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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 client’s 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 physician’s 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,
1337] G. she sweeps the street in front of the store of her daughter and she helps in the store whenever there are many costumers.m.. hindi naman matigas. (4) Environmental availability of foods. she said four to six. Moreover. 1289] Elimination of the waste products of digestion is a natural process critical for human functioning. ELIMINATION PATTERN The client defecates once a day. She does household chores for exercise. Social and Cultural patterns. Hindi naman ako nahihirapan dumumi. hydration. Problem involving urinary elimination can be so embarrassing to patients that they may no longer participate in activities outside the home.(2) Family. For example: as growth and maturation proceed. She also has a work. diagnostic tests. ANALYSIS: Elimination from the urinary tract helps to rid the body of waste products and materials that exceed bodily needs. hindi naman madilaw na madilaw ang ihi ko. [Taylor p.” As she estimated the number of times she urinates a day. and as she verbalized. nutritional status. Patients differ widely in their expectations about bowel elimination. Sakto lang. and self-concept. many illnesses. Bio Psychosocial factors (including cultural and spiritual) can lead to dysfunctional patterns. 143] F. “Okay naman ‘yung dumi ko. She does not engage with heavy work or exercise because of her goiter.EXERCISE PATTERN Every 4:00 a. [Nursing Diagnosis p. “Masakit kasi kapag nagbubuhat ako ng mabigat o . (3) Learned psychological associations between food and basic needs. “Hindi naman mapusyaw. and the social psychological milieu of eating changes. such as exogenous obesity and nutritional deficit. comfort. method of ingestion. Hindi naman din masakit ‘pag umihi. and the ease with which they speak of bowel problems although most people have experienced minor acute bouts of diarrhea or constipation. she washes her and her daughter’s clothes. and she added. [Taylor p. Bottles and high chairs are replaced by family silverware and social dining. some patient experienced severe or chronic alterations in bowel elimination that affect their fluid and electrolyte balance. she added. and surgical treatments can affect bowel elimination. ACTIVITY. hindi rin matubig. skin integrity. ‘yung normal na kulay lang. medications. the type of foods ingested. their usual pattern of defecation.” She does not have excess perspiration and odor problems. where she does the laundry three times a week and during her free days.
but eventually. [Nursing Diagnosis p. and smelling. it is a universal biological process common to all people. . She stated that she can read and write. The pattern describes the client’s ability and desire to engage with energy-consuming activities. exercise and leisure is a result of bio psychosocial factors. ANALYSIS: Sleep is a basic human need. the sleeping pattern of the client is disturbed because of the barks of dogs outside her house. She often has seven hours of sleep and when she wakes up. she spends it helping her daughter in managing their store and in taking care of her grandchild. COGNITIVE-PERCEPTUAL PATTERN While the interaction is going on. Loss of ability to engage in activities of daily living is associated with feelings of dependency and lack of control over the immediate environment. Alam mo ‘yung parang nakakasakal ‘yung bara sa lalamunan.m.” She is satisfied with the amount of her exercise that she has been doing because she can do her work properly. It is vital not only optimal psychological functioning but also physiological functioning as the rate of healing of damaged tissue is greatest during sleep. ANALYSIS: The client’s pattern of activity. exercise. work. and social acceptability. She can easily fall asleep. she can only read well with the use of her correction glasses. she feels refreshed. The desire to do energy-consuming activities and the choice of activities are influenced by psychological and socio-environmental factors such as motivation. However. and leisure. The client does not have any problem in listening.di naman kaya’y kapag napapagod ako.146] H. [p. and wakes up at 4:00 a. Whenever she has a spare time. our client is cooperating well and she is confident during the interview.1164 Kozier] I. mood state. Sometimes. Ability is influenced by the development of coordination. risks. skill. and also when she feels the urge to void. SLEEP-REST PATTERN She usually sleeps at 9:00 p. skill. self-care. and nutrients supply to tissues (cardiovascular and respiratory reserve). strength. she will sleep again. speaking. and personal perception of benefits. endurance. she has difficulty in going back to sleep.m. Humans spend about one-third of their lives as sleep. such as play (child). She takes a nap sometimes if there is chance. More often than not. Sleep enhances daytime functioning.
