HEALTH HISTORY

I. BIOGRAPHIC DATA Name: Teresita Dacles Address: #165 A. Luna St. Barangay Salapan, City of San Juan, Metro Manila Age: 63 years old Gender: Female Date of Birth: April 21, 1958 Place of Birth: Cantanduanes Primary Language: Tagalog Marital Status: Separated Educational: Elementary Graduate Occupation: Laundry woman Religious Orientation: Roman Catholic II. PAST HEALTH HISTORY Though the client had complete immunizations during her childhood years, she still suffered from many childhood diseases such as measles, chicken pox, and mumps. During the interview, the client mentioned that she was allergic to foods such chicken, egg, sea foods, and eggplants. She said that she also experienced allergic reactions when she dyed her hair during her middle age years. Mouth sores and rashes were some of the manifestations that could be seen whenever she has allergic reactions. Other than those that have mentioned earlier, there were no other foods or drugs that cause allergy to the client. Her physician prescribed Anthraquinone Glycosides Salicylic Acid when she once had an allergy, and from then on, she kept on using it whenever an allergy occurs. The client was currently taking Metformin Hydrocloride as maintenance for Diabetes Mellitus. Aside from the maintenance, she was also taking vitamin B-complex because her physician said that it would improve her arthritis. The client had never been hospitalized and she did not suffer from any injuries or accidents even in her childhood days up to now, although she had been diagnosed to have UTI last 2010. The client added that she has been cured without taking medications by just increasing water intake and drinking buko juice frequently. She had neither local nor foreign travels in the past month; however, she came home to Bicol where her relatives lived last May 2011. III. FAMILY HEALTH HISTORY Both sides of the clients parents had history of asthma. It was passed to four of her siblings. Fortunately, she was not one of them. Her mother died due to heart attack at the age of 75, while her father was still alive, but diagnosed to have asthma. Their family did not have any history of hypertension, renal diseases, cardiovascular diseases, mental disorders, cancer and diabetes mellitus or thyroid disorders; however, she was diagnosed to have diabetes mellitus type II and goiter. One of her siblings died because of asthma attack, while the other one died due to lung cancer.

IV. FUNCTIONAL PATTERNS D. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN The client verbalized that her health is good, because she can do her activities of daily living without difficulties and she also does not get sick easily. She had been visiting her physician every three months for her check-up, and she strictly follows whatever the physicians orders are. Whenever she experiences dizziness and head ache, she just takes a rest until she feels better, and if not relieved, she takes Biogesic. She has not been taking any over-the-counter drugs except for Biogesic. She has been diagnosed to have sporadic goiter when she was carrying her fourth child in her womb (1988), but even after her pregnancy, she does not have any plans of undergoing any procedures. She verbalized, natakot akong magpaopera kasi yung pinsan ko nagkaroon din ng goiter, pinaopera niya. Pagkalipas ng tatlong buwan, bumalik din yung goiter niya. The client also verbalized, Pinainom naman na ako nung doktor ko ng pampaliit ng bukol, eh lumiit naman sya, kaya binale-wala ko na. As for her exercise, she has been doing the household chores everyday and every 4:00 a.m., she sweeps the street in front of the store of her daughter. She takes a bath twice a day, and brushes her teeth thrice a day. She does not visit a dentist for dental check-ups, because she does not have time to do so. She does neither cigarette smoking nor drinking any alcohol beverages.

ANALYSIS: Health-Perception-health Management patterns are influential in moving individuals, families, and communities toward their optimal level of human functioning. The two dimensions of this pattern interact: the way clients perceive their general health and health goals influences their health management practices. [Nursing Diagnosis p. 141]

E. NUTRITIONAL & METABOLIC PATTERN According to the client, she eats 3 meals a day and she takes her food slowly because she is having a slight difficulty in swallowing because of the mass in her throat. The dishes that she usually eats are made up of vegetables, since her physician advised her not to eat so much meats, legumes and sweets, as well as eggs due to her arthritis, goiter, diabetes mellitus and allergies. She drinks a cup of coffee for about once a day and 3-4 glasses of water per day. The client experienced neither weight loss nor weight gain as much as her appetite is neither increased nor decreased.

