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.

http://www.wisegeek.com/what-is-metabolism.htm

http://www.wisegeek.com/how-can-i-avoid-weight-gain.htm

http://www.wisegeek.com/what-is-a-colloid.htm

http://www.wisegeek.com/what-is-the-esophagus.htm

http://www.wisegeek.com/what-is-the-thyroid.htm

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 age—when 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: ADRAddress: Taal, Bocaue, BulacanBirth date: June 26, 1961Age: 51 y/oGender: FemaleMarital Status: MarriedOccupation: “Labandera” Laundry MaidReligious Orientation: CatholicEducational Background: Highschool GraduateAdmitting Diagnosis: Multiple Colloid Adenomatous GoiterFinal Diagnosis: Multiple Colloid Adenomatous GoiterAdmission Date: July 4, 2012Admission Time: 10:05amDischarge Date: July 11, 2012Discharge 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 doesn’t have any allergies to any drugs, foods or any environmental factors (dust, smoke, or pollen). When she feels sick she doesn’t buy any over-the-counter drugs and doesn’t 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

SVFJR

52, CVA

NBF

CVA

EVF

60, VA

MA

58, ?

DVF

?

MS

65, RA

AD

60, ?BE

60, ?

ADR

51,RA

LEGEND

- Client VA- vehicular accident

- MCAG ?- unknown

Interpretation:

She can’t remember her grandfather and grandmother in both sides because when she was a child they transferred from Bataan to Manila. She didn’t have a chance to know them. Her mother and father died because cardiovascular accident. She can’t remember her mother and father’s 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)

LEGEND

- Client VA- vehicular accident

- MCAG ?- unknown

FUNCTIONAL HEALTH PATTERN PRIOR DURING

HHealth Perception/ Health Management Pattern 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 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 July 2, 2012 July 3,2012Breakfast2 pcs. of pandesal200ml of coffee

Breakfast2 pcs. pandesal200ml of coffee

Breakfast1 cup fried rice1 pc. Medium size of hotdog200cc cup coffee

Lunch1/2 cup of rice1 pc. Medium size of fried chicken500ml of water

Lunch1 cup of rice1 pc medium sized fried tilapia250 ml of water

Lunch500ml of water1 cup of rice1 med-sized ofInihaw na bangus

Dinner1 cup of rice1 saucer of ginisang gulay250ml of water

Dinner1/2 cup of rice2 pcs small sized longanissa500 ml of water

Dinner250cc of water1/2 cup of rice1 saucer of Adobong manok

Client ADR doesn’t have any food allergies. She loves to eat chicken and drinks 6-7glasses of water.

July 4,2012

July 5,2012 July 6,2012

NPO NPO NPO

NPO NPO NPO

NPO NPO NPO

After the surgery our client is NPO as the doctors order.

EElimination Pattern Urine

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.

Our client is in Foley catheter. 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_grooming_0_bathing _0_general mobility_0_toileting _0_cooking_0_bed mobility _0_home maintenance_0_dressing _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 careLevel I- Requires use of equipments/ deviceLevel II- Requires assistance or supervision

July 1,2012

July 2,2012

July 3,2012

Frequency

6 5 6

Amount

1200ml 1000ml 1200ml

Characteristics

Aromatic in odor, amber in

color

Aromatic in odor, amber in color

Aromatic in odor, amber

in color

July 1,2012

July 2,2012

July 3,2012

Frequency 1 1 1Characteristics

Formed,Brown, pungent

odor

Formed, Brown, pungent odor

Formed, Brown,

pungent odor

July 4,2012

July 5,2012

July 6,2012

Frequency

FC FC FC

Amount

1560ml 1500ml 1800ml

Characteristics

Aromatic in odor, amber in

color

Aromatic in odor, amber in color

Aromatic in odor, amber

in color

July 4,2012

July 5,2012

July 6,2012

Frequency

1 1 1

Characteristics

Formed,Brown, pungent

odor

Formed, Brown, pungent odor

Formed, Brown,

pungent odor

Level 0- Full self careLevel I- Requires use of equipments/ deviceLevel II- Requires assistance or supervision Level III- Requires assistance or supervision from another person/ deviceLevel IV- is dependent and does not participate

Level III- Requires assistance or supervision from another person/ deviceLevel IV- is dependent and does not participate

SSleep- Rest PatternThe patient sleeps 7-8 hours a day. She wakes up around 4 am to do her daily routine. She can’t take a nap in the afternoon because of her work. She also stated that she usually sleeps around 8-9pm in the evening with the lights turned off.

During her stay in the hospital, she wasn’t able to have enough rest and sleep. She sleeps only for approximately 8hours intermittently.

