Admission/Final Diagnosis:

MULTINODULAR COLLOID GOITER WITH INTRATHORACIC EXTENSION

I. HEALTH HISTORY

A. DEMOGRAPHIC DATA (BIOGRAPHICAL DATA)

1. Client’s name or initial: M.G.F.

2. Gender (Sex): Female

3. Age: 43 years old

Birthdate: August 21, 1967

Birthplace: Manila

4. Marital (Civil) Status: Married

5. Race and Nationality: Filipino

6. Religion: Catholic

7. Address: General Trias, Cavite

Telephone Number: N/A

E-mail address: N/A

8. Educational Background / Other Significant Framing: 3rd year college

9. Occupation: Midwife

10.Usual Source of Medical Care: Contreras Medical Clinic

11.Date of Admission: Sept. 15, 2010

B. SOURE AND RELIABILITY OF INFORMATION

Client herself seems reliable

C. REASONS FOR SEEKING CARE

“Malakas ang kabog ng dibdib ko”

“Para akong nasasakal”

“Parang may nagbabara kapag kumakain ako”

D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH

The pt. was apparently well until 2 yrs. ago, when she got pregnant, her doctor

advised her to undergo UTZ of her neck & check for goiter. She presented with increased

perspiration, anxiety, nervousness, tachypnea, and thick, tingling, feeling on the right hand.

Without noted aggravating or relieving factors. No consult was done and no medications

were taken.

One year prior to admission, there was persistence of symptoms and the pt. noted a

neck mass sensation. She began folding her pillow to elevate her head when sleeping

because of the neck discomfort.

Four months prior to admission, she experienced heat intolerance and felt an

obstruction on the neck area when swallowing even without food. There was persistence of

symptoms but the thick tingling sensation was felt from the fingertips of the right hand to the

forearm. Palpitations were also noted. No consult was done and no medications were taken.

Tremors on the right hand were noted.

Two months prior to admission, there was persistence of symptoms that prompted

her consult to a physician who referred her to an ENT doctor. She was advised to undergo

an operation ad no medications were prescribed. UTZ of the neck, CT Scan, CBC, X-ray

(Chest), FT4, TSH, ECG was done to prepare for the operation.

On the day of consult, there was persistence of symptoms and she was admitted in

DLS-UMC at around 3:00pm.

E. PAST MEDICAL HISTORY OR PAST HEALTH

Client stated that she had common illnesses in the past like fever, cough and

common cold. She had no serious illnesses experienced aside from these. The

client is not hypertensive and has no history of diabetes mellitus, bronchial asthma

and seizure. She has not experienced any serious injuries or accident.

The client had already undergone 2 operations before she was admitted in the

hospital. According to the client, her first operation was done on 1990’s which is

appendectomy along with unilateral oophorectomy due to a cyst found on her right

ovary. After 2 years, she underwent another operation which is cholecystectomy.

There were no complications reported from any of her operations.

The client’s OB score is G6P4 40240 which indicates that she became

pregnant six times and gave birth at term four times, all under normal delivery. She

currently has four living children. Unfortunately, she also had two spontaneous

abortions. Her age at menarche was 12 years old, her LMP was September 7, 2010

and her menstrual cycle is regular, usually lasting for 4-5 days. The client sometimes

experience heavy menstrual periods in which she uses diapers and change 3 times

in day. She had also experienced dysmenorrhea during her adolescence.

Her immunization status was unrecalled by the client. She has no allergies to

any foods or medications but stated that she has seasonal allergies in which the skin

below her lower lip becomes swollen and reddened.

The client was not a drinker but admits that she smokes whenever she wants

to defecate. According to her, this helps her to feel the urge to defecate and have an

easy bowel movement. The client also admitted that she sometimes consume

carbonated drinks.

F. FAMILY HISTORY

60 y/oDM

UnrecalledStroke

DM

89 Y/OHeart attack

63 y/o A&W

57 y/oDM

HPN-Gouty

Arthritis

50 y/oA&W

49 y/ounrecalled

48 y/oSkin

Asthma

47 y/oHTN

46 y/oHTN

44 y/oKidneydisease

60y/oHTN

56 y/oHTN

53 y/oHTN

48 y/oHTN

45y/oA&W

40y/oHTN

unrecalledTB

UnrecalledGI problem

43y/o 1y/o 33y/o 24y/o

Interpretation:

On her father side, they have a history of hypertension, tuberculosis and

asthma. Her grandfather died due to tuberculosis, unrecalled age while her

grandmother died due to gastrointestinal problem according to patient, unrecalled

specific gastrointestinal disease an age of death. Her father is the eldest among the

six, is sixty years old and is hypertensive. Most of her father’s siblings are

hypertensive except for the fifth child.

