Case Study (Goiter)

DAVAO MEDICAL SCHOOL FOUNDATION, INC. MEDICAL SCHOOL DRIVE, BAJADA, DAVAO CITY COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NCM 103 RLE

CASE STUDY “GOITER”

SUBMITTED TO: GREMMA W. BARATAS, RN, MN CLINICAL INSTRUCTOR

SUBMITTED BY: YASIERAH K. AGALIN, ST. N CHRISTINE JOY R. ALONDAY, ST. N SIVAN WILFRED G. BARBARONA, ST. N CHEENE S. BELACSI, ST. N ISRAEL G. DELMINDO, ST. N EARL GARCIA, ST. N VENICE ATHENA PAJARO, ST. N ABBEGAILE ANNE R. SIENES, ST. N

DATE SUBMITTED: NOVEMBER 12, 2016

TABLE OF CONTENTS

I. INTRODUCTION....................................................................................................1-2 A. Background of the study.........................................................................................1 B. Significance of the study.........................................................................................2 C. Relevance of the study...........................................................................................2 II. OBJECTIVES(General and Specific objectives) .................................................3-4 III. HEALTH HISTORY.................................................................................................5 IV. PATIENT PROFILE.................................................................................................5 V. DEVELOPMENTAL TASK....................................................................................6-7 VI. GENERAL ASSESSMENT..................................................................................8-9 VII. ANATOMY AND PHYSIOLOGY....................................................................10-12 VIII. DEFINITION OF TERMS...............................................................................13-14 IX. ETIOLOGY............................................................................................................15 X. PATHOPHYSIOLOGY......................................................................................16-18 XI. PROGNOSIS........................................................................................................19 XII. SYMPTOMATOLOGY....................................................................................20-22 XIII. LABORATORY (DIAGNOSTIC) TESTS.......................................................23-26 XIV. MEDICAL AND SURGICAL TREATMENT).................................................26-32 XV. NCP................................................................................................................33-35 XVI. DISCHARGE PLANNING (METHOD)..........................................................36-37 A. Medication............................................................................................................36 B. Exercise................................................................................................................37 C. Treatment..............................................................................................................37 D. Health Teaching....................................................................................................37 E. Out-patient order...................................................................................................37 F. Diet........................................................................................................................37

XVII. RECOMMENDATIONS.....................................................................................38 XVIII. BIBLIOGRAPHY/REFERENCES....................................................................39

INTRODUCTION A. BACKGROUND OF THE STUDY Goiter is a swelling of the neck or larynx resulting from enlargement of the thyroid gland (thyromegaly), associated with a thyroid gland that is not functioning properly. The degree of swelling, and the severity of symptoms produced by the goiter depend on the individual. Some cases involve a small amount of swelling, and others can involve considerable swelling that actually constricts the trachea and causes breathing problems. Worldwide, the most common cause for goiter is deficiency, The prevalence of goiter in areas of severe iodine deficiency can be as high as 80%. Populations at particular risk tend to be remote and live in mountainous areas in South-East Asia, Latin America and Central Africa. Iodization programs are of proven value in reducing goiter size and in preventing goiter development and cretinism in children. Autonomy can develop in nodular goiters leading occasionally to thyrotoxicosis and iodization programs can also induce thyrotoxicosis, especially in those aged >40 years with nodular goiters

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SIGNIFICANCE OF THE STUDY

This study will be a significant endeavor in understanding this condition, it will help the students and clinical instructors in gaining more knowledge that will help them deal with future similar cases. By being able to encounter this case and study it, students will become more competent and expectedly will be more confident with themselves. Furthermore this research will provide recommendations on how to plan and proper nursing interventions for the said case.

RELEVANCE OF THE STUDY

We had found this case to be interesting and challenging on our part as student nurses since it’s our first time to encounter it. And we were able to relate to it since its one of the most common diseases that affect the thyroid gland In the Philippines, Based on the studies of urinary iodine levels conducted by the Department of Health, most goiter cases are found in the mountainous provinces and other remote areas of the country. The Food and Nutrition Research Institute performed a nutritional survey in 1998 to assess the extent of iodine deficiency among 10,616 school children aged six to 12 years. It was discovered that the country as a whole had mild iodine deficiency.

