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HEALTH HISTORY
I. BIOGRAPHIC DATA
Name: Teresita Dacles
Address: #165 A. Luna St. Barangay Salapan, City of San Juan, Metro Manila
Age: 63 years old
Gender: Female
Dateof Birth: April 21, 1958
Place of Birth: Cantanduanes
Primary Language: Tagalog
Marital Status: Separated
Educational: Elementary Graduate
Occupation: Laundry woman
Religious Orientation: Roman Catholic
II. PAST HEALTH HISTORY
Though the client had complete immunizations during her childhood years, she still
suffered from many childhood diseases such as measles, chicken pox, and mumps. During the
interview, the client mentioned that she was allergic to foods such chicken, egg, sea foods,
and eggplants. She said that she also experienced allergic reactions when she dyed her hair
during her middle age years. Mouth sores and rashes were some of the manifestations that
could be seen whenever she has allergic reactions. Other than those that have mentionedearlier, there were no other foods or drugs that cause allergy to the client. Her physician
prescribed Anthraquinone Glycosides Salicylic Acid when she once had an allergy, and from
then on, she kept on using it whenever an allergy occurs. The client was currently taking
Metformin Hydrocloride as maintenance for Diabetes Mellitus. Aside from the maintenance,
she was also taking vitamin B-complex because her physician said that it would improve her
arthritis. The client had never been hospitalized and she did not suffer from any injuries or
accidents even in her childhood days up to now, although she had been diagnosed to have
UTI last 2010. The client added that she has been cured without taking medications by just
increasing water intake and drinking buko juice frequently. She had neither local nor foreign
travels in the past month; however, she came home to Bicol where her relatives lived last
May 2011.
III. FAMILY HEALTH HISTORY
Both sides of the clients parents had history of asthma. It was passed to four of her
siblings. Fortunately, she was not one of them. Her mother died due to heart attack at the age
of 75, while her father was still alive, but diagnosed to have asthma. Their family did not
have any history of hypertension, renal diseases, cardiovascular diseases, mental disorders,
cancer and diabetes mellitus or thyroid disorders; however, she was diagnosed to have
diabetes mellitus type II and goiter. One of her siblings died because of asthma attack, while
the other one died due to lung cancer.
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IV. FUNCTIONAL PATTERNS
D. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN
The client verbalized that her health is good, because she can do her activities of dailyliving without difficulties and she also does not get sick easily. She had been visiting her
physician every three months for her check-up, and she strictly follows whatever the
physicians orders are. Whenever she experiences dizziness and head ache, she just takes a
rest until she feels better, and if not relieved, she takes Biogesic. She has not been taking any
over-the-counter drugs except for Biogesic. She has been diagnosed to have sporadic goiter
when she was carrying her fourth child in her womb (1988), but even after her pregnancy, she
does not have any plans of undergoing any procedures. She verbalized, natakot akong
magpaopera kasi yung pinsan ko nagkaroon din ng goiter, pinaopera niya. Pagkalipas ng
tatlong buwan, bumalik din yung goiter niya. The client also verbalized, Pinainom naman
na ako nung doktor ko ng pampaliit ng bukol, eh lumiit naman sya, kaya binale-wala ko na.
As for her exercise, she has been doing the household chores everyday and every 4:00 a.m.,
she sweeps the street in front of the store of her daughter. She takes a bath twice a day, and
brushes her teeth thrice a day. She does not visit a dentist for dental check-ups, because she
does not have time to do so. She does neither cigarette smoking nor drinking any alcohol
beverages.
ANALYSIS: Health-Perception-health Management patterns are influential in moving
individuals, families, and communities toward their optimal level of human functioning. The
two dimensions of this pattern interact: the way clients perceive their general health and
health goals influences their health management practices. [Nursing Diagnosis p. 141]
E. NUTRITIONAL & METABOLIC PATTERN
According to the client, she eats 3 meals a day and she takes her food slowly because
she is having a slight difficulty in swallowing because of the mass in her throat. The dishes
that she usually eats are made up of vegetables, since her physician advised her not to eat somuch meats, legumes and sweets, as well as eggs due to her arthritis, goiter, diabetes mellitus
and allergies. She drinks a cup of coffee for about once a day and 3-4 glasses of water per
day. The client experienced neither weight loss nor weight gain as much as her appetite is
neither increased nor decreased.
