COPILED

ANGELES UNIVERSITY FOUNDATION COLLEGE OF NURSING
THYROID STORM
SUBMITTED BY: CARLOS, SARAH VANESSA M. EGENIAS. TRISTANNE CHARISSE PANGILINAN, CARLA
I.
Introduction
Thyrotoxicosis or Thyroid Storm is defined as the clinical syndrome of hypermetabolism resulting from increased free thyroxine (T4) and/or free
triiodothyronine (T3) serum levels. The term thyrotoxicosis is not synonymous with hyperthyroidism, the elevation in thyroid hormone levels caused by an increase in their biosynthesis and secretion by the thyroid gland. For example, thyrotoxicosis can result from the destruction of thyroid follicles and thyrocytes in the various forms of thyroiditis, or it can be caused by an excessive intake of exogenous thyroid hormone. It should also be noted that the elevation of free thyroid hormone levels does not always result in thyrotoxicosis in all tissues. In the syndrome of Resistance to Thyroid Hormone (RTH), dominant negative mutations in the thyroid hormone receptor b (TRb) result in decreased thyroid hormone action in tissues where TRb is the predominant receptor, for example in the liver and the pituitary, whereas other tissues such as the heart, which express mainly TRa, show signs of increased thyroid hormone action.
The incidence of thyrotoxicosis was determined in a collaborative study in 12 towns in England and Wales. Cases were ascertained prospectively through biochemistry laboratories carrying out routine thyroid function tests. The annual incidence varied from 97 to 492 per 100 000. Reassay of sera at a reference laboratory showed that this variation did not result from inter-laboratory differences in the techniques for measuring thyroid function. The incidence of thyrotoxicosis was strongly correlated with the previous prevalence of endemic goitre in the towns. Current high dietary intakes of iodine largely the result of milk contamination may cause toxic nodular goitre in people made
susceptible by a lack of iodine early in life. They may also contribute to the occurrence of Graves' disease. (http://www.medicalnewstoday.com/articles/210922)
It is a rare but life-threatening condition requiring immediate treatment, preferably in an intensive care unit. Its incidence is about 1-2% among patients with overt hyperthyroidism. A thyrotoxic crisis occurs predominantly in the elderly and is three to five times more common in women than in men. The overall mortality is 10-20%. Even though the pathogenesis is still not fully understood, an increased sensitivity to
catecholamines appears to be an important mechanism, and a number of endogenous and exogenous stress factors that can provoke the onset of a thyrotoxic storm have been identified. Thyrotoxicosis is an illness that does not affect many people. But there are still people that are affected by this illness and this means that everyone does still have to remain vigilant when it comes to this disease because it can appear out of the blue so everyone does have to remain vigilant when it comes to this illness appearing in people. This illness only affects 2% of women and 0.2% of men so everyone is at risk. But it seems that not many people will become ill through this illness but it is important that everyone does remain very vigilant when it comes to this illness. It can strike anyone but thankfully there are treatments available for this disease so this shows that there are people that can overcome this illness but it has to be caught early otherwise the chances of someone surviving this illness will be less if they are diagnosed later then compared to someone who got this illness diagnosed earlier then everyone else.
(http://portal.doh.gov.ph/kp/statistics/leading_mortality on December 09.2011)
The diagnosis of a thyrotoxic crisis is made entirely on the clinical findings. Most importantly, there is no difference in thyroid hormone levels between patients with "uncomplicated" thyrotoxicosis and those undergoing a thyroid storm. Any delay in therapy, e.g. by awaiting additional laboratory results, must be strictly avoided, because the mortality rate may rise to 75%. Thus early thyroidectomy should be considered as the treatment of choice, if medical treatment fails to result in clinical improvement. Medical treatment is based on three principles: 1) counteracting the peripheral effects of thyroid hormones; 2) inhibition of thyroid hormone synthesis; and 3) treatment of systemic complications. These measures should bring about clinical improvement within 12-24 hours. If death occurs it is most likely to be cardiopulmonary failure, particularly in the elderly. This case has been chosen by the student nurses for presentation as they are positively seeing that they will be able to assist in the care and treatment of the disease of the patient effectively and also prevent its occurrence to other individuals by way of giving out health teachings of the important information they may get with this study. To be
familiarized well with Thyrotoxicosis is one of the ultimate goals of the researchers, really. More so, a glow of interest in knowing more about the disease process through a comprehensive analysis of the case, live in them. The discovery of new details or better understanding of known facts, sharing of vital medical knowledge to co-students and even to other members of health care family, and provision of proper and quality nursing care to clients are aimed as well.
It is imperative that the student nurses be willing to devote much time and efforts in conducting research, having a good assessment of the patient and studying by heart the disease condition. This, along with the facts that could be collected and interpreted from books and other resources, would surely define the study s success. Nonetheless, such achievement will be helpful both to the student-nurses themselves and to their patients for they will be able to provide the possible best kind of care.
A. Current Trends about the Disease New Guidelines for Diagnosis and Management of Hyperthyroid ScienceDaily (June 13, 2011) New clinical guidelines developed by an expert panel that
include 100 evidence-based recommendations for optimal care of patients with hyperthyroidism and other causes of thyrotoxicosis are presented in the current issue of Thyroid, a peer-reviewed journal published by Mary Ann Liebert, Inc.
SThe guidelines, developed jointly by the American Thyroid Association (ATA) and American Association of Clinical Endocrinologists (AACE), are available free online atwww.liebertpub.com/thy Graves' disease (GD) is the most common form of thyrotoxicosis in North America and affects 1-2% of the population. Other causes of thyrotoxicosis, characterized by excessively high levels of thyroid hormone in the blood, include toxic multinodular goiter (TMG) -which is more common in Europe -- autonomous thyroid nodular disease, and gestational thyrotoxicosis, which occurs during pregnancy. A task force representing the ATA and AACE reviewed the medical literature and current standards of care and developed new guidelines that include recommendations for the
following: initial evaluation and management of thyrotoxicosis; treatment of GD using radioactive iodine, antithyroid drugs, or surgery; management of GD in children, adolescents, and pregnant women; and subclinical hyperthyroidism. The lead author of the guidelines is Task Force Chair Rebecca Bahn, MD, Mayo Clinic, Rochester, MN. "These guidelines combine the vast experience of the expert panel with the latest scientific literature and provide practical guidance for the clinician managing patients with hyperthyroidism," says Gregory A. Brent, MD, Professor of Medicine and Physiology, David Geffen School of Medicine at the University of California Los Angeles and President of the ATA. A related Editorial in this issue of Thyroid by Elizabeth Pearce, MD, MSc (ATA Board of Directors and Boston University School of Medicine) and colleagues highlights the key features and shortcomings of the new guidelines, noting that they are more comprehensive and more modern in format -- providing levels of evidence to support individual recommendations -- than previous versions. Geraldo Medeiros-Neto, MD (Executive Council, Latin American Thyroid Society and Senior Professor, University of So Paulo Medical School, Brazil), and coauthors of another Editorial accompanying the guidelines highlight recommendations developed and accepted equally by members of the task force from America and from Europe. As the prevalence of thyrotoxicosis and its various forms and causes vary across the globe, as do preferred methods of therapy and patient management, this issue of Thyroid also includes an article by George Kahaly, MD, PhD (European Thyroid Association and Gutenberg University Medical Center, Mainz, Germany) and coauthors that presents a European perspective on the new guidelines, and Shunichi Yamashita, MD (Member of the council of the Asia & Oceania Thyroid Association, and Director, Atomic Bomb Disease Institute, Nagasaki University Graduate School of Biomedical Sciences, Japan), providing several expert viewpoints from Japan and Korea. "Hyperthyroidism affects both genders and people of all ages. These state-of-the-art guidelines highlight treatments and practices that improve patient outcomes. Clinicians that follow these guidelines are likely to immediately improve the care of their patients," says Richard T. Kloos, MD, Professor, The Ohio State University and Secretary/Chief Operating Officer of the ATA.
B. OBJECTIVES Nurse Centered: General objectives After the completion of the study, the student nurses will be able to: y Interpret the current trends and statistics regarding the disease condition and relate the state of the client with her personal and pertinent family history y Analyze and interpret the different diagnostic and laboratory procedures, its purpose and its essential relationship to client s disease condition, identified treatment modalities and its importance like drugs, diet, and exercise. y Formulate nursing care plans based on the prioritized health need of the client and maintained sound communication by making use of self as a therapeutic agent thus, acquiring knowledge and understanding of the development of pyelonephritis in relation to risk factors manifested by the patient y Discuss management and treatment and provide better nursing care and health teachings through the utilization of the nursing process. Specific objectives After the completion of the study, the student nurses will be able to: y Define what pyelonephritis is and identified the causative agents and its manifestations y Determine the different factors that have contributed to the occurrence of pyelonephritis, both modifiable and non modifiable cues y Identify the diagnostic tests, laboratory results, pathophysiology medical and nursing management applicable to manage pyelonephritis y Identify and enumerate measures in the prevention of pyelonephritis
Patient centered General Objectives:
During the course of the study, the patient and family will be able to: y Acquire knowledge on the risk factors that have contributed to the development of pyelonephritis y Gain understanding and demonstrated compliance on the treatment management rendered by the health care team to prevent reoccurrence of the disease.
Specific Objectives: During the course of the study, the patient and family will be able to: y Build a trusting relationship with the student nurses as well as the other members of the health care team y Gain knowledge on the definition of pyelonephritis, its causative agents, risk factors, possible complications and prevention y Receive the best possible medical and nursing care, leading to a feeling of security, comfort and good prognosis of the disease condition. y Demonstrate compliance on self-care and home management upon discharge and during follow up home visits.
Research centered: This case study aims to answer the following questions: 1. How may the patient be described as to: 1.1 Age; 1.2 Sex; 1.3 Religion; 1.4 Address; 1.5 Date and Place of Birth; 1.6 Nationality? 2. How may the patient s family history may be determined as to: 2.1 Size of the family;