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OBJECTIVES GENERAL OBJECTIVE: At the end of our two-week exposure in the Davao Medical School Foundation Hospital, medical- surgical ward, we will be able to acquire knowledge and reliable information about goiter in order for us students to become knowledgeable; be able to demonstrate competent nursing care that will address our patients condition; and to demonstrate right attitude and provide quality nursing care.

SPECIFIC OBJECTIVES: This case study is made to achieve the following reasons:

1. Establish rapport with our patient as well as her significant others to gain trust and cooperation. 2. Collect significant information regarding our patient’s conditions as well as the family history, past and present health history. 3. Evaluate client’s data according to the nursing and developmental theory. 4. Describe the structures and normal function of the body organs involved. 5. Trace the Pathophysiology of the disease process and its enduring symptomatology 6. Review and interpret medical order and results of possible laboratory examination that the client has undergone.

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7. Identify the different signs and symptoms, as well as the presentation of its etiology and contributing factors in the development of this condition 8. Make effective nursing care plans that address the present and possible needs. 9. Enumerate client’s medications which include both therapeutic andthe adverse effects 10. Present discharge plan for client’s condition.

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HEALTH HISTORY

PATIENT PROFILE

Name: Sex: Age: Status: Address: Nationality: Religion: Occupation: Birthdate: Mother: Father: Spouse: Birth Place: Chief Complaint:

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GENOGRAM Father’s side

Mother’s Side

Grandfath er 64, alive

Youngest 22, alive

Grandmother 50, alive

Patient 35 eclampsia

Youngest 2 weeks

Second eldest 36, alive

2nd youngest 10 years

Grandfath er 70, dead

Eldest 38, alive

2nd eldest 11 years

Grandmother 60, alive

Daughter 28, alive

Son (husband of the patient) 35, alive

Eldest 14 years

Male Female Patient

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DEVELOPMENTAL TASK

Developmental Task: Erik Erickson Psychosocial Stage:

Developmental Task: Sigmund Freud Psychosexual Theory:

Developmental Task: John Piaget’s Cognitive theory

Developmental Task: Lawrence Kohlberg Moral Development Theory

GENERAL ASSESSMENT 7

Family History: Patient (-) Hypertension (-) Diabetes Mellitus (-) bronchial asthma (-) food and drug allergies

family (-) Hypertension (-) Diabetes Mellitus (-) bronchial asthma (-) cancer

Past history: (+) smoking (-) alcoholic and beverage drinks No noted hospitalizations in the past. Health Care Provider: DOCTOR Final Diagnosis: Complete H.Mole G8P7 General Appearance:  conscious  coherent Level of sensorium:  cooperative EENT: - Anicteric Sclerae, (+) pale palpebral conjunctiva Breast: -Non tender Lungs: -CBS, equal chest expansion Final Diagnosis: GOITER 8

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ANATOMY AND PHYSIOLOGY

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DEFINITION OF TERMS

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ETIOLOGY

Iodine deficiency is the major cause of goiter worldwide, but this is rarely a cause in more economically developed countries that add iodine to salt. As iodine is inconsistently present in plant foods, vegan diets may lack sufficient iodine; this is less of a problem for vegans who live in countries such as the US that add iodine to salt). Rates of goiter are higher in areas where there is a deficiency of the trace mineral, which is found in seafood, plant food grown in iodine-rich soil, and cow's milk.

