Pertainent Data

8/14/2019 Pertainent Data

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PERTAINENT DATASUDENTS NAME:RICHARD B. TANUCO

AREA: CHH 7B

PATINTS NAME: Dela Cruz, Grace R.

ROOM/BED NO.: 755

AGE: 43

STATUS: MARRIEDDIAGNOSIS:Follicular adenoma at the right thyroid

CLINICAL PORTRAIT PERTINENT DATA

ASSESMENT:Received client lying in bed awake, coherent,

conscious with an ongoing ivf of #4 of DLR 1L @

120cc/hr, attached at the right hand and infusingwell.

SIGNIFICANT FINDINGS:

Client was complaining of difficulty in swallowing

and boy malaise.

VITAL SIGNS DURING FIRST CONTACT:

Temperature: 36.8*c

Pulse Rate: 64 bpm

Respiratory Rate: 15 cpmBlood Pressure: 90/60 mmHg

HISTORY OF PRESENT ILLNESS

Client has anterior neck mass 3 yrs. prior to admission; onset of anteriormass noted approximated one by one mass, movable, soft. Consulted a

physician in Thailand, thyroid part taken, given medications with poorcompliance. 2yrs prior to admission, follow-up is done in Thailand. FNAMdone shared cystic mass thyroid. A month prior to admission, follow-updone, advised FNAB which shared follicular neoplasm, thyroid positivedysphagia.

Two weeks prior to admission noted dry cough, given amoxicillin forone week.

CHIEF COMPLAINT:

dysphagia an body malaise.

Vital signs during admission:

Temperature: 36.5*CPulse Rate: 62 bpm

Respiratory Rate: 13 cpmBlood Pressure: 90/80 mmHg

LABORATORY REPORTS:


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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 LEVELOF T1.

ULTRASOUND

MINIMALLY ENLARGED MANDIBULAR LYMPH

NODES.

IMMUNOLOGY REPORT

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


3/18

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

NE

0.6 0.6-1.5 MG/DL

Na serum 140 134.0-143 MMOL/L

K 3.8 3.3-5.3 MMOL/L

SEROLOGY REPORT: O+


4/18

HEMATOLOGY

CBC: LEVEL REFERENCE

WBC 6.80 4.8-10.810^3/ML

RBC 4.39 4.2-5.410^6/ML

HEMOGLOBIN 13.0 120-160 O2/DL

HEMATOCRIT 38.4 37.0-47.0 %

PLATELET 322 120-40010^3/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%


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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%


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7/18

NURSING CARE PLANSUDENTS NAME:RICHARD B. TANUCO

AREA: CHH 7B


ROOM/BED NO.: 755

AGE: 43

STATUS: MARRIEDDIAGNOSIS:Follicular adenoma at the right thyroid

CUES NURSINGACTION

SCIENTIFIC BASIS GOAL AND

OUTCOME

CRITERIA

NURSING

ACTIONS AND

ORDERS

RATIONALE OF

NURSING ORDERS

EVALUATION

SUBJECTI

VE :

SAKIT

AKONG

LIOG, asverbalized

by the

client

OBJECTI

VES:

*

Expressive

behavior

*Restlesnes

s

* Painscale is 7

out of 10

as 1

indicates

no pain

and 10

severe

Acute Pain

related to

tissue trauma

as evidence

by post

surgicaloperation.

Unpleasant sensory and

emotional experience

arising from actual or

potential tissue damage

or described in terms of

such damage,

sudden or slow onset of

any intensity from mild

t severe with ananticipated or

predictable end and a

duration of less than 6

mos.

( nurse's pocket guide,

9

th

edition, page 368)

After 8 hours of

nursing

intervention the

client will be able

to:

GOAL

* report pain is

relieved/

controlled.*follow prescribed

pharmacological

regimen.

OUTCOME

CRITERIA

*verbalized method

that provide relief,

* demonstrate useof relaxation skills

and divisional

activity as

indicated for

individual

situation.

INDEPENDENT:

* perform a

comprehensive

assessment of pain to

include location,

characteristics,onset/duration,

frequency, quality,

severity and

peripheral factors.

*note location of

surgical procedures

*assess clientperceptions, along

with behavioral and

physiologic changes.* note clients focus

of control [internal

or external]

*perform an

*to note the affected

area and to know

proper intervention

can applied.

* this can be

influence of

postoperative pain

experienced.

