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 2. To know and methods in relieving pain 2. Assess patients general determine condition patients needs 3. To obtain baseline data for future 3. Monitor and record 4. To determine the source/origin of pain for 4. Determine the presence necessary of possible interventions pathophysiological/physical cause of pain 5. Individuals with external locus of control may take 5. Note clients locus of little or no control responsibility for pain management Vital Signs 6. To evaluate the severity of pain 7. May be only 6. Use pain rating scale indicator present appropriate for age. when the client is unable to verbalize Long Term: The patient shall have able to demonstrate use of relaxation techniques, skills and diversional activities as indicated for individual situation

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

7. Observe signs of nonverbal cues/pain behaviors and other defining characteristics as noted 8. Note when pain occurs 9. Provide comfort measures, quiet environment and calm activities

8. To mediate prophylactically, as appropriate 9. To promote non pharmalogical pain management

10. to distract attention and 10. Instruct/encourage to reduce tentsion use relaxation techniques 11. to reduce concern of the 11. Review procedures and unknown and tell the client when treated associated muscle may cause pain tension 12. Encourage adequate 12. To prevent rest periods 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 as indicated acceptable level of pain. Problem #2: Impaired Skin Integrity r/t mechanical factors like surgery secondary to Parotidectomy Assessment Nursing Diagnosis Scientific Explanation Planning Interventions Rationale Expected Outcome

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

Impaired Skin Integrity r/t mechanical factors like surgery secondary to Parotidectomy

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.

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.

1. establish rapport 2. assess patients condition 3. monitor & recorded v/s 4. provide AM care 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 DAT diet 8. encourage SO/patient to follow medical regimens 9. regulate IVF 10. due meds given 11. attend needs of the patient

1. to gain trust of the patient 2. to note any abnormalities within the patient 3. to obtain baseline data 4. to promote comfort and prevent contamination 5. to prevent infection 6. to provide comfort 7. for faster wound healing 8. to obtain pharmacologic al benefits 9. to prevent excessive fluid loss 10. to provide pharmacologic al pain management 11. to satisfy the needs of the patient

Short-term: The patient shall have able to participate in preventive measures and treatment regimen. Long-term: The patient shall have demonstrated behaviors to promote healing and to prevent further tissue injury.

Problem #3: Disturbed sensory perception related to altered status of sense organ as evidenced by ingestion of anesthesia secondary to parotidectomy Assessment Nursing Diagnosis Scientific Explanation Planning Interventions Rationale Expected Outcome

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

Disturbed sensory perception related to altered status of sense organ as evidenced by ingestion of anesthesia secondary to parotidectomy

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

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

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 patients 2. To know and appropriately general condition determine patients 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 clients 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 necessary intervention when affected area is located

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

8.

8. Enhances Provide commitment to abd

explanations of the continuation of plan, plan care with the optimizing client, involving SO outcomes 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 bodys 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 individuals causative/risk factors Long term: After 2 3 days of nursing interventions the patient will be able to achieve timely wound healing Interventions Independent: 1. Establish Rapport 2. Assess patients general condition 3. Monitor and record Vital Signs 4. Note risk factors 5. Observe for localized signs of infection at insertion sites of invasive lines, sutures, surgical incisions/wounds 6. Stress proper hand hygiene by all caregivers between therapy 7. Provide for isolation, as indicated 8. Maintain sterile technique for all invasive procedures 9. Change surgical/other wound dressings, as indicated 10. Review individual nutritional needs, appropriate exercise program and need for rest Rationale Independent: 1. To gain the trust and cooperation 2. To know and determine patients needs 3. To obtain baseline data for future 4. For occurrence of infection 5. To assess and locate the possible origin of infection 6. To give first line of defense when giving care to the client 7. Reduces risk of cross contamination 8. To prevent infection or contamination of the wound 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 Expected Outcome Short term: The patient shall have able to verbalize understanding of individuals causative/risk factors Long term: The patient shall have able to achieve timely wound healing

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 volatile anesthetic agents and the neuromuscular

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

6. Monitor/maintain comfortable ambient environment

5. To determine metabolism effect on the body temperature and to identify foods or nutrient deficits that affect metabolism 6. To relax the

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.

7. Monitor core body temperature

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