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Introduction

Papillary thyroid cancer or papillary carcinoma is the most common type (80% thyroid
cancer cases), and usually affects women ageing 50 to 70’s. It spreads slowly and is the least
dangerous type of thyroid cancer. Despite its well differentiated characteristics, papillary
carcinoma may be overtly or minimally invasive. In fact, these tumours may spread easily to
other organs. Papillary tumours have a propensity to invade lymphatic but are less likely to
invade blood vessels.

Thyroid cancer are more often found in patient with history of low or high dose external
irradiation. Papillary tumours of the thyroid are the most common form of thyroid cancer to
result from exposure to radiation. The life expectancy of patient with this cancer is related to
their age. The prognosis is better for the younger patients than for patients who are older than 45
years. Of patient with papillary cancers, about 11% present with metastases outside the neck and
mediastinum. Some years ago, lymph node metastases in the cervical area were thought to be
aberrant thyroids because they contained well differentiated papillary thyroid cancer.

Internationally, thyroid cancers are quite rare, accounting for only 1.5% of all cancers in
adults and 3% of all cancers in children, but the rate of the new cases are increasing for the las
decades. The highest incidence if thyroid carcinoma are found among Chinese females residents
of Hawaii. During the last few years, the frequency of papillary cancer has increased in
frequency is related to an improvement in diagnostic techniques and the information campaign
about this carcinoma. In the USA, there are about 37,000 new cases of thyroid cancer each year
according to National Cancer Institute(2014). Of all thyroid cancers, 74-80% of cases are
papillary cancer. In contrast to other cancer thyroid is the most curable. Most thyroid cancer
grow slowly and are associated with very favourable prognosis.

Thyroid cancer has a higher incidence rate in the Philippines than most of the countries. It
ranks 7th leading form of cancer in our country with an estimated of 2,584 new cases,2,068 in
females and 516 in males (1998). The incidence is three times more in females that that in males.
Thyroid cancer is the most common cancer of woman.

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In the year 2012 to 2014 there were a total of 265 cases papillary carcinoma in Davao
City. 77.65% were female and 22.35% were male. Making it a least common cancer in Davao
City but one research by JKP Sanchez (2016) shows that the incident rate of papillary cancer in
Davao City are slowly increasing due to the low consumptions of carotenoids and a higher
prevalence of Goiter.

For 3 days, the proponent, under Mrs. Mary Hazel Facundo., R.N., MN. were assigned in
the ENT ward of Southern Philippines Medical Center. The proponent chose a case of a 72-year
old patient with Right Lateral Mass FNAB: Consistent with papillary Carcinoma t/c metastasis.
The proponent chose this case for it is one of the most common encounters of disorders of the
thyroid, the proponent would like to gain more knowledge and understanding of it, and be able
to apply and discover additional knowledge under the concept of Endocrine-related fields. This
study will enable the proponent to be aware about the disease and be able to educate the people
with papillary carcinoma that would help boost up awareness in the community.

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Objectives

General Objective

Within the 3 days of duty at the ENT ward of the Southern Philippines Medical Center,
the fundamental goal of the proponent for the study is to be able to select an L and M case, or
disorders that are usually addressed by the ENT ward, and be able to conduct a comprehensive
case study of the illness. With conducting the case study, the proponent would be able to gain
further knowledge surrounding the disease and the concept of Endocrine-related disorders.
Additional goals would be to provide a holistic and effective nursing care to the client with applied
knowledge and skills from the corresponding nursing concepts and fields.

Specific Objectives:
Cognitive:
 Define the complete diagnosis of the patient.
 Identify the developmental data of the patient.
 Review and discuss the human anatomy and physiology of the cardiovascular system, in
particular to the coronary blood circulation.
 Analyze the disease’s risk factors and processes through the genogram and
pathophysiology.
 Recognize and explain the relevance of drug to the patient by doing drug
studies.
 Reflect nursing theories to organize the framework of concepts for our nursing practice.
 Explain a comprehensive prognosis.

Psychomotor
 Conduct a proper cephalocaudal assessment of the patient to identify any abnormalities
within the physical assessment.
 Gather data and comprehend the patient’s data, family background (genogram), health
history and present health condition.
 Collect valid data regarding the past and present health history of the patient.
 Formulate specific, measurable, attainable, realistic, and time- bounded nursing care plans

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to outline the care to be provided for the patient.
 Execute the appropriate nursing care plan to achieve the need of the patient.
 Conduct health teachings to the patient to promote health and prevent disease that can be
acquired.

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.
 Offer health teachings to the client to achieve optimum wellness as well as other relevant
discharge orders.

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PERSONAL DATA

Patients Data
Patient’s Name: Consimino Azucena Amancio CaseNumber:2017071596
Age :72 years old Hrn: 3039169
Sex: Female
Address: Sumilel Bagumbayan, Sultan Kudarat
Birth Date: December 4, 1945
Birth Place: Sultan Kudarat
Civil Status: Married
Occupation: None
Nationality: Filipino
Ethnic Background: Ilongo
Religion: Adventist
Souce of information: Patient’s Chart

Clinical Data
Date of admission: December 15, 2017 6:36pm
Chief Complaint: Neck Mass
Admitting Vital Signs:
Weight: 45kg Bp 118/71 Pain Scale: 6
Height: 157.5 RR: 20/min HR:88/min
Temp:36.9C Non Trauma Department: ENT-HNS

Condition at E.R: Awake Triage Category: 3

Admitting Physician: Dr. Shera L Elefante


Admitting Diagnosis: Right Lateral Mass FNAB: Consistent with papillary Carcinoma t/c
metastasis
Health Care Institution: Southern Philippines Medical Center

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Health History

Genogram

Father’s Side Mother’s Side

Patient

Male Goiter

Female Vehicular
accident

Deceased
Hypertension
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History Record
History of the past illness:
Patient Consimino Azuela is a 72 years old female. When she was a child she had undergone
chicken pox and measles, she also completed her vaccine. No known allergies to any food or
medications. She had no operations done. Her admissions are due to pregnancy of her 4 daughters.
Her next admission was due to LBM. She has no operations or surgeries done. No previous
accidents noted.
A. Communicable disease: None
B. Serious or Chroninc illness: None
C. Family History: Hypertension
D. Special needs:None
E. Allergies or reaction: None
F. Blood transfusion: None

History of the present illness

 Chief Complaint: Bleeding neck mass

3 years prior consult, small mass was noted in the supra clavicular areas associated with
weight loss. Non mobile pulsatile. No consult was done but they treated it with a herbal medicine
called “berrybituon” until the mass became infected and treated it with mx3 capsule. Patient
tolerated and mass grew in size. 4 days prior consult, there was spontaneous bleeding in the center
of the mass. Patient was referred in this institution by a local physician.

B. Family/ Social History

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i. Famioy/ Alcohol/Tobacco/ Drug use
According to the patient they have known fews disease that runs in the family such as
hypertension on the father side and goiter on the mother side.
Patient is not involved in any form of vices.
ii. Travel History
Patient travels to outskirts of sultan kudarat to visit family and relatives once a month.
She has never been outside of the country or Mindanao.
iii. Work Environment
The patient is does not work anymore. She manages her farmland (crops: fruits such as
mango and durian) alongside with her youngest daughter.
iii. Home Environment
She lives 35 minutes away from the town where its far from pollution and more on nature.
Patient lives together with her unmarried youngest daughter. She verbalized that their
surroundings are well kept and over all environment is clean. She and her daughter cleans
the their house everyday but only does the light chores such as sweeping the floor.
vi. Hobbies and Leisure Activities
The patient like to go to her neighbours and gossip, watching television or listening to
radio drama every after lunch. During night time he likes to watch the news and few dramas.
vii. Religion
Patient is a adventist. They go to the nearest church every Saturday to attend mass which
will last for the whole day( 8am-3pm) .
ix. Sleep
Patient did not verbalize of difficulty in sleeping at night. She usually gets 7-8 hours of
sleep. Sleeps around 8pm and wakes up at 4:30am.
x. Diet
Patient mainly eats vegetables and white meat such as fish. She also has a lot of restricted
food such as pork. She doesn’t like sweet and salty foods.
xi. Health Check-ups
Patient gets check up regularly in their local hospital in Sultan Kudarat but not compliance
to the advice and medications.

