I.

INTRODUCTION

A goiter is an enlarged thyroid gland, and it may be diffuse or nodular. A goiter may
extend into the retrosternal space, with or without substantial anterior enlargement. Because of
the anatomic relationship of the thyroid gland to the trachea, larynx, superior and inferior
laryngeal nerves, and esophagus, abnormal growth may cause a variety of compressive
syndromes. Thyroid function may be normal (nontoxic goiter), overactive (toxic goiter), or
underactive (hypothyroid goiter).

Multinodular goiter (MNG) is the most common of all the disorders of the thyroid gland.
MNG is the result of genetic heterogeneity of follicular cells and apparent acquisition of new
cellular qualities that become inheritable. Nodular goiter is most often detected simply as a
mass in the neck, but sometimes an enlarging gland produces pressure symptoms.

According to the 9th edition of Medical-Surgical Nursing by Lewis, the most common
cause of goiter worldwide is a lack of iodine in the diet. MNG is the most common endocrine
disorder affecting 500 to 600 million people worldwide. MNG is said to be endemic when it
affects more than 10% of a given population. Annual incidence in non endemic regions is 0.1%
to 1.5% and prevalence remains between 4 - 6%. Non endemic goiter is more common in
women and elderly . An average figure for sex distribution in both endemic and non endemic
regions is 3:1 (Female: Male). Nodules appear early in endemic goiter and later in sporadic
goiters although patient may be unaware of the goiter until his or her late 40s and 50s.

In the Philippines, one of the most common diseases that affect the thyroid gland is
goiter. “Goiter is prevalent in the Philippines. It is common and is still a formidable disease that
affects women of reproductive age and school children.: (Dr. Jasul, 2014). There is 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 (Phil, F&F, 2001). The national prevalence of goiters in the Philippines was 3.7%
in 1987 and 6.7% in 1993.

1
II. OBJECTIVES

General Objective
Within the 4 days of duty at the Ear, Nose, Throat (ENT) ward of Southern Philippines
Medical Center and Davao Medical School Foundation, the fundamental goal of the student for
the study is to be able to select a patient who has a critical need of care and to conduct a
comprehensive case study of the illness, and most especially, to provide a holistic and effective
nursing care to the client by relating and putting to use the knowledge that we have acquired.

Specific Objectives:

Cognitive:

• Define the complete diagnosis of the patient.

• Identify the developmental data of the patient.

• Create efficient nursing care plan based on actual high-risk health needs.

• Review and discuss the human anatomy and physiology of the affected organ systems.

• Analyze the disease process by explaining its pathophysiology.

• Recognize the relevance of drug to the patient by doing drug 


studies.

• Formulate specific, measurable, attainable, realistic, and time- bounded nursing care plans to
outline the care to be provided for the patient.

Psychomotor

• Gather data and comprehend the patient’s data, family background, health history and
present health condition.

• Conduct a cephalocaudal assessment of the patient and identify any abnormalities observed
during the physical assessment.

• State nursing theories to organize the framework of concepts for our nursing practice.

2
• Choose and apply the different and related nursing theories that are appropriate to the

present health condition of the patient

• Administer medications as prescribed by the physician and its indications given to the patient.

• Conduct a thorough physical and acute assessment to the patient by using this as basis for
NCP.

• Offer health teachings to the patient to achieve optimum wellness as well as other relevant
discharge orders.

Affective

• Establish good rapport with the patient to gain their trust and cooperation.

• Show respect, genuine concern, and empathy to the patient by giving care and attention.

• Provide the best quality of care along with the principles of nurse-patient relationship.

• Give the best quality of care with integrity, honesty, love and compassion by doing bedside
care and regular visit.

• Allow patient to express their feelings and thoughts through active listening and have a good
and open communication.

3
III. PATIENTS DATA

Patient’s Name: RS Sex: Female

Civil Status: Single Age: 46 years old

Birthdate: January 13, 1972 Birthplace: Tanawan, Leyte

Address: P5 BO.2 Beunevista, Agusan del Sur

Religion: Roman Catholic Nationality: Filipino

Occupation: None

Clinical Admission Data

Date of Admission: November 28, 2017 (10:49 AM)

Chief Complaint: Anterior neck mass

Diagnosis: Multinodular non-toxic goiter No. of admission: 1

Admitting Physician: Jordan Lou M. Yap Admitting Clerk: none

Type of Admission: Elective Admission Department: ENT ward

Vital Signs Upon Admission:

BP: 120/90 mmHg PR: 95 bpm

RR: 20 cpm T: 37.0 degrees celsius

O2 saturation: 100% Height: 165 cm

Weight: 60 kg

4
 IV. HEALTH HISTORY

Past Health History

RS was born at Tanawan, Leyte at home by a local midwife. She stated that her
immunizations as she recalls, are not complete. Patient has gone through Tuberculosis on the
year 2010 and completed the six month medication at a health center at Buenavista, Agusan del
Sur. She was then cleared of tuberculosis on the year 2011. On the year 1997, she had a
surgery involving the removal of her vocal cord at east avenue medical center in Manila. The
surgery was done due to a damage to her vocal cord and couldn't speak clearly. She could not
recall the exact diagnosis on why the surgery was done. Since the year 2012, started the slow
growing anterior neck mass without associated signs and symptoms. No medication was given
but only herbal medication was taken, she did not have any consultations with doctors for her
condition was tolerated.

Present Health History

Seven months prior to the admission, RS decided to have the mass removed thus
sought for consultation at ENT at SPMC under Dr. Dogto and Dr. Ruiz. Thus upon consultation,
an ultrasound was done, following laboratories of the levels of TSH and biopsy of the adrenal
surgery and cleared for surgery last december.

Family History
RS has one child at the age of 16 and is currently in 10th grade. Her mother VS is
deceased. Died on the year 1996 due to breast cancer. Her father RS is 72 years old currently
living in leyte and has a history of pneumonia. RS is the only child. She cannot recall the cause
of death of her grandparents on both sides of her mother and father.

5
V. GENOGRAM

6
VI. DEVELOPMENTAL DATA

Erik Erikson’s Psychosocial Development

Erik Erickson was born in 1902 in Frankfurt-am-Main, Germany. After completing

high school, he moved to Florece to pursue his interest in art, and in 1927, he
became an art teacher at psychoanalytically enlightened school for children started
by Dorothy Burlingham and Anna Freud in Vienna. The move changed his life and
career. He earned a certificate from the Maria Montessori School, and then
embarked on psychoanalytic training at thVienna Psychoanalytic Institute. By 1936,
he had joined the Institute of Human Relations, part of the department of psychiatry
at Yale University.
He envisioned life as a sequence of levels of achievement. According to him,
each individual passes through eight developmental stages, also known as
psychological crisis. Each stage is characterized by different psychological crises,
which must be achieved or resolved by the individual before he/she can move on to
the next stage. The resolution of the conflicts at each stage enables the person to
function effectively in the society.
The Stages

Hopes: Trust vs. Mistrust (Oral-sensory, Birth-2 years)

Will: Autonomy vs. Shame & Doubt (Muscular-Anal, 2-3 years)

Purpose: Initiative vs. Guilt (Locomotor-Genital, Preschool, 3-5 years)

Competence: Industry vs. Inferiority (Latency, 5-12 years) Fidelity: Identity vs.
Role Confusion (Adolescence, 13-19 years)

Love: Intimacy vs. Isolation (Young adulthood, 20-24, or 20-39 years)

Care: Generativity vs. Stagnation (Middle adulthood, 25-64, or 40-64 years)

Wisdom: Ego Integrity vs. Despair (Late adulthood, 65-death

7
STATE DESCRIPTION RESULT JUSTIFICATION

GENERATIVITY VS During this time, ACHIEVED The patient

STAGNATION adults strive to GENERATIVITY achieved
create or nurture generativity since
things that will she is able to care
outlast them; often for others through
by parenting simply caring for her
children or family. She has
contributing to done things such as
positive changes working hard for her
that benefit other family to make their
people. Contributing life good.
to society and doing
things to benefit
future generations
are important needs
at the generativity
versus stagnation
stage of
development.

8
 Robert Havighurst’s Developmental Task Model

Robert James Havighurst (June 5, 1900 in De Pere, Wisconsin – January 31, 1991
in Richmond, Indiana) was a professor, physicist, educator, and aging expert. Both his father,
Freeman Alfred Havighurst, and mother, Winifred Weter Havighurst, had been educators
at Lawrence University. Havighurst worked and published well into his 80s. According to his
family, Havighurst died of Alzheimer's disease at the age of ninety.

