People Ke. Africa and The Western Pacifi People (WHO

INTRODUCTION
The concept for this case study is cancer. Cancer is a group of diseases
involving abnormal cell growth with the potential to invade or spread to other parts of the
body. Unfortunately, we weren’t able to find a cancer case during our exposure in the
clinical area. The topic that we have chosen for our case study is Toxic Multinodular
Goiter.
Our patient has a final diagnosis of Toxic Multinodular Goiter in Euthyroid State.
Multinodular goiter is the most common of all the disorders of the
thyroid gland. Toxic Multinodular Goiter is also known as Toxic Nodular Goiter, this
is basically the excessive secretion of thyroid hormones (thyroxine) which is
characterized by the enlargement of thyroid gland and presence of multiple nodules.
This is most often detected simply as a mass in the neck, but sometimes an enlarging
gland produces pressure symptoms. (Dua, S, 2015).
The incidence of goiter, diffuse and nodular, is very much

dependent on the status of iodine intake of the population. In areas of
iodine deficiency, goiter prevalence may be very high and especially in
goiters of longstanding, multinodularity develops frequently. Single
and multiple thyroid nodules were found in 0.8% of men and 5.3% of
women with a ratio of 13:1, with an increased frequency in women
over 45 years of age. In general, in iodine sufficient countries the
prevalence of multinodular goiter is not higher than 4. In countries
with previous deficiency that was corrected by universal salt
iodination, elderly subjects may have an incidence of, approximately,
10% of nodular and multinodular goiter, attributed to lack of nutritional
iodine in early adult life. The most affected region is South-East Asia where 96
million people have a low iodine inta ke. Africa and the Western Pacifi c follow, both with an
estimated 50 million people with a low iodine intake. (WHO, 2010). In the Philippines,
thyroid disorders still affect a significant segment of Philippine society, the 2013
National Nutrition Survey revealed that about 5.8 million Filipinos were afflicted with
thyroid disorders in different clinical presentations and 55% were females with a mean
age of 48 years (DOH, 2013).
Our patient is a 63 years old female who came in due to dysphagia last
November 16, 2018 @ San Lorenzo Ward, Room 306-1 and was scheduled for total
thyroidectomy. We chose her as our client for our case study since, by her disease
condition we will learn more about its disease process and management which will help
us enhance our knowledge and skills as a student nurse. Also, our patient have agreed
to be a part of our case study and shows willingness during our interview.
In Nursing Education, this case study will serve as an additional learning for us
and will broaden our knowledge as student nurses in regards with the disease condition
and management given to our client. We can also apply what we have learned form our
lectures, in to the clinical setting. For the Nursing Practice, it will enhance our
knowledge, skills, attitude and confidence in dealing with our patient and this will also
serve as a guide for us in the future in times we will get to encounter the same disease
condition in the clinical area. Lastly, in Nursing Research, we can use this study as a
guide or basis if we wanted to further study or enhance this topic regarding with its
disease process, management, and interventions to be given.
GOAL
That within our 4 weeks of Cancer Nursing Rotation, the BSN 4C Group 2 Subgroup 2,
will be able to come up with a comprehensive case study of a patient which covers the
concept of cancer nursing, applying the knowledge, skills, and attitude they have
learned from the cancer nursing lecture and RLE exposure.
OBJECTIVES
To achieve our goal, we specifically aim to:
a) Choose a client to be the subject of the case study;
b) describe the concept and the client through a well- written introduction;
c) formulate specific, measurable, attainable, realistic and time bound objectives;
d) gather necessary data that will serve as the baseline information for the case
study through an interview;
e) present the database of the client;
f) perform a comprehensive cephalocaudal physical assessment
g) define Multinodular Toxic Goiter in Euthyroid State;
h) discuss the anatomy and physiology of the endocrine system;
i) trace the pathophysiology of Multinodular Toxic Goiter in Euthyroid State;
j) present the medical management done for the patient’s case
k) formulate five Nursing Care Plans applicable to the patient;
l) relate our case study to two nursing theories;
m) formulate a discharge plan subjective to the patient’s case;
n) rationalize the prognosis of the case; and
o) cite the resources used in this case study following the APA format; and
p) present the case study in a comprehensive manner.
BIOGRAPHIC DATA
I. Biographical Data
Name: LP
Age: 63
Gender: Female
Birth Date: October 4, 1955
Place of Birth: Davao City
Home Address: Bucana, Davao City
Nationality: Filipino
Religion: Roman Catholic
Marital Status: Single
Occupation: Unemployed
Educational Attainment: High school graduate
Number of Children: 1
Family income: 50-60k every month
II. Clinical Data
Ward: San Lorenzo Ward

Bed Number: 306-1
Chief Complaint: Dysphagia
Impression: Multinodule Toxic Goiter in Euthyroid State
Attending Physician: Dr. Isaguirre, Raul Jerry Quiaoit
Date & Time of Admission: November 11, 2018 @ 9:20 AM
Manner of Admission: Ambulatory
Final Diagnosis: Toxic Goiter in Euthyroid State
Procedure: Total Thyroidectomy
PAST HEALTH HISTORY

Patient LP was born full term via NSVD on October 4, 1955 at home with the
help of a midwife. She is not allergic to anything. She has had childhood illnesses such
as mumps, chicken pox, and measles. If with a fever, she self medicates with medicol
(400mg) or paracetamol (500mg). She takes robitussin if she has cough. She has only
two maintenance medicine: levothyroxine 100 mcg and neo-mercazole 5mg . On 1997,
she had a myoma and underwent TAHBSO in SPH to remove it. Then on 2016, she
was diagnosed to have calculous cholecystitis. She is fond of vegetables, fried fish,
chicken, fruits and sweets but she has been trying to adjust to a healthier diet the past 3
years by limiting her sugar and salt intake. She does not drink alcohol or smoke.
PRESENT HEALTH HISTORY

Three years prior to admission, patient noted a small mass in the neck
associated with dysphagia of solid foods and sought consultation at AP’s clinic. She
was diagnosed with hypothyroidism and was prescribed with levothyroxine once a day
but with poor compliance. In the interim, the size of the mass tends to increase in size
associated with dysphagia of solid foods. No other associated problems were noted.
One week prior to admission, the patient consulted at AP’s clinic with complaints
of persisting symptoms. Hence, she was scheduled for possible total thyroidectomy for
multinodular non-toxic goiter, hence admission.
FAMILY HEALTH HISTORY

The patient’s grandparents are all deceased but her grandparents on the
mother’s side both had hypertension while her grandfather on the paternal side had
asthma. They all died due to old age. Her father and his siblings are all deceased; the
3rd sibling, FR, had asthma while the 5th sibling, VP, had hypertension. Her mother and
her siblings are all alive and are all diagnosed with hypertension. Patient, LP, is the 3rd
child out of 9 and has goiter. The 1st born whom was diagnosed with hypertension died
due to myocardial infarction. The rest of her siblings are alive but the 2nd and 7th both
have asthma.
R
DEVELOPMENTAL THEORIES
Erik Erikson’s Psychosocial Theory

PSYCHOSOCIAL ACHIEVED/
AGE RATIONALE
CRISIS NOT ACHIEVED
MIDDLE Generativity ACHIEVED We classified our client as
ADULTHOOD Vs. achieved and belongs to the
Stagnation 7th stage of generativity vs.
35-65 years stagnation. Our client belongs
old to generativity instead of
stagnation since our client
strives to nurture things that
will outlast. Our client is very
proud with all the
accomplishment that she had
in her life. She was able to
send her only daughter to
school and finished a college
degree. Client L also has a
strong and good relationship
with his husband since they
have been together for 34
years in marriage. Client L
and her husband live with her
daughter’s house in abroad.
Her daily routine is to do
chores and attain to the
needs of her family. During
weekends she goes out with
her friends and catch up with
their talks. Every Sunday
Client L together with her
family goes to church every
Sunday and thank God for all
the blessings that He have
showered upon them.
Robert Havighurst’s Developmental Tasks
Task Achieved/Not Achieved Rationale

1. Adjusting to Achieved Patient had accepted that due
deteriorating health to her old age she can no
and strength longer do the things that she
can easily do back in her
days.
2. Adjusting to Achieved The patient stopped working
retirement because her husband doesn’t
want her to work.
3. Meeting social and Not achieved Patient doesn’t participate to
civic obligations baranggay activities here in
the Philippines and not active
in any community activities in
Guam though she’s very
friendly and has a lot of
friends in their church.
4. Adjusting to death Not applicable This is not applicable since
or loss of spouse the husband of the patient is
still alive.
PHYSICAL ASSESSMENT
Our physical assessment was done on October 30, 2018 at 4 PM.
GENERAL SURVEY
The patient is oriented to time and place, and is able to answer questions in an
organized manner using appropriate words. She appears to be her stated chronologic
age (63 years old) and she is an endomorph. Her height is 1.49 meter and weight is 46
kg. Her BMI is 20.7 which indicates that she is of normal weight. She is well-groomed
and is wearing a gown during the assessment. An IVF of PLR 1L is attached to her right
cephalic vein.
VITAL SIGNS RESULT NORMAL RANGE

