PERTAINENT DATA

SUDENTS NAME:RICHARD B. TANUCO

AREA: CHH 7B
PATINTS NAME: Dela Cruz, Grace R.
ROOM/BED NO.: 755
AGE: 43
STATUS: MARRIED
DIAGNOSIS:Follicular adenoma at the right thyroid
CLINICAL PORTRAIT PERTINENT DATA

ASSESMENT:
Received client lying in bed awake, coherent, HISTORY OF PRESENT ILLNESS
conscious with an ongoing ivf of #4 of DLR 1L @
120cc/hr, attached at the right hand and infusing
well.
Client has anterior neck mass 3 yrs. prior to admission; onset of anterior
mass noted approximated one by one mass, movable, soft. Consulted a
SIGNIFICANT FINDINGS: physician in Thailand, thyroid part taken, given medications with poor
compliance. 2yrs prior to admission, follow-up is done in Thailand. FNAM
Client was complaining of difficulty in swallowing done shared cystic mass thyroid. A month prior to admission, follow-up
and boy malaise. done, advised FNAB which shared follicular neoplasm, thyroid positive
dysphagia.
VITAL SIGNS DURING FIRST CONTACT: Two weeks prior to admission noted dry cough, given amoxicillin for
one week.
Temperature: 36.8*c
Pulse Rate: 64 bpm CHIEF COMPLAINT:
dysphagia an body malaise.
Respiratory Rate: 15 cpm
Blood Pressure: 90/60 mmHg Vital signs during admission:
Temperature: 36.5*C
Pulse Rate: 62 bpm
Respiratory Rate: 13 cpm
Blood Pressure: 90/80 mmHg

LABORATORY REPORTS:
CHEST X-RAY

LUNGS ARE CLEAR. HEART IS NOT ENLARGED. THE

TRACHEAL IS AT THE MIDLINE, THERE IS AN NODULE
NOTED AT THE RIGHT PARATRACHEAL WALL AT THE LEVEL
OF T1.

ULTRASOUND

RIGHT LOBE: 5.0 X 1.0 cm. 4-6 cm.

LEFT LOBE: 4.2 cm. 2-3 cm.

ISTHMUS: 0.2 cm thick 1-2 cm

 MINIMALLY ENLARGED MANDIBULAR LYMPH

NODES.

IMMUNOLOGY REPORT
THYROID FUNCTION TEST

TSH = 1.42 REFERENCE: 0.30-0.50 micro international units

per milliliter

CHEMISTRY REPORTS

VALUE REFERENCE

GLUCOSE 109 70-100 MG/DL

CREATINI 0.6 0.6-1.5 MG/DL

NE

Na serum 140 134.0-143 MMOL/L

K 3.8 3.3-5.3 MMOL/L

SEROLOGY REPORT: O+
HEMATOLOGY

CBC: LEVEL REFERENCE

WBC 6.80 4.8-10.8

10^3/ML

RBC 4.39 4.2-5.4

10^6/ML

HEMOGLOBIN 13.0 120-160 O2/DL

HEMATOCRIT 38.4 37.0-47.0 %

PLATELET 322 120-400

10^3/ML

MCV 88 81-99 fl

MCH 29.7 27.0-31.0 pg

MCH C 33.9 33.0-37.0 g/dl

RDN 11.3 11.6%

PDN 13.0 9.0-14.0%

MPV 9.2 9.2-11.1 fl

RELATIVE:

NEUTROPHIL 50.2 40-74 %

LYMPHOCYTE 41.1 19-48%

MONOCYTE 4.9 3.4-9.0%

ESONPHILS 3.6 0.0-7.0%

BASOPHILS 0.2 0.0-1.5%

 NURSING CARE PLAN
SUDENTS NAME:RICHARD B. TANUCO
AREA: CHH 7B
PATINTS NAME: Dela Cruz, Grace R.
ROOM/BED NO.: 755
AGE: 43
STATUS: MARRIED
DIAGNOSIS:Follicular adenoma at the right thyroid

