Thyroidectomy

I.
INTRODUCTION A. INTRODUCTION This is a case of client ADR with an initial diagnosis of MCAG (Multiple Colloid Adenomatous Goiter). A 51 years old woman from Taal Bocaue Bulacan who admitted at Bulacan Medical Centerl last July 4,2012 with a chief complaint lumalaki ung bukol sa leeg ko as verbalized by the client. MCAG (Multiple Colloid Adenomatous Goiter) An enlargement of the thyroid gland caused by the growth of one or more encapsulated adenomas or multiple non encapsulated colloid nodules within its substance. Goiter is the term used to describe enlarging or swelling of the thyroid, a tiny gland found near the Adam's apple. The swollen area may be sore and tender or may not be painful at all. In some cases, the goiter can cause pressure on the esophagus, which can result in a tight feeling around the throat, causing shortness of breath or a choking sensation. There are different kinds of goiter. The most common types are colloid, toxic nodular and nontoxic. Colloid refers to goiter caused by hypothyroidism, or decreased production of thyroid hormones. In this case, the thyroid gland increases in size because it is attempting to produce a greater amount of hormones. Weight gain or the inability to lose weight may be an issue for people suffering from this condition, because the hormones made by the thyroid are essential to healthy metabolism. Slow metabolism causes people to burn calories at a decreased rate. MCAG ranks 7th overall, 4th in females and 17th in males. An estimated 2,584 new cases, 2,068 in females and 516 in males, will occur in 1998. The incidence is three times more in females than that in males. Most common among women ages 15-24. (DOH) Goiters (swollen thyroid glands) are less common in the USA, being experienced by approximately 5% of Americans and many of these do not involve thyroid hormone imbalance. When looked at worldwide, approximately 740 million people are experiencing goiters with approximately 50 million cases being caused by iodine deficiency, a cause that is rare in the USA. (WHO) Colloid goiters occur between the ages of 20 and 50, and affect women more than men. The use of iodized table salt in the United States today prevents iodine deficiency. However, the Great Lakes, Midwest, and inner mountain areas of the United States were once called the "goiter belt," because a high number of goiter cases occurred there. A lack of enough iodine is still common in central Asia, the Andes region of South America, and central Africa.
In the Philippines, the national prevalence of goiter was first reported in 1987. Clinical examination for the presence of goiter was undertaken during the 1987 and 1993 National Nutrition Surveys allowing comparisons. Previous studies only documented the prevalence of goiter based on clinical examination. There appeared to be an increase in the prevalence of goiter during this six-year period, with the initial rate in 1987 of 3.7% to 6.7% in 1993. By year 2000, the goiter rate was 6.9 per 100. In the latter data, the highest prevalence rate was seen in pregnant women aged 13 to 20 years at 27.4%.(doh.gov.ph) Goiter is one particular disease that has not been given much attention in the country. Based on one of the nationwide nutrition surveys, which covered all 76 provinces in all regions of the Philippines, including eight clusters of cities and municipalities in Metro Manila, goiter is highly prevalent, afflicting close to 7 percent of the entire population across all ages. So that would be around seven million with enlarged thyroid glands and the most common cause of a diffuse enlargement of the thyroid gland is iodine deficiency which could be easily prevented. The disease is commonly found in parts of the country where the iodine contents in the soil, water and food are deficient. The Cordillera Autonomous Region is one of these high prevalence areas. If one looks at the statistics covering Filipinos age 15 years or older, the prevalence of goiter jumps to 18 percent. This is because the likelihood of having a diffuse goiter increases in females during the reproductive agewhen they get pregnant or are lactating. The other type of goiter is nodular, which is found only in less than one percent of the population, and is not significantly increased with pregnancy or lactation. The prognosis is dependent on the final pathology: if the nodules are benign- then the prognosis is not an issue and the patient is 100% healthy. If a thyroid cancer is diagnosed than obviously there is a risk of locoregional recurrence or distant spread. Prognosis is good if the iodine deficiency is corrected. This case was chosen because its relevance to Nursing education gives way to better understanding of Multiple Colloid Adenomatous Goiter; its symptoms, probable causes, effects, and treatments which allow the members of health care team foster health promotion and render its specific management to lessen further complications as well as for those who undergone Total Thyroidectomy.
B. OBJECTIVES General Objectives: To be able to acquired knowledge and awareness to the nursing students who chance or might have handled cases of MCAG.
Student- centered Knowledge: To be able to nurture knowledge about Goiter. To be able to understand the Goiter on how, where and when it starts To be able to learn the facts on Goiter
Skills: To be able to assess causative factors of Goiter. To be able to provide proper comfort measures of Goiter. To be able to assist patients to maintain and manage desired health practices
Attitudes: To be able to established rapport with our patient To be able to express more realistic understanding and expectations of the care receiver To provide opportunity for the patient to deal with the situation in own way
Client- centered Knowledge: To be able to verbalize accurate knowledge of condition and understanding about the treatment regimen of Goiter.
To be able to verbalized understanding of factors contributing current situation To be able to learn his own disease and have maintenance for her own health
Skills: To be able to identify necessary health maintenance activities To be able to demonstrate progress toward desired outcomes To be able to involve self and control own self care and activities of daily living Attitudes: To be able to assume responsibility for own health care needs within level of ability To be able to adopt lifestyle changes supporting healthcare goals To be able to recognize and verbalize feelings
II.
NURSING HEALTH HISTORY A. PERSONAL HISTORY Demographic Data Name: ADR Address: Taal, Bocaue, Bulacan Birth date: June 26, 1961 Age: 51 y/o Gender: Female Marital Status: Married Occupation: Labandera Laundry Maid Religious Orientation: Catholic Educational Background: Highschool Graduate Admitting Diagnosis: Multiple Colloid Adenomatous Goiter Final Diagnosis: Multiple Colloid Adenomatous Goiter Admission Date: July 4, 2012 Admission Time: 10:05am Discharge Date: July 11, 2012 Discharge Time: 1:15pm
B. CHIEF COMPLAINT Lumalaki ang bukol ko sa leeg as verbalized by the patient.
C. HISTORY OF PAST ILLNESS According to Mrs. ADR she had a complete vaccination. She had chickenpox during her childhood and treated it with guava leaves. Patient doesnt have any allergies to any drugs, foods or any environmental factors (dust, smoke, or pollen). When she feels sick she doesnt buy any overthe-counter drugs and doesnt like to take any medicine instead she drinks luyang dilaw tea three times a week and take a rest. Her last hospitalization was when she had her last delivery. In the year 1977 her sister noticed that her neck was getting bigger than the usual and immediately they went to the hospital to have a check up and they found out that she had a goiter. The doctor prescribed her drugs: Tapazole and Iodone to be taken three times a day. She stopped taking her medication in the year 1980.
D. HISTORY OF PRESENT ILLNESS
January 2012, she returned to the hospital to have a check up due to her large mass on the neck. When asked about if she experienced any pain she stated, Wala,wala akong naramdamang sakit o pangingirot sa aking lee gang nararamdaman ko lang na parang lumalaki yung goiter ko saka nahihirapan akong lumunok kaya nagpacheck up na ko. Three insecutive month she had a regular check ups. July 4,2012 she admitted to the hospital to undergone thyroidectomy
E. GENOGRAM
SVF CVA
NBF CVA
ADR
51,RA
MA
58, ?
DVF
?
SVFJR
52, CVA
BE
60, ?
AD
60, ?
MS
65, RA
EVF
60, VA
LEGEND
- Client - MCAG VA- vehicular accident ?- unknown - ceased CVA- Cardiovascular Accident
Ra- Rheumatoid Arthritis
Interpretation: She cant remember her grandfather and grandmother in both sides because when she was a child they transferred from Bataan to Manila. She didnt have a chance to know them. Her mother and father died because cardiovascular accident. She cant remember her mother and fathers siblings. Her brother SVFJR died from cardiovascular accident while EVF died from a vehicular accident.
III.
FUNCTIONAL HEALTH PATTERN
F. Functional Health Pattern (Gordon Approach) FUNCTIONAL HEALTH PATTERN HHealth Perception/ Health Management Pattern PRIOR When we asked our client how does she feel prior to her admission she stated that Ok naman ako, malusog. She is not smoking and drinking alcohol for her entire life. DURING During hospitalization our client perceives that she is healthy even though she is In the hospital. She also followed the prescribed medication of her doctor for her maintenance on the right time and dose.