2.2 Mother s previous pregnancies, her attitude towards them, mode of deliveries; 2.3 Living condition with housing and economic status; 2.4 Cultural factors affecting the health of the family? 3. How may the patient s personal history be described as to: 3.1 Mother s practices during pregnancy 3.2 Birth duration and circumstances of labor, complications, birth weight 4. How may the patient s illness be described as to: 4.1 History of Past Illness; and, 4.2 History of Present Illness? 5. What are the assessment findings of the patient on a cephalocaudal approach from its day of admission to discharge? 6. What are the diagnostic and lab procedures done with their indications, analysis and interpretation including the nursing responsibilities prior to, during, and after the diagnostic procedure? 7. What are the anatomy and physiology data related to the case? 8. How may the patient s illness be determined as to: 8.1 Book and patient based pathophysiology; and, 8.2 Synthesis of the disease? 9. How may the patient and his care be described as to: 9.1 Medical Management; and, 9.2 Nursing Management 10. How is the Client s Daily Progress of the patient in the hospital?
II. NURSING PROCESS a. ASSESSMENT i. PERSONAL DATA The subject of this case study is a 51 year old woman named as Mrs. Thyra Storm, she was born on June 30, 1960 as a Filipino and is a Protestant. She is currently residing in San Jose, Pampanga with her immediate family. Mrs. Thyra Storm is living with her husband and children. Last November 21, 2011, she was admitted at a tertiary hospital located in San Fernando Pampanga with a chief complaint of melena and was diagnosed with Thyroid Storm and Upper Gastrointestinal Bleeding. Furthermore,
the patient stayed at the said hospital until November 25, 2011, her manifestations subside and thus was discharge from the hospital. All of the information in written above was gathered from the patient during the nurse-patient interaction and so as the information s lifted from the patient s chart.
ii. PERTINENT FAMILY HISTORY Mrs. Thyra Storm belongs to a family with 6 members. According to her there are no history of Diabetes Mellitus, Hypertension or Heart Diseases on both her father and mother s side. Her Grandparents on both sides died because of old age. She stated that her mother had glaucoma. Both her parents died because of old age. She is youngest in the family. Her eldest brother is hypertensive while others are not.
GrandPa GrandPa v (+) GrandMa (+)
GrandMa
Legend: -male
-female
-dead
Mrs, Thyra Storm stated that her husband s parents are both still alive. According to her, her husband is third of the four children Daddy Wolverine is the only guy among them. Daddy Wolverine parents have no known disease condition during the past and up to present.
Mrs, Thyra Storm and Mr. Wolverine have five (5) children. Child 1 is already 26 years old, the 2nd child is 25 years old, the third child is 23 years old, the 4th child is 18 years old and the youngest is 16 years old. According to her, all of her children have not yet been exposed to any major illnesses experienced except minor cough and colds with fever for about 3 days. Mrs. Thyra Storm usually manages this by having them take over the counter Drugs such as Paracetamol and Carbocisteine and by taking them for a check-up as a management.
As regards to economic stability, Daddy Wolverine works as a jeepney driver wherein he is earning an estimated amount of 500 pesos a day and works for 5 days in a week that is approximately 10,000 pesos in a month. Mrs. Thyra Storm is a sari-sari store owner and for a month she earns in approximation an amount of 2, 000 pesos. The total family income per month is approximately 12, 000 pesos. Looking upon this, according to NEDA (2003), the ideal average income for a family must suffice P2, 768.60 per individual per month; thus the food family is considered as poor because of the average income of 2400 pesos per individual per month. The Family seeks help in Abularyos. In times of illness, they first seek medical attention to quack doctors before seeking the help to medical professionals. In cases when the quack doctor s management doesn t seem to be effective that is the time the family will subject for medical checkup.
iii. HISTORY OF PAST ILLNESS
Mrs. Thyra Storm developed common childhood conditions such as fever, cough, colds and abdominal pain which did not require hospitalization but was managed through OTC drugs such as Biogesic and Neozep.
iv. HISTORY OF PRESENT ILLNESS Four years ago, the patient was hospitalized because of thyroid storm. Before the admission, Mrs. Thyra Storm did not take her medication of Propylthiouracil because she is feeling okay, because of that she was then rushed to a tertiary hospital in Pampanga and was confined for about 3-4 days. After that, she was instructed to continue taking her medications. Days prior to admission, the patient experienced weakness and fever. She then took 2 pieces of Mefenamic Acid; she took the medication with an empty stomach. After that, Mrs. Thyra then experienced epigastric pain and melena. She also experienced palpitations, fever and vomiting. She was then consulted to JBL, was rushed to Emergency Room and was confined in the Medicine Ward.
v. PHYSICAL ASSESSMENT
November 21, 2011 lifted from patient s chart (Admission)
Skin: (-) pallor, (-) cyanosis, (+) rash bilateral lower extremities with hyperpigmentation, with desquamation Head: anicteric sclera, Lungs: Symmetrical Chest Expansion Cardiovascular: Adynamic Precordium, Tachycardia, Irregular Rhythm Abdomen: No mass, Non-Tender
VS: T-38.1C P-103 bpm C-24 cpm BP-110/60 mmHg
November 23, 2011 First Nursing-Patient Interaction I. Vital Signs
RR = 24 cpm T = 37.8 C
PR = 95 bpm BP= 110/70 mmHg
1. Head and Face a. Hair: Her hair is wavy, smooth, evenly distributed with the no presence of pediculosis. b. Skull and Face: She has a smooth skull contour and round, without nodules noted. She has a symmetric facial feature and facial movements as evidenced by client s ability to smile, frown, raise her eyebrows and shows teeth. She is able to turn his head from right to left and vice versa; and upward and downward without any difficulty. c. Eye structure and visual acuity: Eyebrows are symmetrically aligned and evenly distributed with an equal movement and skin intact. Eyelashes are distributed and curled slightly outward. The
skin in the eyelids are intact, no discharge, no discoloration and lids closes symmetrically. The bulbar conjunctiva is transparent, pale palpebral conjunctiva; sclerae appears white and capillaries evident. No lesions or nodules found. The cornea are transparent shiny and smooth. Iris is flat and round and the details of it are visible. Pupils appear in black, round and equal in size, when illuminated by the use of penlight, pupils constricts. She can read newsprint. She can also see objects in the periphery, when looking straight. d. Ears and Hearing: Auricles are symmetrical, in the same color as in facial skin, aligned with outer cantus of eye. Her ear canals are seen with dry cerumen. It is mobile, firm, not tender, and pinna recoils after it is folded. She is able to hear whispered words at the back of her ears.
e. Nose and Sinuses: Her nose is in proportion, uniform in color, no lesions and discharges and not tender; air moves freely as the client breathes through the nares, with good patency of nostrils upon occlusion of one nostril and let the client breathe while other nostril is not occluded, then vice versa. Nasal septum is intact in the midline. Facial sinuses are not tender. f. Mouth and Oropharynx: Her lips are pink in color, symmetry of contour, smooth in texture, soft, and moist. She has 32 yellowish teeth. Her gums are pink, moist and no signs of bleeding. She has a pink tongue and it is in the midline and moves freely, with no signs of swelling and ulceration. The palates and uvula are light pink in color, smooth. Uvula is positioned in midline of soft palate. There are no discoloration and irritations. With presence of tooth decay. The oropharynx and tonsils are pink in color and smooth with no discharge and enlargement. 2. Neck Her neck is uniform in color, coordinated with movement, and no enlargement of the lymph nodes upon palpation; trachea is placed on the central midline of the neck; she is able to extend her head laterally to the shoulder; She is able to turn her head to one side against the resistance of the hand; her thyroid gland is not visible upon inspection and bruit is not present upon auscultation of the thyroid gland using the bell of the stethoscope. 3. Thorax and Lungs
Skin is intact with uniform in color, full and symmetric chest expansion upon inspection. No inflammation, lesions, deformities, masses, and tenderness noted. Has clear breath sounds upon auscultation and with tactile fremitus; which is done by placing the palm at the back of the client and let him say ninety-nine , there should be vibration on the palm once the client says those words. There is bilateral symmetry of vocal fremitus. 4. Heart She has a normal heart rate of 95 bpm. There is no presence of abnormal heart sounds noted upon auscultation. 5. Breast and Axillae Her skin is uniform in color, round, equal in size of breast, intact with no discharges, inflammation and lesions noted. No abnormal mass upon palpation. 6. Abdomen Skin in his abdomen is uniform in color, flabby and soft; with the presence of tympanic sound over the stomach and gas filled sound upon percussion, no evidence of enlargement of the liver and spleen, her abdominal movement is symmetric caused by respiration. 7. Skin Her skin is fair in color, warm to touch, moist and with good skin turgor. Presence of rash bilateral lower extremities with hyperpigmentation, with desquamation. 8. Nails She has a trimmed and cleaned toenails and fingernails, but smooth in texture, nail bed is pale in color, nails are convex curved and nail plates are colorless. With smooth texture of nails and intact tissues around the nails. She has a good capillary refill upon blanching, it returns to its usual color within 3 seconds. Negative to Schamroth test. 9. Back and Spine Spine is vertically aligned. Her composure is slightly slouched. Her back is uniform in color. Both shoulders are aligned.
10. Upper and Lower Extremities Arms and legs are symmetrical in shape, size, and color and there are no deformities, tenderness, lesions, or swelling noted with full range of motion. With normal temperature upon palpation of both upper and lower extremities. Neurological Examination Mental: conscious and coherent and she is oriented to time, person and place. Motor: could move but needs another person for assistance and supervision. Sensory: was able to distinguish or perceive dull and sharp sensations by striking the tip of the ballpen`s cap on the clients skin. Cranial Nerve Assessment
Cra nial Nerves
Type and Function
Assessment Procedure Result
Expected
Actu al Result
I. Olfactory smell from mucous
Sensory Carries impulses nasal
Ask
the
Client
will
Mrs.
Client to close her correctly eyes and try to tell the scent. what scent
identify Thyra Storm was able to identify scent. the
(isopropyl alcohol) is being presented to to her.
membrane brain
II. Optic
Sensory Carries
Client
will
Client
will
She was able to correctly
be asked to read a be able to read the sentence in a book sentence correctly.
visual impulses from eyes
14 inches away.
read sentence 14 inches away.
to brain III. OculomoThis tor another nerve action of the eye of that controls part the client to light of the eye. This Round nerve responsible is for Pupils Reactive dilates in a lightly dim environment Light) Pupils are dilated in lightly dim the pupil size and the movement of the eye. to and observed (Pupil Equally Light) will be PERRLA is examine papillary and Reactive to manifested Motor will A be penlight used PERRLA Mrs.
to (Pupil Equally Round Thyra Storm
and constricts upon introduction of light.
environment and constricted upon introduction of the light. IV. Trochlear Controls Lateral movements. eye different directions. penlight Client s eyes without was able to the will any abnormal jerky follow eye movements object through her eyes without difficulty. V. Trigeminal This nerve client s cornea cornea is slightly able to blink Both wisp, Use a cotton touch the blink She when must the client The was Motor An penlight Eyes will be Mrs.
was moved to 6 able to follow the Thyra Storm
then be observed.
controls blinking, approaching touch and pain.
from touched
with
when
a wisp
her back. Ask client cotton. Then client cotton
to close her eyes must be able to touched the and ask her to identify if part the cornea of the is client. She
identify if it is the touched
pointed or dull part sharp or dull. that touched the
was able to identify if the touched part is sharp or dull.
client s skin.
VI. Abducens
Motor This nerve
Client
will
Muscles will
Mrs.
be observed while contract chewing allows for many mucles functions, palpated including the ability to feel the face, inside the mouth, and move the involved chewing. muscles with will be and her chewing
with Thyra Storm muscles contract while chewing
VII. Facial
Sensory and Motor This nerve is responsible for various functions, client