He believed that learning is basic to life. In his theory, a person is viewed as individual
who continues to learn throughout life. No matter how painful, though or easy a struggle could
be, a person may win or fail but still learn in different ways to cope up. A developmental task is a
task which arises at about a certain period in the life of an individual, successful achievement of
which leads to his happiness and success with later task, while failure leads to unhappiness in
the individual, disapproval by society, and difficulty with later task and will make other task in the
higher stage more difficult for the person. Yet, achievement will boost individual’s personality
that will build happiness and satisfaction enabling to move or and achieve other tasks.

6 MAJOR PERIODS

Infancy & Early Childhood (Birth to 5 years old)

Middle Childhood (6 to 12 years old)

Adolescence (13 to 18 years old)

Early Adulthood (19 to 29 years old)

Middle Adulthood (30 to 60 years old)

Later Adulthood (61 years old and over)

9
Developmental task Justification
Achieved The patient has a business with a
stable income, enough to support
their needs.
Achieved The patient, along with her
husband, has always been giving
and supportive of their child, thus,
achieving their role as parents.
Achieved The patient establishes a strong
bond with her husband, and also
acknowledges their relationship as
full of respect and love.
Achieved The patient recognizes the need
for changes in her daily routine,
upon knowing his diagnosis.

10
 Sigmund Freud’s Psychosexual Development

An Austrian neurologist, founder of pyschoanalysis. Sigismund Schlomo Freud was born

on May 6, 1856 in Freiberg, Moravia, the Austrian Empire (now Pribor in the Czech Republic).
In 1877, he abbreviated his name from Sigismund Schlomo Freud to Sigmund Freud.
Freud’s Stages of Psychosexual Development are completed in a predetermined
sequence and can result in either successful completion or a healthy personality or can result in
failure, leading to an unhealthy personality. This theory is probably the best known as well as
the most controversial; as Freud believed that we develop through stages based upon a
particular erogenous zone. During each stage, an unsuccessful completion means that a child
becomes fixated on that particular erogenous zone and either over– or under-indulges once he
or she becomes an adult.

Stage Age Range Erogenous zone

Oral Birth-1 year Mouth
Anal 1-3 years Bowel and bladder
elimination
Phallic 3-6 years Genitalia
Latency 6-puberty Dormant sexual feelings
Genital Puberty-death Sexual interests mature

11
 Psychosexual Stage Achieved Rationale Justification
Achieved During the final stage The patient lives
It is a time of adolescent
of psychosexual with her husband.
sexual experimentation,
development, the They are not
the successful resolution
individual develops a married but they
of which is settling down
strong sexual interest already have one
in a loving one-to-one
in the opposite sex. child.
relationship with another
This stage begins
person in our 20's.
during puberty but
Sexual instinct is
last throughout the
directed to heterosexual
rest of a person's life.
pleasure, rather than
Where in earlier
self-pleasure like during
stages the focus was
the phallic stage. For
solely on individual
Freud, the proper outlet
needs, interest in the
of the sexual instinct in
welfare of others
adults was through
grows during this
h e t e r o s e x u a l
stage. If the other
intercourse. Fixation
stages have been
and conflict may prevent
completed
this with the
successfully, the
consequence that
individual should now
sexual perversions may
be well-balanced,
develop.
warm, and caring.
The goal of this stage
is to establish a
balance between the
various life areas.

12
VII. Patients Diagnosis

Non-Toxic Multinodular Goiter

GOITER

A goiter is an enlarged thyroid gland. In a person with a goiter the thyroid cels are
simulated to grow, which may result in an overactive thyroid (hyperthyroidism) or an under
active thyroid (hypothyroidism). In a person with goiter, TSH and T4 levels are measured to
determine whether a goiter is associated with normal thyroid function, hyperthyroidism or
hypothyroidism.

NONTOXIC GOITER

A nontoxic goiter is a diffuse enlargement of the thyroid gland that does not result from a
malignancy or inflammatory process. Normal levels of thyroid hormone are associated with this
type of goiter. Normal levels of thyroid hormone are associated with this type of goiter. Nodular
goiters are thyroid hormone secreting nodules that function independent of TSH stimulation.
There may be multiple nodules (multinodular goiter) or a single nodule (solitary autonomus
nodule).

13
VIII. Anatomy and Physiology

The thyroid is part of the endocrine system, which is made up of glands that produce,
store, and release hormones into the bloodstream so the hormones can reach the body's cells. It is
a butterfly shape gland, about 2-inches long and lies in front of your throat below the prominence
of thyroid cartilage sometimes called the Adam's apple. The thyroid has two sides called lobes
that lie on either side of your windpipe, and is usually connected by a strip of thyroid tissue
known as an isthmus.

Thyroid hormones
The thyroid makes two hormones that it secretes into the blood stream. One is called
thyroxine; this hormone contains four atoms of iodine and is often called T4. The other is called
triiodothyronine, which contains three atoms of iodine and is often called T3. In the cells and
tissues of the body the T4 is converted to T3. It is the T3, derived from T4 or secreted as T3 from
the thyroid gland, which is biologically active and influences the activity of all the cells and
tissues of your body.

The thyroid makes hormones that control the body’s growth, development and
metabolism (how the body uses energy). These hormones help:

14
 ▪ Break down food and change it into energy
▪ Control body temperature
▪ Control heart rate and blood pressure
▪ Control breathing
▪ Keep the nervous system working normally
▪ The brain develop in children

The follicular cells take in iodine from the blood, which is used to make the hormones T4
and T3 (Thyroxine (T4) and triiodothyronine (T3). The action of T3 and T4 are:
▪ Increase BMR = cellular metabolism of carbs, lipids, proteins
▪ Stimulate synthesis of additional Na-K pump
▪ Stimulate protein synthesis and increase the use of glucose and fatty acidy for
ATP production
▪ Enhance catecholamines (epinephrine & norepinephrine) because they up-
regulate B receptors
▪ Accelerate body growth.

15
Hypothalamus and Pituitary Gland

The hypothalamus and the pituitary communicate to

maintain T3 and T4 balance.
The hypothalamus produces TSH Releasing
Hormone (TRH) that signals the pituitary to tell the
thyroid gland to produce more or less of T3 and T4 by
either increasing or decreasing the release of a
hormone called thyroid stimulating hormone (TSH).

▪When T3 and T4 levels are low in the blood, the

pituitary gland releases more TSH to tell the thyroid
gland to produce more thyroid hormones.

▪If T3 and T4 levels are high, the pituitary gland

releases less TSH to the thyroid gland to slow
production of these hormones.

16
IX. PHYSICAL ASSESSMENT
General Survey
The patient was a 46 year old female, admitted at the ENT Ward of Southern Philippine Medical
Center on November 28, 2017 due to the enlargement of the thyroid gland having a
measurement of 6.3x4.7x4.9 cm, status post total thyroidectomy. She was stable and vital signs
were stable. She was not weak and she was awake, alert, responsive, oriented and cooperative
during the assessment. She had overall good grooming. Speech is spontaneous with a normal
tone of voice. IVF of D5LR @ 120cc/hr. GCS score of 15.

Vital Signs
• BP – 120/60
• T – 36.9
• PR – 88
• RR – 18
• SpO2 – 100%

Skin, Hair and Nails

The patient’s skin is slightly brown in color and warm to touch with a temperature of
36.9. Body hair is black in color. Fine and thin on the head area. Eyebrow hair and eyelashes
were evenly distributed. Scalp was white with lesions noted. Nail beds are pinkish with capillary
refill of 2 seconds. Skin turgor of 2 seconds noted.

Head, Neck, Regional Lymphatics

The patient’s head is in the midline. Status post thyroidectomy with dressing on the surgical
area, Dressing is dry and clean. Neck mass is no longer noted. Limited range of motion was
noted on her head and neck.

Eye Assessment
Eyes are symmetrical upon inspection. The patient’s eyelids are of the same level. Eyelashes
are evenly distributed as well as the eyebrows. Sclera is white upon inspection. Tiny vessels
are present. Conjunctiva was pinkish. The iris of the both eye was black. The pupils were equal,
round, reactive to light and accommodation at 2 mm, brisk. The cornea is moist and shiny. Right
and left eyeballs are slightly bulging.

17
Ears, Nose, Mouth and Throat Assessment
Both ears are in symmetric position and match the flesh color of the patient’s skin. The top of
the ears is aligned with the outer canthus of the eye. The patient’s tympanic membrane wasn’t
observed properly since there was minimal earwax blocking the site. No drainage and/or lesions
noted. The patient reported no history of ear pain, ringing of the ear, or ear infections of the
patient. Nose is located in the midline of the face. No discharges, swelling, bleeding, lesions, or
masses noted. The patient is able to breathe through her nose. The patient’s teeth are
incomplete, right upper and left lower wisdom teeth were already extracted.

Thorax and Lungs Assessment

The patient’s thorax is symmetrical. The chest movement is symmetric. No lumps and
tenderness noted. The patient’s respiratory rate is 18 per minute. The chest rises upon inhaling
and falls upon exhaling. Difficulty of breathing was not observed.