ANALYSIS: Diagnosis describing dysfunctional nutritional-metabolic patterns are bio
psychosocial conditions related to nutrient intake and supply. Nutrients are necessary for
cellular metabolic processes, such as energy production and synthesis of substances used incellular function, growth and repair. Nutritional patterns are influenced by (1) Maturation,
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(2) Family, Social and Cultural patterns, (3) Learned psychological associations between
food and basic needs, (4) Environmental availability of foods. For example: as growth and
maturation proceed, the type of foods ingested, method of ingestion, and the social
psychological milieu of eating changes. Bottles and high chairs are replaced by family
silverware and social dining. Bio Psychosocial factors (including cultural and spiritual) canlead to dysfunctional patterns, such as exogenous obesity and nutritional deficit. [Nursing
Diagnosis p. 143]
F. ELIMINATION PATTERN
The client defecates once a day, and she added, Okay naman yung dumi ko, hindi
naman matigas, hindi rin matubig. Sakto lang. Hindi naman ako nahihirapan dumumi. As
she estimated the number of times she urinates a day, she said four to six, and as she
verbalized, Hindi naman mapusyaw, yung normal na kulay lang, hindi naman madilaw na
madilaw ang ihi ko. Hindi naman din masakit pag umihi. She does not have excess
perspiration and odor problems.
ANALYSIS: Elimination from the urinary tract helps to rid the body of waste products and
materials that exceed bodily needs. Problem involving urinary elimination can be so
embarrassing to patients that they may no longer participate in activities outside the home.
[Taylor p. 1289]
Elimination of the waste products of digestion is a natural process critical for human
functioning. Patients differ widely in their expectations about bowel elimination, their usual
pattern of defecation, and the ease with which they speak of bowel problems although most
people have experienced minor acute bouts of diarrhea or constipation, some patient
experienced severe or chronic alterations in bowel elimination that affect their fluid and
electrolyte balance, hydration, nutritional status, skin integrity, comfort, and self-concept.
Moreover, many illnesses, diagnostic tests, medications, and surgical treatments can affect
bowel elimination. [Taylor p. 1337]
G. ACTIVITY- EXERCISE PATTERN
Every 4:00 a.m., she sweeps the street in front of the store of her daughter and she
helps in the store whenever there are many costumers. She also has a work, where she does
the laundry three times a week and during her free days, she washes her and her daughters
clothes. She does household chores for exercise. She does not engage with heavy work orexercise because of her goiter, she added, Masakit kasi kapag nagbubuhat ako ng mabigat o
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di naman kayay kapag napapagod ako. Alam mo yung parang nakakasakal yung bara sa
lalamunan. She is satisfied with the amount of her exercise that she has been doing because
she can do her work properly. Whenever she has a spare time, she spends it helping her
daughter in managing their store and in taking care of her grandchild.
ANALYSIS: The clients pattern of activity, exercise and leisure is a result of bio
psychosocial factors. The pattern describes the clients ability and desire to engage with
energy-consuming activities, such as play (child), work, exercise, self-care, and leisure.
Ability is influenced by the development of coordination, strength, skill, endurance, and
nutrients supply to tissues (cardiovascular and respiratory reserve). Loss of ability to engage
in activities of daily living is associated with feelings of dependency and lack of control over
the immediate environment. The desire to do energy-consuming activities and the choice of
activities are influenced by psychological and socio-environmental factors such as
motivation, mood state, and personal perception of benefits, risks, skill, and social
acceptability. [Nursing Diagnosis p.146]
H. SLEEP-REST PATTERN
She usually sleeps at 9:00 p.m. and wakes up at 4:00 a.m. She often has seven hours
of sleep and when she wakes up, she feels refreshed. She can easily fall asleep. Sometimes,
the sleeping pattern of the client is disturbed because of the barks of dogs outside her house,
and also when she feels the urge to void. More often than not, she has difficulty in going backto sleep, but eventually, she will sleep again. She takes a nap sometimes if there is chance.
ANALYSIS: Sleep is a basic human need; it is a universal biological process common to all
people. Humans spend about one-third of their lives as sleep. Sleep enhances daytime
functioning. It is vital not only optimal psychological functioning but also physiological
functioning as the rate of healing of damaged tissue is greatest during sleep. [p.1164 Kozier]
I. COGNITIVE-PERCEPTUAL PATTERN
While the interaction is going on, our client is cooperating well and she is confident
during the interview. She stated that she can read and write. However, she can only read
well with the use of her correction glasses. The client does not have any problem in
listening, speaking, and smelling.
