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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 because of the barks of dogs outside her house,

and also when she feels the urge to void. More often than not, she has difficulty in going backto sleep, but eventually, she will sleep again. She takes a nap sometimes if there is chance.

ANALYSIS: Sleep is a basic human need; it is a universal biological process common to all

people. Humans spend about one-third of their lives as sleep. Sleep enhances daytime

functioning. It is vital not only optimal psychological functioning but also physiological

functioning as the rate of healing of damaged tissue is greatest during sleep. [p.1164 Kozier]

I. COGNITIVE-PERCEPTUAL PATTERN

While the interaction is going on, our client is cooperating well and she is confident

during the interview. She stated that she can read and write. However, she can only read

well with the use of her correction glasses. The client does not have any problem in

listening, speaking, and smelling.

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ANALYSIS: Pertaining to the mental processes of knowing, perceiving, or being aware; an

expression of intellectual capacity. In the case of our patient, she is educated and is actively

participating in her school activities. She is very much aware of her cognitive condition. A

patient with enough knowledge with her health situation is better than those who do not

know. Collaborating with any health care provider will help a lot in his restoration ofwellness. [Nursing Diagnosis p.150-151]

J . SELF-PERCEPTION AND SELF-CONCEPT PATTERNS

She described herself as a happy and jolly person, and she feels good most of the

time. She is not having a hard time in socializing with her family members and friends. She

added, Okay naman, tingin ko naman, wala naman akong kaaway. She handles her

problems lightly, and like what she said, Binabalewala ko na lang yung problema, lalo lang

nakakatanda. Matanda na nga ako, iisipin ko pa ba yun? \

ANALYSIS: Self-concept is ones mental image of oneself. A positive self-concept is

essential to a persons mental and physical health. Individuals with a relationship and resist

psychological illness. [Kozier p.970]

K. ROLE- RELATIONSHIP PATTERN

She lives with her sister, youngest daughter and son-in-law. She takes care of her

youngest daughter who is pregnant. They have a good relationship with each other. The only

problem that she encountered in her relationships was when she and her husband separated

ten years ago because her husband had an affair with other woman. She also considers her

son, as mentioned above, a problem whenever he comes home drunk. She is not a member of

any social groups in their community, but she has a good relationship with her neighbours.

ANALYSIS:People establish relationships to meet the human need for contact andinteraction with others. Role and Relationship serves as a structure for family units,

friendships, works and play, community group and society. Dysfunctional patterns of role

performance, interactions, and relationship can be the source of developmental problems or

role stress in persons, families for communities. [ND 154}

L. SEXUALITY-REPRODUCTIVE PATTERN

Her first menstruation started when she was 18 years of age. She had regular

menstruation before, until the age of 59 when she got menopaused. Since when she had

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separation from her husband, she never had any other affair and any sexual activity from then

on up to the present.

ANALYSIS: Sexuality is degree to which a person exhibits and experiences maleness orfemaleness physically, emotionally and mentally. Sexuality is define not only by the persons

genitalia but also by attitudes and feelings. It can also be define as learned behaviours in

how a person reacts to his or her own sexuality and by how one behaves in relationships with

others. Sexuality is an integral part of a persons identity and is present in ones demeanor

through actions, communications, and physical appearance. [Taylor p.931]

M. COPING-STRESS TOLERANCE PATTERN

She feels happy most of the time, but if she feels stressed, she usually talks to her

sister about her problems. She is not taking any medicines to cope with her stress; she only

takes a rest. If she feels angry, she screams to release her feelings and emotions.

N. VALUE-BELIEF PATTERN

The client has a very strong faith with God. Even though she is busy, she always finds

time to pray at night and in the morning and attend mass every Sunday. Like what she said,

Dapat unahin ang Diyos, higit sa kung ano pa man. Aside from that, she also takes care ofherself well because she believes that Health is wealth.

ANALYSIS: Values, beliefs, goals and life commitments guide the choices made by a person,

family, or community; they can influence the evaluation of situations in terms of personal

meaning. Thus, values, beliefs, goals and commitments can explain why a situation may be

stressful for one patient and not other and why one person is highly motivated in a situation

and another is not. [Nursing Diagnosis p.160]

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Institute of Nursing

Nursing Care Plan

CUES NURSING DIAGNOSIS ANALYSIS GOAL AND OBJECTIVE INTERVENTION R

Subjective:

She does not have any plans

of undergoing any

procedures. She verbalized,

natakot akong magpaoperakasi 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.