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Review of system
(-) Dizziness
(-) Headache
(+) Mild weight loss
(+) Cataract on right eye
(+) Lichenification on skin of right knuckles. (the skin has become thickened and leathery)
(-) Chest Pain
(-) Any extremity weakness

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Developmental Data

Robert James Havighurst

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)

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Developmental task Justification
Maintaining economic Achieved The patient has a farmland with different
standard of living fruit crops such as mango and durian with a
stable income, enough to support their
needs.
Performing civic and social Achieved The patient is part of their purok officer as
responsibilities there vice president. She has been a officer 2
years ago. She is also part of senior citizen
group in there barangay where they give
money to a fellow deceased senior citizen.
Relating to spouse as a person Achieved The patient establishes a strong bond with
her husband before he died, and also
acknowledges their relationship as full of
respect ,love, forgiveness and sincerity.
Adjusting to physiological Achieved The patient recognizes the need for changes
changes in her daily routine, upon knowing her
present illness.

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Erick Erickson

Erik Erickson was born in 1902 in Frankfurt-am-Main, Germany. After completing high school,
he moved to Florence 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, then embarked on psychoanalytic training at the Vienna 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 pass 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)

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Developmental Task Achieved Rationale Justification
Integrity versus despair is the Integrity During this period, the The patient
eighth and final stage of Erik individual experiences a verbalizes that she is
Erikson’s stage theory of sense of integrity when he happy on what she
psychosocial development. feels proud of her have done to this
During this period, people achievements and is world. She has a lot
reflect back on the life they satisfied with the hand that of achievements as a
have lived and come away he was dealt with. With the mother (all her
with either a sense of experience of integrity, the children are college
fulfillment from a life well individual has few regrets graduate with a
lived or a sense of regret and or recriminations. This, degree) and as a
despair over a life misspent. however, is truly possible wife( she took care
only if the person has of her husband until
successfully resolved the his last breath), even
other seven psychosocial thou she and a little
crises. With successful bit of regrets such as
resolution of earlier crises, her youngest
old- aged people are likely daughter offered her
to reflect on their lives 31 years of her life
positively and attain instead of making
wisdom even in the face of her own family.
imminent death.
Transitions between
previous stages of
Erikson’s theory become
clearer and feeling at peace
with the world and the self
becomes more apparent.

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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

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Psychosexual Stage Achieved Rationale Justification
It is a time of adolescent sexual Achieve The onset of puberty The patient is happily
experimentation, the successful causes the libido to married with 4 lovely
resolution of which is settling become active once again. children( 2 sons and 2
down in a loving one-to-one During the final stage of daughters).The
relationship with another person psychosexual patient got married
in our 20's. Sexual instinct is development, the after they graduated
directed to heterosexual pleasure, individual develops a from college (2 years
rather than self-pleasure like strong sexual interest in course) at the age of
during the phallic stage. For the opposite sex. This 23.
Freud, the proper outlet of the stage begins during
sexual instinct in adults was puberty but last
through heterosexual throughout the rest of a
intercourse. Fixation and conflict person's life. Where in
may prevent this with the earlier stages the focus
consequence that sexual was solely on individual
perversions may develop. needs, interest in the
welfare of others grows
during this stage. If the
other stages have been
completed successfully,
the individual should now
be well-balanced, warm,
and caring. The goal of
this stage is to establish a
balance between the
various life areas.

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Patient’s Diagnosis

Final Diagnosis: Right Lateral Mass Fine Needle Aspiration Biopsy: Consistent with papillary
Carcinoma t/c metastasis.

Lateral Mass The lateral masses are the thick, bulky portions forming
the entire lateral aspect of the ring of bone. They
resemble pillars of support for the skull
(http://www.anatomyexpert.com/app/structure/754/947/)

The bulkiest, solid parts of the atlas (C1) vertebra, upon


which the skull is supported ( Jonas: Mosby's Dictionary
of Complementary and Alternative Medicine. (c) 2005,
Elsevier.)

The lateral masses are the most bulky and solid parts of
the atlas, in order to support the weight of the head
(Gray's Anatomy, 20th edition 2008)
Fine needle aspiration biopsy
Fine needle aspiration is a type of biopsy procedure. In fine
needle aspiration, a thin needle is inserted into an area of
abnormal-appearing tissue or body fluid.
(https://www.webmd.com/a-to-z-guides/common-topics)

A Fine Needle Aspiration (FNA) Biopsy is a simple


procedure that involves passing a thin needle through the
skin to sample fluid or tissue from a cyst or solid mass
(Britton PD. Fine needle aspiration or core biopsy. The
Breast 1999)

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Fine needle aspiration biopsy of the thyroid (FNAB) is
used to rule out thyroid cancer, make a diagnosis or select
therapy for a thyroid nodule, or drain a thyroid cyst
(https://www.medicinenet.com/fine-
needle_aspiration_biopsy_of_the_thyroid/article.html)
Papillary carcinoma Papillary carcinoma (PTC) is the most common form of
well-differentiated thyroid cancer, and the most common
form of thyroid cancer to result from exposure to radiation.
(https://emedicine.medscape.com/article/282276-
overview)

Papillary carcinoma of the thyroid is a slow-growing


cancer that typically develops in only one lobe of the
thyroid gland. When caught in its early stages this cancer
has a high survival rate.
(https://www.healthline.com/health/thyroid-cancer-
papillary-carcinoma)

Cancer that forms in follicular cells in the thyroid and


grows in small finger-like shapes. It grows slowly, is more
common in women than in men, and often occurs before
age 45. It is the most common type of thyroid cancer.(
https://www.cancer.gov/publications/dictionaries/cancer-
terms?cdrid=44553)

Metastasis Metastasis is the medical term for cancer that spreads to a


different part of the body from where it started (American
Society of Clinical Oncology (2008).

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Metastasis is a pathogenic agent's spread from an initial or
primary site to a different or secondary site within the
host's body it is typically spoken of as such spread by a
cancerous tumor. The newly pathological sites, then, are
metastases (mets).(Klein CA (September 2008). "Cancer.
The metastasis cascade". Science.)

In metastasis, cancer cells break away from where they


first formed (primary cancer), travel through the blood or
lymph system, and form new tumors (metastatic tumors)
in other parts of the body. The metastatic tumor is the same
type of cancer as the primary tumor
(https://www.cancer.gov/types/metastatic-cancer)

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Anatomy and Physiology

Thyroid gland
“Thyroid’ was name in the 1600s. The
word is Greek for shield, because of its
butterfly shape. Thyroid is located in
the lower part of your nexk, in front of
your wind pipe and it produces two
thyroid hormone: thyroxine, known as
T4, and triiodothyronine, know as T3.
Thyroid hormone is then secreted into
the circulator system and becomes
widely distributed thought the body. It’s one of the basic regulators of the functions of every cell
and every tissue within the body, and a steady supply is crucial for good health. In essence, thyroid
affects from head to toe including the hair and skin.
90% percent of the thyroid output is T4, and only 10% is T3. Although these hormones
have the same effect in the body, T4 must be converted to T3 by shedding an iodine atom, a
process that is regulated different body parts.
The normal thyroid gland is composed histologically of two main parenchymal cell types.
Follicular cells line the colloid follicles, concentrated iodine and produce thyroid hormone. These
cells give rise to both well differentiated cancers (papillary carcinoma and follicular) and
anaplastic thyroid cancer. The second cell type, the C or Para follicular cell, produces the hormone
calcitonin and is the cell of origin for medullary thyroid carcinoma.

Iodine
Thyroid gland extracts iodine from various foods, including certain vegetables, shell fish,
milk products and anything with iodized salt. Normally we take in sufficient iodine through our

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diet. Our thyroids are very sensitive to iodine. When the thyroid gland isn’t able to attain sufficient
quantities of iodine, it can enlarge and our develop goiter.

Pituitary Gland
The pituitary gland “master gland” is situated at the base of the skull and regularly
monitors T4 and T3 “stock” in your body’s blood vessels. When stock is low it sends a message
to your thyroid gland in the form of a stimulating hormone called TST (thyroid stimulating
hormone) and orders it to produce more. The pituary gland secretes increased amounts of TSH
wen T4 and or T3 levels are low. When your TSH level is high it is a sign that you’re hypothyroid;
when its low, it is a sign that you’re hyperthyroid.

The role of calcitonin


Thyroid gland rents space to additional thyroid cells called C cells, which make the
hormone calcitonin and do not make thyroid hormone. This hormone helps to regulate calcium
and hence to prevent osteoporosis. But to the bones, calcitonin is kind of like a tonsil; it serves a
useful purpose, but when the hormone isn’t manufactured, due to the absence of a thyroid gland
(if its remove), it wont really notice the effects. Calcium levels are really controlled by the
parathyroid glands.

The role of thyroglobulin


Thyroglobulin is a specific protein made only by thyroid cells, used mostly by the thyroid
gland itself to make and store thyroid hormone. Like calcitonin, this substance isn’t all that
important to your body once your thyroid is gone. The only role thyroglubin plays is in screening
for the thyroid cancer recurrence.