Observe as
Client
will
Mrs.
she be able to smile and Thyra Storm frown facial symmetry. with was smile frown. able and
demonstrates different expressions. Observe for signs of
including
the asymmetry. Observe also her increased
movement of the face muscle and appetite to foods
taste
that are sweet or tasty
VIII . Vestibulo-
Sensory. This nerve is involved with
Call patient s
the
Client able to to
will
Mrs.
attention be
give Thyra Storm the was able to look her when name
with her name or attention loud noise
cochlear
hearing.
direction where the sound comes from
was called IX. Glossophar This nerve yngeal is involved with refuse to eat taste. tasty foods towards tasty foods tasty food does not Sensory Observe patient s attitude Patient does not refuse to eat Mrs. Thyra Storm
Motor Provides secretory fibers to the salivary promotes swallowing movements X. Vagus is responsible the ability This nerve mainly patient parotid glands;
Assess
Client
will She was able to
patient s ability to be able to swallow swallow without difficulty swallow without difficulty
Assess as
Client
will
Mrs.
she be able to swallow Thyra Storm without difficulty is able to
for swallows to
swallow without difficulty
swallow, the gag reflex, some taste, and part of
speech. XI. Accessory This nerve Observe the Client s Mrs.
is involved in the movement of the shoulders and neck Thyra Storm movement of the patient s neck and move shoulders and shoulders. Ask the symmetry. to shrug mus against shrug be with has Client symmetrical able to movements her
neck. It controls client
the trapezius & shoulders strernocleidomast oid muscles.
shoulders of resistance; shoulders
resistance; rotate & against move the neck.
should move and and
neck.
rotate neck without Was able to difficulty. shrug shoulders against resistance and was able to move and rotate without difficulty. XII. Hypoglossal The final Observe the Client will Mrs. neck
cranial nerve is movement of the be able to move her Thyra Storm mainly responsible client s tongue. Ask tongue for the client to difficulty without was able to move tongue without difficulty her
movement of the protrude tongue. tongue.
November 24, 2011
Second Nursing-Patient Interaction I. Vital Signs
RR = 25 cpm T = 36.6 C
1. Head and Face a. Hair: Her hair is wavy, smooth, evenly distributed with the no presence of pediculosis. b. Skull and Face: She has a smooth skull contour and round, without nodules noted. She has a symmetric facial feature and facial movements as evidenced by client s ability to smile, frown, raise her eyebrows and shows teeth. She is able to turn his head from right to left and vice versa; and upward and downward without any difficulty. c. Eye structure and visual acuity: Eyebrows are symmetrically aligned and evenly distributed with an equal movement and skin intact. Eyelashes are distributed and curled slightly outward. The skin in the eyelids are intact, no discharge, no discoloration and lids closes symmetrically. The bulbar conjunctiva is transparent, pale palpebral conjunctiva; sclerae appears white and capillaries evident. No lesions or nodules found. The cornea are transparent shiny and smooth. Iris is flat and round and the details of it are visible. Pupils appear in black, round and equal in size, when illuminated by the use of penlight, pupils constricts. She can read newsprint. She can also see objects in the periphery, when looking straight. d. Ears and Hearing: Auricles are symmetrical, in the same color as in facial skin, aligned with outer cantus of eye. Her ear canals are seen with dry cerumen. It is mobile, firm, not tender, and pinna recoils after it is folded. She is able to hear whispered words at the back of her ears.
e. Nose and Sinuses: Her nose is in proportion, uniform in color, no lesions and discharges and not tender; air moves freely as the client breathes through the nares, with good patency of nostrils upon occlusion of one nostril and let the client breathe while other nostril is not occluded, then vice versa. Nasal septum is intact in the midline. Facial sinuses are not tender. f. Mouth and Oropharynx: Her lips are pink in color, symmetry of contour, smooth in texture, soft, and moist. She has 32 yellowish teeth. Her gums are pink, moist and no signs of bleeding. She has a pink tongue and it is in the midline and moves freely, with no signs of swelling and ulceration. The palates and uvula are light pink in color, smooth. Uvula is positioned in midline of soft palate. There are no discoloration and irritations. With presence of tooth decay. The oropharynx and tonsils are pink in color and smooth with no discharge and enlargement. 2. Neck Her neck is uniform in color, coordinated with movement, and no enlargement of the lymph nodes upon palpation; trachea is placed on the central midline of the neck; she is able to extend her head laterally to the shoulder; She is able to turn her head to one side against the resistance of the hand; her thyroid gland is not visible upon inspection and bruit is not present upon auscultation of the thyroid gland using the bell of the stethoscope. 3. Thorax and Lungs Skin is intact with uniform in color, full and symmetric chest expansion upon inspection. No inflammation, lesions, deformities, masses, and tenderness noted. Has clear breath sounds upon auscultation and with tactile fremitus; which is done by placing the palm at the back of the client and let him say ninety-nine , there should be vibration on the palm once the client says those words. There is bilateral symmetry of vocal fremitus. 4. Heart She has a normal heart rate of 95 bpm. There is no presence of abnormal heart sounds noted upon auscultation. 5. Breast and Axillae Her skin is uniform in color, round, equal in size of breast, intact with no discharges, inflammation and lesions noted. No abnormal mass upon palpation.
6. Abdomen Skin in his abdomen is uniform in color, flabby and soft; with the presence of tympanic sound over the stomach and gas filled sound upon percussion, no evidence of enlargement of the liver and spleen, her abdominal movement is symmetric caused by respiration. 7. Skin Her skin is fair in color, warm to touch, moist and with good skin turgor. Presence of rash bilateral lower extremities with hyperpigmentation, with desquamation. 8. Nails She has a trimmed and cleaned toenails and fingernails, but smooth in texture, nail bed is pale in color, nails are convex curved and nail plates are colorless. With smooth texture of nails and intact tissues around the nails. She has a good capillary refill upon blanching, it returns to its usual color within 3 seconds. Negative to Schamroth test. 9. Back and Spine Spine is vertically aligned. Her composure is slightly slouched. Her back is uniform in color. Both shoulders are aligned. 10. Upper and Lower Extremities Arms and legs are symmetrical in shape, size, and color and there are no deformities, tenderness, lesions, or swelling noted with full range of motion. With normal temperature upon palpation of both upper and lower extremities. Neurological Examination Mental: conscious and coherent and she is oriented to time, person and place. Motor: could move but needs another person for assistance and supervision. Sensory: was able to distinguish or perceive dull and sharp sensations by striking the tip of the ballpen`s cap on the clients skin. Cranial Nerve Assessment
Cra nial Nerves
Type and Function
Expected
Actu al Result
I. Olfactory
Sensory Carries smell from mucous membrane brain to impulses nasal
Ask
the
Client
will
Mrs.
Client to close her correctly eyes and try to tell the scent. what scent
identify Thyra Storm was able to identify scent. the
(isopropyl alcohol) is being presented to her.
II. Optic
Sensory Carries
Client
will
Client
will
She was able to correctly read sentence 14 inches away.
be asked to read a be able to read the sentence in a book visual impulses 14 inches away. from eyes to brain III. Motor This another is nerve will A be penlight used PERRLA sentence correctly.
Mrs.
Oculomotor
to (Pupil Equally Round Thyra Storm Reactive will to manifested be PERRLA (Pupil Equally Round and to
examine
papillary and Light)
that controls part of the eye. This nerve responsible is for
action of the eye of the client to light
observed Pupils
Reactive dilates in a lightly the pupil size and the movement of dim environment
Light) Pupils are dilated in and constricts upon lightly dim
the eye.
introduction of light.
environment and constricted upon introduction of the light.
IV. Trochlear
Motor Controls
An penlight
Eyes will be
Mrs.
was moved to 6 able to follow the Thyra Storm different directions. penlight Lateral movements. then be observed. eye movements object through her eyes without difficulty. eye Client s eyes will any abnormal jerky follow the without was able to
V. Trigeminal
Both This nerve controls blinking, wisp, client s
Use a cotton touch the blink
She when is
must the client
The was
cornea cornea from touched
slightly able to blink with a when a wisp
approaching touch and pain.
client s skin.
VI. Abducens
Motor This nerve
Client
will
Muscles will
Mrs.
be observed while contract chewing allows for many and her chewing
with Thyra Storm muscles
functions, including
mucles the palpated
will
be
contract while chewing
ability to feel the face, inside the mouth, and move the involved chewing. VII. Facial Sensory and Motor This nerve different is responsible for expressions. various functions, Observe for signs of including the asymmetry. Observe movement of the face muscle and taste also her increased appetite to foods that are sweet or tasty VIII . VestibuloThis nerve with her name or attention is involved with loud noise cochlear hearing. sound comes from direction where the to the Sensory. Call patient s the Client able to will facial symmetry. client Observe as Client will muscles with
Mrs.
she be able to smile and Thyra Storm frown with was smile frown. able and
demonstrates
Mrs.
attention be
give Thyra Storm was able to look her when name
was called IX. Glossophar yngeal is involved with refuse to eat taste. tasty foods Sensory This nerve Observe patient s attitude Patient does not refuse to eat tasty food Mrs. Thyra Storm does not
towards tasty foods
Motor Provides secretory fibers to the salivary promotes swallowing movements X. Vagus is responsible the ability This nerve mainly patient parotid
Assess
Client
will
She
patient s ability to be able to swallow was able to swallow without difficulty swallow without difficulty
glands;
Assess as
Client
will
Mrs.
for swallows to
swallow, the gag reflex, some taste, and speech. XI. Accessory This nerve Observe the Client s part of
Mrs.
should move and and
neck.
rotate neck without Was able to difficulty. shrug shoulders against resistance
and was able to move and rotate without difficulty. XII. Hypoglossal The final Observe the Client will Mrs. neck
cranial nerve is movement of the be able to move her Thyra Storm mainly responsible client s tongue. Ask tongue for the client to difficulty without was able to move tongue without difficulty her
movement of the protrude tongue. tongue.
November 25, 2011 Last Nursing-Patient Interaction (MGH) II. Vital Signs
RR = 24 cpm T = 36.1 C
1. Head and Face
a. Hair: Her hair is wavy, smooth, evenly distributed with the no presence of pediculosis. b. Skull and Face: She has a smooth skull contour and round, without nodules noted. She has a symmetric facial feature and facial movements as evidenced by client s ability to smile, frown, raise her eyebrows and shows teeth. She is able to turn his head from right to left and vice versa; and upward and downward without any difficulty. c. Eye structure and visual acuity: Eyebrows are symmetrically aligned and evenly distributed with an equal movement and skin intact. Eyelashes are distributed and curled slightly outward. The skin in the eyelids are intact, no discharge, no discoloration and lids closes symmetrically. The bulbar conjunctiva is transparent, pale palpebral conjunctiva; sclerae appears white and capillaries evident. No lesions or nodules found. The cornea are transparent shiny and smooth. Iris is flat and round and the details of it are visible. Pupils appear in black, round and equal in size, when illuminated by the use of penlight, pupils constricts. She can read newsprint. She can also see objects in the periphery, when looking straight. d. Ears and Hearing: Auricles are symmetrical, in the same color as in facial skin, aligned with outer cantus of eye. Her ear canals are seen with dry cerumen. It is mobile, firm, not tender, and pinna recoils after it is folded. She is able to hear whispered words at the back of her ears.
