I.

General Profile

Name: Mr. F
Age: 44 years old
Sex: Male
Marital Status: Married
Occupation: Farmer
Address: Ambuklao Road, Baguio City
Religion: United Church of Christ of the Philippines

II. Chief complaint

 Mass on the neck area for 2 years

 Difficulty of breathing for 5 days
 Difficulty of swallowing for 4 days

III. History of Present Illness

a. Complaint/s

Chief complaint is mass on the neck area for 2 years prior to admission. He describes an enlargement in the area of the neck and the feeling that there is an
obstruction. He also claimed experiencing dyspnea for 5 days accompanied by dysphagia for 4 days.

b. Duration

Chief complaint of mass on the neck area for 2 years prior to admission. The problem progresses that he needed a supply of oxygen at 1 – 2 liters per minute via
nasal cannula due to difficulty of breathing and compliance for liquid or soft diet suitable for his difficulty of swallowing.

c. Domain/ Localization

The localization of the mass happens in the anterior part of the neck just under the skin and in front of the Adam’s apple.
 d. Progression

2 years prior to admission, patient experience enlargement of his thyroid followed by difficulty of breathing and swallowing.

e. Character

Upon assessment, there was an enlargement on the anterior part of the neck just under the skin and in front of the Adam’s apple accompanied by distortion in the
appearance of the neck. Difficulty of breathing was noted with the presence of wheezing sounds upon auscultation that leads him to labored breathing evident by
labial respiration, the mouth held slightly open and the corners of the lips are retracted and the use of accessory muscles accompanied by difficulty of swallowing.

f. Relation to Physiological Function

Patient’s condition truly influence his usual way of living. He already has limitations in his diet in which he must comply to a strict diet of goitrogen free foods or
goiter – producing agents that inhibit thyroxine production like cabbage, soybeans, peanuts, strawberries, radish, and cabbage well in fact he also wanted to eat
cabbage and as long as his job is concern, his earnings are coming from planting cabbage and strawberries. He was refrained from farming since he suffers from
difficulty of breathing as he is avoided to be tired. Difficulty of breathing exacerbate during activities like plowing in the farm and through rest or sleep as he is in
supine position. He was also having trouble about his diet that he is oblige to comply with liquid or soft diet which is easy to swallow. He feels disturbance of body
image owed to the enlargement on his neck that he is already anxious of leaving elsewhere because of people’s reaction to his appearance. The large mass on his
neck affect his posture. The client cannot bow his head. When he walks, he stands straight because there is slight pain on his neck.

IV. Past Medical History

The client has no history of hospitalization even with the presence of mass on his neck for 2 years. He did not seek for any medical consultations since he did not
feel any serious manifestations of the mass on his neck aside from its enlargement. He has not taken any drugs that aggravated his condition. He has no allergies to
food or drug medications. The client has past history of hypertension and diabetes. However, he did not take any drug or undergo any treatment for his hypertension.

V. Social and Environmental History

Mr. F is an Ibaloi and resides with her wife in Ambuklao Road, Baguio City. He is 44 years old, married and with three children. He belong lower middle class
where financial necessity is just enough. The family’s income is enough to sustain the needs of every family member. His wife works as farmer at Ambuklao along
with him prior to admission. Farming is the source of income in the family and is enough for the family since they owned the land used for farming. Their house is
along the road and is semi – concrete. The house is not well ventilated and the rooms are enough for his family. The house is near in the hospital to have an easy
access when feeling sick.

VI. Family History

The patient has a family history of disease like hypertension especially on maternal sides.

VII. Physical Examination

 General Survey
The client is lying on bed in semi – fowler’s position with an ongoing IVF of PNSS 1 liter regulated at 25 gtts/min. He has difficulty of breathing noted upon
admission.

 HEENT

Patient’s head is proportionate to his body. Color of hair is black among are hairs of colors brown and white. He is bald on the frontal portion of head. No lice or any
parasites found on the scalp and no masses palpated during physical assessment. The pupils are equally rounded and reactive to light. The patient does not use any
eye wares and does not have any problems with his vision. The patient is able to identify objects at a specified distance. He can also recognize voices and noise
around him and does not use any hearing aids. No ear swelling, inflammation, or tenderness noted. Patient has a minimal difficulty of distinguishing smell around
him linked with the enlargement of the thyroid, which impedes the detection of olfactory stimuli. Gums have no lesions and no dental carries noted. Mass is
palpated on the neck specifically in the anterior part of the neck just under the skin and in front of the Adam’s apple. Patient has difficulty of swallowing associated
with the enlargement of his thyroid that causes the compression of trachea and esophagus, which obstructed the passageway of food.