What is cancer?
Cancer is the general term for the abnormal growth cell reproduces, it has the ability to
invade or metastasize to other parts of the body. The cancer cell frequently destroys the orgn from
which it originates. As it spreads into various parts of the body, it interferes with the jjobs of
regular cell, confuses other organs, can wreak havoc. It’s basically a terrorist cell, hijacking
surrounding organs and other cells. Cancer cells use the lymph system or blood vessels to get into

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the bloodstream and then travel through the body. These cells love organs that have multiple
blood vessels and nutrients, such as bones, lungs and brains- common areas when cancers spread.
Cancer cells are classified into four main groups: carcinoma, sarcoma, leukaemia and
lymphoma. A carcinoma refers to cancerous cells coming from epithelial cells-cells that line
various organs. Carcinomas are found in the organs that tend to secrete smething (milk, mucus,
digestive juices etc). Common sites are breast, lungs and colons. Carcinomas account for 80 to
90 percent of all human cancers, and are generally slow growing. There is always a prefix attached
to the end, as in adenocarcinoma. When it comes to thyroid tumours, benign tumors are more
frequent than adenocarcinomas, which are malignant.
Since cancer cells are living cells, it is in their nature to continue to live. So the first thing
cancer cell do is grow; they’ll simply begin growing where they first originated, be it in thyroid,
lung, or colon. Then mutate around them. After they get to a certain age, they want to move out
and leave their original nest. So they spread out into the surrounding fat and tissue
A very crucial need of the cancer cell is to eat. So the cancer sends out protein messengers
(called angiogenesis factors) that create a new blood vessels to feed it. If cancer cell manages to
grow, spread and eat, it will live and result in tumour.

The cancer that first develops in a tissue or organ is called the primary cancer. A malignant
tumour is usually named after the organ or type of cell affected.

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A malignant tumour that has not spread to other parts of the body is called localised cancer. A
tumour may invade deeper into surrounding tissue and can grow its own blood vessels
(angiogenesis).

If cancerous cells grow and form another tumour at a new site, it is called a secondary cancer or
metastasis. A metastasis keeps the name of the original cancer. For example, bowel cancer that
has spread to the liver is called metastatic bowel cancer, even though the person may be
experiencing symptoms caused by problems in the liver.

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Physical Assessment
General Survey
Received the patient in bed sitting awake and responsive, with an IVF of PNSS 1L running
at 80cc/hr infusing well at left metacarpal vein, ne redness in the site noted. The patient is well
groomed. Mass on the right lateral neck is well dress and intact with an presence of small blood
on the dressing.
Vital Signs:
 BP-110/60
 T- 36.9 OC
 PR-81 bpm
 RR-20 cpm

Skin, Hair, and Nails


Skin is brown, warm, dry and wrinkled. Lichenification on the right knuckles is present. No
lesions or excoriations noted on the lower extremities. But on the patient right lateral neck there is a
presence of 12cmx8cm mass solid, doughy and bleeding and no other lesions noted on the upper
extremities. Hair brown, 7x7 boy cut length hair, clean, shiny with little bit of gray hair. Normal
distribution of hair on scalp. Nails are long, hard, smooth and dirty. Nailbeds pink without
clubbing. Cuticles smooth, no detachment of nail plate.

Head, Neck, Regional Lymphatics


Head symmetrically round, hard, and smooth without lesions or bumps. Face oval,
smooth, and symmetrical. Neck symmetric with centered head position and with bulging mass
located at the right lateral area of the neck with a size of 12x8cm firm, non-tender, fixed mass
with ulceration and pruritus on the site of the wound and lastly itchiness in the throat is noted. Pain
of 6/10 especially when neck is move to the right. Has limited range of motion of neck. Left neck
has no presence of any lesions and masses. Thyroid gland is not palpable when
swallowing. Trachea in midline.

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Eye Assessment
Extraocular movements smooth and symmetric with no nystagmus. Eye lids in normal
position with no abnormal widening or ptosis. No redness, discharge, or crusting noted on lid
margins. Patient has cataract on the right eye. While on the left eye conjunctiva and sclera
appear moist and smooth. Sclera white with no lesions or redness. No swelling or redness over
lacrimal gland. Cornea is transparent, smooth, and moist with no opacities, lens is free of
opacities on the left eye. On the other hand left eye there is a small response to light because of
the presence of opacity. Pupils are equal in size.

Ears, Nose, Mouth, and Throat Assessment


Ears are equal in size bilaterally. Auricles are aligned with the corner of each eye. Skin
smooth, no lumps, lesions, nodules. No discharge. Nontender on palpation. Small amount of
moist yellow cerumen in external canal and 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. The patient
can hear well. Lips brown, smooth, and moist without lesions. Buccal mucosa pink, moist, and
without exudates. 320 white to yellowish teeth present. Gums pink without redness or
swelling. Tongue in midline with no tremors. Equal bilateral strength in tongue. Ventral
surface of tongue smooth and shiny pink with small visible veins present. Frenulum in
midline. Soft palate smooth and pink. Nose somewhat large but smooth and symmetric. Able to
sniff through each nostril. No purulent drainage noted. Frontal and maxillary sinuses are no
tender to palpation.

Thorax and Lungs Assessment


Respirations 20/minute, relaxed and even. Chest expansion symmetric. No retraction or
bulging of interspaces. No pain or tenderness on palpation. Percussion tones resonant over all lung
fields. No adventitious, wheezing and crackles sounds present upon auscultation.

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Breast and lymphatic Assessment
Bilateral breasts moderate in size with moderate in sagging. Breast skin is brown, dark
brown areola. Nipples everted bilaterally. Free movement of breasts with position changes of
arms and hands. No dimpling, retraction, lesions, or inflammation noted. Axillae free of rashes
or inflammation. No masses or tenderness noted on palpation.No discharge noted from
nipples. Axillary ( central, posterior, or anterior) and lateral arm lymph nodes nonpalpable.

Heart and Peripheral Vasculature Assessment


The patient’s cardiac rate is 79 beats per minute. The patient’s pulse rate is 81 beats per
minute with strong, regular pulses. No Murmurs upon auscultation. Adequate perfusion noted as
manifested by warm skin. Arms are equal in size, no swelling, pinkish skin tone, no clubbing of
finger tips, warm bilaterally. Capillary refill time less than 2 seconds, radial and brachial pulses
strong bilaterally. Legs are warm bilaterally. Femoral, popliteal, dorsalis pedis, and posterior
tibial pulses strongly palpated bilaterally. No apparent varicosities or superficial
thrombophlebitis noted.

Abdominal Assessment
Skin of abdomen is free of rashes. On the left side of the lower abdomen there’s a
presence of striae. No lesion, scars and lesions noted. Umbilicus is midline and recessed with
no bulging. Abdomen is flat and symmetric with no bulges or lumps. No bulges noted when
patient raises hand. No peristaltic movements seen. No tenderness or guarding in any quadrant
with light palpation. Umbilicus and surrounding area free of masses, swelling, and bulges.

Musculoskeletal System Assessment


Gait smooth, with good base of support. Full ROM with no pain, tenderness, clicking
Normal curves of cervical, thoracic, and lumbar spine. Full smooth ROM of cervical and lumbar
spine. Upper and lower extremities symmetric without, deformities ,or swelling. Full smooth
ROM against gravity and resistance. No atrophy, tremors, weakness, full ROM of all
extremities. No tremors. Gait and tandem walk normal and steady.

Sensory Assessment

25
Identifies light touch, dull and sharp sensations to trunk and extremities.

Female Genitalia
Patient refuses further assessment but verbalized normal hair distribution, no lesions,
masses, or swelling. Vagina is free of lesions, swelling or discharge. No discharge from
urethral opening noted.

26
Etiology

Predisposing Remarks Rationale Justification


Factors
Age Present Thyroid cancer can occur Patient had felt one
at any age, but the risk of signs of thyroid
peaks earlier for women cancer at the age of
(who are most often in 69 which was the
their 40s or 70s when hard and painless
diagnosed) than for men lump located at the
(who are usually in their right neck.
60s or 70s). (ASCOCancer
2016)
Sex Present For unclear reasons thyroid The patient gender
cancers (like almost all is female
diseases of the thyroid)
occur about 3 times more
often in women than in
men. But some studies
shows possibly due to the
reproductive hormones and
related factors.(American
Cancer Society2017)
Race Present Thyroid cancer rates were The patient is a
relatively high among natural born
Filipinos compared to in Filipino citizen.
other Asian subgroups and
non-Hispanic whites,
although the reasons for

27
this were unclear.( Kim, B.
H. (2016). Differentiated
Thyroid Cancer in Asians.
Endocrinology and
Metabolism)
Genetics Present -An abnormal RET The patient’ states
/Family oncogene, which can be that her
History passed from parent to child, grandmother in the
may cause MTC. Not mother side has an
everyone with an altered goitre.
RET oncogene will develop
cancer. Blood tests and
genetic tests can detect the
gene. Once the altered RET
oncogene is identified, a
doctor may recommend
surgery to remove the
thyroid gland before cancer
develops. People with MTC
are encouraged to have
genetic testing to determine
if a mutation of the RET
proto-oncogene is present. If
so, genetic testing of
parents, siblings and
children will be
recommended.