e. Nose and Sinuses: Her nose is in proportion, uniform in color, no lesions and discharges and not tender; air moves freely as the client breathes through the nares, with good patency of nostrils upon occlusion of one nostril and let the client breathe while other nostril is not occluded, then vice versa. Nasal septum is intact in the midline. Facial sinuses are not tender. f. Mouth and Oropharynx: Her lips are pink in color, symmetry of contour, smooth in texture, soft, and moist. She has 32 yellowish teeth. Her gums are pink, moist and no signs of bleeding. She has a pink tongue and it is in the midline and moves freely, with no signs of swelling and ulceration. The palates and uvula are light pink in color, smooth. Uvula is positioned in midline of soft palate. There are no discoloration and irritations. With presence of tooth decay. The oropharynx and tonsils are pink in color and smooth with no discharge and enlargement. 2. Neck
Her neck is uniform in color, coordinated with movement, and no enlargement of the lymph nodes upon palpation; trachea is placed on the central midline of the neck; she is able to extend her head laterally to the shoulder; She is able to turn her head to one side against the resistance of the hand; her thyroid gland is not visible upon inspection and bruit is not present upon auscultation of the thyroid gland using the bell of the stethoscope. 3. Thorax and Lungs Skin is intact with uniform in color, full and symmetric chest expansion upon inspection. No inflammation, lesions, deformities, masses, and tenderness noted. Has clear breath sounds upon auscultation and with tactile fremitus; which is done by placing the palm at the back of the client and let him say ninety-nine , there should be vibration on the palm once the client says those words. There is bilateral symmetry of vocal fremitus. 4. Heart She has a normal heart rate of 95 bpm. There is no presence of abnormal heart sounds noted upon auscultation. 5. Breast and Axillae Her skin is uniform in color, round, equal in size of breast, intact with no discharges, inflammation and lesions noted. No abnormal mass upon palpation. 6. Abdomen Skin in his abdomen is uniform in color, flabby and soft; with the presence of tympanic sound over the stomach and gas filled sound upon percussion, no evidence of enlargement of the liver and spleen, her abdominal movement is symmetric caused by respiration. 7. Skin Her skin is fair in color, warm to touch, moist and with good skin turgor. Presence of rash bilateral lower extremities with hyperpigmentation, with desquamation. 8. Nails
She has a trimmed and cleaned toenails and fingernails, but smooth in texture, nail bed is pale in color, nails are convex curved and nail plates are colorless. With smooth texture of nails and intact tissues around the nails. She has a good capillary refill upon blanching, it returns to its usual color within 3 seconds. Negative to Schamroth test. 9. Back and Spine Spine is vertically aligned. Her composure is slightly slouched. Her back is uniform in color. Both shoulders are aligned. 10. Upper and Lower Extremities Arms and legs are symmetrical in shape, size, and color and there are no deformities, tenderness, lesions, or swelling noted with full range of motion. With normal temperature upon palpation of both upper and lower extremities. Neurological Examination Mental: conscious and coherent and she is oriented to time, person and place. Motor: could move but needs another person for assistance and supervision. Sensory: was able to distinguish or perceive dull and sharp sensations by striking the tip of the ballpen`s cap on the clients skin. Cranial Nerve Assessment
Cra nial Nerves
Type and Function
Expected
Actu al Result
I. Olfactory
Sensory Carries
Ask
the
Client
will
Mrs.
Client to close her correctly eyes and try to tell the scent. smell from impulses what nasal scent
identify Thyra Storm was able to identify the
mucous membrane brain
(isopropyl alcohol) is to being presented to her.
scent.
II. Optic
Sensory Carries
Client
will
Client
will
She was able to correctly read sentence 14 inches away.
be asked to read a be able to read the sentence in a book visual impulses 14 inches away. from eyes to brain III. Motor This another is nerve action of the eye of that controls part the client to light of the eye. This nerve responsible is for observed Pupils Light) will will A be penlight used PERRLA sentence correctly.
Mrs.
Oculomotor
to (Pupil Equally Round Thyra Storm Reactive to manifested be PERRLA (Pupil Equally Round Reactive dilates in a lightly Light) Pupils dim environment are dilated in lightly dim and to
examine
papillary and
the pupil size and the movement of the eye.
and constricts upon introduction of light. environment and constricted upon introduction of the light.
IV. Trochlear
Motor Controls
An penlight
Eyes will be
Mrs.
was moved to 6 able to follow the Thyra Storm different directions. penlight Lateral eye Client s eyes will any abnormal jerky follow the without was able to
movements.
then be observed.
eye movements
object through her eyes without difficulty.
V. Trigeminal
Both This nerve controls blinking, wisp, client s
Use a cotton touch the blink
She when is
must the client
The was
cornea cornea from touched
slightly able to blink with a when a wisp
approaching touch and pain.
client s skin.
VI. Abducens
Motor This nerve
Client
will
Muscles will
Mrs.
be observed while contract chewing allows for many mucles functions, palpated including the ability to feel the face, inside the mouth, and move the involved chewing. muscles with will be and her chewing
with Thyra Storm muscles contract while chewing
VII.
Sensory client
Observe as
Client
will
Mrs.
she be able to smile and Thyra Storm
Facial
and Motor This nerve
demonstrates different expressions.
frown facial symmetry.
with was smile frown.
able and
is responsible for Observe for signs of various functions, including the asymmetry. Observe also her increased appetite to foods that are sweet or tasty VIII . VestibuloThis nerve with her name or attention is involved with loud noise cochlear hearing. sound comes from her name was called IX. Glossophar This nerve yngeal is involved with refuse to eat taste. tasty foods towards tasty foods tasty food does not Sensory Observe patient s attitude Patient does not refuse to eat Mrs. Thyra Storm direction where the look when to the was able to Sensory. Call patient s the Client able to will Mrs.
movement of the face muscle and taste
attention be
give Thyra Storm
Motor Provides
Assess
Client
will She was able to
patient s ability to be able to swallow swallow secretory fibers to the salivary promotes swallowing movements parotid glands; without difficulty swallow without difficulty
X. Vagus is
This nerve mainly patient
Assess as
Client
will
Mrs.
responsible the ability
for swallows to
swallow, the gag reflex, some taste, and speech. XI. Accessory This nerve Observe the Client s part of
Mrs.
should move and and
neck.
rotate neck without Was able to difficulty. shrug shoulders against resistance and was able to move and rotate without difficulty. XII. Hypoglossal The final Observe the Client will Mrs. neck
cranial nerve is movement of the be able to move her Thyra Storm mainly responsible client s tongue. Ask tongue for the client to difficulty without was able to move tongue her
movement of the
tongue.
protrude tongue.
without difficulty
ANATOMY AND PHYSIOLOGY
The endocrine system is a network of glands that produce and secrete hormones involved in controlling many functions of the body. This includes growth and development, stability of internal bodily systems (homeostasis), metabolism and sexual function.
Glands and hormones are the primary features of the endocrine system. Glands are collections of cells that produce and secrete hormones. Hormones act as chemical messengers in the body, moving information and instructions from one group of cells to another by traveling through the blood.
Each of the endocrine glands produces certain types of hormones by the body. The release of these hormones causes specific reactions to occur in the body. For example, the hypothalamus produces hormones such used
as growth hormone-releasing hormone (GHRH) produces and the pituitary gland
hormones
including
prolactin and endorphins.
The endocrine system is a network of glands that plays a vital role in a wide variety of bodily functions. The glands of this system produce and secrete hormones that control the following processes:
Growth and development
Internal balance of bodily systems (homeostasis)
Metabolism
Regulation of mood and energy levels
Responses to surroundings, stress and injury
Sexual function and reproduction
Tissue function
The endocrine system specializes in processes of the body that occur gradually, whereas the nervous system generally directs faster processes, such as breathing and body movements. However, in many cases the endocrine system and nervous system work together to guide some body processes.
Glands and hormones are the primary features of the endocrine system. Glands are collections of cells that produce and secrete substances called hormones that act as chemical messengers in the body. Glands that do not make hormones, such as sweat glands, salivary glands and the prostate gland, are not part of the endocrine system. Hormones move information and instructions from one group of cells to another.
Imbalances in the endocrine system can cause problems. Too much or too little of a hormone, trouble with the receptor sites, trouble with the feedback system or regulating system, glandular problems, or problems with the blood supply can throw the whole system out of balance. This creates problems in the body on a glandular or functional level. For this reason, the chemicals of the endocrine system must be kept in precise balance. Imbalances can lead to systemic dysfunctions and disorders that affect body functions necessary for sustaining life.
Some endocrine djavascript:void(null);iseases are autoimmune conditions, meaning the body s immune system mistakenly identifies healthy tissues as a threat and attacks them. Examples include type 1 diabetes, Hashimoto s thyroiditis, Graves disease and Addison disease. Some endocrine disorders involve more than one gland, such as autoimmune polyglandular syndrome.
Some endocrine conditions involve benign (noncancerous) tumors, such as thyroid nodules and insulinoma. In rare cases, cancer can develop in the endocrine glands.
Physicians have many ways of assessing endocrine function and diagnosing endocrine disorders, including glucose tests, thyroid blood tests, other blood tests, a physical examination, urine tests, ultrasound and thyroid imaging tests. A primary care physician will typically refer a patient with an endocrine condition to an endocrinologist.
Major Glands of the Endocrine System:
Glands are units of cells that secrete substances used in other parts of the body. There are two types of glands in the body:
Exocrine. Glands that release their secretions through a duct or directly to epithelial tissue (skin and linings of body cavities and passageways). Examples include the sweat glands, sebaceous glands, salivary glands and prostate gland. Glands in the digestive system that secrete enzymes through ducts also are considered to be exocrine glands.
Endocrine. A variety of ductless glands that secrete more than 20 hormones into the bloodstream or lymph nodes. These substances are then transported to other parts of the body and carry messages for how those body parts should act.
Endocrine glands use material in the blood, and synthesize and secrete the chemical or hormone that supports the specified function elsewhere. The major glands in the endocrine system are:
Pituitary gland. Located at the base of brain, this master gland plays a crucial in regulating the workings of the
the role
endocrine system. Though only the size of the pituitary gland controls and regulates of the functions of the other endocrine glands.
a pea, most
The pituitary gland is made up of two parts: the anterior and posterior lobes. Each lobe produces its own hormones. Various factors can influence the production and secretion of pituitary hormones. These range from shifts in emotion to seasonal changes. Pituitary problems include growth disorders such as acromegaly.
Hypothalamus. Located in lower central part of the brain just above gland, the the
the
pituitary
hypothalamus
regulates
homeostasis in the body,
including breathing, metabolism, hunger, thirst and temperature. It is considered the switchboard of the endocrine system because it is the part of the brain that exerts control over the endocrine system.