She does not engage with

heavy work or exercise

because of her goiter, she

added, Masakit kasi kapag

nagbubuhat ako ng mabigat

o di naman kayay kapag

napapagod ako. Alam mo

yung parang nakakasakal

yung bara sa lalamunan.

Deficient Knowledge

related to Disease

Process and Treatment

Regimen

Deficient knowledge is

the absence or

deficiency of cognitive

information related to

specific topic or lack of

specific informationnecessary for clients to

make informed choices

regarding condition,

treatment, and/or

lifestyle changes.

(Nurses Pocket Guide,

12th edition, p.495)

GOAL:

After 1 day of nursing

intervention, the client will

have adequate knowledge

regarding disease processand treatment regimen as

evidenced by verbalization

of understanding of

condition, disease process

and treatment.

OBJECTIVES:

a. After 10 minutes ofdiscussion, the client willbe able to define theconditiona nd nature ofsporadic goiter in her ownwords and understanding.

b. After 10 minutes ofdiscussion, the client willbe albe to enumerate atleast 3 out of 5 signs andsymptoms of a personhaving sporadic goiter.

c. After 10 minutes ofdiscussion, the client willbe able to understand andexplain pathophysiology ofsporadic goiiter in her ownwords.

d. After 10 minutes ofdiscussion, the client willbe able to enumerate 3out 5 management ofclients with sporadic

Developmental;

Independent

a. Discuss the definition of

Sporadic Goiter.

b. Discuss the signs and

symptoms that can be

manifested in a person

having a Sporadic Goiter.

c. Discuss the

pathophysiology of

Sporadic Goiter.

d. Discuss the possible

management for clients

with Sporadic Goiter.

To incre

of knowl

sporadic

of compmeeting

indepen

A well in

better ab

distressi

Provides

developi

identifyin

needs.

Knowled

factors e

to begin

that may

disease.

This fulfil

deficit an

with info

care.

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goiter.

e. After the 8-hour shift

duty in the community, the

client will start to apply the

learned managements in

her daily life, as

manifested by:

-verbalization of

willingness to seek

medical advice concerning

her goiter

-allotment of time for

appointment with a

physician for a check-up

-physicians prescription or

lab results (if possible)

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V. PHYSICAL ASSESSMENT

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Normal Findings Actual Findings Remarks

BEHAVIOR

Height Proportionate,

varies with

lifestyle

411 ft. Normal

Weight Proportionate,

varies with

lifestyle

48 kgs. Normal

BMI Normal 18.6 to

22.9

19.5 Normal

MEASUREMENTS

Body temperature

Pulse rate 120mmHg/

80mmHg

120mmHg/

80mmHg

Normal

Respiratory rate 12-20cpm 14cpm Normal

Blood pressure 60-100bpm 83pbm Normal

A. Describe theclients body built,

height and weight in

relation to clients

age, lifestyle and

behavior

Proportionatevaries with her age

and lifestyle

Proportionatevaries with her age

and lifestyle

Normal

B. Describe the

clients posture and

gait, standing, sitting

and walking

Relaxed and erect

posture,

coordinated

movements

Relaxed and erect

posture,

coordinated

movements

Normal

C. Describe the

clients overall

hygiene and

grooming

Clean and neat

appearance and

well-groomed

Clean and neat

appearance and

well-groomed

Normal

D. Describe the body

and breath odor

No body and

breath odor

No body and

breath odor

Normal

E. Identify the signs

of distress, in posture

or facial expression

No signs of

distress noted

No signs of

distress noted

Normal

F. Describe obvious

signs of health or

illness

Healthy

appearance

Healthy

appearance

Normal

G. Describe the

clients attitude

Coherent,

conscious

Coherent,

conscious

Normal

H. Describe clients

affect or mood;

assess the

appropriateness ofthe clients response

Appropriate to the

situation

Appropriate to the

situation

Normal

I. Describe quantity

and quality of speech

Understandable

and moderate

pace, exhibits

thoughts

association

Understandable

and moderate

pace, exhibits

thoughts

association

Normal

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INTEGUMENTARY

Skin

Inspect for color,

uniformity of color

Generally,

uniform except

in areas exposedto the sun; areas

lighter

pigmentation

(palms, lips, nail

beds) in dark

skinned people.

