the presence of pulmonary congestion for further intervention.
  • Cleaning airway and facilitate the flow of oxygen.
  • Lowers oxygen consumption and maximize lung development.
  • Can be severe hypoxemia during pulmonary edema.
  • Increasing alveolar oxygen concentration to improve tissue hypoxemia.
  • Diuretics can reduce congestion and improve the alveolar gas exchange. Broncodilator for airway dilatation.

2. Activity intolerance related to imbalance between oxygen supply / needs, weaknesses.
characterized by; The patient said wearily continuously throughout the day, shortness of breath on exertion, changes in vital signs during activity.

Goal: Activity achieve optimal limit, as indicated by the patient participating in a desired activity and is able to meet the needs of their own care.

Interventions :
  • Check vital signs before and after the activity.
  • Note the cardiopulmonary response to activity, tachycardia, dysrhythmias, dyspnea, sweating, pale.
  • Provide assistance in self-care activities as indicated. Interspersed periods of activity with periods of rest.
  • Collaboration to implement a cardiac rehabilitation program.
Rationale :
  • Orthostatic hypotension can occur with activity due to the effects of the drug, fluid shifts, influence heart function.
  • The inability of the myocardium, increasing stroke volume during exercise, can increase heart rate, oxygen consumption and increased fatigue.
  • Self care needs without affecting the stress myocardial / excessive oxygen demand.
  • Gradual increase in the activity of the heart and avoid excessive oxygen consumption.

3. Altered Peripheral Tissue Perfusion related to decreased blood flow in the peripheral area secondary to decreased cardiac output.
characterized by; capillary filling is slow, pale or cyanotic nail color.

Goal: peripheral tissue perfusion can be improved (adequate) with expected outcomes:
  • The skin is warm and dry.
  • Strong pulse, capillary refill strong.
  • Normal vital signs.
  • No cyanosis or pale.
Interventions :
  • Monitor vital signs, capillary refill, skin color, skin moisture, edema, peripheral O2 saturation in the area.
  • Increase bed rest during the acute phase.
  • Emphasize the importance of avoiding straining especially during defecation.
  • Collaboration in the delivery of oxygen and inotropic drugs.

Rationale :
  • Knowing adequacy of peripheral perfusion.
  • Restrictions activity lowers oxygen and nutrient needs of peripheral areas.
  • Avoid increasing hypoxia in peripheral tissues.
  • Oxygen increase alveolar oxygen concentration, thereby improving tissue hypoxemia.
  • Inotropic drugs to increase myocardial contractility.

4. Anxiety related to tissue oxygenation disorders, stress due to difficulty in breathing and the knowledge that the heart is not functioning properly.
characterized by; anxiety, fear, worry, stress-related illness, anxiety, anger, irritability.

Goal: The patient does not feel anxious.
with expected outcomes:
  • The patient said that anxiety decreased to a level that can be overcome.
  • The patient demonstrated problem-solving skills and know the feeling.

  • Provide the opportunity for the patient to express feelings.
  • Encourage friends and family to consider patients as before.
  • Tell patient medical programs that have been made to lower the impending attack and increase the stability of the heart.
  • Help the patient a comfortable position to sleep or rest, limit visitors.
  • Collaboration for the administration of sedatives and tranquiliser.

Rationale :
  • Statement of the problem can reduce tension, classify the level of coping and facilitate understanding of feelings.
  • Reassure patients that role in the family and work unchanged.
  • Encourage the patient to control symptoms, improve confidence in the medical program and integrate capabilities in self-perception.
  • Creating an atmosphere that allows the patient to sleep.
  • Help the patient relax until physically able to make adequate coping strategies.

5. Disturbed Sleep Pattern related to waking up frequently secondary to respiratory disorders (tightness, cough).
characterized by; lethargy, insomnia, shortness of breath and coughing during sleep.

Goal: The patient can sleep more comfortably.