On her mother side, they have history of heart problems, Diabetes Mellitus,

skin asthma, gouty arthritis and renal problems. Her grandmother died at the age of

89 due to heart attack while her grandfather died at the age of sixty due to stroke,

also her grandfather had diabetes mellitus. Her mother is the second among the

nine children. The eldest died at the age of sixty years old due to Diabetes

complication. Her mother is sixty three years old. The third child has diabetes

mellitus and hypertension. The fourth child is fifty years old, has hypertension and

with gouty arthritis. The fifth child died at forty nine years old with unrecalled cause

of death. The sixth child is forty eight years old with skin asthma. The seventh and

eight child aged forty seven and forty six respectively, have hypertension, and the

youngest child aged fort four has kidney disease and is undergoing hemodialysis

twice a week for six years.

G. SOCIO ECONOMIC

The client stated that she does not work at present. She lives in three

different houses: her mother’s, her husband’s and her uncle’s house. This is

because she does not have any source of income to support her and her children’s

basic needs. Her 2 children are living with her mother and the other two are living

with her uncle. Her husband works as a security guard and earns 4,000 pesos every

15th of the month but his income is not enough to support their needs. Additional

taxes would still be subtracted from her husband’s income. The client’s brother

sometimes helps in paying for the expenses of the family. The client’s mother also

shares in paying the expenses because she works in a small grocery and has a

small apartment. Their other relatives abroad offer financial support to them and they

also help in paying for her hospitalization and other expenses they incur. Due to lack

of the sources of income of the client, her family experiences financial problems but

stated that they were lucky because they can still manage to pay for their basic

needs at present.

H. DEVELOPMENTAL HISTORY

According to Erik Erikson’s Developmental Theory, patient is in middle

adulthood stage with an ego development task of Generativity vs. Self absorption or

Stagnation and with the basic strengths of production and care

Now work is most crucial. Erikson observed that middle-age is when we tend

to be occupied with creative and meaningful work and with issues surrounding our

family. Also, middle adulthood is when we can expect to "be in charge," the role

we've longer envied. The significant task is to perpetuate culture and transmit values

of the culture through the family-like taming the kids and working to establish a

stable environment. Strength comes through care of others and production of

something that contributes to the betterment of society, which Erikson calls

generativity, so when we're in this stage we often fear inactivity and

meaninglessness.

As our children leave home, or our relationships or goals change, we may be

faced with major life changes—the mid-life crisis—and struggle with finding new

meanings and purposes. If we don't get through this stage successfully, we can

become self-absorbed and stagnate. Significant relationships are within the

workplace, the community and the family.

I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION

1. ROS AND PE

Date: Sept, 16, 2010

System ROS PE

a. General/overall health

status

“Nabawasan ang

timbang ko ng 4 kilos”

“Init na init yung

pakiramdam ko, gusto

ko na maligo”

“Hindi ako

nakakaramdam ng

panghihina ngayon”

Received patient

sitting on bed,

conscious,

awake and

communicative

Patient appears F/N

With heplock at right

metacarpal vein

V/S:

BP: 130/60mmHg

PR: 80 bpm

RR: 32cpm

Temp: 36.0°C

Good capillary refill (3

secs.)

large-size body build

Diet is DAT

b. Integument “Pakiramdam ko

parang may

tumutusok tusok sa

kamay ko, minsan

nawawala”

“Wala naman akong

sakit sa balat”

“Hindi naman ako

nangangati ngayon,

init na init lang ang

pakiramdam ko”

SKIN

Inspection

soft, smooth, dark

colored skin

(+) dark nuccal

(-) erythema

>(-) hyperpigmentation

on the skin

>(+)pruritus

Palpation

normothermic

(-) edema

HAIR

Inspection

gray-white colored hair

usual for age

(-) patches or lesions

on areas with hair

(-) parasites

Palpation

(+) thin hair strands

(+) dry hair

NAILS

Inspection

Nail surface are

smooth and slightly

curved w/ elongated

dirty nail edges

Convex shape

Pale pink nail beds w.

no linear pigmentation

Palpation

Smooth and rounded

posterior and lateral

nail folds

Good capillary refill for

3 secs.

Good skin turgor and

mobility

c. Head “Hindi naman palaging

sumasakit ang ulo ko,

hindi naman ako

nahihilo”

INSPECTION

>short black hair, well

to distributed

>Proportion to the body

>Bilateral symmetric

facial features

>(-) dandruff

>normocephalic

Palpation

>(-) tenderness

>(-) lumps observed

and palpated

d. Eyes “Medyo malabo na

ang mata ko”

“Nakakabasa ako sa

malayo pero kapag

sobrang lapit, medyo

malabo na”

“May salamin ako

kaya lang limang taon

ko na hindi nagamit

kasi hindi ko na

kasukat”

EYEBROWS

Inspection

Eyebrows evenly

distributed on both

sides

(-) lesions

(-) scaling

Both are bilaterally

equal and maintains

symmetry even after

movement

EYELIDS

Inspection

Completely close when

clients sleeps

With baggy eyelids

SCLERA:

Inspection:

White sclera

EYELAHES:

Inspection

>Lids close

symmetrically

>Pink palpebral

conjunctiva

Palpation:

>Skin intact

>Nodules or lesions

EYEBALLS:

Inspection:

>(-) protusion or

sunken

>Aligned normally in

their sockets

>Bilaterally

symmetrical

>(+) parallel eye

movements

CONJUNCTIVA:

Inspection:

>Pallor

>Shiny, smooth

>(+) parallel eye

movement

>(-) discharge

>(-) redness

CORNEA

Inspection:

>(+) corneal reflex

>transparent

PUPILS:

Inspection:

>Black in color

>(+) PERRLA

e. Ears “Nagkaroon ng

impeksyon yung

kaliwang tenga ko

dati, two years ago na.