In some parts of the world, the prevalence of the condition can be as high as 80 per cent - such populations tend to be in remotely mountainous areas of southeast Asia, Latin America and central Africa, where daily intake of iodine can fall below 25 micrograms a day and children are often born with hypothyroidism.4 The thyroid gland needs iodine in order to manufacture thyroid hormones, which regulate the body's rate of metabolism. The main cause of goiter in developed countries is autoimmune disease. Women over the age of 40 are at greater risk of goiter, as are people with a family history of the condition.2 Hypothyroidism is the result of an underactive thyroid gland, and this causes goiter. Because the gland produces too little thyroid hormone, it is stimulated to produce more, leading to the swelling.3 This usually results from Hashimoto's thyroiditis/disease, a condition in which the body's immune system turns on itself and causes inflammation within the thyroid gland.2,3

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Hyperthyroidism is also a cause of goiter - from an overactive thyroid gland, which produces too much thyroid hormone. This usually happens as a result of Graves' disease, also an autoimmune disorder in which the body's immunity turns on itself and attacks the thyroid gland, causing it to swell.

Less common causes of goiter include the following: 

Nodules - benign lumps, single or multiple



Smoking - thiocyanate in tobacco smoke interferes with iodine absorption



Hormonal changes - pregnancy, puberty and the menopause can affect thyroid function



Thyroiditis - inflammation caused by infection, for example



Lithium - the psychiatric drug can interfere with thyroid function



Overconsumption of iodine - too much iodine can cause goiter, just as too little does



Radiation therapy - particularly if to the neck.

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PATHOPHYSIOLOGY

  

Predisposing Sex: female (4:1) Age: over 40 years old Family history of goiter

  

Precipitating History of radiation therapy to haed or neck Excessive amounts of iodine Iodine deficiency

Etiology: may be caused by one or several factors stated

Presence of uniform follicular epithelial hyperplasia

Development of areas of involution and fibrosis interspersed with areas of focal hyperplasia

Thyroid architecture loses uniformity

Development of nodules

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Thyroid gland slowly increases in size

Development of functional automony

Reduced TSH levels

May lead to thyrotoxicosis Pressure on anterior neck structures

Visible anterior neck mass

Venous outflow obstruction of the head and the neck

Pressure on the esophagus

Pressure on the trachea

dysphagia

Facial plethora

Engorgement of the neck veins

dyspnea

If treated

hoarseness

coughing

wheezing

If not treated

May complicate into thypoid cancer

Good prognosis

PROGNOSIS

Pressure on the recurrent laryngeal nerve

death

Poor prognosis

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A simple goiter may disappear on its own, or may become larger. Over time, the thyroid gland may stop making enough thyroid hormone. This condition is called hypothyroidism.

In some cases, a goiter becomes toxic and produces thyroid hormone on its own. This can cause high levels of thyroid hormone, a condition called hyperthyroidism.

Results vary depending on the underlying condition. The early stages of goiter often respond well to medication (hormone therapy); a marked reduction in size or complete resolution can occur within 3 to 6 months. When nodules are present, only about onethird of individuals see a reduction in gland size after hormone therapy. Surgery (thyroidectomy) is generally effective. Even in cases in which the goiter regresses with treatment, it may recur in months or years. Undiagnosed progressive thyroid cancer can be fatal.

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SYMPTOMATOLOGY SIGNS AND SYMPTOMS Uterine enlargement

RATIONALE Uterine enlargement is cause excessive trophoblastic growth and retained blood.

Vaginal Bleeding

Most common sign of H. mole. May occur in abdominal cavity causing pain. Molar tissue seperates from the decidua causing bleeding. The uterus may become distended by large amount of blood and dark fluid may leak into vagina.

Absence of fetal

H.mole is a “fake pregnancy” and therefore there is no fetus or fetal

heart tone Severe Nausea and

heart rate Nausea is very common during pregnancy. This is due to extremely

vomiting

high levels of human chorionic gonadotropin (hCG).

Hyperthyroidism

Can be present due to stimulation of the thyroid gland by the high levels of circulating HCG or by a thyroid stimulating substance produced by the trophobasts.