NNutritional Metabolic Pattern July 1, 2012 Breakfast 2 pcs. of pandesal 200ml of coffee July 2, 2012 Breakfast 2 pcs. pandesal 200ml of coffee July 3,2012 Breakfast 1 cup fried rice 1 pc. Medium size of hotdog 200cc cup coffee Lunch 500ml of water 1 cup of rice 1 med-sized of Inihaw na bangus July 4,2012 NPO July 5,2012 July 6,2012
NPO
NPO
Lunch 1/2 cup of rice 1 pc. Medium size of fried chicken 500ml of water Dinner 1 cup of rice 1 saucer of ginisang gulay 250ml of water
Lunch 1 cup of rice 1 pc medium sized fried tilapia 250 ml of water Dinner 1/2 cup of rice 2 pcs small sized longanissa 500 ml of water
NPO
NPO
NPO
NPO NPO NPO Dinner 250cc of water 1/2 cup of rice 1 saucer of After the surgery our client is NPO as the doctors Adobong order. manok
PO
Client ADR doesnt have any food allergies. She
loves to eat chicken and drinks 6-7glasses of water.
EElimination Pattern
Urine July 1,2012 6 1200ml Aromatic in odor, amber in color July 1,2012 Freque ncy Charac teristics 1 Formed, Brown, pungent July 2,2012 5 1000ml Aromati c in odor, amber in color July 2,2012 1 Formed, Brown, pungent July 3,2012 6 1200ml Aromatic in odor, amber in color July 4,2012 FC July 5,2012 FC 1500ml Aromati c in odor, amber in color July 5,2012 1 Formed, Brown, pungent odor July 6,2012 FC 1800ml Aromatic in odor, amber in color
Freque ncy Amoun t Charac teristics
Freque ncy Amoun 1560ml t Charac Aromatic teristics in odor, amber in color July 4,2012 1 Formed, Brown, pungent odor
July 3,2012 Freque ncy Charac teristics
July 6,2012 1 Formed, Brown, pungent odor
1 Formed, Brown, pungent odor
Our client is in Foley catheter.
odor
odor
The patient has regular bowel movement, it has a pungent odor, brown in color and it is formed. She urinated for at least 5-6 times a day.
AActivity-Exercise Pattern
The patient can do her daily activities. Her activities includes mostly of her household chores (cooking, cleaning, washing, ironing, etc.). She walks 15mins every morning. _0_feeding _0_bathing _0_toileting _0_bed mobility _0_dressing _0_grooming _0_general mobility _0_cooking _0_home maintenance _0_shopping
During hospital, when she needs anything she ask the help of her daughter. _0_feeding _0_grooming _IV_ bathing _III_ general mobility _III_ toileting _0_bed mobility _II_ dressing Level 0- Full self care Level I- Requires use of equipments/ device Level II- Requires assistance or supervision Level III- Requires assistance or supervision from another person/ device Level IV- is dependent and does not participate
Level 0- Full self care Level I- Requires use of equipments/ device Level II- Requires assistance or supervision Level III- Requires assistance or supervision from another person/ device Level IV- is dependent and does not participate
SSleep- Rest Pattern The patient sleeps 7-8 hours a day. She wakes up around 4 am to do her daily routine. She cant take a nap in the afternoon because of her work. She also stated that she usually sleeps around 89pm in the evening with the lights turned off. CCognitive Perceptual Pattern She watches television and listen to radio to gain knowledge and also to get rid of boredom. She can also easily express and verbalized. She also mentioned that she has a blurred vision. She doesnt wear glasses and contact lenses. SSelf Perception and Self concept Pattern Our client experience blurring of vision. Every time she get bored he always pray. During her stay in the hospital, she wasnt able to have enough rest and sleep. She sleeps only for approximately 8hours intermittently.
The patient is a friendly person. When she was asked if there is something she wants to change in her body, she said that she is satisfied in her body.
She doesnt feel insecurities about her looks she is still contended.
RRole Relationship Pattern The patient lives with an extended type of family. Her three children her parents and her husband. She belongs to an egalitarian type of family which means that they both decide on specific matter. She is responsible of taking care of his husband and her children. SSexuality Reproduction Pattern She was 16 years old when she had her first menstruation period. It lasts for 7days and takes 30 days from the beginning of the cycle until the beginning of another. When they make love they dont used any contraceptives. Shes not taking She doesnt experienced menstrual cycle because she is already a menopause. She said that she will be more responsible in taking care of her family and she believes that she is a good mother to her children.
any pills.
CCoping stress tolerance Pattern When shes stress she just listen to soft music while folding clothes and doing household chores. VValues Beliefs Pattern She is a Roman Catholic. They regularly attend mass and they always have an open communication with God. Her religion doesnt affect herself when she was at the hospital. She always pray during bedtime. Shes a bit irritated with noise in the hospital but instead of being angry she just keep ignoring them as much she can.
IV.
GROWTH AND DEVELOPMENT ERICKSONS STAGES OF DEVELOPMENT PIAGETS THEORY OF COGNITIVE DEVELOPMENT KOHLBERGS THEORY OF MORAL DEVELOPMENT FOWLERS THEORY OF SPIRITUAL DEVELOPMENT
FREUDS THEORY OF DEVELOPMENT
STAGES
Genital Stage
Our patient is belongs to Late adulthood because her age is 51. Age Range: 25 to 65 Ego Development Outcome: Generatively vs. Stagnation
Formal operational (12 years and up)
Age Range: Puberty to Death
Our patient is belongs to post conventional (social contract legalistic Orientation)
Conjunctive
DEFINITION
This stage focus solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas.
Generatively is when the individual is creative, productive, and shows concern to others. While stagnation is when an individual is to selfindulge, self-concern and shows lack of interest and commitments.
The formal operational stage begins at approximately age twelve and lasts into adulthood. During this time, people develop the ability to think about abstract concepts. Skills such as logical thought, deductive reasoning, and systematic planning also emerge during this stage.
This person lives autonomously and defines moral values and principles that are distinct from personal identification with group values. A person lives according to principles that are universally agreed on and that the person consider appropriate for life. (universal focus)
The person faces up to the paradoxes of experience and begins to develop universal ideas and becomes more oriented towards other people.
OUTCOME
Positive (She attained this stage because she is working hard for her children and husband that suffered from mild stroke. She makes sure that the needs of her family are being met.)
Positive (She attained this stage because she is creative, productive and she had concern with others, thinking she is helping her husband in work/finances.)
Positive (She attained this stage because she quickly plans an organized approach to solving a problem.)
Positive (She already attained this stage because even her family stopped her to move in Bocaue with her husbands parents, she lived with her principle that they can survive in Bocaue and live happily.
Positive (She attained this stage because she is less dogmatic about superstitious beliefs and religion often offers more comfort. She prays to God to be with her and to give past recovery.)
V.
ANATOMY AND PHYSIOLOGY
Thyroxine (T4) and Triiodothyronine (T3), are tyrosine-based hormones produced by the thyroid gland primarily responsible for regulation of metabolism. Iodine is important for the production of T3 and T4. A deficiency of iodine leads to decreased production of T3 and T4, enlarges the thyroid tissue and will cause the disease known as goitre. The major form of thyroid hormone in the blood is thyroxine (T4), which has a longer half-life than T3. The ratio of T4 to T3 released into the blood is roughly 20 to 1. T4 is converted to the active T3 (three to four times more potent than T4) within cells by deiodinases (5'-iodinase). These are further processed by decarboxylation and deiodination to produce iodothyronamine (T1a) and thyronamine Parathyroid glands function is to control calcium within the blood in a very tight range between 8.5 and 10.5. In doing so, parathyroid glands also control how much calcium is in the bones, and therefore, how strong and dense the bones are. Although the parathyroid glands are intimately related to the thyroid gland anatomically, they have no related function. The thyroid gland regulates the bodys metabolism and has no effect on calcium levels while parathyroid glands regulate calcium levels and have no effect on metabolism.
(a) Anterior pituitary (Adenohypophysis) The anterior pituitary synthesizes and secretes the following important endocrine hormones: Somatotrophins:
Growth hormone (also referred to as 'Human Growth Hormone', 'HGH' or 'GH' or somatotropin), released under influence of hypothalamic Growth Hormone-Releasing Hormone (GHRH); inhibited by hypothalamic Somatostatin
Thyrotrophins:
Thyroid-stimulating hormone (TSH), released under influence of hypothalamic Thyrotropin-Releasing Hormone (TRH)
Corticotropins:

Adrenocorticotropic hormone (ACTH), released under influence of hypothalamic Corticotropin-Releasing Hormone (CRH) Beta-endorphin, released under influence of hypothalamic Corticotropin-Releasing Hormone (CRH)[3]
Lactotrophins:
Prolactin (PRL), also known as 'Luteotropic' hormone (LTH), whose release is inconsistently stimulated by hypothalamic TRH, oxytocin, vasopressin, vasoactive intestinal peptide, angiotensin II, neuropeptide Y, galanin, substance P, bombesin-like peptides (gastrin-releasing peptide, neuromedin B and C), and neurotensin, and inhibited by hypothalamic dopamine.[4]
Gonadotropins:

Luteinizing hormone (also referred to as 'Lutropin' or 'LH' or, in males, 'Interstitial Cell-Stimulating Hormone' (ICSH)) Follicle-stimulating hormone (FSH), both released under influence of Gonadotropin-Releasing Hormone (GnRH)
Melanotrophins
Melanocytestimulating hormones (MSHs) or "intermedins," as these are released by the pars intermedia, which is "the middle part"; adjacent to the posterior pituitary lobe, pars intermedia is a specific part developed from the anterior pituitary lobe.
VI.
PATIENT AND HER ILLNESS A. PATHOPHYSIOLOGY Modifiable Factor Diet Insufficient iodine intake Release of estrogen Decrease in thyroid hormone synthesis Excessive production of thyroid-binding globulin Age: 51 y/o Non-modifiable Factor Female
Decrease circulating thyroid hormones
Compensatory hyperplasia Accumulation of nonfunctional tissue Thyroid Function Test (June 20, 2012): FT4 = 0.6 ng/dl TSH = 0.4 uIu/ml
Follicular involution Reaccumulation of colloid Stimulates production of TSH Overinvoluted
Decrease T3 and T4 level
Decrease metabolism
Altered GI motility and tone 19 | P a g e A C a s e o f 5 1 y r s o l d M u l t i p l e C o l l o i d A d e n o m a t o u s G o i t e r
Acculmulation of mucopolysaccharide in larynx
Diffusely enlarged gland Hoarseness of voice Difficulty in swallowing Thyroid Ultrasound (June 20, 2012) REPORT: There is a poorly defined 5.4 x 4.0 x 3.8 cm solid mass in the anterior neck located more to the right side which is difficult to distinguish from the right lobe of the thyroid.
Presence of distortion and pressure at vascular network
Infarction and degeneration present Fibrosis develops
Release of EGF, FGF and IGF Cell proliferation and colloid accumulation
Nodularity of gland FNAB (June 20, 2012): FINAL HISTOPATHOLOGIC DX: Cell findings consistent with colloid nodule with cystic degeneration. Background chronic lympocytic thyroiditis.
20 | P a g e A C a s e o f 5 1 y r s o l d M u l t i p l e C o l l o i d A d e n o m a t o u s G o i t e r
B. PHYSICAL ASSESSMENT Name: Mrs. A.D.R Age: 51 y/o VITAL SIGNS: BP: 120/80mmHg RR: 21cpm PR: 64bpm TEMP: 35.5 C Date Assessed: July 9, 2012
GENERAL APPEARANCE Methods 1. Body Built Height: 51 Weight: 47 kg Inspection and observation ( By getting the weight and height of the patient to determine the BMI ) Normal Findings Proportionate Normal BMI: 18.5-24.9 Actual Findings Underweight BMI:19.5 Remarks Deviation from normal due to present condition.
2. Posture and gait
Inspection and observation
Relaxed, erect posture, coordinated movements
The patient has relaxed coordinated movements.
Normal
3. Over-all hygiene and grooming
Clean and neat
The patient is clean and neat.
Normal
4. Attitude and mood
Appropriate to situation and cooperative
The patient is cooperative during the assessment, and her responses are appropriate to the situation. Clear and understandable.
Normal
5. Speech quality
Understandable, moderate pace, exhibits through association. No body and breath odor
Normal
6. Describe body and breath odor 7. Identify signs of distress in posture or facial expression 8. Identify obvious signs of
Smelling
The patient has body odor and breath odor.
Deviation from normal due to present illness.
Inspection
No distress noted
Presence of facial grimacing and guarding on the affected area with the pain scale of 5/10
Deviation from normal due to pain felt located at the midline of the neck.
Inspection
Healthy appearance
Slightly weak in appearance.
Deviation from normal due to pain felt located at the
illness 9. Describe client's affect/mood; assess the appropriateness of the client's responses Inspection Appropriate to the situation Answer questions when asked, and able to follow instructions
midline of the neck. Normal
INTEGUMENTARY .SKIN 1. Color Inspection Methods Normal Findings Color- varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive. No edema No lesions, has birthmarks, freckles Actual Findings The patient's skin is light brown color, uniform in color except in areas that are exposed to the sun. No edema Presence of lesion that is light brown in color(lower extremities and lower lip); moles ( face,arm, neck ).has lesion in the neck. Remarks Normal
2. Edema 3. Lesions
Inspection and palpation Inspection
Normal Deviation from normal due to chicken pox and accident during childhood. Due to Total Thyroidectomy
4. Moisture
Palpation on the skin folds and inspection of the axilla Palpation
Moisture in skin folds and the axilla Uniform; within normal range.
Moisture in skin folds and the axilla The patient's skin temperature is uniform; when pinched, the skin springs back quickly to previous state.
Normal
5. Temperature and skin turgor
Normal
NAILS 1. Fingernail plate shape Inspection Convex curvature, angle of nail plate is approximately 160 Highly vascular and pinkish in color Smooth texture Convex curvature, angle of nail plate is approximately 160 Pinkish in color Normal
2. Color
Inspection
Normal
3. Toenail and fingernail texture 4. Tissue surrounding nails
Inspection and palpation
Smooth in texture
Normal
Inspection
Intact epidermis
The patient's nails are intact to the skin. The color return to usual within 3 seconds.
Normal
5. Capillary refill
Prompt return o pink or usual color within 3 seconds
Normal
HEAD SKULL 1. Shape 2. Presence of nodules, masses and depressions. 3. Evenness and thinness/ thickness of hair Inspection and palpation Hair evenly distributed Thick hair Hair are evenly distributed, thick hair Normal Inspection Palpation Rounded; smooth skull contour Smooth, uniform, consistency; absence of nodules and masses. Rounded, smooth looking skull contour. Smooth with absence of nodules and masses. Normal Normal
4. Hair texture and oiliness
Silky and resilient hair
The patient's hair is oily.
Deviation from normal due to not taking a bath.
1. Facial features 2. Symmetry of facial movements.
Inspection Inspection
FACE Symmetric or slightly asymmetric The patient's face is symmetrical in facial features facial features. Symmetric facial movements. Facial movements are symmetrical.
Normal Normal
EYES
1. Hair distribution 2.Alignment 3. Skin quality and movements 1. Evenness of hair 2. Direction of curl 1. Surface characteristics 2. Frequency of blinking
Inspection
EYEBROWS Hair evenly distributed
Hair evenly distributed. Eyebrows are symmetrically aligned. Intact skin , equal movements
Normal Normal Normal
Inspection by asking the patient Symmetrically aligned to raise and lower the eyebrows. Inspection Intact skin , equal movements EYELASHES Hair is equally distributed Curl is slightly outward EYELIDS Skin intact, no discharge and discoloration. Approximately 15 20 involuntary blinks per minute CONJUNCTIVA
Inspection Inspection Inspection Inspection
Hair is equally distributed Curl is slightly outward The patient's eyelids are intact to the skin, no discharge. Approximately 15 20 involuntary blinks per minute
Normal Normal Normal Normal
1. Color, texture, and presence of lesions.
Inspection by retracting the eyelids with thumb and index finger and asking the patient to look up and down, side to side Inspection, by everting the eyelids Inspection
BULBAR CONJUNCTIVA Transparent, capillaries Transparent, no presence of sometimes evident, no presence lesions. of lesions PALPEBRAL CONJUNCTIVA Shiny, smooth, pink or red in Pink in color, smooth and shiny. color SCLERA Sclera appears white CORNEA Transparent, shiny and smooth. The patient's sclera is white in color. Transparent, shiny and smooth.
Normal
1.Color, texture, and presence of lesions. 1. Color
Normal
Normal
2. Clarity and texture
Inspection using a penlight.
Normal
1. Color, shape and symmetry of size . 2. Test each pupil for light reaction and accommodation.
PUPIL Black in color; round, smooth border, iris flat and round. Pupils constrict when looking at near objects; pupils dilate when looking at far object; pupils converged when near object is moved toward nose. VISUAL ACUITY Able to read news print
Black in color, round, smooth border; the iris is flat and round. The patient's pupils constrict when looking at near objects; pupils dilate when looking at far object; pupils converged when near object is moved toward nose. NOT DONE
Normal Normal
1. Test near vision
With the use of newspaper or magazine note if the patient was able to read the sentences. Use a snellen chart
2. Test distant vision
20/20 vision on Snellen chart
NOT DONE
1. Test peripheral vision.
1.Color,symmetry of size
VISUAL FIELD Assess peripheral visual field to When looking straight ahead, NOT DONE determine function of the retina client can see objects in the and the neuronal visual periphery. pathways to the brain and second cranial nerve. EARS AURICLES Inspection for color,symmetry Color as same as the facial skin, Same color with the facial skin, of size, and position. To inspect symmetrical, auricle aligned symmetrical. position, note the level at which with the outer canthus of the the superior aspect of the eye. auricles attaches to the head in relation to the eye. Palpation by gently pulling the Mobile, firm and not tender Mobile, firm and not tender.
Normal
2. Texture, elasticity and
Normal
areas of tenderness.
auricle upward then backward and folding the pinna. Dry cerumen, grayish color; or sticky, wet in various shades of brown.
Pinna recoils after being folded. Dry cerumen, grayish color; or sticky, wet in various shades of brown. Normal
3. Inspect external ear canal for Inspection cerumen, skin lesions, pus and blood. 1. Assess client's response to normal voice tones. While interviewing, note if the patient was able to understand and answer the questions being asked. ( Perform by placing a wrist watch near the ear. ) ( Perform by placing the vibrating fork on the middle of the patient's head and ask the patient if the sound is heard better in one ear or the same in the both ears ) ( Perform by pacing the vibrating tuning fork on the base of the mastoid bone and ask patient to tell you when the sound is no longer heard then immediately move the tuning fork to the auditory meatus and ask the patient to tell you when the sound is no longer heard.) Inspection