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ANALYSIS: Pertaining to the mental processes of knowing, perceiving, or being aware; an
expression of intellectual capacity. In the case of our patient, she is educated and is actively
participating in her school activities. She is very much aware of her cognitive condition. A
patient with enough knowledge with her health situation is better than those who do not
know. Collaborating with any health care provider will help a lot in his restoration ofwellness. [Nursing Diagnosis p.150-151]
J . SELF-PERCEPTION AND SELF-CONCEPT PATTERNS
She described herself as a happy and jolly person, and she feels good most of the
time. She is not having a hard time in socializing with her family members and friends. She
added, Okay naman, tingin ko naman, wala naman akong kaaway. She handles her
problems lightly, and like what she said, Binabalewala ko na lang yung problema, lalo lang
nakakatanda. Matanda na nga ako, iisipin ko pa ba yun? \
ANALYSIS: Self-concept is ones mental image of oneself. A positive self-concept is
essential to a persons mental and physical health. Individuals with a relationship and resist
psychological illness. [Kozier p.970]
K. ROLE- RELATIONSHIP PATTERN
She lives with her sister, youngest daughter and son-in-law. She takes care of her
youngest daughter who is pregnant. They have a good relationship with each other. The only
problem that she encountered in her relationships was when she and her husband separated
ten years ago because her husband had an affair with other woman. She also considers her
son, as mentioned above, a problem whenever he comes home drunk. She is not a member of
any social groups in their community, but she has a good relationship with her neighbours.
ANALYSIS:People establish relationships to meet the human need for contact andinteraction with others. Role and Relationship serves as a structure for family units,
friendships, works and play, community group and society. Dysfunctional patterns of role
performance, interactions, and relationship can be the source of developmental problems or
role stress in persons, families for communities. [ND 154}
L. SEXUALITY-REPRODUCTIVE PATTERN
Her first menstruation started when she was 18 years of age. She had regular
menstruation before, until the age of 59 when she got menopaused. Since when she had
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separation from her husband, she never had any other affair and any sexual activity from then
on up to the present.
ANALYSIS: Sexuality is degree to which a person exhibits and experiences maleness orfemaleness physically, emotionally and mentally. Sexuality is define not only by the persons
genitalia but also by attitudes and feelings. It can also be define as learned behaviours in
how a person reacts to his or her own sexuality and by how one behaves in relationships with
others. Sexuality is an integral part of a persons identity and is present in ones demeanor
through actions, communications, and physical appearance. [Taylor p.931]
M. COPING-STRESS TOLERANCE PATTERN
She feels happy most of the time, but if she feels stressed, she usually talks to her
sister about her problems. She is not taking any medicines to cope with her stress; she only
takes a rest. If she feels angry, she screams to release her feelings and emotions.
N. VALUE-BELIEF PATTERN
The client has a very strong faith with God. Even though she is busy, she always finds
time to pray at night and in the morning and attend mass every Sunday. Like what she said,
Dapat unahin ang Diyos, higit sa kung ano pa man. Aside from that, she also takes care ofherself well because she believes that Health is wealth.
ANALYSIS: Values, beliefs, goals and life commitments guide the choices made by a person,
family, or community; they can influence the evaluation of situations in terms of personal
meaning. Thus, values, beliefs, goals and commitments can explain why a situation may be
stressful for one patient and not other and why one person is highly motivated in a situation
and another is not. [Nursing Diagnosis p.160]
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Institute of Nursing
Nursing Care Plan
CUES NURSING DIAGNOSIS ANALYSIS GOAL AND OBJECTIVE INTERVENTION R
Subjective:
She does not have any plans
of undergoing any
procedures. She verbalized,
natakot akong magpaoperakasi yung pinsan ko
nagkaroon din ng goiter,
pinaopera niya. Pagkalipas
ng tatlong buwan, bumalik
din yung goiter niya.
The client also verbalized,
Pinainom naman na ako
nung doktor ko ng pampaliit
ng bukol, eh lumiit naman
sya, kaya binale-wala ko
na.
She does not engage with
heavy work or exercise
because of her goiter, she
added, Masakit kasi kapag
nagbubuhat ako ng mabigat
o di naman kayay kapag
napapagod ako. Alam mo
yung parang nakakasakal
yung bara sa lalamunan.
Deficient Knowledge
related to Disease
Process and Treatment
Regimen
Deficient knowledge is
the absence or
deficiency of cognitive
information related to
specific topic or lack of
specific informationnecessary for clients to
make informed choices
regarding condition,
treatment, and/or
lifestyle changes.
(Nurses Pocket Guide,
12th edition, p.495)
GOAL:
After 1 day of nursing
intervention, the client will
have adequate knowledge
regarding disease processand treatment regimen as
evidenced by verbalization
of understanding of
condition, disease process
and treatment.
OBJECTIVES:
a. After 10 minutes ofdiscussion, the client willbe able to define theconditiona nd nature ofsporadic goiter in her ownwords and understanding.
b. After 10 minutes ofdiscussion, the client willbe albe to enumerate atleast 3 out of 5 signs andsymptoms of a personhaving sporadic goiter.
c. After 10 minutes ofdiscussion, the client willbe able to understand andexplain pathophysiology ofsporadic goiiter in her ownwords.
d. After 10 minutes ofdiscussion, the client willbe able to enumerate 3out 5 management ofclients with sporadic
Developmental;
Independent
a. Discuss the definition of
Sporadic Goiter.
b. Discuss the signs and
symptoms that can be
manifested in a person
having a Sporadic Goiter.
c. Discuss the
pathophysiology of
Sporadic Goiter.
d. Discuss the possible
management for clients
with Sporadic Goiter.
