Foundation University

COLLEGE OF NURSING
Dumaguete City

(Google, 2019)

A CASE STUDY ON THE LEFT ANTERIOR NECK MASS

Submitted by: Jehannah Mae Z. Callao

Submitted to: Ms. Christine Janice L. Silot, RN
Date submitted: September
 Table of Contents

Mission & Vision ------------------------------------------------------------------------1

Objectives ---------------------------------------------------------------------------------2
Acknowledgement------------------------------------------------------------------------3
Introduction -------------------------------------------------------------------------------4
Review of Related Literature------------------------------------------------------------5
Anatomy & Physiology ------------------------------------------------------------------6
Nursing History & Management-------------------------------------------------------12
Developmental Task---------------------------------------------------------------------13
Comprehensive Health History & Physical Assessment----------------------------15
Gordon’s Functional Health Pattern --------------------------------------------------22
Diagnostic Lab Results -----------------------------------------------------------------45
Genogram --------------------------------------------------------------------------------47
Nursing Care Plan ----------------------------------------------------------------------48
Pathophysiology ------------------------------------------------------------------------51
Drug Study ------------------------------------------------------------------------------53
Nursing Theory -------------------------------------------------------------------------72
Annotated Reading ---------------------------------------------------------------------73
References -------------------------------------------------------------------------------78
 Foundation University
COLLEGE OF NURSING
Dumaguete City

Mission:
To enhance and promote a climate of excellence relevant to the challenges of the time, where individuals are committed to pursue new knowledge and life.
Vision:
Foundation University envisions itself as a dynamic, progressive environment that cultivates effective learning, generates creative ideas, response to societal needs
and offers equal opportunity for all.
Life Purpose:
To educate and develop individuals to become productive, creative, useful, and responsible citizens of the society.
Core Values:
 Excellence
 Commitment
 Integrity
 Service

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Central Objective

At the end of my case presentation, the learners shall augment their knowledge, expand beginning skills, manifest positive attitude, and obtain suitable values in

the care of the patient who has neck mass.

Specific Objectives

At the end of my case presentation, the learners will be able to:

 Define what is a neck mass

 Know the manifestations of neck mass

 Enumerate the different causes of neck mass

 Present the anatomy and physiology of the systems involved in relation to the condition of the patient

 Present the pathophysiology of the condition

 Know the possible health teachings to be done

 Formulate and apply nursing care plans utilizing the nursing process

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 ACKNOWLEDGEMENT

I would like to take this opportunity to express my profound gratitude and deep regards to the persons who have contributed and supported the fulfillment of my
case study.

To Mr. John Robert General, RN, Dean, College of Nursing, for allowing us to have this exposure and for the all-out support.

To Ms. Christina Janice L. Silot, RN, our clinical instructor, for the patience and time she extended in checking our paper works, for sharing suggestions and
constructive criticisms and for guiding us during the rotation, which meant so much for the completion of this study.

To my patient and to the SO, for being approachable, cooperative and for spending their time in answering all the questions being asked.

To my beloved family, for their unending emotional, moral, spiritual, and financial support.

And most of all, I would like to extend wholeheartedly the gratitude and praise to the author of knowledge and wisdom,

ever loving and merciful God for touching and bringing together those people who literally shared their abundant resources, talents, skills, time, and effort for the
completion of this study.

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 INTRODUCTION
A neck mass or a lump on the neck can be large and visible, or they can be very small. Most neck masses aren’t harmful. Most are benign or noncancerous.

But a neck mass can also be a sign of a serious problem. Neck mass is a relatively common head and neck problem in patients presenting to physicians. There

often are no associated symptoms other than the recognition of a new "lump" noted incidentally on palpation while grooming or noticed by another individual.

The mass may be the only manifestation of a serious and potentially malignant pathology, especially in the adult population. (Albany Medical Center) These

cases were distributed into 166 (66%) midline, 55 (22%) lateral, and 31 (12%) entire neck masses. (J Oral Maxillofac Surg. 2007).

The differential diagnosis is broad, and the workup can be challenging. Often the only history is a new “lump” that is found incidentally. Infectious or

inflammatory causes are the most common etiologies in children and young adults. The incidence of malignancy increases with age, particularly in patients over

the age of 40 years. The type of malignancy varies with age as well, with lymphomas being more prevalent in patients under the age of 40 and carcinomas being

more common in patients over age 40 years. The incidence of malignancy increases with age and with risk factors such as tobacco or alcohol use.