The hypothalamus and the pituitary gland are the regulators of the endocrine system. The hypothalamus secretes hormones that direct the pituitary to either stimulate or suppress the secretion of pituitary hormones. Diabetes insipidus ( water diabetes ) usually involves a problem with the hypothalamus or pituitary gland. This condition is unrelated to the far more common diabetes mellitus ( sugar diabetes ).
Adrenal
glands.
Two
triangular-shap ed glands located above each kidney. There are two distinct of the adrenal glands parts
(adrenal cortex and the adrenal medulla) that
secrete two distinct sets of hormones. The adrenal
glands are responsible for controlling a host of
functions, including regulation of salt and water balance, immune system regulation, body reaction to stress, and sexual development. Adrenal gland disorders include hypoadrenal (reduced function) conditions such as Addison disease and hyperadrenal (excessive function) conditions such as Cushing s syndrome, a disease that may be caused by excessive levels of cortisol (hormone produced by the adrenal glands).
Thyroid gland. A small gland located in the lower front part of the throat, the thyroid gland produces thyroid hormones that regulate the body s metabolism, bone growth and development of the brain and nervous system. Thyroid hormones maintain blood pressure, heart rate, digestion, muscle tone, body temper ature, weight and reproductive functions. Thyroid disorders include hypothyroidism and
hyperthyroidism.
Parathyroid glands. Two pairs of tiny glands located behind the thyroid gland, one set on each side of the gland. They are essential to regulate the balance of calcium in the body. Hyperparathyroidism may cause hypercalcemia, and hypoparathyroidism may cause hypocalcemia.
Pancreas.
Located
behind the stomach, the pancreas functions: serves two
digestive
(exocrine) and hormonal (endocrine). The portion the pancreas that of
secretes
digestive
enzymes is considered
exocrine in its function. The other part consists of cells called islets of Langerhans. They secrete hormones including insulin and glucagon, which work together to regulate glucose (blood sugar).
The various forms of diabetes mellitus, including type 1 diabetes and type 2 diabetes, are pancreatic endocrine diseases. An example of a pancreatic exocrine disease is pancreatitis.
Pineal body. Located in the base of the brain, it is involved in regulating the body s wake-sleep cycle.
Thymus. Located in children chest above and in front of the heart, this gland is present in infancy and early childhood provides immune system
in the
and
functioning for the growing The gland grows throughout childhood u ntil puberty,
child.
when
its function begins to decline. Afterward, the tissue is
replaced by fat cells and the body s immune system replaces the immune function formerly provided by the thymus.
Gonads. Located in the lower trunk, the reproductive organs produce steroid hormones specific to the sexual characteristics and reproductive functions of males and females beginning at puberty. The reproductive organs in males are the testes (testicles) and in females are the ovaries.
Other parts of the body that release hormones include the gastrointestinal tract and the kidneys.
Major Hormones of the Endocrine System:
Each of the endocrine glands produces certain types of hormones used by the body. The release of these hormones causes specific reactions to occur in the body.
The hypothalamus produces several hormones that regulate the pituitary gland. They include:
Growth hormone-releasing hormone (GHRH). Sent to the pituitary gland to release growth hormone (GH).
Thyrotropin-releasing hormone (TRH). Sent to the pituitary gland to release thyroidstimulating hormone (TSH).
Corticotropin-releasing hormone (CRH). Sent to the pituitary gland to release adrenocorticotropin hormone (ACTH).
Somatostatin. Suppresses production of GH and TSH in the pituitary gland.
Gonadotropin-releasing hormone (GRH). Stimulates the pituitary gland to produce and release luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which aid puberty and reproductive functions in males and females.
The pituitary gland produces different hormones from its two regions, the anterior and posterior lobes. The hormones produced by the anterior (front) lobe include:
Growth hormone (GH). Stimulates bone and muscle growth and healthy body composition. In children, too much GH can cause gigantism, a condition in which excessive growth of the long bones results in excessive tallness. Too little GH in children can stunt growth. Deficiencies in adults lead to fat, muscle and bone mass imbalances and
deficiencies. Excessive growth hormone in adulthood can lead to acromegaly, a condition in which the bones increase in size.
Thyroid-stimulating hormone (also called TSH or thyrotropin). Stimulates the release of thyroid hormones to control metabolism, energy, growth and the nervous system.
Adrenocorticotropin hormone (ACTH). Stimulates the adrenal glands to produce aldosterone (which controls sodium and water retention by the kidneys) and cortisol (a steroid hormone that helps maintain blood pressure and glucose levels in times of stress).
Luteinizing hormone (LH). Stimulates the cells of the testes to produce and regulate testosterone. Stimulates ovulation (egg release) in women and release of estrogen from a gland known as the corpus luteum. LH also stimulates the secretion of sex hormones in the gonads.
Follicle-stimulating hormone (FSH). Stimulates maturation of ovarian follicles (eggs) in females and promotes the process of spermatogenesis (sperm production) in males. FSH also stimulates the secretion of sex hormones in the gonads.
Prolactin (PRL). Stimulates milk production in females after childbirth. It plays a role in the metabolism of carbohydrates and fats. PRL also affects the levels of sex hormones in the ovaries and testes.
Corticotropin.
Stimulates
the
adrenal
glands
to
produce
hormones.
Endorphins. Chemical messengers sent to the nervous system to reduce pain sensitivity by deadening pain receptors. Endorphins are chemically related to morphine and are naturally produced by the body in response to pain.
Melanocyte-stimulating hormone (MSH). Stimulates the melanocytes in the skin to produce melanin (skin pigment).
The posterior (back) lobe of the pituitary gland stores the following hormones that are secreted by the hypothalamus and transported to the pituitary gland:
Antidiuretic hormone (ADH or vasopressin). Inhibits the amount of water and sodium excreted from the body. ADH causes the kidneys to produce concentrated urine in lower volumes, and problems with this hormone can cause kidney problems. ADH also stimulates constriction of blood vessels and smooth muscles.
Oxytocin. Stimulates milk production and contracts the uterus during childbirth.
The adrenal glands have two distinct parts (adrenal cortex and the adrenal medulla) that secrete two distinct sets of hormones. The adrenal cortex is the outer portion of the adrenal gland, and it produces corticosteroids such as cortisone. Cortisone is an anti-inflammatory hormone that suppresses immune system response. Corticosteroids raise blood pressure and can produce problems for people with hypertension. The following are corticosteroids secreted by the adrenal cortex:
Glucocorticoids, such as cortisol. Helps regulate metabolism of carbohydrates (including glucose), fats and proteins. Cortisol also causes the release of glycogen to elevate levels of glucose in the bloodstream and help the body cope with stress.
Mineralocorticoids (such as aldosterone). Secreted to stimulate sodium and water retention and the excretion of potassium from the kidneys. These functions help to maintain blood volume and pressure.
The adrenal medulla is the inner portion of the adrenal gland associated with the sympathetic nervous system. It produces the following hormones:
Epinephrine (also known as adrenaline). Produced in response to fright, stress, caffeine, anger and hypoglycemia (low glucose). Adrenaline increases heart rate, as well as the rate of metabolism and blood flow to muscles. This hormone is secreted as an emergency
response to stress. Adrenaline inhibits insulin and raises glucose by stimulating the liver to break down stored glycogen into glucose and release it into the bloodstream.
Norepinephrine. Allows the body to maintain normal functioning as opposed to emergency reactions. This hormone stimulates and maintains a normal heart beat.
The thyroid gland produces hormones including thyroxine and triiodothyronine. These help regulate metabolism. Hyperthyroidism occurs when the thyroid gland is too active. Symptoms include unexplained weight loss and restlessness. Hypothyroidism, in which the thyroid gland is underactive, causes symptoms such as unexplained weight gain and fatigue.
The parathyroid glands produce parathyroid hormone (PTH). This hormone increases calcium and reduces phosphorus levels in the body and is produced in response to low levels of dietary calcium in the diet. Proper nerve, muscle and bone structure and functioning are supported by PTH. The pancreas produces hormones such as:
Glucagon. Produced by the alpha cells in the islets of Langerhans, glucagon is secreted by the pancreas to stimulate the liver to change stored glycogen to glucose for release into the bloodstream to raise glucose levels. This is an emergency response when the blood sugar levels are too low.
Insulin. Produced by the beta cells in the islets of Langerhans, insulin enables sugar in the blood (glucose) to enter cells so they can produce heat and energy. Glucose is the body s fuel, and insulin is the catalyst that enables the body to use it. If this system works properly, it lowers the blood sugar levels. If not, blood sugar levels may rise out of control, leading to diabetes. Insulin also stimulates glycogen production and storage.
Amylin. Produced by the beta cells, it delays emptying of the stomach, promotes feelings of fullness (satiety) and inhibits glucagon. Synthetic amylin is an injected medication recently
approved
to
help
treat
some
cases
of
type1
diabetes.
Somatostatin. Produced by the islet delta cells, it suppresses insulin and glucagon.
The pineal body produces melatonin. This hormone regulates sleep cycles and is stimulated by the nerves of the eyes. Production increases sharply at night and decreases sharply in the daytime. It also helps the pituitary gland inhibit production of GRH by the hypothalamus.
The thymus releases thymosin. This hormone stimulates the production of T-cells, which attack foreign substances invading the body and are part of the body s immune system. Thymosin stimulates an immune system response from the lymphoid tissues.
The gonads consist of the ovaries and testes (testicles). The ovaries are the female reproductive organs that produce eggs. They also produce the following female sex hormones:
Estrogen. Hormones that affect female sexual characteristics such as breast development and widening of the hips that is evident in puberty. Estrogen also affects reproductive functions such as menstruation, pregnancy and egg production.
Progesterone. Also crucial in reproductive functions such as menstruation, pregnancy and egg production. Progesterone prepares the uterus for the implantation of the embryo. Also, secretions of progesterone from the placenta help maintain pregnancy. Progesterone also plays a part in regulating menstruation.
Inhibin. A protein that inhibits the release of FSH from the pituitary gland to regulate egg development.
Testes
are
the
male
reproductive organs that produce sperm and male sex hormones (androgens), including testosterone. These hormones of affect male the sexual puberty, and
development characteristics including
during
sexual
growth
development, facial hair and voice changes. These hormones continue affect aspects of an adult male s sexual life, including sex drive and sperm production, and contribute to male hair patterns, bone mass and muscle mass.
Some gonadal disorders are linked to insulin resistance, including polycystic ovarian syndrome in females and hypogonadism (low levels of testosterone) in men. Deficits in sex hormones can contribute to conditions including sexual dysfunction and some musculoskeletal disorders.
to
b. Synthesis of the Disease b.1 Definition of the Disease
Hyperthyroidism is a condition in which an overactive thyroid gland is producing an excessive amount of thyroid hormones that circulate in the blood. ("Hyper" means "over" in Greek). Thyrotoxicosis is a toxic condition that is caused by an excess of thyroid hormones from any cause. Thyrotoxicosis can be caused by an excessive intake of thyroid hormone or by overproduction of thyroid hormones by the thyroid gland.
b.2 Modifiable and Non-modifiable Factors Non-Modifiable Factors

