A surgical floor nurse is caring for a post-operative client who has undergone a total thyroidectomy. Which of the following are important nursing assessment measures during post-operative care?
• Assess for signs of latent tetany due to calcium deficiency, including tingling of toes, fingers, and lips; muscular twitches; positive Chvostek’s and Trousseau’s signs; and decreased serum calcium levels. Tetany may occur in 1 to 7 days after thyroidectomy. Monitoring for Chvostek’s & Trousseau’s signs allows for immediate reporting of positive responses.
• Assessing for hemorrhage is always important. The danger of hemorrhage is greatest in the first 12 to 24 hours after surgery. Examination of the back of the neck and shoulders for bleeding is needed because blood tends to drain posteriorly in a client with thyroidectomy.
• Meperidine and morphine sulfate are both used during the early post-operative period to relieve pain and promote rest. Pain management is one of the important post-operative care interventions. The question is asking for post-operative assessment measures.
• Although oxygen therapy allows improvement of gas exchange, it is considered as implementation of dependent nursing interventions, not an assessment measure during post-operative care. Monitoring the client’s airway and breathing constitute a priority nursing assessment measure.
• Proper positioning relieves pressure on the diaphragm. This is an implementation of nursing intervention during post-operative care that helps promote a patent airway and adequate gas exchange. This is not an assessment measure.