To incre
of knowl
sporadic
of compmeeting
indepen
A well in
better ab
distressi
Provides
developi
identifyin
needs.
Knowled
factors e
to begin
that may
disease.
This fulfil
deficit an
with info
care.
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goiter.
e. After the 8-hour shift
duty in the community, the
client will start to apply the
learned managements in
her daily life, as
manifested by:
-verbalization of
willingness to seek
medical advice concerning
her goiter
-allotment of time for
appointment with a
physician for a check-up
-physicians prescription or
lab results (if possible)
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V. PHYSICAL ASSESSMENT
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Normal Findings Actual Findings Remarks
BEHAVIOR
Height Proportionate,
varies with
lifestyle
411 ft. Normal
Weight Proportionate,
varies with
lifestyle
48 kgs. Normal
BMI Normal 18.6 to
22.9
19.5 Normal
MEASUREMENTS
Body temperature
Pulse rate 120mmHg/
80mmHg
120mmHg/
80mmHg
Normal
Respiratory rate 12-20cpm 14cpm Normal
Blood pressure 60-100bpm 83pbm Normal
A. Describe theclients body built,
height and weight in
relation to clients
age, lifestyle and
behavior
Proportionatevaries with her age
and lifestyle
Proportionatevaries with her age
and lifestyle
Normal
B. Describe the
clients posture and
gait, standing, sitting
and walking
Relaxed and erect
posture,
coordinated
movements
Relaxed and erect
posture,
coordinated
movements
Normal
C. Describe the
clients overall
hygiene and
grooming
Clean and neat
appearance and
well-groomed
Clean and neat
appearance and
well-groomed
Normal
D. Describe the body
and breath odor
No body and
breath odor
No body and
breath odor
Normal
E. Identify the signs
of distress, in posture
or facial expression
No signs of
distress noted
No signs of
distress noted
Normal
F. Describe obvious
signs of health or
illness
Healthy
appearance
Healthy
appearance
Normal
G. Describe the
clients attitude
Coherent,
conscious
Coherent,
conscious
Normal
H. Describe clients
affect or mood;
assess the
appropriateness ofthe clients response
Appropriate to the
situation
Appropriate to the
situation
Normal
I. Describe quantity
and quality of speech
Understandable
and moderate
pace, exhibits
thoughts
association
Understandable
and moderate
pace, exhibits
thoughts
association
Normal
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INTEGUMENTARY
Skin
Inspect for color,
uniformity of color
Generally,
uniform except
in areas exposedto the sun; areas
lighter
pigmentation
(palms, lips, nail
beds) in dark
skinned people.
( Kozier pg. 579)
Generally,
uniform except
in areas exposedto the sun; areas
lighter
pigmentation
(palms, lips, nail
beds) in dark
skinned people.
Normal
Inspect for presence
of edema
No presence of
edema( Kozier pg. 579)
No presence of
edema
Normal
Inspect for lesions
according to location,
distribution, color,
configuration, size,
shape, type structure
No lesions or
abrasion; Flat
and raised nevi
( Kozier pg. 579)
No lesions or
abrasion; Flat
and raised nevi
Normal
Palpate skin moisture Moisture in skin
folds and axillae
( Kozier pg. 579)
Skin on
extremities is dry
Abnormal
Palpate skin
temperature
Uniform; with
normal range
( Kozier pg. 579)
Uniform; with
normal range
Normal
Palpate skin turgor When pinched,
skin brings back
to previous state
( Kozier pg. 579)
When pinched,
skin brings back
to previous state
Normal
Nails
Inspect fingernail
plate shape to
determine its
curvature and angle
Convex
curvature; angle
of nail plate is
about 160
degrees
( Kozier pg. 583)
Slightly spoon
nail in shape
Abnormal
Inspect fingernail and
toenail bed color
Highly vascular
and pink in light
skinned clients;
dark skinned
clients may have
Highly vascular
and pink in light
skinned clients;
dark skinned
clients may have
Normal
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brown or black
pigmentation in
longitudinal
streaks
( Kozier pg. 583)
brown or black
pigmentation in
longitudinal
streaks
Palpate fingernail and
toenail texture
Smooth texture
( Kozier pg. 583)
Rough Texture Abnormal
Inspect tissues
surrounding nails
Intact epidermis
( Kozier pg. 583)
Hard skin Abnormal
Perform blanch test
capillary refill
Prompt return in
pink or usual
color
( Kozier pg. 583)
Prompt return in
pink or usual
color
Normal
HEAD TO TOE EXAMINATION
HEAD
Skull
Inspect the skull
for size, shape or
symmetry
Rounded, smooth
skull contour
( Kozier pg. 585)
Rounded, smooth