HEARING ACUITY TEST Normal voice tones audible. Normal voice tones audible
Normal
2. Perform the watch tick test. 3. Perform Weber's test.
Able hearing ticking in both ears.
NOT DONE
Sound is heard in both ears or is NOT DONE localized at the center of the head.
4. Perform Rinne's test
Air conducted hearing is greater NOT DONE than bone conducted hearing. POSITIVE RINNE: AC>BC NEGATIVE RINNE: AC<BC
1. Inspect external nose for
NOSE Symmetric and straight
Symmetric and straight
Normal
any deviation in shape, size or color and flaring or discharge. 2. Inspect nasal cavities for redness, swelling, growths, and discharge. 3. Inspect nasal septum between the nasal chambers. 4. Lightly palpate for tenderness masses or any displacement of bone or cartilage. Inspection
No discharge or flaring, Uniform in color. Mucosa pink Clear, watery discharge No lesions Nasal septum intact and in mid line No tenderness; no lesions
No discharge, Uniform in color.
Pink color of the mucosa, no lesions The patient's nasal septum is intact and in mid line. No tenderness noted.
Normal
Inspection
Normal
Palpation
Normal
5. Palpate the maxillary and Palpation frontal sinuses for tenderness
Not tender. MOUTH
No tenderness noted.
Normal
1. Outer lips for symmetry of contour, color and texture. 2. Inner lips and buccal mucosa for color, moisture, texture and presence of lesions. 1. Characteristics
Inspection
LIPS AND BUCCAL MUCOSA Uniform pink in color, soft, The patients lips are uniform moist, smooth texture. pink in color, soft and moist. Uniform pink in color, moist, no lesions. Uniform in color, no lesions.
Normal
Normal
Inspection
TEETH AND GUMS Smooth, white shiny tooth enamel, pink gums with moist, firm texture. Central position; smooth lateral
Yellowish tooth enamel, pink gums with moist. Central in position; no lesions;
Deviation from normal due to poor oral hygiene. Normal
2. Tongue movement
Inspection
margins; no lesions; raised papillae 3. Base of the tongue, floor of the mouth, and frenulum. 4. Presence of nodules, lumps or excoriated areas. Inspection
raised papillae and moves freely. Normal
Smooth base of the tongue with Smooth base of the tongue with prominent veins. prominent veins. Smooth with no palpable nodules. When palpated, there are no palpable nodules.
Normal
1. Hard and soft palate for shape, texture and presence of bony prominences. 2. Uvula position and mobility
Inspection
PALATES AND UVULA Light pink, smooth soft palate; Light pink in color, smooth soft lighter pink; hard palate; no palate and lighter pink hard bony prominences. palate; no bony prominences. Position in the mid line of the soft palate. TRACHEA Central placement in mid line of neck Not palpable THYROID GLAND Not visible Lobes may not be palpated The patient's uvula when inspected was position in mid line of the soft palate. The patient trachea is at the central midline of the neck. The patients lymph nodes are palpable There are no masses Lobes of the patient are not palpable.
Normal
Inspection
Normal
1. Lateral deviations 2. Identify lymph nodes and note for tenderness 1.Symmetry and visible masses 2. Smoothness and areas of enlargement masses or nodules. 1. Carotid artery
Palpation Palpation
Normal Deviation from normal due to Total Thyroidectomy Deviation from normal due to the removal of thyroid gland. Deviation from normal due to Total Thyroidectomy
Inspection Palpation
Palpation
CAROTID ARTERIES Symmetry pulses volumes
The pulses volumes of the
Normal
carotid arteries of the patient are symmetrical. 2. Jugular vein Inspection JUGULAR VEIN Veins not visible The patients jugular veins are not visible. Normal
1 Size,symmetry, shape and color
Inspection
BREAST AND AXILLA Female: Rounded shape; slightly The patient breasts are rounded unequal in size; generally and symmetrical symmetric. No presence of edema Round or oval in shape, from light pink to dark brown color, equal in size. Round, equal in size, nipples point in the same directions, similar in color, and normally erect. No tenderness or masses. The patients breast and axilla have no edema. The patients areola is round, dark brown in color and equal in size. The patients nipples are equal in size, both pointing downward, dark brown in color and normally erected. There is no tenderness and masses on the patients breast.
Normal
2. Swelling or edema 3. Areola: size,shape and color
Normal Normal
4. Nipples: size,shape and discharge
Inspection
Normal
5. Masses ad tenderness
Inspection for presence of swelling and palpation for presence of edema. Inspection
Normal
1. Shape and symmetry of the thorax from posterior and lateral views. 2. Breath sounds 3. Breathing pattern
THORAX Antero-posterior to transverse diameter ratio of 1:2.
Antero-posterior thorax of the patient transverse diameter ratio is 1:2
Normal
Auscultation Inspection
Vesicular and broncho-vesicular Vesicular and broncho-vesicular breath sounds. breath sounds Rhythmic; effortless. Rhythmic; effortless
Normal Normal
1. Skin Integrity 2. Contour and symmetry 3. Bowel sounds 4. Tenderness
Inspection Inspection Auscultation Palpation
ABDOMEN Unblemished skin; uniform color; no lesions. Flat, rounded or scaphoid; symmetrical. Audible bowel sounds May be tender when palpated.
The abdomen is uniform in color no lesion The patients abdomen is flat and symmetric. The patients bowel sound is audible. There is no tenderness on the patients abdomen when palpated.
Normal Normal Normal Normal
MUSKULOSKELETAL SYSTEM 1. Size 2. Tendons 3.Tremors 1. Structure and deformities 2. Tenderness Inspection Inspection Palpation Inspection Palpation MUSCLES Equal in both sides of the body. No contractures. None BONES No deformities and aligned No tenderness JOINT No pain, no swelling. No pain, smooth The size of patients muscles is equal in both sides of the body. There is no contractures on the tendons of the patient. There is no presence of tremors The patients bones are aligned and there are no deformities. There is no tenderness of the bones when palpated. There is no pain and swelling of the bones when palpated. The joints of the patients have no tenderness and smooth. Normal Normal Normal Normal Normal
1. Swelling 2. Tenderness, smoothness
Inspection Palpation
Normal Normal
C. DIAGNOSTIC PROCEDURE/LABORATORY DIAGNOSTIC LABORATORY PROCEDURE DATE ORDERED AND DATE RESULT IN INDICATIONS OR PURPOSE NORMAL VALUES RESULT INTERPRETATION NURSING RESPONSIBILITIES (prior, during, after) PRIOR: Normal 1. Explain to the patient the purpose of the test. 0.38 Normal 2. Inform them that the test requires a blood sample and that the patient may experience discomfort/pain from the needle puncture. 3. Inform them that there are no food or fluid restrictions. 4. Lists drugs being taken by the client to detect any effect on results.
HEMATOLOGY
February 12, 2012
The complete blood count or CBC test is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood The CBC is a very common test. Many patients will have baseline CBC tests to help determine their general health status.
Hemoglobin 115-158g/L Hematocrit 0.36-0.40 White Blood Cell 411x10/L Lymphocytes 0.20-0.40 Monocytes 4-7% Granulocytes RBC 3.5 - 5.5 mill/mm3
126 g/L
6.1x 10/L
Normal
0.40
Normal
6.9% 42.7% 4.61 m1ll/mm3
DURING: 1. Inform the patient that venous blood is to be collected. 2. Venipuncture should be performed in an aseptic technique as well as the collection of the sample. 3. Handle the specimen gently to avoid hemolysis. Normal AFTER: 14.9% Normal 1. Make sure that the specimen bottles are labelled correctly. 2. Put pressure over the puncture site. Normal 3. Inform them that the results will be out as soon as the specimen is interpreted in the laboratory.
MCV 80 - 100 fl
83fl
Normal
MCH 25.4 - 34.6 pg/cell
27.4 pg/cell
Normal
MCHC 31 - 36 Hb/cell
33 Hb/cel
RDW 11-15%. 256, 000mm3
PLT 150,000 400,000/mm 3
7.7fL
Normal
MPV 7.5-11.5 fL
0.198
PCT <0.5 PDW 10.0% 17.9% 14.0%
Normal
Normal
URINALYSIS
February 12, 2012
A routine Color: straw urinalysis may be to yellow done when you are admitted to the Chemical Exam: hospital. It may also be part of a wellness exam Urobilinogen urinalysis will most likely be Transparency performed when : Clear you see your health care provider complaining of Specific symptoms of gravity: a UTI or other 1.005-1.025 urinary system problem such as kidney disease. pH 4.5-7.8 Some Sugar: (-) signs and symptom Protein (-) Yellow
Normal PRIOR 1. Inform the mother that there are no food or fluid restrictions before the test.
Normal
Normal This is an indication of an infection in the urine. Normal 2. Advise the mother of the procedure and the reason for the test. DURING 1. The specimen should be sent to the laboratory within 1 hour after collection or if the specimen cannot be processed immediately, refrigerate it.
Turbid
1.005
7.0 (-)
s may include abdominal pain.
Nitrite (-) Leukocytes
(-) (-) (+)
Glucose (-) Bilirubin (-) Ketone (-)
(-) (-) (-)
Normal This is an indication of an infection. Normal Normal Normal
2. If a 24 hour urine collection is requested the specimen should be refrigerated or preserved within formalin during the collecting time. AFTER
Microscopic: Mucous Thread: None Few Normal
1. Record data. 2. Relay result to the doctor
URINALYSIS
July 6, 2012
A routine urinalysis may be done when you are admitted to the hospital. It may also be part of a wellness exam urinalysis will most likely be performed when you see your health care provider complaining of
Color: straw to yellow
Yellow
Normal
PRIOR 3. Inform the mother that there are no food or fluid restrictions before the test.
Chemical Exam: Urobilinogen Transparency : Clear Normal Normal This is an indication of an infection in the urine.
Turbid
4. Advise the mother of the procedure and the reason for the test. DURING 3. The specimen should
symptoms of a UTI or other urinary system problem such as kidney disease. Some signs and symptom s may include abdominal pain.
Specific gravity: 1.005-1.025 pH 4.5-7.8 Protein (-) Nitrite (-) Leukocytes
1.005
Normal
7.0 (-) (-) (1+)
Glucose (-) Bilirubin (-) Ketone (-)
(-) (-) (-)
Normal Normal Normal Normal This is an indication of an infection. Normal Normal Normal
be sent to the laboratory within 1 hour after collection or if the specimen cannot be processed immediately, refrigerate it. 4. If a 24 hour urine collection is requested the specimen should be refrigerated or preserved within formalin during the collecting time. AFTER 3. Record data.
Microscopic: RBC: 0-5/hpf Crystals (-) Amorphous Urates: Few Epithelial Cell: Few Bacteria: None WBC: 0-4hp 3-4/hpf Normal
4. Relay result to the doctor