ANALYSIS: People establish relationships to meet the human need for contact and interaction with others. She is not having a hard time in socializing with her family members and friends. and relationship can be the source of developmental problems or role stress in persons. Since when she had . and she feels good most of the time. “Binabalewala ko na lang ‘yung problema. She also considers her son. She added. interactions. Dysfunctional patterns of role performance.970] K. families for communities. Role and Relationship serves as a structure for family units. A patient with enough knowledge with her health situation is better than those who do not know.150-151] J .RELATIONSHIP PATTERN She lives with her sister. [Nursing Diagnosis p. an expression of intellectual capacity. or being aware. and like what she said. 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. friendships.ANALYSIS: Pertaining to the mental processes of knowing. youngest daughter and son-in-law. SELF-PERCEPTION AND SELF-CONCEPT PATTERNS She described herself as a happy and jolly person. community group and society. wala naman akong kaaway. [ND 154} L. She takes care of her youngest daughter who is pregnant. She had regular menstruation before. They have a good relationship with each other. she is educated and is actively participating in her school activities. She is not a member of any social groups in their community. iisipin ko pa ba yun?” \ ANALYSIS: Self-concept is one’s mental image of oneself. She is very much aware of her cognitive condition. but she has a good relationship with her neighbours. Matanda na nga ako. as mentioned above. “Okay naman. ROLE. a problem whenever he comes home drunk. lalo lang nakakatanda. [Kozier p. until the age of 59 when she got menopaused. A positive self-concept is essential to a person’s mental and physical health. perceiving. works and play. tingin ko naman. SEXUALITY-REPRODUCTIVE PATTERN Her first menstruation started when she was 18 years of age. Individuals with a relationship and resist psychological illness. In the case of our patient.” She handles her problems lightly. Collaborating with any health care provider will help a lot in his restoration of wellness.
Sexuality is define not only by the person’s genitalia but also by attitudes and feelings. [Nursing Diagnosis p.931] M. beliefs. emotionally and mentally. they can influence the evaluation of situations in terms of personal meaning. goals and life commitments guide the choices made by a person. values.separation from her husband. but if she feels stressed. If she feels angry. VALUE-BELIEF PATTERN The client has a very strong faith with God.” Aside from that. she always finds time to pray at night and in the morning and attend mass every Sunday. she only takes a rest. higit sa kung ano pa man. Thus. she screams to release her feelings and emotions. Like what she said. communications. ANALYSIS: Sexuality is degree to which a person exhibits and experiences maleness or femaleness physically. and physical appearance.” ANALYSIS: Values. she never had any other affair and any sexual activity from then on up to the present. She is not taking any medicines to cope with her stress. 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 person’s identity and is present in ones demeanor through actions. [Taylor p. she usually talks to her sister about her problems.160] . COPING-STRESS TOLERANCE PATTERN She feels happy most of the time. beliefs. N. family. “Dapat unahin ang Diyos. or community. she also takes care of herself well because she believes that “Health is wealth. Even though she is busy. 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.
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. Knowledg factors en to begin t that may disease.Institute of Nursing Nursing Care Plan CUES Subjective: She does not have any plans of undergoing any procedures. c. a. the client will be albe to enumerate at least 3 out of 5 signs and symptoms of a person having sporadic goiter. Pagkalipas ng tatlong buwan. bumalik din ‘yung goiter niya. p.” 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.” The client also verbalized. the client will be able to enumerate 3 out 5 management of client’s with sporadic d. and/or lifestyle changes. Provides developin identifyin needs. INTERVENTION Developmental. d. .” She does not engage with heavy work or exercise because of her goiter. Discuss the possible management for clients with Sporadic Goiter. Alam mo ‘yung parang nakakasakal ‘yung bara sa lalamunan. 12th edition. She verbalized. the client will be able to understand and explain pathophysiology of sporadic goiiter in her own words. (Nurse’s Pocket Guide. Discuss the definition of Sporadic Goiter. “Pinainom naman na ako nung doktor ko ng pampaliit ng bukol.495) GOAL AND OBJECTIVE GOAL: After 1 day of nursing intervention. b. After 10 minutes of discussion. c. kaya binale-wala ko na. eh lumiit naman ‘sya. “natakot akong magpaopera kasi ‘yung pinsan ko nagkaroon din ng goiter. Independent RA To increa of knowle sporadic of compe meeting h independ OBJECTIVES: a. she added. This fulfil deficit an with infor care. After 10 minutes of discussion. Discuss the pathophysiology of Sporadic Goiter. A well inf better ab distressin b. After 10 minutes of discussion. pinaopera niya. the client will have adequate knowledge regarding disease process and treatment regimen as evidenced by verbalization of understanding of condition. “Masakit kasi kapag nagbubuhat ako ng mabigat o di naman kaya’y kapag napapagod ako. disease process and treatment. Discuss the signs and symptoms that can be manifested in a person having a Sporadic Goiter.
e. the client will start to apply the learned managements in her daily life. After the 8-hour shift duty in the community.goiter. 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 -physician’s prescription or lab results (if possible) .