-A family history of MTC


increases a person’s risk.
People with MEN2

28
syndrome are also at risk for
developing other types of
cancers.
-A family history of goiters
increases the risk of
developing papillary thyroid
cancer.

-A family history of
precancerous polyps in the
colon, also called the large
intestines, increases the risk
of developing papillary
thyroid cancer.

(ASCOCancer,2016)

29
Precipitating Remarks Rationale Justification
Factors
Diet low in Absent Follicular thyroid cancers Patient verbalizes
iodine are more common in areas that they cook
of the world where they’re food with
people’s diets are low in enough (not too
iodine. In the United less and not too
States, most people get much )spices such
enough iodine in their diet as salt.
because it is added to table
salt and other foods. A diet
low in iodine may also
increase the risk of
papillary cancer if the
person also is exposed to
radioactivity. .(American
Cancer Society2017)
Radiation Absent Radiation exposure is a Patient location
exposure/ xray proven risk factor for had no record of
exposure thyroid cancer. Sources of being positive in
such radiation include radiation fallout
certain medical treatments from powerplant
such as x-rays and radiation accidents or any
fallout from power plant nuclear weapon
accidents or nuclear that has been
weapons. launched. She also
verbalizes that she
Having had head or neck
doesn’t get a lot of
radiation treatments in
X-rays exposures
childhood is a risk factor for
ever since she was
thyroid cancer. Risk
a child.

30
depends on how much
radiation is given and the
age of the child. In general,
the risk increases with larger
doses and with younger age
at treatment. .(American
Cancer Society2017)

Breast cancer Absent A recent study showed that Patient has no


breast cancer survivors history of breast
may have a higher risk of cancer and so does
thyroid cancer, particularly she.
in the first 5 years after
diagnosis and for those
diagnosed with breast
cancer at a younger age.
This finding continues to
be examined by
researchers.
(American Cancer
Society2017)

31
SYMPTOMATOLOGY

SYMPTOM PRESEN RATIONALE JUSTIFICATION


T
Lump(nodule) in Present The nuclei of papillary carcinoma are 3 years Pta the
the neck that enlarged and ovoid and contain thick patient had a
continue to enlarge membrane, intranuclear grooves, and nodule located at
intranuclear cytoplasmic inclusions. the right lateral
Because the nuclei are enlarged, they neck she would
frequently overlap one another, which describe it as
is a helpful clue for diagnosing it. “gamay na bukol
Papillary carcinoma has a propensity mura sang jolen”.
to invade lymphatic spaces and And it continued
therefore, leads to microscopic to grow up to its
multimodal lesions in the gland as well current size of
as high incidence of regional lymph 12cm x 8cm.
node metastases. This may be a
symptoms of a thyroid papillary
carcinoma, in some cases, a primary
tumour is very small. (DeVita,
Hellman, and Rosenberg's Cancer:
Principles and Practice of Oncology,
2008)
Trouble breathing Absent Widespread tumor infiltration of the However, the
pulmonary parenchyma is well known patient have
to precipitate dyspnea and hypoxia, identified no
and there are many cases of reported other reports of
airflow obstruction related to direct small airway
tumor invasion of central airways, such obstruction
as the trachea and major bronchi precipitated by

32
(Manganaris C, Wittlin S, Xu H, tumor metastases
Gurell M, Sime P, Kottmann RM. therefore the
Metastatic Papillary Thyroid patient had no
Carcinoma and Severe Airflow evidence of upper
Obstruction. Chest.2010.) airway or central
airway
obstruction on
flow-volume
loops.
Trouble swallowing Absent Consistent compression of the Not felt by the
food esophagus by the thyroid mass.( Lee patient. Patient is
SL. Endocrine Today. 2008) still on DAT with
SAP diet.
Hoarseness Absent The voice box sits right on top of your According to her
thyroid, so changes to the gland could daughter there
makes the voice chronically hoarse..( were no changes
Lee SL. Endocrine Today. 2008) on the patients
voice.
Cough that persist Present A cough that just won't seem to go According to the
and not cause by flu away. Like the nodules that cause patient the cough
swallowing symptoms, thyroid nodules started a year ago
that cause the patient to cough are when the lump
almost always on the back side of the became obvious.
thyroid. The caugh is caused by the
nodule irritating the trachea, or the
vocal cord nerve. We have two vocal
cord nerves (one on each side of the
neck, behind the thyroid) and a nodule
growing back there can rub or stretch
the nerve causing irritation and the
need to cough

33
Sleep Apnea Absent A thyroid nodule will be in such a Not felt by the
location that it is compressing the patient
trachea, but this is almost always due
to a thyroid goiter that is comprised of
lots (dozens) of thyroid nodules. This
can cause the symptom of feeling like
you can't catch your breath sometimes.

34
Pathophysiology

35
DOCTOR’S ORDER

Date & Time Doctor’s Order Rationale Remarks


Ordered
12- 15-2018 - Please admit patient at
ENT ward under the
8:00pm sense of DR
Chest Pa Espal/Ruiz/Eufunre.
-Consider LV
Cardiomegaly -Secure consent to care Consent gives an opportunity Significant others
-Atherosclerotic to the patient to be informed signed and
Aorta about all the procedures that secured consent.
- Consider Right will be applied. Done
Lateral Neck Mass
Sonographic/ct -DAT
scan of neck
suggested LABS
CBC + Platelet was done to Done taken on 12-
CBC + PLT the patient to monitor his 15-1814:36
blood components especially
his WBC since having high Hemoglobin –L
WBC count is associated with 96
increased mortality rates in Hematocrit L 0.28
patients who have ACS RBC count- L3.31
WBC 8:68
CT/ BT A bleeding time test Done taken on 12-
determines how quickly your 15-18 14:36
blood clots to stop bleeding.
The test involves making NORMAL
small, superficial cuts on your CT: 5:00

36
skin. They're similar to light BT: 1:00
scratches. The test is a basic
assessment of how well your
blood platelets work -form
clots

PT/ APTT Measures how long it takes Done


blood to clot. It characterizes PT Patient- H 26.5
blood coagulation. It can also APTT- L 26.5
be used to check whether
medicines to prevent clots are
working.
12 L ECG The standard 12-lead Not attached to
electrocardiogram is a chart
representation of the heart's
electrical activity recorded
from electrodes on the body
surface DONE

NA Sodium test checks how much Result out on


sodium is in the blood. It helps 12/15/17 2.9
keep the water and electrolyte
DONE
balance of the body.

Crea Result-72.0
Creatinine (Crea) levels is a
Crea 12/15/17 out
reliable indicator of kidney
14:49
function.

A blood calcium test is


Ca DONE
ordered to screen for,
Result 2.19
diagnose, and monitor a range

37
of conditions relating to the
bones, heart, nerves, kidneys,
and teeth.

GRBS Random blood sugar (RBS)


measures blood glucose DONE
regardless of when you last Date released:
ate. Several random 12/15/17 8:49pm
measurements may be taken Result H 8.241
throughout the day. Random
testing is useful because
glucose levels in healthy
people do not vary widely
throughout the day
LDH An LD blood test may be Done
used: ; to help stage, 12/15/1714:49
determine prognosis, and/or Result : H 630.4
response to treatment of
certain cancers; to help
evaluate body fluid

Pottasium Potassium is an electrolyte Done


that is vital to cell 12/15/1714:49
metabolism. It helps transport
nutrients into cells and Result 4.2
removes waste products out
of cells. It is also important in
muscle function, helping to
transmit messages between
nerves and muscles, and is
important to heart function.

38
This test measures the amount
TSH of TSH in the blood. Thyroid- Done results are:
stimulating hormone (TSH) is Free t4- 12.45
produced by the pituitary TSH3- 2.21
gland, a tiny organ located
below the brain and behind
the sinus cavities. TSH
stimulates the thyroid gland to
release the hormones
thyroxine (T4) and
triiodothyronine (T3) into the
blood.

An ABG test uses blood


ABG drawn from an artery, where Done 12/15/17
FT4 the oxygen and carbon 11:07pm
dioxide levels can be
measured before they enter
body tissues
The PA view examines the
Chest Pa lungs, bony thoracic cavity, Result :
mediastinum and great -Consider LV
vessels. The chest X-ray is Cardiomegaly
frequently used to aid -Atherosclerotic
diagnosis of acute and chronic Aorta
conditions.