CCognitive Perceptual PatternShe 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 doesn’t wear glasses and contact lenses.

Our client experience blurring of vision. Every time she get bored he always pray.

SSelf Perception and Self concept Pattern 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 doesn’t feel insecurities about her looks she is still contended.

RRole Relationship PatternThe 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

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.

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 don’t used any contraceptives. She’s not taking any pills.

She doesn’t experienced menstrual cycle because she is already a menopause.

CCoping stress tolerance PatternWhen she’s stress she just listen to soft music while folding clothes and doing household chores.

She’s a bit irritated with noise in the hospital but instead of being angry she just keep ignoring them as much she can.

VValues Beliefs PatternShe is a Roman Catholic. They regularly attend mass and they always have an open communication with God.

Her religion doesn’t affect herself when she was at the hospital. She always pray during bedtime.

IV. GROWTH AND DEVELOPMENT

FREUD’S THEORY OF DEVELOPMENT

ERICKSON’S STAGES OF

DEVELOPMENT

PIAGET’S THEORY OF COGNITIVE DEVELOPMENT

KOHLBERG’S THEORY OF MORAL

DEVELOPMENT

FOWLER’S THEORY OF SPIRITUAL

DEVELOPMENT

STAGES Genital Stage

Age Range: Puberty to Death

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)

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

Conjunctive

DEFINITIONThis 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 self-indulge, 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 husband’s 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 body’s 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:

http://www.endocrineweb.com/conditions/thyroid/your-thyroid-gland

http://en.wikipedia.org/wiki/Thyronamine

http://en.wikipedia.org/wiki/Iodothyronamine

http://en.wikipedia.org/wiki/Decarboxylation

http://en.wikipedia.org/wiki/Deiodinase

http://en.wikipedia.org/wiki/Cell_(biology)

http://en.wikipedia.org/wiki/Goitre

http://en.wikipedia.org/wiki/Thyroid

http://en.wikipedia.org/wiki/Iodine

http://en.wikipedia.org/wiki/Thyroid_gland

http://en.wikipedia.org/wiki/Hormone

http://en.wikipedia.org/wiki/Tyrosine

http://en.wikipedia.org/wiki/Triiodothyronine

http://en.wikipedia.org/wiki/Thyroxine

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

Melanocyte–stimulating 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.

http://en.wikipedia.org/wiki/Melanocyte-stimulating_hormone

http://en.wikipedia.org/wiki/Melanotrope

http://en.wikipedia.org/wiki/Follicle-stimulating_hormone

http://en.wikipedia.org/wiki/Luteinizing_hormone

http://en.wikipedia.org/wiki/Gonadotroph

http://en.wikipedia.org/wiki/Pituitary_gland#cite_note-Melmed2010-3

http://en.wikipedia.org/wiki/Prolactin

http://en.wikipedia.org/wiki/Lactotroph

http://en.wikipedia.org/wiki/Pituitary_gland#cite_note-2

http://en.wikipedia.org/wiki/Beta-endorphin

http://en.wikipedia.org/wiki/Adrenocorticotropic_hormone

http://en.wikipedia.org/wiki/Corticotropin

http://en.wikipedia.org/wiki/Thyroid-stimulating_hormone

http://en.wikipedia.org/wiki/Thyroid-stimulating_hormone

http://en.wikipedia.org/wiki/Human_growth_hormone

http://en.wikipedia.org/wiki/Somatotroph

VI. PATIENT AND HER ILLNESS

A. PATHOPHYSIOLOGY

Modifiable Factor Non-modifiable Factor

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

Diet Female

Decrease circulating thyroid hormones

Accumulation of nonfunctional tissue

Overinvoluted

Thyroid Function Test (June 20, 2012):FT4 = 0.6 ng/dlTSH = 0.4 uIu/mlDecrease T3 and T4 levelFollicular involution

Reaccumulation of colloid

Age: 51 y/o

Insufficient iodine intake

Compensatory hyperplasia

Release of estrogen

Altered GI motility and tone

Excessive production of thyroid-binding globulinDecrease in thyroid hormone synthesis

Decrease metabolism

Acculmulation of mucopolysaccharide in larynx

Stimulates production of TSH


FNAB (June 20, 2012):FINAL HISTOPATHOLOGIC DX: Cell findings consistent with colloid nodule with cystic degeneration. Background chronic lympocytic thyroiditis.