Interventions :
  • Raise the head of the bed 20 -30 cm. Chock forearm with a pillow.
  • In patients with orthopnea, the patient is seated on the side of the bed with both feet supported on the seat, head and put on the table bed and lumbosacral vertebrae supported by a pillow.
Rationale :
  • Venous return to the heart is reduced, pulmonary congestion is reduced and the suppression of the liver to the diaphragm is reduced and reducing muscle fatigue shoulder.
  • Reduce difficulty breathing and reduces the flow back to the heart.

Excess Fluid Volume related to Heart Failure

Nursing Care Plan for Heart Failure

Heart failure is often called congestive heart failure is the inability of the heart to pump adequate blood to meet the needs of tissues for oxygen and nutrients.
The term congestive heart failure is most often used in case of heart failure, left and right sides.

Signs and symptoms

In general can be described as follows:

1. Shortness of breath (dyspnea)
Increased pressure filling the left ventricle, causing transudation of fluid into the lung tissue. Decreased compliance (strain) lung add breath work. Sensation of shortness of breath is also caused by decreased blood flow to the respiratory muscles. Initially, shortness of breath occurs when the activity (dyspnea on effort) and if the more heavily congested heart failure also arise when resting.

2. Orthopnea (shortness of the time lying down)
At the time lying down position, then there is a decrease in peripheral blood flow and increase in central blood volume (chest cavity). This resulted in an increase in pressure of the left ventricle and pulmonary edema. Vital capacity also decreases when lying position.

3. Paroxysmal nocturnal dyspnea (PND) is chock suddenly at night with coughing.

4. Tachycardia and palpitations are increased heart rate due to increased sympathetic tone.

5. Coughing
Caused by edema in the bronchus and emphasis bronchus by left atrial dilatation. Cough is often a wet cough and frothy, sometimes accompanied by blood spots.

6. Easy tired
Caused by cardiac output less that inhibits tissue from normal circulation and oxygen as well as decreasing the disposal of catabolism. Also occur due to increased energy used for breathing and insomnia that occurs due to respiratory distress and cough.

7. Cyanosis
Decreased oxygen pressure in peripheral tissues and increased oxygen extraction resulted in an increase in methemoglobin approximately 5 grams / 100 ml causing cyanosis.

8. The presence of heart sounds P2, S3, S4 shows mitral insufficiency due to dilation of the left ventricle or papillary muscle dysfunction.

9. Edema (usually pitting edema) that starts in the feet and ankles and gradually grow up with weight gain.

10. Hepatomegaly (enlarged liver)
Caused by enlargement of veins in the liver. When this process develops, the pressure in the portal vein increases so that the liquid is pushed out of the abdominal cavity called ascites.

11. Anorexia and nausea due to the enlargement of veins and venous stasis in the abdominal cavity.

12. Nocturia (feeling to urinate at night)
Occurs because of renal perfusion and improves cardiac output at rest.

Nursing Diagnosis : Excess Fluid Volume related to the initial load increases, a decrease in cardiac output secondary to heart failure.
characterized by; weight gain, edema, ascites, hepatomegaly, crackles breath sounds, wheezing.

Goal: Excess fluid volume can be reduced to the following criteria:
  • balance intake and output.
  • breath sounds clean / clear.
  • vital signs within normal limits.
  • stable weight.
  • no edema.

Interventions :
  • Monitor urine output, color, quantity.
  • Monitor intake and output for 24 hours.
  • Maintain a sitting position or semifowler during the acute period.
  • Measure weight every day.
  • Assess distended neck and peripheral vessels, edema in the body.
  • Auscultation of breath sounds, record additional sound eg crackles, wheezing. Note the increase in dyspnea, tachypnea, persistent cough.
  • Assess complaints sudden extreme dyspnea, sensation of breathlessness, panic.
  • Monitor blood pressure and central venous pressure.
  • Measure the circumference of the abdomen.
  • Palpation hepatomegaly. Record complaints right upper quadrant abdominal pain.
  • Collaboration in drug delivery.
  • Collaboration to maintain fluid / sodium restriction as indicated.
  • Consultation with nutrition section.
  • Collaboration for monitoring X-ray of the thorax.