Cervical APL Cervical spine x-ray (XR


cervical spine or CS spine) is

39
performed to investigate neck
pain, particularly following
trauma or in cases of chronic
neck pain with findings of
upper limb weakness,
numbness or tingling. Result not done
and not attached
A CT or CAT scan is a to chart
CT scan of neck with shortened name for

contrast computerized tomography. A


CT scan takes pictures of the
inside of the body. The Result :
pictures are more detailed Consider Right
than a typical x-ray. During a Lateral Neck
CT scan of the neck, pictures Mass
are taken of cross sections or Sonographic/ct
slices of the structures in your
scan of neck
body. When contrast is used suggested
during a CT scan of the neck,
the structures are highlighted
even more

Packed red blood cells


(PRBCs) are made from a unit
-Secure 1”u” PRBC with
of whole blood by
patient blood type and
centrifugation and removal of
transfuse after proper
most of the plasma, leaving a
crossmatching.
unit with a hematocrit of
about 60%. One PRBC unit
will raise the hematocrit of a
Not done. Still to
standard adult patient by 3%
secure.

40
Meds
-Tranexamic acid 500mg To treat heavy bleeding during
1 tab tid x 3 days your menstrual period. Trexami
acid works by slowing the
breakdown of blood clots,
which helps to prevent
prolonged bleeding.

-Celecoxib 200ml tab BID Celecoxib Is used to treat pain


PRN for Pain and redness, swelling, and
heat (inflammation) from
osteoarthritis, rheumatoid
arthritis, juvenile rheumatoid
arthritis in patients 2 years
and older, and ankylosing
spondylitis; and for the
management of acute pain in
adults, and for the
management of menstrual
cramps

-Clindamycin 300mg Clindamycin is indicated in


IVTT q8 x 3 days ( ) the treatment of serious
ANST infections caused by
susceptible anaerobic bacteria
-Third saline solution Irrigation is done to remove
daily hygiene at right debris or necrotic tissue, to
cervical neck. clean the wound and to make
it easier for your clinician to

41
examine it. Using sterile
saline water to irrigate
wounds is one of the most
common cleansing methods
used by hospitals because it's
a nontoxic isotonic solution
-HTIG 250min IM R Tetanus immune globulin is
deltoid used to prevent tetanus
infection Tetanus is a serious
illness that causes convulsions
(seizures) and severe muscle
spasms that can be strong
enough to cause bone fractures
of the spine

-TT 5mg IM L deltoid TT is indicated for booster


injection. This should be
enough to give you long-term
protection from tetanus.
However, if you're not sure
how many doses you've
received, you may need a
booster dose after an injury
that breaks your skin

For wound GS and CS A Gram stain is typically


ordered along with a culture
when a bacterial or sometimes
fungal infection is suspected.
It is also usually performed
when the result of a culture is

42
positive, on a sample of the
bacteria grown in the culture.
Test results are reported
promptly to help guide
treatment.
Refer to IM Pulmo for Seen and
evaluation and co examined on
management 12/16/17 6am by
D.R Glojebo
Refer to IM Gen for co Not seen
management

12/15/17 IVF of Pnss 1L at


8:15pm Start IVF PNSS 1L at Using sterile saline water to 80cc/hr running at
80cc/hr irrigate wounds is one of the left metacarpal
most common cleansing vein, infusing
methods used by hospitals well.
because it's a nontoxic
isotonic solution

IM NOTES Patient is seen and


12/16/17 Thank you for this examined on
referral 12/16/17 by Dr.
(-) fever Patient is seen and Gojebo.
(-)dyspnea examined
(+) throat ichiness History reviwed

43
(-) crackles IVF : Pnss 1L at 120cchr Using sterile saline water to IVF of Pnss 1L at
(-) edema irrigate wounds is one of the 80cc/hr running at
most common cleansing left metacarpal
methods used by hospitals vein, infusing
because it's a nontoxic well.
isotonic solution
Diet: DAT with SAP Diet as tolerated is a term that Instructed the
indicates that the patient and her
gastrointestinal tracts is daughter about
tolerating food . Aspiration her diet.
precautionare measures taken
to prevent a person from
aspirating, or choking.
DX
Lipid Profle Measure the amount of Done result
“good” and “bad” cholesterol attached chart
and triglycerides, a type of 12/15/17
fat, in your blood.
FBS Measures blood glucose after Done result
you have not eaten for at least 8 attached chart
hours. It is often the first test 12/15/17
done to check
for prediabetes and diabetes.
Done result
.Crea attached chart
12/15/17
Mg Done result
attached chart
Clindamycin 600mg 12/15/17
+100cc PNSS to infuse
for 30 minutes q8

44
Not done on our
shift.

Additional Cefotoxime 1g Result (-)


ivtt q8 for ANST ( )

Secure 1 unit PRBC after Not done. To


proper blood typing and secure 1unit
crossmatching PRBC

VS to monitor baseline data DONE


VSQ4
I and O q shift Hourly urine output is a very Done
useful guide to the adequacy Output (12-16-17)
of cardiac output, splanchnic 300cc.
perfusion, and renal function
CBG q6 Monitoring patient’s glucose Done
daily to obtain data and to Results:
manage his diabetes. Also, to 12-16-17 @ 6am
avoid complications of 104mg/dl
diabetes and to minimize risk 12-16-17 @ 11am
12/16/17 of hyperglycemia. 106mg/dl
8am
Please carry out IM
orders
For daily wound care and Done on 12/16/17
dressing

45
For wound discharge Done on 12/16/17
KOH, AFB, GS/CS

For blood transfusion to Not done.


12/16/17 secure 1 PRBC after
12:13pm proper crossmatching.
= 12mx 8cm ENT- HNS
doughy mass +
Wound care done using Dressing is a sterile pad or Done
ulceration
third solution. compress applied to a wound
to promote healing and
protect the wound from
further harm
Wound discharge sent for Done
GS/CS/KOH, AFB Pending results.

46
Laboratory Results

Date Printed: 12/15/17 17:23

MEASURED RESULTS REFERENCE JUSTIFICATION


TESTS RANGE
Hemoglobin Hematology is the study of blood and its
disorders. Hematology tests can help diagnose
anemia, hemophilia, blood-clotting disorders,
and leukemia. It is actually a panel of tests that
examines different parts of the blood. It also
helps to determine the general health status of
the patient.

CT/BT
Clotting time 5:00 Min:sec 2.0-5.0
Bleeding Time 1:00 Min:sec 1:00-3:00

Hemoglobin L97.0 115.0-155.0

Hematocrit L0.28 0.36-0.48


RBC Count L3.31 4.20-6.10
WBC Count 8.68 5.0-10.0
Differential
Count
Neutrophil 71 55.00-75.00
Lymphocytes L17 20-35
Monocyte 10 2-10
Esonophil 2 1.8
Basophil 0
Platelet count 263 150-400

47
MCV 83.40 79.40-94.80
MCH 29.1 28.60-32.20
MCHC 35.1 32.20-35.50
Prothrombin A prothrombin time (PT) is a test used to help
time test with detect and diagnose a bleeding disorder or
INR excessive clotting disorder; the international
normalized ratio (INR) is calculated from a PT
result and is used to monitor how well the
blood-thinning medication (anticoagulant)
warfarin is working to prevent blood clots
PT Patient H26.5 11.5-14.3
PT Inr 1.08
PT B Activity 89.0
PT Control 138 12.0-16.0

APTT The partial thromboplastin time or activated


partial thromboplastin time is a medical test
that characterizes blood coagulation, also
known as clotting
APPT L26.7 27.7-32.9
APTT Control 31.2 26.0-34.0

Arterial Blood
Gas
Measured Test
PH 7.41 7.35-7.45
Pco2 28 35-45
PO2 103 80-100
TEMP 37
Calculated Test
BEecf -6.9 Compensated Respiratory

48
BE (B) L 5.7 -2 -+2
HCO3 17.7 21-27 Alkalosis with good oxygenation
TCO2 18.6 19-24
SO2 98 95-100
Serology and
immunology
Free T4 12.45 7.90-14.400
T3H3 2.21 0.38-5.33
Glucose RBS H 8.241 4.10-6.60

49
Special Procedure

CT- Scan

A computerized tomography (CT) scan combines


a series of X-ray images taken from different
angles and uses computer processing to create
cross-sectional images, or slices, of the bones,
blood vessels and soft tissues inside your body.
CT scan images provide more detailed
information than plain X-rays do.