Namaga tapos

pinacheck-up ko sa

doktor, binigyan ako

ng pampatak pati ng

antibiotic”

“Minsan sa isang

linggo ko lang nililinis

ang tenga ko kasi sabi

ng doktor hindi dapat

araw araw ang

paglilinis noon”

Inspection:

>Both ears are

bilaterally equal and

inline with the eyes

>Color same as facial

skin

>No discharge

>(+) cerumen

>(-) lesions

>(-)Swelling

Palpation:

>Pinna recoils after it is

folded

>Firm

>No tenderness on the

auricle and tragus

>(-) masses

f. Nose “Hindi naman ako

madalas magkasipon.

Pag nagkasipon ako

hindi naman barado”

Inspection:

>Symmetric and at the

midline

>Nasal septum intact

at midline of the head

without perforations

>(-) nasal flaring

>(-) nasal discharge

>(-) lesions

>(-) swelling of sinuses

>(-) nasal congestion

>(-) epistaxis

Palpation:

>(-) tenderness upon

palpation of the

maxillary and frontal

sinuses

>Both nasal airways

patent

g. Mouth & throat “Minsan sumasakit

ang lalamunan ko

kapag lumulunok at

kapag namamaga

yung tonsil ko”

“Medyo namamalat

din yung boses ko”

“Last year pa ako

nagpunta sa dentist.

Wala akong pustiso

kasi natatakot ako sa

dentista, masakit kasi

yung tusok ng

injection”

MOUTH, TEETH & GUMS,

PLATES, UVULA, THROAT

AND TONSILS:

Inspection:

unable to perform,

patient cannot open

her mouth still.

LIPS:

Inspection:

>(+) chapped lips

>(-)pallor

>(-) lesions

h. Neck “Nangangalay yung

batok ko”

“May goiter ako kaya

ako inoperahan, buti

natanggal na”

“Hindi ko masyado

magalaw pa ngayon

yung leeg ko, masakit

kasi”

Inspection:

post surgical operation

– thyroidectomy

Slow, limited

movements

>Positioned in midline

>Accessory neck

muscle are

symmetrical

>Head position is

centered in the midline

i. Breast & Axillary “Kinakapa ko yung

dede ko kung kailan

ko lang maisipan,

wala namang bukol”

“Lahat ng anak ko

breastfeed talaga sila,

mahal kasi yung

gatas”

Inspection:

>equal size of breast

>dark brown nipples

>(-)discharge

>small montgomery

tubercles present

j. Respiratory “Wala naman akong

sakit sa baga kasi

minsan lang ako

manigarilyo kapag

gusto ko lang

dumumi”

“Kanina may dugo

yung dura ko pero

ngayon wala na”

Inspection:

>RR=32 cpm

>(+) difficulty of breathing

>Thorax is symmetric,

Elliptical in shape

>(+) symmetrical chest

expansion

>AP diameter of the chest 1:2

>(+) cough; non-productive

Palpation:

>(+) equal tactile fremitus on

both lungs

Percussion:

>(+) resonant in both lung

fields

Auscultation:

>(-) adventitious sound

k. Cardiovascular Mabilis ako mapagod

lalo na kapag

umaakyat sa hagdan

kaya kapag umaalis

ako ng bahay lagi

akong sumasakay ng

tricycle”

“Nagpalpitate ako

bago ako maospital,

ngayon meron pa rin

pero konti na lang”

“Lagi akong

pinupulikat”

Inspection:

>(-) Cyanosis

>(-) Varicose veins

>(-) edema

Palpation:

>BP= 130/60 mmHg

>PR= 80 bpm

>(-) chest pain

>(-) palpitations

>Carotid artery pulsation

>(-) jugular vein distention

Auscultation:

(-) heart murmur

(-) tachycardia

(+)dyspnea

l. Gastrointestinal and

Abdomen

“Kahit ano kinakain

ko, medyo hirap nga

lang akong kumain

ngayon”

“Hindi ako umiinom ng

Inspection:

two incisions –

(previous

cholecystectomy and

appendectomy)

pampadumi”

“Regular naman ako

dumumi kasi pag

kumain ako, dudumi

ako pagkatapos”

(-) rahes

>+) striae

Ausculation:

15 Bowel

sounds/minutes

Palpation:

(+) dry skin

Percussion:

(+) tympanic sound

m. Urinary “Madami yung iniihi

ko, madilaw yung

kulay”

