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539
PATIENT GOALS
OUTCOMES (NOC)
Anxiety Self-Control
Encourage verbalization of feelings, perceptions, and fears to understand patients perspective of situation, treatment, and prognosis to begin adjustment and acceptance.
Provide factual information concerning diagnosis, treatment, and prognosis to reduce patients sense
of helplessness and increase sense of control.
Assist patient to articulate a realistic description of upcoming event.
Encourage family to stay with patient to provide caring and support.
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
NURSING DIAGNOSIS
PATIENT GOALS
Acute pain related to surgical tissue injury as evidenced by report of discomfort; facial mask of pain; changes in blood
pressure, pulse, and respiratory rate
1. Reports satisfaction with pain relief
2. Uses pain relief techniques effectively
OUTCOMES (NOC)
Pain Control
Observe for nonverbal cues of discomfort, especially in those unable to communicate effectively (e.g.,
facial expression, reluctance to cough or move) to plan appropriate interventions.
Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity, or severity of pain and precipitating factors.
Teach use of nonpharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, and massage) before, after, and, if possible, during painful activities; before pain occurs or
increases; and along with other pain relief measures to manage pain.
Provide the person optimal pain relief with prescribed analgesics to provide consistent therapeutic
levels of analgesics.
Use pain control measures before pain becomes severe.
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
NURSING DIAGNOSIS
PATIENT GOAL
Imbalanced nutrition: less than body requirements related to surgical procedure, edema, and dysphagia as evidenced by
absence of or inadequate oral intake
1. Maintains body weight
2. Consumes adequate fluids and nutrients to meet metabolic needs in the postoperative period
OUTCOMES (NOC)
Nutritional Status
Measurement Scale
Continued
540
Instruct patient and family on use of speech aids (e.g., tracheal-esophageal prosthesis and artificial
larynx).
Use picture board.
Listen attentively.
Reinforce need for follow-up with speech pathologist after discharge to learn use of voice prosthesis,
electrolarynx, or esophageal speech.
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
NURSING DIAGNOSIS
PATIENT GOAL
Disturbed body image related to disfiguring surgery and loss of speaking ability as evidenced by withdrawal, depression,
isolation, unwillingness to look at self or assist with care, and refusal to see visitors
1. Acknowledges changes in body image
2. Discusses feelings about and the meaning of changes in physical appearance
3. Participates in self-care
OUTCOMES (NOC)
Body Image
Use anticipatory guidance to prepare patient for predictable changes in body image to facilitate effective coping mechanisms.
Assist patient to discuss changes caused by illness or surgery.
Identify means of reducing the impact of any disfigurement through clothing or cosmetics to aid in successful adjustment.
Assist patient to separate physical appearance from feelings of personal worth to increase acceptance
of altered physical appearance.
Measurement Scale
Socialization Enhancement
1 = Never positive
2 = Rarely positive
3 = Sometimes positive
4 = Often positive
5 = Consistently positive
Encourage enhanced involvement in already established relationships as acceptance by significant others is a critical factor in patients own acceptance.
Self-Care Assistance
Encourage patient to perform normal activities of daily living to level of ability as participation in selfcare is a sign of successful adjustment.
NURSING DIAGNOSIS
PATIENT GOALS
Deficient knowledge related to lack of exposure to information and unfamiliarity with informational resources as evidenced
by verbalized concern about ability to manage self-care at home
1. Demonstrates satisfactory care of tubes and incisions
2. Verbalizes key elements of the therapeutic regimen and speech rehabilitation, including knowledge of disease, complications, and
treatment plan
OUTCOMES (NOC)
Discharge Readiness: Independent
Living
Seeks assistance appropriately _____
Uses available social support _____
Describes signs and symptoms to health
care professional _____
Describes prescribed treatments _____
Describes risks for complications _____
Manages own medications _____
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
*Because a tracheostomy is usually performed for the patient with a total laryngectomy and/or radical neck surgery, see the related nursing care plan, NCP 27-1, on pp. 532 to 534 for
these nursing diagnoses.