I. INTRODUCTION THYROID COLLOID NODULAR GOITER A.

Definition/Etiology Colloid goiter or endemic goiter is a diffuse enlargement of the thyroid gland in which the contents of the follicles increase greatly, causing pressure atrophy of the epithelium so that the gelatinous matter predominates. It is a visible enlargement of the thyroid gland without obvious signs of hypofunction or hyperfunction of the gland resulting from inadequate intake or from an increased demand for iodine. It is
characterized

by the presence of a large soft thyroid gland with its glandular space

distended with colloid. It is an enlargement of the thyroid gland caused by the intake of inadequate amounts of dietary iodine. Iodine deprivation leads to diminished production and secretion of thyroid hormone by the gland. The pituitary gland, operating on a negative feedback system, senses the deficiency and secretes increased amounts of thyroidstimulating hormone, causing hyperplasia and hypertrophy of the thyroid gland. The goiter may grow during the winter months and shrink during the summer months when the person eats more iodine-containing fresh vegetables. Endemic goiter occurs occasionally in adolescents at puberty and widely in population groups in geographic areas in which limited amounts of iodine are present in soil, water, and food. The use of iodized salt is a prophylactic treatment. Desiccated thyroid given orally may prevent further growth of adult goiters and may reduce the size of diffuse goiters. A large goiter may cause dysphagia, dyspnea, cough and wheezing. Typically, the goiter is asymptomatic. The cause of the condition is unknown. In the past it has been ascribed to the intermediate phase of the Marine cycle between the hyperplastic stage and the multinodular (end) stage of the thyroid gland. On gross inspection, the excised gland is reddish-tan or pale tan in color and homogeneous on the cut surface. On histologic section, the parenchyma is seen to be nonnodular and composed of uniform follicles filled with colloid. The follicles may be of normal size, in which case it must be considered that an increase in the number of normal follicles has

produced the increased bulk of the gland, or the follicles may be uniformly distended to several times the usual diameter. Fibrosis and lymphocyte infiltration are not prominent. More recent studies in mice suggest that such goiters can be induced in animals by TSH without a prior hyperplastic phase. The stimulus to TSH secretion in these patients may be an increased requirement for thyroid hormone, possible associated with puberty or pregnancy, a period of decreased iodide intake, or the presence within the thyroid of a biochemical lesion interfering with the normal synthesis of thyroid hormone. A diagnosis of colloid goiter cannot be made with certainty without histologic confirmation. Thyroid function tests are variable, but the results are frequently normal. Antithyroid antibodies are absent if Hashimoto's thyroiditis is not present. Needle biopsy will confirm the diagnosis but is seldom warranted. Reassurance that the lesion is not a malignant neoplasm, and that the thyroid is not overactive, is often the only therapy required. If the goiter is large, thyroid hormone may be given in an attempt to decrease its size. If one accepts the theory that the goiter has grown in response to a need for more thyroid hormone, it is logical to expect that exogenous thyroid hormone would cause it to decrease in size. Only about 70%71 of patients will respond with complete or partial regression of goiter. If there are significant pressure symptoms or if the goiter is a serious problem, administration of 131I or surgical resection may be indicated. Subsequent replacement therapy with T4 will be then necessary. Hereditary factors may cause goiters. Risk factors for the development of a goiter include female sex, age over 40 years, inadequate dietary intake of iodine, living in an endemic area, and a family history of goiter.

Significance of iodine In areas of the world where iodine (essential for the production of thyroxine, which contains four iodine atoms) is lacking in the diet, the thyroid gland can be considerably enlarged, resulting in the swollen necks of endemic goiter. Thyroxine is critical to the regulation of metabolism and growth.