Blood Pressure 130/70 mmHg 110/70 – 130/90 mmHg
Temperature 36.2 °C 36 – 37.5 °C
Cardiac Rate 81 bpm 60 – 100 bpm
Pulse Rate 79 bpm 60 – 100 bpm
Respiratory Rate 19 cpm 15 – 20 cpm
SKIN
The skin is tan, smooth, and warm to touch but her feet were slightly cooler than the
rest of her body, with no edema present. Senile skin turgor and sagging skin present.
Skin still pinches easily and almost immediately returns to its original position.
SCALP AND HAIR
The patient has natural dark brown hair with strands of white hair. The scalp is clean
and dry, and the hair is well distributed. There are no lesions in her scalp with absence
of lice and dandruff noted.
NAILS
The nails are pink and untrimmed. Her nails are well-trimmed with a capillary refill test of
2 seconds on both her fingernails and toenails. The nail plate is firmly attached to the
nail bed. Nail surface is smooth and the thickness of all her nails are uniform
throughout. Angle of the nail base doesn’t indicate clubbing.
HEAD
The client has a normocephalic skull with symmetrical facial movement when
performing actions such as raising the eyebrows and smiling. The head is hard, smooth,
and non tender upon palpation. The face is symmetric with no abnormal movements
observed.
EYES
The eyebrows are able to perform equal movements, and the hair is distributed evenly.
The eyelashes are curled outwards, and are equally distributed along the eyelid. The
upper and lower eyelids close easily, meeting completely when the eyes are closed.
The eyeballs are symmetrically aligned in the sockets. The bulbar conjunctiva is clear,
moist and smooth. The sclera is white. The palpebral conjunctivae are clear and free of
swelling and lesions. The cornea is transparent and smooth. The iris is dark brown,
round, flat, and evenly colored. The pupils are equally round, reactive to light and
accommodation. Both eyes constricts briskly when tested for light accommodation. The
patient is able to perform smooth and equal eye movements. She needs prescription
glasses in order to see and is myopic.
EARS
The ears are equal in size bilaterally. The auricle is aligned with the corner of each eye.
The ear color matches the rest of the patient’s skin. There’s no lesions and tenderness
upon palpation. The pinna is normoset. A small amount of odorless cerumen is present,
and the canal walls are pink and smooth. The patient had no problems hearing
throughout the assessment.
NOSE
The nose is the same color as the rest of the face. Her nose is located in the midline of
the face and is without swelling and lesions. The patient is able to sniff through each
nostril with the other nostril occluded meaning both nostrils are patent. Intact skin with
the nasal septum located midline. The nasal mucosa is dark pink, moist, and free of
exudates. The frontal and maxillary sinuses are non-tender to palpation. She was able
to distinguish the smell of rubbing alcohol, orange, and lotion when tested for her sense
of smell.
MOUTH
The lips are smooth and moist, and are pale. She has 26 teeth in total with no dentures.
She has slightly yellow teeth with no plaque buildup noted. The buccal mucosa is pink,
smooth and moist. Her tongue is tongue is pink and moist located in the midline. It is
free of lesions and is able to move freely when instructed to do so. The gums and palate
of the patient is reddish with absence of swelling and bleeding. No unusual mouth odor
is noted. The uvula hangs freely in the midline. Tonsils are not inflamed with a positive
gag reflex noted.
NECK
The thyroid cartilage, cricoid cartilage and thyroid gland move upward symmetrically
when the client swallows. The patient is able to move the neck left, right, upwards and
downwards. The trachea is midline. Incision site from total thyroidectomy is covered
with dressing and is 9.5cm in length. There is equal muscle strength when the patient
was asked to turn the head and shrug the shoulders against resistance.
THORAX AND HEART
The scapulae are nonprotruding. The shoulders and scapulae are at equal horizontal
positions. She has an aligned spine and the shoulders are of the same height and no
masses were noted upon palpation. No accessory muscles are used when breathing.
Respirations are normal in rhythm with a rate of 19 cpm. Bronchial, bronchovesicular,
and vesicular breath sounds were heard upon auscultation of both lung fields.
The precordium is normodynamic, with distinct heart sounds heard at aortic, pulmonic,
tricuspid, and apical sites. No adventitious sounds noted. The cardiac rate of the patient
is 81 per minute. Carotid, temporal, popliteal and dorsalis pedis pulses are strong and
the radial and brachial pulses are strong upon palpation of the peripheral pulses. No
irregularity on the pulses were noted.
ABDOMEN
The skin is uniform in color, intact, and with a round contour. The umbilicus is midline at
lateral line. When auscultating for bowel sounds, normoactive bowel sounds can be
heard at a rate of 10 per minute. The abdomen is nontender and soft upon palpation,
with no muscle guarding or tenderness. The bladder is nonpalpable. A vertical keloid
scar of 4 inches midline noted.
GENITO-URINARY SYSTEM
No lesions, swelling, or pain. Hair is evenly distributed.
MUSCULOSKELETAL SYSTEM
The jaw has full range of motion against resistance, and when the client clenches the
teeth, the contraction is palpated with no pain or spasms. The shoulders are
symmetrically round, with no redness, swelling or deformity. The arms are at an equal
length. The patient is able to move the arms, both with and without resistance. The
knees are symmetric, and lower leg is in alignment with the upper leg. The legs are at
an equal length. No pain when performing various motions with her legs.
NEUROLOGICAL ASSESSMENT
The patient has a result of RLS: 1 and GCS: 15.
Glasgow Coma Scale RESPONSE SCORE
EYE OPENING SPONTANEOUS 4
MOTOR RESPONSE OBEYS 6
VERBAL RESPONSE ORIENTED 5
RESULT: 15/15
Reaction Level Scale DEFINITION SCORE

STATUS
ALERT NO DELAYED 1
RESPONSE
RESULT: 1/8
CRANIAL NERVES ASSESSMENT
I Olfactory Able to distinguish the smell of rubbing alcohol, orange,

and lotion.
II Able to see clearly with corrective lenses; visual fields
Optic
are normal.
III Both Pupil is round, reactive to light, accommodates and
Oculomotor constricts to 2mm; Able to follow direction of penlight
through EOM, with no deviations
IV Able to follow direction of penlight through EOM, with no
Trochlear
deviations
V Able to move the jaw with no difficulties; can open and
Trigeminal
close mouth freely
VI Able to follow direction of penlight through EOM, with no
Abducens
deviations
VII Facial Able to smile, frown and pout
VIII Able to hear properly without the need for the examiner
Acoustic
to go closer to her ear.
IX Glossopharyngeal Able to swallow without any difficulty;
X Vagus Gag reflex is present
XI Accessory Able to shrug shoulders against resistance.
XII Hypoglossal No tongue deviation, no slurring of speech
DEFINITION OF DIAGNOSIS
Final Diagnosis: Multinodular Toxic Goiter in Euthyroid State
MULTINODULAR TOXIC GOITER

o Toxic Multinodular Goiter is basically the excessive secretion of thyroid
hormones(thyroxine) which is characterized by the enlargement of thyroid gland
and presence of multiple nodules.
Dua, S. (2015)
o Toxic Multinodular Goiter literally means ‘toxic’ due to the

production of too much thyroid hormone causing enlargement of
the thyroid gland accompanied with multiple nodules.
McDougall, R. (2013)
o Multinodular Toxic Goiter refers to a pathological condition of

thyroid enlargement associated with over production of thyroid
hormones with a presence of more pre-existing nodules in the
area of parenchyma.
Crucitti, A. (2018)
o Toxic Multinodular Goiter is a condition in which the thyroid gland contains

multiple lumps (nodules) that are overactive and that produce excess thyroid
hormones.
Medicinenet (2016, June 9)
o A Toxic Multinodular Goiter (also known as toxic nodular goiter) involves an

enlarged thyroid gland which contains areas that have increased in size and
formed nodules.
MedlinePlus. (2018, November 13)
o Toxic multinodular goiter is an active multinodular goiter associated

with hyperthyroidism.
Wikipedia. (2018, November 25)
EUTHYROID STATE
o Euthyroid State is the normal state that results from having a normal thyroid
production.
De Groot, L. J., & Jameson, L. J. (2013)
o Euthyroid State is the ability to maintain normal sufficient thyroid hormone

concentration and appropriate stimulation by pituitary thyroid stimulating
hormone (TSH).
Dietrich, J. W., Midgley, J. E., & Hoermann, R. (2018)
o Euthyroid is the state in which the FT4 and TSH hormone levels are normal.
McDougall, R. (2013)
o Euthyroid is the state of having normal thyroid gland function.
Medicinenet. (2016, May 13)
o Euthyroid State is the confirmation of normal TSH or normal functioning thyroid.
Sciencedirect. (2018)
o Euthyroid State is defined as having normal thyroid function.
Cappola, A. R., Arnold, A. M., Wulczyn, K., Carlson, M., Robbins, J., & Psaty, B. M.
(2015, March 1)
ANATOMY AND PHYSIOLOGY

The Endocrine System
To understand toxic multinodular goiter

better, it is helpful to review the endocrine system.
The endocrine system is the second great
controlling system of the body. Along with the
nervous system, it coordinates and direct the
activity of the body’s cells. It uses chemical
messengers called hormones.
Hormone is the key to the incredible power

of the endocrine glands. It regulates the metabolic
activity of other cells in the body. A hormone affects only certain organs or tissue cells,
called target organs or cells. Specific protein receptors must be present in the target cell
to respond to a hormone. Release of hormone is controlled by negative feedback
mechanism.
The major endocrine organs of the body include the pituitary, thyroid,
parathyroid, adrenal, pineal and thymus glands, pancreas, and the gonads. The
hypothalamus is also considered to be a major endocrine organ because it produces
several hormones.
The pituitary gland hangs by a stalk

from the inferior surface of the hypothalamus
of the brain. It has two functional lobes,
anterior pituitary and posterior pituitary. APG
releases six hormones. Two are growth
hormone and prolactin which exert effects on
nonendocrine targets. While the remaining
four are thyrotropic hormone,
adrenocorticotropic hormone, and two
gonadotropic hormone which are all tropic hormones. Tropic hormones stimulate their
target organs to secrete hormones. Growth hormone is a general metabolic hormone.
Its major effects are directed to the growth skeletal muscles and long bones of the body
causing target cells to divide and grow. Prolactin is a similar to growth hormone
structurally. It stimulates and maintains milk production by the mother’s breast.
Adrenocorticotropic hormone regulates the adrenal gland. Thyroid-stimulating hormone
influences the growth and activity of the thyroid gland. Follicle stimulating hormone in
females stimulates the follicle development. While in males, it stimulates sperm
development. Luteinizing hormone triggers ovulation of egg and causes estrogen and
progesterone production. While in men, it stimulates testosterone production.
The thyroid gland is located at the base of

the throat, it consists of two lobes joined by a
central mass called isthmus. It makes two
hormones – thyroid hormone and calcitonin.
Internally it is composed of hollow structures
called follicles. Thyroid hormone is often called
the major metabolic hormone and is actually a
two active iodine-containing hormones. Thyroxine
(T4) and triiodotyronine (T3). Thyroxine is the major hormone produced by the follicles
while triiodothyronine is formed at the target cells. Thyroid hormones control the
metabolic rate of the body.
Without iodine, functional hormones can’t be made. Our diet is the primary
source of iodine and seafoods are the richest source of iodine. When iodine is deficient,
goiter, an enlargement if the thyroid may develop. Also, without iodine the thyroid
makes nonfunctional hormones and fails to provide negative feedback to stop the
release of TSH. Hyposecretion of thyroxine may indicate other problems such as lack of
stimulation by TSH. Early diagnosis and treatment will prevent mental retardation and
other signs and symptoms. Hyperthyroidism generally results from a tumor of the
thyroid tumor and can be treated by surgery or administering thyroid-blocking agents or
radioactive iodine.
The second hormone produced by the

thyroid is calcitonin which decreases blood
calcium levels. It is made by the c cells found in the connective tissue between follicles.
It is released directly when blood calcium levels are high. In relation to blood calcium
levels, the parathyroid gland found in the posterior surface of the thyroid gland secretes
parathyroid hormone which is the most important regulator of calcium. When calcium
drops below a certain level it releases calcium from the bones.
The adrenal glands are the two

bean-shaped glands on top of the kidneys.
It produces three hormones –
mineralocorticoids, glucocorticoids and sex
hormones. Mineralocorticoids are important
in regulating the mineral content of the
blood by targeting the kidney tubules that
selectively reabsorb minerals or allow them to be flushed out. Thus, it helps regulate
both water and electrolyte balance in body fluids. Glucocorticoids, which include
cortisone and cortisol, promote normal cell metabolism and help body resist long-term
stressors by increasing blood glucose levels. It also control unpleasant effect of
inflammation by decreasing edema and pain. The adrenal glands also produce both
male and female sex hormones.
The pancreatic islets formerly called islets of