This is a case of a 41-year-old man currently residing at Tandayag, Amlan, Negros Oriental. A husband and a father of two girls. The patient presents for

evaluation of a painful lump on his left anterior neck. About 2 weeks ago before the admission, he noticed a 6 cm round swelling on his neck, and since it has

grown slightly in size. He had previous hospitalization due to persistent cough. He had a history of pneumonia and is diabetic at the same time.

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 REVIEW OF RELATED LITERATURE

First, about half of the 62,000 cases of head and neck cancer diagnosed in 2016 will present with a neck mass, suggesting that 30,000 patients will present with

a malignant neck mass (cancer.org) Head and neck squamous cell carcinoma has a worldwide annual incidence of 550,000 cases, representing five percent of all newly

diagnosed cancers. From 1988 to 2004, the U.S. population experienced a 225 percent increase in HPV positive oropharyngeal (tonsil and base of tongue) head and neck

squamous cell carcinoma. If current trends continue, the incidence of HPV-positive oropharyngeal (tonsil and base of tongue) head and neck squamous cell carcinoma

will surpass that of HPV positive cancer of the uterine cervix by 2020 and constitute 50% percent of all head and neck cancer by 2030. (American Academy of

Otolaryngology—Head and Neck Surgery, Chicago)

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 ANATOMY & PHYSIOLOGY
Integumentary System

The integumentary system consists of the skin, hair, nails, the subcutaneous tissue below the skin, and assorted glands.The most
obvious function of the integumentary system is the protection that the skin gives to underlying tissues. The skin not only keeps
most harmful substances out, but also prevents the loss of fluids.

A major function of the subcutaneous tissue is to connect the skin to underlying tissues such as muscles. Hair on the scalp provides
insulation from cold for the head. The hair of eyelashes and eyebrows helps keep dust and perspiration out of the eyes, and the hair
in our nostrils helps keep dust out of the nasal cavities. Nails protect the tips of fingers and toes from mechanical injury. Fingernails
give the fingers greater ability to pick up small objects.
lumenlearning2017
There are four types of glands in the integumentary system: sudoriferous (sweat) glands, sebaceous glands, ceruminous glands, and

mammary glands. These are all exocrine glands, secreting materials outside the cells and body. Sudoriferous glands are sweat producing glands. These are important to

help maintain body temperature. Sebaceous glands are oil producing glands which help inhibit bacteria, keep us waterproof and prevent our hair and skin from drying

out. Ceruminous glands produce earwax which keeps the outer surface of the eardrum pliable and prevents drying.

Epidermis
The outermost layer of the skin is composed of epithelial tissue and is known as the epidermis. It contains squamous cells or keratinocytes, which synthesize a tough
protein called keratin. Keratin is a major component of skin, hair, and nails. Keratinocytes on the surface of the epidermis are dead and are continually shed and replaced
by cells from beneath. This layer also contains specialized cells called Langerhans cells that signal the immune system of an infection by presenting antigenic information
to lymphocytes in lymphnodes. This aids in the development of antigen immunity.

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Dermis
The layer beneath the epidermis is the dermis. This is the thickest layer of skin composing almost 90 percent of its thickness. Fibroblasts are the main cell type found in
the dermis. These cells generate connective tissue as well as the extracellular matrix that exists between the epidermis and dermis. The dermis also contains
specialized cells that help regulate temperature, fight infection, store water, and supply blood and nutrients to the skin.

Hypodermis
The innermost layer of the skin is the hypodermis or subcutis. Composed of fat and loose connective tissue, this layer of the skin insulates the body and cushions and
protects internal organs and bones from injury. The hypodermis also connects skin to underlying tissues through collagen, elastin, and reticular fibers that extend from
the dermis.

A major component of the hypodermis is a type of specialized connective tissue called adipose tissue that stores excess energy as fat. Adipose tissue consists primarily
of cells called adipocytes that are capable of storing fat droplets. Adipocytes swell when fat is being stored and shrink when fat is being used. The storage of fat helps to
insulate the body and the burning of fat helps to generate heat. Areas of the body in which the hypodermis is most thick include the buttocks, palms, and soles of the feet.