Hoarseness of voice

Diffusely enlarged gland

Presence of distortion and pressure at vascular network

Release of EGF, FGF and IGF

Difficulty in swallowing

Infarction and degeneration present

Fibrosis develops

Nodularity of gland

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. Cell proliferation and

colloid accumulation

B. PHYSICAL ASSESSMENT

Name: Mrs. A.D.R Date Assessed: July 9, 2012

Age: 51 y/o

VITAL SIGNS:

BP: 120/80mmHg PR: 64bpm

RR: 21cpm TEMP: 35.5 C

GENERAL APPEARANCE

Methods Normal Findings Actual Findings Remarks

1. Body Built

Height: 5’1’’

Weight: 47 kg

Inspection and observation ( By getting the weight and

height of the patient to determine the BMI )

Proportionate

Normal BMI: 18.5-24.9

Underweight

BMI:19.5

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

Inspection and observation Clean and neat The patient is clean and neat. Normal

4. Attitude and mood Inspection and observation Appropriate to situation and cooperative

The patient is cooperative during the assessment, and her responses are appropriate to the situation.

Normal

5. Speech quality Inspection and observation Understandable, moderate pace, exhibits through association.

Clear and understandable. Normal

6. Describe body and

breath odor

Smelling No body and breath odor The patient has body odor and breath odor.

Deviation from normal due to present illness.

7. Identify signs of distress

in posture or facial

expression

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.

8. Identify obvious signs of Inspection Healthy appearance Slightly weak in appearance. Deviation from normal due to pain felt located at the


illnessmidline of the neck.

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

Normal

INTEGUMENTARY

.SKINMethods Normal Findings Actual Findings Remarks

1. Color Inspection Color- varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive.

The patient's skin is light brown color, uniform in color except in areas that are exposed to the sun.

Normal

2. Edema Inspection and palpation No edema No edema Normal

3. Lesions Inspection No lesions, has birthmarks, freckles

Presence of lesion that is light brown in color(lower extremities and lower lip); moles ( face,arm, neck ).has lesion in the neck.

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

Moisture in skin folds and the axilla

Moisture in skin folds and the axilla

Normal

5. Temperature and skin

turgor

Palpation Uniform; within normal range. The patient's skin temperature is uniform; when pinched, the skin springs back quickly to previous state.

Normal

NAILS

1. Fingernail plate shapeInspection Convex curvature, angle of

nail plate is approximately 160

Convex curvature, angle of nail plate is approximately 160

Normal

2. Color Inspection Highly vascular and pinkish in color

Pinkish in color Normal

3. Toenail and fingernail

texture

Inspection and palpation Smooth texture Smooth in texture Normal

4. Tissue surrounding nails Inspection Intact epidermis The patient's nails are intact to the skin.

Normal

5. Capillary refill Inspection and palpation Prompt return o pink or usual color within 3 seconds

The color return to usual within 3 seconds.

Normal


HEAD

SKULL

1. ShapeInspection Rounded; smooth skull contour Rounded, smooth – looking skull

contour.Normal

2. Presence of nodules,

masses and depressions.

Palpation Smooth, uniform, consistency; absence of nodules and masses.

Smooth with absence of nodules and masses.

Normal

3. Evenness and thinness/

thickness of hair

Inspection and palpation Hair evenly distributed

Thick hair

Hair are evenly distributed, thick hair

Normal

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.

FACE

1. Facial features Inspection Symmetric or slightly asymmetric facial features

The patient's face is symmetrical in facial features.

Normal

2. Symmetry of facial movements.

Inspection Symmetric facial movements. Facial movements are symmetrical. Normal

EYES


EYEBROWS

1. Hair distribution Inspection Hair evenly distributed Hair evenly distributed. Normal

2.Alignment Inspection by asking the patient to raise and lower the eyebrows.

Symmetrically aligned Eyebrows are symmetrically aligned.

Normal

3. Skin quality and movements

Inspection Intact skin , equal movements Intact skin , equal movements Normal

EYELASHES

1. Evenness of hair Inspection Hair is equally distributed Hair is equally distributed Normal

2. Direction of curl Inspection Curl is slightly outward Curl is slightly outward Normal

EYELIDS

1. Surface characteristics Inspection Skin intact, no discharge and discoloration.

The patient's eyelids are intact to the skin, no discharge.

Normal

2. Frequency of blinking Inspection Approximately 15 – 20 involuntary blinks per minute

Approximately 15 – 20 involuntary blinks per minute

Normal

CONJUNCTIVA

BULBAR CONJUNCTIVA

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

Transparent, capillaries sometimes evident, no presence of lesions

Transparent, no presence of lesions.

Normal

PALPEBRAL CONJUNCTIVA

1.Color, texture, and presence of lesions.