ANALYSIS: Diagnosis describing dysfunctional nutritional-metabolic patterns are bio psychosocial conditions related to nutrient intake and supply. Nutrients are necessary for cellular metabolic processes, such as energy production and synthesis of substances used in cellular function, growth and repair. Nutritional patterns are influenced by (1) Maturation,

(2) Family, Social and Cultural patterns, (3) Learned psychological associations between food and basic needs, (4) Environmental availability of foods. For example: as growth and maturation proceed, the type of foods ingested, method of ingestion, and the social psychological milieu of eating changes. Bottles and high chairs are replaced by family silverware and social dining. Bio Psychosocial factors (including cultural and spiritual) can lead to dysfunctional patterns, such as exogenous obesity and nutritional deficit. [Nursing Diagnosis p. 143]

F. ELIMINATION PATTERN The client defecates once a day, and she added, Okay naman yung dumi ko, hindi naman matigas, hindi rin matubig. Sakto lang. Hindi naman ako nahihirapan dumumi. As she estimated the number of times she urinates a day, she said four to six, and as she verbalized, Hindi naman mapusyaw, yung normal na kulay lang, hindi naman madilaw na madilaw ang ihi ko. Hindi naman din masakit pag umihi. She does not have excess perspiration and odor problems.

ANALYSIS: Elimination from the urinary tract helps to rid the body of waste products and materials that exceed bodily needs. Problem involving urinary elimination can be so embarrassing to patients that they may no longer participate in activities outside the home. [Taylor p. 1289] Elimination of the waste products of digestion is a natural process critical for human functioning. Patients differ widely in their expectations about bowel elimination, their usual pattern of defecation, and the ease with which they speak of bowel problems although most people have experienced minor acute bouts of diarrhea or constipation, some patient experienced severe or chronic alterations in bowel elimination that affect their fluid and electrolyte balance, hydration, nutritional status, skin integrity, comfort, and self-concept. Moreover, many illnesses, diagnostic tests, medications, and surgical treatments can affect bowel elimination. [Taylor p. 1337]

G. ACTIVITY- EXERCISE PATTERN Every 4:00 a.m., she sweeps the street in front of the store of her daughter and she helps in the store whenever there are many costumers. She also has a work, where she does the laundry three times a week and during her free days, she washes her and her daughters clothes. She does household chores for exercise. She does not engage with heavy work or exercise because of her goiter, she added, Masakit kasi kapag nagbubuhat ako ng mabigat o

di naman kayay kapag napapagod ako. Alam mo yung parang nakakasakal yung bara sa lalamunan. She is satisfied with the amount of her exercise that she has been doing because she can do her work properly. Whenever she has a spare time, she spends it helping her daughter in managing their store and in taking care of her grandchild.

ANALYSIS: The clients pattern of activity, exercise and leisure is a result of bio psychosocial factors. The pattern describes the clients ability and desire to engage with energy-consuming activities, such as play (child), work, exercise, self-care, and leisure. Ability is influenced by the development of coordination, strength, skill, endurance, and nutrients supply to tissues (cardiovascular and respiratory reserve). Loss of ability to engage in activities of daily living is associated with feelings of dependency and lack of control over the immediate environment. The desire to do energy-consuming activities and the choice of activities are influenced by psychological and socio-environmental factors such as motivation, mood state, and personal perception of benefits, risks, skill, and social acceptability. [Nursing Diagnosis p.146]

H. SLEEP-REST PATTERN She usually sleeps at 9:00 p.m. and wakes up at 4:00 a.m. She often has seven hours of sleep and when she wakes up, she feels refreshed. She can easily fall asleep. Sometimes, the sleeping pattern of the client is disturbed because of the barks of dogs outside her house, and also when she feels the urge to void. More often than not, she has difficulty in going back to sleep, but eventually, she will sleep again. She takes a nap sometimes if there is chance.

ANALYSIS: Sleep is a basic human need; it is a universal biological process common to all people. Humans spend about one-third of their lives as sleep. Sleep enhances daytime functioning. It is vital not only optimal psychological functioning but also physiological functioning as the rate of healing of damaged tissue is greatest during sleep. [p.1164 Kozier]

I.

COGNITIVE-PERCEPTUAL PATTERN

While the interaction is going on, our client is cooperating well and she is confident during the interview. She stated that she can read and write. However, she can only read well with the use of her correction glasses. The client does not have any problem in listening, speaking, and smelling.