Few Few 18-25
Normal This is an indication of an infection. Indicate the presence of an inflammatory
process Mucous Threats Few Normal
Blood Chemistry Result
Chemistry July 6, 2012 Biochem Glucose Hexoki
Results
Interpretation
Range
3.9mmo/L
Normal
3.8-6
Creatinine Kinetic Sodium Potassium Calcium Chloride July 7, 2012 Calcium
60.7umo/L 142.3mmol/L 3.5
35.4-123.8 135-148 3.5-5.3 1.1-1.32 96-107
SI: 1.91 Traditional: 7.64
Low These are also associated with dietary insufficiencies, parathyroid problems, and intestinal problems
SI: 2.10-2.54 Traditional: 8.4-10.2
Laboratory Procedure
Date Ordered, Date Result
Indication/ Purposes
Components
Normal Values
Actual Values
Analysis/ Interpretation
Nursing Responsibilities
Thyroid Function Tests
June 20, 2012
Blood tests used to check the function of thyroid.
Prior: Verify the doctors order Identify the client
FT4 ELISA
0.8-2.0 ng/dl
1.3
Within normal range
Explain the procedure. Explain that slight discomfort may be felt when the skin is punctured. During: Provide an adequate light for easy visualization of the vein. Assist the medical technologist.
TSH ELISA
0.6-5.0 uIu/ml
0.76
Within normal range
After:
Apply pressure using dry cotton ball in the site. Secure the specimen.
Laboratory Procedure
Date Ordered, Date Result
Indication/ Purposes
Components
Normal Values
Actual Values
Analysis/ Interpretation
Nursing Responsibilities
Thyroid Function Test
June 20, 2012
Prior: Verify the doctors order Identify the client
FT4 ELISA
0.8-2.0 ng/dl
0.6 ng/dl
FT4 ELISA and TSH ELISA are below normal. Hypothyroidism is present.
Explain the procedure. Explain that slight discomfort may be felt when the skin is punctured. During: After: Apply pressure using dry cotton ball in the site. Secure the specimen. Provide an adequate light for easy visualization of the vein. Assist the medical technologist.
0.4 uIu/ml TSH ELISA 0.6-5.0 uIu/ml
DIAGNOSTIC PROCEDURE
DATE ORDERED, DATE OF RESULT
INDICATION/ PURPOSES
REPORT AND IMPRESSION
ANALYSIS/ INTERPRETATION
NURSING RESPONSIBILITIES (PRIOR,DURING,AFTER)
Thyroid Ultrasound
REPORT: Date of result: Imaging Masses are present in right anterior neck. method used to June 20, There is a poorly defined 5.4 x 4.0 x 3.8 see the thyroid. cm solid mass in the anterior neck located 2011 more to the right side which is difficult to An exam distinguish from the right lobe of the thyroid. which helps to tell the The left lobe of the thyroid is normal in difference size measuring 3.5 x 1.2 x 0.9 mass with no between a sac nodules appreciated. containing The isthmus is not visualized. fluid and abnormal IMPRESSION: tissue growth which may or Poorly defined anterior neck mass can may not be represent an enlarged multinodular right cancerous. thyroid or a separate lesion; suggest clinical correlation and/or CT scan of the neck for further evaluation.
Article II. Article III. PRIOR: Article IV. -Check the physician order Article V. -Identify the client Article VI. -Explain procedure to the client Article VII. Article VIII. DURING: Article IX. - Assist the client in going to x-ray room. -Teachings rendered as follows: a. Remove any jewelries b. Remain still during the procedure Article X. Article XI. AFTER: Article XII. -Document the procedure done Article XIII. -Secure the result
Radiologic Report Findings: Chest PA Atheromatous Aorta Cardiomegaly
VII.
THE PATIENT AND HER CARE A. MEDICAL MANAGEMENT 1. INTRAVENOUS SOLUTION
MEDICAL MANAGEMENT D5LRS 1L 30gtts/min
DATE ORDERED, DATE DISCONTINUED Date Ordered: July 4, 2012 Date Discontinued: July 8, 2012
GENERAL DESCRIPTION
INDICATIONS OR PURPOSES Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.
CLIENTS RESPONSE The client response well with no signs of irritation and adverse reaction.
NURSING RESPONSIBILITIES (prior, during, after) PRIOR Monitor the IV site to make sure the catheter is in the vein. Usually listen to the lung sounds especially if the fluids are going fast and the person is elderly. If it has problems with fluid overload and congestive heart failure, monitor the labs to make sure the physician doesnt need to change the IV fluids to correct an
Hypertonic Solutions are those that have an effective osmolarity greater than the body fluids. This pulls the fluid into the vascular by osmosis resulting in an increase vascular volume. It raises intravascular osmotic pressure and provides fluid electrolytes and
calories for energy. Osmolarity is higher than the serum. When infused, it initially increases osmolarity causing the fluid to be pulled from the interstitial & intracellular compartments into the blood vessel (intravascular space).
electrolyte problem. DURING Start the IV somewhere convenient for the patient. Check central lines for patency and make sure the lines are flushed and secured with no s/s of infection. AFTER Do not administer unless solution is clear and container is undamaged. Caution must be exercised in the administration of parenteral fluids.
2. DRUGS DATE ORDERED, DATE DISCONTINUED Date Ordered: July 5, 2012 Date Discontinued: July 8, 2012
NAME OF DRUG
ROUTE, DOSAGE, FREQUENCY
GENERAL DESCRIPTION
INDICATION OR PURPOSE
CLIENTS RESPONSE
NURSING RESPONSIBILITIES (prior, during, after)
RANITIDINE CLASSIFICATION: Anti-ulcer agents Histamine H2
50 mg Inhibits the action of TIV q8 once IVF histamine at the H2 started receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion
Treatment of heartburn, acid indigestion, sour stomach
Dizziness Drowsiness Headache Nausea/ Vomiting
PRIOR Assess patient for epigastric or abdominal pain and frank or occult blood in the
Antagonist
stool, emesis,or gastric aspirate.>Assess geriatric and debilitatedpatients routinely for confusion.Report promptly. DURING Administer over at least 5 min.Rapid administration may causehypotension and arrhythmias.
AFTER Ranitidine may cause false-positive results for urine protein;test with sulfosalicylic acid. Administer with meals or immediately afterward and atbedtime to prolong effect.
KETOROLAC
Date Ordered: July 5, 2012
30 mg TIV q 6x 4 doses
Inhibits prostaglandin
Short term management of pain
Dizziness Headache
PRIOR
CLASSIFICATION: Nonsteroidal antiinflammatory agents, nonopioid analagesics Date Discontinued: July 8, 2012
synthesis, producing peripherally mediated analgesia Also has antipyretic and antiinflammatory properties. Therapeutic effect: Decreased pain
Pallor Dry mouth Nausea Sweating
Review the physicians order. Determine the materials needed. Wash hand Gather the materials needed. Identify the client Explain the procedure to the client. Assess for any adverse effect. Establish rapport
DURING Check for the vital signs Administer only those drugs that you have prepared.
AFTER Document drug given, dose, time, route and signature. Record for effectiveness and results of meds given Instruct client to avoidalcohol and maintainadequate hydration (2-3L/day of
fluids) unlessinstructed to restrict fluidintake. Monitor for signs of pain relief, such as anincreased appetite andactivity Instruct client to avoidtaking ketorolac withaspirin or other NSAIDssuch as ibuprofen(Motrin, Advil),naproxen (Aleve, Naprosyn), piroxicam(Feldene), etc.
Cefuroxime Classification: Anti-Infectives
Date Ordered: July 5, 2012 Date Discontinued: July 5, 2012
15gm TIV Bactericidal/Antibacterial Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death
For dermatologic infections, caused by S. aureus, S. pyogenes fights bacteria in the body. is used to treat many different types of bacterial infections
Nausea Pain Sweating Dry mouth Itching wheezing
PRIOR Identify the patient and check the physicians order for the right dosage and right route. Check the patency of the IV and the insertion site for infection. Before giving drug, ask patient if he / she is allergic to penicillins cephalosporin. Perform skin test before giving the medication.
DURING Explain to the patient and significant others what is the purpose of the drugs.
AFTER Tell patient to take drug as prescribed even after he / she feels better. Advise patient receiving drug to report any discomfort at the insertion site. Instruct the patient to notify prescriber any side effects.
Cefuroxime Classification: Anti-Infectives
Date Ordered: July 6, 2012 Date Discontinued: July 7, 2012
750mg TIV q8 Bactericidal/Antibacterial Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death
For dermatologic infections, caused by S. aureus, S. pyogenes fights bacteria in the body. is used to
Nausea Pain Sweating Dry mouth Itching wheezing
PRIOR Identify the patient and check the physicians order for the right dosage and right route. Check the patency of the IV and the insertion site for infection.
treat many different types of bacterial infections
Before giving drug, ask patient if he / she is allergic to penicillins cephalosporin. Perform skin test before giving the medication.
DURING Explain to the patient and significant others what is the purpose of the drugs.
AFTER Tell patient to take drug as prescribed even after he / she feels better. Advise patient receiving drug to report any discomfort at the insertion site. Instruct the patient to notify prescriber any side effects.
Cefuroxime Classification:
Date Ordered: July 8, 2012
500mg BID PO
For dermatologic
Nausea Pain
PRIOR Prior to reconstitution,
Anti-Infectives
Date Discontinued: N/A
Bactericidal/Antibacterial Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death
infections, caused by S. aureus, S. pyogenes fights bacteria in the body. is used to treat many different types of bacterial infections
Sweating Dry mouth Itching wheezing
protect drug from light. The power and reconstituted drug may darken without affecting potency. Instruct the client to swallow tablets whole and not crush, crushed tablet has a strong, bitter, persistent taste. The tablets may be taken without regard for food. Protect tablets from excessive moisture. Tablet are not bioequivalent and not substitutable on a mg-permg basis.
DURING Check for the vital signs Administer only those drugs that you have prepared.
AFTER Do not take cefuroxime if patient have ever had
an allergic reaction to another cephalosporin or to penicillin unless the doctor is aware of the allergy and monitors their therapy.
CELECOXIB CLASSIFICATION S Therapeutic: Anti-rheumatics, NSAIDS
Date Ordered: July 5, 2012 Date Discontinued: N/A
200mg BID PO
Decreased pain and inflammation caused by arthiritis Inhibits the enzyme COX-2. This enzyme is required for the synthesis of prostaglandins. Has analgesic, antiinflammatory, and antipyretic properties.
Relief of signs and symptoms of osteoarthritis. Relief of signs and symptoms of rheumatoid arthritis in adults.