Heart and Peripheral Vasculature Assessment

The patient’s cardiac rate is 88 per minute. The patient’s left and right radial pulse rate is
88 per minute with strong, regular pulses. Her left and right brachial pulses were 89 and 88.
There were no additional heart sounds noted upon auscultation.

Abdominal Assessment
The abdomen was not large and not bloated. The abdomen has the same color with the rest of
the patient’s body. The abdomen was soft upon palpation. The abdomen has symmetrical
movements caused by respirations. No masses and lesions noted. Normal oral mucosa noted.
Bowel sounds of 10 sounds/minute. Patient is well nourished with a fair appetite, eating 3 meals
a day, able to feed self.

Muscoloskeletal System Assessment

The patient was ambulatory. She can freely move and perform tasks without difficulty and
without assistance. Normal Range of Motion is noted except for her head and neck. The patient
did not verbalize on weakness on either side of his body. 2 Bowel movement noted with brown,
soft stool, estimating 100cc.

18
Female Genitalia Assessment
The patient did not consent to conduct a physical assessment on her genitalia. However, she
verbalized that there were no unusualities, no swelling, no itchiness observed. Also, minimal
pubic hair was noted. Last voided 9am of 300cc of clear yellow urine. Patient can void freely.



19
X. REVIEW OF SYSTEMS

GENERAL “gi operahan ko ma’am thyroidectomy, kay

waning goiter nako 5 years naman, unsay this
year lang ko naka decide na patangalon. Wala
man gud koy gi bati, ga dako lang dyud siya”
INTEGUMENTARY “Wala man koy problema sa panit maam”

MUSCULOSKELETAL “Ok lang ko ma’am. wala man put koy gi bati

nga sakit”

RESPIRATORY “Karon ma'am kay gina ubo ko, sukad

gahapon. Tas naa ko plema, pero wala man ko
naglisod ug ginhawa”
GASTROINTESTINAL “wala pa ko nakalibang karong adlawa maam,
pero wala man pud sakit sa titan"

CARDIOVASCULAR “wala man koy gi bati maam”

URINARY “naka ihi ko gaina maam, kapila na pud”

20
DIGESTIVE “Maka kaon man ko, wala may sakit sa pag
tulon nako, kani lang gina ubo ma'am unya
naay plema”

21
XI. ETIOLOGY

PRECIPITATING
FACTORS

FACTORS PRESENT/ABSENT RATIONALE REMARKS

History of radiation ABSENT Radiation therapy Patient does not live in

therapy to head or neck, can trigger a a place where radiation
especially during is strong.
swollen thyroid,
childhood.
particularly when
administered to the
neck.
Iodine Deficiency PRESENT Stimulation of new Patient is vegetarian
follicle generation and mostly eats dark
green leafy vegetables.
seems to be
And lesses iodized salt
necessary in the intake.
formation of simple
goiter. Evidence
accumulated from
many studies
indicates that iodine
deficiency or
impairment of iodine
metabolism by the
thyroid gland,
perhaps due to
congenital
biochemical
defects, may be an
important
mechanism leading
to increases in TSH
secretion (30,53)

22
Diet high in Goitergens PRESENT Intake of cassava, Patient is vegetarian
cabbage, and mostly eats dark
green leafy vegetables.
cauliflower, brussels
And lesses iodized salt
sprouts and turnips intake.
interfere with T3 /
T4 synthesis
Cassava contains a
thiocyanate which
inhibits iodide
transport within the
thyroid

Smoking ABSENT • Thiocyanate in Patient does not have a

tobacco smoke history of smoking.
interferes with
iodine absorption
PREDISPOSING
FACTORS

Genetics ABSENT A strong genetic Patient does not have a

predisposition is family history of goiter.
indicated by
family.Thus,
children of parents
with goiter have a
significantly higher
risk of developing
goiter compared
with children of
nongoitrous
parents.

23
XII. SYMPTOMATOLOGY

SYMPTOMS PRESENT/ABSENT RATIONALE JUSTIFICATION

DYSPHAGIA PRESENT the natural Upon interview that

expectation patient verbalized that
of goiters is continued she had difficulty in
progressive growth, swelling when the neck
which may result in mass was still present
lower-neck which led her to the
discomfort, a decision of having it
noticeable neck removed due to
mass, and irritability of the neck
progressive mass.
compression of the
trachea, esophagus,
and great vessels,
thereby causing
dyspnea, dysphagia/
globus (Ryan, et al,
2015)
THROAT TIGHTNESS PRESENT The butterfly-shaped The patient verbalized
thyroid gland in your that she had discomfort/
neck produces neck tightness when the
hormones that help neck mass was still
control your body’s present
metabolism.
An enlarged thyroid
gland can make your
throat feel tight and
make it hard to
breathe or swallow.
DYSPNEA PRESENT Tracheal compression The patient verbalized
is generally that she had difficulty in
asymptomatic until breathing when the
critical narrowing has neck mass was still
occurred. Patients present
develop a dry
cough, dyspnea, and
stridor, especially with
exertion.

24
HIGH-PITCH SOUND ABSENT When a goiter or Patient RS is not
nodule is due diagnosed with
to cancer, the tumor cancerous goiter, but
may actually grow non-toxic goiter.
into nearby
structures, causing
pain, hoarseness
when nerves to the
voice box are
invaded, or coughing
up blood when the
trachea is penetrated
(Ladenson, 2008).

25
XIII. PATHO…


26
27
XIV. DOCTORS ORDER

DATE & TIME DOCTORS ORDER RATIONAL REMARKS

11/28/17 - Please admit this Patients admitted under Patient was admitted at
10AM patient to ENT ward the ENT ward are with the ENT ward on
under Head/Neck conditions that underly 11/28/17 under the
service anything that involve the service of Dr. Espa
Ears, Nose and Throat

- Secure consent to The purpose of The patient signed

care informed consent it to consent.
ensure that the patient
is not undergoing a
procedure without being
informed and helps
protect the team from
liability.

- VS Q shift For baseline data and VS was monitored Q

monitoring purposes. shift.

- DAT For nutritional build-up Patient is on DAT

and not contraindicated
for DAT.

- Diagnostics - Pls Rpt. The use of diagnostic The diagnostic

1. CBC, platelet tests is a crucial aspect procedures were carried
2. S. Na, K, Ca of clinical practice since out.
3. Creatinine they assist the health
4. ECG 12L care team in
5. Chest PA establishing whether a
6. Sputum AFB patient has or does not
7. TSH, FT4 have particular condition
8. FBS and it helps determine
9. CT,BT proper procedures and
treatment for the patient

- No meds temporarily The patient is currently Patient is currently not

in no need for following any
medications as there medication regimen,
are no s/sx that would
lead to complication the
the patient’s current
condition.

- No IVF temporarily Patient is currently not

in need for Intra venous
fluid.

28
- Plan: for Plan for thyroidectomy Patient was informed of
Thyroidectomy is ordered which thyroidectomy
involves the surgical procedure.
removal of all or part of
the thyroid gland, since
an anterior neck mass is
noted.

- Pls refer to IM for co- To ensure that the Patient was not yet
management and CP cardio-pulmonary health assessed by IM.
clearance of the patient will not
post added risks during
the surgery.

- WOF unusualities The health care team is Patient was monitored

responsible to watch out for unsualities.
for unsualities that can
lead to further
complications to the
patients health.

- Refer Accordingly

29
12/29/17 - T/S labs, attach once Labs are to be secured Laboratory results were
7PM available since they assist the secured.
health care team in
establishing whether a
patient has or does not
have particular condition
and it helps determine
proper procedures and
treatment for the patient

- Continue present Referral to IM to ensure Referred to IM.

meds and that the cardio-
management pulmonary health of the
- Refer to IM for co- patient will not post
management and CP added risks during the
clearance once all surgery.
labs in

- WOF unusualities The health care team is Monitored for

responsible to watch out unsualities.
for unsualities that can
lead to further
complications to the
patients health.

- Refer

30
11/29/17 - Thank you for this
6:35PM referral
- Patient seen & Patient is seen and Patient was seen and
examined examined by the IM to examined by IM on duty.
- History review and assess for further
recorded complication of the
patients condition and
further complications
during the surgery.

- Assessment:
Multinodular Goiter Goiter, or the Patient has non-toxic
Euthyroid state enlargement of the multinodular goiter.
thyroid gland,
comprises a variety of
conditions. Goiters can
be
classified as toxic or
non toxic, diffuse or
nodular
and solitary or multiple [

- Plans:
- ff up official CXR Follow up of the official CXR result was followed
result CXR would allow the up
health team to identify
the possible underlying
condition that may be
present

- for HBA1C The HbA1c test, also HBA1C test, done.

known as the
hemoglobin A1c or
glycated hemoglobin
test, is an important
blood test that gives a
good indication of how
well your diabetes is
being controlled.