Preparation for a CT scan typically depends of which part of the body is to be scanned.
Usually, the patient will be asked to:

 Take off some or all of the clothing and wear a hospital gown.
 Remove any metal objects, such as a belt or jewelry, which might interfere with image
results.
 Stop eating for a few hours before the scan.
 If a patient is going to have a contrast injection, he or she should not have anything to eat
or drink for a few hours before the CT scan because the injection may cause stomach
upset.
 To receive the contrast injection, an IV is inserted into the arm just prior to the scan. The
contrast then enters the body through the IV.
 Prior to most CT scans of the abdomen and pelvis, it is important to drink an oral contrast
agent that contains dilute barium. This contrast agent helps the radiologist identify the
gastrointestinal tract (stomach, small and large bowel), detect abnormalities of these
organs, and to separate these structures from other structures within the abdomen.

50
 If the patient has a history of allergy to contrast material (such as iodine), the requesting
physician and radiology staff should be notified.
 The patient will be asked to drink slightly less than a quart spread out over 1.5 to 2 hours.

Fine needle Aspiration Biopsy

A fine needle aspiration biopsy of a thyroid nodule is a simple and


safe procedure performed in the doctor’s office. Typically, the
biopsy is performed under ultrasound guidance to ensure accurate
placement of the needle within the thyroid nodule. You will be
asked to lie down on your back with your head tipped backwards,
so that your neck is extended. Sometimes, a pillow is placed under
your shoulders to help you get in best position for the biopsy.

Nursing interventions:

1. Instruct the patient that during the procedure she may feel some neck pressure from the
ultrasound probe and from the needle.

2. Ask the patient to remain as still as possible and avoid coughing, talking and swallowing
during the biopsy.

3. Assess if any of the risk are present such as bleeding in the site, infection and damage near to
the thyroid as most health care use with ultrasound.

4. Advice the patient that the site of the biopsy might be sore for a day or two after the
procedure.

5. Assist the D.R in doing the procedure and make sure to keep it sterile.

51
Drug Study

Generic Name

Tranexamic Acid

Brand Name Cyklokapron, Lysteda


Classification Antifibrinolytics, Anti haemorrhagic
Dosage 500mg; 100mg/ml ;650mg
To treat heavy bleeding during your menstrual period. Trexami acid
Mechanism of Action works by slowing the breakdown of blood clots, which helps to
prevent prolonged bleeding.
Indication  Hemorrhage following dental and/or oral surgery in patients
with hemophilia
 Management of hemophilic patients (those having Factor VIII
or Factor IX deficiency) who have oral mucosal bleeding, or are
undergoing tooth extraction or other oral surgical procedures.
 Surgical: General surgical cases but most especially operative
procedures on the prostate, uterus, thyroid, lungs, heart, ovaries,
adrenals, kidneys, brain, tonsils, lymph nodes and soft tissues.
 Obstetrical and gynecological: abortion, post-partum
hemorrhage and menometrorrahgia
 Medical: epistaxis, hemoptysis, hematuria, peptic ulcer with
hemorrhage and blood dyscrasias with hemorrhage

52
 Effective in promoting hemostasis in traumatic injuries.
 Preventing hemorrhage after orthopedic surgeries.

Contraindication  Allergic reaction to the drug or hypersensitivity


 Presence of blood clots (eg, in the leg, lung, eye, brain), have a
history of blood clots, or are at risk for blood clots.

Side effects Nausea, vomiting, diarrhoea, coughing up blood clot, allergic


reaction, itchy throat, dizziness, trouble breathing. Swelling, sudden
numbness and chest pain.
Nursing  Unusual change in bleeding pattern should be immediately
Responsibilities reported to the physician.
 The medication can be taken with or without meals
 Swallow with plenty of water. Do now break, crush or chew
before swallowing
 If missed take it when you remember, then take next dose at least
6 house later.
 Inform client the she should inform the physician immediately if
any of the side effects occur.

53
Generic Name Celecoxib

Brand Name Celebrex


Classification Nonsteroidal anti-inflammatory drug (NSAID), antirheumatics
Dosage 50mg ,100mg, 200mg, 500mg
Mechanism of Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that is used
Action to treat arthritis, pain, menstrual cramps, and colonic polyps.
Indication Is used to treat pain and redness, swelling, and heat (inflammation) from
osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis in
patients 2 years and older, and ankylosing spondylitis; and for the
management of acute pain in adults, and for the management of menstrual
cramps
Contraindication  Sulphonamide hypersensitivity
 Acute bronchospasm
 Asthma
 Hypersensitivity
 Uticaria
 Alcoholism
 Hepatiic disease
 Anemia
 Bone marrow suppression

Side effects Headache, abdominal pain, ingestion, diarhea, nausea, flatulence,


insomnia, fainting

54
Adverse Effects - Headache
- Abdominal pain
- Ingestion
- Diarrhea
- Nausea
- Insomnia
- Flatulence
- Fainting

Nursing
Responsibilities 1. Assess pt’s history of allergic reaction to the drug
2. Assess patient for rash as Steve Johnson syndrome may develop.
3. Instruct patient to take celecoxib exactly as directed.Do not take
more than prescribed dose.
4. Instruct patient not to take the drug with any dairy products.
5. Advice patient to immediately report bloody stools, blood in vomit
or signs and symptoms of liver damage

55
Generic Name Clindamycin

Brand Name Cleocin


Classification Antibiotics
Dosage PO: 75mg, 150mg, 300mg
Mechanism of Action An bacteria in the body. It is used to treat serious infections caused
by bacteria.
Indication Clindamycin is indicated in the treatment of serious infections
caused by susceptible anaerobic bacteria.

Clindamycin is also indicated in the treatment of serious infections


due to susceptible strains of streptococci, pneumococci, and
staphylococci.
Contraindication With a history of hypersensitivity to preparations containing
clindamycin or lincomycin.
Side effects - Diarrhea
- Jaundice
- Urinating less than usual
- Fever, chills , body aches
- Flu symptoms
- Easy bruising
- Unusual bleeding

56
Adverse Effects Skin problems, such as hives, rash, red, shedding, or peeling skin.
Yellow appearance of the skin, nails, or whites of the eyes
(jaundice) Vomiting, severe stomach pain, or diarrhea.

Nursing
Responsibilities
1.Instruct the patient to report the onset of watery diarrhea, with or
without fever; passage of tarry or bloody stools, pus, intestinal
tissue, or mucus; abdominal cramps, or ileus. Symptoms may
appear within a few days to 2 wk after therapy is begun or up to
several weeks following cessation of therapy.

2. Take oral drug with a full glass of water or with food.

3.Take full prescribed course of oral drug. Do not stop taking


without notifying health care provider.

4.Aware the patient experience these side effects: Nausea, vomiting


(eat frequent small meals); superinfections in the mouth)

5. Stop drug therapy if significant diarrhea develops (more than 5


loose stools daily) and notify physician.

57
Generic Name HTIG (Human tetanus immunuglobin)

Brand Name Baytet, HypetTET S/D


Classification Immunoglobulins-Antibacterial Tetanus Sera
Dosage Intramuscular Inj Sol: 250U
Mechanism of Action IgG containing tetanus antibodies; neutralizes exotoxin produced by
Clostridium tetani; provides passive immunity; prophylaxis against
tetanus post injury; adjunct in active tetanus infection
Indication Tetanus immune globulin is used to prevent tetanus infection (also
known as lockjaw). Tetanus is a serious illness that causes
convulsions (seizures) and severe muscle spasms that can be strong
enough to cause bone fractures of the spine
Contraindication - Hypersensitivity
- Infection
- Coagulopathy, hemphilia
- IgA deficiency
- Anaphylactic administration
- Pregnancy
- Breast feeding
- Vaccination
Side effects - Difficulty inbreathing or swallowing
- Hives
- Itching
- Reddening of skin

58
- Swelling of eyes
- Unusual tiredness

Adverse Effects - Anaphylactic shock


- Angioedema
- Nephrotic syndrome
- Fever
- Infection

Nursing 1.Obtain history of systemic allergic reactions to human immune


Responsibilities globulin preparations prior to drug administration.
2 Before injection, the skin over the site to be injected should be
cleansed with a suitable germicide. After insertion of the needle,
aspirate to ensure that the needle has not entered a blood vessel..
3 Advice the patient to report any signs of the side effects and seek
help if felt.

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Generic Name

Anti-tetanus
Brand Name Tetanus toxoid
Classification Epi vaccine, Anti tetanus
Dosage Im injection: o.5 ml, 3ml, 5ml

Mechanism of Action Tetanus vaccine, also known as tetanus toxoid (TT), is an inactive
vaccine used to prevent tetanus
Indication TT is indicated for booster injection. This should be enough to give
you long-term protection from tetanus. However, if you're not sure
how many doses you've received, you may need a booster dose after
an injury that breaks your skin

Contraindication Hypersensitivity to any component of the vacin


A history of systemic allergic reaction
Side effects -Body malaise - hypotension
- Redness - nausea and arthralagia
-edema
- transient fever
-pain
-warmth
Adverse Effects Adverse reactions may be local and include redness, warmth,
edema, induration with or without tenderness as well as urticaria,
and rash. Malaise, transient fever, pain, hypotension, nausea and
arthralgia may develop in some patients after the injection.