The use of iodized salt is an efficient way to add iodine to the diet. It has eliminated endemic cretinism in most developed countries, and some governments have made the iodination of flour or salt mandatory. Potassium iodide and Sodium iodide are the most active forms of supplemental iodine. Contradictory, recent studies on some populations are showing that excess of iodine could be related to the raise of autoimmune disease driving to permanent hypothyroidism. B. Clinical Manifestation, Signs and Symptoms The main symptom is a swollen thyroid gland. The size may range from a single small nodule to large neck lump. The swollen thyroid can put pressure on the windpipe and esophagus, which can lead to:

Breathing difficulties/ dyspnea Cough Swallowing difficulties / dysphagia Wheezing

There may be neck vein swelling and dizziness when the arms are raised above the head. The gland is usually symmetrically enlarged and feels soft or spongy. The symptoms of goiter are mainly the swelling of the front part of the neck and protruding eyes. The small colloid goiter of adolescent girls may disappear over 1-3 years. On the other hand, it may grow gradually and evolve into the nontoxic multinodular goiter found in adults. C. Diagnostic Test/Exams The doctor will feel the neck as you swallow via physical examination. The doctor may be able to feel swelling in the area. Tests that may be done include: Blood tests to monitor thyroid function, including thyroid stimulating hormone (high if under active, low if overactive) Free thyroxine (T4) Thyroid scan Radioactive iodine uptake (normal or increased)

Thyroid ultrasound (if nodules are present, a biopsy should be done to check for thyroid cancer) Urinary excretion of iodine (low)

E. Management Treatment may not be necessary if the goitre is small. Goiter may be related to hyper- and hypothyroidism (especially Graves' disease) and may be reversed by treatment of hyper- and hypothyroidism. A simple goiter may disappear on its own, or may become large. Over time, destruction to the thyroid may cause the gland to stop making enough thyroid hormone. This condition is called hypothyroidism. Occasionally, a goiter may become toxic and produce thyroid hormone on its own. This can cause high levels of thyroid hormone, a condition called hyperthyroidism. Complications includes Hypothyroidism, Hyperthyroidism, Thyroid cancer, Toxic nodular goiter Medical options A goiter only needs to be treated if it is causing symptoms. Treatments for an enlarged thyroid include:

Radioactive iodine to shrink the gland Small doses of Lugol's iodine or potassium iodine solution if the goiter is due to iodine deficiency

Surgical options Thyroidectomy to remove all or part of the gland

Alternative medicine Use of iodized salt in the diet

Nursing Interventions, Relieving Pain Assess pain location, severity, and characteristics. Administer medications or monitor patient-controlled analgesia to control pain. Assist in attaining postion of comforts. 4

II. GENERAL DATA Patients Name: Address: Age: Birth Date: Contact number: Height: Weight: Sex: Nationality: Religion: Civil Status: Birth Place: Occupation: Name of Hospital: Chief Complaint: Impression: Proposed surgery: Room number: Attending Physician: C.A.V. Buena Hills Guadalupe Cebu City 52 November 26, 1956 09223844080 52 58 kg Female Filipino Roman Catholic Married Cebu City Housewife Chong Hua Hospital Nape pain Colloid goiter Thyroid surgery with Frozen Section A 719 Dr. Joren Mabalatan

Date of Admission: February 5, 2009

Post operative diagnosis: Multinodular goiter on the Right lobe of thyroid

III. HISTORY OF PRESENT ILLNESS Three months PTA, patient experienced gnawing nape pain. Ultrasound was done but patient requested to include anterior neck area wherein an incidental finding of colloid goiter was made. Sought consult with Attending Physician and advised surgery thus admission.

