Goiter (1)

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    HEALTH HISTORY

    I. BIOGRAPHIC DATA

    Name: Teresita Dacles

    Address: #165 A. Luna St. Barangay Salapan, City of San Juan, Metro Manila

    Age: 63 years old

    Gender: Female

    Dateof Birth: April 21, 1958

    Place of Birth: Cantanduanes

    Primary Language: Tagalog

    Marital Status: Separated

    Educational: Elementary Graduate

    Occupation: Laundry woman

    Religious Orientation: Roman Catholic

    II. PAST HEALTH HISTORY

    Though the client had complete immunizations during her childhood years, she still

    suffered from many childhood diseases such as measles, chicken pox, and mumps. During the

    interview, the client mentioned that she was allergic to foods such chicken, egg, sea foods,

    and eggplants. She said that she also experienced allergic reactions when she dyed her hair

    during her middle age years. Mouth sores and rashes were some of the manifestations that

    could be seen whenever she has allergic reactions. Other than those that have mentionedearlier, there were no other foods or drugs that cause allergy to the client. Her physician

    prescribed Anthraquinone Glycosides Salicylic Acid when she once had an allergy, and from

    then on, she kept on using it whenever an allergy occurs. The client was currently taking

    Metformin Hydrocloride as maintenance for Diabetes Mellitus. Aside from the maintenance,

    she was also taking vitamin B-complex because her physician said that it would improve her

    arthritis. The client had never been hospitalized and she did not suffer from any injuries or

    accidents even in her childhood days up to now, although she had been diagnosed to have

    UTI last 2010. The client added that she has been cured without taking medications by just

    increasing water intake and drinking buko juice frequently. She had neither local nor foreign

    travels in the past month; however, she came home to Bicol where her relatives lived last

    May 2011.

    III. FAMILY HEALTH HISTORY

    Both sides of the clients parents had history of asthma. It was passed to four of her

    siblings. Fortunately, she was not one of them. Her mother died due to heart attack at the age

    of 75, while her father was still alive, but diagnosed to have asthma. Their family did not

    have any history of hypertension, renal diseases, cardiovascular diseases, mental disorders,

    cancer and diabetes mellitus or thyroid disorders; however, she was diagnosed to have

    diabetes mellitus type II and goiter. One of her siblings died because of asthma attack, while

    the other one died due to lung cancer.

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    IV. FUNCTIONAL PATTERNS

    D. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

    The client verbalized that her health is good, because she can do her activities of dailyliving without difficulties and she also does not get sick easily. She had been visiting her

    physician every three months for her check-up, and she strictly follows whatever the

    physicians orders are. Whenever she experiences dizziness and head ache, she just takes a

    rest until she feels better, and if not relieved, she takes Biogesic. She has not been taking any

    over-the-counter drugs except for Biogesic. She has been diagnosed to have sporadic goiter

    when she was carrying her fourth child in her womb (1988), but even after her pregnancy, she

    does not have any plans of undergoing any procedures. She verbalized, natakot akong

    magpaopera kasi yung pinsan ko nagkaroon din ng goiter, pinaopera niya. Pagkalipas ng

    tatlong buwan, bumalik din yung goiter niya. The client also verbalized, Pinainom naman

    na ako nung doktor ko ng pampaliit ng bukol, eh lumiit naman sya, kaya binale-wala ko na.

    As for her exercise, she has been doing the household chores everyday and every 4:00 a.m.,

    she sweeps the street in front of the store of her daughter. She takes a bath twice a day, and

    brushes her teeth thrice a day. She does not visit a dentist for dental check-ups, because she

    does not have time to do so. She does neither cigarette smoking nor drinking any alcohol

    beverages.

    ANALYSIS: Health-Perception-health Management patterns are influential in moving

    individuals, families, and communities toward their optimal level of human functioning. The

    two dimensions of this pattern interact: the way clients perceive their general health and

    health goals influences their health management practices. [Nursing Diagnosis p. 141]

    E. NUTRITIONAL & METABOLIC PATTERN

    According to the client, she eats 3 meals a day and she takes her food slowly because

    she is having a slight difficulty in swallowing because of the mass in her throat. The dishes

    that she usually eats are made up of vegetables, since her physician advised her not to eat somuch meats, legumes and sweets, as well as eggs due to her arthritis, goiter, diabetes mellitus

    and allergies. She drinks a cup of coffee for about once a day and 3-4 glasses of water per

    day. The client experienced neither weight loss nor weight gain as much as her appetite is

    neither increased nor decreased.