CUES NURSING SCIENTIFIC BASIS GOAL AND NURSING RATIONALE OF EVALUATION

ACTION OUTCOME ACTIONS AND NURSING ORDERS
CRITERIA ORDERS

SUBJECTI Acute Pain Unpleasant sensory and After 8 hours of INDEPENDENT: GOAL MET:
VE : related to emotional experience nursing * perform a *to note the affected Client response to
tissue trauma arising from actual or intervention the comprehensive area and to know interventions/ teaching
“SAKIT as evidence potential tissue damage client will be able assessment of pain to proper intervention and action performed.
AKONG by post or described in terms of to: include location, can applied.
LIOG”, as surgical such damage, characteristics, GOAL PARTIALLY
verbalized operation. GOAL onset/duration, MET:
by the sudden or slow onset of * report pain is frequency, quality, attainment/ progress
client any intensity from mild relieved/ severity and toward desired
t severe with an controlled. peripheral factors. outcomes.
OBJECTI anticipated or *follow prescribed
VES: predictable end and a pharmacological *note location of * this can be GOAL NOT MET:
duration of less than 6 regimen. surgical procedures influence of
* mos. postoperative pain modify client plan of
Expressive OUTCOME experienced. care.
behavior ( nurse's pocket guide, CRITERIA
* 9th edition, page 368) *assess client *note clients attitude
Restlesnes *verbalized method perceptions, along towards pain and use
s that provide relief, with behavioral and of specific
* Pain * demonstrate use physiologic changes. medications.
scale is 7 of relaxation skills * note clients focus *individual with
out of 10 and divisional of control [internal external focus of
as 1 activity as or external] control may take
indicates indicated for little or no
no pain individual responsibilities for
and 10 situation. pain management.
severe *perform an * to rule out
pain. assessment such as worsening of
time pain occurs. underlying condition/
Note the changes development of
from previous report complication.

*pain is a subjective
*accept client experience and
description of pain cannot be felt by
others.
* verbal/ behavioral
*note cultural and cues may have no
developmental direct relationship to
influences affecting the pain perceived.
pan response.

DEPENDENT
* observation may/
*observe non -verbal may not be
cues. congruent to what
client verbalized.
*to help determined
*asses for referred possibility of
pan as appropriate underlying condition
or organ dysfunction
requiring treatment.
* usually altered by
* monitor vital signs acute pain.

*to valuate client

*ascertain client's response to pain.
knowledge of and
about pain
management. *to ave baseline of
* review clients treatment given to
previous experience client.
to pain and method
found either helpful
or unhelpful for
control of pain in the
past.
* maybe exaggerated
* evaluate pain because client
behavior. perception pain is not
believed or because
client believes
caregiver as
discriminating report.
*because pain may
not be resolved but
*review clients can be lessen.
expectations versus
reality.

COLLABORATIVE *timely intervention

is more likely to be
*work with client to successful in
prevent pain. Use alleviating pain.
flow sheet to
document the pain,
therapeutic
interventions,
response and length * to provide non
of time. pharmacological pain
*Provide comfort management.
measures.(back-
rub,changes in *to assist client to
position) explore methods of
*encourage use of alleviation of pain.
relaxation exercises
such as deep
breathing and *to reduce concerns
focused breathing. of the unknown and
*Review procedures associated muscle
and tell client when tension.
treatment will hurt. *to comfort the
client.
*Suggest SO's
during the *to maintain
procedures. acceptable level of
* Administer pain. Notify the
analgesics as physician if regimen
indicated to maximal is inadequate to onset
dosage as needed. pain control goal.
*increasing/decrea
sing dosage ,
stepped program
* Assist client to
alter drug regimen,
(switching from
based on individual injection to oral
needs. route, increased
time span as pain
lessens).
 NURSING CARE PLAN
SUDENTS NAME:RICHARD B. TANUCO
AREA: CHH 7B
PATINTS NAME: Dela Cruz, Grace R.
ROOM/BED NO.: 755
AGE: 43
STATUS: MARRIED
DIAGNOSIS:Follicular adenoma at the right thyroid

CUES NURSING SCIENTIFIC BASIS GOAL AND NURSING RATIONALE OF EVALUATION

ACTION OUTCOME ACTIONS AND NURSING ORDERS
CRITERIA ORDERS

SUBJECTIV Ineffective airway Inability of the client After 8 hours of INDEPENDENT: GOAL MET:
E: clearance related to clear secretions or nursing intervention * Position head mid *to open airway in at Client response to
to laryngeal obstruction from the client will be able line with flexion rest. interventions/
“Naglisod spasm. respiratory tract to to: appropriate for teaching and
man ko ug maintain airway. condition. action performed.
ginhawa”, GOAL
as verbalized * Maintain airway *note location of * this can be GOAL
by the client patency. surgical procedures influence of PARTIALLY
postoperative. MET:
OBJECTIVE OUTCOME attainment/
S: CRITERIA *assess client *note clients attitude progress toward
perceptions, along towards pain and use desired outcomes.
> orthopnea *demonstrate with behavioral and of specific
reduction of physiologic changes. medications. GOAL NOT
> ineffective congestion with MET:
cough breath sounds clear.
*Verbalize * Suction oral as *to clear secretion modify client plan
> difficulty understanding of needed that blocks the of care.
in vocalizing causes and airway.
therapeutic *Elevate head of the * to take advantage
management bead and change on gravity decreasing
regimen. position every 2 pressure on the
hours. diaphragm..