Gender -- hyperthyroidism affect women 8 times more often than men. History -- Having any past history of thyroid problems, autoimmune disease, or endocrine disease yourself or in your family puts you at greater risk for developing hyperthyroidism. Age -- The riskiest age for developing hyperthyroidism is between 20 and 40. Modifiable Factors Iodine Deficiency -- Low amounts of thyroxine (T4, one of the two thyroid hormones) in the blood, due to lack of dietary iodine to make them, gives rise to high levels of thyroid stimulating hormone TSH, which stimulates the thyroid gland to increase many biochemical processes; the cellular growth and proliferation can result in the characteristic swelling or hyperplasia of the thyroid gland, or goiter. Ingestion of large amount of nutritional goitrogens -- goiter producing agents that inhibit thyroxine [T4] production such as cabbage, peanuts, soybeans, peas and radishes. Excessive Intake of Thyroid Hormone -- Taking too much prescription thyroid hormone - whether by accident or by deliberate self-medication can cause hyperthyroidism. Trauma to the Thyroid -- Thyroid trauma can trigger hyperthyroidism in some people. The types of trauma include vigorous manipulation or palpation of the thyroid; surgery to
the thyroid, parathyroids, or the area surrounding the thyroid; injection to the thyroid; biopsy of the thyroid; and neck injury, or from an automobile seat belt after a crash.
b.3 Signs and Symptoms Goiter- because of the increased levels of TSH, the thyroid gland is stimulated to produce large amounts of thyroid hormones resulting to hypertrophy of the thyroid gland Weight Loss- over secretion of thyroid hormones results to weight loss because these hormones increases the metabolic rate Tachycardia and Palpitations- the thyroid hormones increases the responsiveness to catecholamines that s why there is increased nervous system activity which leads to stimulation of the cardiac system Hypertension- there is increased cardiac output and peripheral blood flow caused by hyperstimulation of the cardiac system Exophthalmos- there is protrusion of the eyeballs because fluid accumulates in the fat pads and muscles of the eye Difficulty of Breathing and Dysphagia- these symptoms are felt because of the compression of the structures in the neck and chest due to the continuous enlargement of the thyroid gland Irritability- because there is difficulty in breathing there is decrease in oxygenation in the body Menstrual Irregularities and Decrease Libido- there are affectations in the secretion and metabolism of gonadal hormones.
DIAGNOSTIC LABORATORY PROCEDURES
Laboratory procedures are one of the important factors to consider when diagnosing the condition of the patient. This could reflect on how well the patient is doing or what affect a particular procedure could do to the body. They may be classified as invasive or non invasive procedure; however, the bottom line is to help the HCPs to provide the optimal wellness that the client needs. Diagnostic/Laboratory Procedures Date ordered; Date results in Indications or Purposes Results Normal Values (units used in the hospital) Analysis and Interpretation
COMPLETE BLOOD COUNT
Date Ordered:
Hemoglobin measures the amount of
109 gm/L
120-160 gm/L
The result shows that the oxygen carrying capacity of the client s blood is s decreased. This could indicate that the client. If here are insufficient blood cells to oxygenate the body. This
Hemoglobin
November 21, 2011
oxygen carrying protein in the blood. This is
Date results in:
done to evaluate blood loss, anemia,
November 21, 2011
and response to therapy and erythropoietic activity. It was done to Mrs. Thyra during her
confinement in order to determine her level of blood and if oxygenation is needed due to Hematocrit her condition. 0.32 L/L 0.40-0.52 L/L
could lead to inadequate oxygenation of tissues
The hematocrit determines the percentage of red blood cells in the plasma. to aid diagnosis of abnormal states of hydration, polycythemia WBC and anemia. 6.2 x109 /L 5-10 x109 /L The result shows a decrease in the hematocrit level of the body. This could indicate that the body is compensating in order to convert hypodynamic White blood cells main function is to to hyperdynamic response.
fight infection. This is done to determine the presence of infection and inflammation. It is used determine the capability of the body to destroy Lymphocytes cells that are infected with the virus or other infectious organisms. 0.45 0.20-0.35 The WBC count Is at the normal range. WBCs are cells of the immune system involved in defending the body against both infectious disease and foreign materials. -to determine viral infection -produces antibodies and other chemicals responsible for destroying microorganisms; contributes to Neutrophils allergic reactions, graft rejection, tumor 0.55 High levels may indicate an active infection,
control, and regulation of the immune system.
0.45-0.65
Neutrophils are the most common type of white blood cell, comprising about 50-70% of all white blood cells. They are the body's primary defense against bacterial infection and physiologic stress. They are phagocytic, meaning that they can ingest other cells, though they do Platelets not survive the act. Neutrophils are the first immune cells to arrive at a site of 129 x109 /L 150400x109/L The level is still within normal range.
infection, through a process known as chemotaxis.
Platelets are essential for coagulation, hemostasis and clot formation. Platelets initiate the process of hemostasis by aggregating quickly at the site of a damaged blood cell, forming a platelet clot to plug the opening. The result shows decreased level of platelet. Therefore there is problem in clotting ability by the patient.
NURSING RESPONSIBILITIES:
Before y y y y y Check the doctor s order. Determine the prescribed test Verify the client s identity. Obtain and complete laboratory requisition form. Explain to the patient the procedure of the test, why it is necessary and how the client can cooperate.
During y y Encourage the patient to remain calm during the test. Assist patient with the test as needed.
After y y y Apply pressure on the site to stop bleeding Elevate the affected area. Document the date and time and the patient s reaction.
Diagnostic and Laboratory Procedures
Date Ordered Date Result(s)
Indication(s) or Results Purpose Normal Values
Analys
Urinalysis (UA)
Date Ordered: November 21, 2011
>It is used for diagnosing renal disease or urinary tract infection and for detecting metabolic
Color: yellow
Color: light yellow to dark amber
It show
Mrs. Th
Date Result: November 21, 2011
disease not related to the kidneys. Transparency: turbid Transparency: clear Turbid
caused
abnorm
conditi turbid
precipi
mucus
Abnorm
include
blood c
bacteri
pH: 7.0
pH: 4.5-8.0
the pH
norma
Albumin: negative
Albumin: trace
Sugar: negative
Sugar: negative
Sp. Gravity:
Sp. Gravity:
The Sp
1.005
1.010-1.020
norma
indicat
inabilit urine.
MICROSCOPIC Pus cells: Too numerous to count
MICROSCOPIC Pus cells: 1-3/Hpf
This ma
of bact
RBC: 8-10/Hpf
RBC: 0-2/Hpf
This te
of the k
glomer
membr
identifi
RBCs in
mean i
that ev
macrom
glomer
Before y y y y Check the doctor s order. Determine the prescribed test. Verify the client s identity. Obtain and complete laboratory requisition form.
Explain to the patient the procedure of the test, why it is necessary and how the client can cooperate.
y y y
Ask the patient to wash and dry the genitals and perineal area with soap and water. Explain to the patient the procedure for a clean-catch or midstream urine collection. Prepare specimen container.
During y y Direct or assist the patient to the bathroom. Provide for client privacy.
After y y Secure, label and transport specimen to the laboratory. Document the date and time and the patient s reaction.
Diagnostic and Laboratory Procedures
Date Ordered Date Result(s)
Indication(s) or Results Purpose Normal Values
Analys
Fecalysis
Date Ordered: November 21, 2011
Fecalysis is also known as
Color:
Color: brown
It show
stool analysis. It refers to a brown series of laboratory tests done on fecal samples to
Mrs. Th
Consistency:Soft Consistency:Soft, bulky, small and dry according to diet
Date Result: November 21, 2011
analyze the condition of a person's digestive tract in general.
Ova and Parasites (-)
Ova and Parasites (-)
Before y y y y y Check the doctor s order. Determine the prescribed test. Verify the client s identity. Obtain and complete laboratory requisition form. Explain to the patient the procedure of the test, why it is necessary and how the client can cooperate. y Prepare specimen container.
Diagnostic/Labor atory Procedures
Date ordered ; Date results in
Indications or Purposes
Results
Norm al Values (units used in the hospit al)
Analysis and Interpretati on
ELECTROLYTES:
Date Ordere d: Novem ber 21, 2011
Date Result: Sodium (Na) Novem ber 21, 2011 135mmO l/L 135145 mmOl /L
Creatinine
This is to reveal if there is alteration with the excretory function of the patient s kidneys and it suggest the chronicity since it tends to rise in latter part of the disease condition.
48.7
58-100
Decreased level is usually seen if there is inadequate intake of protein.
Date Result: Novem ber 21, 2011
SGOT AST
This enzyme is released into circulation following the
65.8IU/L
10-40 IU/L
When the AST is greater than ALT, it may indicate mononucle osis, cirrhosis or alcoholrelated damage.
injury or death of cells. The focus is on cellular damage, particularly liver, muscle, and highly metabolic
cells. Aspartate aminotransfe Date Result: Novem ber 21, 2011 rase also reportedly
reflects gonadalfunction and the amount to of oxygen
available
membranes.
Aside from liver, heart, or muscle damage, elevations in AST can indicate a deficiency of certain hormones and vitamin E.
SGPT ALT
The ALT test is used to screen for liver damage by measuring how much ALT, which is necessary for tissue energy production is found primarily in the liver.
21 IU/L
0-39 IU/L
The level of SGPT is within normal range therefore no liver
Date Result: Novem ber 21, 2011
damage is noted.
Before y y y y y Check the doctor s order. Determine the prescribed test Verify the client s identity. Obtain and complete laboratory requisition form. Explain to the patient the procedure of the test, why it is necessary and how the client can cooperate.
During y y Encourage the patient to remain calm during the test. Assist patient with the test as needed.
After y Apply pressure on the site to stop bleeding
y y
Elevate the affected area. Document the date and time and the patient s reaction. Date ordered; Date results in Indications or Purposes Results Normal Values (units used in the hospital) Analysis and Interpretatio n
Diagnostic/Laborato ry Procedures
Prothrombin Time (PT)
Date Ordered: Novembe r 21, 2011
Prothrombin time (PT) is a blood test that measures how long it takes blood to
25 seconds
10-13 seconds
the results show that there is
Control:13.4 Control:11. Activity:70.8 % Activity:70INR:2.37 100% 4-15.8
longer clotting time, which coincides with the result of low
Date Result: Novembe r 21, 2011
clot. A prothrombin time test can be used to check for bleeding problems.
0.8-1.2
platelet count.
(PTT)
Date Ordered:
Partial thromboplasti
30.8 secs
23.8-35.8
The results are within normal range.
Novembe n time (PTT) is r 21, 2011 a blood test that looks at how long it Date Result: takes for blood to clot.