PHYSICAL ASSESSMENT .V.
19. Describe client’s affect or mood. varies with lifestyle Normal 18.5 Remarks Normal Normal Normal MEASUREMENTS Body temperature Pulse rate 120mmHg/ 80mmHg Respiratory rate 12-20cpm Blood pressure 60-100bpm A. exhibits thoughts association Understandable and moderate pace. coordinated movements Clean and neat appearance and well-groomed No body and breath odor No signs of distress noted Healthy appearance Coherent. Describe the client’s body built. lifestyle and behavior B.9 Actual Findings 4’11” ft. standing. height and weight in relation to client’s age. Describe the body and breath odor E. Describe the clients posture and gait. conscious Appropriate to the situation Relaxed and erect posture.Normal Findings BEHAVIOR • Height • Weight • BMI Proportionate.6 to 22. in posture or facial expression F. Describe obvious signs of health or illness G. 48 kgs. coordinated movements Clean and neat appearance and well-groomed No body and breath odor No signs of distress noted Healthy appearance Coherent. 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. Describe the client’s overall hygiene and grooming D. varies with lifestyle Proportionate. sitting and walking C. conscious Appropriate to the situation Normal Normal Normal Normal Normal Normal Normal Understandable and moderate pace. assess the appropriateness of the client’s response I. exhibits thoughts association Normal . Describe the client’s attitude H. Identify the signs of distress.
color. nail beds) in dark skinned people. No presence of edema No lesions or abrasion. 583) Inspect fingernail and Highly vascular toenail bed color and pink in light skinned clients. areas lighter pigmentation (palms. ( Kozier pg. lips. 579) Inspect for lesions No lesions or according to location. 579) Nails Inspect fingernail Convex plate shape to curvature.INTEGUMENTARY Skin Inspect for color. lips. uniformity of color uniform except in areas exposed to the sun. with temperature normal range ( Kozier pg. dark skinned clients may have Normal . uniform except in areas exposed to the sun. Flat distribution. with normal range When pinched. 579) Palpate skin turgor When pinched. areas lighter pigmentation (palms. nail beds) in dark skinned people. skin brings back to previous state Slightly spoon nail in shape Normal Normal Abnormal Highly vascular and pink in light skinned clients. 579) Palpate skin Uniform. Generally. 579) shape. ( Kozier pg. dark skinned clients may have Generally. Flat and raised nevi Normal Normal Normal Skin on Abnormal extremities is dry Uniform. skin brings back to previous state ( Kozier pg. 579) Inspect for presence No presence of of edema edema ( Kozier pg. abrasion. angle determine its of nail plate is curvature and angle about 160 degrees ( Kozier pg. size. and raised nevi configuration. type structure Palpate skin moisture Moisture in skin folds and axillae ( Kozier pg.
583) Prompt return in pink or usual color ( Kozier pg. uniform Normal consistency. 583) Smooth texture ( Kozier pg. smooth skull contour ( Kozier pg. nodules. masses and edema Normal White in color. masses and depressions Scalp Inspect for color and appearance Rounded. uniform consistency. shape or symmetry Palpates for nodules. thick hair growth. no dandruff ( Kozier pg. masses and edema ( Kozier pg. 583) Intact epidermis ( Kozier pg. 582) or thinness Palpate for texture Silky. 582) Hair Inspect for Evenly distributed evenness of hair. thickness ( Kozier pg. 585) Rounded. 582) Palpate for areas of No tenderness. Absence of nodules or masses White in color. 585) Smooth. Absence of nodules or masses ( Kozier pg. no Normal dandruff No tenderness. smooth skull contour Normal Smooth. 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. white. tenderness nodules. Resilient hair Normal . Resilient and oiliness over hair Evenly distributed Abnormal hair. thin hair Silky.Palpate fingernail and toenail texture Inspect tissues surrounding nails Perform blanch test capillary refill brown or black pigmentation in longitudinal streaks ( Kozier pg.