ANALYSIS: Pertaining to the mental processes of knowing, perceiving, or being aware; an expression of intellectual capacity. In the case of our patient, she is educated and is actively participating in her school activities. She is very much aware of her cognitive condition. A patient with enough knowledge with her health situation is better than those who do not know. Collaborating with any health care provider will help a lot in his restoration of wellness. [Nursing Diagnosis p.150-151]

J . SELF-PERCEPTION AND SELF-CONCEPT PATTERNS She described herself as a happy and jolly person, and she feels good most of the time. She is not having a hard time in socializing with her family members and friends. She added, Okay naman, tingin ko naman, wala naman akong kaaway. She handles her problems lightly, and like what she said, Binabalewala ko na lang yung problema, lalo lang nakakatanda. Matanda na nga ako, iisipin ko pa ba yun? \

ANALYSIS: Self-concept is ones mental image of oneself. A positive self-concept is essential to a persons mental and physical health. Individuals with a relationship and resist psychological illness. [Kozier p.970]

K. ROLE- RELATIONSHIP PATTERN She lives with her sister, youngest daughter and son-in-law. She takes care of her youngest daughter who is pregnant. They have a good relationship with each other. The only problem that she encountered in her relationships was when she and her husband separated ten years ago because her husband had an affair with other woman. She also considers her son, as mentioned above, a problem whenever he comes home drunk. She is not a member of any social groups in their community, but she has a good relationship with her neighbours.

ANALYSIS: People establish relationships to meet the human need for contact and interaction with others. Role and Relationship serves as a structure for family units, friendships, works and play, community group and society. Dysfunctional patterns of role performance, interactions, and relationship can be the source of developmental problems or role stress in persons, families for communities. [ND 154}

L. SEXUALITY-REPRODUCTIVE PATTERN Her first menstruation started when she was 18 years of age. She had regular menstruation before, until the age of 59 when she got menopaused. Since when she had

separation from her husband, she never had any other affair and any sexual activity from then on up to the present.

ANALYSIS: Sexuality is degree to which a person exhibits and experiences maleness or femaleness physically, emotionally and mentally. Sexuality is define not only by the persons genitalia but also by attitudes and feelings. It can also be define as learned behaviours in how a person reacts to his or her own sexuality and by how one behaves in relationships with others. Sexuality is an integral part of a persons identity and is present in ones demeanor through actions, communications, and physical appearance. [Taylor p.931]

M. COPING-STRESS TOLERANCE PATTERN She feels happy most of the time, but if she feels stressed, she usually talks to her sister about her problems. She is not taking any medicines to cope with her stress; she only takes a rest. If she feels angry, she screams to release her feelings and emotions.

N. VALUE-BELIEF PATTERN The client has a very strong faith with God. Even though she is busy, she always finds time to pray at night and in the morning and attend mass every Sunday. Like what she said, Dapat unahin ang Diyos, higit sa kung ano pa man. Aside from that, she also takes care of herself well because she believes that Health is wealth.

ANALYSIS: Values, beliefs, goals and life commitments guide the choices made by a person, family, or community; they can influence the evaluation of situations in terms of personal meaning. Thus, values, beliefs, goals and commitments can explain why a situation may be stressful for one patient and not other and why one person is highly motivated in a situation and another is not. [Nursing Diagnosis p.160]

Institute of Nursing Nursing Care Plan

CUES Subjective: She does not have any plans of undergoing any procedures. She verbalized, natakot akong magpaopera kasi yung pinsan ko nagkaroon din ng goiter, pinaopera niya. Pagkalipas ng tatlong buwan, bumalik din yung goiter niya. The client also verbalized, Pinainom naman na ako nung doktor ko ng pampaliit ng bukol, eh lumiit naman sya, kaya binale-wala ko na. She does not engage with heavy work or exercise because of her goiter, she added, Masakit kasi kapag nagbubuhat ako ng mabigat o di naman kayay kapag napapagod ako. Alam mo yung parang nakakasakal yung bara sa lalamunan. NURSING DIAGNOSIS Deficient Knowledge related to Disease Process and Treatment Regimen ANALYSIS Deficient knowledge is the absence or deficiency of cognitive information related to specific topic or lack of specific information necessary for clients to make informed choices regarding condition, treatment, and/or lifestyle changes. (Nurses Pocket Guide, 12th edition, p.495) GOAL AND OBJECTIVE GOAL: After 1 day of nursing intervention, the client will have adequate knowledge regarding disease process and treatment regimen as evidenced by verbalization of understanding of condition, disease process and treatment. INTERVENTION Developmental; Independent