Headache Dizziness Fatigue
PRIOR Assess patients history of allergic reaction to the drug Monitor complete blood count, electrolyte levels, creatinine clearance, and occult fecal blood test and liver function test results every 6 to 12months
DURING Instruct patient to take drug with food or milk.Teach patient to avoid aspirin and other NSAIDs (such as ibuprofen and naproxen)during therapy.
AFTER Advise patient to immediately report
bloody stools, blood in vomit, or signs or symptoms of liver damage(nausea, fatigue, lethargy, pruritus, yellowing of eyes or skin, tenderness on upper right side of abdomen, or flu like symptoms)
3. DIET DATE ORDERED, DATE CHANGED, DATE DISCONTINUED Date Ordered: June 4, 2012
TYPE OF DIET
GENERAL DESCRIPTION
INDICATION/PURPOSES
SPECIFIC FOOD TAKEN
CLIENTS RESPONSE
NURSING RESPONSIBILITIES (prior, during, after)
Nothing per Orem (NPO)
Nothing per Orem (NPO)/Nil per Date Discontinued: os (alternatively June 6, 2012 nihil/non/nulla per os) (NPO) is a medical instruction meaning to withhold oral food and fluids
It is usually ordered because the person has a procedure that requires them to be sedated. If you have a full stomach you could vomit while you are sedated and aspirate the vomit into your lungs.
Any kinds of food or fluid are not allowed to be eaten.
The client was thirsty and felt weak.
PRIOR Explain to the client and significant others the purpose, indication and the duration of the diet. Assist the clients compliance ability to the diet.
from a patient for various reasons. It is a Latin phrase which translates as "nothing through the mouth".
DURING Advise the client to avoid foods. Provide frequent oral hygiene Monitor the compliance of the patient to the diet.
AFTER Evaluate the effect of the diet to the client. Report excessive weight loss. Assess any nutritional disturbances and notify the physician.
Soft Diet
Date Ordered: June 6, 2012
Soft foods include naturally soft, mashed or pureed Date Discontinued: foods that are easy to June 7, 2012 swallow. You might eat foods from all major food groups when following a
A soft diet provides a transition from liquids to regular foods for individuals suffering from various conditions. A health care provider might recommend soft foods that are intended to provide nutrition while
Porridge Water Biscuit (Hansel, Fita) Loaf of Bread
The patient was contented with what she eats rather that nothing at all.
Instruct patient to eat only mashed, ground foods. Avoid roughage foods.
soft diet. Soft grains include dry cereals, refined bread and crackers, plain noodles and white rice. Soft, cooked or canned fruit and vegetables such as salad greens, tomatoes, applesauce, soft banana and melon cubes are acceptable in a soft diet. High protein foods you can eat include soft cheeses, low-fat milk, plain yogurt, scrambled eggs, tofu, mashed beans, and moist meat, fish or poultry. All beverages, mild spices, sugar and seedless jelly are acceptable in a soft diet
you recover from surgery or an illness. Soft foods are easier to consume than regular foods for patients with difficulty swallowing, or dysphagia. A soft diet is helpful for patients undergoing medical treatments or surgery involving the head, neck or stomach. In addition, individuals suffering from pain or other ailments involving their teeth or mouth also require a soft diet.
Diet as Tolerated
Date Ordered: June 7, 2012
Only given when the client can tolerate any food she desired that is nutritious, if
For her to bring back the energy loss from the procedure done.
Any kinds of foods or fluids are allowed.
The client has strength and energy because of the nutritious foods she eats.
Encourage or provide oral hygiene before mealtime.
Date Discontinued: this will not lead to N/A any complications and it would interfere with any lab test result.
Inform the patient about the specific foods allowed and not allowed Assist with meal planning Advise client to properly chew the food. Advise patient to report any allergic reaction to the food taken
4. ACTIVITY/EXERCISE TYPES OF EXERCISE DATE ORDERED, DATE CHANGED, DATE DISCONTINUED Date Ordered: July 5, 2012 Date Discontinued: July 6, 2012 GENERAL DESCRIPTION INDICATION/PURPOSES CLIENTS RESPONSE NURSING RESPONSIBILITIES (prior, during, after)
Deep Breathing Exercise and Incentive Spirometer
Deep breathing is vital to your health. It opens the tiny air sacs in your lungs. It also helps keep your lungs and airways clear. You take many deep breaths each hour without even being aware of it. These deep breaths are automatic and occur in the form of sighs and yawns. Deep breathing exercises
According to the medical experts at drugs.com, combining deep breathing with regular coughing is a technique to minimize symptoms and prevent further lung infections when diagnosed with pleural effusion. To accomplish this, breath in as deeply as you are able. Hold the breath for as long as possible, then release the air from your
The patient tried her best to perform the said activity.
Instruct the client to: 1. Place your hand on your stomach. Breathe in deeply and slowly through your nose. Focus on pushing your stomach out as you breathe in. Hold your breath for a second or two. 2. Breathe out slowly and fully through your mouth. 3. Repeat twice more. 4. Breathe in again, hold your
help to keep the lung muscles healthy to prevent infections and pneumonia from developing, according to MedlinePlus. Deep breathing exercise can be performed hourly to maintain oxygen levels and clear the lungs of excessive carbon dioxide build-up. Incentive Spirometer An incentive spirometer is a tool used to help keep a patient's lungs clear following illness or surgery. Most often made of plastic, it contains a mouthpiece attached to a flexible tube on one side, and a piston or ball in a clear tube marked with milliliters, or mL, on the other. To use a spirometer, blow into the mouthpiece to make the piston or ball reach a certain volume indicator on the tube, explains the Cleveland Clinic. This helps exercise your lungs. Practice this exercise every hour, taking 10 deep breaths every time
body by emitting a strong cough (or series of coughs). This will help breakup fluid and provide a maximal level of oxygen to your body. Ideally, aim to repeat this exercise 10 times in a row, repeating one "set" every single hour of the day.
breath, and then cough (if told to do so) from deep in the lungs (not a shallow throat cough) or repeat step 2. Support (splint) your incision to decrease pain while coughing. 5. Repeat exercise. Using Incentive Spirometer 1. Hold the unit upright, breathe out as usual and place your lips tightly around the mouthpiece. 2. Take a deep breath. Inhale enough air to slowly raise the Flow Rate Guide between the arrows. 3. Hold the deep breath. Continue to inhale, keeping the guide as high as you can for as long as you can, or as directed by your nurse or respiratory therapist. 4. Breathe out and relax. Remove the mouthpiece and breathe out as usual. After each long, deep breath, take a moment to rest, relax, and breathe normally. Repeat this exercise 10 times an hour, every day you are in the hospital or as directed by your nurse. 5. Cough after using your breathing tool ten times.
C. NURSING PROBLEM PRIORITIZATION DATE IDENTIFIED July 7, 2012 S: O: > Presence of surgical incision at neck CUES PROBLEM/ NURSING DIAGNOSIS Impaired skin integrity related to mechanical interruption of muscle tissue as manifested by of surgical incision at neck JUSTIFICATION To properly aid Patient ADR in achieving optimal healing, reestablishing tissues integrity should be given attention and prioritize
July 7, 2012
S-hindi ako makatulog kasi ang iingay nung mga bantay ng ibang pasyente as verbalized by the client. OVital signs: Bp: 120/80
Disturbed sleep pattern related to noisy environment.
Disturbed sleep pattern is our second priority as we follow Maslows Hierarchy of Needs. Physiological needs are the things we need to fulfill for our body to function well. Our client is suffering from disturbed sleep pattern due to noisy environment.
T: 35.5 PR: 64 RR: 21
July 7, 2012
S- OVital signs: Bp:120/80 T: 35.5 PR: 64 RR: 21
Risk for infection related to inadequate primary defense secondary to thyroidectomy.
Risk for infection is our third priority as we follow Maslows Hierarchy of Needs. Safety needs of our client for possible illness problem that he can acquire is really important for his better healing process.
D. NURSING CARE PLAN Impaired Skin Integrity (Nursing Care Plan) Assessment S: Diagnosis Planning Intervention Independent: Use of proper dressing such as sterile gauze, adhesive and non adhesive films Use of appropriate antiseptic solution - To facilitate wound healing and preventing spread of microorganism - To control formation of bacteria and help in the bodys natural wound healing - Proper nutrition promotes wound healing - To promote wound healing Rationale Evaluation Short Term Goal: After 2-3 of nursing intervention: _ goal met _ goal partially met _ goal unmet Verbalized understanding of condition Identified and demonstrated interventions appropriate with the condition Demonstrated
O: >Presence of surgical incision at neck (5 in.)
Impaired skin integrity Short Term Goal: related to mechanical Within 2-3 of nursing interruption of muscle intervention the client will: tissue as manifested by of surgical incision -Verbalize understanding of at neck condition -Identify and demonstrate interventions appropriate with the condition -Demonstrate behavior/lifestyle changes to promote healing
Long Term Goal:
Promote optimum nutrition with high quality protein and sufficient calories Instruct the client to
Within 2 weeks of nursing intervention, the client will be able to display progressive improvement in wound healing without complications
increase fluid intake Instruct client about proper wound care Encourage adequate rest periods - To limit metabolic demands, maximize energy available for healing - To prevent excessive tissue pressure - To promote circulation - To promote wound healing
behavior/lifestyle changes to promote healing Long Term Goal: -Not evaluated
Promote early mobility; encourage position changes Assist with active/passive exercises Dependent: Administer antibiotic, Cefuroxime 500mg PO BID, as ordered
- The drugs may inhibit the formation of bacteria
Assessment
Nursing Diagnosis
Planning
Interventions
Rationale
Evaluation
