Admission/Final Diagnosis:

MULTINODULAR COLLOID GOITER WITH INTRATHORACIC EXTENSION

I. HEALTH HISTORY

A. DEMOGRAPHIC DATA (BIOGRAPHICAL DATA)

1. Client’s name or initial: M.G.F.
2. Gender (Sex): Female
3. Age: 43 years old
Birthdate: August 21, 1967
Birthplace: Manila
4. Marital (Civil) Status: Married
5. Race and Nationality: Filipino
6. Religion: Catholic
7. Address: General Trias, Cavite
Telephone Number: N/A
E-mail address: N/A
8. Educational Background / Other Significant Framing: 3 rd year college
9. Occupation: Midwife
10. Usual Source of Medical Care: Contreras Medical Clinic
11. Date of Admission: Sept. 15, 2010
B. SOURE AND RELIABILITY OF INFORMATION

Client herself seems reliable

C. REASONS FOR SEEKING CARE

 “Malakas ang kabog ng dibdib ko”

 “Para akong nasasakal”
 “Parang may nagbabara kapag kumakain ako”
D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH
The pt. was apparently well until 2 yrs. ago, when she got pregnant, her doctor
advised her to undergo UTZ of her neck & check for goiter. She presented with increased
perspiration, anxiety, nervousness, tachypnea, and thick, tingling, feeling on the right hand.
Without noted aggravating or relieving factors. No consult was done and no medications
were taken.
One year prior to admission, there was persistence of symptoms and the pt. noted a
neck mass sensation. She began folding her pillow to elevate her head when sleeping
because of the neck discomfort.
Four months prior to admission, she experienced heat intolerance and felt an
obstruction on the neck area when swallowing even without food. There was persistence of
symptoms but the thick tingling sensation was felt from the fingertips of the right hand to the
forearm. Palpitations were also noted. No consult was done and no medications were taken.
Tremors on the right hand were noted.
Two months prior to admission, there was persistence of symptoms that prompted
her consult to a physician who referred her to an ENT doctor. She was advised to undergo
an operation ad no medications were prescribed. UTZ of the neck, CT Scan, CBC, X-ray
(Chest), FT4, TSH, ECG was done to prepare for the operation.
On the day of consult, there was persistence of symptoms and she was admitted in
DLS-UMC at around 3:00pm.

E. PAST MEDICAL HISTORY OR PAST HEALTH

Client stated that she had common illnesses in the past like fever, cough and
common cold. She had no serious illnesses experienced aside from these. The
client is not hypertensive and has no history of diabetes mellitus, bronchial asthma
and seizure. She has not experienced any serious injuries or accident.
The client had already undergone 2 operations before she was admitted in the
hospital. According to the client, her first operation was done on 1990’s which is
appendectomy along with unilateral oophorectomy due to a cyst found on her right
ovary. After 2 years, she underwent another operation which is cholecystectomy.
There were no complications reported from any of her operations.
 The client’s OB score is G6P4 40240 which indicates that she became
pregnant six times and gave birth at term four times, all under normal delivery. She
currently has four living children. Unfortunately, she also had two spontaneous
abortions. Her age at menarche was 12 years old, her LMP was September 7, 2010
and her menstrual cycle is regular, usually lasting for 4-5 days. The client sometimes
experience heavy menstrual periods in which she uses diapers and change 3 times
in day. She had also experienced dysmenorrhea during her adolescence.
Her immunization status was unrecalled by the client. She has no allergies to
any foods or medications but stated that she has seasonal allergies in which the skin
below her lower lip becomes swollen and reddened.
The client was not a drinker but admits that she smokes whenever she wants
to defecate. According to her, this helps her to feel the urge to defecate and have an
easy bowel movement. The client also admitted that she sometimes consume
carbonated drinks.
 F. FAMILY HISTORY

Unrecalled 89 Y/O unrecalled Unrecalled

Stroke Heart attack TB GI problem
DM

60 y/o 63 y/o 57 y/o 50 y/o 49 y/o 48 y/o 47 y/o 46 y/o 44 y/o 60y/o 56 y/o 53 y/o 48 y/o 45y/o 40y/o
DM A&W DM A&W unrecalled Skin HTN HTN Kidney HTN HTN HTN HTN A&W HTN
HPN- Asthma disease
Gouty
Arthritis

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

Interpretation:
 On her father side, they have a history of hypertension, tuberculosis and
asthma. Her grandfather died due to tuberculosis, unrecalled age while her
grandmother died due to gastrointestinal problem according to patient, unrecalled
specific gastrointestinal disease an age of death. Her father is the eldest among the
six, is sixty years old and is hypertensive. Most of her father’s siblings are
hypertensive except for the fifth child.