Digestive System
The function of the digestive system is to break down the foods you eat, release their nutrients, and absorb those nutrients into the body. Although the small intestine is
the workhorse of the system, where the majority of digestion occurs, and where most of the released nutrients are absorbed into the blood or lymph, each of the digestive
system organs makes a vital contribution to this process.
As is the case with all body systems, the digestive system does not work in isolation; it functions cooperatively with the other systems of the body. Consider for example, the
interrelationship between the digestive and cardiovascular systems. Arteries supply the digestive organs with oxygen and processed nutrients, and veins drain the digestive tract. These
intestinal veins, constituting the hepatic portal system, are unique; they do not return blood directly to the heart. Rather, this blood is diverted to the liver where its nutrients are off-
loaded for processing before blood completes its circuit back to the heart. At the same time, the digestive system provides nutrients to the heart muscle and vascular tissue to support
their functioning. The interrelationship of the digestive and endocrine systems is also critical. Hormones secreted by several endocrine glands, as well as endocrine cells of the pancreas,
the stomach, and the small intestine, contribute to the control of digestion and nutrient metabolism. In turn, the digestive system provides the nutrients to fuel endocrine function.

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Respiratory Sytem
Functionally, the respiratory system can be divided into a conducting zone and a respiratory zone. The conducting zone of the respiratory system includes the organs
and structures not directly involved in gas exchange. The gas exchange occurs in the respiratory zone.

Musculoskeletal System

Bone, or osseous tissue, is a hard, dense connective tissue that forms most of the adult skeleton, the support structure of the body. In the areas of the skeleton where
bones move (for example, the ribcage and joints), cartilage, a semi-rigid form of connective tissue, provides flexibility and smooth surfaces for movement. The skeletal
system is the body system composed of bones and cartilage and performs the following critical functions for the human body:

 supports the body

 facilitates movement
 protects internal organs
 produces blood cells
 stores and releases minerals and fat

Support, Movement, and Protection

The most apparent functions of the skeletal system are the gross functions—those visible by observation. Simply by looking at a person, you can see how the bones
support, facilitate movement, and protect the human body.

Just as the steel beams of a building provide a scaffold to support its weight, the bones and cartilage of your skeletal system compose the scaffold that supports the rest
of your body. Without the skeletal system, you would be a limp mass of organs, muscle, and skin.

Bones also facilitate movement by serving as points of attachment for your muscles. While some bones only serve as a support for the muscles, others also transmit the
forces produced when your muscles contract. From a mechanical point of view, bones act as levers and joints serve as fulcrums. Unless a muscle spans a joint and
contracts, a bone is not going to move. For information on the interaction of the skeletal and muscular systems, that is, the musculoskeletal system, seek additional
content. The kidneys are two bean-shaped organs in the renal system. They help the body pass waste as urine. They also help filter blood before sending it back to the
heart.

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Kidney

The kidneys perform many crucial functions, including:

 maintaining overall fluid balance

 regulating and filtering minerals from blood
 filtering waste materials from food, medications, and toxic substances
 creating hormones that help produce red blood cells, promote bone health, and regulate blood pressure

Nephrons

Nephrons are the most important part of each kidney. They take in blood, metabolize nutrients, and help pass out waste products from filtered blood. Each kidney has
about 1 million nephrons. Each has its own internal set of structures.

Renal corpuscle

After blood enters a nephron, it goes into the renal corpuscle, also called a Malpighian body. The renal corpuscle contains two additional structures:

 The glomerulus. This is a cluster of capillaries that absorb protein from blood traveling through the renal corpuscle.
 The Bowman capsule. The remaining fluid, called capsular urine, passes through the Bowman capsule into the renal tubules.

Renal tubules

The renal tubules are a series of tubes that begin after the Bowman capsule and end at collecting ducts. Each tubule has several parts:

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  Proximal convoluted tubule. This section absorbs water, sodium, and glucose back into the blood.
 Loop of Henle. This section further absorbs potassium, chloride, and sodium into the blood.
 Distal convoluted tubule. This section absorbs more sodium into the blood and takes in potassium and acid.

By the time fluid reaches the end of the tubule, it’s diluted and filled with urea. Urea is byproduct of protein metabolism that’s released in urine.