Inspection, by everting the eyelids

Shiny, smooth, pink or red in color

Pink in color, smooth and shiny. Normal

SCLERA

1. Color Inspection Sclera appears white The patient's sclera is white in color.

Normal

CORNEA

2. Clarity and texture Inspection using a penlight. Transparent, shiny and smooth. Transparent, shiny and smooth. Normal


PUPIL

1. Color, shape and symmetry of size .

Inspection Black in color; round, smooth border, iris flat and round.

Black in color, round, smooth border; the iris is flat and round.

Normal

2. Test each pupil for light reaction and accommodation.

Inspection Pupils constrict when looking at near objects; pupils dilate when looking at far object; pupils converged when near object is moved toward nose.

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.

Normal

VISUAL ACUITY

1. Test near vision With the use of newspaper or magazine note if the patient was able to read the sentences.

Able to read news print NOT DONE

2. Test distant vision Use a snellen chart 20/20 vision on Snellen chart NOT DONE

VISUAL FIELD

1. Test peripheral vision. Assess peripheral visual field to determine function of the retina and the neuronal visual pathways to the brain and second cranial nerve.

When looking straight ahead, client can see objects in the periphery.

NOT DONE

EARSAURICLES

1.Color,symmetry of size Inspection for color,symmetry of size, and position. To inspect position, note the level at which the superior aspect of the auricles attaches to the head in relation to the eye.

Color as same as the facial skin, symmetrical, auricle aligned with the outer canthus of the eye.

Same color with the facial skin, symmetrical.

Normal

2. Texture, elasticity and Palpation by gently pulling the Mobile, firm and not tender Mobile, firm and not tender. Normal


areas of tenderness. auricle upward then backward and folding the pinna.

Pinna recoils after being folded.

3. Inspect external ear canal for cerumen, skin lesions, pus and blood.

Inspection Dry cerumen, grayish color; or sticky, wet in various shades of brown.

Dry cerumen, grayish color; or sticky, wet in various shades of brown.

Normal

HEARING ACUITY TEST

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.

Normal voice tones audible. Normal voice tones audible Normal

2. Perform the watch tick test.

( Perform by placing a wrist watch near the ear. )

Able hearing ticking in both ears.

NOT DONE

3. Perform Weber's test. ( 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 )

Sound is heard in both ears or is localized at the center of the head.

NOT DONE

4. Perform Rinne's test ( 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.)

Air conducted hearing is greater than bone – conducted hearing.POSITIVE RINNE: AC>BCNEGATIVE RINNE: AC<BC

NOT DONE

NOSE

1. Inspect external nose for Inspection Symmetric and straight Symmetric and straight Normal


any deviation in shape, size or color and flaring or discharge.

No discharge or flaring, Uniform in color.

No discharge, Uniform in color.

2. Inspect nasal cavities for redness, swelling, growths, and discharge.

Inspection Mucosa pink Clear, watery dischargeNo lesions

Pink color of the mucosa, no lesions

Normal

3. Inspect nasal septum between the nasal chambers.

Inspection Nasal septum intact and in mid line

The patient's nasal septum is intact and in mid line.

Normal

4. Lightly palpate for tenderness masses or any displacement of bone or cartilage.

Palpation No tenderness; no lesions No tenderness noted. Normal

5. Palpate the maxillary and frontal sinuses for tenderness

Palpation Not tender. No tenderness noted. Normal

MOUTH

LIPS AND BUCCAL MUCOSA

1. Outer lips for symmetryof contour, color and

texture.

Inspection Uniform pink in color, soft, moist, smooth texture.

The patient’s lips are uniform pink in color, soft and moist.

Normal

2. Inner lips and buccalmucosa for color,

moisture, texture andpresence of lesions.

Inspection and palpation Uniform pink in color, moist, no lesions.

Uniform in color, no lesions. Normal

TEETH AND GUMS

1. Characteristics Inspection Smooth, white shiny tooth enamel, pink gums with moist,

firm texture.

Yellowish tooth enamel, pink gums with moist.

Deviation from normal due to poor oral hygiene.

2. Tongue movement Inspection Central position; smooth lateral Central in position; no lesions; Normal


margins; no lesions; raised papillae

raised papillae and moves freely.

3. Base of the tongue, floorof the mouth, and

frenulum.

Inspection Smooth base of the tongue with prominent veins.

Smooth base of the tongue with prominent veins.

Normal

4. Presence of nodules, lumps orexcoriated areas.

Inspection and palpation Smooth with no palpable nodules.

When palpated, there are no palpable nodules.

Normal

PALATES AND UVULA

1. Hard and soft palate forshape, texture andpresence of bony

prominences.

Inspection Light pink, smooth soft palate; lighter pink; hard palate; no

bony prominences.

Light pink in color, smooth soft palate and lighter pink hard

palate; no bony prominences.