Langerhans is probably the best-hidden endocrine
glands because it is located close to the stomach in
the abdominal cavity. It releases two important
hormones called insulin and glucagon. Insulin is
stimulated by high levels of blood glucose in the blood
and is released by the beta cells. Insulin increases the
ability of cells to transport and utilize glucose across
their plasma membrane. On the other hand, glucagon
is the opposite of insulin. It is stimulated by low levels
of blood glucose and is secreted by the alpha cells. It targets the liver to breakdown
stored glycogen to glucose and release it to the blood.
The pineal gland is located in the roof of
the third ventricle of the brain. The only hormone
that appears to be secreted in substantial
amounts is melatonin. The levels of melatonin
rise and fall during sthe course of the day but its
peak occurs at night making us drowsy. The
thymus gland is located in the upper thorax, it
produces thymosin and during childhood thymus
acts as an incubator for the maturation of special group of white blood cells.
Gonads produce sex hormones that are identical to those produced by the
adrenal cortex cells. The ovaries produce two groups of steroid hormones, estrogens
and progesterone. Estrogen primarily produced by the graafian follicles, stimulate the
development of secondary sex characteristics and work with progesterone to prepare
uterus to receive fertilized egg. Progesterone quiets the muscles of the uterus so that an
implanted embryo will not be aborted. The testes produces testosterone which causes
development of the adult male sex characteristics, promotes growth and maturation of
the reproductive system organs, and causes secondary sex characteristics to appear.
PATHOPHYSIOLOGY
Etiology
Predisposing Factors
PRESEN
PREDISPOSING
T/ABSEN JUSTIFICATION RATIONALE
FACTOR
T
Prevalence of toxic
multinodular goiter
The patient is
increases with age and in
Age Present currently 63 years
the presence of iodine
old.
deficiency. Most patients
are more than 50 years old.
Gender Present The patient is Toxic nodular goiter occurs
more commonly in women
than in men. Respectively,
the prevalence rate in
female.
women and men older than
40 years old is 5-7% and 1-
2%.
A gene located on
chromosome 14q dubbed
The patient has a MNG-1 has been
family history of associated with familial
Genetic Influences Present
thyroid problem in nontoxic MNG and
her maternal side. polymorphism of codon 727
has been associated with
toxic MNG.
Uncommon cause of
nontoxic goiter and six
separate intrathyroidal
disturbances have been
incriminated in
dyshormonogenesis:
 Defects of iodine
No evidence or tests trap.
Dysphormogenesis Absent done to determine  Defects of
dysphormogenesis. organification - most
common defect.
 Defect of coupling.
 Protease enzyme
deficiency.
 Synthesis of
abnormal
iodoproteins.
Precipitating Factors
PRESEN
PRECIPITATING
T/ABSEN JUSTIFICATION RATIONALE
FACTOR
T
Diet: Low Iodine Absent The patient eats Toxic multinodular goiter
Diet foods with iodine- starts as a nontoxic
rich foods regularly. multinodular goiter and is
commonly caused by
chronic lack of iodine intake.
Vegetables of brassica
family, Turnips, Soyabean
flour, Cassava. Cabbage
contains thiocyanates which
inhibit iodine uptake.
Goitrogen drugs such as
Thiocarbamides,
The patient does not Chlorpropamide, PAS,
Drugs Absent take any goitrogen Amiodarone, Glutathiamide,
drugs. etc. blocks steps in thyroid
hormone synthesis or
inhibits iodine uptake.
Previous thyroid irradiation
The patient did not
increases the incidence of
receive any
Radiation Absent both benign
radiation as
and malignant nodules in
treatment.
the gland
When your thyroid over
Three years ago, exerts itself in an effort to
the patient was produce an adequate
diagnosed with amount of hormones, the
Hypothyroidism Present hypothyroidism but excessive stimulation may
with poor cause the thyroid gland to
compliance to enlarge to the point where
treatment regimen. you have a bulge in your
neck.
Symptomatology
SYMPTOMS PRESEN JUSTIFICATION RATIONALE
T/ABSEN
T
Enlarged thyroid Present The patient’s chief Increase in production of
gland complaint was TSH causes thyroid
difficulty in hypertrophy which is the
swallowing which is buildup of thyroid tissue and
caused by an hyperplasia which is the
enlarged thyroid increase in follicular cells
gland. making the thyroid gland
bigger.
Heat intolerance Absent She reported that The body is producing more
she did not feel any heat and basal metabolic
heat intolerance rate is higher.
prior to admission.
Fatigue Absent The patient Fatigue can be a result of
verbalized that she insomnia, anxiety or
does not get tired disturbed sleep patterns.
easily when doing
house chores.
Excessive sweating Absent The patient did not Excessive sweating is a
experience result of an overactive
excessive sweating thyroid and increase in
in the past. thyroid hormones.
Increased appetite Absent She said that her Increase in thyroid hormone
appetite did not may have you feeling
change at all. hungry all the time since
metabolic rate is fast and
the body burns more fat and
sugar.
Weight loss Present Although her Despite the increased
appetite did not appetite weight loss can
change, she said happen because of higher
that she lost around basal metabolic rate which
5 kilos. results to cells producing
more proteins and burning
more energy.
Dysphagia Present Prior to admission, The thyroid gland is
she experienced enlarged and it can cause
difficulty in obstruction in the airway
swallowing. and cause difficulty in
swallowing.
Irregular or rapid Absent Upon auscultation, This is the effect of the
heartbeat patient’s heartbeat thyroid hormones on the
was within normal sympathetic nervous
range. system.
Brittle bones Present The patient’s Increase in T3 can stimulate
calcium level is bone resorption which thins
below normal range out the bones and makes it
and she is taking more fragile.
calcitrol and caltrate
plus.
Tremors Absent She did not Hyperthyroidism is a
experience any condition in which the
tremors. metabolic balance of the
body is up regulated,
resulting in increased
energy production by every
cell of the body. As a result,
the nervous stimuli become
excessive, resulting in hand
tremor.
Exophthalmia Absent Her eyes appeared Overstimulation of the
normal and did not muscles that control eye
appear to be more movement can cause the
open. eye to appear more open.
Thyroid storm Absent The client did not A life-threatening
experience high complication where there is
fever and cardiac severe hypermetabolism
arrhythmias. and all normal symptoms
become exaggerated such
as high fever and cardiac
arrhythmias.
SCHEMATIC DIAGRAM
PREDISPOSING FACTORS:
 Hypothyroidism
PREDISPOSING FACTORS:
 Age
 Gender
 Genetic Influences
Enlarged
Thyroid Gland
and Dysphagia
Decrease in thyroid hormone levels

Mgt:
The hypothalamus senses the low thyroid hormone levels
Thyroidectomy and releases TRH or Thyrotropin-releasing hormone
Some parts are more responsive to TSH than others,
growth becomes uneven
TRH stimulates the pituitary gland to release TSH or Thyroid

stimulating hormone to increase production of thyroid hormones
NON-TOXIC MULTINODULAR GOITER: Those
responsive parts grow quickly and become a nodule; over
the years it becomes multinodular
EUTHYROID STATE: Less thyroid hormone is

compensated by more follicular cells and TSH level goes
down
TOXIC MULTINODULAR GOITER: Genetic mutation in

Ifdividing follicular
it worsens, cellsround
another and affects
of TSHthe TSH receptor
stimulates thyroid
leaving
growth;the receptor
overtime theconstantly on and
thyroid gland willremains stimulated
experience many
cycles of growth and balance
Weight loss In response, thyroid hormone is constantly produced Brittle bones
Mgt: Mgt:
If leftCalcitrol
untreated:
1 cap
Increase caloric
requirement  BID, Caltrate
Cardiomyopathy
 plus 2 tabs q heart
Congestive
6hrs
failure
If treated:  Thyroid crisis or
storm
 Symptoms will be
regulated  Bone loss
 Excess hormone  Malignancy (rare)
 DEATH
produced will be
reduced
 Good prognosis Hypermetabolism state of cells where cellular reactions
happen at faster pace
Even though thyroid hormones are high and TSH
production shut down, independent nodules use any
iodine to make more thyroid hormone
The present predisposing factors are age, gender and genetic influences. While
precipitating factor present is hypothyroidism. Toxic Multinodular Goiter or Plummer’s
disease is commonly caused by chronic lack of dietary iodine which results to decrease
in thyroid hormones. The hypothalamus then senses the low levels of thyroid hormones
and releases TRH or Thyrotropin-releasing hormone which stimulates the anterior
pituitary gland to release TSH or thyroid stimulating hormone. In response to increased
TSH, hypertrophy and hyperplasia of the thyroid happens. Some parts of the thyroid are
more responsive to TSH than others which causes an uneven growth. Those parts
which are more responsive grow quickly and become a nodule. Over the years, it
becomes non-toxic multinodular goiter. When the thyroid gland is able to compensate
for the lack of thyroid hormones, it enters a euthyroid state where TSH level goes down
and less thyroid hormones is compensated.
However, if lack of thyroid hormone worsens another round of TSH stimulates

the thyroid gland to produce more thyroid hormones. Overtime, the body will experience
many cycles of growth and balance. Non-toxic multinodular goiter becomes toxic when
a genetic mutation happens in dividing follicular cells and affects the TSH receptor –
leaving it constantly stimulated. As a result, thyroid hormone is constantly produced
more than the body needs. The independent nodules make use of any iodine to make
more thyroid hormone then cells enter a hypermetabolism state where cellular reactions
happen at a faster rate. If toxic multinodular goiter is treated, symptoms will be
regulated, excess hormone produced will be reduced and the patient will have good
prognosis. On the other hand, if left untreated, complications such as cardiomyopathy,
congestive heart failure, thyroid crisis or storm, bone loss, and malignancy may arise
and eventually cause death.
MEDICAL MANAGEMENT
Possible Lab/Diagnostic Test
This test measures the amount of TSH in the blood to