Short term goal: Subjective: -hindi ako makatulog kasi ang iingay nung mga bantay ng ibang pasyente as verbalized by the client. Objective: Vital signs: Bp:120/80 T: 35.5 PR:64 RR: 21 Disturbed sleep pattern related to noisy Within 6 hours of nursing environment. intervention the client will be able improve sleep pattern as evidence by: a.achieve optimal amount of sleep. b. at least 3-4 hours of uninterrupted sleep c. minimize sleep disrupting factors. >instruct relative to provide with comfortable bed linens and pillows. >these may help to enhance sleep patterns in terms of good and conditioned environment. >ensure patient has electric fan >to enhance relaxation. c. patient minimized sleep disrupting factors. Independent >request only 1visitor per patient. >to minimize noisy environment. Within 6 hours of nursing intervention, short goal was met as evidenced by: a.patient achieved optimal amount of sleep B. patient had at least 3-4 hours of sleep
Assessment
Nursing Diagnosis
Planning
Interventions
Rationale
Evaluation
Short term goal: Subjective: Objective: Vital signs: Bp: 120/80 T: 35.5 PR: 64 RR: 21 Risk for infection related to inadequate primary defense secondary to thyroidectomy. Independent Within 2 hours of nursing intervention the client will be able to manifest absence of infection through: a.maintaining V/S within normal range >demonstrate proper b.absence signs of infection. handwashing c. maintaining proper hygiene Long term goal: Patient will not acquire infection due to inadequate primary defenses throughout hospitalization Dependent >administer antibiotic as ordered. >inhibit or kills bacteria that can cause infections. >handwashing is the first-line of defense from acquiring infections. >monitor vital signs >increase in temperature and tachycardia may indicate infection Within 2 hours of nursing intervention, short goal was met as evidenced by: a.maintained pulse rate and temperature within normal range. T-36.8 PR-66bpm B. had no sign of infection c. client maintained his good proper hygiene.
VIII. SURGICAL MANGEMENT A. BRIEF DESCRIPTION
TOTAL THYROIDECTOMY Thyroidectomy is a surgical procedure in which all or part of the thyroid gland is removed. The thyroid gland is located in the forward (anterior) part of the neck just under the skin and in front of the Adam's apple. The thyroid is one of the body's endocrine glands, which means that it secretes its products inside the body, into the blood or lymph. The thyroid produces several hormones that have two primary functions: they increase the synthesis of proteins in most of the body's tissues, and they raise the level of the body's oxygen consumption. All or part of the thyroid gland may be removed to correct a variety of abnormalities. If a person has a goiter, which is an enlargement of the thyroid gland that causes swelling in the front of the neck, the swollen gland may cause difficulties with swallowing or breathing. Hyperthyroidism (overactivity of the thyroid gland) produces hypermetabolism, a condition in which the body uses abnormal amounts of oxygen, nutrients, and other materials. A thyroidectomy may be performed if the hypermetabolism cannot be adequately controlled by medication, or if the condition occurs in a child or pregnant woman. Both cancerous and noncancerous tumors (frequently called nodules) may develop in the thyroid gland. These growths must be removed, in addition to some or the entire gland itself.
B. VISUALS
C. PATIENT'S RESPONSE TO OPERATION While we're interviewing our client she verbalized, Noong nalaman ko na malapit na akong operahan, nababalisa talaga ako kasi hindi ko alam ang maaring mangyari.
D. NURSING RESPONSIBILITIES PRIOR TO, DURING AND AFTER THE OPERATION
PRIOR Obtain and review signed informed consent attached in the chart. Greet patient by name, and positioned comfortably on the stretcher or bed. The patient changes into a hospital gown that is left untied and open in the back. The patient with longhair may braid it, remove hairpins, and cover the head completely with a disposable paper cap. The mouth is inspected, and dentures or plates are removed. If left in the mouth, these items could easily fall to the back of the throat during induction of anesthesia and cause respiratory obstruction. Jewelry is not worn to the OR; wedding rings and jewelry of body piercings should be removed to prevent injury. All articles of value, including assistive devices, dentures, glasses, and prosthetic devices, are given to family members or are labelled clearly with the patient's name and stored in a safe and secure place according to the institution's policy. All patients (except those with urologic disorders) should void immediately before going to the OR to promote continence during low abdominal surgery and to make abdominal organs more accessible. Urinary catheterization is performed in the OR as necessary. Administering pre-anesthetic medication. Observe the patient for any untoward reaction to the medications. The immediate surroundings are kept quiet to promote relaxation. Maintaining the preoperative record. Preoperative checklists contain critical elements that must be checked and verified preoperatively and must be completed. All wires and plugs are inspected for correct attachment. All equipments are checked.
DURING Identify the client, the operation to be performed (thyroidectomy), and the operative site (neck). Position (dorsal recumbent) the client comfortably on the operating table. Skin preparation is done along with any other procedures that must be completed (e.g. catheterization). Gathering of additional and special supplies. Draping and creation of sterile field. Perform Time-Out. Surgical counting before initial incision is done, during the surgery, and immediately before the incision is closed. Maintain surgical asepsis. Keep patient warm as possible. Monitor for any emergencies. Wipe off any excess blood especially on the neck or the operative site. Documentation of the intraoperative care. Maintain safety in transporting the patient.
AFTER Proper transferring and positioning on bed from stretcher. Patient is placed in supine position. Assessment of the ABCs and sensorium. Ensure patent airway. Reorient the patient. Maintain safety all the time. Keep all cardio-resuscitating equipments readily available at bedside. Monitor vital signs every 15 minutes. Monitor for any complications or any signs/symptoms of shock. Administer any ordered drug (analgesics). Promote comfort to the patient. Document all appropriate information thoroughly. Endorse and refer patient accordingly.
IX.
DISCHARGE PLANNING
MEDICATION Inform the patient of the importance of compliance of medication especially maintenance of medicines (Cefuroxime 500mg BID, Celoxib 200mg BID). Inform the patient that she must take her medications at the right time prescribed by the doctor Since the patient is taking several medications, advice her to organize medications in a container so that it would be easier to access the medications on time Inform the patient not to skip medication, and if skipped, do not double the next dose EXERCISE Avoid lifting heavy things Encourage the patient to do stretching in the morning and at night as this would help in the circulation of the blood in the body Encourage to do range of motion exercise to prevent dizziness and weakness Encourage patient to do deep breathing exercise Avoid over-exertion, eg. gardening
TREATMENT Inform the patient to take prescribed medications on time and with the right dosage If any signs and symptoms of recurrence of illness, immediately report to the doctor so that it can be intervened on Do not use any herbal medications to cure sickness, immediately seek medical advice Avoid becoming too fatigue. Always make sure that she will be having adequate rest Avoid stressful environment If dizzy, advise to sit or lie down to avoids casualties
HEALTH TEACHING Encourage the patient to have adequate rest and sleep Advise the patient to have proper hygiene Encourage the patient to contact health care provider once symptoms are felt Relaxation technique can be done to help reduce blood pressure Lifestyle modification should be done because they are effective in preventing further illnesses Encourage increase fluid intake Advice her to eat low fat, low protein diet and also low sodium intake Avoid constipationeat a nutritious diet and drink plenty of water Expect:
Some pain/discomfort at your wound site may be experienced. This is generally aggravated by movement, coughing and sneezing. Gently support the
wound area when you need to cough. This discomfort will eventually settle. You can take analgesia as discussed with your doctor or nurse. You may notice redness, slight swelling and bruising around the wound, this is quite normal. The skin closures (steristrips) applied will fall off naturally. You may notice that you have a poor appetite for some time. Post-operative lethargy often lasts for a month or more
Return if: You have any difficulty swallowing or breathing. You notice increased swelling from/around the wound and/or a discharge from the wound, inflammation, throbbing around the wound or it feels hot to touch. You experience a tingling feeling in your mouth or fingers and/or numbness in your fingers. You feel feverish. You have nausea and vomiting which does not settle. You have any other concerns
OUT-PATIENT Encourage the patient to be back on June 18, 2012 for follow up check-up Encourage patient to have regular check-ups to monitor her health status Inform the patient not to self diagnose if there are cases where signs and symptoms are felt Encourage the client to follow the doctors order and test that should be done
X.
CONCLUSION
We therefore conclude that being aware and conscious is the main action to prevent this sort of illness. Because of this, we became familiar about the complications and how this illness starts. Also, we understand the factors, contributing in this condition. We can assess the clients condition to do the plan of nursing care with intervention for the recovery of the client. We can how evaluate the effectiveness and modify the plan of care for client with Multiple Colloid Adenomatous Goiter. As a nursing student, we care for the patient with a good manner without discrimination. As a client, she can socialize with the people around her without anxiety, known that her condition can be managed.
XI.
BIBLIOGRAPHY Pathophysiology: Incredibly visual. Philadelphia, Wolters Kluwer, Lippincott, Williams and Wilkins 2008 Delmars Nursing Drug Handbook: George R. Spratto, AdriennE l. Woods, 2010 edition Nurses Pocket Guide: Marilynn E. Doenges, Mary Frances Moorehouse, Alice C. Murr, 11th edition Holes Essential of Human Anatomy and Physiology: David Shier, Jackie Butler, Ricki Lewis, 9th edition
Medical- Surgical Nursing: Brunner and Suddart Vol.2, 12th edition