  • Monitor decreased renal perfusion.
  • Diuretic therapy can cause a sudden loss of fluid although edema is still there.
  • Supine position increases renal filtration and decrease the production of ADH thus increasing diuresis.
  • Monitor response to therapy.
  • Excessive fluid retention manifested by the damming of the veins and edema formation.
  • Excess fluid volume often lead to pulmonary congestion.
  • Indicates the presence of complications of pulmonary edema or pulmonary embolism.
  • Hypertension and increased central venous pressure showed excess fluid volume.
  • Monitor the presence of ascites.
  • Expansion of the heart causing venous congestion, causing abdominal distension, liver enlargement and pain.
  • Diuretics increase urine flow rate and can inhibit sodium and chloride reabsorption in the renal tubules.
  • Increase diuresis without excessive potassium loss.
  • Lowering the total body water / prevent re-accumulation of fluid.
  • Provide an acceptable diet of patients who meet caloric needs in sodium restriction.
  • Showed changes indicative of improvement / repair the lung.

Thyroid Carcinoma (Post-operative) - 3 Nursing Diagnosis and Interventions

Friday, November 7, 2014

Thyroid Carcinoma (Post-operative)

1. Anxiety related to change in health status.

Goal: be able to reduce stressors that burden individual sources.

  • Anxiety is reduced, evidenced by showing aggression control, control anxiety, coping.
  • Planning coping strategies for situations that create stress.
  • No manifestations of behavior due to anxiety.

1) Observation of the behavior that indicates the level of anxiety.
Rationale: measure the level of anxiety.

2) Monitor the physical response, palpitations, repetitive movements, hyperventilation, insomnia.
Rationale: The effects of excess thyroid hormones cause the clinical manifestations of catecholamine excess events when levels of epinephrine in normal circumstances.

3) Give the antianxiety drugs and monitor their effects.
Rational: helping clients reduce anxiety in the face of the operation.

2. Imbalance Nutrition Less than Body Requirements related to the inability of the client to enter or swallow food.

Goal: the level of available nutrients are able to meet metabolic demands.

  • Fulfilled intake of food, fluids, and nutrients.
  • Tolerance to the recommended diet.
  • Maintaining body mass and body weight in the normal range.
  • Reported adequacy of the level of energy.

1) Auscultation of bowel sounds.
Rationale: hyperactive bowel sounds reflect an increase in gastric motalitas degrade or alter the function of absorption.

2) Monitor input of food every day. And balanced body weight every day and report a decrease.
Rationale: weight loss constantly in a state of sufficient caloric intake is an indication of the failure of antithyroid therapy.

3) Avoid feeding can increase intestinal peristaltic.
Rationale: increased motalitas gastrointestinal tract can cause diarrhea and impaired absorption of necessary nutrients.

4) Collaborate with physicians medications or vitamins that are needed to meet the nutritional needs of the client.

3. Impaired Verbal Communication related to vocal cord injury.
Goal: be able to demonstrate no injury with minimal complications or controlled.

Outcomes: Ability to create a method of communication in which needs can be understood.


1) Anticipate the needs as best as possible, visit the patient regularly.
Rationale: Reduce anxiety and the patient needs to communicate.

2) Maintain a quiet environment.
Rationale: Increasing the capacity of listening and communication slowly lowered loudness should be pronounced the patient to be heard.

3) Advise not to talk continuously.
Rationale: hoarseness and sore throat due to tissue edema or nerve damage due to laryngeal surgery and ends in a few days.

4) Collaborate with physicians medications needed to relieve pain.

Diagnostic Test for Thyroid Carcinoma
Pathophysiology of Thyroid Carcinoma

Diagnostic Test for Thyroid Carcinoma

Diagnostic test for thyroid carcinoma among others :

1. Laboratory tests

Laboratory tests that distinguish benign and malignant tumors, thyroid yet nothing special, except for medullary cancer, namely serum calcitonin examination. Examination of T3 and T4 is sometimes necessary, as in carcinoma of the thyroid, thyrotoxicosis can occur rarely. Human thyroglobulin (HTG) Tera can be used as a tumor marker and better differentiation of thyroid cancer. Although these tests are not typical for thyroid cancer, but this HTG elevation after total thyroidectomy is an indicator of recurrent tumor or regrowth (barsano). Calcitonin levels in serum can be determined for the diagnosis of medullary carcinoma.