 Respiratory System

Wheezing sounds heard upon auscultation due to the compression of trachea and esophagus. Difficulty of breathing was noted and his respiratory rate ranges from
20 – 25 cycles per minute. He uses accessory muscles while breathing accompanied by labial respiration. The patient is hooked to oxygen inhalation at 1 – 2 liters
per minute via nasal cannula.

 Cardiovascular System
His pulse rate ranges from 85 – 90 with regular rhythm but has weak pulsation. His blood pressure ranges from 130/100– 150/110 mmHg. The heart sound is normal
upon auscultation and is regular in rhythm. Intensity is soft, but heard with every beat. No murmurs, gallops, rubs, or clicks auscultated. Heart sounds are
appreciated as “lubb – dupp”

 Gastrointestinal System

No wounds, lesions, or scars found on his abdomen and rectum. No problem noted concerning his stomach. He neither is constipated nor experiencing hyperacidity.
The patient has no problem on defecation. Patient has no any disorder in digestion, absorption, and defecation except he has difficulty of swallowing that impairs in
ingestion because of the obstruction in the esophagus. No any other problem like gastroesophageal reflux the patient have incurred aside from the obstruction of the
passageway of food.

 Genito – Urinary System

Patient urinates accordingly to input of fluid. The patient’s input of fluid is 5 – 7 glasses of water a day. Color of urine is amber, clear, and mildly aromatic in odor.
He urinates about 1 – 2 times within an eight – hour shift. He defecates once within shift. Color of stool is brownish and semisolid. No wounds, lesions, or scars
found on his genital or rectum. No disorders found regarding elimination patterns.

 Musculo – Skeletal System

Upon musculo – skeletal assessment, no hypertrophy or atrophy noted by comparing the limbs one side with the other. Muscles strength is normal in the score of 5/5
means the person completes full range of motion against normal resistance and gravity for upper and lower extremities excluding to head and neck part. No
tenderness noted except for the neck. The enlargement on his neck affected the patient’s posture. The patient is often on straight pose and he has difficulty of moving
his head and neck. However, the patient can perform activities of daily living and seldom needs assistance.

 Integumentary System

Patient is fair in complexion; color distribution is proportionate to the entire body and skin is dry. Patient’s skin is warm to touch upon palpation. Skin is rough in
texture and has a good skin turgor upon skin pinch, which returns quickly to its original position. No wound, lesions, abrasions, scars or bruises noted in any part of
the body. No clubbing of nails found and capillary refill is 1 – 2 seconds.
VIII. Diagnostics – Laboratory
Hematology Test

Date and Time the Diagnostic Description of the Diagnostic Significance/ Purpose of the
Diagnostic Procedure Implications of the Findings
Procedure Conducted Procedure Procedure
Hemoglobin Count The hemoglobin test is Measure the severity of The patient’s hemoglobin level
normally ordered as a part of anemia or polycythemia, is within the normal range. No
the complete blood count, monitor the response to indications of anemia,
which is ordered for many treatment of anemia or erythropoietin deficiency,
different reasons, including for polycythemia, and help make bleeding, or any condition that
a general health screen. Used decisions about blood may indicate low hemoglobin
to determine how much transfusions if the anemia is level. Furthermore, no
hemoglobin a patient has in his severe. indications of polycythemia
or her body. This test is vera, excess erythropoietin, or
usually performed as part of a any condition that may
complete blood count, a indicate elevated hemoglobin
routine screening that checks level.
on the levels of a number of
blood components. Levels of
hemoglobin that differ from
the normal can be indicative of
a wide variety of health
problems, and this test can be
a very useful diagnostic tool.
Additionally, people may
utilize hemoglobin tests to
monitor the progress of
various medical conditions,
such as anemia.