Vaginal discharge anemia

parts of the mole deteriorate, small amounts of tissue, which resemble a bunch of grapes, may pass through the vagina In cases of serious or prolonged bleeding, a woman's body is not able to replace red blood cells as fast as they are lost. This can lead to anemia (low red blood cell counts). Symptoms can include fatigue

Ovarian cysts

and shortness of breath, especially with physical activity. hCG may cause fluid-filled cysts to form in the ovaries. These cysts can be large enough to cause abdominal swelling. They only occur with very high levels of HCG. Even though they can become quite large, they usually go away on their own about 8 weeks after the molar pregnancy is removed. 17

infection

In larger tumors, some of the tumor cells may die, creating an area where bacteria can grow. Infection may develop, which can cause

Lung symptoms

vaginal discharge, pelvic cramps, and fever. The lung is a common site for distant spread of GTD. Spread to the lungs may cause coughing up of blood, a dry cough, chest pain, or trouble breathing.

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DIAGNOSTIC TEST HEMATOLOGY Hemoglobin

Result L 63.0

Range 115.0 – 155.0 g/L

Hematocrit

L 0.23

0.36 – 0.48

RBC

L 3.86

4.20 – 6.10 x10^6/uL

WBC

H 10.42

5.0 – 10.0 x10^3/uL

MCV

L 58.80

79.40 – 94.80 fl

Interpretation A low hemoglobin count is a commonly seen blood test result. Hemoglobin (Hb or Hgb) is a protein in red blood cells that carries oxygen throughout the body. In many cases, a low hemoglobin count is only slightly lower than normal and doesn't affect how you feel. If it gets more severe and causes symptoms, your low hemoglobin count may indicate you have anemia. Causes of low hematocrit, or anemia, include: Bleeding (ulcers, trauma, colon cancer, internal bleeding) Destruction of red blood cells (sickle cell anemia, enlarged spleen) Decreased production of red blood cells (bone marrow supression, cancer, drugs) When the hemoglobin count is low, the body is not able to get as much oxygen to go throughout the body. An increased production of white blood cells to fight an infection Mean corpuscular volume (MCV) is the average volume of red cells in a specimen. MCV is elevated or decreased in accordance with average red cell size; ie, low MCV indicates microcytic (small average RBC size), normal MCV indicates normocytic (normal average RBC size), and high MCV indicates macrocytic (large average RBC size). 19

MCHC

L 27.8

32.20 – 35.50 g/dL

Neutrophil

H 79

55.00 – 75.00 %

Lymphocyte

L 16

20 – 35%

Monocyte

4

2 – 10 %

Eosinophil

1.000

1–8%

Differential count

The mean corpuscular hemoglobin concentration, a measure of the concentration of hemoglobin in a given volume of packed red blood cells. It is reported as part of a standard complete blood count. The blood differential test measures the percentage of each type of white blood cell (WBC) that you have in your blood. It also reveals if there are any abnormal or immature cells. It is important to realize that an abnormal increase in one type of white blood cell can cause a decrease in the percentage of other types of white blood cells. An increased percentage of neutrophils may be due to: Acute infection. Acute stress. Lymphocytopenia is an abnormally low number of lymphocytes (a type of white blood cell) in the blood. Many disorders can decrease the number of lymphocytes in the blood, but viral infections (including AIDS) and undernutrition are the most common. A blood differential test, also called a white blood cell count differential, measures the number of each of the five types of white blood cells present in your blood: neutrophils. lymphocytes. monocytes. Eosinophils have two distinct functions in your immune system. They destroy invading germs like viruses, bacteria, or parasites such as Giardia and pinworm. Eosinophils also create an inflammatory response, especially if an allergy is 20

Basophil

Platelet Count

Urinalysis Chemical Analysis pH

319

150 – 400 x10^3/uL

Result 6.5

Range

involved. Basophils are produced in your bone marrow, circulate in the blood and are the least abundant of all leukocytes. They are classified as immune cells and categorized a granulocytes. Therefore, the basic function of this white blood cell is release of its substances in response to a foreign invasion. A platelet count is a lab test to measure how many platelets you have in your blood. Platelets are parts of the blood that help the blood clot. They are smaller than red or white blood cells.

