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MANILA TYTANA COLLEGE

FORMERLY MANILA DOCTORS COLLEGE OF NURSING

Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City

Nursing Process Manila Doctors Hospital, Manila

BSN III-A05 (RLE103)

Submitted to:

Jennifer T. Navarro, R.N., MAN

Submitted by:

Group 1

Amacio, Ivy Frances

Canlas, Monique

Ferrer, Danille

Lutrinia, Gloraine Joanne

Date Submitted:January 18, 2012



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MANILA TYTANA COLLEGE

MANILA DOCTORS COLLEGE OF NURSING

Pres. Diosdado Macapagal Blvd., Metropolitan park, Pasay City

NURSING PROCESS

I. ASSESSMENT

A. General Data

Patient’s Initial: C.A.O

Address: Bangalon Daraga, Albay Date of Admission: 01/07/2012

Age: 48y 11m 28d No. of days in this Hospital: 5 days

Sex: Female

Date of Birth: 01/10/1963

Place of Birth: Guionobatan

Civil Status: Married

Occupation: N/A

B. Chief Complaints

Anterior neck mass

C. History of Present Illness

One year prior to admission, patient noted weight loss with associated episodes of

palpitations and easy fatigability. This prompted consult in a local clinic in Bicol where

she was also noted to have anterior neck mass on physical examination. She was givenoral medications (unrecalled) which gave relief of symptoms.

Patient was apparently well until..

One month prior to admission when the patient noted easy fatigability with episodes of

shortness of breath. She also noted increasing size of her abdomen and both lower

extremities. Consult done in a hospital where she was given medications. Patient

decided to seek consult in Manila hence, this admission.

D. History of Past Illness

Childhood Illness/es: N/A

Adult Illness/es:

(+) Hypertension x 8 years (no maintenance of meds given)

(-) DM

(+) Bronchial Asthma: Last attack 2004; no maintenance of meds.

Immunization: Unrecalled

Previous Hospitalization:

Operation/s: S/P EL for Ectopic pregnancy (1989)



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Injuries: N/A

Medication taken prior to confinement (for 6 months): Unrecalled

E. System Reviews

1. Health Perception-Health Management Pattern

The patient rated her health 7 out of 10 (10 being the highest). She does

not have routine physical examination and she does not perform self-breast

examination. The patient stated that “siguro my mga magbabago pagkatapos ko

ma-operahan”. She drinks alcohol occasional but she does not smoke. She does

not have any idea what is the cause of her illness but when she felt something is

wrong, she consulted a physician and medications were given.

2. Nutritional-Metabolic Health Pattern

3-Day Diet RecallSunday Monday Tuesday

Breakfast Scramble egg, 1 cup

of Rice, 1 glass of

water

Hotdog, 1 cup of

Rice, 1 glass of

water

Scamble egg, 1 cup

of Rice, 1 glass of

water

Lunch Fried fish, 1 cup of

Rice, 1 glass of

water

Sinigang na isda, 1

cup of Rice, 1 glass

of water

Tinola, 1 cup of

Rice, 1 glass of

water

Dinner Munggo, 1 cup of Rice, 1 glass of

water

Cream of mushroom, 1 cup of

Rice, 1 glass of

water

Pinakbet, 1 cup of Rice, 1 glass of

water

The patient typical daily food intake is meat and her snack is junk foods.

Her typical fluid intake is soft drinks but drinks also water. According to her, she

lost some weight and she eats but when she swallows the food there is pain.

Before she does not have any kind of diet but now her diet is low salt low fat diet.

3. Elimination Pattern

The patient is not experiencing any discomforts during bowel eliminationand urinary elimination. Her usual stool is brown and hard. She urinates 2-3 times

a day. The color of her urine is yellow and there is no odor. The patient does not

have any body cavity drainage.



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4. Activity-Exercise Pattern

The usual activity of the patient is when she wakes up she takes a bath

then brushes her teeth. She cooks food for the family. During her spare time, she

is sleeping, eating, watching television or reading some magazines. Before the

patient experience shortness of breathe and easily gets tired.