Renal cortex

The renal cortex is the outer part of the kidney. It contains the glomerulus and convoluted tubules.

The renal cortex is surrounded on its outer edges by the renal capsule, a layer of fatty tissue. Together, the renal cortex and capsule house and protect the inner
structures of the kidney.

Renal medulla

The renal medulla is the smooth, inner tissue of the kidney. It contains the loop of Henle as well as renal pyramids.

Renal pyramids

Renal pyramids are small structures that contain strings of nephrons and tubules. These tubules transport fluid into the kidney. This fluid then moves away from the
nephrons toward the inner structures that collect and transport urine out of the kidney.

Collecting ducts

There’s a collecting duct at the end of each nephron in the renal medulla. This is where filtered fluids exit the nephrons.

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Once in the collecting duct, the fluid moves on to its final stops in the renal pelvis.

Renal pelvis

The renal pelvis is a funnel-shaped space in the innermost part of the kidney. It functions as a pathway for fluid on its way to the bladder

Calyces

The first part of the renal pelvis contains the calyces. These are small cup-shaped spaces that collect fluid before it moves into the bladder. This is also where extra fluid
and waste become urine.

Hilum

The hilum is a small opening located on the inner edge of the kidney, where it curves inward to create its distinct beanlike shape. The renal pelvis passes through it, as
well as the:

 Renal artery. This brings oxygenated blood from the heart to the kidney for filtration.
 Renal vein. This carries filtered blood from the kidneys back to the heart.

Ureter

The ureter is a tube of muscle that pushes urine into the bladder, where it collects and exits the body.

Nursing History & Nursing Management

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DEMOGRAPHIC PROFILE

NAME: P.Q.G.
AGE: 41
DATE OF BIRTH:
SEX: Male
CIVIL STATUS: Married
NATIONALITY: Filipino
RELIGION: Roman Catholic
DATE OF ADMISSION: August 26, 2019
ATTENDING PHYSICIAN: Dr. B.J.A.

DEVELOPMENTAL TASK

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Generativity versus stagnation is the seventh of eight stages of Erik Erikson’s theory of psychosocial development. This stage takes place during middle adulthood
between the ages of approximately 40 and 65. During this time, adults strive to create or nurture things that will outlast them; often by parenting children or contributing
to positive changes that benefit other people. Contributing to society and doing things to benefit future generations are important needs at the generativity versus stagnation
stage of development.

Generativity refers to "making your mark" on the world by caring for others as well as creating and accomplishing things that make the world a better place.
Stagnation refers to the failure to find a way to contribute. These individuals may feel disconnected or uninvolved with their community and with society as a whole.

Those who are successful during this phase will feel that they are contributing to the world by being active in their home and

community. Those who fail to attain this skill will feel unproductive and uninvolved in the world. (Cherry, 2018 )

Correlation: Patient P.Q.G. is a 41 years old tocino vendor. A husband and a father of two and are currently living at Tandayag, Amlan, Negros Oriental. Being
hospitalized is a problem to him because he can’t do the things that help him and his wife earn for a living. In correlation with Erik Erikson's Stages of Psychosocial
Development (Generativity vs. Stagnation), the key characteristics of generativity include making commitments to other people, developing relationships with family,
mentoring others and contributing to the next generation. And as we all know, these sorts of things are frequently realized through having and raising children and earn a
living for the family.

CHIEF COMPLAINT: Left Anterior Neck Mass

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HISTORY OF PRESENT ILLNESS: 2 weeks before admission, the patient noticed a 6 cm round swelling on his left anterior neck. The lump was mobile and slightly
tender when palpated.

GENERAL IMPRESSION: Received the patient lying on bed number 2 at the North East Surgery room, conscious, oriented to time, day & year. A gauge 20 cannula
is attached at the left metacarpal vein with ongoing PNSS 1L at 44 gtts/min. The patient was slightly yellowish and edematous.

PAST MEDICAL HISTORY: The patient has a Diabetes Mellitus and was taking Metformin as prescribed by the physician.

PAST HEALTH HISTORY: The patient was hospitalized due to Pneumonia way back 1998. He was again hospitalized recently at Holy Child Hospital due to persistent
cough. He has no known food/drug allergies.

FAMILY HISTORY: The patient has a history of Diabetes Mellitus.