Normal

2. Uvula position andmobility

Inspection Position in the mid line of the soft palate.

The patient's uvula when inspected was position in mid

line of the soft palate.

Normal

TRACHEA

1. Lateral deviations Palpation Central placement in mid line of neck

The patient trachea is at the central midline of the neck.

Normal

2. Identify lymph nodes and notefor tenderness

Palpation Not palpable The patient’s lymph nodes are palpable

Deviation from normal due to Total Thyroidectomy

THYROID GLAND

1.Symmetry and visible masses Inspection Not visible There are no masses Deviation from normal due to the removal of thyroid gland.

2. Smoothness and areas ofenlargement masses or

nodules.

Palpation Lobes may not be palpated Lobes of the patient are not palpable.

Deviation from normal due to Total Thyroidectomy

CAROTID ARTERIES

1. Carotid artery Palpation Symmetry pulses volumes The pulses volumes of the Normal


carotid arteries of the patient are symmetrical.

JUGULAR VEIN

2. Jugular vein Inspection Veins not visible The patient’s jugular veins are not visible.

Normal

BREAST AND AXILLA

1 Size,symmetry, shape and color Inspection Female: Rounded shape; slightly unequal in size; generally

symmetric.

The patient breasts are rounded and symmetrical

Normal

2. Swelling or edema Inspection No presence of edema The patient’s breast and axilla have no edema.

Normal

3. Areola: size,shape and color Inspection Round or oval in shape, from light pink to dark brown color,

equal in size.

The patient’s areola is round, dark brown in color and equal

in size.

Normal

4. Nipples: size,shape anddischarge

Inspection Round, equal in size, nipples point in the same directions,

similar in color, and normally erect.

The patient’s nipples are equal in size, both pointing

downward, dark brown in color and normally erected.

Normal

5. Masses ad tenderness Inspection for presence of swelling and palpation for

presence of edema.

No tenderness or masses. There is no tenderness and masses on the patient’s breast.

Normal

THORAX

1. Shape and symmetry of thethorax from posterior and lateral

views.

Inspection Antero-posterior to transverse diameter ratio of 1:2.

Antero-posterior thorax of the patient transverse diameter ratio

is 1:2

Normal

2. Breath sounds Auscultation Vesicular and broncho-vesicular breath sounds.

Vesicular and broncho-vesicular breath sounds

Normal

3. Breathing pattern Inspection Rhythmic; effortless. Rhythmic; effortless Normal


ABDOMEN

1. Skin Integrity Inspection Unblemished skin; uniform color; no lesions.

The abdomen is uniform in color no lesion

Normal

2. Contour and symmetry Inspection Flat, rounded or scaphoid; symmetrical.

The patient’s abdomen is flat and symmetric.

Normal

3. Bowel sounds Auscultation Audible bowel sounds The patient’s bowel sound is audible.

Normal

4. Tenderness Palpation May be tender when palpated. There is no tenderness on the patient’s abdomen when

palpated.

Normal

MUSKULOSKELETAL SYSTEM

MUSCLES

1. Size Inspection Equal in both sides of the body. The size of patient’s muscles is equal in both sides of the body.

Normal

2. Tendons Inspection No contractures. There is no contractures on the tendons of the patient.

Normal

3.Tremors Palpation None There is no presence of tremors Normal

BONES

1. Structure and deformities Inspection No deformities and aligned The patient’s bones are aligned and there are no deformities.

Normal

2. Tenderness Palpation No tenderness There is no tenderness of the bones when palpated.

Normal

JOINT

1. Swelling Inspection No pain, no swelling. There is no pain and swelling of the bones when palpated.

Normal

2. Tenderness, smoothness Palpation No pain, smooth The joints of the patient’s have no tenderness and smooth.

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)

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 4-11x10/L

Lymphocytes 0.20-0.40

Monocytes 4-7%

Granulocytes

RBC 3.5 - 5.5 mill/mm3

126 g/L

0.38

6.1x 10/L

0.40

6.9%

42.7%

4.61 m1ll/mm3

\

Normal

Normal

Normal

Normal

Normal

Normal

Normal

PRIOR:

1. Explain to the patient the purpose of the test.

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.


http://labtestsonline.org/understanding/conditions/anemia

MCV 80 - 100 fl

MCH 25.4 - 34.6 pg/cell

MCHC 31 - 36 Hb/cell

RDW 11-15%.

PLT 150,000 - 400,000/mm3

MPV

83fl

27.4 pg/cell

33 Hb/cel

14.9%

256, 000mm3

7.7fL

0.198

Normal

Normal

Normal

Normal

Normal

Normal

Normal

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.

