NURSING DIAGNOSIS: Injury, risk for [tetany]
- Risk factors may include
- Chemical imbalance: excessive CNS stimulation
Possibly evidenced by
- [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Safety Status: Physical Injury (NOC)
- Demonstrate absence of injury with complications minimized/controlled.
: Risk for Injury — Thyroidectomy Nursing Care Plan (NCP)Nursing Interventions & Rationale
|Monitor vital signs noting elevating temperature, tachycardia (140–200 beats/min), dysrhythmias, respiratory distress, cyanosis (developing pulmonary edema/HF).||Manipulation of gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm.|
|Evaluate reflexes periodically. Observe for neuromuscular irritability, e.g., twitching, numbness, paresthesias, positive Chvostek’s and Trousseau’s signs, seizure activity.||Hypocalcemia with tetany (usually transient) may occur 1–7 days postoperatively and indicates hypoparathyroidism, which can occur as a result of inadvertent trauma to/partial-to-total removal of parathyroid gland(s) during surgery.|
|Keep side rails raised/padded, bed in low position, and airway at bedside. Avoid use of restraints.||Reduces potential for injury if seizures occur.|
|Monitor serum calcium levels.||Patients with levels less than 7.5 mg/100 mL generally require replacement therapy.|
| Administer medications as indicated:|
Calcium (gluconate, lactate);Phosphate-binding agents;Sedatives;Anticonvulsants.
|Corrects deficiency, which is usually temporary but may be permanent. Note: Use with caution in patients taking digitalis because calcium increases cardiac sensitivity to digitalis, potentiating risk of toxicity.Helpful in lowering elevated phosphorus levels associated with hypocalcemia.Promotes rest, reducing exogenous stimulation.Controls seizure activity until corrective therapy is successful.|