- CBG monitoring Q6 Capillary Blood Glucose CBG was monitored Q6.

- Give RI 6 units for is done to monitor
CBG > 180mg/dL patient’s level of
glucose in the blood.

- Pending CP Cardio-pulmonary Still waiting on CP

clearance clearance is needed to clearance.
weigh the risks of
complications that may
possibly arise during the
surgery

31
11/30/17 - T/S official CXR
2PM result
- T/S HBA1C
- Continue Present Present medication and Present meds and
meds and management for the management continued.
management continued care for the
patient.

- WOF unusualities The health care team is Health care team

responsible to watch out watched out the by
for unsualities that can health care team.
lead to further
complications to the
patients health.

- Refer
12/01/17 - Refer to IM for To ensure that the Referred to Im
7AM evaluation, co- cardio-pulmonary health
management, of the patient will not
clearance post added risks during
the surgery.

- Continue present Present medication and Meds and management

medication and management for the continued.
management. continued care for the
patient.

- WOF unusualities The health care team is Health care team

- refer responsible to watch out watched to for
for unsualities that can unsualities.
lead to further
complications to the
patients health.

12/01/17 - Suggest to do Chest

6:20PM CT scan with contrast
and review of Chest
XRAY without
radiology
- refer
- Will inform yellow
service under Dr.
Gutierrez/Dr. Berrafe
- refer

32
12/02/17 - For FBS today
7:10AM - Refer Accordingly
- Refer to IM for CP To ensure that the
clearance cardio-pulmonary health
of the patient will not
post added risks during
the surgery.

12/05/17 - S/F chest CT scan

7AM with contrast, please
facilitate
- Please carry out IM
orders
- Continue Present
Medication
- Refer Accordingly

12/06/17 - Schedule for OR

3:00 PM tomorrow as 2nd
case
- Plan: Total Total thyroidectomy: Scheduled for total
Thyroidectomy The gland is removed thyroidectomy as 2nd
completely. Usually case.
done in the case of
malignancy. Thyroid
replacement therapy is
necessary for life.

- Surgeons: Dr. Ducto

- Secure consent The purpose of Patient signed the
informed consent it to consent.
ensure that the patient
is not undergoing a
procedure without being
informed and helps
protect the team from
liability.

- Secure OR materials In préparation of NOD informed OR to

surgical procedure secure total
thyroidectomy set
- Refer Accordingly

33
12/06/17 - Patient seen and
4:30 PM examined
- History and chart
revised
- NPO @ 2 AM For per-operative Patient was on NPO
purposes beginning 2 am

- IVF of D5LR 1L @
120cc/hr
- MEDS:
1. Ranitidine 50 mg - Inhibits the action of Given
IVTT Q8 while on NPO histamine at the H2
receptor site located
primarily in gastric
parietal cells,
resulting in inhibition
of gastric acid
secretion

2. Metoclopremide 10 Stimulates motility of Given

mg IVTT PRN upper GI tract,
Deceases reflux into
esophagus. Raises
threshold activity in
chemoreceptor trigger
zone.

3. Amlodipine 10 mg Inhibits calcium Given

tab, 1 tab PTOR movement across
cardiac and vascular
smooth muscle cell
membranes.

4 5. Ensure IV
potency PTOR
5. VS to OR
- Refer Accordingly
- Thank you!

12/07/17 - Refer today as 2nd

7:00AM case

34
12/07/17 - Post OP order
4:45PM - S/P Total
Thyroidectomy
- May have full diet
once fully awake at
ward
- Medication:
1. Co-amoxiclav 1g/ An antibiotic that Given
tab BID x 7 combines amoxicillin
and clavulanic acid. It
destroys bacteriaa by
disrupting their ability to
form cell walls

2. Eperisone 50mg/ Inhibits The Vicious Given

tab TIDx 5 days Cycle Of Myotonia
By Decreasing
Pain, Ischemia, And
Hypertonia In
Skeletal Muscles,
Thus Alleviating
Stiffness And
S p a s t i c i t y, A n d
Facilitating Muscle
Movement.
Inhibits bacterial protein,
3. Mupirosin ointment Given
RNA synthesis. Less
apply during dressing
- Give ff medications effective on DNA
synthesis.
after blood extraction
Stimulates calcium
4. Calcitrol 1 tab OD Given
transport in intestines,
resorption in bones, and
tubular reabsorption in
kidney
5. CaCO3 1 tab TID
- Start protamine Electrolyte replenisher.
Given
500cc IVTT to run at
Heparin antagonist,
90cc/hour as side Given
antidote
drip x 2 cycles
- Watch out for
cyanosis desaturation
expanding neck
swelling, dyspnea,
bleeding, or any
unusalities
- Refer accordingly
- Thank you!

35
12/07/17 - To PACU until stable
5:00 PM then to ward
- VS Q15x1hour,
Q30minsx3hours, Q4
hoursx4hours then
Q4
- DAT
- IVF of d5LR 1L @
120cc/hr
- LABS: Serum Ca
- MEDS:
1. Ketrolac 30mg Inhibits prostaglandin Given
IVTT Q6x3 more doses synthesis, reduces
next due @ 10:30 then prostaglandin levels in
shift to Celecoxib aqueous humor.
200mg tab, 1 tab BIDx4
days
2. Tramadol 50mg Reduces intensity of Given
IVTT Q8x 3 more days. pain stimuli incoming
2nd dose @ 10:30 then from sensory nerve
PRN for sever pain. endings

3. Metaclopromide 10
mg IVTT x Q8 x 2 more
doses, next due @ 11
pm
- I & O Qshift To monitor I&O I&O monitored Qs
- O2 inhalation @
4-6LPM facemask
- Suction secretion as
needed
- Keep
thermoregulated
- Refer Accordingly
- Thank you!
12/08/17 - Daily dressing To prevent from Daily dressing done by
7:00 AM infection ROD.

- Continue present
meds and
management
- Avoid strong valsation
- Encourage daily To prevent infection Health teaching on
hygiene hygiene given by NOD
and SN.
- Refer Accordingly
12/08/17 - D/C meds
7:15AM 1. CaCO3 tab
2. Calcitrol tab
- Continue other meds.

36
12/08/17 - review of meds:
4:00PM 1. Co-amoxiclav 1gram
tab BID PO
2. Mupirosin ointment
apply TID
3. Celcoxib 200g tab
BID
4. Epirisone 50g tab, 1
tab TID x 5 days

37
XV. DIAGNOSTIC / LABORATORIES

DIAGNOSTICS/LABS RESULT RANGE JUSTIFICATION

HEMATOLOGY A complete blood count

(11/29/2017) (CBC) is a blood test
used to evaluate your
CBC+PLT 147.0 g/L 115-155 overall health and
Hemoglobin 0.40 0.36-0.48 detect a wide range of
Hematocrit 4.61 x10^6/uL 4.20-6.10 disorders, including
RBC count 9.67 x10^3/uL 5.0 - 10.0 anemia, infection and
WBC count leukemia.

Differential count 62% 55-75

Neutrophil 26% 20-35
Lymphocytes 5.0% 2-10
Monocytes 6.0% 1-8
Eosoniphil 1.000% 0-1
Basophil 354 x10^3/uL 150-400
Platelet Count 31.9 pg 25.60-32.20
MCH 37.2 g/dL HIGH 32.20-35.50
MCHC 85.7 fl 79.40-94.80
MCV

38
CLINICAL CHEMISTRY The most
c o m m o n
(12/08/17)
specimens tested
in clinical
chemistry are
Calcium 2.14 mmol/L 1.75-2.39
blood and urine.
Glucose - FBS 4.82 mmol/L 4.10-6.60 Many different
HBA1c 5.2 % 4.0-6.5 tests exist to test
for almost any
type of chemical
component in
blood or urine.
Components may
include blood
g l u c o s e ,
electrolytes,
e n z y m e s ,
hormones, lipids
(fats), other
m e t a b o l i c
substances, and
proteins.

CLINICAL CHEMISTRY
11/29/17

Calcium 2.19 mmol/L 1.75-2.39

Creatinine 54.83 umol/L 39.00-113.00
Glucose-FBS 8.17 mmol/L HIGH 4.10-6.60
Potassium 4.14 mmol/L 3.6-5.1
Sodium 136.15 mmol/L 136.00-144.00

39
SEROLOGY AND Blood tests for thyroid
IMMUNOLOGY function are an
11/29/17 important part of the
process for diagnosing
Free t4 11.83 7.90-14.400 thyroid disease and
TSH 6.246 0.38-5.33 treating thyroid
conditions. Here is a
summary to help you
gain a better
understanding of the
key thyroid blood tests,
what they are
measuring, what the
results mean, and the
impact on the diagnosis
and management of
your thyroid condition.
You can then delve into
the details of each and
gain a better
understanding of what it
all means.