Interpretation A urine pH test can tell your doctor how acidic or basic (alkaline) your urine is using a simple, painless urine test. Many diseases, your diet, and the medicines you take can affect how acidic or basic your urine is. For instance, results that are either too high or low can indicate the likelihood that your body will form kidney stones. If your urine is at an extreme on either the low or high end of pH levels, you can adjust your diet to reduce the likelihood painful kidney stones will form. In short, your urine pH is an indicator 21

Glucose

Negative

Protein

Negative

Urine Flowcytometry WBC

8.0

of your overall health and gives your doctor important clues as to what is going on in your body. The glucose urine test measures the amount of sugar (glucose) in a urine sample. The presence of glucose in the urine is called glycosuria or glucosuria. Urine protein testing is used to detect protein in the urine, to help evaluate and monitor kidney function, and to help detect and diagnose early kidney damage and disease. 0 – 27 /uL

Leukocyte esterase is an enzyme present in most white blood cells (WBCs). Normally, a few white blood cells (see microscopic examination) are present in urine and this test is negative. When the number of WBCs in urine increases significantly, this screening test will become positive. When the WBC count in urine is high, it means that there is inflammation in the urinary tract or kidneys. The most common cause for WBCs in urine (leukocyturia) is a 22

RBC

H 40

0 – 28 /uL

Epithelial Cells

H 14

0 – 7/uL

Cast

bacterial urinary tract infection (UTI), such as a bladder or kidney infection. This test is used to detect hemoglobin in the urine (hemoglobinuria). Hemoglobin is an oxygen-transporting protein found inside red blood cells (RBCs). Its presence in the urine indicates blood in the urine (known as hematuria). The small number of RBCs normally present in urine usually result in a "negative" test. However, when the number of RBCs increases, they are detected as a "positive" test result. Epithelial cells in urine may be a cause for concern if the numbers are higher than normal. The sloughing of epithelia is quite a normal process of the body sheddingdead cells and creating new ones. If epithelial cells are high in your urine it could signal a problem with your kidneys or an infection in your urinary system. This article will examine some possible causes of epithelial cells in urine and what urinalysis means. Urinary casts are 23

Bacteria

formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron). The proximal convoluted tubule (PCT) and loop of Henle are not locations for cast formation. Hyaline casts are composed primarily of a mucoprotein (TammHorsfall protein) secreted by tubule cells. Urine is normally sterile, which means that it contains no bacteria. A small number of bacteria may be found in the urine of many healthy people. This is usually considered to be harmless. However, a certain level of bacteria can mean that the bladder, urethra, or kidneys are infected.

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NCP Assessment

Diagnosis

Planning

Intervention

evaluation

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Objective:  VS Taken and recorded Temp: 36.2 C Pulse: 71 RR: 19 BP: 110/80

Risk for infection r/t surgical incision secondary to total abdominal hysterectomy

After 8 hours  of nursing intervention, the patient will be able to:  Identify  and demonstrat e interventio  n to prevent infection  Patient will show no signs and symptoms of infection

Establish rapport Rationale: To gain patient’s trust and cooperation Monitor V.S. Rationale: To obtain baseline data

Goal met as evidenced by normal vital signs and patient showed no signs and symptoms of infection

Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. Rationale: With the onset of infection the immune system is activated and signs of infection appear.



Note and report laboratory values (e.g., white blood cell count) rationale: Laboratory values provide a global view of the client's immune function



Use proper hand washing techniques before and after giving care to client. Rationale: Hand washing significantly decreases the number of microorganisms



Provide wound healing such as cleaning of wound Rationale: To reduce risk for infection 25



Provide care, change dressing as needed To promote healing to the incision

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Assessment

Diagnosis

Planning

Intervention

Objective:  VS Taken and recorded Temp: 36.2 C Pulse: 71 RR: 19 BP: 110/80

Risk for infection r/t surgical incision secondary to total abdominal hysterectomy

After 8 hours  of nursing intervention, the patient will be able to:  Identify  and demonstrat e interventio  n to prevent infection  Patient will show no signs and symptoms of infection

Establish rapport Rationale: To gain patient’s trust and cooperation Monitor V.S. Rationale: To obtain baseline data

evaluation Goal met as evidenced by normal vital signs and patient showed no signs and symptoms of infection

Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. Rationale: With the onset of infection the immune system is activated and signs of infection appear.