* monitr vital signs * to know the

progress of clients
status.
* keep environment * to minimize
free from allergens. causative factor.

DEPENDENT

*observe non -verbal * observation may/

cues. may not be
congruent to what
client verbalized.
*Encourage deep *to maximize effort
breathing exercise made by the client.
and coughing
exercise.

* administer * to improve cough

analgesic prn. when pain is
inhibiting effort.

*Encourage warm *decreases

versus cold liquids as bronchospasm.
appropriate.
Management.

* Provide *to enhance client

supplemental breathing pattern.
humidification.

* Discourage use of *To prevent

oil based products aspiration in the
around the nose. lungs.

COLLABORATIVE

* Auscultate breath * To ascertain client

sounds progress.
*encourage use of *to assist client to
relaxation exercises explore methods of
such as deep alleviation of pain in
breathing and coughing.
focused breathing.

*Review procedures *to reduce concerns

and tell client when of the unknown and
treatment will hurt. associated muscle
tension.
*Suggest SO's during *to comfort the
the procedures. client.

*Observe form of *to make proper

respiratory distsress. intervention.

* Obtain sputum *to verify

specimen before appropriateness of
antimicrobial the intervention.
treatment is given.
 NURSING CARE PLAN
SUDENTS NAME:RICHARD B. TANUCO
AREA: CHH 7B
PATINTS NAME: Dela Cruz, Grace R.
ROOM/BED NO.: 755
AGE: 43
STATUS: MARRIED
DIAGNOSIS:Follicular adenoma at the right thyroid

CUES NURSING SCIENTIFIC BASIS GOAL AND NURSING RATIONALE OF EVALUATION

ACTION OUTCOME ACTIONS AND NURSING ORDERS
CRITERIA ORDERS

SUBJECTI Risk for Altered epidermis. After 8 hours of INDEPENDENT: GOAL MET:
VE : impaired skin Due to the surgical nursing * Identify underlying *to assess causative Client response to
integrity operation done, skin intervention the condition involved. factor. interventions/ teaching
“Katol related to integrity impaired as a client will be able and action performed.
man ang tissue trauma surgical site for the to: *note location of * this can be the
akong as evidence procedure. surgical procedures reason of the GOAL PARTIALLY
samad.”, by GOAL problem. MET:
as thyroidectom ( nurse's pocket guide, * Display timely attainment/ progress
verbalized y. 9th edition, page 368) healing of the skin *Obtain history of *to asses extent of toward desired
by the lesion. condition including injury. outcomes.
client age at onset.
*follow prescribed GOAL NOT MET:
OBJECTI pharmacological * palpate skin lesion *to be able to
VES: regimen. for size, shape, recognize the modify client plan of
consistency and existence of the care.
* OUTCOME texture. injury.
Disruption CRITERIA
of the skin *monitor vital signs. * to have the baseline
surface. *Maintain optimal of client status.
*invasion nutrition physical
of body well-being. *Ascertain attitudes *Identifies areas to
structure. of individual about be addressed during
*Participate in the condition. patient teaching.
prevention and
treatment program.
*Verbalize feeling
of self-esteem and
ability to mange DEPENDENT
situation.
*observe non -verbal * observation may/
cues. may not be
congruent to what
client verbalized.

*Note the presence *skin is particularly

of compromises important avenue of
vision, hearing or communication for
speech. the people and when
compromised.

* monitor vital signs * to note progress of

the client.

*Keep the area clean *to assist body's

and dry, carefully natural process of
dress wound and repair.
support incision site.

* evaluate pain *to ave baseline of

behavior. treatment given to
client.

*review clients * maybe exaggerated

expectations versus because client
reality. perception pain is not
believed or because
client believes
caregiver as
discriminating report.
COLLABORATIVE

*Use appropriate *to reduce pressure

padding devices. and enhance
*Provide comfort circulation.
measures

*encourage use of *timely intervention

relaxation exercises is more likely to be
such as deep successful in
breathing and alleviating pain.
focused breathing.

*Review procedures * to provide non

and tell client when pharmacological pain
treatment will hurt. management.

*Encourage early *to promote

ambulation. circulation and
* Administer reduces risk
analgesics as associated with
indicated to maximal immobility.
dosage as needed.

* Assist client to *to reduce concerns

alter drug regimen, of the unknown and
based on individual associated muscle
needs. tension.
*to comfort the
client.