AFTER:

1. Make sure that the specimen bottles are labelled correctly.

2. Put pressure over the puncture site.

3. Inform them that the results will be out as soon as the specimen is interpreted in the laboratory.


7.5-11.5 fL

PCT <0.5

PDW 10.0%–17.9%

14.0%

Normal

URINALYSIS February 12, 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 symptoms of a UTI or other urinary system problem such as kidney disease. Some

Color: straw to yellow

Chemical Exam:

Urobilinogen

Transparency: Clear

Specific gravity: 1.005-1.025

pH 4.5-7.8

Yellow

Normal

Turbid

1.005

7.0 (-)

Normal

Normal

This is an indication of an infection in the urine.

Normal

Normal

PRIOR

1. Inform the mother that there are no food or fluid restrictions before the test.

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,


signs and symptoms may include abdominal pain.

Sugar: (-) Protein (-) Nitrite (-) Leukocytes

Glucose (-) Bilirubin (-) Ketone (-)

Microscopic:

Mucous Thread: None

(-) (-) (+)

(-) (-) (-)

Few

Normal Normal Normal This is an

indication of an infection.

Normal Normal Normal

Normal

refrigerate it.

2. If a 24 – hour urine collection is requested the specimen should be refrigerated or preserved within formalin during the collecting time.

AFTER

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

Color: straw to yellow

Chemical Exam:

Urobilinogen

Transparency: Clear

Yellow

Normal

Turbid

Normal

Normal

This is an indication of an infection in the

PRIOR

3. Inform the mother that there are no food or fluid restrictions before the test.

4. Advise the mother of the procedure and the reason for the test.

DURING


provider complaining of symptoms of a UTI or other urinary system problem such as kidney disease. Some signs and symptoms may include abdominal pain.

Specific gravity: 1.005-1.025

pH 4.5-7.8 Protein (-) Nitrite (-) Leukocytes

Glucose (-) Bilirubin (-) Ketone (-)

Microscopic:

RBC: 0-5/hpf Crystals (-) Amorphous

Urates: Few Epithelial

Cell: Few Bacteria:

None

WBC: 0-4hp

1.005

7.0 (-) (-) (1+)

(-) (-) (-)

3-4/hpf

Few

Few

urine.

Normal

Normal Normal Normal Normal This is an


Normal Normal Normal

Normal

Normal This is an


Indicate the presence of an

3. The specimen should 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.

4. Relay result to the doctor


Mucous Threats

18-25

Few

inflammatory process

Normal

Blood Chemistry Result

Chemistry Results Interpretation Range

July 6, 2012


Biochem Glucose Hexoki

Creatinine Kinetic

Sodium

Potassium

Calcium

Chloride

3.9mmo/L

60.7umo/L

142.3mmol/L

3.5

Normal

Normal

Normal

Normal

3.8-6

35.4-123.8

135-148

3.5-5.3

1.1-1.32

96-107

July 7, 2012

Calcium SI: 1.91Traditional: 7.64

LowThese are also associated with dietary insufficiencies, parathyroid problems,

and intestinal problems

SI: 2.10-2.54Traditional: 8.4-10.2

Laboratory

Procedure

Date Ordered,

Date Result

Indication/Purposes

Components Normal Values Actual Values

Analysis/ Interpretation

Nursing Responsibilities

Thyroid June 20, Blood tests used


Function Tests

2012 to check the function of thyroid.

FT4 ELISA

TSH ELISA

0.8-2.0 ng/dl

0.6-5.0 uIu/ml

1.3

0.76

Within normal range

Within normal range

Prior:

Verify the doctor’s order Identify the client 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.

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

FT4 ELISA

TSH ELISA

0.8-2.0 ng/dl

0.6-5.0 uIu/ml

0.6 ng/dl

0.4 uIu/ml

FT4 ELISA and TSH ELISA are below normal.

Hypothyroidism is present.

Prior:

Verify the doctor’s order Identify the client 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.

After:

Apply pressure using dry cotton ball in the site.

Secure the specimen.

DIAGNOSTIC PROCEDURE

DATE ORDERED, DATE OF RESULT

INDICATION/

PURPOSES

REPORT AND IMPRESSION ANALYSIS/

INTERPRETATION

NURSING RESPONSIBILITIES

(PRIOR,DURING,AFTER)

Thyroid Ultrasound

Date of result: Imaging method used to see the thyroid.

REPORT: There is a poorly defined 5.4 x 4.0 x 3.8

Masses are present in right anterior neck.

Article II.Article III. PRIOR:Article IV. -Check the physician orderArticle V. -Identify the


June 20, 2011

An exam which helps to tell the difference between a sac containing fluid and abnormal tissue growth which may or may not be cancerous.