screen for and help diagnose thyroid disorders; to
monitor treatment of hypothyroidism and
Thyroid Stimulating
hyperthyroidism. Thyroid-stimulating hormone (TSH) is
Hormone
produced by the pituitary gland. TSH stimulates the
thyroid gland to release the hormones thyroxine (T4) and
triiodothyronine (T3) into the blood.
Triiodothyronine (T3) is one of two major hormones
produced by the thyroid gland. The other major thyroid
hormone is called thyroxine (T4) and together they help
control the rate at which the body uses energy
Free & Total T3 and T4 Almost all of the T3 and T4 found in the blood is bound
to protein. The rest is free (unbound) and is the
biologically active form of the hormone. Tests can
measure the amount free and total t3 and t4 in the blood,
and helps diagnose hypo and hyperthyroidism.
A radioactive isotope will be injected into the vein and a
special camera produces an image of the thyroid gland
Thyroid Scan
on a computer screen. This test shows how iodine
collects in the thyroid.
This test uses high-frequency sound waves to produce
images of the thyroid. Ultrasound may be better at
Thyroid Ultrasound
detecting thyroid nodules than other tests, and there's no
exposure to any radiation.
NORMAL INTERPRE NURSING
TEST RATIONALE RESULT SIGNIFICANCE
RANGE TATION RESPONSIBILITIES
November Since she has no
1) Confirm patient’s
17, 2018 thyroid anymore,
identity by asking
(11:12am) calcitonin is no longer
her to recite her full
being produced.
name
2.01 Calcitonin is a
2) Explain that reason
hormone produced by
November for the test
Total calcium the thyroid which
17, 2018 3) Apply pressure on
is monitored regulates the total
(6:23pm) the punctured site
because the calcium level in the
Total 2.23 – 2.5 with cotton ball.
patient has LOW body. This puts the
Calcium 2.08 mmol/L 4) Monitor the puncture
undergone patient at risk for
site for signs of
total having low calcium
November bleeding or bruising
thyroidectomy. levels, requiring her to
18, 2018 (ecchymosis) of the
have calcium
skin.
supplements for life.
1.95 5) Document the
November
procedure done
18, 2018
Follow up for the result
of the test
1.92
Therapeutics
DATE/TIME ORDER RATIONALE

Dr. Raul Isaguirre is a doctor who
specializes in ENT-HNS (eyes,
Please admit under my service
nose, throat-head neck surgery),
-Dr. Isaguirre
and is an expert regarding the
patient’s case.
Hyperthyroidism does not require
any changes in diet. The patient
DAT may eat her usual diet as long as
she is able to swallow properly
and tolerate the pain.
Surgical removal of the thyroid is
November Schedule for total thyroidectomy already necessary since the
16, 2018 on November 17, 2018, Saturday, thyroid has enlarged too much
7:30 AM and alters other physiologic
5:30pm functions needed by the patient.
PNSS is an isotonic solution that
provides hydration and is
Start IVF PNSS 1L at 120cc/hour compatible with blood and most
medications necessary for the
IVTT drugs of the patient.
VS monitoring is critical in
creating decisions for patient
care. I&O monitoring is important
VS q 4 hours, I&O q shift
to monitor fluid balance especially
in patients who are to undergo
surgery.
Since the patient is to undergo
surgery, NPO is necessary to
prevent intra-operative pulmonary
aspiration. This is because
anesthesia causes one to lose
NPO post-midnight their protective airway reflexes,
such as gag or cough, becoming
7:00 PM at risk of aspiration of gastric
contents that may be actively
vomited or passively regurgitated
during or shortly after induction.
PLR is usually the IVF of choice
IVF to follow, PLR 1L at for post-operative patients as fluid
120cc/hour resuscitation for the blood loss
during surgery.
November General liquids once fully awake Since patient is post-operative,
gastric reflexes have been
reduced due to anesthesia, thus
should only have liquids per orem
when anesthesia has fully worn
off.
Close VS monitoring is critical in
creating decisions for patient
VS q 15 minutes x 1 hour, q 30
care, especially for post-operative
minutes x 2 hours, q hourly x 4
patients whose physiologic
hours
functions have been slowed down
17, 2018
after anesthesia administration.
To facilitate drainage of fluid from
2:42pm Moderate high back rest
the operative site from the neck.
Monitoring surgical drains is
important to evaluate if site is
healing properly or not. Aside
Measure JP drain output q shift
from amount, exudate
characteristics should also be
monitored.
The patient has already passed
May resume diet flatus and is fully awake, thus, she
may already resume her full diet
After surgery, shallow breathing is
common because of pain or
limited mobility. This may cause
secretions to stay in the lungs and
Encourage deep breathing
collapse the air sacs. Deep
exercises
breathing after surgery keeps the
lungs fully expanded and prevents
November complications such as post-
18, 2018 operative pneumonia.
Since physiologic functions are
slowed down after surgery due to
the anesthesia, early ambulation
Encourage to ambulate is helpful to improve blood flow.
Ambulating late may cause
increased constipation and gas
pain, weakness.
November Patient is now stable and may
May go home
20, 2018 continue management at home.
Drug Studies
Generic Name Midazolam
Brand Name Dormicum
Date Ordered November 16, 2018
Ordered Dose Midazolam 15g ½tab 6am NOW
Mechanism of A benzodiazepine that enhances the action of gamma-aminobutyric

Action acid, one of the major inhibitory neurotransmitters in the brain.
Therapeutic Effect: Produces anxiolytic, hypnotic, anticonvulsant,
muscle relaxant, and amnestic effects.
Indications Preoperative sedation; Conscious sedation for diagnostic, and
endoscopic procedures; Conscious sedation during mechanical
ventilation; Status epilepticus
Contraindications Acute alcohol intoxication, acute angle-closure glaucoma, coma, shock
Side Effects Frequent (10%-4%):
Decreased respiratory rate, tenderness at IM or IV injection site, pain
during injection, oxygen desaturation, hiccups
Occasional (3%-2%):
Hypotension, paradoxical CNS reaction
Rare (less than 2%):
Nausea, vomiting, headache, coughing
Adverse Reactions  Inadequate or excessive dosage or improper administration may
result in cerebral hypoxia, agitation, involuntary movements,
hyperactivity, and combativeness.
 A too-rapid IV rate, excessive doses, or a single large dose
increases the risk of respiratory depression or arrest.
 Respiratory depression or apnea may produce hypoxia and cardiac
arrest.
Drug Interactions Drug:
 Alcohol, other CNS depressants: May increase CNS and respiratory
depression and hypotensive effects of midazolam.
 Hypotension-producing medications: May increase hypotensive
effects of midazolam.
Herbal:
Kava Kava, valerian: May increase CNS depression.
Food:
Grapefruit, grapefruit juice: Increases the oral absorption and systemic
availability of midazolam.
Nursing 1. Obtain the patient’s vital signs before administering midazolam.
Responsibilities 2. In the elderly, age-related renal impairment may require dosage
adjustment.
3. Use midazolam cautiously in patients with acute illness; CHF;
pulmonary, renal, or hepatic impairment; severe fluid or electrolyte
imbalance; and treated angle-closure glaucoma.
4. Midazolam dosage is individualized based on the patient's age,
underlying disease, and medications and on the desired effect.
5. Monitor the patient's respiratory rate and oxygen saturation
continuously during parenteral administration to detect apnea and
respiratory depression.
6. Monitor the patient's level of sedation every 3 to 5 minutes and
assess vital signs during the recovery period.
7. Inform the patient before the procedure that midazolam produces
an amnesic effect.
8. Urge the female patient on long-term therapy to use effective
contraception during therapy and to notify the physician
immediately if she becomes or may be pregnant.
Generic Name Hydrocortisone

Brand Name Solu-Cortef
Ordered Dose Hydrocortisone 20mg IVTT @
6am
Mechanism of An adrenocortical steroid that inhibits accumulation of inflammatory
Action cells at inflammation sites, phagocytosis, lysosomal enzyme release
and synthesis and release of mediators of inflammation. Therapeutic
Effect: Prevents or suppresses cell-mediated immune reactions.
Decreases or prevents tissue response to inflammatory process.
Indications Anti-inflammation, immunosuppression; Physiologic replacement;
Shock; Adjunctive treatment of ulcerative colitis
Contraindications Fungal, tuberculosis, or viral skin lesions; serious infections
Side Effects Frequent:
Insomnia, heartburn, nervousness, abdominal distention, diaphoresis,
acne, mood swings, increased appetite, facial flushing, delayed wound
healing, increased susceptibility to infection, diarrhea or constipation
Occasional:
Headache, edema, change in skin color, frequent urination
Topical: Itching, redness, irritation
Rare:
Tachycardia, allergic reaction (such as rash and hives), psychological
changes, hallucinations, depression
Topical: Allergic contact dermatitis, purpura
Systemic: Absorption more likely with use of occlusive dressings or
extensive application in young children
Adverse Reactions  Long-term therapy may cause hypocalcemia, hypokalemia, muscle
wasting (especially in arms and legs), osteoporosis, spontaneous
fractures, amenorrhea, cataracts, glaucoma, peptic ulcer disease,
and CHF.
 Abruptly withdrawing the drug after long-term therapy may cause
anorexia, nausea, fever, headache, sudden severe joint pain,
rebound inflammation, fatigue, weakness, lethargy, dizziness, and
orthostatic hypotension.
 Amphotericin: May increase hypokalemia.
 Digoxin: May increase the risk of digoxin toxicity caused by
hypokalemia.
 Diuretics, insulin, oral hypoglycemics, potassium supplements: May
decrease the effects of these drugs.
 Hepatic enzyme inducers: May decrease the effects of
hydrocortisone.
 Live-virus vaccines: May decrease the patient's antibody response
to vaccine, increase vaccine side effects, and potentiate virus
replication.
Herbal: None known.
Food: None known.
Nursing 1. Determine if the patient has a hypersensitivity to corticosteroids.
Responsibilities 2. Obtain the patient's BP, blood glucose and serum electrolyte levels,
height, and weight.
3. Evaluate the results of initial tests, such as tuberculosis skin test, X-
rays, and EKG.
4. Determine if the patient has diabetes mellitus, and anticipate an
increase in his or her antidiabetic drug regimen because of raised
blood glucose level.
5. Use hydrocortisone cautiously in patients with cirrhosis, CHF,
diabetes mellitus, hypertension, hyperthyroidism, osteoporosis,
peptic ulcer disease, seizure disorders, thromboembolic tendencies,
thrombophlebitis, or ulcerative colitis.
6. Examine the patient for edema.
7. Be alert to signs and symptoms of infection, such as fever and sore
throat, that indicate reduced immune response.
8. Assess the patient's pattern of daily bowel activity and stool
consistency.
9. Monitor the patient's electrolyte levels.
10. Monitor the patient for signs and symptoms of hypocalcemia (such
as cramps and muscle twitching), or hypokalemia (such as EKG
changes, irritability, nausea and vomiting, numbness or tingling of
lower extremities, and weakness).
11. Evaluate the patient's ability to sleep and emotional status.
12. Warn the patient to report fever, muscle aches, sore throat, or
sudden weight gain or swelling.
13. Instruct the patient to consult the physician before taking aspirin or
other medications during hydrocortisone therapy.
14. Urge the patient to limit caffeine intake during hydrocortisone
therapy.
15. Explain that steroids often cause mood swings, ranging from
euphoria to depression.
Generic Name Omeprazole
Brand Name Omepron
November 17, 2018
Ordered Dose Omeprazole 40mg IVTT @ NOW
Omeprazole 40mg 1 tab OD x 2
days
Mechanism of A benzimidazole that is converted to active metabolites that irreversibly