40
SPUTUM Sputum collects in the
MICROSPOPY
lower parts of your
SPECIMEN 1 lungs and bronchi,
Visual Appearance Salivary which are the tube-like
Reading O pathways that air moves
Laboratory Dx Negative through to reach your
lungs. The test can
reveal what may be
SPECIMEN 2 causing:
Visual Appearance Salivary
Reading O - bronchitis
Laboratory Dx Negative - a lung abscess
-pneumonia
-tuberculosis
-chronic obstructive -
pulmonary disease
-cystic fibrosis

XRAY (Chest PA) Reticular and hazy A chest radiograph,

densities are seen on colloquially called a
the right upper lobe with chest X-ray, or chest
associated ipsilateral film, is a projection
tracheal deviation with radiograph of the chest
elevation of right used to diagnose
hemidiaphragm. The conditions affecting the
heart is not enlarged. chest, its contents, and
No other significant nearby structures.
findings.

IMPRESSION:
Consider pub with
cicatricial atelectasis,
right

41
ELECTROCARDIOGRA SINUS RYTHM An electrocardiogram is
PH (ECG) DIFFUSE WAVE a simple, painless test
FLATTENING that measures your
heart’s electrical activity.
It’s also known as an
ECG or EKG. Every
heartbeat is triggered by
an electrical signal that
starts at the top of your
heart and travels to the
bottom. Heart problems
often affect the electrical
activity of your heart.

42
XVI. DRUG STUDIES

GENERIC NAME RANITIDINE

BRAND NAME Taladine

DOSAGE 50 mg IVTT
Q8 WHILE ON NPO

CLASSIFICATION Anti-Ulcer

MECHANISM OF ACTION - Inhibits the action of histamine at the H2

receptor site located primarily in gastric parietal
cells, resulting in inhibition of gastric acid
secretion
- Has some antibacterial action against H. Pylori

INDICATIONS - Treatment and prevention of heartburn, acid

indigestion
- Prophylaxis of GI hemorrhage from stress
ulceration

CONTRAINDICATIONS -Hypersensitivity

43
SIDE/ADVERSE EFFECTS -chest pain, fever, feeling short of breath, coughing
up green or yellow mucus;

-easy bruising or bleeding, unusual weakness;

-fast or slow heart rate;

-problems with your vision;

-fever, sore throat, and headache with a severe

blistering, peeling, and red skin rash; or

-nausea, stomach pain, low fever, loss of appetite,

dark urine, clay-colored stools, jaundice (yellowing
of the skin or eyes).

Less serious ranitidine side effects may include:

-headache (may be severe);

-drowsiness, dizziness;

-sleep problems (insomnia);

-decreased sex drive, impotence, or difficulty

having an orgasm; or

-swollen or tender breasts (in men);

-nausea, vomiting, stomach pain; or

-diarrhea or constipation.

44
NURSING RESPONSIBILITIES 1. Instruct patient not to take new medication w/o
consulting physician

2. Instruct patient to take as directed and do not

increase dose

3. Allow 1 hour between any other antacid and

ranitidine

4. Avoid excessive alcohol

5. Assess patient for epigastric or abdominal pain

and frank or occult blood in the stool, emesis, or
gastric aspirate

6. Nurse should know that it may cause false-

positive results for urine protein; test with
sulfosalicylic acid

7. Inform patient that it may cause drowsiness or

dizziness

8. Inform patient that increased fluid and fiber

intake may minimize constipation

9. Advise patient to report onset of black, tarry

stools; fever, sore throat; diarrhea; dizziness; rash;
confusion; or hallucinations to health car
professional promptly

10. Inform patient that medication may temporarily

cause stools and tongue to appear gray
blackInstruct patients to monitor for and report
occurrence of drug-induced adverse reaction

45
GENERIC NAME METOCLOPROMIDE

BRAND NAME Metozolv ODT

DOSAGE 10 mg IVTT (PRN)

CLASSIFICATION PHARMACOTHERAPEUTIC: Dopamine receptor

antagonist
CLINICAL; GI emptying adjunct, peristaltic
stimulant, antiemetic

MECHANISM OF ACTION Stimulates motility of upper GI tract, Deceases

reflux into esophagus. Raises threshold activity in
chemoreceptor trigger zone.
THERAPEUTIC EFFECT: Accelerates intestinal
transit, gastric emptying. Relieves nausea,
vomiting.

INDICATIONS - Post-operative Nausea/Vomiting

- Gastoparesis
- Symptomatic Gastroesophageal Reflux Disease
(GERD)
- Facilitate Small Bowel Intubation
- Renal impairment
CONTRAINDICATIONS - Concurrent use f medications likely to produce
extrapyramidal reactions.
- GI hemorrhage
- GI obstruction/perforation
- History of seizure disorder
- Pheochromocytoma
CAUTIONS:
- Renal impairment
- CHF
- Cirrhosis
- Hypertension
- Depression

46
SIDE/ADVERSE EFFECTS SIDE EFFECTS: Drowsiness, restless- ness,
fatigue, lethargy. Occasional (3%): Dizziness,
anxiety, headache, insomnia, breast
tenderness, altered menstrua- tion,
constipation, rash, dry mouth, galactorrhea,
gynecomastia. Rare (less than 3%):
Hypotension, hypertension, tachycardia.

ADVERSE EFFECTS: Extrapyramidal

reactions occur most fre- quently in children,
young adults (18–30 yrs) receiving large
doses (2 mg/kg) during chemotherapy and
usually are lim- ited to akathisia (involuntary
limb move- ment, facial grimacing, motor
restlessness). Neuroleptic malignant
syndrome (diapho- resis, fever, unstable B/P,
muscular rigidity).

NURSING RESPONSIBILITIES BASELINE ASSESSMENT:

Antiemetic:
1. Assess for dehydration
2. Assess for nausea, vomiting, abdominal
distention, bowel sounds.

INTERVENTION EVALUATION
3. Monitor for anxiety, restlessness, extrapyramidal
symptoms (EPS) during IV administration
4. Monitor daily pattern of bowel activity, stool
consistency.
5. Assess skin for as.
6. Evaluate for therapeutic response from
gastroparesis.
7. Monitor renal function, BP, heart rate

PATIENT FAMILY TEACHING:

8. Avoid tasks that require alertness, motor skills
until response to drug is established.
9. Report Involuntary eye, facial, limb movement
10. Avoid Alcohol

47
GENERIC NAME AMLODIPINE

BRAND NAME Norvasc

DOSAGE 10 mg TAB, 1 tab PTOR

CLASSIFICATION Calcium channel blocker

CLINICAL: Antihypersensitive, antianginal

MECHANISM OF ACTION Inhibits calcium movement across cardiac and

vascular smooth muscle cell membranes.
THERAPEUTIC EFFECT: Dilates coronary
arteries, peripheral arteries/arterioles. Decreases
total peripheral vascular resistance and BP by
vasodilation.

INDICATIONS - Hypertension
- Angina
- Hepatic Impairment
CONTRAINDICATIONS - None known

CAUTIONS: Hepatic impairment, aortic stenosis,

hypertonic cardiomyopathy.

SIDE/ADVERSE EFFECTS SIDE EFFECTS: Frequent (greater than

5%): Peripheral edema, headache, ushing.
Occasional (5%–1%): Dizziness, palpitations,
nausea, unusual fatigue or weakness
(asthenia). Rare (less than 1%): Chest pain,
bradycar- dia, orthostatic hypotension.
ADVERSE EFFECTS: Overdose may
produce excessive periph- eral vasodilation,
marked hypotension with re ex tachycardia.

NURSING RESPONSIBILITIES BASELINE ASSESSMENT:

1. Assess baseline renal/hepatic function tests,
BP, apical pulse
INTERVENTION/EVALUATION:
2. Assess BP
3. Assess for peripheral edema behind medial
malleolus
4. Assess skin for flushing
PATIENT/FAMILY TEACHING
5. Do not abruptly discontinue medication
6. Compliance with therapy regimen is essential to
control hypertension.
7. Avoid tasks that require alertness, motor skills
until response to drug is established.
8. Avoid concomitant ingestion of grapefruit juice.

48
GENERIC NAME CELECOXIB

BRAND NAME Celebrex

DOSAGE 200 mg tab, 1 tab BID x 4 days

CLASSIFICATION PHARMACOTHERAPUETIC: NSAID

CLINICAL: Anti-inflammatory

MECHANISM OF ACTION Inhibits cyclooxygenase-2, the enzyme

responsible for prostaglandin synthesis.
Therapuetic effect: Reduces inflammation, relieves
pain

INDICATIONS - Osteoarthritis
- Rheumatoid Arthritis
- Juvenile Rheumatoid Arthritis
- Acute Pain
- Ankylosing Spondylitis
- Hepatic Impairment

CONTRAINDICATIONS Hypersensitivity to aspirin, NSAIDs,

sulfonamides. Treatment of perioperative pain
in coronary artery bypass graft (CABG)
surgery.