2. Radiological

a. An X-Ray
X-ray examination of the soft tissues in the neck sometimes necessary to look at the tracheal obstruction due to tumor suppression and see calcification in the tumor mass. In papillary carcinoma with agencies psamoma, subtle calcifications can be seen, which is accompanied by stippled calcification, whereas in medullary carcinoma, calcification more clearly in the tumor mass. Sometimes calcifications were also seen in metastatic carcinoma in lymph nodes. In the X-ray examination is also used to survey the lung and bone metastases. If there is a complaint of dysphagia, the barium meal photos need to see an infiltration of tumors in the esophagus.

b. ultrasound
Ultrasound is required for solid and cystic tumors. This method is safe and appropriate, but this is likely to be pressed by the presence of aspiration biopsy technique is a technique that is simple and inexpensive.

c. Computerized Tomography
CT scan is used to look at the expansion of the tumor, but can not definitively distinguish between benign and malignant tumors of the thyroid tumor cases.

d. Scintisgrafi
By using an isotropic radio indistinguishable hot nodule and a cold nodule. Regions cold nodule suspected malignancy. This technique is also used as a guide for aspiration biopsy to obtain adequate specimens.

3. Aspiration Biopsy
In this decade of fine-needle aspiration biopsy, widely used as a preliminary diagnostic procedures from a variety of tumors, especially in tumors of the thyroid. Techniques and equipment is very simple, low cost and high diagnostic accuracy. Using needle tube 10 ml, and the needle no.22 - 23 as well as a tool holder, tumor aspirator preparations taken for cytology. Architecture based cytology can be identified papillary carcinoma, follicular carcinoma, anaplastic carcinoma and medullary carcinoma.

Pathophysiology of Thyroid Carcinoma

Thyroid carcinoma usually capture radioactive iodine than normal thyroid gland is located in the surroundings. Therefore, when done scintiscan, nodules will appear as an area with less retrieval, a cold lesion.

Other diagnostic techniques that can be used for differential diagnosis of thyroid nodules are thyroid Ecography. This technique allows to distinguish carefully between solid masses and cystic masses. Thyroid carcinoma usually solid, while the cystic mass is usually a benign cyst.

Thyroid carcinoma should be suspected based on clinical signs if there is only one palpable nodules, hard, basically can not be moved, and is associated with satellite lymphadenopathy.

It was generally agreed that clinical thyroid cancer can be divided into a large group of well differentiated neoplasms, with a slow growth rate and high cure is possible, and a small group of anaplastic tumor with possible fatal. There are four types of thyroid cancer according to morphologic and biological properties: papillary, follicularis, medullary, and anaplastic. (Price, 1995, p: 1078)

Papillary carcinoma of the thyroid gland is usually in the form of hard nodules, single, "cold" on the isotope scan, and "solid" on thyroid ultrasound, which is very different from other parts of the gland. In multinodular goiter, cancer in the form of "dominant nodule" bigger, louder and clear from the surroundings. Approximately 10% of papillary carcinoma, especially in children, with enlarged cervical lymph nodes, but careful examination will usually reveal nodules are "cold" in the thyroid. Rarely, will hemorrhage, necrosis and cyst formation in malignant nodules but on thyroid ultrasonography, there will be a clearly bounded internal echo is useful for semi malignant cystic lesions of "pure cysts" were not malignant. Finally, papillary carcinoma can be found accidentally as a microscopic focus of cancer in the middle of the gland removed for other reasons such as: Graves' disease or multinodular goitre.