Action bind to and inhibit hydrogen-potassium adenosine triphosphatase, an
enzyme on the surface of gastric parietal cells. Inhibits hydrogen ion
transport into gastric lumen. Therapeutic Effect: Increases gastric pH,
reduces gastric acid production.
Indications Erosive esophagitis, poorly responsive gastroesophageal reflux
disease, active duodenal ulcer, prevention and treatment of NSAID-
induced ulcers; To maintain healing of erosive esophagitis; Pathologic
hypersecretory conditions; Duodenal ulcer caused by Helibacter Pylori;
Usual pediatric dosage
Contraindications None known.
Side Effects Frequent (7%):
Headache
Occasional (3%-2%):
Diarrhea, abdominal pain, nausea
Rare (2%):
Dizziness, asthenia or loss of strength, vomiting, constipation, upper
respiratory tract infection, back pain, rash, cough
Adverse Reactions None known.
Drug Interactions Drug: Diazepam, oral anticoagulants, phenytoin: May increase the
blood concentration of diazepam, oral anticoagulants, and phenytoin.
Herbal: None known.
Food: None known.
Nursing 1. Expect to obtain serum chemistry laboratory values, particularly
Responsibilities serum alkaline phosphatase, AST and ALT levels to assess liver
function.
2. Give omeprazole before meals.
3. Do not crush or open capsules; have the patient swallow capsules
whole.
4. Assess the patient for diarrhea, discomfort, and nausea.
5. Evaluate the patient for therapeutic response (relief of GI
symptoms).
6. Warn the patient to notify the physician if headache occurs during
omeprazole therapy.
7. Instruct the patient to swallow omeprazole capsules whole and not
to open or crush them.
8. Teach the patient to take omeprazole capsules before eating.
Generic Name Nalbuphine

Brand Name Nubain
Ordered Dose Nalbuphine 5mg IVTT q 8
hours prn for pain
Mechanism of A narcotic agonist-antagonist that binds with opioid receptors in the
Action CNS. May displace opioid agonists and competitively inhibit their action;
may precipitate withdrawal symptoms. Therapeutic Effect: Alters the
perception of and emotional response to pain.
Indications Analgesia; Supplement to anesthesia
Contraindications Respiratory rate less than 12 breaths/minute
Side Effects Frequent (35%): Sedation
Occasional (9%-3%): Diaphoresis, cold and clammy skin, nausea,
vomiting, dizziness, vertigo, dry mouth, headache
Rare (less than 1%): Restlessness, emotional lability, paresthesia,
flushing, paradoxical reaction
Adverse Reactions  Abrupt withdrawal after prolonged use may produce symptoms of
narcotic withdrawal, such as abdominal cramping, rhinorrhea,
lacrimation, anxiety, fever, and piloerection (goose bumps).
 Overdose results in severe respiratory depression, skeletal muscle
flaccidity, cyanosis, and extreme somnolence progressing to
seizures, stupor, and coma.
 Repeated use may result in drug tolerance and physical
dependence.
Drug Interactions Drug: Alcohol, other CNS depressants: May increase CNS or respiratory
depression and hypotension.
Buprenorphine: May decrease the effects of nalbuphine.
MAOIs: May produce a severe, possibly fatal reaction; plan to
administer 25% of the usual nalbuphine dose.
Herbal: None known.
Food: None known.
Nursing 1. Obtain the patient's vital signs before giving nalbuphine.
Responsibilities 2. Assess the duration, location, onset, and type of pain.
3. Use nalbuphine cautiously in pregnant patients; opioid-dependent
patients; patients with head trauma, increased intracranial pressure,
hepatic or renal impairment, recent MI, or respiratory depression;
and those about to undergo biliary tract surgery.
4. ALERT P Keep in mind that nalbuphine dosage is based on the
patient's physical condition, the severity of pain, and concurrent use
of other drugs.
5. Store vials at room temperature.
6. Nalbuphine may be given undiluted.
7. Know that the drug's analgesic effect is reduced if a full pain
response recurs before the next dose.
8. Be aware that nalbuphine has a low abuse potential.
9. Monitor the patient's BP, pulse rate, and respiratory status.
consistency.
11. Initiate deep-breathing and coughing exercises, particularly in
patients with impaired pulmonary function.
12. Assess the patient for clinical improvement and record the onset of
relief of pain. Notify the physician if pain relief is inadequate.
13. Instruct the patient to alert you as soon as pain occurs and not to
wait until the pain is unbearable because nalbuphine is more
effective when given at the onset of pain.
14. Urge the patient to avoid CNS depressants during nalbuphine
therapy.
15. Inform the patient that nalbuphine may cause dry mouth.
Generic Name Calcium Carbonate
Brand Name Caltrate Plus

Ordered Dose Caltrate Plus 1 tab QID
Caltrate Plus 2 tabs q 6 hours
Mechanism of Reduces total acid load in GI tract, elevates gastric pH to reduce
Action pepsin activity, strengthens gastric mucosal barrier, and increases
esophageal sphincter tone
Indications Acid indigestion, calcium supplement
Contraindications Contraindicated in patients with ventricular fibrillation or hypercalcemia
Side Effects Gas, incomplete bowel movement, constipation, nausea and stomach
pain
Adverse Reactions Headache, irritability, weakness, hypercalcemia, hypercalciuria
Drug Interactions Drug: Digoxin: may increase risk of arrhythmias. Magnesium
methenamine: may decrease effects of these drugs. Ketoconazole,
phenytoin, tetracyclines: may decrease absorption of these drugs.
Herbal: none known.
Food: none known.
Nursing 1. Obtain patient’s BP, EKG, serum Mg, K, and phosphate levels, and
Responsibilities renal function tests.
2. Give tablets with full glass of water 30 minutes to one hour after
meals.
3. Monitor for signs of hypercalcemia.
4. Advise patient to drink liquids before meals.
5. Emphasize importance of diet if patient is receiving calcium as
supplement.
6. Urge patient to avoid consuming alcohol, caffeine.
7. Advise not to take calcium within 2 hours of consuming other oral
drugs or fiber-containing foods.
Generic Name Cefuroxime

Brand Name Zinacef
Ordered Dose Cefuroxime 750mg IVTT q 8 hours
ANST (-)
Mechanism of A second-generation cephalosporin that binds to bacterial cell
Action membranes and inhibits cell wall synthesis. Therapeutic Effect:
Bactericidal.
Indications Ampicillin-resistant influenza; bacterial meningitis; early Lyme disease;
GU tract, gynecologic, skin, and bone infections; septicemia;
gonorrhea, and other gonococcal infections; Pharyngitis, tonsillitis;
Acute otitis media, acute bacterial maxillary sinusitis, impetigo;
Bacterial meningitis; Perioperative prophylaxis; Usual neonatal dosage;
Dosage in renal impairment
Contraindications History of anaphylactic reaction to penicillins or hypersensitivity to
cephalosporins
Discomfort with IM administration, oral candidiasis, mild diarrhea, mild
abdominal cramping, vaginal candidiasis
Occasional:
Nausea, serum sickness-like reaction (marked by fever and joint pain;
usually occurs after the second course of therapy and resolves after the
drug is discontinued)
Rare:
Allergic reaction (rash, pruritus, urticaria), thrombophlebitis (pain,
redness, swelling at injection site)
Adverse Reactions  Antibiotic-associated colitis and other superinfections may result
from altered bacterial balance.
 Nephrotoxicity may occur, especially in patients with pre-existing
renal disease.
 Patients with a history of allergies, especially to penicillin, are at
increased risk for developing a severe hypersensitivity reaction,
marked by severe pruritus, angioedema, bronchospasm, and
anaphylaxis.
1. Probenecid: Increases serum concentration of cefuroxime.
Herbal: None known.

Food: None known.
Nursing 1. Determine if the patient has a history of allergies, particularly to
Responsibilities cefuroxime, other cephalosporins, or penicillins, before beginning
drug therapy.
2. Use cefuroxime cautiously in patients with renal impairment or a
history of GI disease, especially antibiotic-associated or ulcerative
colitis.
3. Use the drug cautiously in patients using nephrotoxic drugs
concurrently.
4. Assess the patient's mouth for white patches on the mucous
membranes and tongue.
consistency. Mild GI effects may be tolerable, but severe symptoms
may indicate the onset of antibiotic-associated colitis.
6. Monitor the patient's intake and output and renal function test
results to assess for nephrotoxicity.
7. Be alert for signs and symptoms of superinfection, including
abdominal pain or cramping, moderate to severe diarrhea, severe
anal or genital pruritus or discharge, and severe mouth or tongue
soreness.
8. Advise the patient taking oral cefuroxime to space doses evenly
around the clock and to continue therapy for the full course of
treatment.
Generic Name Calcitriol

Brand Name Rocaltrol
Ordered Dose Calcitriol 1 tab TID
Mechanism of Provides calcitriol supplementation which is the active form of vitamin

Action D. Vitamin D helps control parathyroid hormone and the levels of
certain minerals (e.g., calcium, phosphorus) that are needed for
building and keeping strong bones
Indications Kidney disease who can't make enough of the active form of Vitamin D;
Prevention and treatment of certain types of calcium/phosphorus/
parathyroid problems that can happen with long-term kidney dialysis or
hypoparathyroidism.
Contraindications Hypercalcemia, metastatic calcification, vitamin D toxicity
Side Effects Loss of appetite, back/bone/joint/muscle pain, constipation, dry mouth,
eye pain/redness/sensitivity to light, headache, fast/slow/irregular
heartbeat, nausea/vomiting/diarrhea, sleepiness, stomach/abdominal
pain, increased thirst, signs of kidney problems (such as change in the
amount of urine), weakness
Adverse Reactions rash, itching/swelling (especially of the face/tongue/throat), severe
dizziness, trouble breathing
Drug Interactions Drug: Cardiac glycosides, magnesium-containing medications,
phosphate binders, vitamins/nutritional supplements (especially calcium
and vitamin D): can speed up the removal of calcitriol from the body
Nursing 1. Encourage patient to consume food rich in vitamin D, including milk,
Responsibilities eggs, leafy vegetables, margarine, meats, and vegetable oils and
shortening.
2. Advise patient to drink plenty of liquids.
3. Have patient swallow capsules whole and avoid crushing chewing
or opening them.
4. Monitor Bun level, serum alkaline phosphatase, calcium, creatinine,
magnesium, phosphate, and urinary calcium level.
5. Estimate patient’s daily dietary calcium intake.
Generic Name Etoricoxib