*note clients attitudetowards pain and use

of specific

medications.*individual with

external focus of

control may take

little or no

responsibilities for

pain management.

* to rule out

GOAL MET:

Client response to

interventions/ teaching

and action performed.

GOAL PARTIALLYMET:

attainment/ progress

toward desired

outcomes.

GOAL NOT MET:

modify client plan of

care.


8/18

pain. assessment such as

time pain occurs.

Note the changes

from previous report

*accept clientdescription of pain

*note cultural and

developmental

influences affecting

pan response.

DEPENDENT

*observe non -verbal

cues.

*asses for referred

pan as appropriate

* monitor vital signs

*ascertain client's

knowledge of and

about pain

management.

* review clientsprevious experience

to pain and method

found either helpful

or unhelpful for

control of pain in the

worsening of

underlying condition/

development of

complication.

*pain is a subjective

experience andcannot be felt by

others.

* verbal/ behavioral

cues may have no

direct relationship to

the pain perceived.

* observation may/may not be

congruent to what

client verbalized.

*to help determined

possibility of

underlying condition

or organ dysfunctionrequiring treatment.

* usually altered by

acute pain.

*to valuate clientresponse to pain.

*to ave baseline of

treatment given toclient.


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past.

* evaluate pain

behavior.

*review clients

expectations versus

reality.

COLLABORATIVE

*work with client to

prevent pain. Useflow sheet to

document the pain,

therapeutic

interventions,

response and length

of time.

*Provide comfortmeasures.(back-

rub,changes in

position)

*encourage use of

relaxation exercisessuch as deep

breathing and

focused breathing.

*Review procedures

and tell client whentreatment will hurt.

*Suggest SO's

during the

procedures.

* maybe exaggerated

because client

perception pain is notbelieved or because

client believes

caregiver asdiscriminating report.

*because pain may

not be resolved but

can be lessen.

*timely intervention

is more likely to be

successful in

alleviating pain.

* to provide non

pharmacological pain

management.

*to assist client to

explore methods of

alleviation of pain.

*to reduce concerns

of the unknown and

associated muscle

tension.*to comfort the

client.

*to maintain

acceptable level of


10/18

* Administer

analgesics as

indicated to maximal

dosage as needed.

* Assist client to

alter drug regimen,

based on individual

needs.

pain. Notify the

physician if regimen

is inadequate to onset

pain control goal.

*increasing/decrea

sing dosage ,

stepped program(switching from

injection to oralroute, increased

time span as pain

lessens).


11/18


AREA: CHH 7B


ROOM/BED NO.: 755

AGE: 43

STATUS: MARRIED

DIAGNOSIS:Follicular adenoma at the right thyroid

CUES NURSINGACTION


OUTCOME

CRITERIA

NURSING

ACTIONS AND

ORDERS

RATIONALE OF

NURSING ORDERS

EVALUATION

SUBJECTIV

E :

Naglisod

man ko ug

ginhawa,as verbalized

by the client

OBJECTIVES:

> orthopnea

> ineffective

cough

> difficulty

in vocalizing

Ineffective airway

clearance related

to laryngeal

spasm.

Inability of the client

to clear secretions or

obstruction from

respiratory tract to

maintain airway.

After 8 hours of

nursing intervention

the client will be able

to:

GOAL* Maintain airway

patency.

OUTCOMECRITERIA

*demonstrate

reduction of

congestion with

breath sounds clear.

*Verbalizeunderstanding of

causes and

therapeuticmanagement

regimen.

INDEPENDENT:

* Position head mid

line with flexion

appropriate for

condition.

*note location of

surgical procedures

*assess client

perceptions, along

with behavioral and

physiologic changes.

* Suction oral asneeded

*Elevate head of the

bead and change

position every 2

hours.

* monitr vital signs

*to open airway in at

rest.

* this can be

influence of

postoperative.

*note clients attitude

towards pain and use

of specific

medications.

*to clear secretionthat blocks the

airway.

* to take advantageon gravity decreasing

pressure on the

diaphragm..

* to know the

progress of clients

status.

GOAL MET:

Client response to

interventions/

teaching and

action performed.

GOAL

PARTIALLY

MET:

attainment/progress toward

desired outcomes.

GOAL NOT

MET:

modify client planof care.


12/18

* keep environment

free from allergens.

DEPENDENT

*observe non -verbalcues.

*Encourage deep

breathing exercise

and coughing

exercise.