Number

of days

(time)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

6:00 a.m

Wakes up Wakes up Wakes up Wakes up Wakes up Wakes up Wakes u

6:30 a.m

Take a bath Take a bath Take a bath Take a bath Take a bath Take a bath Take a ba

7:00 a.m

Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast Breakfas

8:30 a.m Walking Walking Walking Walking Walking Walking Walking

10a.m

Watch TV Watch TV Watch TV Watch TV Watch TV Watch TV Watch T

10:30

a.m

Cooks lunch Cooks lunch Cooks lunch Cooks lunch Cooks lunch Cooks lunch Cooks lun

11:00

a.m

Lunch Lunch Lunch Lunch Lunch Lunch Attend amass

11:30

a.m

Doing household chores

(Cleaning, washing clothes,etc.)

1:00 p.m Lunch

2:00 p.m

Taking

Rest/Sleep

Taking

Rest/Sleep

Taking

Rest/Sleep

Taking

Rest/Sleep

Taking

Rest/Sleep

Taking

Rest/Sleep

Taking

Rest/Slee

3:00 p.m

Watch T.V/ Watch T.V/ Watch T.V/ Watch T.V/ Watch T.V/ Watch T.V/ Watch T.

6:00 pm Cooksdinner

Cooksdinner

Cooks dinner Cooksdinner

Cooksdinner

Cooksdinner

Cooksdinner

7:00p.m

Dinner Dinner Dinner Dinner Dinner Dinner Dinner

7:30p.mWashing

dishesWashing

dishesWashing

dishesWashing

dishesWashing

dishesWashing

dishesWashing

dishes

9:30 p.m

Watch TV Watch TV Watch TV Watch TV Watch TV Watch TV Watch T

10:00p.m Sleep Sleep Sleep Sleep Sleep Sleep Sleep



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5. Sleep-Rest Pattern

The patient usually sleeps for 8-9 hours and she is satisfied with that.

There are no disturbances when she is sleeping. She does not have a bed routine

and she allows herself to relax if there is time. She experience difficulty of sleeping before she was admitted.

6. Cognitive-Perception Pattern

The patient is able to read and write. Her hearing and vision is good. She

does not experiencing difficulty in her memory. When it comes to decisionmaking she consults her husband for her to decide easily. For her, the easiest way

to learn things is visualization and verbalization.

7. Self - Perception Pattern

According to the client she described herself as “pumanget” and

“pumayat”, she even stated that her skin got darker. Sometimes the patient feels

she just wanted to die because of her condition. She doesn’t easily get irritated butshe did stated that “kapag lang paulit-ulit, nakakainis na.”

Examination (examples of objective data):The patient was a bit distracted. Her voice is hoarse and tuned down. Closed body

posture, gives the impression of detached and uninterested contact.

8. Roles – Relationship Pattern

According to the client she is now living with her husband. Her 4 children

already had their own work and family. She stated that her children were shocked

hearing her condition, but they have to accept the truth. Her husband is still

working and according to the client, her husband’s income is sufficient for their

daily needs.

9. Sexuality – Reproductive Pattern

According to the client she had her first menstrual period when she was in

2nd

year high school (14 years old). Ever since then, she has had regular

menstruations monthly. As the life with her husband, she states that she is

satisfied, “ngayon kasi, hindi na kami nagsesex, parang mag kapatid nalang ang

turing namin sa isa’t-isa.”. As for their family planning, client says that they don’t

use any contraceptives; either natural or artificial. The client’s LMP was last

December 3, 2011.



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10. Coping – Stress Tolerance Pattern

According to the client she is just relaxed since she doesn’t have any

work. If there is a big decision to make, she first consults her husband before

making a decision. Before, she used to drink alcohol, but not too much.

11. Values – Beliefs Pattern

According to the client, she is a Roman Catholic but goes to church rarely.

F. Family Assessment

Name Relation Sex Occupation Educational Attainment

R.A Husband M Employee College Graduate

C.A Son M Employee College Graduate

S.A Daughter F Employee College Graduate

I.A Daughter F Employee College Graduate

B.A Son M Employee College Graduate

G. Heredo

*Family Illness:

(+) Hypertension-Mother

(-) DM

(-) Thyroid diseases

H. Developmental History

Theorist Age Task Patient Description

Erik Erikson 48 years old Generativity vs

Stagnation

The patient cares

about her

environment andsociety. The patient

loves and cares her

family.