RA

To increa of knowle sporadic of compe meeting h independ

OBJECTIVES: a. After 10 minutes of discussion, the client will be able to define the conditiona nd nature of sporadic goiter in her own words and understanding. b. After 10 minutes of discussion, the client will be albe to enumerate at least 3 out of 5 signs and symptoms of a person having sporadic goiter. a. Discuss the definition of Sporadic Goiter.

A well inf better ab distressin

b. Discuss the signs and symptoms that can be manifested in a person having a Sporadic Goiter.

Provides developin identifyin needs.

c. After 10 minutes of discussion, the client will be able to understand and explain pathophysiology of sporadic goiiter in her own words.

c. Discuss the pathophysiology of Sporadic Goiter.

Knowledg factors en to begin t that may disease.

d. After 10 minutes of discussion, the client will be able to enumerate 3 out 5 management of clients with sporadic

d. Discuss the possible management for clients with Sporadic Goiter.

This fulfil deficit an with infor care.

goiter. e. After the 8-hour shift duty in the community, the client will start to apply the learned managements in her daily life, as manifested by: -verbalization of willingness to seek medical advice concerning her goiter -allotment of time for appointment with a physician for a check-up -physicians prescription or lab results (if possible)

V. PHYSICAL ASSESSMENT

Normal Findings BEHAVIOR Height Weight BMI Proportionate, varies with lifestyle Proportionate, varies with lifestyle Normal 18.6 to 22.9

Actual Findings 411 ft. 48 kgs. 19.5

Remarks Normal Normal Normal

MEASUREMENTS Body temperature Pulse rate 120mmHg/ 80mmHg Respiratory rate 12-20cpm Blood pressure 60-100bpm A. Describe the clients body built, height and weight in relation to clients age, lifestyle and behavior B. Describe the clients posture and gait, standing, sitting and walking C. Describe the clients overall hygiene and grooming D. Describe the body and breath odor E. Identify the signs of distress, in posture or facial expression F. Describe obvious signs of health or illness G. Describe the clients attitude H. Describe clients affect or mood; assess the appropriateness of the clients response I. Describe quantity and quality of speech

120mmHg/ 80mmHg 14cpm 83pbm

Normal Normal Normal

Proportionate Proportionate Normal varies with her age varies with her age and lifestyle and lifestyle

Relaxed and erect posture, coordinated movements Clean and neat appearance and well-groomed No body and breath odor No signs of distress noted Healthy appearance Coherent, conscious Appropriate to the situation

Relaxed and erect posture, coordinated movements Clean and neat appearance and well-groomed No body and breath odor No signs of distress noted Healthy appearance Coherent, conscious Appropriate to the situation

Normal

Normal

Normal Normal Normal Normal Normal

Understandable and moderate pace, exhibits thoughts association

Understandable and moderate pace, exhibits thoughts association

Normal

INTEGUMENTARY Skin Inspect for color, Generally, uniformity of color uniform except in areas exposed to the sun; areas lighter pigmentation (palms, lips, nail beds) in dark skinned people. ( Kozier pg. 579) Inspect for presence No presence of of edema edema ( Kozier pg. 579) Inspect for lesions No lesions or according to location, abrasion; Flat distribution, color, and raised nevi configuration, size, ( Kozier pg. 579) shape, type structure Palpate skin moisture Moisture in skin folds and axillae ( Kozier pg. 579) Palpate skin Uniform; with temperature normal range ( Kozier pg. 579) Palpate skin turgor When pinched, skin brings back to previous state ( Kozier pg. 579) Nails Inspect fingernail Convex plate shape to curvature; angle determine its of nail plate is curvature and angle about 160 degrees ( Kozier pg. 583) Inspect fingernail and Highly vascular toenail bed color and pink in light skinned clients; dark skinned clients may have

Generally, uniform except in areas exposed to the sun; areas lighter pigmentation (palms, lips, nail beds) in dark skinned people. No presence of edema No lesions or abrasion; Flat and raised nevi