Novembe It can help tell
r 21, 2011
if you have bleeding or clotting problems.
Before y y y y y Check the doctor s order. Determine the prescribed test. Verify the client s identity. Obtain and complete laboratory requisition form. Explain to the patient the procedure of the test, why it is necessary and how the client can cooperate. y Prepare specimen container.
SOAPIEs November 23, 2011
November 24, 2011 S>O O>Received patient on bed, awake, conscious and coherent, on semi fowlers position, with an ongoing IV fluid of PNSS 1L regulated at 50-51 gtts/min @ 900 cc level infusing well over the left hand, with no signs of infiltration, patient appears weak, needs assistance when moving, cannot do ADLs by herself, with capillary refill time of 3seconds, with pale palpebral conjunctiva, with moist mucous membrane, with VS taken and recorded as follows: T-36.6 P-95 R-25 BP-90/50 A>Activity Intolerance related to imbalanced between O2 supply and demand P>after 4 hours of nursing intervention, the patient will be able to do simple activities without exhaustion. I> -Established Rapport Assessed General Condition Monitored and Recorded Vital Signs Noted client s report of weakness/fatigue Assisted client when moving Provided adequate rest periods before and after activities Ascertained ability to stand and move about and degree of assistance needed Adjusted activities to prevent overexertion Increased activity gradually Provided comfort and safety measures Seen on rounds by Dr. Cayabyab with the following orders made and carried out -for repeat CBC with PC today-requested -for PBS and refer to hema consultant c/o MROD
-for 2d echo-advised -Continue meds-done -for repeat serum K post correction-requested E>The patient was able to do simple activities without exhaustion.
SOAPIE-METHOD November 25, 2011 S>O O>Received patient on bed, awake, conscious and coherent, on semi fowlers position, with an ongoing IV fluid of PNSS 1L regulated at 50-51 gtts/min @ 100 cc level infusing well over the left hand, with no signs of infiltration, with capillary refill time of 3seconds, with pale palpebral conjunctiva, with moist mucous membrane, with VS taken and recorded as follows: T-36.1 P-85 R-24 BP-120/80 A> For home maintenance and management P>After 4hours of nursing intervention, the patient will verbalizeunderstanding of health teachings given. I> M: Instructed to take medications religiously:
PTU 50mg 2tab q6 Lanoxin 0.25 mg/tab 1tab OD FeSO4 + Folic Acid 1tab OD E: Instructed to do activities within client s ability T: For 2d Echo and PBS result as out patient H: instructed on proper performance of self care Instructed to avoid activities that may cause easy fatigability
Instructed to have adequate rest period O: Instructed to come back on December 2, 2011 at OPD room 2 @ 8:00am D: Instructed to eat foods rich in Fe Instructed to eat nutritious foods like fruits and vegetables
C. IMPLEMENTATION 1. MEDICAL MANAGEMENT A. IVF
Medical Management Treatment
Date ordered Date performed General Date changed Description
Indication(s) Purpose(s)
or Client s response to the treatment
Intravenous PNSS 1L x 50-51 DO: 11.21.11 gtts/min DP: 11.21.11
It
is
used
to The patient was fluid well hydrated.
Fluids are sterile. maintain Introduced intake and
re- There are no of
directly into the establish vein. The type of volume which regulation depends
water signs because dehydration
and these fluids stays noted. in the vascular are abnormal it responses
There no
upon compartment,
the fluid needs of therefore, the patients. expands
to
the the fluid, such as phlebitis or swelling.
vascular volume PNSS is an
isotonic solution. No net fluid shifts
occur
between
isotonic solution because solution equally concentrated. the are
NURSING RESPONSIBILITIES
Prior:
y y y
Check doctor s order Check for the label of the IVF Identify the correct patient by checking the name on the chart or by asking directly the patient.
y y y y y y
Explain the procedure to the patient. Wash hands thoroughly before performing the procedure Check for the patency of the line Regulate as ordered Label IVF on the date and time started and on the infusion rate Place on the kardex the fluid type
DURING:
y y y
Check for the patency of the line every two hours Check for the infusion rate Monitor for the level of fluid
AFTER:
y y y
Monitor patient s therapeutic response to treatment. Check the IV infusion site for signs of infiltration: bulging, heat, pain, and redness. Remove IVF based on the doctor s order
OXYGEN THERAPY
Medical Management Treatment
Date ordered Date performed Date changed General Description
Indication(s) Purpose(s)
or Client s response to
the treatment
Oxygen Therapy DO: 11.21.11 via nasal cannula DP: 11.21.11 @ 2-3 LPM DIC:11.22.11
Oxygen therapy is The goal is to No the administration relieve of oxygen at hypoxemia increasing
adverse
reactions by noted. The
concentrations
patient did not any of
greater than that alveolar tension, develop in room air. to reduce the signs of hypoxia
work
breathing, and to decrease work myocardium. the of
NURSING RESPONSIBILITIES: BEFORE: y y Check doctor s order Identify the correct patient by checking the name on the chart or by asking directly the patient.
y y
Explain the procedure to the patient. Wash hands thoroughly before performing the procedure
DURING: y y y y Ensure equipment is functioning correctly at beginning of each shift. Periodic assessment and documentation of oxygen saturation levels is required Water-based lubricants can be used to relieve dryness of the lips and nostrils. Check that the oxygen is humidified and running at the ordered number of litres per minute. y Check also that there is enough oxygen in the tank
AFTER:
y y y
Monitor patient s therapeutic response to treatment. Check the site for signs of any complication Remove tubing based on the doctor s order
B. DRUGS
Name of Drug Generic Name Brand Name
Date Ordered Date Given Date Changed/DIC
Route of Administration, Dosage and Frequency
General Action Functional Classification Mechanism of Action
Indication (S) Initial Reaction Purpose(S)
Client s Reaction to the Medication with Actual Side Effect
Kalium Durule
DO: 11.21.11 DG: 11.22.11 DIC:11.24.11
1tab TID x 3days
Electolyte
Prevention and Correction of
The patient s initial laboratory result of potassium is
Principle intracellular
Potassium Deficiency
cation of most body tissues. Potassium ions participate in a number of essential physiological processes including the maintenance of intracellular tonicity, the
below the normal range but follow up laboratory results are not done to see if the deficiency is corrected.
transmission of nerve
impulses, the contraction of cardiac, skeletal smooth muscle, the maintenance of normal and and
renal function. Ceftriaxone DO: 11.21.11 DG: 11.21.11 Rocephin 1gm/IV + 90cc D5W to run for 30 mins q12 Bactericidal: 3rd Generation Cephalosporin Prevention and Treatment of Infection The patient did not develop any signs of infection.
inhibits the synthesis of bacterial cell wall, causing cell death Ferrous Sulfate + Folic Acid DO: 11.21.11 DG: 11.21.11 1tablet OD Vitamin Supplement It is given to the patient because she has Ferrograd It helps the body for the synthesis and formation of red blood cells manifestations of anemia such as pale nail beds and pale palpebral conjunctiva Omeprazole Prilosec DO: 11.21.11 DG: 11.21.11 40 mg IV OD Proton Pump Inhibitor Reduction of the risk of Upper GI Gastric pump inhibitor; suppresses acid gastric by acid bleeding The patient did not developed further signs of GI bleeding as evidenced by (-) melena and vomiting. The patient still manifests pale nail beds and palpebral conjunctiva when she was handled by the student nurses.
secretion specific inhibition
of
the hydrogen potassium ATPase enzyme
system at the secretory surface of the gastric parietal cells; blocks the
final step of acid production. Digoxin Lanoxin DO: 11.21.11 DG: 11.21.11 0.25mg/tab 1tab OD Cardiac Glycoside Cardiotonic To prevent heart failure and treat palpitations Increases intracellular calcium allows calcium enter myocardial cell during and more to the The patient s pulse rate was within normal range.
depolarization via sodium-
potassium pump mechanism; this increases force contraction, of
increases renal perfusion, decreased heart rate,
and decreases AV node
conduction velocity. Acetaminophen Paracetamol DO: 11.21.11 DG: 11.21.11 200mg IV q4 PRN for fever (37.8C) Reduces fever by acting Analgesic Antipyretic Reduction Fever of The Client s
temperature decreased and
was free from fever.
directly on the hypothalamic heat regulating center cause vasodilation and sweating, which helps to
dissipate heat Propylthiouracil (PTU) Thyracil Inhibits synthesis the of DO: 11.21.11 DG: 11.21.11 2tablets every 6 hours Antithyroid drug Treatment of hyperthyroidism The client did not manifest further signs of her thyroid storm.
thyroid hormones; partially inhibits peripheral conversion of T4 to T3 the more form thyroid hormone. potent of the
NURSING RESPONSIBILITIES: BEFORE: y y y y y Check and confirm the order dose (dosage, frequency, and route) for the said drug. Check and recheck the drug indication and computation. Inform the patient of the drug and its purpose and action. Explain the importance of strict compliance to medical regimen. Question for any history of allergies.
DURING: y y AFTER: y Notify prescriber if adverse effects occur Monitor patient s reaction to treatment regimen Report any signs of adverse reactions
C. DIET Type of Diet Date Ordered Date Started Date Changed NPO (Nothing DO: Per except medications Orem) 11.21.11 DS: 11.21.11 NPO is a type To prepare the None of diet where client for any no drink food or possible is surgical The patient General Description Indication or Purpose(S) Specific Food Taken Client s Response and Reaction to Diet
was able to tolerate the diet and did not develop duodenal ulcers.
allowed except procedure and for her for diagnostic procedure. To prevent aspiration food substances, to make sure the digestive tract is empty to prevent possible aspiration. of
medications
Soft Diet with DO: Strict Aspiration 11.21.11 DS: 11.21.11
This is the type This is done to of wherein diet have the transition
Lugaw
The
patient
a Bread
was able to tolerate the
Precaution (SAP)
patient
is from to
liquid the diet patient
diet.
allowed to eat diet
soft or liquid regular foods that she the can tolerate. has.
NURSING RESPONSIBILITIES: BEFORE: y y y Check for doctor's order. Instruct the patient about the prescribed diet ordered by the physician. Explain the purpose and importance of the diet and no foods are allowed for the patient. DURING: y AFTER: y y Monitor the reaction of the patient. Assess improvement on the pt. condition Remind patient on the food she is allowed to take.
D. ACTIVITY/ EXERCISE Type Exercise of Date Ordered: Date Performed: Date Changed: Activity tolerated as DO:11.21.11 DP:11.21.11 Patient is To promote rest Patient was to her General Description Exercise of Indication/Purpose Client s Response
allowed to do and prevent pain or able things within her fatigue. ability. tolerate activities.
NURSING RESPONSIBILITIES: 1. Identify the patient 2. Explain to the patient the need for such activity. 3. Provide comfort measures. 4. Provide an environment conducive for rest. 5. Attend patient s needs while at bed rest. 6. Be with the patient always when at bed rest.

