Question

The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should: A. Maintain the client in a semi-Fowler's position with the head and neck supported by pillows B. Encourage the client to turn her head side to side, to promote drainage of oral secretions C. Maintain the client in a supine position with sandbags placed on either side of the head and neck D. Encourage the client to cough and breathe deeply every 2 hours, with the neck in a flexed position

Short answer

Answer: The most appropriate post-operative nursing intervention for this patient is maintaining the client in a semi-Fowler's position with the head and neck supported by pillows. This position promotes proper healing and breathing, while minimizing the risk of complications.

Step-by-step solution

Evaluate Option A

Assess whether maintaining the client in a semi-Fowler's position with the head and neck supported by pillows is appropriate after a thyroidectomy. This position promotes breathing and healing. Proper support for the head and neck can minimize tension on the incision area and prevent complications such as bleeding or pressure on the airway.

Evaluate Option B

Consider if encouraging the client to turn her head side to side to promote drainage of oral secretions is a suitable intervention after thyroid surgery. Turning the head side to side can cause tension on the incision site, potentially leading to complications like bleeding or infection. Therefore, this option is not ideal.

Evaluate Option C

Examine whether maintaining the client in a supine position with sandbags placed on either side of the head and neck is an appropriate intervention following thyroidectomy. This position does not promote breathing and can put pressure on the incision site. Furthermore, sandbags can cause discomfort and do not provide the necessary support for healing. This option is not ideal.

Evaluate Option D

Determine if encouraging the client to cough and breathe deeply every 2 hours, with the neck in a flexed position, is suitable for post-operative care. Deep breathing and coughing can be helpful in preventing post-operative complications, such as infections and atelectasis. Nonetheless, maintaining the neck in a flexed position can put tension on the incision site and lead to complications. This option is not ideal.

Select the Correct Nursing Intervention

Based on the analysis, Option A - maintaining the client in a semi-Fowler's position with the head and neck supported by pillows - is the most appropriate post-operative nursing intervention for this patient following removal of the thyroid. This position promotes proper healing and breathing, while minimizing the risk of complications.

Key concepts

Post-Operative Nursing Care

After any surgery, careful nursing care is crucial for a patient's recovery. Post-operative care involves monitoring vital signs, managing pain, preventing infections, and ensuring patient safety. Immediately after surgery, patients are usually transferred to a recovery area where nurses ensure that they are comfortable and stable.

• Monitoring vital signs like heart rate, blood pressure, and oxygen levels is essential. This helps in quickly identifying any complications.
• Pain management is another critical aspect. Adequate pain relief promotes rest and aids recovery.
• Preventing infections is also a top priority. Nurses must follow strict hand hygiene and care for any incisions to minimize infection risks.
• Ensuring patient safety involves helping them move safely and preventing falls.

Every patient's needs differ based on the type of surgery, age, and overall health. Nurses must adapt their care to each specific situation, always aiming to support healing and comfort.

Thyroidectomy Patient Management

Managing a thyroidectomy patient requires special attention due to the surgery's impact on the neck area. The thyroid gland's location means that care must focus on supporting the head and neck to reduce strain on the surgical site.

• Positioning in a semi-Fowler's position is crucial. This involves having the head elevated at a 30 to 45-degree angle, which can help reduce swelling and promote better breathing.
• Supportive pillows keep the head and neck stable, reducing tension on the incision.
• Monitoring for any signs of bleeding, which can be a complication due to the proximity of blood vessels, is also important.
• Keeping communication open with the patient about any changes or discomfort ensures timely intervention.

Patients must follow a gentle recovery routine. The nurse plays a key role in educating the patient about the importance of minimizing neck movements and following a balanced act to aid in optimal healing.

Nursing Intervention Selection

Choosing the most appropriate nursing interventions involves understanding the specific needs of the patient and the surgery performed. Nurses use their knowledge and assessment skills to select interventions that meet care goals.

• The chosen interventions must aim to promote healing, prevent complications, and ensure patient comfort.
• In the case of a thyroidectomy, interventions include maintaining appropriate positioning to avoid stress on neck incisions.
• Nurses must always evaluate each intervention's effectiveness and be ready to adjust care plans based on patient responses.
• Effective communication with the patient and the healthcare team is vital for shared decision-making and continuous assessment of patient needs.

The selection process is dynamic, requiring nurses to blend scientific knowledge with compassionate care. This approach helps in facilitating a smoother recovery and enhances the overall patient experience.