IV. PAST HEALTH HISTORY Patient C.A.V. claims to be non-hypertensive and non-diabetic, has no known drug allergies and has food allergy of dried fish and chicken. Patient has a history for bronchial asthma. V. PREVIOUS HOSPITALIZATION Patient underwent three times for Normal Spontaneous Delivery last 1976, 1979, 1982 and caesarean section last 1985. Last July 2006, patient underwent TAHBSO (Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy). VI. NURSING REVIEW OF SYSTEMS A. GORDONS FUNCTIONAL HEALTH PATTERNS 1. Health Perception-Health Management Pattern Patient has a good perception regarding her life and her health. She rated her health with a score of 9/10 before her hospitalization and a score of 6/10 during her admission. Patient does not seek consult to quack doctors and does not use any herbal medicine. She sometimes self-medicates especially when experiencing a common illness specifically fever, head ache, cold and flu. Medications she uses are Biogesic (Paracetamol) and Neozep. Whenever she seeks help from a medical health care provider and is given prescriptions, she follows them accordingly. She considers her household chores as her form of exercise at home. Patient is fully immunized. C.A.V. claims to be a known smoker for 15 years with 5-10 sticks per day but was able to quit three years ago (2006). She does not drink alcoholic beverages. Her health practice includes proper environmental sanitation-maintaining cleanliness and proper food intake like eating fruits and vegetables. 2. Nutritional-Metabolic Pattern Patient is in NPO post-operatively. Before and during hospitalization, patient eats 3 meals per day: breakfast, lunch and dinner. C.A.V takes one snack in the morning and one in the afternoon. Before hospitalization, she usually eats bread and coffee for

breakfast, meats or vegetables for lunch and dinner. She stated that her favorite viand is adobo. She does not have any difficulty in chewing except for swallowing which she feels pain. She sees her dentist once a year. She has dentures in her upper and lower teeth. She takes vitamins daily (Vitamin C and Calcium) and often eats fruits like bananas, oranges and apples. C.A.V drinks 6-8 glasses of liquids per day. 3. Elimination Pattern Patient normally defecates with a maximum of two times a day, one in the morning and on the evening right before bed time, before and during hospitalization. She does not experience constipation. Her stool is usually light in color. Patient voids normally with a maximum of 4 times per day most often one upon waking up and does not experience any pain upon urination, does not experience urinary incontinence as well. Her urine is clear and pale yellow in color. 4. Activity-Exercise Pattern Patient is a plain housewife. Patient usually wakes up at around 3-4 oclock in the morning. Upon waking up, she prepares food for her family and so with lunch and dinner. She does household chores like cleaning the house and washing clothes. After all her chores done, she spends her free time listening to the radio, reading newspapers, Bible and doing the rosary every night together with her family. She takes siesta by 3pm. She does not engage in any other type of exercise aside from her daily household routines. 5. Sleep-Rest Pattern Patient sleeps at 7-8 pm and wakes up at around 3 4 oclock in the morning. She uses one pillow and a blanket as her sleeping aids and prefers the room to be dark. She does not take any sedatives to facilitate sleeping. She does not have any problems in sleeping and feels rested there after before and during hospitalization. 6. Cognitive-Perceptual Pattern Patients level of consciousness is accurate, she is oriented to time, place, date, and people. She is able to recall past events including her birthday, husbands birthday,

childrens birthday and date of marriage. C.A.V. is able to state her name and age. Patient comprehends and talks Cebuano, Tagalog, and English. She is able to express her emotions well and able to make mindful decisions. While talking to her, she has no problems in hearing. C.A.V. uses reading glasses. She understands and cooperates well with instructions given. She claimed that she has reached secondary level of education. 7. Self-Perception-Self-Concept Pattern Patient sees herself as a God-fearing and a loving wife and mother. She says that she had already given all the love that she have inside her towards her children and husband. She claimed that she had able to provide her family with physical, social, spiritual, and emotional support. C.A.V. says that she is satisfied and happy with her life, she has no regrets especially seeing her children all grown ups with good values instilled. She stated that being a wife and a mother at the same time is the most difficult yet rewarding job of all which no amount of money could every pay back all the efforts. 8. Role-Relationship Pattern Patient is a mother of four, two boys and two girls. She has been married with her husband for about 27 years now. She has a good relationship with her husband, children, parents, and other siblings. As observed inside her room, there is an evidence of support among her family who is watching over her. Patient stated that she is thankful and happy to feel how it is to be cared by her own children. Patient has a lot of friends and acquaintances which she has a good relationship with. 9. Sexuality-Reproductive Pattern Patient claims that her puberty occurred at 14 years of age. Patient had her first sexual contact at the age of 23 with her husband. She does not have any other sexual partner. Patient claims not to have any history of STD. C.A.V. and her husband uses contraceptives like condom and she has tried using pills. Patient is not currently sexually active.