Sigmund Freud 48 years old Genital Stage The patient is living

with her husband.They have children.

The patient loves and

cares her family.

Jean Piaget 48 years old Formal Operational

Stage

The patient has no

difficulty inperceiving things.

The patient usually



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does visualizationand verbalization on

learning. She is not

dependent on to

others on doing suchactivities of her daily

life.

Lawrence Kohlberg 48 years old Conventional: Stage

IV

The patient knows

her role to the

community. Shefaces the

consequences and

does her obligationsto her family.

James Fowler 48 years old Stage V: Conjunctive The patient

developed her ownfaith and belief but

goes to church rarely.

She always looksforward to God when

problems arise. She

prays for her familyand others.

I. Physical Examination (date and time)

Height: 5’1 Actual Weight: 135lbs

Actual Height: 5’2 Ideal Body Weight: 118lbs.

Vital Signs:

Temperature: 36.8˚C

PR: 93 beats per min.

RR: 20 breaths per min.

BP: 160/100 mmHg

A. Skin

Inspection: no lesions

no edema

skin color is light brown

skin color is uniform

Palpation:

skin is moist



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B. NailsInspection:

smooth texture

pink in color

C. Head and Face

Inspection:

the client’s head is normocephalic

symmetric facial features

no edema present

with facial grimace

D. EyesInspection:

eyebrows are evenly distributed

no discharges

no discoloration in eyelids

no edema pupils are equal, round

F. Ears

Inspection:

auricle’s color is same as facial color

symmetrical

no lesions

G. Mouth and Pharynx

Inspection:

outer lip is pink in color soft and has the ability to purse her lips

H. NeckInspection:

muscles of the neck are equal

head is in the center

has coordinated movement

dysphagia

Palpation:

negative lymph nodes

I. Thorax/Lungs

Inspection:

Spine vertically aligned with anteroposterior to transverse diameter of ratio 1:2.



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J. Spine

Inspection:

Spinal column is straight, right and left shoulders and hips are at the same height. There

is bilateral symmetry of vocal fremitus. In terms of breathing pattern there is a quiet, rhythmic

and effortless respiration.

Palpation: chest wall is intact

no tenderness or masses

K. ExtremetiesInspection:

both extremities are equal in size

no involuntary movement

can perform complete range of motion

L. Breast

Inspection:

Rounded in shape, slightly unequal in size, generally symmetric. Skin color is uniform and

same with the color of the abdomen. The areola is round and bilaterally the same. Its color is

dark brown. The Nipples are inverted and color is darker than the areola.

M. Abdomen

Inspection:

Has the same color with the body color but it is lighter because of less exposure to sun.

Symmetric in contour

symmetric in movement caused by respiration

Auscultation:

Audible sounds were heard and there are absence of both arterial bruits and friction rub

Palpation:

There is no evidence of enlargement of liver.

There is no tenderness while palpating the abdomen.

N. Genitals

No opportunity. Client reported of discharges coming out of her vagina, but she seems

agitated. Hence, the examiner did not proceed with the assessment.

O. Rectum and Anus

No opportunity.



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II. PERSONAL/ SOCIAL HISTORY

Habits: Watching T.V, Cleaning the house, Sleeping

Vices: none Travel (for the last 6 months only): N/A

Lifestyle:N/A Educational Attainment: College graduate

Social Affiliation: None

Client’s usual day like: The usual activity of the patient is when she wakes up she takes a bath

then brushes her teeth. She cooks food for the family. During her spare time, she is sleeping,

eating, watching television or reading some magazines. Before the patient experience shortness of

breathe and easily gets tired.

III. ENVIRONMENTAL HISTORY

The patient lives in their house in Bongalon Albay, They live in a Bungalow type. It has

approx 4 large windows and 5 doors. They have two comfort room that has water sealed type of

toilet system. Their water supply comes from NAWASA and the water their drinking also came

from NAWASA but was filtered and boiled before drinking to ensure safety for human

consumption. The patient lives in a barangay with clean surroundings, good environmental

sanitation but with open drainage, they practice waste segregation. If vectors occur they use

insecticide and household cleaning.