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I.

B. CHIEF COMPLAINT Lumalaki ang bukol ko sa leeg as verbalized by the patient.

D. HISTORY OF PRESENT ILLNESS

FUNCTIONAL HEALTH PATTERN

Client ADR doesnt have any food allergies. She

loves to eat chicken and drinks 6-7glasses of water.

Freque ncy Amoun t Charac teristics

July 3,2012 Freque ncy Charac teristics

July 6,2012 1 Formed, Brown, pungent odor

1 Formed, Brown, pungent odor

Our client is in Foley catheter.

FREUDS THEORY OF DEVELOPMENT

Formal operational (12 years and up)

Age Range: Puberty to Death

Our patient is belongs to post conventional (social contract legalistic Orientation)

ANATOMY AND PHYSIOLOGY

Decrease circulating thyroid hormones

Follicular involution Reaccumulation of colloid Stimulates production of TSH Overinvoluted

Decrease T3 and T4 level

Altered GI motility and tone 19 | P a g e A C a s e o f 5 1 y r s o l d M u l t i p l e C o l l o i d A d e n o m a t o u s G o i t e r

Acculmulation of mucopolysaccharide in larynx

Presence of distortion and pressure at vascular network

Infarction and degeneration present Fibrosis develops

2. Posture and gait

Inspection and observation

Relaxed, erect posture, coordinated movements

The patient has relaxed coordinated movements.

3. Over-all hygiene and grooming

Inspection and observation

Clean and neat

The patient is clean and neat.

4. Attitude and mood

Inspection and observation

Appropriate to situation and cooperative

Inspection and observation

The patient has body odor and breath odor.

Deviation from normal due to present illness.

Slightly weak in appearance.

Deviation from normal due to pain felt located at the

midline of the neck. Normal

Inspection and palpation Inspection

Palpation on the skin folds and inspection of the axilla Palpation

5. Temperature and skin turgor

3. Toenail and fingernail texture 4. Tissue surrounding nails

Inspection and palpation

Inspection and palpation

Prompt return o pink or usual color within 3 seconds

4. Hair texture and oiliness

Inspection and palpation

Silky and resilient hair

The patient's hair is oily.

Deviation from normal due to not taking a bath.

1. Facial features 2. Symmetry of facial movements.

EYEBROWS Hair evenly distributed

Normal Normal Normal

Inspection Inspection Inspection Inspection

Normal Normal Normal Normal

1. Color, texture, and presence of lesions.

1.Color, texture, and presence of lesions. 1. Color

2. Clarity and texture

Inspection using a penlight.

1. Test near vision

2. Test distant vision