“Nagkaroon ako ng

UTI noong nagbuntis

ako”

Inspection:

>UO= 150 cc from 2-10pm

>Amber yellow urine

Palpation:

>(-)low back pain

>(-) umbilical area tenderness

n. Genitalia “12 years old ako

unang nagkaroon,

irregular pa dati pero

regular na ngayon”

“Minsan nagsusuot

ako ng diaper kapag

malakas yung period

ko”

Client refused to be

examined

o. Muscoloskeletal “Medyo masakit yung

likod ko pati balikat

ko”

Inspection:

Elbows, wrists, hands,

fingers, and feet are

“Yung kanang binti ko

medyo masakit din,

parang nangalay”

bilaterally symmetrical

(+) tremors

(+) Chvostek’s sign

(+) Trousseau sign

full range of motion of

hands and feet, as well

as wrists and ankles,

elbows, and knees but

limited range of motion

of neck

>Both sides of the

body are symmetrical

Palpation:

(-) joint stiffness

(-) joint swelling

(-) bone pain

(-) lethargy

p. Neurologic “Maayos pa naman

yung memorya ko”

“Hindi pa ako

nakaranas

mahimatay. Wag

naman sana”

“Minsan nerbyosa ako

pero depende rin sa

sitwasyon”

Inspection:

>Conscious and cohisent

Alert and oriented to person,

place and time

> Able to speak

>(-) tremors

>(-)depression

>CNS I = without difficulty in

smeling aromatic substances

>CNS II = equality responsive

to light, (+) pulpillary reflex,

bilateral eyeballs

>CNS III, IV, VI = EOMs

>CNS V = good temporalic

tone, with corneal reflex

>CNS VII = symmetric facial

muscle tone

>CNS VIII = able to hear

whispered words

>CNS IX & X = present gag

reflex, able to swallow

>CNS XI = able to move/shrug

the shoulders

>CNS XII = able to move

tongue side to side

q. Hematologic “Hindi ako mabilis

magkapasa”

“Apat na beses na ako

nagdonate ng dugo”

Inspection:

>(-) hematomas

>(-) bruises

>(-) hx of clotting of bleeding

d/o

r. Endocrine “Wala akong diabetes”

“May goiter ako pero

natanggal na”

“Wala akong iniinom

na pills, hindi ako

gumagamit ng family

planning”

Inspection:

(-) diaphoresis

(+) tremors

Palpation

(-) abdominal

tenderness

2. LABORATORY STUDIES/DIAGNOSIS

Procedure date IndicationNormal values/finding

Actual findings

Nursing Responsibilities

HEMATOLOGYComplete Blood Count(August 12, 2010)

For evaluation of all blood components to discern if there are any

WBC Count:5-10x10^9/L

Hemoglobin:123-153g/L

9.9

145

PRE:-Check’s doctors order-Check whether fasting is required

Differential Count

changes in hematological condition before the patient becomes symptomatic.

To determine properties of different kinds of white cells.

Hematocrit:0.36 – 0.45 vol.

Platelet:150-400x10^9/L

Segmenters:0.36-0.66 %

Lymphocytes:0.22-0.40

Eosinophils:0.01-0.04

Stab cells:0.04-0.08

0.43

380

0.63

0.35

0.01

0.02-0.05

-Explain the patient the purpose of the procedure-if ordered, withhold medication until the blood is drawn-Explain that blood samples will be extracted-Prepare the needed equipment-observe universal precaution in collecting blood specimen

INTRA:-Practice aseptic technique-collect the specimen from the arm without an IV device, if possible.-to obtain valid result, do not fasten the tourniquet for longer than 1 minute. Prolonged tourniquet application can cause stasis % hemo-concentration.-Aspirate only the needed amt. of bld.-After the specimen is drawn, apply pressure/pressure dressing to the venipuncture site-note the time % date the blood is drawn. Hemolysis may result from vigorous shaking &

invalidate the result.

POST:-record/ document the exact time when the specimen was collected. Indicate drugs that the patient is taking-ensure that the blood tubes are correctly labeled.-secure the laboratory samples and label it accordingly-Assess the venipuncture site for redness and swelling.-reinstitute appropriate diet if fasting was done

Blood chemistry (Calcium, Albumin Creatinine,)(Sept. 10, 2010)

Assess a known or suspected disorder involving muscles in the absence of a renal disease.

Evaluate known or suspected renal function.

Determine whole body stores of sodium, predominantly extracellular.

Calcium:2.10-2.55umol/L

Albumin:35-50g/L

Creatinine:46-92umol/L

2.0

34.0

64

PRE:- Check doctor’s order.-Explain the procedure to the patient.-Tell the patient that no fasting is required.- Explain that blood samples will be extracted-Prepare the needed equipment.- Observe universal precaution in collecting blood specimen.INTRA:-practice aseptic

Monitor effectiveness of drug therapy, especially diuretics.

Assist in evaluation of electrolyte imbalances.