PSYCHOSOCIAL HISTORY: Patient is friendly and cooperative. He has a good relationship with his wife and family.

ENVIRONMENTAL HISTORY: Patient is living with his wife and two daughters at Tandayag, Amlan, Negros Oriental.

SPIRITUAL HEALTH: Patient’s religion is a Roman Catholic. According to the patient they seldom go to church.

COMPREHENSIVE HEALTH HISTORY AND PHYSICAL ASSESSMENT

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General Survey:

 State of Awareness: verbally responsive, coherent, alert and well-oriented.

 Obvious Signs of Distress: complaints of pain in the surgical wound on his left anterior neck.

 Gait: ambulatory

 Posture: non guarding position

 Body Movements: coordinated movements.

 Hygiene: poor hygiene noted, slightly soiled fingernails

 Speech: coherent

Vital measurements:

Temparature: 36.5 celcius/ axilla

Pulse rate: 98

Respiratory rate: 30

BP: 110/70 mmHg

INTEGUMENTARY SYSTEM

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Health History

Multiple scars and brown pigmented discoloration noted on the lower extremities. Dry skin noted on both arms and legs.

SKIN

Inspection
 The skin is jaundice, dry and generally warm.
 Multiple scars and brown pigmented discoloration noted on the lower extremities
 Dry skin noted.

Palpation

 The whole body is warm.

 Skin with normal turgor
 The IV insertion site was cold to touch. No tenderness when palpated
 Edema noted in his lower extremities

Nails

Inspection

 Fingernail plate has a convex curvatures

 Has a brown pigmentation
 Intact epidermis on the surrounding nails noted.
 Fingernails and toe nails were cut but slightly soiled.
 Capillary refill: < 3 sec

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 Palpation

 Fingernails and toenails have a smooth texture.

 Capillary refill is less than 3 seconds (2 seconds).
 No tenderness when palpated.

Hair

Inspection

 Hair is long, black and evenly distributed.

Palpation

 No tenderness of the scalp noted upon palpation.

Head

 There were no presence of lesions, deformities and lumps.

 Rounded normocephalic and symmetrical, smooth skull contour, still and upright, erect with no tremors.
 Absence of nodules or masses.

Face

 Contour: Oval shape, slightly yellow in color and has the same color with the rest of the body
 Symmetry: Symmetrical
 No edema noted.
 Absence of masses and pustules; no lesions noted.

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Eyebrows

 Quantity: Equally distributed and curled slightly outward.

 No crusting or infestation.

Eyes

 Eyes clear and bright, in parallel alignment

 Skin intact with no discharges and no discoloration.
 No lesions.
 Sclera; appears white.
 Eyelids; Lids close symmetrically and blinks involuntary.
 Eyeball; No protrusion beyond frontal bone.
 Lacrimal gland, Lacrimal sac, Nasolacrimal duct; No swelling. Redness or drainage.
 Bulbar conjunctiva; Transparent with capillaries slightly visible.

Ears

Inspection

 Normal shape and presence of landmarks; Helix, antihelix, antitragus, tragus and lobule.
 Drainage: cerumen is present.
 Absence of pits, creases or lesions.

Palpation

 Texture of the skin is smooth.

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Nose

Inspection

 External structure of the nose was symmetrical, smooth, same color of the face with no deformity.
 Nasal mucosa, the color was pink and moist without lesions, there were no swelling, exudates and bleeding noted.

Palpation

 Mucosa is pink, no lesions and nasal septum intact and in middle with no tenderness.

Mouth

 Lips; Dry lips noted.

 Teeth; dental carries noted
 Tongue; Central position, pink but with whitish coating which is normal, with veins prominent in the floor of the mouth.

Neck

 Positioned at the midline. Tenderness around the surgical wound.

 Unable to flex due to surgical wound
 Redness of skin around the surgical wound noted

ABDOMEN

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Health history

Defecates preferably in the morning. No difficulties and discomforts upon defecating as claimed.

Inspection

 The skin was slightly yellow with no scars noted.

 Abdomen is slightly bloated and round.
Light Palpation
 No tenderness as claimed
 Abdomen feels soft
 No muscle guarding
 No mass noted
Auscultation
 Bowel sounds present

RESPIRATORY

Health History: Did not feel any chest pain. Experiencing shortness of breath. Oxygen therapy already removed.