CAUTIONS: History of GI disease (bleeding/

ulcers); concurrent use with aspirin,
anticoagu- lants; smoking; alcohol; elderly;
debilitated pts; asthma; renal/hepatic impair-
ment; heart failure. Pts with edema,
cerebrovascular disease, ischemic heart
disease, known or suspected de ciency of
cytochrome P450 isoenzyme 2C9.

SIDE/ADVERSE EFFECTS SIDE EFFECTS: Frequent (16%–5%):

Diarrhea, dyspepsia, headache, upper
respiratory tract infec- tion. Occasional (less
than 5%): Abdomi- nal pain, atulence,
nausea, back pain, peripheral edema,
dizziness, insomnia, rash.

ADVERSE EFFECTS:Increased risk of

cardiovascular events, (MI, CVA), serious,
potentially life-threat- ening GI bleeding.

49
NURSING RESPONSIBILITIES BASELINE ASSESSMENT:
1. Assess onset, type, location, duration of pain/
inflammation
2. Inspect appearance of affected joints for
immobility, deformity, skin condition.
3. Assess for allergy to sulfa, aspirin, or NSAIDS
(Contraindicated)

INTERVENTIONS/EVALUATION
4. Assess for therapeutic response: pain relief,
decreased stiffness, selling, increased joint
mobility, reduced join tenderness, improved grip
strength.
5. Observe for bleeding, bruising, weight gain

PATIENT/FAMILY TEACHING:
6. If GI upset occurs, takes with food.
7. Avoid aspirin, alcohol (increases risk of GI
bleeding)

50
GENERIC NAME KETOROLAC

BRAND NAME Toradol

DOSAGE 30 mg IVTT Q6 x 3 more doses

CLASSIFICATION PHARMACOTHERAPEUTIC: NSAID

CLINICAL: Analgesic, intraocular anti-inflammatory

MECHANISM OF ACTION Inhibits prostaglandin synthesis, reduces

prostaglandin levels in aqueous humor.
Therapeutic effect: Reduces intensity of pain
stimulus, reduced intraocular inflammation

INDICATIONS - Short-term relief of mild to moderate pain

- Allergic Conjunctivits
- Cataract Extraction
- Refractive Surgery

CONTRAINDICATIONS Advanced renal im- pairment, active peptic

ulcer disease, chronic in ammation of GI tract,
GI bleeding/ulceration, history of hypersen-
sitivity to aspirin, NSAIDs. Perioperative pain
in setting of CABG surgery.

CAUTIONS: Renal/hepatic impairment,

history of GI tract disease, predisposition to
uid re- tention, asthma, coagulation disorders,
receiving anticoagulants.

51
SIDE/ADVERSE EFFECTS SIDE EFFECTS: Frequent (17%–12%):
Headache, nausea, abdominal cramps/pain,
dyspepsia (heart- burn, indigestion, epigastric
pain). Occa- sional (9%–3%): Diarrhea.
Nasal: Nasal discomfort, rhinalgia, increased
lacrima- tion, throat irritation, rhinitis. Ophthal-
mic: Transient stinging, burning. Rare (3%–
1%): Constipation, vomiting, atu- lence,
stomatitis. Ophthalmic: Ocular ir- ritation,
allergic reactions (manifested by pruritus,
stinging), super cial ocular in- fection, keratitis.

ADVERSE EFFECTS: Peptic ulcer, GI

bleeding, gastritis, severe hepatic reaction
(cholestasis, jaundice) occur rarely.
Nephrotoxicity (glomerular nephritis, interstitial
nephritis, nephrotic syndrome) may occur in
pts with preex- isting renal impairment. Acute
hypersen- sitivity reaction (fever, chills, joint
pain) occurs rarely.

NURSING RESPONSIBILITIES BASELINE ASSESSMENT:

1. Assess onset, type, location, duration of pain.
2. Obtain baseline renal/hepatic function tests

INTERVENTIONS/EVALUATIONS:
3. Monitor renal/hepatic function tests, urinary
output.
4. Monitor daily pattern of bowel activity, stool
consistency.
5. Observe for occult blood loss.
6. Asses for therapeutic response
7. Be alert to signs of bleeding

PATIENT/FAMILY TEACHING:
8. Avoid aspirin, alcohol
9. If GI upset occurs, take with food, milk
10. Avoid tasks that require alertness, motor skills,
until response to drug established

52
GENERIC NAME CALCITRIOL

BRAND NAME Calcijex

DOSAGE 1 tab OD

CLASSIFICATION PHARMACOTHERAPEUTIC: Fat-soluble vitamin

CLINICAL: Vitamin D analogue

MECHANISM OF ACTION Stimulates calcium transport in intestines,

resorption in bones, and tubular reabsorption in
kidney. Suppresses parathyroid hormone (PTH)
secretion/synthesis.

INDICATIONS - Hypocalcemia on Chronic Renal Dialysis

- Hypocalcemia in Hypoparathyroidism
- Secondary Hyperthyroidism Associated with
moderate to sever CKD not on dialysis

CONTRAINDICATIONS Vitamin D toxicity, hy- percalcemia,

malabsorption syndrome.

CAUTIONS: Immobilization (increases risk of

hypercalcemia), dehydration (in- creases
serum creatinine, risk of hyper- calcemia,
dialysis pts (increases risk of
hypermagnesemia/hyperphosphatemia),
preexisting renal failure (ectopic calci - cation
may occur), impaired hepatic function, renal
osteodystrophy with hy- perphosphatemia.

53
SIDE/ADVERSE EFFECTS SIDE EFFECTS: Cardiac arrhythmias,
headache, pruritus, hypercalcemia,
polydipsia, abdominal pain, metallic taste,
nausea, vomiting, myalgia, soft tissue calci
cation.

ADVERSE EFFECTS:Early signs of overdose

manifested as weakness, headache,
drowsiness, nau- sea, vomiting, dry mouth,
constipation, muscle/bone pain, metallic taste.
Later signs of overdose evidenced by
polyuria, polydipsia, anorexia, weight loss,
nocturia, photophobia, rhinorrhea, pruritus,
disorientation, hallucinations, hyperthermia,
hypertension, cardiac dysrhythmias.

NURSING RESPONSIBILITIES BASELINE ASSESSMENT:

1. Obtain baseline serum calcium, phosphorus,
alkaline phosphatase, creatinine, iPTH

INTERVENTIONS/EVALUATION:
2. Monitor serum, urinary serum calcium levels,
serum phosphate, magnesium, creatine, alkaline
phosphatase, BUN determinations, iPTH
measurements.
3. Encourage adequate calcium intake.
4. Encourage adequate fluid intake.
5. Monitor for signs/symptoms of vitamin D
intoxication

PATIENT/FAMILY TEACHING:
6. Adequate calcium intake should be maintained.
7. Dietary phosphorus may need to be restricted
8. Oral formulations may cause hypersensitivity
9. Avoid excessive doses
10. Maintain adequate hydration.

54
GENERIC NAME TRAMADOL

BRAND NAME Ultram

DOSAGE 50 mg IVTT Q8 x 3 days

PRN for sever pain

CLASSIFICATION PHARMACOTHERAPEUTIC: Centrally acting

synthetic opioid analgesic.
CLINICAL: Analgesic

MECHANISM OF ACTION Binds u-opoid receptors, inhibits re-uptake of

norepinephrine, serotonin. Reduces intensity of
pain stimuli incoming from sensory nerve endings.
THERAPEUTIC EFFECT: Reduces pain

INDICATIONS - Moderate to moderatley severe pain

- Renal Impairment
- Hepatic Impairment
CONTRAINDICATIONS Acute alcohol intoxication, concurrent use of
centrally acting analgesics, hypnotics, opioids,
psycho- tropic drugs, hypersensitivity to
opioids. ConZip, Ryzolt: (Additional) Severe/
acute bronchial asthma, hypercapnia,
significant respiratory depression.

CAUTION: CNS depression, anoxia,

advanced hepatic cirrhosis, respiratory
depression, increased ICP, history of seizures
or risk for seizures, hepatic/renal impairment,
acute abdominal conditions, opioid-de-
pendent pts, head injury, myxedema,
hypothyroidism, hypoadrenalism, pregnancy.

55
SIDE/ADVERSE EFFECTS SIDE EFFECTS: Frequent (25%–15%):
Dizziness, vertigo, nausea, constipation,
headache, drowsi- ness. Occasional (10%–
5%): Vomiting, pruritus, CNS stimulation (e.g.,
nervous- ness, anxiety, agitation, tremor,
euphoria, mood swings, hallucinations),
asthenia (loss of strength, energy),
diaphoresis, dyspepsia (heartburn,
indigestion, epi- gastric pain), dry mouth,
diarrhea. Rare (less than 5%): Malaise,
vasodilation, an- orexia, atulence, rash,
blurred vision, urinary retention/frequency,
menopausal
symptoms.