588593) Hair evenly distributed. no discharge. symmetry of facial movements ( Kozier pg. 585) Able to read newsprint ( Kozier pg. eyebrows symmetrically aligned.the scalp Face Inspect the facial features. bilateral blinking. skin intact. 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. lids close symmetrically. 582) Symmetric or slightly asymmetrical features. when lids are open no visible sclera above Skin intact. ability to blink. skin intact. lids close symmetrically. 15 involuntary involuntary blinks per minute. equal movement Normal Eyelids Inspect for the surface characteristics. 588593) 20/20 vision on Snellen Chart ( Kozier pg. bilateral blinking. symmetrical facial movements ( Kozier pg. skin and quality movement Abnormal Hair evenly distributed. no Normal discharge. approximately 1520 involuntary blinks per minute. position in relation to the cornea. equal movement ( Kozier pg. when lids are open no visible sclera above . no discoloration. alignment. no discoloration. and frequency of blinking Skin intact. eyebrows symmetrically aligned.
moist. 588593) Cornea Inspect for clarity Transparent. no tearing ( Kozier pg. 588593) Conjunctiva Inspect the bulbar for color.cornea. cornea. darker or yellowish with small brown macules in darkskinned clients Normal Transparent. 588593) Inspect the Pinkish or red in palpebral color with conjunctiva for presence of color. no tearing Normal White. Normal . 588593) Sclera Inspect the color White. and upper and lower borders of cornea are slightly covered ( Kozier pg. presence of lesions no foreign bodies ( Kozier pg. texture. darker or and clarity yellowish with small brown macules in darkskinned clients ( Kozier pg. and capillaries. 588593) Lacrimal gland. sclera appears white (yellowish in dark skinned clients) ( Kozier pg. lacrimal sac and nasolacrimal duct Inspect and palpate No edema nor the lacrimal gland tenderness over lacrimal duct. and presence of lesions Transparent capillaries sometimes evident. texture. 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.
588593) shiny. pupils dilate when looking at far objects. with parallel alignment ( Kozier pg. 588593) Pupils constrict when looking at near objects. round. color depends on the person’s face Normal Pupils Inspect color. pupils converge when near object is moved towards the nose ( Kozier pg. equal in size. 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.and texture shiny. smooth border Normal Test each pupil for light reaction and accommodation Pupils constrict Normal when looking at near objects. smooth. pupils dilate when looking at far objects. normally 37mm in diameter. shape and symmetry of size Black. round. details of the iris are visible ( Kozier pg. details of the iris are visible Iris Inspect for shape and color Round. smooth border ( Kozier pg. move in unison. with parallel alignment Normal Visual Fields . 588593) Black. color depends on the person’s face ( Kozier pg. normally 37mm in diameter. 588593) Both eyes are coordinated. 588593) Round. smooth. equal in size.
(cerumengrayish Normal Normal voice tones audible Normal . skin contains hair lesion. about 10 degree from vertical Mobile. 596598) Palpate for texture. Elastic: firm and not tender: Pinna recoils back after it is folded Normal Distal third contains hair follicle and glands. auricle aligned with outer canthus of eye. Mobile. 596598) Color same as Normal facial skin. blood (cerumen-grayish tan in color) ( Kozier pg. pus and follicle and glands. symmetry and position Color same as facial skin. 596598) Hearing acuity test Assess client’s Normal voice tones response to normal audible voice tones ( Kozier pg. 588593) When looking straight ahead. about 10 degree from vertical ( Kozier pg. auricle aligned with outer canthus of eye. The client can see object in periphery Normal EARS Auricles Inspect for color. The client can see object in periphery ( Kozier pg. symmetrical. symmetrical. 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.Test peripheral fields When looking straight ahead.
growths and discharge. 596598) Sounds are heard in both ears or is localized at the center of the head. 600) Normal . No dicharge. no lesion Normal Normal Palpate for any No tenderness. Weber(-) ( 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. Rinne (+) ( Kozier pg. uniform color Mucosa pink. uniform color ( Kozier pg. clear. lesion displacements of ( Kozier pg. size or color and flaring or discharge from nerves Inspect the nasal cavities for the presence of redness. watery. no lesions Normal Normal Nasal septum intact Nasal septum and in midline intact and in ( Kozier pg.Perform watch tick test Perform Weber’s test Conduct Rinne’s test Able to hear a ticking in both ears ( Kozier pg. no discharge. no lesions ( Kozier pg. 596598 Air conducted hearing is greater than bone conducted hearing. 600) Mucosa pink. 596598) Symmetric. No dicharge. clear. no tenderness. no flarin. 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 flarin. swelling. masses. watery. shape. using the penlight Inspect the nasal septum between nasal chambers Test patency of both nasal cavities Symmetric. no discharge.