On her mother side, they have history of heart problems, Diabetes Mellitus,
skin asthma, gouty arthritis and renal problems. Her grandmother died at the age of
89 due to heart attack while her grandfather died at the age of sixty due to stroke,
also her grandfather had diabetes mellitus. Her mother is the second among the
nine children. The eldest died at the age of sixty years old due to Diabetes
complication. Her mother is sixty three years old. The third child has diabetes
mellitus and hypertension. The fourth child is fifty years old, has hypertension and
with gouty arthritis. The fifth child died at forty nine years old with unrecalled cause
of death. The sixth child is forty eight years old with skin asthma. The seventh and
eight child aged forty seven and forty six respectively, have hypertension, and the
youngest child aged fort four has kidney disease and is undergoing hemodialysis
twice a week for six years.

G. SOCIO ECONOMIC

The client stated that she does not work at present. She lives in three
different houses: her mother’s, her husband’s and her uncle’s house. This is
because she does not have any source of income to support her and her children’s
basic needs. Her 2 children are living with her mother and the other two are living
with her uncle. Her husband works as a security guard and earns 4,000 pesos every
15th of the month but his income is not enough to support their needs. Additional
taxes would still be subtracted from her husband’s income. The client’s brother
sometimes helps in paying for the expenses of the family. The client’s mother also
shares in paying the expenses because she works in a small grocery and has a
small apartment. Their other relatives abroad offer financial support to them and they
 also help in paying for her hospitalization and other expenses they incur. Due to lack
of the sources of income of the client, her family experiences financial problems but
stated that they were lucky because they can still manage to pay for their basic
needs at present.

H. DEVELOPMENTAL HISTORY

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

adulthood stage with an ego development task of Generativity vs. Self absorption or
Stagnation and with the basic strengths of production and care

Now work is most crucial. Erikson observed that middle-age is when we tend
to be occupied with creative and meaningful work and with issues surrounding our
family. Also, middle adulthood is when we can expect to "be in charge," the role
we've longer envied. The significant task is to perpetuate culture and transmit values
of the culture through the family-like taming the kids and working to establish a
stable environment. Strength comes through care of others and production of
something that contributes to the betterment of society, which Erikson calls
generativity, so when we're in this stage we often fear inactivity and
meaninglessness.

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

faced with major life changes—the mid-life crisis—and struggle with finding new
meanings and purposes. If we don't get through this stage successfully, we can
become self-absorbed and stagnate. Significant relationships are within the
workplace, the community and the family.

I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION

1. ROS AND PE
Date: Sept, 16, 2010

System ROS PE
a. General/overall health “Nabawasan ang  Received patient
status timbang ko ng 4 kilos” sitting on bed,
conscious,
“Init na init yung  awake and
pakiramdam ko, gusto communicative
ko na maligo”  Patient appears F/N
 With heplock at right
“Hindi ako metacarpal vein
nakakaramdam ng  V/S:
panghihina ngayon” BP: 130/60mmHg
PR: 80 bpm
RR: 32cpm
Temp: 36.0°C
 Good capillary refill (3
secs.)
 large-size body build
 Diet is DAT
b. Integument “Pakiramdam ko SKIN
parang may Inspection
tumutusok tusok sa  soft, smooth, dark
kamay ko, minsan colored skin
nawawala”  (+) dark nuccal
 (-) erythema
“Wala naman akong  >(-) hyperpigmentation
sakit sa balat” on the skin
 >(+)pruritus
“Hindi naman ako
nangangati ngayon, Palpation
init na init lang ang  normothermic
pakiramdam ko”  (-) edema

HAIR
Inspection
 gray-white colored hair
 usual for age
 (-) patches or lesions
on areas with hair
 (-) parasites

Palpation
 (+) thin hair strands
 (+) dry hair

NAILS
Inspection
 Nail surface are
smooth and slightly
curved w/ elongated
dirty nail edges
 Convex shape
 Pale pink nail beds w.
no linear pigmentation

Palpation
 Smooth and rounded
posterior and lateral
nail folds
 Good capillary refill for
3 secs.
 Good skin turgor and
mobility

c. Head “Hindi naman palaging INSPECTION

sumasakit ang ulo ko,  >short black hair, well
hindi naman ako to distributed
nahihilo”  >Proportion to the body
 >Bilateral symmetric
facial features
  >(-) dandruff
 >normocephalic

Palpation
 >(-) tenderness
 >(-) lumps observed
and palpated
d. Eyes “Medyo malabo na EYEBROWS
ang mata ko” Inspection
 Eyebrows evenly
“Nakakabasa ako sa distributed on both
malayo pero kapag sides
sobrang lapit, medyo  (-) lesions
malabo na”  (-) scaling
 Both are bilaterally
“May salamin ako equal and maintains
kaya lang limang taon symmetry even after
ko na hindi nagamit movement
kasi hindi ko na
kasukat” EYELIDS
Inspection
 Completely close when
clients sleeps
 With baggy eyelids
SCLERA:
Inspection:
 White sclera

EYELAHES:
Inspection
 >Lids close
symmetrically
 >Pink palpebral
conjunctiva
Palpation:
 >Skin intact
 >Nodules or lesions