( Kozier pg. 579)

Generally,

uniform except

in areas exposedto the sun; areas

lighter

pigmentation

(palms, lips, nail

beds) in dark

skinned people.

Normal

Inspect for presence

of edema

No presence of

edema( Kozier pg. 579)

No presence of

edema

Normal

Inspect for lesions

according to location,

distribution, color,

configuration, size,

shape, type structure

No lesions or

abrasion; Flat

and raised nevi

( Kozier pg. 579)

No lesions or

abrasion; Flat

and raised nevi

Normal

Palpate skin moisture Moisture in skin

folds and axillae

( Kozier pg. 579)

Skin on

extremities is dry

Abnormal

Palpate skin

temperature

Uniform; with

normal range

( Kozier pg. 579)

Uniform; with

normal range

Normal

Palpate skin turgor When pinched,

skin brings back

to previous state

( Kozier pg. 579)

When pinched,

skin brings back

to previous state

Normal

Nails

Inspect fingernail

plate shape to

determine its

curvature and angle

Convex

curvature; angle

of nail plate is

about 160

degrees

( Kozier pg. 583)

Slightly spoon

nail in shape

Abnormal

Inspect fingernail and

toenail bed color

Highly vascular

and pink in light

skinned clients;

dark skinned

clients may have

Highly vascular

and pink in light

skinned clients;

dark skinned

clients may have

Normal

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brown or black

pigmentation in

longitudinal

streaks

( Kozier pg. 583)

brown or black

pigmentation in

longitudinal

streaks

Palpate fingernail and

toenail texture

Smooth texture

( Kozier pg. 583)

Rough Texture Abnormal

Inspect tissues

surrounding nails

Intact epidermis

( Kozier pg. 583)

Hard skin Abnormal

Perform blanch test

capillary refill

Prompt return in

pink or usual

color

( Kozier pg. 583)

Prompt return in

pink or usual

color

Normal

HEAD TO TOE EXAMINATION

HEAD

Skull

Inspect the skull

for size, shape or

symmetry

Rounded, smooth

skull contour

( Kozier pg. 585)

Rounded, smooth

skull contour

Normal

Palpates fornodules, masses

and depressions

Smooth, uniformconsistency;

Absence of

nodules or masses

( Kozier pg. 585)

Smooth, uniformconsistency;

Absence of

nodules or masses

Normal

Scalp

Inspect for color

and appearance

White in color; no

dandruff

( Kozier pg. 582)

White in color; no

dandruff

Normal

Palpate for areas of

tenderness

No tenderness,

nodules, masses

and edema

( Kozier pg. 582)

No tenderness,

nodules, masses

and edema

Normal

Hair

Inspect for

evenness of

growth, thickness

or thinness

Evenly distributed

hair; thick hair

( Kozier pg. 582)

Evenly distributed

hair; white, thin

hair

Abnormal

Palpate for texture

and oiliness over

Silky; Resilient

hair

Silky; Resilient

hair

Normal

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the scalp ( Kozier pg. 582)

Face

Inspect the facial

features, symmetry

of facial

movements

Symmetric or

slightly

asymmetrical

features;

symmetrical facial

movements

( Kozier pg. 585)

Assymetrical

involuntary facial

movements/ facial

tremors

Abnormal

Eyes

Visual acuity

Test near vision Able to read

newsprint

( Kozier pg. 588-

593)

Able to read

newsprint

Normal

Test distance

vision

20/20 vision on

Snellen Chart

( Kozier pg. 588-

593)

500 lens grade Abnormal

Eyebrows

Inspect for hair

distribution,

alignment, skinand quality

movement

Hair evenly

distributed; skin

intact, eyebrowssymmetrically

aligned; equal

movement

( Kozier pg. 588-

593)