Microscopically, the tumor is composed of a single layer of thyroid cells organized in "vascular stalk", with protrusion of the optic disc into the microscopic space such as a cyst. Cell nuclei are large and often contain inclusion bodies pale nucleus intra clear and glassy. Approximately 40% of papillary carcinoma forming a layered spheres classification, often at the end of the optic disc bulge called "psammoma body", is usually diagnostic for papillary carcinoma. This cancer is usually spread by metastasis in the gland and the thyroid gland invasion and local lymph nodes. In elderly patients, they can be more aggressive and invade locally into the muscle and trachea. In stage further, they can spread to the lungs. Death is usually due to local disease, with invasion into the neck, more rarely death could be due to extensive pulmonary metastases. In some elderly patients, a slow-growing papillary carcinoma will begin to grow rapidly and transform into anaplastic carcinoma. Further anaplastic changes are another cause of death from papillary carcinoma, papillary carcinoma secreting lots of thyroglobulin, which can be used as a sign of recurrence or metastasis of cancer.

Follicular carcinoma is characterized by the persistence of small follicles despite bad colloid formation. Indeed, follicular carcinoma can not be distinguished from follicular adenomas except with capsule invasion or vascular invasion. The tumor is slightly more aggressive than papillary carcinoma and spreads either by local invasion or lymph node invasion of blood vessels accompanied by distant metastases to bone or lung. Microscopically, these cells are cuboidal shaped with large nuclei were irregular around the follicle, often containing colloid. These tumors are often still have the ability to concentrate radioactive iodine to form tiroglubulin and rarely, to synthesize T3 and T4. Thus, the function of the thyroid cancer that is almost always a rare follicular carcinoma. These characteristics make these tumors more it is likely to give good results against radioactive iodine treatment. In untreated patients, death due to local extension or distant metastases because the flow of blood with extensive involvement of the bones, lungs, and viscera.

A variant of follicular carcinoma is carcinoma "Hurthle cell" which is characterized by cells alone great with pink cytoplasm containing mitochondria. They behave more like papillary carcinoma unless they are rare radioiodine uptake. Papillary and follicular carcinoma of the mixture is more like a papillary carcinoma. Thyroglobulin secretion produced by follicular carcinoma can be used to follow the course of the disease.

Medullary carcinoma is a disease of the cell C (parafolikular cells) derived from primary branchial body and is able to secrete calcitonin, histaminase, prostaglandins, serotonin, and other peptides. Microscopically, the tumor is composed of layers of cells separated by stained with a red substance. Amyloid is composed of a chain of calcitonin, which are arranged in the pattern of fibrils, or as opposed to other forms of amyloid, which can have a light chain immunoglobulins or other proteins that are deposited with a pattern of fibrils.

Medullary carcinoma is more aggressive than papillary or follicular carcinomas but not as aggressive as undifferentiated thyroid cancer. It extends locally to the lymph nodes and into the surrounding muscles and trachea. Could lymphatic invasion, and blood vessels and metastasis to the lungs and viscera. Calcitonin and Carcinoembryonic antigen (CEA), which is secreted by the tumor is of clinical signs that aid in the diagnosis and follow-up. Approximately one third of medullary carcinoma, is familial, involving multiple nodes (Multiple Endocrin neoplasia type II = MEN II, Sipple syndrome). MEN II is characterized by medullary carcinoma, pheochromocytoma, and multiple neuromas on the tongue, lips, and intestines. Approximately one-third is simply a case of malignancy. If medullary carcinoma diagnosed by fine needle aspiration biopsy or during surgery, it is important patients examined for other endocrine disorders encountered in MEN II and members are checked for the presence of medullary carcinoma and MEN II. Measurement of serum calcitonin after pentagastrin stimulation or infusion of calcium can be used to screen for medullary carcinoma. Abnormal increase of serum calcitonin in the minutes to 3 or 5 is indicative of malignancy.

Anaplastic carcinoma, undifferentiated thyroid gland tumors including small cell carcinoma, giant cells, and spindle cells. It usually occurs in older patients with a long history of goiter in which the glands suddenly within a few weeks or months began to swell and produce pressure symptoms, dysphagia or vocal cord paralysis, death due to local expansion usually occurs within 6-36 months . These tumors are highly resistant to treatment.

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