EYEBALLS:
Inspection:
 >(-) protusion or
sunken
 >Aligned normally in
their sockets
 >Bilaterally
symmetrical
 >(+) parallel eye
movements

CONJUNCTIVA:
Inspection:
 >Pallor
 >Shiny, smooth
 >(+) parallel eye
movement
 >(-) discharge
 >(-) redness

CORNEA
Inspection:
 >(+) corneal reflex
 >transparent

PUPILS:
Inspection:
 >Black in color
 >(+) PERRLA
e. Ears “Nagkaroon ng Inspection:
impeksyon yung
kaliwang tenga ko
dati, two years ago
na. Namaga tapos
pinacheck-up ko sa
doktor, binigyan ako
ng pampatak pati ng
antibiotic”
“Minsan sa isang
linggo ko lang nililinis Palpation:
ang tenga ko kasi sabi
ng doktor hindi dapat
araw araw ang
paglilinis noon”
f. Nose “Hindi naman ako Inspection:
madalas magkasipon.
Pag nagkasipon ako
hindi naman barado”
 >Both ears are
bilaterally equal and
inline with the eyes
 >Color same as facial
skin
 >No discharge
 >(+) cerumen
 >(-) lesions
 >(-)Swelling
 >Pinna recoils after it is
folded
 >Firm
 >No tenderness on the
auricle and tragus
 >(-) masses
 >Symmetric and at the
midline
 >Nasal septum intact at
midline of the head
without perforations
 >(-) nasal flaring
 >(-) nasal discharge
 >(-) lesions
 >(-) swelling of sinuses
 >(-) nasal congestion
 >(-) epistaxis
 Palpation:
 >(-) tenderness upon
palpation of the
maxillary and frontal
sinuses
 >Both nasal airways
patent

g. Mouth & throat “Minsan sumasakit MOUTH, TEETH & GUMS,

ang lalamunan ko PLATES, UVULA, THROAT
kapag lumulunok at AND TONSILS:
kapag namamaga Inspection:
yung tonsil ko”  unable to perform,
patient cannot open
“Medyo namamalat her mouth still.
din yung boses ko” LIPS:
Inspection:
“Last year pa ako  >(+) chapped lips
nagpunta sa dentist.  >(-)pallor
Wala akong pustiso  >(-) lesions
kasi natatakot ako sa
dentista, masakit kasi
yung tusok ng
injection”
h. Neck “Nangangalay yung Inspection:
batok ko”  post surgical operation
– thyroidectomy
“May goiter ako kaya  Slow, limited
ako inoperahan, buti movements
natanggal na”
 >Positioned in midline
“Hindi ko masyado  >Accessory neck
magalaw pa ngayon muscle are
yung leeg ko, masakit symmetrical
 kasi”  >Head position is
centered in the midline

i. Breast & Axillary “Kinakapa ko yung Inspection:

dede ko kung kailan  >equal size of breast
ko lang maisipan,  >dark brown nipples
wala namang bukol”  >(-)discharge
 >small montgomery
“Lahat ng anak ko tubercles present
breastfeed talaga sila,
mahal kasi yung
gatas”
j. Respiratory “Wala naman akong Inspection:
sakit sa baga kasi >RR=32 cpm
minsan lang ako >(+) difficulty of breathing
manigarilyo kapag >Thorax is symmetric,
gusto ko lang Elliptical in shape
dumumi” >(+) symmetrical chest
expansion
“Kanina may dugo >AP diameter of the chest 1:2
yung dura ko pero >(+) cough; non-productive
ngayon wala na”
Palpation:
>(+) equal tactile fremitus on
both lungs

Percussion:
>(+) resonant in both lung
fields

Auscultation:
>(-) adventitious sound

k. Cardiovascular Mabilis ako mapagod Inspection:

lalo na kapag >(-) Cyanosis
 umaakyat sa hagdan >(-) Varicose veins
kaya kapag umaalis >(-) edema
ako ng bahay lagi
akong sumasakay ng Palpation:
tricycle” >BP= 130/60 mmHg
>PR= 80 bpm
“Nagpalpitate ako >(-) chest pain
bago ako maospital, >(-) palpitations
ngayon meron pa rin >Carotid artery pulsation
pero konti na lang” >(-) jugular vein distention

“Lagi akong Auscultation:

pinupulikat” (-) heart murmur
(-) tachycardia
(+)dyspnea
l. Gastrointestinal and “Kahit ano kinakain Inspection:
Abdomen ko, medyo hirap nga  two incisions –
lang akong kumain (previous
ngayon” cholecystectomy and
appendectomy)
“Hindi ako umiinom ng
pampadumi”  (-) rahes
 >+) striae
“Regular naman ako
dumumi kasi pag Ausculation:
kumain ako, dudumi  15 Bowel
ako pagkatapos” sounds/minutes

Palpation:
 (+) dry skin

Percussion:
 (+) tympanic sound
m. Urinary “Madami yung iniihi Inspection:
ko, madilaw yung >UO= 150 cc from 2-10pm
kulay” >Amber yellow urine