10. Coping-Stress Tolerance Pattern Patient defines stress as something that is mentally challenging and physically tiring. She claims that she is quite stressed right now due to her hospitalization which increases her anxiety level. In her household, the major decision maker is her and her husband. They both takes control over the family. Patient claims that their current major family problem is her condition because their family does not like seeing one member not in good condition. To handle their problems, they talk about it and are open to each others opinions and advices. To relieve stress and tension, she usually watches TV, read Bible and pray. 11. Value-Belief Pattern Patient is a Roman Catholic and believes in God. She stated that she prays everyday by doing the rosary every evening together with her family, and attends mass every Sunday. Patient says that her illness did not change the way she looks at her relationship with God. VII. A. MEMBERS OF IMMEDIATE FAMILY Position in the Educational Family Attainment Husband and Father Wife and Mother Son Son Daughter Daughter High school Level High school Level College Graduate College Graduate College Graduate College Graduate General Health Status Healthy Post-op Healthy Healthy Healthy Healthy

Name M.A.C.S. C.A.V. I.A.V. MA.C. I.R.A.V M.A.A.V.

Age 59 52 33 30 27 24

Occupation Taxi Driver House Wife Employee Employee Employee Employee

B. PERSONAL AND SOCIAL HISTORY Patient C.A.V. shared that they have a harmonious family. She said that she loves her husband and children so much. She claims that she has done her best to be a very good wife and mother to them. They discuss family matters so as to avoid misunderstandings which may affect their family relationship. 9

C.ENVIRONMENTAL HISTORY C.A.V. and her family reside in Buena Hills Guadalupe Cebu. They have lived there for 5 years now. They have a two story concrete house with five bedrooms, 8 windows, and 2 comfort rooms which is renovated by time to time with her childrens help. They live in a suburban area. Their house and lot is owned. Their children have their own bedrooms and she sleeps with her husband in another room. They do not have any pets in their home. It will take only a few minutes of ride to the nearest health center. The nearest church will also take a few minutes ride. The barangay hall is only 50 m away from their home. All of them except I.A.V. live together and comes only to visit most of the time. The market place is only a six-minute walk and the main road is right outside their house. Their community is well organized and peaceful. Their electricity is supplied by MECO and their water supply is supplied by MCWD, they use mineral water for drinking. Their garbage is being collected every weekend. D. HEREDO-FAMILIAL DISEASE Patient C.A.V. says that their heredofamilial disease on the paternal side includes Pulmonary Tuberculosis and Hypertension for both paternal and maternal side. VIII. PHYSICAL ASSESSMENT Physical Examination: Date: February 5, 2009 Time: 6:00 pm (Pre-operative Phase) Height: 5 ft. 2 in Weight: 58 kg

General Appearance: Received patient lying on bed, ambulatory, conscious and coherent, awake, responsive, afebrile, not in respiratory distress, with no IVF being infused with ff. vital signs: BP = 110/80 mmHg, PR = 82 bpm, RR = 18 cpm, T = 36.7C/ axilla. Date: February 7, 2009 Time: 6:00 pm (Post-operative Phase)