Evaluate response to treatment.

technique-collect approximately 5ml of blood in red tap tube-for pediatric patients, blood is usually drawn from a heel sick POST:-apply pressure or a pressure dressing to the venipuncture site-observe the venipuncture site for bleeding

THYROID FUNCTION TEST

(June 29, 2010)

It is used to evaluate the thyroid’s functioning and to diagnose and help determine the cause of thyroid diseases.

T3:

1.20-2.80nmol/L

FT4:

11.5-23.0pmol/L

TSH:

0.27-3.75µTU/ml

2.10

14.36

0.53

PRE:

-Check the doctor’s order

-Know the reason for the procedure.

-Introduce self and verify the client’s identity.

-Check the vital signs

-Explain the procedure that will be done to prepare the patient

-Provide privacy

INTRA:

-Ensure the use of standard precautions and sterile technique as appropriate

-Provide emotional

and physical support as needed

-Ensure the correct labeling, storage and transportation of specimen

POST:

-Provide nursing care for the client

-Check vital signs

3.Report the results to appropriate health team worker

CHEST X-RAY(August 12, 2010)

To visualize the internal organs and bones of the body to see if there are any deformities and abnormalities in it.

Lungs are both clear

Heart is not enlarged

Diaphragm and sinuses are intact

Findings:Lungs are clear

Heart is mildly enlarged

Aorta tortuous

Diaphragm sulci and bones are intact

Impression:Mild Cardiomegaly

Atheromatous Aorta

PRE:

- Check the doctor’s order

- Know the reason for the procedure.

- Introduce self and verify the client’s identity.

- Check the vital signs

- Explain the procedure that will be done to prepare the patient

- Provide privacy

INTRA:

- Ask the client to remove any

jewelry from her

- Give the obtained jewelry to a trustful relative and inform the client whom you have given the jewelry to

- Assist the client in going to the x-ray room

POST:

- Wait for the result and check the client for further questions

CT SCAN &MRI SECTION(August11, 2010)

To note for any remarkable structures

To look for lesions and masses

Unremarkable Impression: -Thyomegaly with intathoracic extension as described -cardiomegaly-sub centimeter pulmonary nodule, left upper lobe, as described. consider pulmonary AV malformation

PRE:-Explain the procedure to the client.-Ask the patient if she is claustrophobic -Ask to remove any jewelries and metals

INTRA:-Instruct the patient not to move when she is inside the capsule

POST:-Inform the result to patient

FNAB(July 13, 2010)

to check if the goiter is toxic or non toxic

Unremarkable Impression:-Blood and Colloid

PRE:-explain procedure to patient

POST:

-inform the result to patient

Urinalysis (September 15, 2010)

To determine urine composition and possible abnormal components (e.g., protein or glucose) or infection

Color:Light yellow amber

Trans-parency:Clear

Spec. Gravity:1.005-1.030

Albumin:Negative

Sugar:Negative

RBC:Negative

WBC:Negative

Epithelial cells:Negative

yellow

Cloudy

1.025

trace

Negative

0-2/HPF

5-8/HPF

+3

PRE:- Check doctor’s order.-Explain the procedure to the patient.-Tell the patient that no fasting is required.- Explain that blood samples will be extracted-Prepare the needed equipment.- Observe universal precaution in collecting blood specimen.

INTRA:-practice aseptic technique-collect approximately 5ml of blood in red tap tube-for pediatric patients, blood is usually drawn from a heel sick

POST:-apply pressure or a pressure dressing to the venipuncture site-observe the venipuncture site for bleeding

2. OTHER ASSESSMENT TOOLS

Date Taken Comprehensive Actual Actual Result

Content/Legend

Sept. 16, 2010 Level 0 – Full Self Care

Level 1 – Requires use of

device

Level 2 – Requires

assistance from another

person

Level 3 – Requires use of

assistance from another

person or device

Level 4 – It depends and

does not participate

Level 0 – Full self care

J. FUNCTIONAL ASSESSMENT

1. Health Perception/ Health Management Pattern

Client describes her health as good even though she was hospitalized. She rates her

general health status as 9 in the scale of 0-10 wherein 0 represents poor health status and

10 represents good health status. The most important thing that she does in order to keep

her body healthy is to eat a balanced diet. She thinks that these are also the things that

doctors and nurses would suggest to her. When asked about the cause of her illness, she

states that she failed to comply with the doctor’s advice to her that’s why her goiter

progressively increased in size before she sought consultation to the hospital. Her current

health does not interfere with desired activities of daily living. However, there is a limitation

of movement in her neck area due to thyroidectomy. The thing that is important to her while

she is in the hospital is her immediate recovery so that she can already go home and take

care of her aunt undergoing hemodialysis.

2. Self-Esteem/ Self-Concept/ Self-Perception Pattern

She describes herself as good after undergoing an operation. At present, she admits that

she still feels nervous for the result of her biopsy. The client also states that there really is a

change about how she feels since she had a goiter. Despite the incision made in her body,

she still feels good about her physical appearance because what’s important to her at the

moment is that the thing that causes pain is already removed from her body. She does not

get easily angry, depressed or anxious. However, she becomes really angry if she finds out

that somebody is a traitor. As a result, she just shouts so hard in order to let out the anger

that she feels. Sometimes, she would go to her friends and make them laugh in order to

forget that she is angry.