“Nagkaroon ako ng Palpation:

UTI noong nagbuntis >(-)low back pain
ako” >(-) umbilical area tenderness

n. Genitalia “12 years old ako Client refused to be

unang nagkaroon, examined
irregular pa dati pero
regular na ngayon”

“Minsan nagsusuot
ako ng diaper kapag
malakas yung period
ko”
o. Muscoloskeletal “Medyo masakit yung Inspection:
likod ko pati balikat  Elbows, wrists, hands,
ko” fingers, and feet are
bilaterally symmetrical
“Yung kanang binti ko  (+) tremors
medyo masakit din,  (+) Chvostek’s sign
parang nangalay”  (+) Trousseau sign
 full range of motion of
hands and feet, as well
as wrists and ankles,
elbows, and knees but
limited range of motion
of neck
 >Both sides of the body
are symmetrical

Palpation:
  (-) joint stiffness
 (-) joint swelling
 (-) bone pain
 (-) lethargy
p. Neurologic “Maayos pa naman Inspection:
yung memorya ko” >Conscious and cohisent
Alert and oriented to person,
“Hindi pa ako place and time
nakaranas > Able to speak
mahimatay. Wag >(-) tremors
naman sana” >(-)depression
>CNS I = without difficulty in
“Minsan nerbyosa ako smeling aromatic substances
pero depende rin sa >CNS II = equality responsive
sitwasyon” to light, (+) pulpillary reflex,
bilateral eyeballs
>CNS III, IV, VI = EOMs
>CNS V = good temporalic
tone, with corneal reflex
>CNS VII = symmetric facial
muscle tone
>CNS VIII = able to hear
whispered words
>CNS IX & X = present gag
reflex, able to swallow
>CNS XI = able to move/shrug
the shoulders
>CNS XII = able to move
tongue side to side
q. Hematologic “Hindi ako mabilis Inspection:
magkapasa” >(-) hematomas
>(-) bruises
“Apat na beses na ako >(-) hx of clotting of bleeding
nagdonate ng dugo” d/o
r. Endocrine “Wala akong diabetes” Inspection:
  (-) diaphoresis
“May goiter ako pero  (+) tremors
natanggal na”

“Wala akong iniinom Palpation

na pills, hindi ako  (-) abdominal
gumagamit ng family tenderness
planning”

2. LABORATORY STUDIES/DIAGNOSIS

Normal Actual Nursing

Procedure date Indication
values/finding findings Responsibilities
HEMATOLOGY For evaluation WBC Count: PRE:
Complete of all blood 5-10x10^9/L 9.9 -Check’s doctors
Blood Count components to order
(August 12, discern if there Hemoglobin: -Check whether
2010) are any 123-153g/L 145 fasting is required
changes in -Explain the patient
hematological Hematocrit: the purpose of the
condition before 0.36 – 0.45 vol. 0.43 procedure
the patient -if ordered,
becomes Platelet: withhold
symptomatic. 150-400x10^9/L medication until
the blood is drawn
Segmenters: 380 -Explain that blood
To determine 0.36-0.66 % samples will be
properties of extracted
different kinds of Lymphocytes: 0.63 -Prepare the
white cells. 0.22-0.40 needed equipment
Differential -observe universal
Count Eosinophils: 0.35 precaution in
0.01-0.04 collecting blood
specimen
Stab cells: 0.01
0.04-0.08
INTRA:
0.02-0.05 -Practice aseptic
technique
-collect the
specimen from the
arm without an IV
device, if possible.
-to obtain valid
result, do not
fasten the
tourniquet for
longer than 1
minute. Prolonged
tourniquet
application can
cause stasis %
hemo-
concentration.
-Aspirate only the
needed amt. of bld.
-After the
specimen is drawn,
apply
pressure/pressure
dressing to the
venipuncture site
-note the time %
date the blood is
drawn. Hemolysis
may result from
vigorous shaking &
invalidate the
result.

POST:
-record/ document
the exact time
when the
specimen was
collected. Indicate
drugs that the
patient is taking
-ensure that the
blood tubes are
correctly labeled.
-secure the
laboratory samples
and label it
accordingly
-Assess the
venipuncture site
for redness and
swelling.
-reinstitute
appropriate diet if
fasting was done
Blood Assess a Calcium: PRE:
chemistry known or 2.10-2.55umol/L - Check doctor’s
(Calcium, 2.0
suspected order.
Albumin disorder Albumin: -Explain the
Creatinine,) 35-50g/L
involving procedure to the
(Sept. 10, 2010)
muscles in the Creatinine: patient.
absence of a 46-92umol/L -Tell the patient
34.0
renal disease. that no fasting is
required.
Evaluate - Explain that blood
known or samples will be
suspected 64 extracted
renal function.
-Prepare the
needed equipment.
Determine
whole body - Observe
stores of universal
sodium, precaution in
predominantly collecting blood
extracellular. specimen.
INTRA:
Monitor -practice aseptic
effectiveness technique
of drug -collect
therapy, approximately 5ml
especially of blood in red tap
diuretics. tube
-for pediatric
Assist in patients, blood is
evaluation of usually drawn from
electrolyte a heel sick
imbalances.
POST:
-apply pressure or
Evaluate
a pressure
response to
dressing to the
treatment.
venipuncture site
-observe the
venipuncture site
for bleeding