skull contour
Normal
Palpates fornodules, masses
and depressions
Smooth, uniformconsistency;
Absence of
nodules or masses
( Kozier pg. 585)
Smooth, uniformconsistency;
Absence of
nodules or masses
Normal
Scalp
Inspect for color
and appearance
White in color; no
dandruff
( Kozier pg. 582)
White in color; no
dandruff
Normal
Palpate for areas of
tenderness
No tenderness,
nodules, masses
and edema
( Kozier pg. 582)
No tenderness,
nodules, masses
and edema
Normal
Hair
Inspect for
evenness of
growth, thickness
or thinness
Evenly distributed
hair; thick hair
( Kozier pg. 582)
Evenly distributed
hair; white, thin
hair
Abnormal
Palpate for texture
and oiliness over
Silky; Resilient
hair
Silky; Resilient
hair
Normal
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the scalp ( Kozier pg. 582)
Face
Inspect the facial
features, symmetry
of facial
movements
Symmetric or
slightly
asymmetrical
features;
symmetrical facial
movements
( Kozier pg. 585)
Assymetrical
involuntary facial
movements/ facial
tremors
Abnormal
Eyes
Visual acuity
Test near vision Able to read
newsprint
( Kozier pg. 588-
593)
Able to read
newsprint
Normal
Test distance
vision
20/20 vision on
Snellen Chart
( Kozier pg. 588-
593)
500 lens grade Abnormal
Eyebrows
Inspect for hair
distribution,
alignment, skinand quality
movement
Hair evenly
distributed; skin
intact, eyebrowssymmetrically
aligned; equal
movement
( Kozier pg. 588-
593)
Hair evenly
distributed; skin
intact, eyebrowssymmetrically
aligned; equal
movement
Normal
Eyelids
Inspect for the
surfacecharacteristics,
position in relation
to the cornea,
ability to blink;
and frequency of
blinking
Skin intact; no
discharge; nodiscoloration; lids
close
symmetrically;
approximately 15-
20 involuntary
blinks per minute;
bilateral blinking;
when lids are
open no visiblesclera above
Skin intact; no
discharge; nodiscoloration; lids
close
symmetrically; 15
involuntary
involuntary blinks
per minute;
bilateral blinking;
when lids are
open no visiblesclera above
Normal
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cornea, and upper
and lower borders
of cornea are
slightly covered
( Kozier pg. 588-593)
cornea, and upper
and lower borders
of cornea are
slightly covered
Conjunctiva
Inspect the bulbar
for color, texture,
and presence of
lesions
Transparent
capillaries
sometimes
evident; sclera
appears white
(yellowish in darkskinned clients)
( Kozier pg. 588-
593)
Pale bulbar
conjunctiva
Abnormal
Inspect the
palpebral
conjunctiva for
color, texture, and
presence of lesions
Pinkish or red in
color with
presence of
capillaries; moist;
no foreign bodies
( Kozier pg. 588-
593)
Pale palpevral
conjunctiva
Abnormal
Lacrimal gland,
lacrimal sac and
nasolacrimal duct
Inspect and palpate
the lacrimal gland
No edema nor
tenderness over
lacrimal duct; no
tearing
( Kozier pg. 588-
593)
No edema nor
tenderness over
lacrimal duct; no
tearing
Normal
Sclera
Inspect the color
and clarity
White; darker or
yellowish with
small brown
macules in dark-
skinned clients
( Kozier pg. 588-
593)
White; darker or
yellowish with
small brown
macules in dark-
skinned clients
Normal
CorneaInspect for clarity Transparent; Transparent; Normal
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and texture shiny; smooth;
details of the iris
are visible
( Kozier pg. 588-
593)
shiny; smooth;
details of the iris
are visible
Iris
Inspect for shape
and color
Round; color
depends on the
persons face
( Kozier pg. 588-
593)
Round; color
depends on the
persons face
Normal
Pupils
Inspect color,shape and
symmetry of size
Black; equal insize; normally 3-
7mm in diameter;
round; smooth
border
( Kozier pg. 588-
593)
Black; equal insize; normally 3-
7mm in diameter;
round; smooth
border
Normal
Test each pupil for
light reaction and
accommodation
Pupils constrict
when looking at
near objects;
pupils dilate when
looking at far
objects; pupils
converge when
near object is
moved towards
the nose
( Kozier pg. 588-
593)
Pupils constrict
when looking at
near objects;
pupils dilate when
looking at far
objects; pupils
converge when
near object is
moved towards
the nose
Normal
Extra ocular
Muscles
Test each eye for
alignment and
coordination
Both eyes are
coordinated;
move in unison,
with parallel
alignment
( Kozier pg. 588-
593)
Both eyes are
coordinated;
move in unison,
with parallel
alignment
Normal
Visual Fields
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Test peripheral
fields
When looking
straight ahead.