3. Activity-Exercise Pattern

Upon waking up in the morning, the client would open the windows in order to let the

fresh air fill their house. Then, she would prepare breakfast for her sick aunt who has kidney

problem. She would also put everything in place and prepare all necessary things that they

might use for the day. She would also sweep the floors, clean the house and take care of

her aunt. She would rest for a while and then take a bath. After that, she would eat a light

meal and go to her mother’s house to visit her children. Sometimes, she would also go to

her husband’s house and stay there. Her usual routine includes going to the houses where

she and her children are staying because she prefers to be with other people instead of

being alone. She would then go home to the house where she is staying at around 10 in the

evening. According to her, this routine serves as her exercise. During her spare time, she

usually plays word games like scrabble and word puzzles together with her children or

friends.

Feeding = lvl.0 Grooming = lvl. 0

Bathing = lvl.0 Cooking = N/A

Toileting = lvl.0 Home Maintenance = N/A

Bed Mobility= lvl.0 Shopping = N/A

Dressing = lvl.0 General Mobility = lvl.0

Legend: Functional Legend Code:

Level 0 Full Self Care

Level 1 Requires use of device

Level 2 Requires use of assistance from another person

Level 3 Requires use of assistance from another person or device

Level 4 It depends and does not participate.

4. Sleep/ Rest Pattern

The client states that she does not have a particular time for sleeping and waking up.

Sometimes, she sleeps early at around 9 PM and sometimes she sleeps late at around 11

PM. She never used any sleep medications even though she experience insomnia. Usually,

she exchanges stories with her relatives before going to sleep. She describes the quality of

her sleep as good but she often wakes up in the middle of the night to void or when her sick

aunt needs some help. The client admits that she sleeps lightly and wakes up easily

whenever there are disturbing sounds in the place where she sleeps. She often wakes up at

around 7 AM and usually gets 8 hours of sleep. Despite of being a light sleeper, the client

feels well rested upon waking up in the morning. She also takes a nap in the afternoon

whenever she was not able to sleep well in the evening in order to have enough rest to

regain energy.

5. Nutrition/ Elimination Pattern

The client’s typical food intake includes 2 cups of rice, vegetables like ampalaya, beef

and sometimes pork. She does not take any food supplements. She states that she eats all

kinds of food and she has a good appetite. She also eats snacks in between meals, usually

consists of bread loaves, until she feels that her stomach is already full. The client does not

follow a certain kind of diet. She can consume 5-6 glasses of water per day. Despite her

good appetite, she reported that she experienced weight loss of approximately 4 kilos upon

hospitalization. She also experienced difficulty in swallowing due to her condition. The client

does not have any known food allergies or intolerance.

Her wounds heal very well and she does not have any skin problem at present. When it

comes to her elimination pattern, her bowel movement is regular and she usually smokes

whenever she wants to defecate. According to her, this helps her to feel the urge to defecate

and have an easy bowel movement. Her stool is usually brown in color and formed and but

she does not feel any discomfort during elimination. She voids 3-4 times a day and her urine

was yellowish in color. She also does not experience any discomfort while voiding.

6. Sexuality/ Reproductive

The client had a cyst on her right ovary several years ago. She had undergone

unilateral oophorectomy because of this. She married her husband and had her first

pregnancy at the age of 25. She does not take any pills or use any family planning methods.

She is contented with her sexuality at present because she already has four children. Her

menstruation started when she was 12 years old and describes her menstrual cycle as

regular, usually lasts for 4-5 days. The client sometimes experience heavy menstrual

periods in which she uses diapers and change 3 times in day. She had also experienced

dysmenorrhea during her adolescence. Her LMP was last September 7, 2010 and her OB

score is G6P4 40240 which indicates that she became pregnant six times and gave birth at

term four times, all under normal delivery.

7. Interpersonal Relationships/ Resources

The client states that she is a perfect mother, a perfect friend but an imperfect daughter.

She gets along well with other people and has many friends that she can go to in good and

in bad times. She is a member of the parents and teachers association in her children’s

school. Her support system is her mother because according to her, her mother knows

almost everything about her and definitely her mother knows what’s best for her. She states

that her relationship with her family is the most important relationship at present. Whenever

she has a problem, she does not go to any one for support because she wants to solve all

her problems by herself. She prefers to laugh with her family and friends instead of worrying

about her problems.

8. Coping and Stress Management/ Tolerance Pattern

The kinds of stresses she had in life were only minor ones. Most of the time, her stress

is because of financial problems in the family, including the house rental and allowance of

her children. However, she can still manage because of financial support given to her by her

family and relatives. She takes a rest when under stress so that she would regain energy

and to forget all about the things that brings stress to her life. She does not feel tense most

of the time. When she had big problems in her life, she goes to her family or friends, not to

talk about her problem but to laugh with them in order to forget all her problems. Most of the

time, this way is successful in handling her life problems.