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.

The left lobe of the thyroid is normal in size measuring 3.5 x 1.2 x 0.9 mass with no nodules appreciated.

The isthmus is not visualized.

IMPRESSION:

Poorly defined anterior neck mass can represent an enlarged multinodular right thyroid or a separate lesion; suggest clinical correlation and/or CT scan of the neck for further evaluation.

clientArticle VI. -Explain procedure to the clientArticle 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 doneArticle 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

DATE ORDERED, DATE

DISCONTINUEDGENERAL DESCRIPTION

INDICATIONS OR PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITIES (prior, during, after)

D5LRS 1L

30gtts/min

Date Ordered:July 4, 2012

Date Discontinued: July 8, 2012

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

Replacement therapyparticularly inextracellular fluiddeficit accompaniedby acidosis.

The client response well with no signs of irritation and adverse reaction.

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 doesn’t need to change the IV fluids to correct an electrolyte problem.

DURING

Start the IV somewhere convenient for


pulled from the interstitial & intracellular compartments into the blood vessel (intravascular space).

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

NAME OF DRUG

DATE ORDERED,

DATE DISCONTINUE

D

ROUTE, DOSAGE,

FREQUENCY

GENERAL DESCRIPTION

INDICATION OR PURPOSE

CLIENTS RESPONSE

NURSING RESPONSIBILITIES(prior, during, after)

RANITIDINE

CLASSIFICATION:

Anti-ulcer agentsHistamine H2 Antagonist


Date Discontinued:July 8, 2012

50 mgTIV q8 once IVF started

Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion

Treatment of heartburn, acidindigestion, sour stomach

Dizziness Drowsiness Headache Nausea/

Vomiting

PRIOR

Assess patient for epigastric or abdominal pain and frank or occult blood in the 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: 30 mg TIV q Inhibits Short term Dizziness PRIOR


CLASSIFICATION:

Nonsteroidal anti-inflammatory agents, nonopioid analagesics

July 5, 2012


6x 4 doses prostaglandin synthesis, producing peripherally mediated analgesia

Also has antipyretic and anti-inflammatory properties.

Therapeutic effect: Decreased pain

management of pain

Headache 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



15gm TIVBactericidal/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.

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,


is used to treat many different types of bacterial infections

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




750mg TIV q8Bactericidal/Antibacterial






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



Date Discontinued:N/A

500mg BID PO Bactericidal/

Antibacterial






PRIOR

Prior to reconstitution, 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 bio-equivalent and not substitutable on a mg-per-mg 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

CLASSIFICATIONS


Date

200mg BID PO

• Decreased pain and inflammation caused by arthiritis• Inhibits the enzyme

• Relief of signs and symptoms of osteoarthritis.• Relief of signs

Headache Dizziness Fatigue

PRIOR

Assess patient’s history of allergic


http://www.drugs.com/mtm/cefuroxime.html

http://www.drugs.com/mtm/cefuroxime.html

Therapeutic: Anti-rheumatics, NSAIDS

Discontinued:N/A

COX-2. This enzyme is required for the synthesis of prostaglandins.• Has analgesic, anti-inflammatory, and antipyretic properties.

and symptoms of rheumatoid arthritis in adults.

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

TYPE OF DIET

DATE ORDERED,

DATE CHANGED,

DATE DISCONTINUED

GENERAL DESCRIPTION

INDICATION/PURPOSES SPECIFIC FOOD TAKEN

CLIENT’S RESPONSE

NURSING RESPONSIBILITIES (prior, during, after)

Nothing per Orem (NPO)

Date Ordered: June 4, 2012

Date Discontinued: June 6, 2012

Nothing per Orem

(NPO)/Nil per

os (alternatively

nihil/non/nulla per

os) (NPO) is a

medical instruction

meaning to withhold

oral food and fluids

from a patient for

various reasons. It is

a Latin phrase which

translates as "nothing

through the mouth".

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 client’s

compliance ability to the

diet.

DURING

Advise the client to

avoid foods.

Provide frequent oral


http://en.wikipedia.org/wiki/Latin

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

Date Discontinued: June 7, 2012

Soft foods include naturally soft, mashed or pureed foods that are easy to swallow. You might eat foods from all major food groups when following a soft diet. Soft grains include dry cereals, refined bread and crackers, plain noodles and white rice. Soft, cooked or canned fruit and

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 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

PorridgeWaterBiscuit (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.


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

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

Date Discontinued: N/A

Only given when the client can tolerate any food she desired that is nutritious, if this will not lead to any complications and it would interfere with any lab test result.

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.

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

GENERAL DESCRIPTION

INDICATION/PURPOSES CLIENT’S 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 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

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 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.