* administer

analgesic prn.

*Encourage warm

versus cold liquids as

appropriate.

Management.

* Providesupplemental

humidification.

* Discourage use of

oil based productsaround the nose.

COLLABORATIVE

* Auscultate breath

sounds

* to minimize

causative factor.

* observation may/may not be

congruent to what

client verbalized.

*to maximize effort

made by the client.

* to improve cough

when pain is

inhibiting effort.

*decreases

bronchospasm.

*to enhance clientbreathing pattern.

*To prevent

aspiration in thelungs.

* To ascertain client

progress.


13/18

*encourage use of

relaxation exercises

such as deep

breathing andfocused breathing.

*Review proceduresand tell client when

treatment will hurt.

*Suggest SO's during

the procedures.

*Observe form of

respiratory distsress.

* Obtain sputum

specimen before

antimicrobial

treatment is given.

*to assist client to

explore methods of

alleviation of pain in

coughing.

*to reduce concernsof the unknown and

associated muscle

tension.

*to comfort the

client.

*to make proper

intervention.

*to verify

appropriateness ofthe intervention.


14/18


15/18


AREA: CHH 7B


ROOM/BED NO.: 755

AGE: 43

STATUS: MARRIED

DIAGNOSIS:Follicular adenoma at the right thyroid

CUES NURSINGACTION


OUTCOME

CRITERIA

NURSING

ACTIONS AND

ORDERS

RATIONALE OF

NURSING ORDERS

EVALUATION

SUBJECTI

VE :

Katol

man ang

akongsamad.,

as

verbalized

by theclient

OBJECTI

VES:

*

Disruption

of the skin

surface.

*invasionof body

structure.

Risk for

impaired skin

integrity

related to

tissue trauma

as evidenceby

thyroidectom

y.

Altered epidermis.

Due to the surgical

operation done, skin

integrity impaired as a

surgical site for the

procedure.

( nurse's pocket guide,

9th edition, page 368)

After 8 hours of

nursing

intervention the

client will be able

to:

GOAL

* Display timely

healing of the skin

lesion.

*follow prescribed

pharmacological

regimen.

OUTCOME

CRITERIA

*Maintain optimal

nutrition physicalwell-being.

*Participate in

prevention and

treatment program.

INDEPENDENT:

* Identify underlying

condition involved.

*note location of

surgical procedures

*Obtain history of

condition includingage at onset.

* palpate skin lesion

for size, shape,

consistency and

texture.

*monitor vital signs.

*Ascertain attitudes

of individual about

the condition.

*to assess causative

factor.

* this can be the

reason of theproblem.

*to asses extent of

injury.

*to be able to

recognize the

existence of the

injury.

* to have the baseline

of client status.

*Identifies areas to

be addressed during

patient teaching.

GOAL MET:

Client response to

interventions/ teaching

and action performed.

GOAL PARTIALLYMET:

attainment/ progress

toward desired

outcomes.

GOAL NOT MET:

modify client plan of

care.


16/18

*Verbalize feeling

of self-esteem and

ability to mange

situation.

DEPENDENT

*observe non -verbal

cues.

*Note the presence

of compromises

vision, hearing or

speech.

* monitor vital signs

*Keep the area clean

and dry, carefully

dress wound and

support incision site.

* evaluate pain

behavior.

*review clients

expectations versus

reality.

* observation may/

may not be

congruent to whatclient verbalized.

*skin is particularly

important avenue of

communication for

the people and when

compromised.

* to note progress of

the client.

*to assist body's

natural process of

repair.

*to ave baseline of

treatment given toclient.

* maybe exaggerated

because client

perception pain is notbelieved or because

client believes

caregiver as

discriminating report.


17/18

COLLABORATIVE

*Use appropriate

padding devices.

*Provide comfortmeasures

*encourage use of

relaxation exercises

such as deep

breathing andfocused breathing.

*Review procedures

and tell client when

treatment will hurt.

*Encourage early

ambulation.

* Administer

analgesics asindicated to maximal

dosage as needed.

* Assist client to

alter drug regimen,

based on individual

needs.

*to reduce pressure

and enhance

circulation.

*timely intervention

is more likely to be

successful in

alleviating pain.

* to provide non

pharmacological pain

management.

*to promote

circulation and

reduces risk

associated withimmobility.

*to reduce concerns

of the unknown and

associated muscle

tension.

*to comfort theclient.


18/18

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