Leukocyte Differential Count The white blood cell count and The white blood cell count The patient’s lymphocyte level
 differential determine the
number of white blood cells
and the percentage of each
type of white blood cell in a
person's blood. There are five
types of white cells, each with
different functions:
neutrophils, lymphocytes,
monocytes, eosinophils, and
basophils. The differential
reveals if these cells are
present in a normal
distribution, or if one cell type
is increased or decreased. This
information helps diagnose
specific types of illness. These
tests are included in general
health examinations and help
investigate a variety of
illnesses, including infection,
allergy, and leukemia.
provides a clue to the presence is within normal range.
of illness. White cells protect No indications of bacterial
the body by fighting infection infections, inflammation,
and attacking foreign material. leukemia, trauma, and stress or
When extra white cells are any other condition that
needed, the bone marrow indicate leukocytosis. No
increases production. indications of autoimmune
Conditions or medications that diseases, bacterial infections or
weaken the immune system, any other condition that may
such as AIDS or indicate leukopenia.
chemotherapy, cause a
decrease in white cells. The
white cell count detects
dangerously low numbers of
white cells. Recovery from
illness can be monitored by the
white cell count. Counts
continuing to rise or fall to
abnormal levels indicate a
worsening condition; counts
returning to normal indicate
improvement

Date and Time the Diagnostic Description of the Diagnostic
Diagnostic Procedure
Procedure Conducted Procedure
Serum Test for TSH and T4 The TSH test is often the test
of choice for evaluating
thyroid function and/or
symptoms of hyper- or
hypothyroidism. It is
frequently ordered along with
Significance/ Purpose of the
Procedure
The purpose of TSH testing is
to diagnose a thyroid disorder
in a person with symptoms,
screen newborns for an
underactive thyroid, monitor
thyroid replacement therapy in
Implications of the Findings
Serum thyroid test falls within
normal levels. Depletion of
glandular organic iodine along
with impaired hormone
synthesis increases the
thyroid’s responsiveness to
 or preceding a T4 test. Other
thyroid tests that may be
ordered include a T3 test and
thyroid antibodies (if
autoimmune-related thyroid
disease is suspected).
Date and Time the Diagnostic Description of the Diagnostic
Diagnostic Procedure
Procedure Conducted Procedure
Chest x – ray A chest x-ray makes images of
the heart, lungs, airways,
blood vessels, and the bones of
the spine and chest. An x-ray
(radiograph) is a noninvasive
medical test that helps
people with hypothyroidism normal TSH and T4 levels.
diagnose and monitor female Although the patient has a
infertility problems, goiter, his metabolic functions
help evaluate the function of are normal.
the pituitary gland
(occasionally), and
screen adults for thyroid
disorders, although expert
opinions vary on who can
benefit from screening and at
what age to begin. Whether
high or low, an abnormal TSH
indicates an excess or
deficiency in the amount of
thyroid hormone available to
the body, but it does not
indicate the reason why.
Additional testing to
investigate the cause of the
increase or decrease usually
follows an abnormal TSH test
result.
Significance/ Purpose of the
Implications of the Findings
Procedure
Chest x rays are ordered for a Chest is normal. There are no
wide variety of diagnostic active lung infiltrates. The
purposes. In fact, this is heart is not enlarged. Bones
probably the most frequently are intact.
performed x ray exam. In
some cases, chest x rays are
 physicians diagnose and treat
medical conditions. Imaging
with x-rays involves exposing
a part of the body to a small
dose of ionizing radiation to
produce pictures of the inside
of the body. X-rays are the
oldest and most frequently
used form of medical imaging.
ordered for a single check of
an organ's condition, and at
other times, serial x rays are
ordered to compare to
previous studies. Some
common reasons for chest x
rays include: Pulmonary
disorders, Cancer, and Cardiac
disorders