THYROID It is used to T3: PRE:

FUNCTION evaluate the
TEST thyroid’s 1.20-2.80nmol/L 2.10 -Check the
functioning and doctor’s order
(June 29, 2010) to diagnose and
help determine -Know the reason
 the cause of FT4: for the procedure.
thyroid
diseases. 11.5-23.0pmol/L 14.36 -Introduce self and
verify the client’s
identity.
TSH: -Check the vital
signs
0.27- 0.53
3.75µTU/ml -Explain the
procedure that will
be done to prepare
the patient

-Provide privacy

INTRA:

-Ensure the use of

standard
precautions and
sterile technique
as appropriate

-Provide emotional
and physical
support as needed

-Ensure the correct

labeling, storage
and transportation
of specimen

POST:

-Provide nursing
care for the client

-Check vital signs

3.Report the
results to
appropriate health
team worker

CHEST X-RAY To visualize the Lungs are both Findings: PRE:

(August 12, internal organs clear Lungs are
2010) and bones of clear - Check the
the body to see Heart is not doctor’s order
if there are any
 deformities and enlarged Heart is - Know the reason
abnormalities in mildly for the procedure.
it. Diaphragm and enlarged
sinuses are - Introduce self and
intact verify the client’s
Aorta
tortuous identity.

Diaphragm - Check the vital

sulci and signs
bones are
- Explain the
intact
procedure that will
be done to prepare
Impression:
Mild the patient
Cardiomegaly - Provide privacy

Atheromatous INTRA:
Aorta
- Ask the client to
remove any
jewelry from her

- Give the obtained

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

- Assist the client

in going to the x-
ray room

POST:

- Wait for the result

and check the
client for further
questions

CT SCAN & To note for any Unremarkable Impression: PRE:

MRI SECTION remarkable -Thyomegaly -Explain the
(August11, structures with procedure to the
2010) intathoracic client.
To look for extension as -Ask the patient if
lesions and described she is
 masses -cardiomegaly claustrophobic
-sub -Ask to remove
centimeter any jewelries and
pulmonary metals
nodule, left
upper lobe, as INTRA:
described. -Instruct the patient
consider not to move when
pulmonary AV she is inside the
malformation capsule

POST:
-Inform the result
to patient

FNAB to check if the Unremarkable Impression: PRE:

(July 13, 2010) goiter is toxic or -Blood and -explain procedure
non toxic Colloid to patient

POST:
-inform the result
to patient

Urinalysis To determine Color: PRE:

(September 15, urine composition Light yellow yellow - Check doctor’s
2010) and possible amber order.
abnormal -Explain the
components (e.g.,
Trans-parency: procedure to the
protein or
glucose) or Clear patient.
infection Cloudy -Tell the patient
Spec. Gravity: that no fasting is
1.005-1.030 required.
1.025 - Explain that blood
Albumin: samples will be
Negative extracted
trace -Prepare the
Sugar: needed equipment.
Negative - Observe
Negative universal
RBC: precaution in
Negative collecting blood
0-2/HPF specimen.
WBC:
Negative
5-8/HPF INTRA:
Epithelial -practice aseptic
cells: technique
Negative -collect
+3 approximately 5ml
 of blood in red tap
tube
-for pediatric
patients, blood is
usually drawn from
a heel sick

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

2. OTHER ASSESSMENT TOOLS

Comprehensive Actual
Date Taken Actual Result
Content/Legend

Sept. 16, 2010 Level 0 – Full Self Care Level 0 – Full self care
Level 1 – Requires use of
device
Level 2 – Requires
assistance from another
person
Level 3 – Requires use of
assistance from another
person or device
Level 4 – It depends and
does not participate

J. FUNCTIONAL ASSESSMENT

1. Health Perception/ Health Management Pattern

Client describes her health as good even though she was hospitalized. She rates her
general health status as 9 in the scale of 0-10 wherein 0 represents poor health status and
10 represents good health status. The most important thing that she does in order to keep
 her body healthy is to eat a balanced diet. She thinks that these are also the things that
doctors and nurses would suggest to her. When asked about the cause of her illness, she
states that she failed to comply with the doctor’s advice to her that’s why her goiter
progressively increased in size before she sought consultation to the hospital. Her current
health does not interfere with desired activities of daily living. However, there is a limitation
of movement in her neck area due to thyroidectomy. The thing that is important to her while
she is in the hospital is her immediate recovery so that she can already go home and take
care of her aunt undergoing hemodialysis.