Normal

Normal Normal

Skin on Abnormal extremities is dry Uniform; with normal range When pinched, skin brings back to previous state Slightly spoon nail in shape Normal Normal

Abnormal

Highly vascular and pink in light skinned clients; dark skinned clients may have

Normal

Palpate fingernail and toenail texture Inspect tissues surrounding nails Perform blanch test capillary refill

brown or black pigmentation in longitudinal streaks ( Kozier pg. 583) Smooth texture ( Kozier pg. 583) Intact epidermis ( Kozier pg. 583) Prompt return in pink or usual color ( Kozier pg. 583)

brown or black pigmentation in longitudinal streaks Rough Texture Hard skin Prompt return in pink or usual color Abnormal Abnormal Normal

HEAD TO TOE EXAMINATION HEAD Skull Inspect the skull for size, shape or symmetry Palpates for nodules, masses and depressions Scalp Inspect for color and appearance Rounded, smooth skull contour ( Kozier pg. 585) Smooth, uniform consistency; Absence of nodules or masses ( Kozier pg. 585) Rounded, smooth skull contour Normal

Smooth, uniform Normal consistency; Absence of nodules or masses White in color; no Normal dandruff No tenderness, nodules, masses and edema Normal

White in color; no dandruff ( Kozier pg. 582) Palpate for areas of No tenderness, tenderness nodules, masses and edema ( Kozier pg. 582) Hair Inspect for Evenly distributed evenness of hair; thick hair growth, thickness ( Kozier pg. 582) or thinness Palpate for texture Silky; Resilient and oiliness over hair

Evenly distributed Abnormal hair; white, thin hair Silky; Resilient hair Normal

the scalp Face Inspect the facial features, symmetry of facial movements

( Kozier pg. 582) Symmetric or slightly asymmetrical features; symmetrical facial movements ( Kozier pg. 585) Able to read newsprint ( Kozier pg. 588593) 20/20 vision on Snellen Chart ( Kozier pg. 588593) Hair evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement ( Kozier pg. 588593) Assymetrical Abnormal involuntary facial movements/ facial tremors

Eyes Visual acuity Test near vision

Able to read newsprint 500 lens grade

Normal

Test distance vision Eyebrows Inspect for hair distribution, alignment, skin and quality movement

Abnormal

Hair evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement

Normal

Eyelids Inspect for the surface characteristics, position in relation to the cornea, ability to blink; and frequency of blinking

Skin intact; no discharge; no discoloration; lids close symmetrically; approximately 1520 involuntary blinks per minute; bilateral blinking; when lids are open no visible sclera above

Skin intact; no Normal discharge; no discoloration; lids close symmetrically; 15 involuntary involuntary blinks per minute; bilateral blinking; when lids are open no visible sclera above

cornea, and upper and lower borders of cornea are slightly covered ( Kozier pg. 588593) Conjunctiva Inspect the bulbar for color, texture, and presence of lesions Transparent capillaries sometimes evident; sclera appears white (yellowish in dark skinned clients) ( Kozier pg. 588593) Inspect the Pinkish or red in palpebral color with conjunctiva for presence of color, texture, and capillaries; moist; presence of lesions no foreign bodies ( Kozier pg. 588593) Lacrimal gland, lacrimal sac and nasolacrimal duct Inspect and palpate No edema nor the lacrimal gland tenderness over lacrimal duct; no tearing ( Kozier pg. 588593) Sclera Inspect the color White; darker or and clarity yellowish with small brown macules in darkskinned clients ( Kozier pg. 588593) Cornea Inspect for clarity Transparent;

cornea, and upper and lower borders of cornea are slightly covered

Pale bulbar conjunctiva

Abnormal

Pale palpevral conjunctiva

Abnormal

No edema nor tenderness over lacrimal duct; no tearing

Normal

White; darker or yellowish with small brown macules in darkskinned clients

Normal

Transparent;

Normal

and texture

shiny; smooth; details of the iris are visible ( Kozier pg. 588593) Round; color depends on the persons face ( Kozier pg. 588593) Black; equal in size; normally 37mm in diameter; round; smooth border ( Kozier pg. 588593) Pupils constrict when looking at near objects; pupils dilate when looking at far objects; pupils converge when near object is moved towards the nose ( Kozier pg. 588593) Both eyes are coordinated; move in unison, with parallel alignment ( Kozier pg. 588593)

shiny; smooth; details of the iris are visible

Iris Inspect for shape and color

Round; color depends on the persons face

Normal

Pupils Inspect color, shape and symmetry of size

Black; equal in size; normally 37mm in diameter; round; smooth border

Normal

Test each pupil for light reaction and accommodation

Pupils constrict Normal when looking at near objects; pupils dilate when looking at far objects; pupils converge when near object is moved towards the nose