Brand Name Arcoxia
Ordered Dose Etoricoxib 90mg 1tab BID
Mechanism of An NSAID that inhibits cyclooxygenase-2, the enzyme responsible for

Action prostaglandin synthesis. Therapeutic effect: Reduces inflammation and
relieves pain.
Indications Osteoarthritis, rheumatoid arthritis, acute pain, familial adenomatous
polyposis.
Contraindications Hypersensitivity to aspirin, NSAIDs, or sulfonamides.
Side Effects Frequent (greater than 5%): Diarrhea, dyspepsia, headache, upper
respiratory tract infection.
Occasional(5%-1%): abdominal pain, flatulence, nausea, backpain
peripheral edema, dizziness, rash.
Adverse Reactions None known.
Drug Interactions Drug: Fluconazole: may increase etoricoxib blood level.
Warfarin: May increase risk of bleeding.
Herbal: none known.
Food: none known.
Nursing 1. Assess duration, location, onset, and type of inflammation or pain.
Responsibilities 2. Inspect patients joints for deformity and skin condition.
3. Evaluate for evidence of therapeutic response, such as decreased
pain, stiffness, swelling, and tenderness; improved grip strength.
4. Advise patient to take drug with food if GI upset occurs.
5. Warn patient to avoid alcohol during therapy as it may increase risk
of GI bleeding.
Generic Name Dexamethasone

Brand Name -
Ordered Dose Dexamethasone 5mg IVTT q 8
hours x 3 days
Mechanism of A long-acting glucocorticoid that inhibits accumulation of inflammatory

Action cells at inflammation sites, phagocytosis, lysosomal enzyme release
and synthesis, and release of mediators of inflammation. Therapeutic
Effect: Prevents and suppresses cell and tissue immune reactions and
inflammatory process.
Indications Anti-inflammatory; Cerebral edema; Nausea and vomiting in
chemotherapy patients; Physiologic replacement; Usual ophthalmic
dosage, ocular inflammatory conditions
Contraindications Active untreated infections, fungal, tuberculosis, or viral diseases of the
eye
Inhalation: Cough, dry mouth, hoarseness, throat irritation
Intranasal: Burning, mucosal dryness
Ophthalmic: Blurred vision
Systemic: Insomnia, facial swelling or cushingoid appearance,
moderate abdominal distention, indigestion, increased appetite,
nervousness, facial flushing, diaphoresis
Occasional:
Inhalation: Localized fungal infection, such as thrush
Intranasal: Crusting inside nose, nosebleed, sore throat, ulceration of
nasal mucosa.
Ophthalmic: Decreased vision, watering of eyes, eye pain, burning,
stinging, redness of eyes, nausea, vomiting
Systemic: Dizziness, decreased or blurred vision
Topical: Allergic contact dermatitis, purpura or blood-containing blisters,
thinning of skin with easy bruising, telangiectasis or raised dark red
spots on skin
Rare:
Inhalation: Increased bronchospasm, esophageal candidiasis
Intranasal: Nasal and pharyngeal candidiasis, eye pain
Systemic: General allergic reaction (such as rash and hives); pain,
redness, or swelling at injection site; psychological changes; false
sense of well-being; hallucinations; depression
Adverse Reactions  Long-term therapy may cause muscle wasting (especially in the
arms and legs), osteoporosis, spontaneous fractures, amenorrhea,
cataracts, glaucoma, peptic ulcer disease, and CHF.
 The ophthalmic form may cause glaucoma, ocular hypertension,
and cataracts.
 Abrupt withdrawal following long-term therapy may cause severe
joint pain, severe headache, anorexia, nausea, fever, rebound
inflammation, fatigue, weakness, lethargy, dizziness, and
orthostatic hypotension.
 Amphotericin: May increase hypokalemia.
 Digoxin: May increase digoxin toxicity caused by hypokalemia.
 Diuretics, insulin, oral hypoglycemics, potassium supplements: May
decrease the effects of these drugs.
 Hepatic enzyme inducers: May decrease the effects of
dexamethasone.
 Live-virus vaccines: May decrease the patient's antibody response
to vaccine, increase vaccine side effects, and potentiate virus
replication.
Herbal: None known.

Food: None known.
Nursing 1. Determine if the patient is hypersensitive to any corticosteroids.
Responsibilities 2. Obtain the patient's baselines for blood glucose levels, BP, serum
electrolyte levels, height, and weight.
3. Evaluate the results of initial tests, such as tuberculosis skin test, X-
rays, and EKG.
4. Determine if the patient has diabetes mellitus, and anticipate an
increase in his or her antidiabetic drug regimen because of raised
blood glucose levels.
5. Use dexamethasone cautiously in patients with cirrhosis, CHF,
diabetes mellitus, high thromboembolic risk, hypertension,
hyperthyroidism, ocular herpes simplex, osteoporosis, peptic ulcer
disease, respiratory tuberculosis, seizure disorders, ulcerative
colitis, or untreated systemic infections.
6. Use the ophthalmic form cautiously in patients on long-term therapy
because prolonged use may result in cataracts or glaucoma.
7. Monitor the patient's intake and output and record weight daily.
8. Evaluate the patient's food tolerance. Assess the patient's pattern of
daily bowel activity.
9. If the patient experiences hyperacidity, report it promptly.
10. Be alert to signs and symptoms of infection such as fever, sore
throat, and vague symptoms.
11. Monitor the patient's electrolyte levels.
12. Monitor the patient for signs and symptoms of hypercalcemia (such
as cramps and muscle twitching) or hypokalemia (such as
irritability, nausea and vomiting, muscle cramps and weakness, and
numbness or tingling, especially of the lower extremities).
13. Assess the patient's ability to sleep and emotional status.
14. Caution the patient against abruptly discontinuing the drug or
changing the dosage or schedule. Explain to the patient that the
drug must be withdrawn gradually under medical supervision.
15. Warn the patient to report fever, muscle aches, sore throat, and
sudden weight gain or swelling.
NURSING THEORIES
Katharine Kolcaba’s Comfort Theory
Holistic comfort is defined as the immediate

experience of being strengthened through having the needs for relief, ease, and
transcendence met in four contexts of experience (physical, psychospiritual, social, and
environmental). It appreciates the holistic nature of human beings that individuals have
mental, spiritual and emotional lives which is intimately connected with their physical
bodies.
We chose this theory since it deals with the pain that felt with our client after the
surgery. We picked Kolcaba to assess the comfort that the patient needs and the
reassessment of comfort levels after implementation. Comfort is only achieved when the
patient’s pain needs are met. Where the patient receives pain medication for his incision
site, he feel a relief from the medication’s effect on their pain. Relief is achieved when
comfort is focused on the psychological state of the patient which is the main goal of
this theory.
Lydia Hall’s Care, Core, Cure Theory
The theory contains of three independent but

interconnected circles: the core, the care and the cure. The body (care), the illness,
(cure), and the person (core).
We choose this theory because according to the theory, the core is the person or
patient to whom nursing care is directed, since our patient needs an aid so we, the
nurses, will serve as the care, we will be the one performing the task of nurturing our
patients, which may include provision of comfort measures, provision of patient some
teaching activities and helping them to meet their needs where help is needed. The
cure, is the attention given to patients by the medical professionals. This explains that
the cure is handled by the nurse together with the other health professionals. These are
the interventions or actions on treating or “curing” the patient from any illness or disease
she may be suffering from. In this case, when all of the healthcare workers will focus on
how to make the cure circle better, our patient will have a greater chance of recovery.
Name: ______________L.P._____________ Age: _63y.o._ Sex: _Female_ Ward: _San Lorenzo_ Room: _306_ Bed#:
_1_
Chief Complaint: ____dysphagia______ Diagnosis: _Multinodular Toxic Goiter in Euthyroid State s/p
thyroidectomy______
DATE
Nee Objectives of
/ Cues Nursing Diagnosis Nursing Interventions Evaluation
d Care
TIME
S: “Pawala wala Acute pain related A That within 30 1. Assess vital signs. NOVEMBER
N pero ngayon to post-operative C minutes of R: To have baseline 20, 2018 @
O medyo masakit surgical incision T nursing care data. 9:00 AM
lalo na pag I the patient will 2. Assess verbal and GOAL MET
V
ginagalaw “ as R: More than 75% V report pain is nonverbal reports of
E verbalized by the of patients I controlled as pain. Note location, After my 30
M client undergoing surgery T evidenced by: intensity and duration. minutes of
B suffer from acute Y R: to evaluate pain, nursing care
E O: pain. Most of this a.) Pain scale intervention and the patient will
R  Post total pain transforms into E of 0 out of effectiveness. report pain is
thyroidectom chronic pain. X 3; no pain 3. Place on semi-fowler’s controlled as
y November Currently, treatment E b.) Vital signs position and support evidenced by:
20
17, 2018 of postoperative R maintained head and neck.
 VS pain is based mainly C within the R: To prevent a.) Pain scale
2 T: 36.2C on opioids, but I normal hyperextension of neck of 0 out of
0 BP: 130/70 results are not quite S range and protect integrity of 3; no pain
1 mmHg satisfactory. E c.) Absence suture line. b.) Vital signs
8 CR: 81 bpm Postoperative pain of grimace 4. Maintain head and neck maintained
RR: 19 cpm is defined as a P face or in neutral position and within the
 With wound condition of tissue A protective support during position normal
@
dressing on injury together with T behavior changes. range
incision site muscle spasm after T R: To prevent stress on T: 36.4
8:00 dry and intact surgery. Recently, E suture line and reduce BP:120/70
am peripheral and R muscle tension. CR:69
 With Jackson central sensitization 5. Keep frequently needed RR:19
pratt has been shown items within reach. c.) Absence
 With pain within the R: To avoid stretching, of grimace
scale of 1 out mechanisms of muscle strain in and
of 3; 0 as no postoperative pain operative area. protective
pain, 1 as generation. 6. Encourage to use behavior
mild pain, 2 relaxation techniques:
as moderate Reference: soft music and breathing Maxin Anne L.
pain and 3 as Ceyhan, D. & Gulec, exercises. Ledda St.N.
severe pain MS. (2010, April R: Helps in managing
 Slight 22). Is postoperative pain and diverts
grimace face pain only a attention.
Meds: nociceptive pain. 7. Administer analgesics as
 Nalbuphine 5 PubMed PMID: ordered.
mg IVTT q 8 20582745. N R: Reduces pain and
hrs PRN for Retrieved discomfort and to
pain November 30, 2018 enhance rest.
 Etoricoxib 90 from 8. Encourage adequate
mg 1 tab BID rest periods.
https://www.ncbi.nl
 Celecoxib R: To prevent fatigue
m that can impair ability to
200mg BID
prn for pain manage and cope with
pain.