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General Appearance: Received patient lying on bed, awake, afebrile, not in respiratory distress, with an IVF 1 D5LR 1L @ 30gtts/min infusing well on the Left arm with a visible operative site at the neck area with the ff. vital signs: BP = 130/90 mmHg, PR = 68 bpm, RR = 19cpm, T = 37C/ axilla. Skin: fair brown in color, no lesions upon inspection, warm and moist to touch, senile skin turgor Head and hair: hair is black and equally distributed with streaks of gray, straight, no dandruff, no lice and nits, scalp is oily; head is normocephalic, no lesions, no masses and tenderness upon palpation Nails: pinkish nail beds, CRT <2 seconds, nail base is firm; when pressure was released Eyes: Symmetrical eye movement, free from inflammation, no abnormal discharges noted, pupils are black and are equal in size, has pinkish palpebral conjunctiva, no swelling and tenderness of lacrimal apparatus, (+) cardinal gaze, (+) reaction to light accommodation and able to read at a regular distance with the use of eyeglass. Eyebrows are black, symmetrical and evenly distributed. Ears: ears are symmetrical, firm, smooth, no deformities, no lesions, (+) cerumen but not impacted, no unusual discharges noted, auricle flexible & is not tender upon palpation, can hear whispered voices Nose and Sinuses: symmetrical & proportional to other facial features, no inflammation, no lesions, moist & pinkish nasal mucosa, no nasal flaring, no swelling, no abnormal discharges, no bleeding, frontal and maxillary sinuses has no tenderness upon percussion, both nostrils are patent Mouth: cracked, dry lips related to environmental factors (airconed room), relatively symmetrical in position, was able to protrude tongue or move tongue upward, sideward

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and downward, pink and moist uvula at midline, incomplete set of teeth 5 on upper jaw and 9 on lower jaw, without dental carries, moist oral mucosa Neck: operative site with incision, with Penrose drain Anterior Chest: Scapula of the same height, fremitus is equal on both sides of the lungs, no crackles heard upon auscultation Posterior Chest: Respiration is not labored, no harsh breath sounds, and posterior thorax is free from tenderness and lesions Heart: Distinct S1 and S2, No murmurs heard Abdomen: abdomen is flabby, light in complexion, soft and warm Musculoskeletal System: Has firm grip strength, cannot freely twist her head from side to side due to the operation site, and does not have difficulty in moving her hands, feet and shoulders Neurological Assessment: Patient is conscious, oriented to place and persons, not irritable, looks tired but still cooperative, responds appropriately to questions, and writes words to communicate rather than talk. Genital Urinary: no pain upon urination, no lesions, no abnormal discharges. Sensory Function: can feel light touch and pain (pinch) at upper and lower extremities Cranial Nerve Testing: I (olfactory) Sensory: can distinguish scent of coffee and juice II (optic): can read using eyeglasses III(occulomotor), IV(trochlear), VI (abducens): pupils equally round & reactive to light & accommodation for both eyes, (+) cardinal gaze

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V(trigeminal) Sensory: (+) blinking reflex, able to move jaw and masticate VII (facial) Sensory and Motor: facial symmetrical is able to obtain different facial expressions VIII (auditory) Sensory: able to hear whispered words at 1 foot distance IX (glossopharyngeal) Sensory able to taste X (vagus) Sensory and Motor: (+) gag reflex XI (spinal accessory) motor: not assessed XII (hypoglossal) Motor: was able to protrude tongue, move side to side, upward and downward

Muscle Strength R 4/5 4/5 L 4/5 4/5

Scale for grading muscle strength: 5- Full ROM against gravity, full resistance 4- Full ROM against gravity, some resistance 3- Full ROM with gravity 2- Full ROM with gravity eliminated 1-slight reaction 0-no reaction IX. DEVELOPMENTAL DATA Developmental Task Erik Ericksons Psychosocial Development Theory: Generativity vs. Stagnation

Basic Strengths: Production and Care

Generativity is demonstrated by sense of parenthood and creativity and concern about providing for others that is equal to concern of providing for self. The significant 13

task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. X. A. ANATOMY OF THE THYROID GLAND

The thyroid is one of the largest endocrine glands in the body. This gland is found in the neck inferior to (below) the thyroid cartilage (also known as the Adam's apple in men) and at approximately the same level as the cricoid cartilage. The thyroid controls how quickly the body burns energy, makes proteins, and how sensitive the body should be to other hormones.