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

She describes herself as good after undergoing an operation. At present, she admits that
she still feels nervous for the result of her biopsy. The client also states that there really is a
change about how she feels since she had a goiter. Despite the incision made in her body,
she still feels good about her physical appearance because what’s important to her at the
moment is that the thing that causes pain is already removed from her body. She does not
get easily angry, depressed or anxious. However, she becomes really angry if she finds out
that somebody is a traitor. As a result, she just shouts so hard in order to let out the anger
that she feels. Sometimes, she would go to her friends and make them laugh in order to
forget that she is angry.

3. Activity-Exercise Pattern

Upon waking up in the morning, the client would open the windows in order to let the
fresh air fill their house. Then, she would prepare breakfast for her sick aunt who has kidney
problem. She would also put everything in place and prepare all necessary things that they
might use for the day. She would also sweep the floors, clean the house and take care of
her aunt. She would rest for a while and then take a bath. After that, she would eat a light
meal and go to her mother’s house to visit her children. Sometimes, she would also go to
her husband’s house and stay there. Her usual routine includes going to the houses where
she and her children are staying because she prefers to be with other people instead of
being alone. She would then go home to the house where she is staying at around 10 in the
evening. According to her, this routine serves as her exercise. During her spare time, she
usually plays word games like scrabble and word puzzles together with her children or
friends.
 Feeding = lvl.0 Grooming = lvl. 0

Bathing = lvl.0 Cooking = N/A

Toileting = lvl.0 Home Maintenance = N/A

Bed Mobility= lvl.0 Shopping = N/A

Dressing = lvl.0 General Mobility = lvl.0

Legend: Functional Legend Code:

Level 0 Full Self Care

Level 1 Requires use of device

Level 2 Requires use of assistance from another person

Level 3 Requires use of assistance from another person or device

Level 4 It depends and does not participate.

4. Sleep/ Rest Pattern

The client states that she does not have a particular time for sleeping and waking up.
Sometimes, she sleeps early at around 9 PM and sometimes she sleeps late at around 11
PM. She never used any sleep medications even though she experience insomnia. Usually,
she exchanges stories with her relatives before going to sleep. She describes the quality of
her sleep as good but she often wakes up in the middle of the night to void or when her sick
aunt needs some help. The client admits that she sleeps lightly and wakes up easily
whenever there are disturbing sounds in the place where she sleeps. She often wakes up at
around 7 AM and usually gets 8 hours of sleep. Despite of being a light sleeper, the client
feels well rested upon waking up in the morning. She also takes a nap in the afternoon
whenever she was not able to sleep well in the evening in order to have enough rest to
regain energy.

5. Nutrition/ Elimination Pattern

The client’s typical food intake includes 2 cups of rice, vegetables like ampalaya, beef
and sometimes pork. She does not take any food supplements. She states that she eats all
kinds of food and she has a good appetite. She also eats snacks in between meals, usually
 consists of bread loaves, until she feels that her stomach is already full. The client does not
follow a certain kind of diet. She can consume 5-6 glasses of water per day. Despite her
good appetite, she reported that she experienced weight loss of approximately 4 kilos upon
hospitalization. She also experienced difficulty in swallowing due to her condition. The client
does not have any known food allergies or intolerance.
Her wounds heal very well and she does not have any skin problem at present. When it
comes to her elimination pattern, her bowel movement is regular and she usually smokes
whenever she wants to defecate. According to her, this helps her to feel the urge to defecate
and have an easy bowel movement. Her stool is usually brown in color and formed and but
she does not feel any discomfort during elimination. She voids 3-4 times a day and her urine
was yellowish in color. She also does not experience any discomfort while voiding.

6. Sexuality/ Reproductive
The client had a cyst on her right ovary several years ago. She had undergone
unilateral oophorectomy because of this. She married her husband and had her first
pregnancy at the age of 25. She does not take any pills or use any family planning methods.
She is contented with her sexuality at present because she already has four children. Her
menstruation started when she was 12 years old and describes her menstrual cycle as
regular, usually lasts for 4-5 days. The client sometimes experience heavy menstrual
periods in which she uses diapers and change 3 times in day. She had also experienced
dysmenorrhea during her adolescence. Her LMP was last September 7, 2010 and her OB
score is G6P4 40240 which indicates that she became pregnant six times and gave birth at
term four times, all under normal delivery.

7. Interpersonal Relationships/ Resources

The client states that she is a perfect mother, a perfect friend but an imperfect daughter.
She gets along well with other people and has many friends that she can go to in good and
in bad times. She is a member of the parents and teachers association in her children’s
school. Her support system is her mother because according to her, her mother knows
almost everything about her and definitely her mother knows what’s best for her. She states
that her relationship with her family is the most important relationship at present. Whenever
she has a problem, she does not go to any one for support because she wants to solve all
her problems by herself. She prefers to laugh with her family and friends instead of worrying
about her problems.
8. Coping and Stress Management/ Tolerance Pattern
The kinds of stresses she had in life were only minor ones. Most of the time, her stress
is because of financial problems in the family, including the house rental and allowance of
her children. However, she can still manage because of financial support given to her by her
family and relatives. She takes a rest when under stress so that she would regain energy
and to forget all about the things that brings stress to her life. She does not feel tense most
of the time. When she had big problems in her life, she goes to her family or friends, not to
talk about her problem but to laugh with them in order to forget all her problems. Most of the
time, this way is successful in handling her life problems.