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ANGELES UNIVERSITY FOUNDATION COLLEGE OF NURSING

(http://portal.doh.gov.ph/kp/statistics/leading_mortality on December 09.2011)

Patient centered General Objectives:

GrandPa GrandPa v (+) GrandMa (+)

iii. HISTORY OF PAST ILLNESS

November 21, 2011 lifted from patient s chart (Admission)

VS: T-38.1C P-103 bpm C-24 cpm BP-110/60 mmHg

November 23, 2011 First Nursing-Patient Interaction I. Vital Signs

PR = 95 bpm BP= 110/70 mmHg

Cra nial Nerves

Type and Function

Assessment Procedure Result

I. Olfactory smell from mucous

Sensory Carries impulses nasal

identify Thyra Storm was able to identify scent. the

(isopropyl alcohol) is being presented to to her.

She was able to correctly

be asked to read a be able to read the sentence in a book sentence correctly.

visual impulses from eyes

read sentence 14 inches away.

to (Pupil Equally Round Thyra Storm

and constricts upon introduction of light.

was moved to 6 able to follow the Thyra Storm

controls blinking, approaching touch and pain.

her back. Ask client cotton. Then client cotton

identify if it is the touched

pointed or dull part sharp or dull. that touched the

was able to identify if the touched part is sharp or dull.

Motor This nerve

with Thyra Storm muscles contract while chewing

demonstrates different expressions. Observe for signs of

the asymmetry. Observe also her increased

movement of the face muscle and appetite to foods

that are sweet or tasty

Sensory. This nerve is involved with

with her name or attention loud noise

direction where the sound comes from

will She was able to

she be able to swallow Thyra Storm without difficulty is able to

swallow without difficulty

swallow, the gag reflex, some taste, and part of

speech. XI. Accessory This nerve Observe the Client s Mrs.

neck. It controls client

the trapezius & shoulders strernocleidomast oid muscles.

shoulders of resistance; shoulders

resistance; rotate & against move the neck.

should move and and

movement of the protrude tongue. tongue.

November 24, 2011

Second Nursing-Patient Interaction I. Vital Signs

PR = 95 bpm BP= 90/50 mmHg

Cra nial Nerves

Type and Function

Assessment Procedure Result

Sensory Carries smell from mucous membrane brain to impulses nasal

identify Thyra Storm was able to identify scent. the

(isopropyl alcohol) is being presented to her.

She was able to correctly read sentence 14 inches away.

papillary and Light)

that controls part of the eye. This nerve responsible is for

action of the eye of the client to light

Light) Pupils are dilated in and constricts upon lightly dim

environment and constricted upon introduction of the light.