Note and report laboratory values (e.g., white blood cell count) rationale: Laboratory values provide a global view of the client's immune function



Use proper hand washing techniques before and after giving care to client. Rationale: Hand washing significantly decreases the number of microorganisms



Provide wound healing such as cleaning of wound Rationale: To reduce 27

risk for infection 

Provide care, change dressing as needed To promote healing to the incision

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Assessment

Diagnosis

Planning

Intervention

Objective:  VS Taken and recorded Temp: 36.2 C Pulse: 71 RR: 19 BP: 110/80

Risk for infection r/t surgical incision secondary to total abdominal hysterectomy

After 8 hours  of nursing intervention, the patient will be able to:  Identify  and demonstrat e interventio  n to prevent infection  Patient will show no signs and symptoms of infection

Establish rapport Rationale: To gain patient’s trust and cooperation Monitor V.S. Rationale: To obtain baseline data

evaluation Goal met as evidenced by normal vital signs and patient showed no signs and symptoms of infection

Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. Rationale: With the onset of infection the immune system is activated and signs of infection appear.



Note and report laboratory values (e.g., white blood cell count) rationale: Laboratory values provide a global view of the client's immune function



Use proper hand washing techniques before and after giving care to client. Rationale: Hand washing significantly decreases the number of microorganisms



Provide wound healing such as cleaning of wound 29

Rationale: To reduce risk for infection 

Provide care, change dressing as needed To promote healing to the incision

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Assessment

Diagnosis

Planning

Intervention

Objective:  VS Taken and recorded Temp: 36.2 C Pulse: 71 RR: 19 BP: 110/80

Risk for infection r/t surgical incision secondary to total abdominal hysterectomy

After 8 hours  of nursing intervention, the patient will be able to:  Identify  and demonstrat e interventio  n to prevent infection  Patient will show no signs and symptoms of infection

Establish rapport Rationale: To gain patient’s trust and cooperation Monitor V.S. Rationale: To obtain baseline data

evaluation Goal met as evidenced by normal vital signs and patient showed no signs and symptoms of infection

Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. Rationale: With the onset of infection the immune system is activated and signs of infection appear.



Note and report laboratory values (e.g., white blood cell count) rationale: Laboratory values provide a global view of the client's immune function



Use proper hand washing techniques before and after giving care to client. Rationale: Hand washing significantly decreases the number of microorganisms



Provide wound healing such as cleaning of wound Rationale: To reduce 31

risk for infection 

Provide care, change dressing as needed To promote healing to the incision

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Assessment

Diagnosis

Planning

Intervention

Objective:  VS Taken and recorded Temp: 36.2 C Pulse: 71 RR: 19 BP: 110/80

Risk for infection r/t surgical incision secondary to total abdominal hysterectomy

After 8 hours  of nursing intervention, the patient will be able to:  Identify  and demonstrat e interventio  n to prevent infection  Patient will show no signs and symptoms of infection

Establish rapport Rationale: To gain patient’s trust and cooperation Monitor V.S. Rationale: To obtain baseline data

evaluation Goal met as evidenced by normal vital signs and patient showed no signs and symptoms of infection

Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. Rationale: With the onset of infection the immune system is activated and signs of infection appear.



Note and report laboratory values (e.g., white blood cell count) rationale: Laboratory values provide a global view of the client's immune function



Use proper hand washing techniques before and after giving care to client. Rationale: Hand washing significantly decreases the number of microorganisms



Provide wound healing such as cleaning of wound Rationale: To reduce 33

risk for infection 

Provide care, change dressing as needed To promote healing to the incision

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DISCHARGE PLANNING Medication



Instruct the patient to comply with the treatment regimen faithfully. Rationale: this would promote faster recovery and prevention of relapse.