9. Personal Habits
The client admits that she smokes whenever she wants to defecate. According to her,
this helps her to feel the urge to defecate and have an easy bowel movement. The client
also admitted that she sometimes consumes carbonated drinks but she is not an alcoholic
drinker.

10. Environmental Hazards

The client lives in three different houses. According to her, the houses are not far from
each other and can be reached through tricycle. The house where she lives has adequate
heat and utilities. There is no pollution in the neighborhood and only minimal noise can be
heard. One health hazard in the area is the clogged drainage system. The neighborhood in
which the client lives is safe because there is a baranggay tanod patrolling the area. When it
comes to transportation, there are tricycles that pass in front of their house and everything
was accessible due to this. The client is not involved in any community services. There are
no environmental hazards in the workplace. The client has never travelled to other countries
yet.
II. PROBLEM LIST
A. ACTUAL or Active

Problem No. Problem Date Identified Date Resolved/

Remarks

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

Resolved. Pt.
1
verbalized decrease
of pain.

Impaired Tissue Sept. 16, 2010 Sept. 16, 2010

Integrity Resolved. Pt. did
2
not show any signs
of infection.

Ineffective Health Sept. 16, 2010 Sept. 16, 2010

Maintenance Resolved. Pt. was
3 able to understand
ways to maintain
health.

B. HIGH RISK or Potential

Problem No. Problem Date Identified

1 Risk for Infection Sept. 16, 2010

III. NURSING CARE PLAN

NURSING
CUES LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
 NURSING
CUES LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
IV.ANATOMY AND PHYSIOLOGY

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

secretes a type of hormone into the bloodstream to regulate the body. The endocrine
system is an information signal system like the nervous system. Hormones regulate
many functions of an organism, including mood, growth and development, tissue
function, and metabolism.

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

produce chemicals called hormones. A number of glands that signal each other
in sequence is usually referred to as an axis, for example, the hypothalamic-
pituitary-adrenal axis. Typical endocrine glands are the pituitary, thyroid, and
adrenal glands. Features of endocrine glands are, in general, their ductless
nature, their vascularity, and usually the presence of intracellular vacuoles or
granules storing their hormones. In contrast, exocrine glands, such as salivary
glands, sweat glands, and glands within the gastrointestinal tract, tend to be
much less vascular and have ducts or a hollow lumen.
 The thyroid gland is a butterfly-shape organ and is composed of two cone-
like lobes or wings, lobus dexter (right lobe) and lobus sinister (left lobe),
connected via the isthmus. The organ is situated on the anterior side of the neck,
lying against and around the larynx and trachea, reaching posteriorly the
oesophagus and carotid sheath. It starts cranially at the oblique line on the
thyroid cartilage (just below the laryngeal prominence, or 'Adam's Apple'), and
extends inferiorly to approximately the fifth or sixth tracheal ring. It is difficult to
demarcate the gland's upper and lower border with vertebral levels because it
moves position in relation to these during swallowing.

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

the largest endocrine glands in the body, and is not to be confused with the
"parathyroid glands" (a completely different set of glands). The thyroid gland is
found in the neck, inferior to (below) the thyroid cartilage (also known as the
'Adam's Apple') and at approximately the same level as the cricoid cartilage. The
thyroid controls how quickly the body uses energy, makes proteins, and controls
how sensitive the body should be to other hormones.

The thyroid gland participates in these processes by producing thyroid

hormones, principally triiodothyronine (T3) and thyroxine (T4). These hormones
regulate the rate of metabolism and affect the growth and rate of function of
many other systems in the body. T3 and T4 are synthesized utilizing both iodine
and tyrosine. The thyroid gland also produces a hormone called 'calcitonin',
which plays a role in calcium homeostasis.
V. PATHOPHYSIOLOGY
VI.MEDICAL-SURGICAL MANAGEMENT

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

NURSING
PROCEDURE/DATE INDICATION/ANALYSIS RESPONSIBILITIES
(PRE, INTRA, POST)

Total Thyroidectomy -To remove the enlarge PRE:

Sept. 15, 2010 -give preview about the
thyroid
procedure to be done
and let the surgeon to
explain the rest
-check for pre-op meds
-check for the consent
form
-check for the right
identity and procedure to
be done

INTRA:
-maintain sterility on the
procedure

POST:
-assist for the recovery of
the patient

2. Pharmacotherapeutics/ Medicines (IV Fluids, Drugs)

 GN (BN) Indication (client-specific) NURSING
Classification Dosage RESPONSIBILITIES
Stock Dose Frequency (PRE, INTRA, POST)

Ketorolac(Kortezor) I:Pain PRE:

NSAID D: 30mg - Check doctor’s order
30mg F: Q6 X 6 doses INTRA :
Injectio: 30mg/ml - Check the right name of
drug and dose for the
patient.
POST:
- Monitor side effects.