Hair evenly

distributed; skin

intact, eyebrowssymmetrically

aligned; equal

movement

Normal

Eyelids

Inspect for the

surfacecharacteristics,

position in relation

to the cornea,

ability to blink;

and frequency of

blinking

Skin intact; no

discharge; nodiscoloration; lids

close

symmetrically;

approximately 15-

20 involuntary

blinks per minute;

bilateral blinking;

when lids are

open no visiblesclera above

Skin intact; no

discharge; nodiscoloration; lids

close

symmetrically; 15

involuntary

involuntary blinks

per minute;

bilateral blinking;

when lids are

open no visiblesclera above

Normal

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cornea, and upper

and lower borders

of cornea are

slightly covered

( Kozier pg. 588-593)

cornea, and upper

and lower borders

of cornea are

slightly covered

Conjunctiva

Inspect the bulbar

for color, texture,

and presence of

lesions

Transparent

capillaries

sometimes

evident; sclera

appears white

(yellowish in darkskinned clients)

( Kozier pg. 588-

593)

Pale bulbar

conjunctiva

Abnormal

Inspect the

palpebral

conjunctiva for

color, texture, and

presence of lesions

Pinkish or red in

color with

presence of

capillaries; moist;

no foreign bodies

( Kozier pg. 588-

593)

Pale palpevral

conjunctiva

Abnormal

Lacrimal gland,

lacrimal sac and

nasolacrimal duct

Inspect and palpate

the lacrimal gland

No edema nor

tenderness over

lacrimal duct; no

tearing

( Kozier pg. 588-

593)

No edema nor

tenderness over

lacrimal duct; no

tearing

Normal

Sclera

Inspect the color

and clarity

White; darker or

yellowish with

small brown

macules in dark-

skinned clients

( Kozier pg. 588-

593)

White; darker or

yellowish with

small brown

macules in dark-

skinned clients

Normal

CorneaInspect for clarity Transparent; Transparent; Normal

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and texture shiny; smooth;

details of the iris

are visible

( Kozier pg. 588-

593)

shiny; smooth;

details of the iris

are visible

Iris

Inspect for shape

and color

Round; color

depends on the

persons face

( Kozier pg. 588-

593)

Round; color

depends on the

persons face

Normal

Pupils

Inspect color,shape and

symmetry of size

Black; equal insize; normally 3-

7mm in diameter;

round; smooth

border

( Kozier pg. 588-

593)

Black; equal insize; normally 3-

7mm in diameter;

round; smooth

border

Normal

Test each pupil for

light reaction and

accommodation

Pupils constrict

when looking at

near objects;

pupils dilate when

looking at far

objects; pupils

converge when

near object is

moved towards

the nose

( Kozier pg. 588-

593)

Pupils constrict

when looking at

near objects;

pupils dilate when

looking at far

objects; pupils

converge when

near object is

moved towards

the nose

Normal

Extra ocular

Muscles

Test each eye for

alignment and

coordination

Both eyes are

coordinated;

move in unison,

with parallel

alignment

( Kozier pg. 588-

593)

Both eyes are

coordinated;

move in unison,

with parallel

alignment

Normal

Visual Fields

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Test peripheral

fields

When looking

straight ahead.

The client can see

object in

periphery( Kozier pg. 588-

593)

When looking

straight ahead.

The client can see

object in

periphery

Normal

EARS

Auricles

Inspect for color,

symmetry and

position

Color same as

facial skin;

symmetrical;auricle aligned

with outer canthus

of eye, about 10

degree from

vertical

( Kozier pg. 596-

598)

Color same as

facial skin;

symmetrical;auricle aligned

with outer canthus

of eye, about 10

degree from

vertical

Normal

Palpate for texture,

elasticity and are of

tenderness

Mobile; Elastic:

firm and not

tender: Pinna

recoils back after it

is folded

( Kozier pg. 596-

598)

Mobile; Elastic:

firm and not

tender: Pinna

recoils back after

it is folded

Normal

External Ear

canal

Inspect ear canal

for cerumen, skin

lesion, pus and

blood

Distal third

contains hair

follicle and glands;

(cerumen-grayish

tan in color)

( Kozier pg. 596-

598)

Distal third

contains hair

follicle and

glands; (cerumen-

grayish

Normal

Hearing acuity

test

Assess clients

response to normal

voice tones

Normal voice tones

audible

( Kozier pg. 596-598)