Intruct to take medication with exact dosge as ordered Rationale: correct dosage hinders from possible adverse effects due to overdosing of a certain drug



Explain the side effects of medication Rationale: to orient or to have knowledge of what possible side effects to expectg upon taking the drugs. Refer for further reassessment.



Intruct patient to avoid taking medication that are not prescribed by the physicians. Rationale:over the counter drugs might cause side effects or even adverse effects that may worsen status.



Remind the patient’s significant others for the scheduled consultsation with the physician Rationale: in order to determine the effectiveness of the drug.



Take full course of medication Rationale: to kill microorganisms resistance.



Instruct significant others to refere immediately if there is an adverse reaction of the drug Rationale: to complications.

discontinue

theraphy

and

to

lessen

Exercise



Discuss to the client importance or help client develop a program of exercise and relaxation techniques as tolerated.

Health Teaching



Moreover, a teaching plan that affect client’s holistic wellness should be done in order to maintain an environment that is 35

Out-patient



conducive for health promotion. Proper referral is best for the health care provider to evaluate

Order

condition of the client, whether it is improving or not. Also, for

Diet

early diagnosis of any other underlying conditions Proper execution of client’s diet is very important so informing



and instructing client or clients watcher about proper meals to be given to the client and increasing oral fluid intake is important. ( Dietary Salt: moderate intake, and high in cholesterol foods) 

Encouraged to increase fluid intake to at least 8-10glasses per day as tolerated to maintain hydration.



Advised to eat as fruits and green leafy vegetables.

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RECOMMENDATIONS As nurses, our vital role is to provide health care and deliver services in the hospital to improve the health status of each individual. This nursing care study is important for us because it in enables to give the proper health teaching to our chosen client. We recommended this case to the following persons and institution for the further improvement of the study. TO THE FAMILY: This study for the family of our patient to follow the treatment prescribed such as to take the medications as on time and right dosage and other recommended measures by the physicians, encourage having adequate rest to hasten the recovery of the patient. Through the adherence of fulfillment of the suitable medical management, for the fast recovery of the patient. TO THE STUDENT: We recommended this study for the students as a reference for the future cases, in order to have some based line datas to refer. TO THE COLLEGE OF NURSING We recommended this study to our department for giving us a precise details and an access of further study of this case. We advocate also for giving us an abundance time to research in order to prevent typographical and grammatical errors. TO THE DAVAOMEDICAL SCHOOL FOUNDATION HOSPITAL We recommended this study to Southern Philippines Medical Center for them to able to evaluate and appreciate the said case and share this as a reference and information having those patients who has certain condition.

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BIBLIOGRAPHY/REFERENCES 1. Blackwell’s Nursing Dictionary Second Edition (2011), Blackwell’s Publishing Ltd. 2. Fundamentals of Nursing Eight Edition, Kozier&Erb’s, Pearson, Prentice Hall 3. Nurses Pocket Guide, Diagnoses Prioritized Interventions, and rationales,MarilynnE.Doenges,Mary Frances Moorhoouse,Alice C. Murr, 13 th edition. 4. Lippincott’s Nursing Drug Handbook, Lippincott, 2014 5. Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. G. (2016). Brunner & Suddarth’s Canadian textbook of medical-surgical nursing (3rd Canadian ed.). Philadelphia: Lippincott Williams & Wilkins 6. gnatavicius, D. D., Workman, M. L., & Henderson, L. (2015). Medical-surgical nursing: Critical thinking for collaborative care (7th ed.). Toronto: Elsevier Saunders. (ISBN 978-1-4377-2801-9) 7. Jarvis, C. (2014). Physical examination & health assessment (2nd Canadian ed.). St. Louis, MO: Saunders. (ISBN 978-1-9266-4872-9)

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