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The thyroid participates in these processes by producing thyroid hormones, principally thyroxine (T4) and triiodothyronine (T3). These hormones regulate the rate of metabolism and affect the growth and rate of function of many other systems in the body. Iodine is an essential component of both T3 and T4. The thyroid also produces the hormone calcitonin, which plays a role in calcium homeostasis. The thyroid is controlled by the hypothalamus and pituitary. The gland gets its name from the Greek word for "shield", after the shape of the related thyroid cartilage. B. PHYSIOLOGY OF THE THYROID GLAND T3 and t4 The production of thyroxine and triiodothyronine is regulated by thyroidstimulating hormone (TSH), released by the anterior pituitary (that is in turn released as a result of TRH release by the hypothalamus). The thyroid and thyrotropes form a negative feedback loop: TSH production is suppressed when the T4 levels are high, and vice versa. The TSH production itself is modulated by thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus and secreted at an increased rate in situations such as cold (in which an accelerated metabolism would generate more heat). TSH production is blunted by somatostatin (SRIH), rising levels of glucocorticoids and sex hormones (estrogen and testosterone), and excessively high blood iodide concentration. Calcitonin An additional hormone produced by the thyroid contributes to the regulation of blood calcium levels. Parafollicular cells produce calcitonin in response to hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition to the effects of parathyroid hormone (PTH). However, calcitonin seems far less essential than PTH, as calcium metabolism remains clinically normal after removal of the thyroid, but not the parathyroids. XI. PATHOPHYSIOLOGY A. Conceptual Framework of the Pathophysiology THYROID GLAND Energetic exchange of the calorie gene

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Increase need of TSH Compensated increase Hormonal production Hyperplasia into local follicles Enlarged Thyroid/ Nodular Goiter Compression of trachea and esophagus Difficulty in swallowing Difficulty of breathing SUBTOTAL THYROIDECTOMY

B. Discussion of the Pathophysiology of Thyroid Colloid Nodular Goiter Thyroid hormone synthesis is impaired when the iodine intake is low. This impairment leads to an increased thyroid clearance of iodide from the plasma and decreased urinary clearance of iodide, an adaptation towards iodine conservation. The synthesis of T3 is increased because it is 3-4 times more potent than T4 and contains only as much iodide. Peripheral conversion of T4 to T3 also takes place. Clinical euthyroidism is thus maintained, but biochemically the pattern of low T4, elevated TSH and normal or elevated T3 levels is often found. In endemic cretinism, where thyroid failure is severe, serum T3 and T4 levels are low and serum TSH concentration is markedly elevated. In less severe situations, serum T3 and T4 levels may remain normal. The serum TSH may also be normal or only moderately elevated. In endemic areas, a wide variation in the level of TSH has been observed in normal and goitrous individuals. Such dissociation between goiter size and biochemical findings suggests the possible role of circulating thyroid growth factors, such as epidermal growth factors, or an autoimmune process in the pathogenesis of goiter. The 16

physiologic changes to iodine deficiency discussed above, are usually accompanied by an increase in the size of the thyroid gland. Generalized epithelial hyperplasia occurs, with cellular hypertrophy and reduction in follicular spaces. In chronic iodine deficiency, the follicles become inactive and distended with colloid accumulation. These changes persist into adulthood, and focal nodular hyperplasia may develop, leading to nodular formation. Some of these nodules retain the ability to secrete thyroxine and form functioning thyroid nodules. Others do not retain this ability, become inactive and form cold nodules. Necrosis and scarring results in fibrous septae, which contribute to the formation of multinodular goiter. XII. MEDICAL MANAGEMENT A. Treatment and Procedures After the patient diagnosed that she had a nodular colloid goiter an enlargement of her thyroid gland (hyperplasia), she was advised to undergo thyroid surgery. B. Medications 1. Tramadol (Siverol) 50mg slow IVTT every 6hours 2. Dynastat 40mg slow IVTT every 12hours 3. Dolcet 1tablet P.O. every 8hours 4. Ventolin Nebulization every 6hours C. Diagnostic Procedure COMPLETE BLOOD COUNT Date & time performed: January 12, 2009 2:21pm Lab No. 0819739 Requesting Doctor: Dr. Imelda Bilocura MD. Test White blood cells RBC Hemoglobin Hematocrite Result 6.10 4.50 13.4 39.7 Reference 4.8-10.8 4.2-5.4 12.0-16.0 37.0-47.0 Unit 10^3/uL 10^6/uL g/dl %

