COMPREHENSIVE HEALTH HISTORY

I. DEMOGRAPHIC PROFILE

Name of client: Estaco, Constancio Age: 72 yrs old
Birthdate: Aug. 31, 1937 Place of Birth: San Jose Dulag, Leyte
Nationality: Filipino Sex: Male
Marital Status: Widower Occupation: Former Fisherman
Religion: Roman Catholic Room #: 333
Address: San Jose, Dulag, Leyte Physician: Dr. Abril
Source of History: patient`s SigniIicant Other Date of Admission: Aug. 9, 2010
and the patient himselI.


II.CHIEF COMPLAINT

'Ginkuri-an hiya paghinga asya ginpa-admit namon, as verbalized by the signiIicant other.


III. HISTORY OF PRESENT ILLNESS

%wo days prior to admission, Saturday morning oI Aug. 7, 2010, the patient experienced
mild diIIiculty oI breathing. %he patient was nebulized to relieve DOB. A day prior to
admission, the patient still persistently complains oI diIIiculty breathing but the intervention oI
nebulization has not been administered and no medication was taken. As a result, he was not
able to sleep the night beIore the admission day. On Aug. 9, 2010, the patient was Iirst brought
to Eastern Visayas Regional Medical Center but due to lack oI Iacilities, they were reIerred to
Divine Word Hospital hence, admitted.

Upon arrival, initial vital signs were taken and recorded as Iollows, %-37.7 C, P-116
bpm, RR-25 cpm, and BP-130/80 mmHg. Series oI laboratory examinations were done, such as,
Chest X-ray, clinical chemistry results and hematology test. %he patient was diagnosed with
Laryngeal Mass that causes DOB and so the Iollowing day, the patient underwent tracheostomy.

%he patient is currently taking oral medications as Iollows LevoIloxacin, hydrocortisone,
and budexonide, Parenteral medications; D5Nmicx 12 mg, 0.9 NaCl, Kabiven, Emulsion, and
Plain NSS, Enhalant medication; Combivent.


IV. PAST MEDICAL HISTORY

In the year 2009, the patient suIIered Irom hoarseness. On July 2009, the patient went to
Philippine Government Hospital to sought consult. However, the S.O. was not able to give the
diagnosis. Months later, a mass on his laryngeal part started to develop. %he patient is asthmatic,
non-hypertensive and non-diabetic. He was inIlected with childhood illnesses such as mumps
and measles. %he patient could not recall iI he had completed his immunizations or not. %here
were no injuries and allergies noted. %he patient has been hospitalized twice but he was not able
to recall the cause oI his Iirst hospitalization. According to the SO the patient was Iirst
hospitalized due to a minor excision operation on his scapular area.






V.FAMILY HEALTH HISTORY

%he patient`s wiIe died due to a complication that was caused by amoebiasis. Patient`s
children were not suIIerers oI any heredoIamilial diseases such as hypertension, diabetes,
tuberculosis and the like. No history oI heart diseases were noted as well.


VI. PSYCHOSOCIAL HISTORY

Patient is currently living with his son and his son`s Iamily. He was Iormerly a smoker
and an occasional alcohol drinker. Usually, the patient wakes up at 4:30-5:00 AM, eats
breakIast at 7:30 AM, and takes a bath at around 8 o`clock. AIter taking a bath, patient would
usually spend time watching %V as his past time. %hen, he eats his lunch at 11:30 AM. %he
patient is not used to sleeping at noon time rather, he`s Iond oI conversing with his neighbors
instead. At 7:30 PM, he eats his dinner and he usually goes to bed at 9:00 PM. %he patient used
to be a Iisherman and serves as his Iorm oI exercise.









































PATHOPHYSIOLOGY
































Cigarette Smoking and alcohol drinking
(Risk Factors)
Llderly
(8lsk lacLor)
Synergistic Carcinogenic EIIects
New abnormal growth oI Laryngeal tissues
Laryngeal neoplasm
(Mass on the Neck)

Obstruction oI
Airway
DiIIiculty
Breathing
Invasion oI tumor in
muscle and cartilage
surrounding the
larynx
Persistent
Hoarseness
oI voice
Impaired
cough reIlex
Accumulation
oI phlegm
Risk Ior
Pneumonia
Dysphagia
REFERENCES:
1. http://www.Ipnotebook.com/EN%/Hemeonc/LrynglNplsm.htm
2. http://www.Ipnotebook.com/EN%/Mouth/Phryngts.htm
3. http://www.scribd.com/doc/20916100/Laryngeal-Carcinoma
4. Fundamentals oI Nursing 8
th
edition By Kozier and Erb Vol. 1 and 2
5. Medical Surgical Nursing 8
th
edition by Black and Hawks Vol. 2
6. Medical Surgical Nursing 11
th
edition by Brunner and Suddarth


























DISCHARGE PLAN
%he nurse has an important role in the recovery and rehabilitation oI the patient.
Tracheostomy care:
%each the patient and caregiver to perIorm suctioning and emergency measures and
tracheostomy and stoma care.
Stress importance oI humidiIication at home to avoid dryness in the stoma thereIore
preventing irritation.
Instruct patient to clean the skin around the stoma and to use ointments and tweezers to
remove encrustations.
Avoid cold air Irom air conditioning and the environment to prevent irritation oI the
airway.

Hygiene and Safety Measures
Caution the patient the need to prevent water Irom entering the stoma by covering the
stoma while taking a bath to prevent aspiration and edemas.
%each patient to wear a loose-Iitting plastic bib over the tracheostomy or simply hold a
hand over the opening would be eIIective.
%each the patient and caregiver the signs and symptoms oI inIection such as Iever and
identiIies indications that require contacting the physician.
%each the patient and Iamily to wash their hands beIore and aIter caring Ior the
tracheostomy, to use tissue to remove mucus, and to dispose oI soiled dressings and
equipment properly.
Encourage patient and to practice recreation and exercise Ior patient`s well-being and
quality oI liIe, however, strenuous exercise and Iatigue should be avoided because it
might lead to more diIIiculty oI speaking.
Encourage patient to perIorm oral care such as brushing the teeth and rinsing the mouth
several times a day to prevent inIection and to drink liberal amount oI water.



















CONCEPT MAP






























Cigarette Smoking and alcohol drinking
(Risk Factors)
Llderly
(8lsk lacLor)
Synergistic Carcinogenic EIIects
New abnormal growth oI Laryngeal tissues
Laryngeal neoplasm
(Mass on the Neck)

Obstruction oI
Airway
DiIIiculty
Breathing
Invasion oI tumor in
muscle and cartilage
surrounding the
larynx
Persistent
Hoarseness
oI voice
Impaired
cough reIlex
Accumulation
oI phlegm
Risk Ior
Pneumonia
Dysphagia