Inspection:
 Chest movement is symmetrical
 Respiratory rate is 30 cpm
 Use of accessory muscles

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Palpation:
 No tenderness upon palpation as claimed by the patient
 No lumps and lesions noted

Auscultation
 Bronchovesicular sound
 No adventitious sounds noted

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 Gordon’s Functional Health Pattern
Source of Information: P.Q.G.

USUAL INITAL INITIAL INITIAL

September 02, 2019 September 03, 2019 September 04, 2019
I. Health Perception- Health  The patient still
Management Pattern VITAL SIGNS:  Feeling better than needs some
Temperature: 36.8 usual assistance
Pulse Rate: 98 - 130  Uncomfortable  The patient was able
 Feels good about Respiratory rate: 26 - 40 because of the to take all his due
himself Blood pressure: 110/70 dressing on his neck meds
 Does drink alcoholic  Admitted last Sept.  Takes all the due  The patient is
drinks occasionally 26, 2019 because of medications edematous
 He was hospitalized at a painful mass in his  The patient is pallor
Holy Child Hospital for left anterior neck
4 days due to persistent  Feels good now that
cough the pain subsided
 Does not perform self-  Feels conscious
examination about the changes
 He has no known food due to his post-
allergies operative wound
Takes all the prescribed medications

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  A coin-sized lump was “okay na sya karon maam, dili na kaayo
noted last Aug. 10, 2019 sakit kompara sauna”…as verbalized
 The patient rated his pain by the patient
as 10 on a scale of 0-10


II. Nutritional- Metabolic Pattern

 Breakfast: He usually  Was given beef,  Still on Full  The patient is still
eats 1 cup rice, 1 fried banana, cup of rice Diabetic Diet on Full Diabetic
fish, 1 fried egg, 1 and egg for his  Eats 2 white eggs Diet
bowl vegetable soup meal per meal  He was given 2
anda glass of milk.  Weighs 75 kg whit eggs per meal
 Lunch:1 bowl vegetable  Fluid intake is  Water intake:
soup, 1 cup rice, 1 fried approximately 1000 1000ml
fish, 1 small banana. ml  Aminoleban
 Snacks: 1 glass milk, I intake: 500ml
piece cooked banana.  He has difficulty in
 Dinner: 1 cup rice, 1 swallowing due to
bowl vegetable soup, 1 the surgical wound
dried fish. in his left anterior
neck

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  He usually drinks 6
glasses of water
everyday
 He did not experienced
sudden weight loss for
the past 6 months
 Appetite is good
 No known for any food
allergies
 Coffee and sweets are
restricted
 Allowed to eat 1 cup of
rice per meal only
 Wounds and skin
lesions take time to heal

 He doesn’t wear

dentures
 He was 65 kg.

III. Elimination Pattern

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  Did not experience  He wasn’t able to  The patient was able  Urine output:
elimination of bowl defecate since to defecate after 3 500ml
difficulty; moves bowel August 31, 2019 - days  The patient was
every day with soft, Saturday  He was able to void able to defecate and
formed and brown stool.  The stool is brown  Urine output: 900ml has no problem in
 Did not experience and soft @ 12nn it
urinary elimination  Urine output: 800ml  Blood-tinged in the
difficulty, urinates at @ 9:30 am, patient’s urine was
least 1 liter a day with yellowish noted
yellow color urine

 Normally perspires when

doing strenuous
activities like household
chores.
IV. Activity-Exercise Pattern
 Rates energy level at 8 (0  Rates energy level at  He is able to sit in  The patient has no
being the lowest and 10 4 (0 being the lowest bed with the help of exercise pattern
is the highest) and 10 is the his SO  The patient cant go
 Helping his wife in doing highest)  Able to walk within far from his bed
the household chores in the bed area
the morning and sells Feeding: 0 Grooming: 2