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MCV MCH MCHC Platelet Neutrophil (%) Lymphocyte (%) Monocyte (%) Eusonophils (%) Basophils (%) Neutrophils (#) Lymphocyte (#) Monocyte (#) Eosonophils (#) Basophils (#) RDW PDW MPV

88.0 29.8 33.7 219 45.4 42.3 8.7 3.4 0.2 2.75 2.56 0.53 0.21 0.01 11.6 13.0 8.8

81-99 27.0-31.0 33.0-37.0 130-400 40-74 19-48 3.4-9.0 0.0-7.0 0.0-1.5 1.9-8.0 0.9-5.2 0.16-1.0 0.0-0.08 0.0-0.2 11-16 9.0-14.0 7.2-11.1

fL Pg g/dl 10^3/uL % % % % % 10^3/uL 10^3/uL 10^3/uL 10^3/uL 10^3/uL % % fL

ELECTROCARDIOGRAPHIC REPORT Lab No. 0819739 Date & time performed: January 12, 2009 1:50pm Standardization 10mm QRS Axis +37 degrees QRS Complexes P-Waves Upright Rhythm Sinus Bradycardia QRS Interval 0.08 sec ST-Segments Isoelectric T-Waves Upright Atrial Rate 56/min Ventricular Rate 56/min PR Interval 0.16 sec

INTERPRETATION: Sinus Bradycardia with non specific S-T wave changes

HEMATOLOGY REPORT EXAMINATION: BLEEDING TIME & CLOTTING TIME Test BT Adult (Simplate) CT (Lec & White) Result 5mins. & 10secs. 9mins. & 48secs. Reference Unit 2.3-9.5mins. Up to 15mins.

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EXAMINATION: PROTHROMBINE TIME Test Result Reference Patient 12.4 Activity 103.0 >70% TNR 1.00 <=1.21 Control 13.6 Control Activity 88.0 CLINICAL CHEMISTRY REPORT Test Result Glucose 90 Creatinine 0.7 Ionized Calcium 1.2 Sodium (serum) 142.0 Potassium 4.0 X-RAY REPORT Reports: Reference 0.6-1.5 0.9-1.4 134.0-148.0 3.3-5.3

Unit Sec % Sec % Unit Mg/dl Mg/dl mmol/L mmol/L mmol/L

The lungs are clear. Heart is not enlarged. Aorta is tortuous & sclerotic. The tracheal air column is at the midline. Both hemi diaphragms & costophrenic sulci are intact. There are osteophytes arising from the lateral articulating margins of the dorsal spine. The rest of the bony structures are unremarkable Conclusion: 1. Arteriosclerosis of the thoracic aorta 2. Hypertrophic Degenerative changes of the dorsal spine ULTRASOUND REPORT Lab No. 00099658 Date & time performed: October 23, 2008 EXAMINATION THYROID Reports: Right Lobe: 5.6 x 1.9 x 1.9 cm (LWH) Left Lobe: 5.7 x 2.1 x 1.9 cm (LWH) Isthmus: 0.7cm thickness Normal: L: 4-6cm W: 2-3cm H: 1-2cm

The thyroid gland presents multiple lesions in both lobes with the following features:

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1. Echogeniity: Ranging from the mildly echogenic to the mildly echogenic 2. Echopterm: Ranging from the homogeneous to heterogeneous; from purely solid to mixed solid & cystic 3. Calcifications: None delineated 4. Vascularity: minimal to insignificant 5. Borders: Mostly faint to well defined: smooth 6. Size range: 0.9-1.7cm The rest of the gland is physiologic in appearance A few slightly enlarged sub mandibular lymph nodes are noted bilaterally The visualized portions of the adjacent vascular structure, trachea, esophagus & strap muscles are unremarkable Conclusion: Multiple focal lesions, as describes, probably representing adenomatous/ colloid nodules, undergoing cystic degenerative changes seen against a background of physiologic thyroid tissue. Correlate with other clinical findings or biopsy as the overlap of non specific features shared both benign & malignant lesions is wide. Few minimally enlarged sub mandibular lymph nodes. D. Diet As ordered by the physician, patient was placed on a Diet as Tolerated status. XIII. NURSING MANAGEMENT A. Actual Care Given Actual care was given to patient like taking and monitoring vital signs. IV being regulated to its prescribed rate as well as proper time taping to prevent excess or deficientcy of fluid consumption. Patient was also provided with bedside care. B. Problems Encountered During Implementation of Nursing Care I did not have any difficulties in caring for the patient for she is very cooperative and compliant with every regimen given to her. She also follows order given by her physician as well as asking for advice on what he should and should not do.

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C. Restorative Measures Used The patient was given actual care. Instructions are given to promote relaxation and prevent further complications and to achieve wellness. Diversional activities and habits such as reading newspaper, bible and other reading materials helped the patients ability to perform activities. Simple exercises were initiated to maintain clients health status. Linens are maintained to be wrinkled free to let the patient feel comfortable. D. Evaluation Patient C.A.V.s condition was improved throughout the treatment process and was able to meet the goal of performing all the advised therapeutic interventions before being discharged and have accepted her condition positively. E. Patient Teaching Patient was able to know about Thyroid colloid nodular goiter specifically the causative factors and preventive measures. C.A.V. was able to gain basic knowledge and advice on how to advice her friends and families on how this disease process can be prevented, and also stressing out the importance of visiting a physician every now and then in helping her to maintain good health. XIV. CONCLUSION If you care for a patient with thyroid colloid nodular goiter, you must be aware of the disease process to understand why patients undergoes such signs and symptoms and so as to help them understand the facts behind what they are going through. We must have enough knowledge to give a specific and right care suitable for our patients. XV. RECOMMENDATION In addition to treating any underlying illness which can increase a persons risk for thyroid colloid nodular goiter, there are several additional ways to prevent such. Proper diet including iodized salt could help. Fluids and enough rest can also contribute

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to help a lot to clients with Thyroid colloid nodular goiter. Doing proper care to clients encourages them to cooperate and follow the said interventions. Patient teaching should always be present in order for them to know the appropriate measures as to what they should do best to regain their health status with the said disease condition. XVI. IMPICATION OF THE STUDY TO: A. Nursing Education This study helps us gain more knowledge especially for the education in the practice of nursing. To be globally competitive, we must be skilled with the right knowledge, skills and attitudes. This helps us to become ready to the real world where there are still a lot of different diseases and illnesses that awaits us for our knowledge to grow and expand. It is one way of achieving nursing profession, improving skills and enhancing attitude on how to handle patients with different values, cultures, beliefs and implementation of the proper care of the specific needs of the different individuals. So if one day we can encounter this kind of disease, we are confident enough to apply our knowledge and answer patients questions and confusions at the back of their mind. B. Nursing Practice It is a way of improving quality care that we should give to our patients together with love and dedication of our work that can help them a lot to be motivated and encouraged for better recovery. This study was done for the betterment of both learner-us student nurses and so as with the patients. Nurses can carry out good implementations of nursing interventions if with good attitude, proper knowledge and skills.

C. Nursing Research This is a way of learning to improve professional education, practice and resources effectively. We study on the disease process to give adjunct quality care to our patients. A research must contain overall patients data and condition. The importance of

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this research is to plan care, both independent and dependent nursing care. This encourages nursing associations to establish ethical research standards appropriately.

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