Celebrex (Celebrex) I:Pain PRE:

NSAID D:200mg - Check doctor’s order
Capsules: 200mg F:BID INTRA :
- Check the right name of
drug and dose for the
patient.
-Give drug after meals.
POST:
- Monitor for adverse drug
reactions

Ciprofloxacin (Cipro) I: Prophylaxis PRE:

Fluoroquinolones - Check doctor’s order
D:500 mg
Tablets: 500mg INTRA :
F: BID - Check the right name of
drug and dose for the
patient.
-Give drug after meals.
POST:
- Monitor for adverse drug
reactions
 Calcium Carbonate I: Rdeuce acid secretion PRE:
(CalciAid) D: 500mg - Check doctor’s order
Antacids F: TID INTRA :
Tablets: 500mg - Check the right name of
drug and dose for the
patient.
- Give on an empty stomach.
POST:
- Monitor side effects.

Piroxicam (Macroxam) I: mild to moderate pain PRE:

NSAID D: 48 mg - Check doctor’s order
Patch: 48mg F: Patch x 3 days INTRA :
- Check the right name of
drug and dose for the
patient.
POST:
- Monitor side effects.

VII. PROGRESS NOTES

Existing Cues; Interventions Actually Done (Nursing Collaborative);

Day Number
Client’s Response

Day 1 In the first day of contact, patient was received awake, conscious and
Sept. 16, coherent in lying position. Patient had her heplock on her right metacarpal
2010 vein. Her initial V/S was: BP: 130/60. PR: 80 bpm, RR 32cpm, T:36° C. She
is ambulatory. Patient had complained of her non-productive cough and
sore throat, thus given Sinecod Forte. Patient had fair skin turgor. And she
had a diet as tolerated.

Day 2 During the second day of contact, patient was received awake, conscious
Sept. 17, and coherent in sitting position. Patient had her heplock on her right
2010 metacarpal vein. Her V/S was: BP: 90/60, PR: 72bpm, RR 18cpm, T: 36°
C. Patient was advised to go home and is instructed for his discharge plans
 and maintenance. Patient had fair skin turgor. And she had a diet as
tolerated.

VIII. DISCHARGE HEALTH TEACHING PLANS

Contents Strategy

1. Compliance The family together with the > Informing the family
a. Medications patient will continue the members about the
prescribed medications with prescribed medications and
proper dosage and its importance regarding the
frequency in order to hasten condition of the patient.
the recovery of patient.
> Reminding and reviewing
Take home meds: the family members about
the drugs in order to make
1. Ciprofloxacin 500mg
the familiar with treatment.
1tab oral 8am
2. Meloxicam 15mg 1 tab > Advise the family
oral 8am members to avoid using any
3. Bactroban ointment non-prescription drug unless
b. Diet 4. Hydrogen peroxide use is approved by the
physician.

> Encouraging the family

members to administer
> Prepare foods that are low medications exactly as
salt, high in protein and low prescribed by the physician.
in fat for the patient in order
to prevent recurrence of the
illness. Also, the family > Encouraging the family
members will know and members to follow the diet
follow the patient’s and fluid intake
restrictions in foods and recommended by the
c. Activity/ Exercise
proper eating of healthy physician for the patient.
 foods.
> The patient will
engaged on doing simple
range of motion exercise in
order to maintain muscle and
bones integrity as well as
maintaining a good body
circulation.
2. Follow-up/ Check-up >Stress to the patient the
importance of scheduling
and keeping check-up
appointments and make sure
he has the doctor’s office
telephone number.
> Educating the family
members to follow the diet
and fluid intake
recommended by the
physician for the patient.
> Educating the family
members as well as the
patient about foods that are
healthy yet appropriate for
be
the diet of the patient.
> Teaching the relatives
about how to assist patient
do simple range of motion
exercises like flexion of
upper and lower extremities
or walking for a short
distance.
> Educating the relatives
about the importance of
exercise in the boy and its
benefits to once health.
> Educating the patients’
relatives about the
importance of having a
regular check-up after
hospitalization.
IX.SUMMARY OF CLIENT”S STATUS OR CONDITION AS OF LAST DAY OF CONTACT

Date: Sept. 17, 2010

During the last day of contact, Ms. MGF was received awake, conscious, coherent in
sitting position. Her vital signs were taken BP: 90/60, PR: 72bpm, RR 18cpm, T: 36°
C. The patient was ready to go home. She is eager to go home and gradually get
back to her daily activities. And she was aware on the modifications she needs to do
with her lifestyle.