9. Personal Habits

The client admits that she smokes whenever she wants to defecate. According to her,

this helps her to feel the urge to defecate and have an easy bowel movement. The client

also admitted that she sometimes consumes carbonated drinks but she is not an alcoholic

drinker.

10. Environmental Hazards

The client lives in three different houses. According to her, the houses are not far from

each other and can be reached through tricycle. The house where she lives has adequate

heat and utilities. There is no pollution in the neighborhood and only minimal noise can be

heard. One health hazard in the area is the clogged drainage system. The neighborhood in

which the client lives is safe because there is a baranggay tanod patrolling the area. When it

comes to transportation, there are tricycles that pass in front of their house and everything

was accessible due to this. The client is not involved in any community services. There are

no environmental hazards in the workplace. The client has never travelled to other countries

yet.

II. PROBLEM LIST

A. ACTUAL or Active

Problem No. Problem Date Identified Date Resolved/

Remarks

1

Acute Pain Sept. 16, 2010 Sept. 16, 2010

Resolved. Pt.

verbalized decrease

of pain.

2

Impaired Tissue

Integrity

Sept. 16, 2010 Sept. 16, 2010

Resolved. Pt. did

not show any signs

of infection.

3

Ineffective Health

Maintenance

Sept. 16, 2010 Sept. 16, 2010

Resolved. Pt. was

able to understand

ways to maintain

health.

B. HIGH RISK or Potential

Problem No. Problem Date Identified

1 Risk for Infection Sept. 16, 2010

III.NURSING CARE PLAN

CUESNURSING

DIAGNOSISLONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION

CUES NURSING

DIAGNOSIS

LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION

IV.ANATOMY AND PHYSIOLOGY

In physiology, the endocrine system is a system of glands, each of which

secretes a type of hormone into the bloodstream to regulate the body. The endocrine

system is an information signal system like the nervous system. Hormones regulate

many functions of an organism, including mood, growth and development, tissue

function, and metabolism.

The endocrine system is made up of a series of ductless glands that

produce chemicals called hormones. A number of glands that signal each other

in sequence is usually referred to as an axis, for example, the hypothalamic-

pituitary-adrenal axis. Typical endocrine glands are the pituitary, thyroid, and

adrenal glands. Features of endocrine glands are, in general, their ductless

nature, their vascularity, and usually the presence of intracellular vacuoles or

granules storing their hormones. In contrast, exocrine glands, such as salivary

glands, sweat glands, and glands within the gastrointestinal tract, tend to be

much less vascular and have ducts or a hollow lumen.

The thyroid gland is a butterfly-shape organ and is composed of two cone-

like lobes or wings, lobus dexter (right lobe) and lobus sinister (left lobe),

connected via the isthmus. The organ is situated on the anterior side of the neck,

lying against and around the larynx and trachea, reaching posteriorly the

oesophagus and carotid sheath. It starts cranially at the oblique line on the

thyroid cartilage (just below the laryngeal prominence, or 'Adam's Apple'), and

extends inferiorly to approximately the fifth or sixth tracheal ring. It is difficult to

demarcate the gland's upper and lower border with vertebral levels because it

moves position in relation to these during swallowing.

In vertebrate anatomy, the thyroid gland or simply, the thyroid, is one of

the largest endocrine glands in the body, and is not to be confused with the

"parathyroid glands" (a completely different set of glands). The thyroid gland is

found in the neck, inferior to (below) the thyroid cartilage (also known as the

'Adam's Apple') and at approximately the same level as the cricoid cartilage. The

thyroid controls how quickly the body uses energy, makes proteins, and controls

how sensitive the body should be to other hormones.

The thyroid gland participates in these processes by producing thyroid

hormones, principally triiodothyronine (T3) and thyroxine (T4). These hormones

regulate the rate of metabolism and affect the growth and rate of function of

many other systems in the body. T3 and T4 are synthesized utilizing both iodine

and tyrosine. The thyroid gland also produces a hormone called 'calcitonin',

which plays a role in calcium homeostasis.

V. PATHOPHYSIOLOGY

VI.MEDICAL-SURGICAL MANAGEMENT

1. Procedure (USN, Gavage, CPT, Surgery, etc.)

PROCEDURE/DATE INDICATION/ANALYSIS

NURSING

RESPONSIBILITIES

(PRE, INTRA, POST)

Total Thyroidectomy

Sept. 15, 2010

-To remove the enlarge

thyroid

PRE:-give preview about the procedure to be done and let the surgeon to explain the rest-check for pre-op meds-check for the consent form-check for the right identity and procedure to be done

INTRA:-maintain sterility on the procedure

POST:-assist for the recovery of

the patient

2. Pharmacotherapeutics/ Medicines (IV Fluids, Drugs)

GN (BN)

Classification

Stock Dose

Indication (client-specific)

Dosage

Frequency

NURSING

RESPONSIBILITIES

(PRE, INTRA, POST)

Ketorolac(Kortezor)

NSAID

30mg

Injectio: 30mg/ml

I:Pain

D: 30mg

F: Q6 X 6 doses

PRE:

- Check doctor’s order

INTRA :

- Check the right name of

drug and dose for the

patient.