Normal voice

tones audible

Normal

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Perform watch tick

test

Able to hear a

ticking in both ears

( Kozier pg. 596-

598)

Able to hear a

ticking in both

ears

Normal

Perform Weberstest

Sounds are heardin both ears or is

localized at the

center of the head;

Weber(-)

( Kozier pg. 596-

598

Sounds are heardin both ears

Abnormal

Conduct Rinnes

test

Air conducted

hearing is greater

than boneconducted hearing;

Rinne (+)

( Kozier pg. 596-

598)

AC=BC Abnormal

NOSE

Inspect for any

deviations, shape,

size or color and

flaring or discharge

from nerves

Symmetric; No

dicharge; no flarin;

uniform color

( Kozier pg. 600)

Symmetric; No

dicharge; no

flarin; uniform

color

Normal

Inspect the nasal

cavities for the

presence of

redness, swelling,

growths and

discharge, using

the penlight

Mucosa pink;

clear; watery; no

discharge; no

lesions

( Kozier pg. 600)

Mucosa pink;

clear; watery; no

discharge; no

lesions

Normal

Inspect the nasal

septum betweennasal chambers

Nasal septum intact

and in midline( Kozier pg. 600)

Nasal septum

intact and inmidline

Normal

Test patency of

both nasal cavities

Air moves freely as

the client breathes

through the nares

( Kozier pg. 600)

Air moves freely

as the client

breathes through

the nares

Normal

Palpate for any

tenderness, masses,displacements of

No tenderness; no

lesion( Kozier pg. 600)

No tenderness; no

lesion

Normal

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bone and cartilage

SINUSES

Locate/Palpate/iden

tify the sinuses and

note for tenderness

No tenderness

( Kozier pg. 600)

No tenderness Normal

MOUTH

Lips

Inspect for

symmetry of

contour, color, and

texture

Uniform pink

color; moist; soft;

glistening; elastic

texture

( Kozier pg. 602-

604)

Purplish in color Abnormal

Buccal MucosaInspect for color,

moisture, texture

and presence of

lesions

Uniform pink

color, moist; soft:

glistening; elastic

texture

( Kozier pg. 602-

604)

Slightly dry Abnormal

Teeth

Inspect for color,

number, andcondition and

presence of

dentures

32 adult teeth;

smooth, white;shiny tooth enamel

( Kozier pg. 602-

604)

10 lower teeth & 6

upper teeth,2 dental carrie

son the lower

premolars

Abnormal

Gums

Inspect for the

color and condition

Pink gums; moist,

firm texture to

gums

( Kozier pg. 602-

604)

Pink gums; moist,

firm texture to

gums

Normal

Tongue/floor of

the mouth

Inspect for color

and texture of the

mouth floor and

frenulum

Pink color; moist;

slightly rough;

presence of whitish

coating; can moves

freely; no

tenderness

( Kozier pg. 602-

604)

Pink color; moist;

slightly rough;

presence of

whitish coating;

can moves freely;

no tenderness.

Normal

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Inspect and palpate

the position, color,

and texture,

movement and base

of the tongue

Central position;

pinkish in color;

slightly rough;

moves freely; no

area of tenderness( Kozier pg. 602-

604)

Central position;

pinkish in color;

slightly rough;

moves freely; no

area of tenderness

Normal

Palpate for any

nodules, lumps or

excoriated areas

Slightly rough; no

palpable nodules,

lumps or

excoriated areas

( Kozier pg. 602-

604)

Slightly rough; no

palpable nodules,

lumps or

excoriated areas

Normal

Palates and uvula

Inspect and palpate

for color, shape,

texture and the

presence of bony

prominences

Pink palate; hard

palate; smooth and

soft; more irregular

texture

(Kozier p.602-604)

Pink palate; hard

palate; smooth and

soft; more

irregular texture

Normal

Inspect for position

of the uvula and

mobility while

examining the

palates

Positioned in

midline of soft

palate

(Kozier p.602-604)

Positioned in

midline of soft

palate

Normal

Oropharynx and

tonsils

Inspect and palpate

for color and

texture

Pink and smooth

posterior wall

(Kozier p.602-604)