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Nursing 1. Before injection, the skin over the site to be injected should be
Responsibilities cleansed with a suitable germicide. After insertion of the needle,
aspirate to ensure that the needle has not entered a blood vessel.
2. Shake well the vial before withdrawing each dose
3 Ensure that the injection does not enter the blood vessel.
4.TT should only be used in geriatric patients know to have received
a primary series of tt containing vaccine, since may such as persons
have no prior immunity.
5. Advice patient to report any abnormalities.

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Nursing Theories

Katharine Kolcaba “Theory of comfort”

Katharine Kolcaba (born December 28, 1944) is an American nursing theorist and nursing
professor. Kolcaba is responsible for the Theory of Comfort, a mid-range nursing theory that
has been implemented at the institutional level.
Assessing patients for their level of comfort utilizing a positive, holistic manner is important for
measuring effectiveness of comforting strategies. Comfort Theory (Kolcaba, 2003), with its
inherent emphasis on physical, psychospiritual, sociocultural, and environmental aspects of
comfort, will contribute to a proactive, well diverse and articulated, and multifaceted approach to
care. It clearly provides a framework for clinical practice guidelines, which state that the
provision of holistic care oriented to comfort must be explicit and well- documented.
Comfort interventions have three categories: (a) standard comfort interventions to maintain
homeostasis and control pain; (b) coaching, to relieve anxiety, provide reassurance and
information, instill hope, listen, and help plan for recovery; and (c) comfort food for the soul,
those extra nice things that nurses do to make children/families feel cared for and strengthened,
such as massage or guided imagery. (Kolcaba, 2003)

Nursing interventions are:


1 Assessment for development and complaints of the side effects of the therapy or surgery
(may use Comfort daisies, Comfort behavior, Checklist, etc.)
2 Frequently check vitals and watch out for fever or signs of nosocomial infections.
3 Administer medications or treatments to relieve the side effects of the therapy/surgery.
4 Avoiding the word "pain" upon assessment, obtaining data, and rendering health teaching
for a paediatric patient
5 Initiate patient and family education as needed.

6 Practice guided imagery to eliminate factors that could increase physical discomfort
7 Provide privacy as Marie is entering pubescent stage when she will be concerned about
her body image and privacy.

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Hildegard Peplau’s Interpersonal Relations Theory

The nursing model identifies four sequential phases in the interpersonal relationship:
orientation, identification, exploitation, and resolution. Peplau defines Nursing Process as a
deliberate intellectual activity that guides the professional practice of nursing in providing care
in an orderly, systematic manner.
Peplau explains 4 phases such as:
 Orientation: Nurse and patient come together as strangers; meeting initiated by patient
who expresses a “felt need”; work together to recognize, clarify and define facts related
to need.

 Identification: Patient participates in goal setting; has feeling of belonging and selectively
responds to those who can meet his or her needs.
 Exploitation: Patient actively seeks and draws knowledge and expertise of those who can
help.
 Resolution: Occurs after other phases are completed successfully. This leads to
termination of the relationship

Nursing interventions are:


Identification Exploitation Resolution
Goal setting was done along with Carried out plans mutually agreed Expresses the feeling of
patient upon. relieved. .

Provide non-pharmacological Provided non pharmacological


measures for pain relief such as measures like diversion, massaging,
diversional activity which diverts and pelvic traction.
the patients mind.
Provided supine position to the
Give the client a neutral client
position Supported the back during position
change
Always use back support while
turning the patient that reduces Used pillows to support the back.
the strain on the back.

Support the areas with extra


pillow to allow the normal
alignment and to prevent strain.

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Administer analgesics as Administered prescribed meds such
prescribed by the physician. as paracetamol.

Provide pelvic traction to the Given pelvic traction and explained


patient the need for traction

Client will achieve and maintain


self-care activities with little
assistance of caregiver

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Nola Pender’s Health Promotion Model

Pender's model focuses on three areas: individual characteristics and experiences, behavior-specific
cognitions and affect, and behavioral outcomes. The theory notes that each person has unique
personal characteristics and experiences that affect subsequent actions. The set of variables for
behavior specific knowledge and affect have important motivational significance. The variables can
be modified through nursing actions. Health promoting behavior is the desired behavioral outcome
which makes it the end point in the Health Promotion Model. These behaviors should result in
improved health, enhanced functional ability and better quality of life at all stages of development.
The significance here is that the medical profession’s purpose is not merely to cure diseases but to
prevent and the best way to do that is instilling in each individual on how to promote their own well-
being. The Healthcare team is not the main ingredient in living a healthy lifestyle. They might play
an important part but always serve as a secondary role to the basic and daily choices of healthy living.
Health-promoting behavior is the endpoint or action outcome directed toward attaining a positive
health outcome such as optimal well-being, personal fulfillment, and productive living.

Nursing Interventions:
1. There must be a commitment to a plan of action, which is the concept of intention and
identification of a planned strategy that leads to implementation of a proper health
behavior.
2. Assist the patient be able to decide herself that she wants to attain and maintain a
healthy lifestyle. It is one thing to say it and it is another to actually execute it.
3. Educated the patient and the family members and must identify the changes that they
have to take and must continue to do it. The patient must also understand her situation
and must be able to accept and not dwell solely on the fact that she is limited but from
it she must strive to live her life to the maximum despite her setback and it doesn’t
have to be in grandiose ways. She can take little steps starting from reflecting about
her situation and deciding on maximizing her capabilities.
4. Advised the patient that the greater the commitments to a specific plan of action, the
more likely health-promoting behaviours are to be maintained over time.

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Nursing Care Plan

Date Cues Nursing N Objective of Nursing interventions Evaluation


and diagnosis e care
time e
d
12/15 Acute Pain P At the end of 1. Determine pain history, for After an 8
/17 at the right h the 8 hour example, location of pain, hour of
@ Subjective lateral neck y shift the frequency, duration, and intensity nursing
ENT “Sakit gali related to s patient will using a rating scale (scale of 0–10), intervention
ward ilihok pa tuo the pressure i be able to : R: Information provides baseline the patient
SPM akon liog” of the tumor c data to evaluate need for, and was able to
C nodule as a Demonstrate effectiveness of, interventions. Pain decreased
7-3 Objective evidence by l decreased of of more than 6 months’ duration the level of
shift -Pain scale pain scale of pain from constitutes chronic pain, which may pain from
6/10 6/10 c 6/10 (severe) affect therapeutic choices. Recurrent 6/10 to 4/10
(severe) (severe). o to 4/10 episodes of acute pain can occur as
-Facial m (Moderate) within chronic pain, requiring verbalized
grimace f as evidence increased level of intervention. by the
while o by patient “
moving r verbalisation 2.Provide nonpharmacological Tapos ko
-Limited t of relief. comfort measures such as massage, inom sang
ROM on the repositioning, and back rub; as well bulong ko
neck area. as diversional activities, such as kaganina
- Has an music and reading. Rationale 12pm
12cmx8cm Promotes relaxation and helps nawalawala
mass on the refocus attention. nang sakit,

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right lateral 3. Place in semi-Fowler’s position apat na gali
neck. and support head and neck in ang score”
neutral position with small pillows.
Instruct client to use hands to
support neck during movement and
to avoid hyperextension of neck.
Rationale Prevents hyperextension
of the neck

4. Provide cutaneous stimulation,


such as heat and cold packs, or sift
massage in the surrounding area of
the mass. Rationale May decrease
inflammation, muscle spasms,
reducing associated pain.

5. Evaluate pain relief at regular


intervals. Adjust medication
regimen as per doctors advice.
Inform patient and her daughter of
the expected therapeutic effects and
discuss management of side effects.
Rationale Goal is maximum pain
control with minimum interference
with ADLs.

6. Encourage use of stress


management skills and
complementary therapies such as
relaxation techniques, visualization,
guided imagery, biofeedback,

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laughter, music, aromatherapy, and
Therapeutic Touch. Rationale
Enables client to participate actively
in nondrug treatment of pain and
enhances sense of control. Pain
produces stress and, in conjunction
with muscle tension and internal
stressors, increases client’s focus on
self, which in turn increases the
level of pain.

7. Administer analgesic such as


Celecoxib 200ml tab BID PRN for
Pain as prescribed by the doctor.
Rationale To decrease level of pain.