texture and presence of lesions Teeth Inspect for color. 602604) Purplish in color Abnormal Slightly dry Abnormal 10 lower teeth & 6 Abnormal upper teeth . soft. firm texture to gums ( Kozier pg. no tenderness. elastic texture ( Kozier pg. and texture Buccal Mucosa Inspect for color. moist. white. 600) No tenderness Normal Uniform pink color. color. slightly rough. moist. moist. glistening. presence of whitish coating. smooth. slightly rough. 602604) Pink color. and condition and presence of dentures Gums Inspect for the color and condition No tenderness ( Kozier pg. moist. moist. moist. no tenderness ( Kozier pg. elastic texture ( Kozier pg.bone and cartilage SINUSES Locate/Palpate/iden tify the sinuses and note for tenderness MOUTH Lips Inspect for symmetry of contour. firm texture to gums Normal Tongue/floor of the mouth Inspect for color and texture of the mouth floor and frenulum Pink color. presence of whitish coating. number. Normal . 602604) 32 adult teeth. shiny tooth enamel ( Kozier pg.2 dental carrie son the lower premolars Pink gums. 602604) Pink gums. can moves freely. 602604) Uniform pink color. can moves freely. moisture. soft: glistening.
normal size Absence of gag reflux upon stimulation Normal Normal Abnormal Muscles equal in Muscles not equal Abnormal . slightly rough. smooth and soft.602-604) Pink and smooth. pinkish in color. more irregular texture (Kozier p. moves freely.Inspect and palpate the position. no palpable nodules. smooth and soft. lumps or excoriated areas ( Kozier pg. no area of tenderness Slightly rough.602-604) Presence of gag reflex (Kozier p.602-604) Positioned in midline of soft palate (Kozier p. 602604) Pink palate.602-604) Pink and smooth posterior wall Pink and smooth. moves freely. lumps or excoriated areas Normal Normal Palates and uvula Inspect and palpate for color. shape. no area of tenderness ( Kozier pg. lumps or excoriated areas Central position. no palpable nodules. hard palate. slightly rough. more irregular texture Positioned in midline of soft palate Normal Pink and smooth posterior wall (Kozier p. hard Normal palate. normal size (Kozier p. 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. and texture. movement and base of the tongue Palpate for any nodules.602-604) Central position. no discharge. 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. pinkish in color. no discharge. 602604) Slightly rough. color.
Palpable mass is approximately 5cm in height.602-604) Spine vertically aligned (Kozier p.607-610) Not palpable Palpable mass (Kozier p. and smooth.602-604) Abnormal Central placement in midline of neck are equal on both sides (Kozier p. tenderness. painless and rise freely with swallowing (Kozier p. If palpable lobes.602-604) Not visible on inspection (Kozier p. they are small. thumbs separate 3-5 cm (1 ½ 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. no masses (Kozier p. head centered in size (Kozier p. Spine vertically aligned Uniform temperature. and masses Assess respiratory excursion Full and Normal symmetric chest expansion. thumbs separate 3-5 cm (1 ½ to 2 inches) . no tenderness.615-618) Full and symmetric chest expansion.muscles for abnormal swellings or masses.602-604) Lobes may not be palpated. no tenderness. smooth centrally located. masses or nodules Palpable lobes. It’s more prominent on the RIGHT side of the neck. Lymph nodes Locate/palpate/iden tify lymph nodes and note for tenderness Trachea Inspect and palpate for placement size.615-618) Uniform temperature. Abnormal they are small. no masses Normal Normal THORAX Posterior Thorax Inspect the spinal alignment Palpate for temperature.
Bronchial (tubular) breath sounds Normal Auscultate the posterior thorax Anterior Thorax Inspect breathing patterns Normal Palpate for temperature.615-618) Quiet.615-618) Bilateral Normal symmetry of vocal fremitus. No tenderness.615-618) Bronchial (tubular) breath sounds (Kozier p.615-618) Normal .Palpate vocal fremitus (Kozier p.615-618) Bilateral symmetry of vocal fremitus. rhythmic and effortless respiration (inspiration and expiration) (Kozier p. No 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. fremitus is normally decreased over heart and breast tissue.615-618) Same as the posterior vocal fremitus. fremitus is heard most clearly in the apex of the lungs (Kozier p.615-618) Warm uniform temperature.615-618) Bronchial. tenderness. no masses (Kozier p. rhythmic and effortless respiration (inspiration and expiration) Warm uniform temperature. fremitus is normally decreased over heart and breast tissue. vesicular and bronchovesicular breath sounds Quiet. vesicular and bronchovesicular breath sounds (Kozier p. no masses Same as the posterior vocal fremitus. fremitus is heard most clearly in the apex of the lungs Bronchial. (Kozier p.