9. Provide environment
conducive for rest.
R: To enhance rest
periods.
_1_
thyroidectomy______
DATE/ Nursing Nee Objectives of
Cues Nursing Interventions Evaluation
TIME Diagnosis d Care
Objective: Impaired skin N That within 7 1. Support and instruct November 20,
N  ć surgical integrity r/t U hours of client in incisional 2018
O incision at surgical incision T nursing care, support when turning,
V anterior neck secondary to R the patient will coughing, deep 3:00pm
E  ć post operative thyroidectomy I remain free breathing, and
M dressing at T from further ambulating Goal Met
B anterior neck, R: A I skin R: Reduces possibility of
E dry and intact thyroidectomy is O impairment at dehiscence. Within 7 hours
R  ć JP catheter the surgical N the surgical 2. Observe incisions of nursing
draining to removal a part A area as periodically, noting care, the
20 serosanguineous of or all of the L evidenced by: approximation of wound patient
discharges thyroid. Various edges, hematoma remained free
2  s/p techniques are M a) Absence of formation and resolution, from further
0 thyroidectomy used to create E bloody and presence of skin
1 11/17/2018 the incision. The T discharges bleeding and drainage impairment at
8  Diagnosis: initial incision is A on JP R: Verifies status of healing, the surgical
Multinodular made over the B catheter provides for early detection area as
@ toxic goiter in marked line as O drain; of developing complications evidenced by:
euthyroid state described in the L b) clean and requiring prompt evaluation
8:00 preparation I intact post- and influencing choice of a) Absence of
am section. A #15 C operative interventions bloody
blade is used to dressing 3. Provide routine incisional discharges
incise through P free from care, being careful to on JP
the epidermis A blood; and keep dressing dry and catheter
and dermis. T c) absence of sterile. Assess and drain;
Using a Shaw T increase in maintain patency of b) clean and
scalpel or E pain. drains. intact post-
monopolar R R: Promotes healing. operative
cautery, N Accumulation of drainage in dressing
dissection is subcutaneous layers free from
carried through increases tension on suture blood; and
the line, may delay wound c) absence of
subcutaneous healing, and serves as a increase in
fat to the medium for bacterial growth pain.
platysma. 4. Provide meticulous skin
care, pay particular
Goyal, N. (May attention to skin folds Belle Patrice
2018). R: Moisture or excoriation G. Fuentes,
Thyroidectomy. enhances growth of bacteria St.N
Emedicine: that can lead to post-
Medscape. operative infection
Retrieved 5. Provide tissue care as
December 2, needed.
2018 from R: The incision may be
http://emedicine covered with wet or dry
. dressing, topical lubricants.
medscape.com/ The dressing serves as
article/1891109 protective function of tissue
during the healing process.
6. Keep a sterile dressing
technique during wound
care.
R: This technique reduces
the risk for infection
7. Assess changes in body
temperature, specifically
increased in body
temperature.
R: Fever is a systemic
manifestation of
inflammation and may
indicate the presence of
infection.
8. Assess patient’s
nutritional status.
Encourage to increase
protein intake.
R: Protein aids the body in
repairing damaged tissues
9. Tell patient to avoid
rubbing and scratching
and even touching the
area. Provide gloves or
clip the nails if
necessary.
R: Touching area may
cause further injury and
delay healing.
10. Educate patient about
proper nutrition,
hydration, and methods
to maintain tissue
integrity
R: The patient needs proper
knowledge on his or her
condition to prevent further
tissue injury
11. Instruct patient,
significant others, and
family in proper care of
the wound including
hand washing, wound
cleansing, dressing
changes, and application
of topical medications)
R: Accurate information
increases the patient’s
ability to manage therapy
independently and reduce
risk for infection.
_1_
thyroidectomy______
DATE
Objectives of
/ Cues Nursing Diagnosis Need Nursing Interventions Evaluation
Care
TIME
S: Electrolyte N That within my 1.Monitor Vital Signs and Neuro November
N O: Imbalance related U 5 hours span of Vital Signs 20, 2018 @
O >Vital Signs: to post total T nursing care, R: This serves as a baseline data. 1pm
BP: thyroidectomy as R client will not Calcium deficit weakens cardiac “Goal Met”
V
130/70mmH evidenced by I manifest muscle contractility After my 5
E g decrease serum T complications 2. Monitor respiratory rate, effort, hours span of
M Temp: 36.2C calcium levels I of electrolyte and rhythm nursing care
B CR: 81bpm O imbalance, as R: Hypocalcemia may result to my client did
E PR: 79bpm Rationale: N evidenced by: laryngeal stridor leading to not manifest
R RR: 19cpm Hypocalcemia is a A respiratory arrest complications
>NVS of major post L A.) Cardiac rate 3. Assess for areas of of electrolyte
1/15 operative M within 60- possible bleeding and observe for imbalance,
20
>11/19 Total complication of total E 100 bpm petechiae and ecchymosis as evidenced
Calcium= thyroidectomy, T B.) Absence of R: Severe hypocalcemia is by:
2 1.92 mmol/L which occurs in up A neuromusc associated with depressed A)Cardiac
0 Normal= to 30% to 35% of B ular circulatory function and alterations Rate of 69
1 2.23- patients. This O irritability in coagulation bpm
8 2.58mmol/L occurs because the L C.) Neuro Vital 4. Observe for neuromuscular B)Signs of
parathyroid glands, I Signs of irritability, including tetany, or neuromuscul
@ which are found C 1/15 seizure activity. Assess for ar irritability
next to the thyroid, presence of Chvostek’s and was not
8:00 are often “bruised” P Trousseau’s signs. noted
during thyroid A R: Calcium deficit causes C) NVS of
am
surgery and don’t T repetitive and uncontrolled nerve 1/15 patient
work too well for a T trans- mission, leading to muscle is alert
short time after E spasms and hyperirritability
surgery. This leads R 5. Encourage relaxation and stress
to a fall in N reduction techniques including
parathyroid deep-breathing exercises Mary
hormone (PTH), R: Tetany can be potentiated by Elizabeth
which is important hyperventilation and stress. Tabuñag.
in regulating blood 6. Encourage to eat foods high in St.N.
calcium levels. calcium such as dark leafy greens,
cheese, low-fat milk, yogurt, eggs,
Ref: American oranges, green beans, and
Thyroid Association. sardines.
(2012, February). R: Vitamin D aids in the
absorption of calcium from the
Thyroid Surgery
intestinal tract.
Postoperative 7. Monitor laboratory studies
Hypocalcemia. R: Evaluates therapy needs and
Retrieved effectiveness
December 2, 2018,
from
https://www.thyroid. Source:
org/patient-thyroid-  Doenges, M. E.,
Moorhouse, M., & Murr, A.
information/ct-for- C. (2016). Nurse's Pocket
patients/vol-5-issue- Guide: Diagnoses,
5/vol-5-issue-5-p-7/ Prioritized Interventions, and
Rationales (14th ed.).
Philadelphia: F.A. Davis
Company.
 Ladwig, G. B., Ackley, B. J.,
& Makic, M. (2017). Mosby's
Guide to Nursing
Diagnosis (5th ed.). St
Louis, Missouri: Elsevier.
_1_
thyroidectomy______
DATE
Nursing Nee Objectives of
/ Cues Nursing Interventions Evaluation
Diagnosis d Care
TIME
S: None. Risk for infection H That within 6 1. Routinely monitor the November 20,
N O: related to post E hours span of patient’s white blood cell 2018 @ 2pm
O Post total surgical incision A care, the count. “Goal partially
V thyroidectomy secondary to total L patient will R. These laboratory values Met”
E thyroidectomy T remain free are closely linked to the After my 6 hours
M Post operative H from signs of patient’s immune function. span of care,
B dressing dry infection as 2. Monitor the patient for any the patient
E and intact P evidence by: signs of swelling, purulent remained free
R E discharge or presence of from signs of
VS taken as R a.) display vital pain from wound. infection as
20 follows: C signs within R. These are the classic evidence by;
T: 36.2 E normal range signs of infection.
2 C:81 bpm P 3.Investigate the use of a.)Vital signs
0 R:19cpm T b.) absence of medications or treatment within normal
1 B:130/70 I purulent modalities that may cause range
8 mmHg O drainage to immunosuppression. T: 36.4
N incision site R. Antineoplastic agents, C:69
@ Cefuroxime corticosteroids, and so on, R:19
750mg IVTT H c.)WBC within can reduce immunity B:120/70
8:00 q8 E normal range 4.Encourage adequate rest l.
am A R.To boost the immune b.)Absence of
L system. purulent
T 5.Keep area around wound drainage to
H dry and clean. incision site
R. Wet area can be lodge
M area of bacteria. c.) Unable to
A 6.Maintain aseptic technique assess WBC
N when changing result
A dressing/wound care.
G R.Regular wound dressing Clashane Kyle
E promote fast healing. C. Cabillo, St. N
M 7.Encourage patient to eat a
E balanced diet.
N R. Vitamins A, C and E, zinc
T and iron is essential in
reducing risk of infection.
7.Take antibiotics as
P prescribed. Instruct patient to
A take the full course of
T antibiotics.
T R. Not completing the
E prescribed antibiotic regimen
can lead to drug resistance
in the pathogen.
Ref: Doenges, M. E.,