IV. OB/GYNE HISTORY

Menarche (age): 11 y/0 When: Dec. 3

Amount and Characteristics: consuming about 2 napkins per day.

Duration: 5 days moderateAssociated symptoms:

Deliveries: G_P_ Operations:

OB Score: T_P_A_L_

V. PEDIATRIC HISTORY

(N/A)



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VI. PATHOPHYSIOLOGY

A.) PATHOPHYSIOLOGY OF HYPERTHYROIDISM

(Client-Based)



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B.) PATHOPHYSIOLOGY OF HYPERTHYROIDISM

(Theoretical based)



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VII. LABORATORY RESULT OR FINDINGS

Laboratory Normal Value Result Interpretation

FBS 3.90-5.55 mmol/L 5.10 Normal Level

Cholesterol 0.00-5.20 mmol/L 2.20 Normal Level

Triglycerides 0.00-2.26 mmol/L 0.60 Normal Level

HDL 1.00-1.60 mmol/L 1.00 Normal Level

LDL 0.00-3.90 mmol/L 0.9 Normal Level

Free T3 2.5-5.8 pmol/L 39.27 High Level

- Indicative of hyperthyrodis

m.

Free T4 11.5-23.0 pmol/L 66.27 High Level

- Indicative of

hyperthyrodis

m.

TSH IRMA 0.27-3.75 uIU/ml 0.01 Low Level- Indicative of

hyperthyrodis

m.

Hemoglobin 123.00-153.00 g/L 127 Normal Level

Hematocrit 0.36-0.45 0.37 Normal Level

RBC Count 4.10-5.10 X 10^12L 4.49 Normal Level

WBC Count 4.00-10.50 X 10^9/L 7.51 Normal Level

Basophil 0.00-0.01 0.00 Normal Level

Eosinophil 0.01-0.04 0.05 High Level

- Although it is

above the

normal level,it doesn’t

have anyindication.

Stab 0.02-0.05 0.00 Normal Level

Neutrophil 0.36-0.66 0.33 Normal Level

Lymphocyte 0.24-0.44 0.53 High Level

- Mayindicative of

cough.

Monocyte 0.02-0.12 0.09 Normal Level

Platelet Count 150.00-450.00 X10^9/L

139 Low Level- May

indicative of

low immune

system or risk of infection.

RDW 12.00-17.00% 14.0 Normal Level

MCV 80.00-96.00 fL 82.4 Normal Level

MCH 27.50-33.20 pg 28.3 Normal Level



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MCHC 33.40-35.50 g/dL 34.3 Normal Level

FBS 3.90-5.55 mmol/L 5.10 Normal Level

BUN 2.50-6.10 mmol/L 5.0 Normal Level

CREATININE 46-92 umol/L 49 Normal Level

SODIUM(Na) 137-145 mmol/L 147 Normal Level

POTASSIUM(K) 3.60-5.00 mmol/L 3.9 Normal Level

CALCIUM(Ca) 2.10-2.55 mmol/L 2.3 Low Level

-

Indication of hypocalcemia

.

MAGNESSIUM(Mg) 0.70-1.00 mmol/L 0.70 Normal Level

SGOT/AST 14-36 u/l 36.0 Normal Level

SGPT/ALT 9-52 u/l 36.0 Normal Level

Uric Acid 0.16-0.36 mmol/L 0.32 Normal Level

VIII. DRUG STUDY

Drug Contraindi

cation

Action Side Effect Nursing Responsibilities

Date: January 07,2012

Classification: For

hyperthyroidism

Generic Name: Neomercazole

Brand Name: Carbimazole

Frequency: BID

Dosage: 20mg

Route: PO

With patientwho has

goiter and

hypersensiti

vity

Responsiblefor its anti-

thyroid

action

-whiterashes

-pruritus

Adverse

Effect:-sore throat

-mouthulcers

-fever

-bruising

-uneasiness-jaundice

-nausea

-loss of taste

-headache

-joint pain

1.)Watch out for rashes2.) Ask for any irritations

occurring after the

medication.