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 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.


lungs of excessive carbon dioxide build-up.

Incentive SpirometerAn 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

Using Incentive Spirometer1. 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 CUES PROBLEM/ NURSING DIAGNOSIS JUSTIFICATION

July 7, 2012 S: Ø

O: > Presence of surgical incision at neck

Impaired skin integrity related to mechanical interruption of muscle tissue as manifested by of surgical incision at neck

To properly aid Patient ADR in achieving optimal healing, reestablishing tissue’s 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.

O- Vital signs:

Bp: 120/80 T: 35.5 PR: 64 RR: 21

Disturbed sleep pattern related to noisy environment.

Disturbed sleep pattern is our second priority as we follow Maslow’s 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.

July 7, 2012 S- Ø

O-Vital signs:

Bp:120/80 T: 35.5

Risk for infection related to inadequate primary defense secondary to thyroidectomy.

Risk for infection is our third priority as we follow Maslow’s Hierarchy of Needs. Safety needs of our client for possible illness problem that he can acquire is really important for his better healing process.


PR: 64 RR: 21

D. NURSING CARE PLAN Impaired Skin Integrity (Nursing Care Plan)

Assessment Diagnosis Planning Intervention Rationale Evaluation

S: Ø Impaired skin integrity related to mechanical

Short Term Goal:

Within 2-3 of nursing ⁰

Independent:

Use of proper dressing - To facilitate wound

Short Term Goal:

After 2-3 of nursing ⁰


O: >Presence of surgical incision at neck (5 in.)

interruption of muscle tissue as manifested by of surgical incision at neck

intervention the client will:

-Verbalize understanding of condition

-Identify and demonstrate interventions appropriate with the condition

-Demonstrate behavior/lifestyle changes to promote healing

Long Term Goal:

Within 2 weeks of nursing intervention, the client will be able to display progressive improvement in wound healing without complications

such as sterile gauze, adhesive and non adhesive films

Use of appropriate antiseptic solution

Promote optimum nutrition with high quality protein and sufficient calories

Instruct the client to increase fluid intake

Instruct client about proper wound care

Encourage adequate rest periods

Promote early mobility; encourage position changes

Assist with

healing and preventing spread of microorganism

- To control formation of bacteria and help in the body’s natural wound healing

- Proper nutrition promotes wound healing

- To promote wound healing

- To promote wound healing

- To limit metabolic demands, maximize energy available for healing

- To prevent excessive tissue

intervention:

_ goal met_ goal partially met

_ goal unmet

Verbalized understanding of condition

Identified and demonstrated interventions appropriate with the condition

Demonstrated behavior/lifestyle changes to promote healing

Long Term Goal:

-Not evaluated


active/passive exercises

Dependent:

- Administer antibiotic, Cefuroxime 500mg PO BID, as ordered

pressure

- To promote circulation

- The drugs may inhibit the formation of bacteria

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation


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 environment.

Short term goal:

Within 6 hours of nursing 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.

Independent

>request only 1visitor per patient.

>ensure patient has electric fan

>instruct relative to provide with comfortable bed linens and pillows.

>to minimize noisy environment.

>to enhance relaxation.

>these may help to enhance sleep patterns in terms of good and conditioned 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

c. patient minimized sleep disrupting factors.

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation


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.

Short term goal:

Within 2 hours of nursing intervention the client will be able to manifest absence of infection through:

a.maintaining V/S within normal range

b.absence signs of infection.

c. maintaining proper hygiene

Long term goal:

Patient will not acquire infection due to inadequate primary defenses throughout hospitalization

Independent

>monitor vital signs

>demonstrate proper handwashing

Dependent

>administer antibiotic as ordered.

>increase in temperature and tachycardia may indicate infection

>handwashing is the first-line of defense from acquiring infections.

>inhibit or kills bacteria that can cause infections.

Within 2 hours of nursing intervention, short goal was met as evidenced by:

a.maintained pulse rate and temperature within normal range. T-36.8PR-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 equipment’s 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 constipation—eat 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 doctor’s 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 client’s 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

Delmar’s Nursing Drug Handbook: George R. Spratto, AdriennE l. Woods, 2010 edition

Nurse’s Pocket Guide: Marilynn E. Doenges, Mary Frances Moorehouse, Alice C. Murr, 11th edition

Hole’s Essential of Human Anatomy and Physiology: David Shier, Jackie Butler, Ricki Lewis, 9th edition

Medical- Surgical Nursing: Brunner and Suddart Vol.2, 12th edition


Thyroidectomy

Documents

pain felt

functional

equally distributed

supervision

parathyroid

facial movements

centered knowledge

hypothalamic