Extra ocular Muscles Test each eye for alignment and coordination

Both eyes are coordinated; move in unison, with parallel alignment

Normal

Visual Fields

Test peripheral fields

When looking straight ahead. The client can see object in periphery ( Kozier pg. 588593)

When looking straight ahead. The client can see object in periphery

Normal

EARS Auricles Inspect for color, symmetry and position

Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degree from vertical ( Kozier pg. 596598) Palpate for texture, Mobile; Elastic: elasticity and are of firm and not tenderness tender: Pinna recoils back after it is folded ( Kozier pg. 596598) External Ear canal Inspect ear canal Distal third for cerumen, skin contains hair lesion, pus and follicle and glands; blood (cerumen-grayish tan in color) ( Kozier pg. 596598) Hearing acuity test Assess clients Normal voice tones response to normal audible voice tones ( Kozier pg. 596598)

Color same as Normal facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degree from vertical Mobile; Elastic: firm and not tender: Pinna recoils back after it is folded Normal

Distal third contains hair follicle and glands; (cerumengrayish

Normal

Normal voice tones audible

Normal

Perform watch tick test Perform Webers test

Conduct Rinnes test

Able to hear a ticking in both ears ( Kozier pg. 596598) Sounds are heard in both ears or is localized at the center of the head; Weber(-) ( Kozier pg. 596598 Air conducted hearing is greater than bone conducted hearing; Rinne (+) ( Kozier pg. 596598) Symmetric; No dicharge; no flarin; uniform color ( Kozier pg. 600) Mucosa pink; clear; watery; no discharge; no lesions ( Kozier pg. 600)

Able to hear a ticking in both ears Sounds are heard in both ears

Normal

Abnormal

AC=BC

Abnormal

NOSE Inspect for any deviations, shape, size or color and flaring or discharge from nerves Inspect the nasal cavities for the presence of redness, swelling, growths and discharge, using the penlight Inspect the nasal septum between nasal chambers Test patency of both nasal cavities

Symmetric; No dicharge; no flarin; uniform color Mucosa pink; clear; watery; no discharge; no lesions

Normal

Normal

Nasal septum intact Nasal septum and in midline intact and in ( Kozier pg. 600) midline Air moves freely as the client breathes through the nares ( Kozier pg. 600) Air moves freely as the client breathes through the nares No tenderness; no lesion

Normal

Normal

Palpate for any No tenderness; no tenderness, masses, lesion displacements of ( Kozier pg. 600)

Normal

bone and cartilage SINUSES Locate/Palpate/iden tify the sinuses and note for tenderness MOUTH Lips Inspect for symmetry of contour, color, and texture Buccal Mucosa Inspect for color, moisture, texture and presence of lesions Teeth Inspect for color, number, and condition and presence of dentures Gums Inspect for the color and condition

No tenderness ( Kozier pg. 600)

No tenderness

Normal

Uniform pink color; moist; soft; glistening; elastic texture ( Kozier pg. 602604) Uniform pink color, moist; soft: glistening; elastic texture ( Kozier pg. 602604) 32 adult teeth; smooth, white; shiny tooth enamel ( Kozier pg. 602604) Pink gums; moist, firm texture to gums ( Kozier pg. 602604) Pink color; moist; slightly rough; presence of whitish coating; can moves freely; no tenderness ( Kozier pg. 602604)

Purplish in color

Abnormal

Slightly dry

Abnormal

10 lower teeth & 6 Abnormal upper teeth ,2 dental carrie son the lower premolars Pink gums; moist, firm texture to gums Normal

Tongue/floor of the mouth Inspect for color and texture of the mouth floor and frenulum

Pink color; moist; slightly rough; presence of whitish coating; can moves freely; no tenderness.