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Drug Contraindication Action Side Effect Nursing

Responsibilities

Date: January07, 2012

Classification: Hypertension

Generic Name: Propanolol

Brand Name: Inderal

Frequency: TID

Dosage: 20mg

Route: PO

-Cardiogenicshock

-Sinus

Bradychardia

-BronchialAsthma

Propranolol is acompetitive

antagonist at

both the β1- and

β2-adrenoceptors. It

has no agonist

activity at the β-adrenoceptor, but

has membrane

stabilizingactivity at

concentrations

exceeding 1-3

mg/L, thoughsuch

concentrations

are rarelyachieved during

oral therapy.

Competitive β-

adrenoceptorblockade has

been

demonstrated in

man by a parallelshift to the right

in the dose-heart

rate responsecurve to β-

agonists eg,

isoprenaline.

-diarrhea-abdomianl

cramps

-insomnia

-fatigue-memory loss

-shortness of

breath

Adverse Effect:

-rashes-itching

-severe dizziness

1.) Monitor BP2.) Monitor

Apical pulse for

1 full minute

3. ) Daily Weight


Responsibilities

Date: January

07, 2012

Classification:To treat

heartburn

symptoms

Generic Name: Pantoprazole

Brand Name:

Protonix

Frequency: OD

Dosage: 40mg

Route: PO

Lactation Pantoprazole is

in a class of

drugs calledproton pump

inhibitors (PPI)

which block theproduction of

acid by the

stomach.

-nausea and

vomiting

-gas, stomachpain

-diarrhea

-constipation-headache

Adverse Effect:

-rash-itching

-trouble

breathing

1.) Monitor for

signs and

symptoms of angioedema

2.) Lab tests



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Responsibilities

Date: January

07, 2012

Classification: Cardiac Drugs

Generic Name: Digoxin

Brand Name: Lanoxin

Frequency: OD

Dosage: 0.25mg

Route: PO

-Venticular

Fibrilation

Digoxin

increases

contractility of the myocardium

by direct

activity. Thiseffect is

proportional to

dose in the lowerrange and some

effect is achieved

with quite low

dosing; it occurseven in normal

myocardium

although it isthen entirely

without

physiological

benefit.

-dizziness

-headache

-nausea andvomiting

Adverse Effect:-heart block

-rapid heartbeat

-slow heart rate

1.) Monitor

Apical pulse for

1 full minute2.) Avoid giving

with meals

3.) Monitor fortherapeutic drug

levels: 0.5-

2mg/ml


Responsibilities

Date: January

07, 2012

Classification: Hypertension

Generic Name: Diltiazem

Brand Name: Cardizem

Frequency: BID

Dosage: 30mg

Route: PO

CHF Anti-Angina;

Increase BP andvariably

decrease HR via

strongdepression of A-

V node

-constipation

-nausea-headache

-Live

dysfunction

Adverse Effect:

-rash-itching

-trouble

breathing

1.) Monitor BP

2.) Check ECG3.) Sign and

symptoms of

CHF



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IX. LIST OF PRIORITY PROBLEM

1.) The first priority nursing diagnosis is Risk for Imbalanced Nutrition: less than body requirements-

Because the patient needs to take sufficient nutrients to meet the metabolic needs of the body to be able

to consume adequate nourishment needed by the body based to patient’s weight, age and height.

2.) The second priority nursing diagnosis is Fatigue; appropriate nursing interventions are necessary toincrease energy and improved well-being of the patient. Because fatigue is overwhelming, sustained

sense of exhaustion and decreased capacity for physical and mental work at usual level.

3.) The third priority nursing diagnosis is Disturbed Body Image; means confusion in mental picture of

one’s physical self. The patient is manifesting weight loss. That’s why necessary nursing interventions

should be done for the patient to accept the change or loss and change in her lifestyle.

X. NURSING CARE PLAN

(Next page)

XI. ONGOING APPRAISAL

XII. DISCHARGE PLAN

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