POST:

- Monitor side effects.

Celebrex (Celebrex)

NSAID

Capsules: 200mg

I:Pain

D:200mg

F:BID

PRE:

- Check doctor’s order

INTRA :

- Check the right name of

drug and dose for the

patient.

-Give drug after meals.

POST:

- Monitor for adverse drug

reactions

Ciprofloxacin (Cipro)

Fluoroquinolones

Tablets: 500mg

I: Prophylaxis

D:500 mg

F: BID

PRE:

- Check doctor’s order

INTRA :

- Check the right name of

drug and dose for the

patient.

-Give drug after meals.

POST:

- Monitor for adverse drug

reactions

Calcium Carbonate

(CalciAid)

Antacids

Tablets: 500mg

I: Rdeuce acid secretion

D: 500mg

F: TID

PRE:

- Check doctor’s order

INTRA :

- Check the right name of

drug and dose for the

patient.

- Give on an empty stomach.

POST:

- Monitor side effects.

Piroxicam (Macroxam)

NSAID

Patch: 48mg

I: mild to moderate pain

D: 48 mg

F: Patch x 3 days

PRE:

- Check doctor’s order

INTRA :

- Check the right name of

drug and dose for the

patient.

POST:

- Monitor side effects.

VII. PROGRESS NOTES

Day NumberExisting Cues; Interventions Actually Done (Nursing Collaborative);

Client’s Response

Day 1

Sept. 16,

2010

In the first day of contact, patient was received awake, conscious and

coherent in lying position. Patient had her heplock on her right metacarpal

vein. Her initial V/S was: BP: 130/60. PR: 80 bpm, RR 32cpm, T:36° C. She

is ambulatory. Patient had complained of her non-productive cough and

sore throat, thus given Sinecod Forte. Patient had fair skin turgor. And she

had a diet as tolerated.

Day 2

Sept. 17,

2010

During the second day of contact, patient was received awake, conscious

and coherent in sitting position. Patient had her heplock on her right

metacarpal vein. Her V/S was: BP: 90/60, PR: 72bpm, RR 18cpm, T: 36°

C. Patient was advised to go home and is instructed for his discharge plans

and maintenance. Patient had fair skin turgor. And she had a diet as

tolerated.

VIII. DISCHARGE HEALTH TEACHING PLANS

Contents Strategy

1. Compliance

a. Medications

b. Diet

The family together with the

patient will continue the

prescribed medications with

proper dosage and

frequency in order to hasten

the recovery of patient.

Take home meds:

1. Ciprofloxacin 500mg

1tab oral 8am

2. Meloxicam 15mg 1 tab

oral 8am

3. Bactroban ointment

4. Hydrogen peroxide

> Prepare foods that are low

> Informing the family

members about the

prescribed medications and

its importance regarding the

condition of the patient.

> Reminding and reviewing

the family members about

the drugs in order to make

the familiar with treatment.

> Advise the family

members to avoid using any

non-prescription drug unless

use is approved by the

physician.

> Encouraging the family

members to administer

medications exactly as

c. Activity/ Exercise

salt, high in protein and low

in fat for the patient in order

to prevent recurrence of the

illness. Also, the family

members will know and

follow the patient’s

restrictions in foods and

proper eating of healthy

foods.

> The patient will be

engaged on doing simple

range of motion exercise in

order to maintain muscle and

bones integrity as well as

maintaining a good body

circulation.

prescribed by the physician.

> Encouraging the family

members to follow the diet

and fluid intake

recommended by the

physician for the patient.

> Educating the family

members to follow the diet

and fluid intake

recommended by the

physician for the patient.

> Educating the family

members as well as the

patient about foods that are

healthy yet appropriate for

the diet of the patient.

> Teaching the relatives

about how to assist patient

do simple range of motion

exercises like flexion of

upper and lower extremities

or walking for a short

distance.

> Educating the relatives

about the importance of

exercise in the boy and its

benefits to once health.

2. Follow-up/ Check-up >Stress to the patient the

importance of scheduling

and keeping check-up

appointments and make sure

he has the doctor’s office

telephone number.

> Educating the patients’

relatives about the

importance of having a

regular check-up after

hospitalization.

IX.SUMMARY OF CLIENT”S STATUS OR CONDITION AS OF LAST DAY OF CONTACT

Date: Sept. 17, 2010

During the last day of contact, Ms. MGF was received awake, conscious, coherent in

sitting position. Her vital signs were taken BP: 90/60, PR: 72bpm, RR 18cpm, T: 36°

C. The patient was ready to go home. She is eager to go home and gradually get

back to her daily activities. And she was aware on the modifications she needs to do

with her lifestyle.