Acute Pain | Nursing Care Plan for Thyroidectomy

Nursing diagnosis: acute Pain related to Surgical interruption and manipulation of tissues and muscles, Postoperative edema

Possibly evidenced by
Reports of pain
Narrowed focus, guarding behavior, restlessness
Autonomic responses

Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved and controlled.
Demonstrate use of relaxation skills and diversional activities appropriate to situation.

Nursing intervention with rationale:
1. Assess verbal reports and nonverbal cues of pain, noting location, intensity (0 to 10 scale), and duration.
Rationale: Useful in evaluating pain, choice of interventions, and effectiveness of therapy.

2. Place in semi-Fowler’s position and support head and neck in neutral position with sandbags or small pillows as required in immediate postoperative phase. Instruct client to use hands to support neck during movement and to avoid hyperextension of neck.
Rationale: Prevents hyperextension of the neck and protects integrity of the suture line. Movement restriction is imposed for only a few hours postoperatively to prevent stress on the suture line and reduce muscle tension. Gentle flexing and stretching is then permitted according to pain tolerance to help prevent neck soreness.

3. Keep call light and frequently needed items within easy reach.
Rationale: Limits stretching and muscle strain in operative area.

4. Give cool liquids or soft foods, such as ice cream or popsicles.
Rationale: Although both may be soothing to sore throat, soft foods may be better tolerated than liquids if client experiences difficulty swallowing.

5. Encourage client to use relaxation techniques, such as guided imagery, soft music, and progressive relaxation.
Rationale: Helps refocus attention and assists client to manage pain and discomfort more effectively.

6. Administer analgesics and throat sprays and lozenges, as necessary.
Rationale: Reduces pain and discomfort; enhances rest.

7. Provide ice collar, if indicated.
Rationale: Reduces tissue edema and decreases perception of pain.