R Moorhouse, M. F., & Murr, A.
N C. (2014). Nurse’s pocket
guide: Diagnoses, prioritized
interventions, and rationales.
Philadelphia: F.A. Davis
_1_
thyroidectomy______
DATE
Objectives of
/ Cues Nursing Diagnosis Need Nursing Interventions Evaluation
Care
TIME
Objective: Risk for Aspiration N Within 7 hours 1. November 20,
N -surgical related to surgical U span of nursing moderate high back 2018@3:00pm
O incision at incision of the T care my client rest or elevate client “Goal Met”
anterior neck anterior neck will be free from to highest position for Within 7 hours
V R
-S/P Total secondary to total aspiration, as eating and drinking. of nursing care,
E thyroidectomy thyroidectomy. I evidenced by: R: To decrease the risk of the patient
M T
B -Difficulty R: Aspiration is the I A. Maintaining a aspiration remained free
E swallowing most clinically O patent airway 2. from aspiration
R significant N with normal ability by assessing as evidenced
consequence of breath sounds the following: by:
A
dysphagia. B. Swallowing coughing, choking A. Maintaining
20 Because of the L and digesting during or after a patent airway
close anatomical meals without swallowing, and with normal
2 relationships M aspiration residual food in mouth breath sounds
0 between thyroid E C. Absence of after eating B. Swallowing
1 gland and laryngeal T complications of R: Impaired swallowing and digesting
8 nerves, sensory- A aspiration such increases the risk for meals without
motor impairment of aspiration. aspiration
B as: shortness of
the laryngeal 3. C. Absence of
@ functions is a well O breath, apnea, thoroughly and eat complications
known possible L and difficulty of slowly during meals. of aspiration
8:00 complication of I breathing R: Well-masticated food is such as:
am thyroid surgery. C easier to swallow, food cut shortness of
Laryngeal nerve into small pieces may also breath, apnea,
paralysis can P be easier to swallow. and difficulty of
present with various 4. breathing
A
and often eaten.
associated T R: Ingesting food and fluids
symptoms like T together increases
dysphagia, E swallowing difficulties.
aspiration, voice R 5.
alteration or N environment away
dyspnea. from excessive stimuli
Finck, Camille. R: A noisy environment
(2006). Laryngeal can be aversive and can
Dysfunction After decrease effective
mastication and
Thyroid Surgery:
swallowing. Talking and
Diagnosis, laughing while eating
Evaluation and increases the risk of
Treatment. Acta aspiration.
chirurgica Belgica. 6.
and after meals.
106. 378-87.
R: Oral care before meals
10.1080/00015458. reduces bacterial counts in
2006.11679911. the oral cavity. Oral care
after eating removes
residual food that could be
aspirated at a later time.
7.
frequently
R: To determine presence
of secretions/silent
aspiration. Aspiration of
small amounts can happen
with sudden onset of
respiratory distress or
without coughing.
8.
depth, and effort.
Note any signs of
aspiration such as
dyspnea, cough,
cyanosis, wheezing,
or fever.
R: Signs of aspiration
should be detected as
soon as possible to prevent
further aspiration and to
initiate treatment.
9.
to assess for
gastrointestinal
motility.
R: Reduced
gastrointestinal motility
increases the risk of
aspiration as fluids and
food build up in the
stomach. Further, elderly
patients have a decrease
in esophageal motility,
which delays esophageal
emptying. When combined
with the weaker gag reflex
of older patients, aspiration
is at higher risk.
10.
abdominal distention
or increased rigidity of
abdomen.
R: Abdominal distention or
rigidity can be associated
with paralytic or
mechanical obstruction and
an increased likelihood of
vomiting and aspiration
References:
•
Moorhouse, M., &
Murr, A. C.
(2016). Nurse's
Pocket Guide:
Diagnoses,
Prioritized
Interventions, and
Rationales (14th
ed.). Philadelphia:
F.A. Davis
Company.
•
J., & Makic, M.
(2017). Mosby's
Guide to Nursing
Diagnosis (5th
ed.). St Louis,
Missouri: Elsevier.
Wayne, Gil. (2016). Risk
for Aspiration. Retrieved
December 2, 2018, from
https://nurseslabs.com/risk-
for-aspiration/
DISCHARGE PLAN
 Follow the physician order for the prescribed medication.
During the stay in San Pedro Hospital –San Lorenzo, patient
had been given with medication of:
 Hydrocortisone 20mg IVTT@6am
 Omeprazole 40mg 1tab OD x 2 days
 Dexamethasone 5 mg IVTT q8hrs x 3 days
 Midazolam 15g ½ tab 6am
 Nalbuphine 5mg IVTT q8hrs
 Calcitrol 1tab TID
Medications
 Cefuroxime 750mg IVTT q8
 Etoricoxib 90mg 1tab BID
 Caltrate plus 2 tabs q6hrd
Home Medications are:
 Cefuroxime 500mg BID x 5 days
 Celecoxib 20mg BID, PRN for pain
 Caltrate plus 2 tabs q6hrs x 2 weeks
 Calcitrol 1cap BID x 2weeks
 Provide adequate rest and sleep for the patient.

R: To restore energy of the patient.
 Massage back of the neck every 1-2 hours
R: For relaxation
 Support the nech if changing position or sitting
R: This will help prevent pain due to neck activity
 Be aware of posture
R: Prevent to neck stiffness
Exercise  Do some neck exercise: Head turns, head lift, look up and
down.
R: Help prevent a tight scar
 Keep active lifestyle. Ambulate as tolerated.
R: Help maintain a level of fitness through the treatment
period
 Scar massage
R: Help improve the size and appearance of the scar and
range of movement of your neck
Treatment  Encourage the patient to follow treatment regimen

Hygiene  Advice the family to provide a clean and relaxing environment
for the patient.
R: To prevent the patient from stress and promote wellness
 Maintain aseptic technique when changing dressing/wound
care.
R.Regular wound dressing promote fast healing.
 Do not soak dressing, after showering pat dry the incision site.
R: Wet area lodge bacteria
 Avoid touching the incision site.
R: Touching the incision site with dirty hands may lead to
infection
 Encourage to strictly attend prescribed follow-up check- up

after discharge as possible.
Outpatient R: This is for proper monitoring of the patient’s condition and
progress of treatment.
 Eat slowly and chew the food properly.
R: Patient may have difficulty swallowing and may choke
 Eat foods rich in protein such as fish, meat and egg.
R: Promote wound healing
 Avoid ingesting liquors, cola, coffee and spicy foods
Diet R: These are irritating foods
 Increase oral fluid intake as tolerated.
R: For hydration
 Eat high fiber foods such as banana and dark leafy vegetables
R: Avoid constipation
PROGNOSIS
Hyperthyroidism is usually progressive over time, and along with it are many
associated complications, some of which are severe and may affect quality of life.
These include complications caused by use of radioactive iodine, surgery, and
medications to replace thyroid hormones. However, hyperthyroidism is generally
treatable and rarely fatal. (MyVirtual Medical Center, 2017). In the patient’s case, she
has already undergone total thyroidectomy. Results vary on how much of the thyroid
was removed. Since the patient’s entire thyroid was removed, her body now
cannot make thyroid hormones and without replacement, she will most
likely develop signs and symptoms of underactive thyroid
(hypothyroidism), unless hormone replacement is provided. She will
need to take a pill every day that contains the synthetic thyroid
hormone levothyroxine.
In the patient’s case, because her entire thyroid has already been
removed, all possible chances of recurrence are now impossible
whether it be benign or malignant. Although she will be needing
lifelong therapy of thyroid hormone replacement, this will not be a
problem because she is very compliant of the doctors orders and
religiously takes medications. She also has the support of her
daughter. Financially, they are capable of purchasing her needs.
Overall, she has a good prognosis as long as she religiously takes her
hormone replacement therapy.
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TOXIC MULTINODULAR GOITER
A Case Study Presented to the

Faculty of the Nursing Department
San Pedro College
Erein Therese B. Acero, RN, MN
In Partial Fulfillment of the requirements

In NCM 106 – RLE
Cancer Nursing Rotation
By:
Cabillo, Clashane Kyle
Fuentes, Belle Patrice
Ledda, Maxin Anne
Tabunag, Mary Elizabeth
Villasario, Chrisca Samantha
BSN 4C
December 3, 2018
TABLE OF CONTENTS
TITLE PAGE i
TABLE OF CONTENTS ii
INTRODUCTION 1
OBJECTIVES 3
BIOGRAPHICAL DATA 4
DEVELOPMENTAL TASK 7
PHYSICAL ASSESSMENT 9
DEFINITION OF DIAGNOSIS 14
ANATOMY AND PHYSIOLOGY 16
PATHOPHYSIOLOGY 20
MEDICAL MANAGEMENT 29
NURSING THEORY 48
NURSING CARE PLANS 51

DISCHARGE PLANNING 66
PROGNOSIS 68
REFERENCE 69

People Ke. Africa and The Western Pacifi People (WHO

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INTRODUCTION

The incidence of goiter, diffuse and nodular, is very much

II. Clinical Data

Ward: San Lorenzo Ward

PAST HEALTH HISTORY

PRESENT HEALTH HISTORY

FAMILY HEALTH HISTORY

Erik Erikson’s Psychosocial Theory

Robert Havighurst’s Developmental Tasks

Task Achieved/Not Achieved Rationale

Our physical assessment was done on October 30, 2018 at 4 PM.

VITAL SIGNS RESULT NORMAL RANGE

Glasgow Coma Scale RESPONSE SCORE

EYE OPENING SPONTANEOUS 4

MOTOR RESPONSE OBEYS 6

VERBAL RESPONSE ORIENTED 5

Reaction Level Scale DEFINITION SCORE

I Olfactory Able to distinguish the smell of rubbing alcohol, orange,

Final Diagnosis: Multinodular Toxic Goiter in Euthyroid State

MULTINODULAR TOXIC GOITER

o Toxic Multinodular Goiter literally means ‘toxic’ due to the

o Multinodular Toxic Goiter refers to a pathological condition of

o Toxic Multinodular Goiter is a condition in which the thyroid gland contains

Medicinenet (2016, June 9)

o A Toxic Multinodular Goiter (also known as toxic nodular goiter) involves an

MedlinePlus. (2018, November 13)

o Toxic multinodular goiter is an active multinodular goiter associated

Wikipedia. (2018, November 25)

De Groot, L. J., & Jameson, L. J. (2013)

o Euthyroid State is the ability to maintain normal sufficient thyroid hormone

o Euthyroid is the state of having normal thyroid gland function.

Medicinenet. (2016, May 13)

o Euthyroid State is the confirmation of normal TSH or normal functioning thyroid.

o Euthyroid State is defined as having normal thyroid function.

ANATOMY AND PHYSIOLOGY

To understand toxic multinodular goiter

Hormone is the key to the incredible power

The pituitary gland hangs by a stalk

The thyroid gland is located at the base of

The second hormone produced by the

The adrenal glands are the two

The pancreatic islets formerly called islets of

Decrease in thyroid hormone levels

TRH stimulates the pituitary gland to release TSH or Thyroid

EUTHYROID STATE: Less thyroid hormone is

TOXIC MULTINODULAR GOITER: Genetic mutation in

However, if lack of thyroid hormone worsens another round of TSH stimulates

Possible Lab/Diagnostic Test

This test measures the amount of TSH in the blood to

DATE/TIME ORDER RATIONALE

Brand Name Dormicum

Date Ordered November 16, 2018

Ordered Dose Midazolam 15g ½tab 6am NOW

Mechanism of A benzodiazepine that enhances the action of gamma-aminobutyric

Generic Name Hydrocortisone

Mechanism of A benzimidazole that is converted to active metabolites that irreversibly

Generic Name Nalbuphine

Brand Name Caltrate Plus

Generic Name Cefuroxime

Herbal: None known.

Generic Name Calcitriol

Mechanism of Provides calcitriol supplementation which is the active form of vitamin