Normal

Inspect and palpate the position, color, and texture, movement and base of the tongue Palpate for any nodules, lumps or excoriated areas

Central position; pinkish in color; slightly rough; moves freely; no area of tenderness ( Kozier pg. 602604) Slightly rough; no palpable nodules, lumps or excoriated areas ( Kozier pg. 602604) Pink palate; hard palate; smooth and soft; more irregular texture (Kozier p.602-604) Positioned in midline of soft palate (Kozier p.602-604)

Central position; pinkish in color; slightly rough; moves freely; no area of tenderness Slightly rough; no palpable nodules, lumps or excoriated areas

Normal

Normal

Palates and uvula Inspect and palpate for color, shape, texture and the presence of bony prominences Inspect for position of the uvula and mobility while examining the palates Oropharynx and tonsils Inspect and palpate for color and texture Inspect the size of the tonsils, color and discharge Presence of gag reflex upon stimulation of the uvula and lower back of the tongue NECK AND LYMPH NODES Inspect the neck

Pink palate; hard Normal palate; smooth and soft; more irregular texture Positioned in midline of soft palate Normal

Pink and smooth posterior wall (Kozier p.602-604) Pink and smooth; no discharge; normal size (Kozier p.602-604) Presence of gag reflex (Kozier p.602-604)

Pink and smooth posterior wall Pink and smooth; no discharge; normal size Absence of gag reflux upon stimulation

Normal Normal

Abnormal

Muscles equal in

Muscles not equal

Abnormal

muscles for abnormal swellings or masses. Lymph nodes Locate/palpate/iden tify lymph nodes and note for tenderness Trachea Inspect and palpate for placement

size; head centered in size (Kozier p.607-610) Not palpable Palpable mass (Kozier p.602-604) Abnormal

Central placement in midline of neck are equal on both sides (Kozier p.602-604) Not visible on inspection (Kozier p.602-604) Lobes may not be palpated. If palpable lobes, they are small, smooth centrally located, painless and rise freely with swallowing (Kozier p.602-604) Spine vertically aligned (Kozier p.615-618) Uniform temperature; no tenderness; no masses (Kozier p.615-618) Full and symmetric chest expansion; thumbs separate 3-5 cm (1 to 2 inches)

Central placement Normal in midline of neck are equal on both sides Visible on inspection Abnormal

Thyroid gland Inspect symmetry and visible masses Palpate for smoothness and areas of enlargement, masses or nodules

Palpable lobes, Abnormal they are small, and smooth. Palpable mass is approximately 5cm in height. Its more prominent on the RIGHT side of the neck. Spine vertically aligned Uniform temperature; no tenderness; no masses Normal Normal

THORAX Posterior Thorax Inspect the spinal alignment Palpate for temperature, tenderness, and masses Assess respiratory excursion

Full and Normal symmetric chest expansion; thumbs separate 3-5 cm (1 to 2 inches)

Palpate vocal fremitus

(Kozier p.615-618) Bilateral symmetry of vocal fremitus; fremitus is heard most clearly in the apex of the lungs (Kozier p.615-618) Bronchial, vesicular and bronchovesicular breath sounds (Kozier p.615-618) Quiet, rhythmic and effortless respiration (inspiration and expiration) (Kozier p.615-618) Warm uniform temperature; No tenderness; no masses (Kozier p.615-618) Same as the posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue. (Kozier p.615-618) Bronchial (tubular) breath sounds (Kozier p.615-618)

Bilateral Normal symmetry of vocal fremitus; fremitus is heard most clearly in the apex of the lungs Bronchial, vesicular and bronchovesicular breath sounds Quiet, rhythmic and effortless respiration (inspiration and expiration) Warm uniform temperature; No tenderness; no masses Same as the posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue. Bronchial (tubular) breath sounds Normal

Auscultate the posterior thorax

Anterior Thorax Inspect breathing patterns

Normal

Palpate for temperature, tenderness, and masses Palpate vocal fremitus

Normal

Normal

Auscultate the trachea Auscultate the anterior thorax JUGULAR VEINS

Normal

Bronchovesicular Bronchovesicular and vesicular and vesicular breath sounds breath sounds (Kozier p.615-618)