Pink and smooth

posterior wall

Normal

Inspect the size of

the tonsils, color

and discharge

Pink and smooth;

no discharge;

normal size

(Kozier p.602-604)

Pink and smooth;

no discharge;

normal size

Normal

Presence of gag

reflex upon

stimulation of the

uvula and lower

back of the tongue

Presence of gag

reflex

(Kozier p.602-604)

Absence of gag

reflux upon

stimulation

Abnormal

NECK AND

LYMPH NODES

Inspect the neck Muscles equal in Muscles not equal Abnormal

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muscles for

abnormal swellings

or masses.

size; head centered

(Kozier p.607-610)

in size

Lymph nodes

Locate/palpate/identify lymph nodes

and note for

tenderness

Not palpable(Kozier p.602-604)

Palpable mass Abnormal

Trachea

Inspect and palpate

for placement

Central placement

in midline of neck

are equal on both

sides

(Kozier p.602-604)

Central placement

in midline of neck

are equal on both

sides

Normal

Thyroid gland

Inspect symmetry

and visible masses

Not visible on

inspection

(Kozier p.602-604)

Visible on

inspection

Abnormal

Palpate for

smoothness and

areas of

enlargement,

masses or nodules

Lobes may not be

palpated. If

palpable lobes,

they are small,

smooth centrallylocated, painless

and rise freely with

swallowing

(Kozier p.602-604)

Palpable lobes,

they are small, and

smooth. Palpable

mass is

approximately5cm in height. Its

more prominent

on the RIGHT

side of the neck.

Abnormal

THORAX

Posterior Thorax

Inspect the spinal

alignment

Spine vertically

aligned

(Kozier p.615-618)

Spine vertically

aligned

Normal

Palpate for

temperature,

tenderness, and

masses

Uniform

temperature; no

tenderness; no

masses

(Kozier p.615-618)

Uniform

temperature; no

tenderness; no

masses

Normal

Assess respiratory

excursion

Full and

symmetric chest

expansion; thumbs

separate 3-5 cm (1

to 2 inches)

Full and

symmetric chest

expansion; thumbs

separate 3-5 cm (1

to 2 inches)

Normal

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(Kozier p.615-618)

Palpate vocal

fremitus

Bilateral symmetry

of vocal fremitus;

fremitus is heard

most clearly in theapex of the lungs

(Kozier p.615-618)

Bilateral

symmetry of vocal

fremitus; fremitus

is heard mostclearly in the apex

of the lungs

Normal

Auscultate the

posterior thorax

Bronchial,

vesicular and

bronchovesicular

breath sounds

(Kozier p.615-618)

Bronchial,

vesicular and

bronchovesicular

breath sounds

Normal

Anterior ThoraxInspect breathing

patterns

Quiet, rhythmic

and effortless

respiration

(inspiration and

expiration)

(Kozier p.615-618)

Quiet, rhythmic

and effortless

respiration

(inspiration and

expiration)

Normal

Palpate for

temperature,

tenderness, and

masses

Warm uniform

temperature; No

tenderness; no

masses

(Kozier p.615-618)

Warm uniform

temperature; No

tenderness; no

masses

Normal

Palpate vocal

fremitus

Same as the

posterior vocal

fremitus; fremitus

is normally

decreased over

heart and breast

tissue.

(Kozier p.615-618)

Same as the

posterior vocal

fremitus; fremitus

is normally

decreased over

heart and breast

tissue.

Normal

Auscultate the

trachea

Bronchial (tubular)

breath sounds

(Kozier p.615-618)

Bronchial

(tubular) breath

sounds

Normal

Auscultate the

anterior thorax

Bronchovesicular

and vesicular

breath sounds

(Kozier p.615-618)

Bronchovesicular

and vesicular

breath sounds

Normal

JUGULARVEINS

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Inspect Jugular

veins

Veins not visible

(Kozier p.615-618)

Normal

MUSCULOSKEL

ETAL SYSTEM

Musclesa. Inspect the

muscles for size.