ADVERSE EFFECTS: Seizures reported in

those receiving tramadol within recommended
dosage range. May have prolonged duration
of action, cumulative effect in pts with he-
patic/renal impairment, serotonin syn- drome
(agitation, hallucinations, tachy- cardia,
hyperre exia)

NURSING RESPONSIBILITIES BASELINE ASSESSMENT:

1. Assess onset, type, location, duration of pain.
2. Assess drug history.
3. Review past medical history.
4. Assess renal/hepatic function lab values.

INTERVENTION/EVALUATION
5. Monitor pulse, BP, renal/hepatic function
6. Assist with ambulation if dizziness, vertigo
occurs
7. Palpate bladder for urinary retention
8. Monitor daily pattern of bowel activity, stool
consistency
9. Sips of tepid water may relieve dry mouth
10. Assess for clinical improvement
11. Record onset of relief of pain

PATIENT/FAMILY TEACHING:
12. Avoid alcohol
13. Avoid tasks requiring alertness, motor skills
until response to drug established.

56
GENERIC NAME PROTAMINE

BRAND NAME Protamine Sulfate

DOSAGE 500cc IVTT side drip to run @ 90cc/hr x 2 cycles

CLASSIFICATION PHARMCOTHERPEUTIC: Protein

CLINICAL: Heparin antagonist, antidote

MECHANISM OF ACTION Combines with heparin to form stable salt.

Therapeutic effect: Reduces anticoagulant activity
of heparin.

INDICATIONS - Heparin overdose

CONTRAINDICATIONS None known.

CAUTION: History of allergy to sh, seafood;

vasecto- mized/infertile men; those on
isophane (NPH) insulin, previous protamine
therapy (propensity to hypersensitivity
reaction).

SIDE/ADVERSE EFFECTS SIDE EFFECTS: Frequent: Decreased B/P,

dyspnea. Occa- sional: Hypersensitivity
reaction (urti- caria, angioedema); nausea/
vomiting, which generally occur in those
sensitive to sh/seafood, vasectomized men,
infer- tile men, those on isophane (NPH) insu-
lin, those previously on protamine ther- apy.
Rare: Back pain.

ADVERSE EFFECTS: Too-rapid IV

administration may produce acute
hypotension, bradycardia, pulmo- nary
hypertension, dyspnea, transient ushing,
feeling of warmth. Heparin re- bound may
occur several hrs after heparin has been
neutralized by protamine (usu- ally evident 8–
9 hrs after protamine ad- ministration).
Heparin rebound occurs most often after
arterial/cardiac surgery.

57
NURSING RESPONSIBILITIES BASELINE ASSESSMENT:
1. Check PT, aPTT, Hct
2. Assess for bleeding

INTERVENTIONS/EVALUATION:
3. Monitor coagulation tests aPTT, or ACT, BP,
cardiac function

58
GENERIC NAME CALCIUM CARBONATE (CaCO3)

BRAND NAME Caltrate 600

DOSAGE 1 tab TID

CLASSIFICATION PHARMACOTHERAPEUTIC: Electrolyte

replenisher.
CLINICAL: Antacid, antihypocalcemic,
antihyperkalemic, antihypermannesmic,
antihyperphosphatemic.

MECHANISM OF ACTION Essential for function, integrity of nervous,

muscular, skeletal systems. Plays an important
role in normal cardiac/renal function, respiration,
blood coagulation, cell membrane, and capillary
permeability. Assists in regulating release/storage
of neurotransmitters/hormones. Neutralizes/
reduces gastric acid.
Therapeutic effect: Replaces calcium in deficiency
states; controls hyperphosphatemia in end-stage
renal disease, relieves heartburn, indigestion

INDICATIONS - Hyperphosphatemia
- Hypocalcemia
- Antacid
- Osteoporosis
- Cardiac Arrest
- Hypocalcemia tetany
- Supplement

CONTRAINDICATIONS alcium-based renal calculi, hypercalcemia,

ventricular bril- lation, digoxin toxicity.

CAUTIONSs: Chronic renal impairment,

hypokalemia, concur- rent use with digoxin.

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SIDE/ADVERSE EFFECTS SIDE EFFECTS: Frequent: PO: Chalky taste.
Parenteral: Pain, rash, redness, burning at
injection site, ushing, feeling of warmth,
nausea, vomiting, diaphoresis, hypotension.
Oc- casional: PO: Mild constipation, fecal im-
paction, peripheral edema, metabolic al-
kalosis (muscle pain, restlessness, slow
respirations, altered taste). Calcium car-
bonate: Milk-alkali syndrome (headache,
decreased appetite, nausea, vomiting, un-
usual fatigue). Rare: Urinary urgency, painful
urination.

ADVERSE EFFECTS: Hypercalcemia: Early

signs: Constipa- tion, headache, dry mouth,
increased thirst, irritability, decreased
appetite, me- tallic taste, fatigue, weakness,
depression. Later signs: Confusion,
drowsiness, hy- pertension, photosensitivity,
arrhythmias, nausea, vomiting, painful
urination.

NURSING RESPONSIBILITIES BASELINE ASSESSMENT:

1. Assess BP, EKG and cardiac rhythm, renal
function, serum magnesium, phosphate,
potassium concentrations.

INTERVENTION/EVALUATION:
2. Monitor BP, EKG, cardiac rhythm, renal function
3. Monitor serum, urine calcium concentrations.
4. Monitor for signs of hypercalcemia.

PATIENT/FAMILY TEACHING:
5. Do not take within 1-2 hours of other oral
medications, fiber-containing foods.
6. Avoid excessive alcohol, tobacco, caffeine.

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GENERIC NAME MUPIROCIN

BRAND NAME Bactroban

DOSAGE Apply during dressing

CLASSIFICATION PHARMACOTHERAPEUTIC: Anti-ineffective

CLINICAL: Topical antibacterial

MECHANISM OF ACTION Inhibits bacterial protein, RNA synthesis. Less

effective on DNA synthesis.
Therapeutic: Prevents bacterial growth, replication.
Bacteriostatic

INDICATIONS - Usual topical

- Usual Nasal
CONTRAINDICATIONS None known.

CAUTIONS: Renal impairment, burn pts.

SIDE/ADVERSE EFFECTS SIDE EFFECTS: Frequent: Nasal (9%–3%):

Headache, rhinitis, upper respiratory
congestion, pharyngitis, altered taste.
Occasional: Nasal (2%): Burning, stinging,
cough. Topical (2%–1%): Pain, burning,
sting- ing, pruritus. Rare: Nasal (less than
1%): Pruritus, diarrhea, dry mouth, epi- staxis,
nausea, rash. Topical (less than 1%): Rash,
nausea, dry skin, contact der- matitis.

ADVERSE EFFECTS: Superinfection may

result in bacterial, fungal infections, esp. with
prolonged, re- peated therapy.

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NURSING RESPONSIBILITIES BASELINE ASSESSMENT:
1. Asses skin for type, extent of lesion

INTERVENTION/EVALUATION:
2. Monitor healing of skin lesions, In event of skin
reaction, stop applications
3. Cleanse area gently, notify physician.

PATIENT/FAMILY TEACHING:
4. For external use only
5. Avoid contact with eyes
6. Explain precautions to avoid spread of
infections.
7. Teach how to apply medication.
8. If skin reaction, irritation develops, notify
physician,
9. If no improvement is noted 3-5 days, contact
physician.

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GENERIC NAME CO-AMOXICLAV

BRAND NAME Amoclav

DOSAGE 1g TAB BID x & days

CLASSIFICATION Penicillin antibiotic

MECHANISM OF ACTION An antibiotic that combines amoxicillin and

clavulanic acid. It destroys bacteriaa by disrupting
their ability to form cell walls. Co-amoxiclav is
active against bacterial infections that have
become resistant to amoxicillin.

INDICATIONS - Infections of:

- respirator tract
- skin and soft tissue
- genitourinary
- ENT
- Scherichia coli
- Proteus mirabills
- Haemophilus influenzaa
- Strep. Pnuemonia
- beta lactamse-producing organisms

CONTRAINDICATIONS - Penicillin hypersensitivity

- history of co-amoxiclav associated penicillin
associated jaundice or hepatic dysfunction.

SIDE/ADVERSE EFFECTS ADVERSE EFFECTS: Lethargy, hallucinations,

seizures, glossitis, sore mouth, furry tongue, n/v,
diarrhea. abdominal pain, bloody diarrhea,
enterocolitis.