Normal

Inspect Jugular veins MUSCULOSKEL ETAL SYSTEM Muscles a. Inspect the muscles for size. Compare the muscles on the side of the body (arm, thigh, calf) to the same muscle on the other side b. Inspect the muscle and tendons for contractures (shortening) c. Inspect the muscles for fasciculations and tremors. Inspect any tremors of the hands and arms out in front of the body d. Palpate muscle tonicity Bones a. Inspect the skeleton for normal structures and deformities 3. Joints a. Inspect joints for swelling ASSESS JOINT RANGE OF MOTION c. Upper extremities (shoulder and scapula) d. Upper

Veins not visible (Kozier p.615-618)

Normal

Equal size on both Equal size on both Normal side of the body side of the body (Kozier p.646-651)

No contractures No contractures (Kozier p.646-651) No fasciculations Presence of fine (Kozier p.646-651) tremors

Normal

Abnormal

Firm Firm (Kozier p.646-651) No deformities No deformities (Kozier p.646-651)

Normal Normal

No swelling No swelling (Kozier p.646-651)

Normal

Smooth coordinate Smooth coordinate Normal movements movements (Kozier p.646-651) Smooth coordinate Smooth coordinate Normal

extremities (elbows) e. Upper extremities (hands) f. Lower extremities (acetabulum or inguinal area) g. Lower extremities (popliteal) h. Lower extremities (ankles)

movements (Kozier p.646-651) Smooth coordinate movements (Kozier p.646-651) Smooth coordinate movements (Kozier p.646-651) Smooth coordinate movements (Kozier p.646-651) Smooth coordinate movements (Kozier p.646-651)

movements Smooth coordinate Normal movements Smooth coordinate Normal movements Smooth coordinate Normal movements Smooth coordinate Normal movements

VI. PROBLEM IDENTIFICATION

CLUSTERED DATA Subjective: She does not have any plans of undergoing any procedures. She verbalized, natakot akong magpaopera kasi yung pinsan ko nagkaroon din ng goiter, pinaopera niya. Pagkalipas ng tatlong buwan, bumalik din yung goiter niya. The client also verbalized, Pinainom naman na ako nung doktor ko ng pampaliit ng bukol, eh lumiit naman sya, kaya binale-wala ko na. She does not engage with heavy work or exercise because of her goiter, she added, Masakit kasi kapag nagbubuhat ako ng mabigat o di naman kayay kapag napapagod ako. Alam mo yung parang nakakasakal yung bara sa lalamunan. Subjective: She had been visiting her physician every three months for her check-up, and she strictly follows whatever the physicians orders are. The dishes that she usually eats are made up of vegetables, since her physician advised her not to eat so much meats, legumes and sweets, as well as eggs due to her arthritis, goiter, diabetes mellitus and allergies. She takes a nap sometimes if there is chance. She is not taking any medicines to cope with her stress; she only takes a rest. Subjective: Pinainom naman na ako nung doktor ko ng pampaliit ng bukol, eh lumiit naman sya, kaya binale-wala ko na. According to the client, she eats 3 times a day and she takes her food slowly because she is having a slight difficulty in swallowing because of the mass in her throat. Masakit kasi kapag nagbubuhat ako ng mabigat o di naman kayay kapag napapagod ako. Alam mo yung parang nakakasakal yung bara sa lalamunan. Objective: The thyroid gland is prominently visible on inspection, palpable and has visible pulsation. The palpable mass is 3.5cm in diameter by estimation.

NURSING DIAGNOSIS Deficient Knowledge related to Disease Process and Treatment Regimen

Readiness for Enhanced Comfort related to Presence of Mass in Neck

Risk for Aspiration

Far Eastern University Institute of Nursing PROBLEM PRIORITIZATION Health Problem Deficient Knowledge related to Disease Process and Treatment Regimen Rank 1 Justification Teaching the client regarding his health is very important because deficient knowledge has a significant impact on clients ability to make effective

decisions and to partner with his health care providers in his health care. It is a health threat that can lead to poorer health outcomes. (Black, 8th Edition, p.7) Readiness for Enhanced Comfort related to Presence of Mass in Neck 2 It is essential that the nurse validates that the behavior of interest is one the client truly wants to change. Readiness to change should be assessed early in the nurse-client interaction. It is a wellness state that allows the individual to have a better health if given enough attention and health teaching. (Black, 8th Edition, p.7) Risk identification and risk management counseling can prevent illness and injury. It is a health threat that may contribute to the occurrence of complications if not supervised by a health care provider. (Black, 8th Edition, p.16)

Risk for Aspiration