Date and Time the Diagnostic Description of the Diagnostic
Diagnostic Procedure
Procedure Conducted Procedure
Ultrasound Ultrasound imaging, also
called ultrasound scanning or
sonography, involves exposing
part of the body to high-
frequency sound waves to
produce pictures of the inside
of the body. Ultrasound exams
do not use ionizing radiation
(as used in x-rays). Because
ultrasound images are captured
in real-time, they can show the
structure and movement of the
body's internal organs, as well
as blood flowing through
blood vessels. Ultrasound
imaging is a noninvasive
medical test that helps
physicians diagnose and treat
Significance/ Purpose of the
Procedure
An ultrasound of the thyroid is
typically used to help diagnose
a lump in the thyroid and a
thyroid that is not functioning
properly. Because ultrasound
provides real-time images, it
also can be used to guide
procedures such as needle
biopsies, in which needles are
used to extract sample cells
from an abnormal area for
laboratory testing. Ultrasound
may also be used to guide the
insertion of a catheter or
drainage device and helps
assure accurate placement.
Implications of the Findings
The right thyroid is enlarged
with a nodule with a cystic
component seen measuring 2.5
x 2.1 x 2.6 cm. No abnormal
calcifications seen. The left
thyroid is not enlarged with a
homogenous parenchymal
echopattern. The isthmus is not
thickened. No focal lesions
seen. A separated cystic mass
is seen anterior to the isthmus
measuring 1.7 x 0.9 x 1.7 cm.
The vascular structures are
unremarkable.
 medical conditions.

IX. Medical Diagnosis – Final/ Principal Diagnosis

 Nodular Non – Toxic Goiter

X. Comprehensive Pathophysiology and Management

XI. Treatment/ Management

a.

Trade Name and Generic Classification of the Drug Mechanism of Action Side Effects Nursing Interventions
Name

Generic Name: Pharmacotherapeutic: -Potent vasodilator. An >Dizziness -Maintain hydration

angiotensin II receptor >Diarrhea -Assess for evidence of upper
Losartan Angiotensin II receptor antagonist, blocks >Cough respiratory infection, cough.
antagonist vasoconstrictor and >Insomnia -Assist with ambulation if
Brand Name: aldosterone- secreting effects >Dyspepsia dizziness occurs.
Clinical: of an angiotensin II, inhibiting >Heartburn -Monitor stool frequency and
Cozaar the binding of angiotensin II to >Muscle cramps consistency.
Antihypertensive the AT, receptors, causing >Nasal congestions
vasodilation, decreased
peripheral resistance, decrease
in Blood Pressure.

b.

Component of the Fluid/s Classification of the Fluid/s Effects or Use/s Significance

 Plain Normal Saline Solution
Isotonic Solution Contain the same concentration of
solute as another solution. When a cell
is placed in an isotonic solution, the
water diffuses into and out of the cell
at the same rate. The fluid that
surrounds the body cells is isotonic.
Use to restore vascular volume and
have the same concentration of solutes
as blood plasma. It has a total
osmolality close to the extracellular
fluid and does not cause red blood cells
to shrink or swell. To avoid
thrombus formation in blood
transfusion.

XII. Nursing Diagnosis – Prioritization of Problems

Actual Problem
1. Ineffective Breathing Pattern
2. Impaired Swallowing
3. Disturbed Body Image

Potential Problem
1. Risk for Imbalance Nutrition: Less than Body Requirements
2. Risk for Activity Intolerance

Nursing Care Plan

Actual: Ineffective Breathing Pattern

Assessment Explanation of the Objectives Nursing Intervention Rationale Evaluation

Problem

Actual: Impaired Swallowing

 Assessment Explanation of the Objectives Nursing Intervention Rationale Evaluation
Problem

Actual: Disturbed Body Image

Assessment Explanation of the Objectives Nursing Intervention Rationale Evaluation

Problem

Potential: Risk for Imbalance Nutrition: Less than Body Requirements

Assessment Explanation of the Objectives Nursing Intervention Rationale Evaluation

Problem

Potential: Risk for Aspiration

Assessment Explanation of the Objectives Nursing Intervention Rationale Evaluation

Problem

XII. Discharge Plan

Criteria Health Teachings

a. Diet Dietary concern in treating goiter and treating iodine deficiency is ensuring
adequate intake of iodine. Iodine is found naturally in foods from ocean, such as
seafood, fish and sea vegetables. It is also found in the plants and animals
products produced in areas where soil and water contain sufficient amount of
iodine.
 Avoid drinks like alcohol, carbonated drinks, and coffee. Food with very high
sugar must also be avoided. Heavy and sour foods should be used very
occasionally as they trigger the symptoms of Goiter.
b. Activities Low exercises such as neck stretches help to stretch the muscles attached with
the thyroid gland. Walking for 30–45 minutes every day is also recommended.
c. Medications Advise the patient to finish her medications
Instruct the patient to follow the doctor’s order.
Continue the prescribe medication given and do not increase dose.
d. Others:

XIII. Conclusions and Recommendations

XIV. List of References

XV. Appendices