NURSING RESPONSIBILITIES 1. Assess bowel pattern before and during

treatments as pseudo membranous colitis may
occur.
2. Report hematuria or oliguria as high doses can
be nephrotoxic.
3. Assess respiratory status
4. Observe for anaphylaxis.
5. Ensure that the patient has adequate fluid
intake during any diarrhea attack.

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GENERIC NAME Eperisone

BRAND NAME Myonal

DOSAGE 50 mg tab TID x 5 days

CLASSIFICATION Muscle Relaxant

MECHANISM OF ACTION Eperisone Inhibits The Vicious Cycle Of

Myotonia By Decreasing Pain, Ischemia,
And Hypertonia In Skeletal Muscles, Thus
Alleviating Stiffness And Spasticity, And
Facilitating Muscle Movement.
INDICATIONS Spastic paralysis in cerebrovascular
diseases, spastic spinal paralysis, cervical
spondylosis, post-op sequelae (including
cerebrospinal tumor), sequelae to trauma
(spinal trauma, head injury), amyotrophic
l a t e r a l s c l e r o s i s , c e r e b r a l p a l s y,
spinocerebellar degeneration, spinal
vascular diseases, other
encephalomyelopathies. Improvement of
myotonic symptoms in cervical syndrome,
periarthritis of the shoulders & lumbago,
tension-type headache.

CONTRAINDICATIONS • Hypersensitivity

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SIDE/ADVERSE EFFECTS Sleepiness, Headache, Diarrhea,

Constipation, Abdominal Pain, Rashes,

Nausea And Vomiting, Anemia, Urinary
Retention.

NURSING RESPONSIBILITIES • Assess the patient for occurrence of

side effects.
• Advice client to stop using medication
if severe side effects occur.
• Advice client to seek physician
immediately when drug is not working.

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XVII. NURSING THEORIES

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XVIII. NCPS

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XIX. PROGNOSIS

Criteria Good (3) Fair (2) Poor (1) Justification

Duration of ✓ RS had the neck mass for 5 years
Illness without associated s/sx and was
tolerated. She decided to have the goiter
removed, and underwent total
thyroidectomy which eliminated the
non-toxic goiter.
Onset of Illness ✓ RS has been annually getting medical
attention for her slow growing neck
mass, although it took 5 years before
she decided to have it removed, there
were no associated s/sx and no further
complications. As soon as the neck
mass has grown large, she immediately
got herself checked and decided to have
it removed.
Precipitating ✓ RS is a vegetarian and would be hard to
Factors change her diet, although the patient
verbalized that she is willing to try to
adjust and learn to eat food rich in
iodine to prevent the reoccurrence of
the condition.
Predisposing ✓ RS does not have a family history of
Factors goiter and is currently following the
treatment regimen that would help in
the elimination of the goiter.
Treatment ✓ RS is undergoing treatment such that
the patient agreed on interventions of
the health care team, including the
physician and the nurses. Her
medications are give to her on right
time and right dose
Family Support ✓ RS family is supportive with her
decisions and helps her throughout the
onset of the disease.

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 Criteria Good (3) Fair (2) Poor (1) Justification
Environmental ✓ Patient is not exposed to radiation and
Factors other toxic chemicals. The patient lives
in a well environment at Buenevista,
Agusan.

Calculations: Range of Value

Good: 3 x 6 = 18 1.0 - 1.6 POOR
Fair: 2x1=2 1.7 - 2.3 FAIR
Poor: 1 x 0 = 0 2.4 - 3.0 GOOD
Total: 15/7 = 2.5

Application
As results show, the patient has a good prognosis with a score of 2.5. The patient was
able to seek medical attention regarding her condition before the illness worsened. During the
consultation the patient immediately agreed on the procedures that were to be done to lead to a
good outcome. Patient was given treatment regimens that she chooses to follow and is willing to
follow the health teachings that was given to her in order to prevent the reoccurrence of the
disease.


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XX. DISCHARGE PLANS
MEDICATION
1. Inform both patient and significant other about importance of continuing medications.
2. Educate both patient and significant about patient’s medications.
3. Inform both patient and significant about prescribed medications, especially the indication.
4. Instruct both patient and significant to seek physician immediately if any bizarre reactions

occur.
EXERCISE
1. Educate patient about active exercises that the patient can perform up to her capability to
promote blood circulation.
2. Instruct patient to have assistance in performing exercises for safety measures.
3. Educate patient about refraining from doing activities beyond her body’s limit & workload.
4. Instruct patient to avoid doing activities that would cause great effort/exertion.

TREATMENT
1. Instruct patient and significant other about following the medication orders given by the
physician.
2. Discuss the importance of taking medications religiously.

3. Discuss proper dressing of wound site such as keeping the site dry, changing the gauze when it
is soaked, putting anti-septic solutions when cleaning the site.
HYGIENE
1. Discuss to the patient about maintaining good oral and body hygiene.
2. Educate the patient about the importance of hand washing before and after especially before

and after handling/touching the wound site.

3. Educate patient about hygienic practices when in contact with other people.
OUT PATIENT ORDERS
1. Instruct patient to religiously follow discharge plan.
2. Encourage patient to have a follow-up check-up by giving her the details on when she is scheduled,
specifically the date and time, and the physician.
3. Educate patient and family about the maintenance of medications.

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4. Discuss the importance of attending or having regular check-ups: to monitor health state.
DIET
1. Instruct patient and family about the diet of the patient, which is taking food that is high in iodine such
as seafood and cow’s milk.
2. Educate patient about what food are included in high iodine diet.
3. Educate patient to lessen green leafy foods in her diet since these food categories are low in iodine.
4. Limit sodium and fat intake.
SPIRITUALITY
1. Encourage patient not to lose hope, still engage and develop spiritual aspect in life.
2. Encourage family to always communicate with patient about not losing faith and keep on hoping and
praying 4together for a better outcome.
 


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XXI. RECOMMENDATIONS

Studying the case of this patient, the student-nurse has learned information about non-
toxic multi nodular goiter. Upon the acquisition and study of this knowledge, the student-nurse
has formulated some recommendations they deemed necessary to share:

To the patient
The patient is highly encouraged to the compliance of her medications and interventions
that the health care providers give to her. The patient is also highly encouraged to communicate
any concerns and any signs and symptoms that have just emerged, worsened, or improved to let
the healthcare providers perform the necessary care.

To the Nursing Education

The school of nursing is recommended to continue to teach their students the proper
techniques and procedures to improve their skills. The school of nursing is recommended to
continue letting their students be exposed to different areas of the field for them to experience the
different types of diseases and witness first-hand the progression of the disease. Along with this,
the students would be able to perform the techniques and skills they have learned in the
classroom setting. The school of nursing is recommended to keep on moving forward in training
their students to continue on producing graduates that are knowledgeable on the different updates
of the different skills that will be applied in their nursing profession.

To the Nursing Practice

It is highly encouraged to step up the nursing practice of each individual. The challenges
facing the health care system and the nursing profession are complex and numerous. Challenges
to nursing practice include regulatory barriers, professional resistance to expanded scopes of
practice, health system fragmentation, insurance company policies, high turnover among nurses,
and a lack of diversity in the nursing workforce. There is a need for greater numbers, better
preparation, and more diversity in the student body and faculty, the workforce, and the cadre of

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researchers. These challenges also include the need for leadership competencies among nurses,
collaborative environments in which nurses can learn and practice, and engagement of nurses at
all levels.

To the Nursing Research

I encourage that student nurses be engage into the nursing research and apply it to the
field. The nursing research should continually go on and be broad enough to guide the students
in attaining their full potential as health care providers. Through this, we may achieve a great
body of data and reference which may help in the collaboration of ideas of the health care
providers all around the world whom are performing care to others.

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XXII. BIBLIOGRAPHY
Porth, C., Matfin, G., & Porth, C. (2009). Pathophysiology: Concepts of altered health states.
Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Huether, S.E, & McCance, K.L. (2017). Undesrtanding Pathophysiology 6th Edition.St. Louis, Missouri
63043: Elsevier.

Townsend, M.C. (2009). Psychiatric Mental Health Nursing 6th Edition. F.A Davis Company

Tortora, G.J., & Derrickson, B. (2006.) Principles of Anatomy and Physiology. Von Hoffman Press, Inc.

Grabowski, S.R., Riesch, B. & Tortora, G.J. (2000). Principles of Anatomy and Physiology. Von Hoffman
Press, Inc.

Williams, L.S. & Hopper, P.D. (2015). Understanding Medical-Surgical Nursing. F.A. Davis Company

Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2013). Nurse’s Pocket Guide: Diagnoses, Prioritized
Interventions, and Rationales. F.A Davis Company

Skidmore-Roth, L. (2015). Mosby’s Nursing Drug Reference 28th edition. Elsevier Inc. Berman, A.T.,
Snyder, S., Kozier, B.J. & Erb, G. (January 8, 2007). Kozier & Erb’s

Fundamentals of Nursing. Pearson Copyright.

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