Compare the muscles on the side of the body (arm. Joints a. Inspect the muscles for fasciculations and tremors.646-651) No contractures No contractures (Kozier p. Upper Veins not visible (Kozier p.646-651) No fasciculations Presence of fine (Kozier p. Inspect any tremors of the hands and arms out in front of the body d. Palpate muscle tonicity Bones a. Upper extremities (shoulder and scapula) d. calf) to the same muscle on the other side b. Inspect the muscle and tendons for contractures (shortening) c. thigh.646-651) Normal Normal No swelling No swelling (Kozier p.646-651) Normal Smooth coordinate Smooth coordinate Normal movements movements (Kozier p. Inspect joints for swelling ASSESS JOINT RANGE OF MOTION c.615-618) Normal Equal size on both Equal size on both Normal side of the body side of the body (Kozier p. Inspect the muscles for size.Inspect Jugular veins MUSCULOSKEL ETAL SYSTEM Muscles a.646-651) No deformities No deformities (Kozier p. Inspect the skeleton for normal structures and deformities 3.646-651) tremors Normal Abnormal Firm Firm (Kozier p.646-651) Smooth coordinate Smooth coordinate Normal .
Lower extremities (popliteal) h.646-651) Smooth coordinate movements (Kozier p. Lower extremities (acetabulum or inguinal area) g.646-651) Smooth coordinate movements (Kozier p. Upper extremities (hands) f.646-651) Smooth coordinate movements (Kozier p. PROBLEM IDENTIFICATION . Lower extremities (ankles) movements (Kozier p.646-651) Smooth coordinate movements (Kozier p.extremities (elbows) e.646-651) movements Smooth coordinate Normal movements Smooth coordinate Normal movements Smooth coordinate Normal movements Smooth coordinate Normal movements VI.
“natakot akong magpaopera kasi ‘yung pinsan ko nagkaroon din ng goiter. kaya binale-wala ko na. The palpable mass is 3. as well as eggs due to her arthritis. eh lumiit naman ‘sya. Alam mo ‘yung parang nakakasakal ‘yung bara sa lalamunan.” According to the client.CLUSTERED DATA Subjective: She does not have any plans of undergoing any procedures. 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 . She verbalized. “Pinainom naman na ako nung doktor ko ng pampaliit ng bukol. Alam mo ‘yung parang nakakasakal ‘yung bara sa lalamunan. 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. diabetes mellitus and allergies. “Masakit kasi kapag nagbubuhat ako ng mabigat o di naman kaya’y kapag napapagod ako. since her physician advised her not to eat so much meats.” The client also verbalized. She is not taking any medicines to cope with her stress.5cm in diameter by estimation. and she strictly follows whatever the physician’s orders are. she added. palpable and has visible pulsation. kaya binale-wala ko na.” Objective: The thyroid gland is prominently visible on inspection. “Masakit kasi kapag nagbubuhat ako ng mabigat o di naman kaya’y kapag napapagod ako. bumalik din ‘yung goiter niya. goiter. eh lumiit naman ‘sya. legumes and sweets.” She does not engage with heavy work or exercise because of her goiter. pinaopera niya. Subjective: “Pinainom naman na ako nung doktor ko ng pampaliit ng bukol. The dishes that she usually eats are made up of vegetables. she only takes a rest. She takes a nap sometimes if there is chance. Pagkalipas ng tatlong buwan.” Subjective: She had been visiting her physician every three months for her check-up.
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 client’s ability to make effective - .
(Black. p. It is a wellness state that allows the individual to have a better health if given enough attention and health teaching. p. It is a health threat that can lead to poorer health outcomes. It is a health threat that may contribute to the occurrence of complications if not supervised by a health care provider.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. p. 8th Edition. Readiness to change should be assessed early in the nurse-client interaction. 8th Edition.16) Risk for Aspiration 3 - .7) Risk identification and risk management counseling can prevent illness and injury. 8th Edition. (Black. (Black.decisions and to partner with his health care providers in his health care.
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