Compare the

muscles on the side

of the body (arm,

thigh, calf) to the

same muscle on the

other side

Equal size on both

side of the body

(Kozier p.646-651)

Equal size on both

side of the body

Normal

b. Inspect themuscle and tendons

for contractures

(shortening)

No contractures(Kozier p.646-651) No contractures Normal

c. Inspect the

muscles for

fasciculations and

tremors. Inspect

any tremors of the

hands and arms out

in front of the body

No fasciculations

(Kozier p.646-651)

Presence of fine

tremors

Abnormal

d. Palpate muscle

tonicity

Firm

(Kozier p.646-651)

Firm Normal

Bones

a. Inspect the

skeleton for normal

structures and

deformities

No deformities

(Kozier p.646-651)

No deformities Normal

3. Joints

a. Inspect joints for

swelling

No swelling

(Kozier p.646-651)

No swelling Normal

ASSESS JOINT

RANGE OF

MOTION

c. Upper

extremities

(shoulder and

scapula)

Smooth coordinate

movements

(Kozier p.646-651)

Smooth coordinate

movements

Normal

d. Upper Smooth coordinate Smooth coordinate Normal

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extremities

(elbows)

movements

(Kozier p.646-651)

movements

e. Upper

extremities (hands)

Smooth coordinate

movements

(Kozier p.646-651)

Smooth coordinate

movements

Normal

f. Lower

extremities

(acetabulum or

inguinal area)

Smooth coordinate

movements

(Kozier p.646-651)

Smooth coordinate

movements

Normal

g. Lower

extremities

(popliteal)

Smooth coordinate

movements

(Kozier p.646-651)

Smooth coordinate

movements

Normal

h. Lower

extremities (ankles)

Smooth coordinate

movements(Kozier p.646-651)

Smooth coordinate

movements

Normal

VI. PROBLEM IDENTIFICATION

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CLUSTERED DATA NURSING DIAGNOSIS

Subjective:

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.

She does not engage with heavy work or

exercise because of her goiter, she added,

Masakit kasi kapag nagbubuhat ako ng

mabigat o di naman kayay kapag napapagod

ako. Alam mo yung parang nakakasakalyung bara sa lalamunan.

Deficient Knowledge related to Disease

Process and Treatment Regimen

Subjective:

She had been visiting her physician every

three months for her check-up, and she strictly

follows whatever the physicians orders are.

The dishes that she usually eats are made up of

vegetables, since her physician advised her not

to eat so much meats, legumes and sweets, as

well as eggs due to her arthritis, goiter,diabetes mellitus and allergies.

She takes a nap sometimes if there is chance.

She is not taking any medicines to cope with

her stress; she only takes a rest.

Readiness for Enhanced Comfort related to

Presence of Mass in Neck

Subjective:

Pinainom naman na ako nung doktor ko ng

pampaliit ng bukol, eh lumiit naman sya,

kaya binale-wala ko na.

According to the client, she eats 3 times a day

and she takes her food slowly because she is

having a slight difficulty in swallowing

because of the mass in her throat.

Masakit kasi kapag nagbubuhat ako ng

mabigat o di naman kayay kapag napapagod

ako. Alam mo yung parang nakakasakal

yung bara sa lalamunan.

Objective:

The thyroid gland is prominently visible on

inspection, palpable and has visible pulsation.

The palpable mass is 3.5cm in diameter by

estimation.

Risk for Aspiration

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Far Eastern UniversityInstitute of Nursing

PROBLEM PRIORITIZATION

Health Problem Rank JustificationDeficient Knowledgerelated to DiseaseProcess and TreatmentRegimen

1 - Teaching the clientregarding his healthis very importantbecause deficientknowledge has asignificant impact on

clients ability tomake effective

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decisions and topartner with hishealth careproviders in hishealth care. It is a

health threat thatcan lead to poorerhealth outcomes.(Black, 8th Edition,

p.7)

Readiness for EnhancedComfort related toPresence of Mass in Neck

2 - It is essential thatthe nurse validatesthat the behavior ofinterest is one theclient truly wants tochange. Readiness

to change should beassessed early in thenurse-clientinteraction. It is awellness state thatallows the individualto have a betterhealth if givenenough attentionand health teaching.(Black, 8th Edition,

p.7)

Risk for Aspiration 3 - Risk identificationand riskmanagementcounseling canprevent illness andinjury. It is a healththreat that maycontribute to theoccurrence ofcomplications if not

supervised by ahealth care provider.(Black, 8th Edition,p.16)

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