The client can see
object in
periphery( Kozier pg. 588-
593)
When looking
straight ahead.
The client can see
object in
periphery
Normal
EARS
Auricles
Inspect for color,
symmetry and
position
Color same as
facial skin;
symmetrical;auricle aligned
with outer canthus
of eye, about 10
degree from
vertical
( Kozier pg. 596-
598)
Color same as
facial skin;
symmetrical;auricle aligned
with outer canthus
of eye, about 10
degree from
vertical
Normal
Palpate for texture,
elasticity and are of
tenderness
Mobile; Elastic:
firm and not
tender: Pinna
recoils back after it
is folded
( Kozier pg. 596-
598)
Mobile; Elastic:
firm and not
tender: Pinna
recoils back after
it is folded
Normal
External Ear
canal
Inspect ear canal
for cerumen, skin
lesion, pus and
blood
Distal third
contains hair
follicle and glands;
(cerumen-grayish
tan in color)
( Kozier pg. 596-
598)
Distal third
contains hair
follicle and
glands; (cerumen-
grayish
Normal
Hearing acuity
test
Assess clients
response to normal
voice tones
Normal voice tones
audible
( Kozier pg. 596-598)
Normal voice
tones audible
Normal
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Perform watch tick
test
Able to hear a
ticking in both ears
( Kozier pg. 596-
598)
Able to hear a
ticking in both
ears
Normal
Perform Weberstest
Sounds are heardin both ears or is
localized at the
center of the head;
Weber(-)
( Kozier pg. 596-
598
Sounds are heardin both ears
Abnormal
Conduct Rinnes
test
Air conducted
hearing is greater
than boneconducted hearing;
Rinne (+)
( Kozier pg. 596-
598)
AC=BC Abnormal
NOSE
Inspect for any
deviations, shape,
size or color and
flaring or discharge
from nerves
Symmetric; No
dicharge; no flarin;
uniform color
( Kozier pg. 600)
Symmetric; No
dicharge; no
flarin; uniform
color
Normal
Inspect the nasal
cavities for the
presence of
redness, swelling,
growths and
discharge, using
the penlight
Mucosa pink;
clear; watery; no
discharge; no
lesions
( Kozier pg. 600)
Mucosa pink;
clear; watery; no
discharge; no
lesions
Normal
Inspect the nasal
septum betweennasal chambers
Nasal septum intact
and in midline( Kozier pg. 600)
Nasal septum
intact and inmidline
Normal
Test patency of
both nasal cavities
Air moves freely as
the client breathes
through the nares
( Kozier pg. 600)
Air moves freely
as the client
breathes through
the nares
Normal
Palpate for any
tenderness, masses,displacements of
No tenderness; no
lesion( Kozier pg. 600)
No tenderness; no
lesion
Normal
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bone and cartilage
SINUSES
Locate/Palpate/iden
tify the sinuses and
note for tenderness
No tenderness
( Kozier pg. 600)
No tenderness Normal
MOUTH
Lips
Inspect for
symmetry of
contour, color, and
texture
Uniform pink
color; moist; soft;
glistening; elastic
texture
( Kozier pg. 602-
604)
Purplish in color Abnormal
Buccal MucosaInspect for color,
moisture, texture
and presence of
lesions
Uniform pink
color, moist; soft:
glistening; elastic
texture
( Kozier pg. 602-
604)
Slightly dry Abnormal
Teeth
Inspect for color,
number, andcondition and
presence of
dentures
32 adult teeth;
smooth, white;shiny tooth enamel
( Kozier pg. 602-
604)
10 lower teeth & 6
upper teeth,2 dental carrie
son the lower
premolars
Abnormal
Gums
Inspect for the
color and condition
Pink gums; moist,
firm texture to
gums
( Kozier pg. 602-
604)
Pink gums; moist,
firm texture to
gums
Normal
Tongue/floor of
the mouth
Inspect for color
and texture of the
mouth floor and
frenulum
Pink color; moist;
slightly rough;
presence of whitish
coating; can moves
freely; no
tenderness
( Kozier pg. 602-
604)
Pink color; moist;
slightly rough;
presence of
whitish coating;
can moves freely;
no tenderness.