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Date Cues Nursing N Objective of Nursing interventions Evaluation
and diagnosis e care
time e
d
12/15 Impaired A Long term 1.Inspect the skin on a daily basis Goal not
/17 Objective skin c and described changes met
@ -Disruption integrity t After 10 days 2. Keep the area clean and assist in
ENT of skin related to i of nursing daily wound dressing and prevent
ward surface at inflammator v intervention infection.
SPM the right y response i the patient R: To assist body’s natural process
C lateral neck. secondary to t will be able to of repair.
7-3 -Wound is infection y display timely 3. Use appropriate wound dressing
shift 12cm x 8cm e healing/repair R: To protect the wound and
x ing of the surrounding tissues
-(+)bleeding e wound. 4. Demonstrated good skin hygiene
r such as washing thoroughly and pat
-(+) c dry carefully R: Maintaining clean
Ulceration i dry skin provides a barrier to
s infection. Patting skin dry instead of
- (+)pruritus e rubbing reduces risk of derma
on the site of p trauma to fragile skin.
the wound. a 5.Provided and applied wound
t dressings carefully R: Wound
t dressing protect the wound and the
e surrounding tissues.
r 6. Administer prescribed medicine
n such as Clindamycin IVTT q8 x 3
days (- ) ANST.

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Date Cues Nursing N Objective of Nursing interventions Evaluation
and diagnosis e care
time e
d
12/15 Subjective Disturbed S After 2 days 1. Acknowledge and accept expression of Goal met
/17 “Mas nami Body Image e of nursing feelings of frustration, grief, The patient
@ kung related to l intervention hostility. Note withdrawn behavior and was able to
ENT butngan changes in f the patient use of denial. R: Acceptance of these verbalize
ward sang scarf the structure - will be able to feelings as a normal response to the changes
SPM para hindi of the body p verbalize what has occurred facilitates in her neck
C laway as evidence e acceptance of resolution. It is not helpful or structure.
7-3 tanawon” as by mass in r self in possible to push patient before ready “Bal-an ko
verbalized the right c situation and to deal with situation. Denial may be man na
by the lateral neck. e adaptation to prolonged and be an adaptive amo sini
patient p altered body mechanism because patient is not (reffering to
t image. ready to cope with personal the mass)
Objective i problems ang dahilan
o 2. Recognize the normalcy of nga nag
-Intentional n response to the actual or perceived dako ning
hiding of m change in body structure or function liog ko, pero
neck park R: Experiencing stages of grief over temporary
loss of a body part or function is lang ni kay
- Actual normal and typically involves a siling ng
change in period of denial, the length of which doctor
the right varies among individuals operahan ko
neck 3. Set limits on maladaptive og tangalon
structure. behavior. Maintain nonjudgmental ni”.
attitude while giving care, and help
patient identify positive behaviors
that will aid in recovery. Patient and
her daughter tend to deal with this

70
crisis in the same way in which they
have dealt with problems in the
past.
4. Be realistic and positive during
treatments, in health teaching, and
in setting goals within limitations R:
This enhances trust and rapport
between patient and nurse.
5. Discuss the present situation
affecting the patient: To determine
the clients acceptance to the
situation.

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PROGNOSIS

CRITERIA POOR FAIR GOOD JUSTIFICATION


3 years prior consult, small mass was noted in the
right neck. No consult was done but they treated it
Onset of Illness X with a herbal medicine called “berrybituon” until the
mass became infected and treated it with mx3
capsule. Patient tolerated and mass grew in size..
4 days prior consult, there was spontaneous bleeding
in the center of the mass. Patient was referred in this
Duration of Illness X
institution by a local physician.

The case was able to identify factors that would


Precipitating Factors X
cause the onset of illness and we’re to provide
correlating justifications and rationale on how they
Predisposing Factors X
contribute to the development of the condition.
Though patient and watcher frequently asks reasons
for taking prescribed medications, they would still
Willingness to take the
X comply and cooperate in the scheduled medication
Medications
for as long as they are informed and understood the
condition.
The patient live in a stress free environment free
Environmental Factor X
from pollution and factories.
The patient is well supported by her family,
especially her youngest daughter. Her daughter is
always on the bedside, talking with the patient and
Family Support X assist in the ADLs and certain nursing interventions.
She was able to encourage the patient to comply
with medication and constantly reminding the
patient on the health teachings of the nurse.

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Poor: 1X1 = 1
Fair: 2X0= 0
Good: 3X6 = 18
TOTAL: 19/7 = 2.71, Good
TOTAL 1 0 6
Range of Values:
Poor = 1.0 – 1.6
Fair = 1.7 – 2.3
Good = 2.4 – 3.0

The prognosis is 2.71, which is GOOD. The prognosis of the patient was rated good because
most of the categories were rated as Good. Although they were not able to seek medical
attention/consultation after the onset and rated as poor but during their stay in the ENT ward they
were very cooperative and following her medication’s religiously. She was well supported by her
youngest daughter. No criteria was rated fair.

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Discharge Plan
MEDICATION
1. Inform watcher/family about importance of continuing medications.
2. Educate family about patient’s medications.
3. Inform family about prescribed medications, especially the indication.
4. Instruct patient’s family to seek physician immediately if any bizarre reactions occur.
EXERCISE
1. Educate patient’s family about passive ROM exercises.
2. Instruct patient’s family to assist patient with passive ROM exercises to promote blood
circulation.
3. Educate patient & family about refraining from doing activities beyond patient’s body
limit & workload.
4. Instruct patient to avoid doing activities that would cause great effort/exertion.
5. Instruct family to assist patient in ADL.
TREATMENT
1. Instruct patient’s family about following the medication orders given by the physician.
2. Discuss the importance of taking medications religiously.
HYGIENE
1. Discuss to patient’s family about maintaining good hygiene of the patient.
2. Instruct family about assisting patient in ADL especially in bathing ,grooming and
dressing.
3. Educate family about the importance of hand washing before and after contact with
patient surgery site.
OUT PATIENT ORDERS
1. Instruct patient and patient’s family 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.
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.

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2. Educate patient about what food are included in diet.
3. Educate patient about the side effects of eating food that are low in iodine.
4. Educate patient and family to include more vegetables and fruits on patient’s diet.
5. Limit fat intake more in vegetable and fruits.
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 together for a better outcome.

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Recommendation

This case study has honed vital knowledge and perceptions on papillary carcinoma, and garnered
wisdom on the said condition: types, signs and symptoms, factors/etiology, and also the
pathophysiology. The proponent would like to recommend the following:

To our patient
The proponent recommend her to continue fighting against her illness and to find ways to
ease the discomfort that comes with it. The proponent would like to encourage her to apply the
therapeutic interventions that we have given that would temporarily alleviate her feelings of
discomfort, and to continue in seeking help from nearest hospital or clinics. Also, the proponent
hope that in time, the patient would get well and live a life that he is genuinely happy of. To
client’s family, the proponent hope that they would eventually offer a helping hand and actually
make a move in seeking healthcare for their mothers current condition. May God let it sink in
their hearts that their mother is in dire need of their help, and also, in need of their utmost care
and support. To the client’s friends, most especially to those who didn’t isolate her despite of her
illness, may all of them receive more blessings from the Lord for they didn’t abandon a friend in
need. May all of them continue in guiding, helping, and supporting the patient.

To the Ateneo De Davao College of Nursing


The exposure of the students in the ENT ward is of great importance in understanding
patients with rare conditions. The proponent recommends that the nursing faculty and staff
continue to help and allow the students to be involved in actual patients, guide the students in
handling them, improve the quality of teaching because the proponent believe that there is always
room for improvement by slowly educating each individual.

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To Ateneo de Davao University
The proponent recommends that the Ateneo University continue to root and ground the
institution in the goal that the students must lead a life of knowledge with compassion to everyone
around them. May the university continue to support the College of Nursing in helping the
students have actual experiences on various activities related to the course. May the university
expand the opportunities of the nursing students in engaging themselves on different institutions
and different affiliations to help the students broaden their horizons.

To the Hospital Institution


The gravity of your tasks in handling critical patients is unimaginable. They require so
much of one’s patience and understanding. The proponent recommends that the institution
continue to improve their quality of care by developing a better and a more therapeutic
environment for their patients and continue to adhere to the ethical principle that all patients must
treated with respect, care, and understanding and lastly the proponent would also like thank the
Southern Philippines Medical Centre for serving as the training ground for the student nurses in
enhancing our expertise through performing patient-oriented interventions with the supervision
of the clinical instructors.

To Nursing Research

The proponent would like to recommend the Ateneo de Davao University Library to
supply more updated nursing-related Philippine version of books, which the proponents can use
as references and can be applicable for clinical exposures because most of the books are an
American version.

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