    ANALYSIS: Diagnosis describing dysfunctional nutritional-metabolic patterns are bio

    psychosocial conditions related to nutrient intake and supply. Nutrients are necessary for

    cellular metabolic processes, such as energy production and synthesis of substances used incellular function, growth and repair. Nutritional patterns are influenced by (1) Maturation,

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    (2) Family, Social and Cultural patterns, (3) Learned psychological associations between

    food and basic needs, (4) Environmental availability of foods. For example: as growth and

    maturation proceed, the type of foods ingested, method of ingestion, and the social

    psychological milieu of eating changes. Bottles and high chairs are replaced by family

    silverware and social dining. Bio Psychosocial factors (including cultural and spiritual) canlead to dysfunctional patterns, such as exogenous obesity and nutritional deficit. [Nursing

    Diagnosis p. 143]

    F. ELIMINATION PATTERN

    The client defecates once a day, and she added, Okay naman yung dumi ko, hindi

    naman matigas, hindi rin matubig. Sakto lang. Hindi naman ako nahihirapan dumumi. As

    she estimated the number of times she urinates a day, she said four to six, and as she

    verbalized, Hindi naman mapusyaw, yung normal na kulay lang, hindi naman madilaw na

    madilaw ang ihi ko. Hindi naman din masakit pag umihi. She does not have excess

    perspiration and odor problems.

    ANALYSIS: Elimination from the urinary tract helps to rid the body of waste products and

    materials that exceed bodily needs. Problem involving urinary elimination can be so

    embarrassing to patients that they may no longer participate in activities outside the home.

    [Taylor p. 1289]

    Elimination of the waste products of digestion is a natural process critical for human

    functioning. Patients differ widely in their expectations about bowel elimination, their usual

    pattern of defecation, and the ease with which they speak of bowel problems although most

    people have experienced minor acute bouts of diarrhea or constipation, some patient

    experienced severe or chronic alterations in bowel elimination that affect their fluid and

    electrolyte balance, hydration, nutritional status, skin integrity, comfort, and self-concept.

    Moreover, many illnesses, diagnostic tests, medications, and surgical treatments can affect

    bowel elimination. [Taylor p. 1337]

    G. ACTIVITY- EXERCISE PATTERN

    Every 4:00 a.m., she sweeps the street in front of the store of her daughter and she

    helps in the store whenever there are many costumers. She also has a work, where she does

    the laundry three times a week and during her free days, she washes her and her daughters

    clothes. She does household chores for exercise. She does not engage with heavy work orexercise because of her goiter, she added, Masakit kasi kapag nagbubuhat ako ng mabigat o

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    di naman kayay kapag napapagod ako. Alam mo yung parang nakakasakal yung bara sa

    lalamunan. She is satisfied with the amount of her exercise that she has been doing because

    she can do her work properly. Whenever she has a spare time, she spends it helping her

    daughter in managing their store and in taking care of her grandchild.

    ANALYSIS: The clients pattern of activity, exercise and leisure is a result of bio

    psychosocial factors. The pattern describes the clients ability and desire to engage with

    energy-consuming activities, such as play (child), work, exercise, self-care, and leisure.

    Ability is influenced by the development of coordination, strength, skill, endurance, and

    nutrients supply to tissues (cardiovascular and respiratory reserve). Loss of ability to engage

    in activities of daily living is associated with feelings of dependency and lack of control over

    the immediate environment. The desire to do energy-consuming activities and the choice of

    activities are influenced by psychological and socio-environmental factors such as

    motivation, mood state, and personal perception of benefits, risks, skill, and social

    acceptability. [Nursing Diagnosis p.146]

    H. SLEEP-REST PATTERN

    She usually sleeps at 9:00 p.m. and wakes up at 4:00 a.m. She often has seven hours

    of sleep and when she wakes up, she feels refreshed. She can easily fall asleep. Sometimes,

    the sleeping pattern of the client is disturbed