Normal
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Inspect and palpate
the position, color,
and texture,
movement and base
of the tongue
Central position;
pinkish in color;
slightly rough;
moves freely; no
area of tenderness( Kozier pg. 602-
604)
Central position;
pinkish in color;
slightly rough;
moves freely; no
area of tenderness
Normal
Palpate for any
nodules, lumps or
excoriated areas
Slightly rough; no
palpable nodules,
lumps or
excoriated areas
( Kozier pg. 602-
604)
Slightly rough; no
palpable nodules,
lumps or
excoriated areas
Normal
Palates and uvula
Inspect and palpate
for color, shape,
texture and the
presence of bony
prominences
Pink palate; hard
palate; smooth and
soft; more irregular
texture
(Kozier p.602-604)
Pink palate; hard
palate; smooth and
soft; more
irregular texture
Normal
Inspect for position
of the uvula and
mobility while
examining the
palates
Positioned in
midline of soft
palate
(Kozier p.602-604)
Positioned in
midline of soft
palate
Normal
Oropharynx and
tonsils
Inspect and palpate
for color and
texture
Pink and smooth
posterior wall
(Kozier p.602-604)
Pink and smooth
posterior wall
Normal
Inspect the size of
the tonsils, color
and discharge
Pink and smooth;
no discharge;
normal size
(Kozier p.602-604)
Pink and smooth;
no discharge;
normal size
Normal
Presence of gag
reflex upon
stimulation of the
uvula and lower
back of the tongue
Presence of gag
reflex
(Kozier p.602-604)
Absence of gag
reflux upon
stimulation
Abnormal
NECK AND
LYMPH NODES
Inspect the neck Muscles equal in Muscles not equal Abnormal
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muscles for
abnormal swellings
or masses.
size; head centered
(Kozier p.607-610)
in size
Lymph nodes
Locate/palpate/identify lymph nodes
and note for
tenderness
Not palpable(Kozier p.602-604)
Palpable mass Abnormal
Trachea
Inspect and palpate
for placement
Central placement
in midline of neck
are equal on both
sides
(Kozier p.602-604)
Central placement
in midline of neck
are equal on both
sides
Normal
Thyroid gland
Inspect symmetry
and visible masses
Not visible on
inspection
(Kozier p.602-604)
Visible on
inspection
Abnormal
Palpate for
smoothness and
areas of
enlargement,
masses or nodules
Lobes may not be
palpated. If
palpable lobes,
they are small,
smooth centrallylocated, painless
and rise freely with
swallowing
(Kozier p.602-604)
Palpable lobes,
they are small, and
smooth. Palpable
mass is
approximately5cm in height. Its
more prominent
on the RIGHT
side of the neck.
Abnormal
THORAX
Posterior Thorax
Inspect the spinal
alignment
Spine vertically
aligned
(Kozier p.615-618)
Spine vertically
aligned
Normal
Palpate for
temperature,
tenderness, and
masses
Uniform
temperature; no
tenderness; no
masses
(Kozier p.615-618)
Uniform
temperature; no
tenderness; no
masses
Normal
Assess respiratory
excursion
Full and
symmetric chest
expansion; thumbs
separate 3-5 cm (1
to 2 inches)
Full and
symmetric chest
expansion; thumbs
separate 3-5 cm (1
to 2 inches)
Normal
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(Kozier p.615-618)
Palpate vocal
fremitus
Bilateral symmetry
of vocal fremitus;
fremitus is heard
most clearly in theapex of the lungs
(Kozier p.615-618)
Bilateral
symmetry of vocal
fremitus; fremitus
is heard mostclearly in the apex
of the lungs
Normal
Auscultate the
posterior thorax
Bronchial,
vesicular and
bronchovesicular
breath sounds
(Kozier p.615-618)
Bronchial,
vesicular and
bronchovesicular
breath sounds
Normal
Anterior ThoraxInspect breathing
patterns
Quiet, rhythmic
and effortless
respiration
(inspiration and
expiration)
(Kozier p.615-618)
Quiet, rhythmic
and effortless
respiration
(inspiration and
expiration)
Normal
Palpate for
temperature,
tenderness, and
masses
Warm uniform
temperature; No
tenderness; no
masses
(Kozier p.615-618)
Warm uniform
temperature; No
tenderness; no
masses
Normal
Palpate vocal
fremitus
Same as the
posterior vocal
fremitus; fremitus
is normally
decreased over
heart and breast
tissue.
(Kozier p.615-618)
Same as the
posterior vocal
fremitus; fremitus
is normally
decreased over
heart and breast
tissue.
Normal
Auscultate the
trachea
Bronchial (tubular)
breath sounds
(Kozier p.615-618)
Bronchial
(tubular) breath
sounds
Normal
Auscultate the
anterior thorax
Bronchovesicular
and vesicular
breath sounds
(Kozier p.615-618)
Bronchovesicular
and vesicular
breath sounds
Normal
JUGULARVEINS
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Inspect Jugular
veins
Veins not visible
(Kozier p.615-618)
Normal
MUSCULOSKEL
ETAL SYSTEM
Musclesa. Inspect the
muscles for size.
