RISK FOR INJURY

ASSESSME
NT
S:
O:
-Muscle
weakness
-Muscle
fatigue
-Easy
fatigability

DIAGNOSI
S
Risk for
injury
related to
fracture.

SCIENTIFIC
EXPLANATION
Parathyroidecto
my should be a
relatively
straightforward
surgical
procedure
devoid of
complications
when carried
out by an
endocrine
surgeon with
appropriate
training.
Complications
relating to the
wound and
damage caused
to nearby
structures
should be of
very low
incidence.
Complications
relating to
operative
strategy,
pathology
(hyperplastic

PLANNING
Short Term:
After 8 hours of
nursing
interventions, the
patient will be able
to demonstrate
behaviors, lifestyle
changes to reduce
risk factors and
protect self from
injury

Long Term:
After 2 days of
nursing
interventions, the
patient will be able
to demonstrate
absence of injury
with complications
minimized/controll
ed.

INTERVENTIONS
Monitor vital
signs noting
elevating
temperature,
tachycardia,
arrhythmias,
respiratory
distress,
cyanosis.

Assess mood,
coping abilities,
personality
styles,
behavior.

Assess general
condition

Assess clients
muscle
strength, gross
and fine motor
coordination

RATIONALE
Manipulation
of gland
during
subtotal
thyroidectomy
may result in
increased
hormone
release,
causing
thyroid storm.
They may
result in
carelessness
or increased
risk taking
without
consideration
of
consequences
To identify
causative
factors

To identify risk
for falls

EVALUATION
Short Term:
After 8 hours of
nursing
interventions, the
patient shall have
demonstrated
behaviors, lifestyle
changes to reduce
risk factors and
protect self from
injury

Long Term:
After 2 days of
nursing
interventions, the
patient shall have
demonstrated
absence of injury
with complications
minimized/controll
ed.

disease versus
multiple
adenomas) and
failure to find an
adenoma are
much more
complex and
difficult to
correct.

Evaluate
reflexes
periodically.
Observe for
neuromuscular
irritability:
twitching,
numbness,
paresthesias,
positive
Chvosteks and
Trousseaus
signs, seizure
activity.

Keep side rails

raised and
padded, bed in
low position,
and airway at
bedside. Avoid
use of
restraints.

Monitor serum
calcium levels.

Hypocalcemia
with tetany
(usually
transient) may
occur 17
days
postoperativel
y and
indicates
hypoparathyro
idism, which
can occur as a
result of
inadvertent
trauma to or
partial-to-total
removal of
parathyroid
gland(s)
during surgery
Reduces
potential for
injury if
seizures
occur.

Patients with
levels less
than 7.5
mg/100 mL

generally
require
replacement
therapy.
Provide
administer
medication by
physician such
as Calcium
gluconate and
lactate

Phosphatebinding agents

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.

Sedatives
Promotes rest,

reducing
exogenous
stimulation.
Aniconvulsants
Controls
seizure
activity until
corrective
therapy is
successful.