Compare the
muscles on the side
of the body (arm,
thigh, calf) to the
same muscle on the
other side
Equal size on both
side of the body
(Kozier p.646-651)
Equal size on both
side of the body
Normal
b. Inspect themuscle and tendons
for contractures
(shortening)
No contractures(Kozier p.646-651) No contractures Normal
c. Inspect the
muscles for
fasciculations and
tremors. Inspect
any tremors of the
hands and arms out
in front of the body
No fasciculations
(Kozier p.646-651)
Presence of fine
tremors
Abnormal
d. Palpate muscle
tonicity
Firm
(Kozier p.646-651)
Firm Normal
Bones
a. Inspect the
skeleton for normal
structures and
deformities
No deformities
(Kozier p.646-651)
No deformities Normal
3. Joints
a. Inspect joints for
swelling
No swelling
(Kozier p.646-651)
No swelling Normal
ASSESS JOINT
RANGE OF
MOTION
c. Upper
extremities
(shoulder and
scapula)
Smooth coordinate
movements
(Kozier p.646-651)
Smooth coordinate
movements
Normal
d. Upper Smooth coordinate Smooth coordinate Normal
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extremities
(elbows)
movements
(Kozier p.646-651)
movements
e. Upper
extremities (hands)
Smooth coordinate
movements
(Kozier p.646-651)
Smooth coordinate
movements
Normal
f. Lower
extremities
(acetabulum or
inguinal area)
Smooth coordinate
movements
(Kozier p.646-651)
Smooth coordinate
movements
Normal
g. Lower
extremities
(popliteal)
Smooth coordinate
movements
(Kozier p.646-651)
Smooth coordinate
movements
Normal
h. Lower
extremities (ankles)
Smooth coordinate
movements(Kozier p.646-651)
Smooth coordinate
movements
Normal
VI. PROBLEM IDENTIFICATION
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CLUSTERED DATA NURSING DIAGNOSIS
Subjective:
She does not have any plans of undergoing
any procedures. She verbalized, natakot
akong magpaopera kasi yung pinsan ko
nagkaroon din ng goiter, pinaopera niya.
Pagkalipas ng tatlong buwan, bumalik din
yung goiter niya.
The client also verbalized, Pinainom naman
na ako nung doktor ko ng pampaliit ng bukol,
eh lumiit naman sya, kaya binale-wala ko
na.
She does not engage with heavy work or
exercise because of her goiter, she added,
Masakit kasi kapag nagbubuhat ako ng
mabigat o di naman kayay kapag napapagod
ako. Alam mo yung parang nakakasakalyung bara sa lalamunan.
Deficient Knowledge related to Disease
Process and Treatment Regimen
Subjective:
She had been visiting her physician every
three months for her check-up, and she strictly
follows whatever the physicians orders are.
The dishes that she usually eats are made up of
vegetables, since her physician advised her not
to eat so much meats, legumes and sweets, as
well as eggs due to her arthritis, goiter,diabetes mellitus and allergies.
She takes a nap sometimes if there is chance.
She is not taking any medicines to cope with
her stress; she only takes a rest.
Readiness for Enhanced Comfort related to
Presence of Mass in Neck
Subjective:
Pinainom naman na ako nung doktor ko ng
pampaliit ng bukol, eh lumiit naman sya,
kaya binale-wala ko na.
According to the client, she eats 3 times a day
and she takes her food slowly because she is
having a slight difficulty in swallowing
because of the mass in her throat.
Masakit kasi kapag nagbubuhat ako ng
mabigat o di naman kayay kapag napapagod
ako. Alam mo yung parang nakakasakal
yung bara sa lalamunan.
Objective:
The thyroid gland is prominently visible on
inspection, palpable and has visible pulsation.
The palpable mass is 3.5cm in diameter by
estimation.
Risk for Aspiration
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Far Eastern UniversityInstitute of Nursing
PROBLEM PRIORITIZATION
Health Problem Rank JustificationDeficient Knowledgerelated to DiseaseProcess and TreatmentRegimen
1 - Teaching the clientregarding his healthis very importantbecause deficientknowledge has asignificant impact on
clients ability tomake effective
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decisions and topartner with hishealth careproviders in hishealth care. It is a
health threat thatcan lead to poorerhealth outcomes.(Black, 8th Edition,
p.7)
Readiness for EnhancedComfort related toPresence of Mass in Neck
2 - It is essential thatthe nurse validatesthat the behavior ofinterest is one theclient truly wants tochange. Readiness
to change should beassessed early in thenurse-clientinteraction. It is awellness state thatallows the individualto have a betterhealth if givenenough attentionand health teaching.(Black, 8th Edition,
p.7)
Risk for Aspiration 3 - Risk identificationand riskmanagementcounseling canprevent illness andinjury. It is a healththreat that maycontribute to theoccurrence ofcomplications if not
supervised by ahealth care provider.(Black, 8th Edition,p.16)
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