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 tocino in the afternoon as Bathing: 3 General mobility:
his way exercise. 2
Toileting: 1
Feeding: 0 Grooming: 0 Bed mobility: 2
Bathing: 0 General mobility: Dressing: 2
0
Toileting: 0 Cooking: 0 Functional Level Codes:
Bed mobility: 0  Level 0 – full self-care
Dressing: 0
 Level I- requires use of
equipment or device
Functional Level Codes:
 Level II- requires assistance or
 Level 0 – full self-care supervision from another person
 Level I- requires use of equipment  Level III- requires assistance or
or device supervision from another person
 Level II- requires assistance or and equipment or device
supervision from another person  Level IV- is dependent and does
 Level III- requires assistance or not participate
supervision from another person and
equipment or device  Still needs
 Level IV- is dependent and does not assistance when
participate lifting his body

26
  Leisure: watching T.V. &
selling tocino
V. Sleep-Rest Pattern
 Wakes up at 5:00 a.am.  “dili magpaareho  He was able to sleep  The pateint’s
and goes to bed at8:00 or  No difficulty in sleeping pattern is
ang tulog ky usahay
9:00 in the evening sleeping not good but still
naay nurse muduol
 Eats lunch usually at able to sleep
maong makamata ko
12:00 noon or earlier
” as verbalized by
than usual.
 Did not experience any the patient.
sleep problem.  Has difficulty in
 Feels rested upon sleeping due to the
waking up pain in his neck

 Does not use any

sleeping aids

VI. Cognitive and Perception

Pattern  Very responsive  The patient is
 Visual: doesn’t wear  The patient is responsive &
glasses. responsive & cooperative

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  Auditory: auditory is participates during  The vision is getting  The pateint is not
exceptionally clear the assessment normal than wearing any
 Olfactory: sense of smell  The patient is previous eyeglasses and
is excellent. experiencing  The patient is now hearing aid
 Tactile: touch is blurredness able to read clearly
sensitive.  It took him a while  “dili na lubog akong
 Gustatory: can clearly before he could read panan-aw” as
tastes salty, sour, bitter, a phrase verbalized by the
sweet and spicy. patient
 No memory gap
 Pain is felt in his neck
mass
VII. Self-Perception Self Concept
Pattern  He is experiencing  The patient states  During assessment,
changes in himself that he is feeling the patient states that
 He is satisfied and  The patient is feeling better than the he is getting better
happy. better by the time he previous days
 He felt changes as was given some 
lump on his neck gets antibiotics &
bigger medicines to ease
 He knows how to handle the pain
emotions.

28
VIII. Role Relationship Pattern
 Currently living with his  The patient is  The patient is still  The patient was
wife and 2 daughters in responsive responsive responsive
Tandayag, Amlan.  He speaks clearly  He still able to  The patient speaks
 Close relationship with and relevant to the answer questions Bisaya
family and friends question being asked being asked.
 They communicate with  He cant help his wife
her siblings through anymore since he is
calling. in the hospital
 She also socializes with
neighbors and friends.
 Her live in partner is
working as maintenance
in the farm and he is
responsible for the
financial needs.

IX. Sexuality-Sexual Pattern

29
  Verbalized that he is  Their sexual  He doesnt have the  Their sexual life is
sexually active with his relationship is poor drive to do sexual poor due to his
wife since he is not in a intercourse because condition
 No sexual problems good condition yet of his current  The patient and his
 The relationship between condition wife is not into
him and his wife is good birth controls

X. Coping-Stress Tolerance
Pattern  The patient has a  The patient usually  He decided with his
 His stressors are good coping talks to his daughters wife
financial problem mechanism in the phone for they  He listens to music
 His coping mechanism  “maminaw kog are his source of when is stress
toward stress is by music para ma divert strength
making himself busy akong gi hunahuna
 He usually talked and ug sakit nga nabati”
shares his problems with as verbalized by the
his wife. patient

30
  He does drink alcoholic
drinks occasionally but
he stopped smoking 7
months ago because he
made a promise to quit
smoking when his wife
give birth to their
youngest
XI. Value-Belief Pattern
 He is happy and  “Kabalo kung  The patient prays all  God is his source of
contented with his life the time strength
makalingkawas rami
 He does not go to church  The patient does
ani sa tabang sa
often but does believe pray to God daily
Ginoo maayo rako”
God exist..
 Believes that healing as verbalized by the
comes with prayer. patient.

 The patient is a Roman  “Di ta pasagdan sa

Catholic
Ginoo” as verbalized
 Does not have any
religious conflicts. by the patient.
 The patient believes
that God has a

31
 purpose on
everything

USUAL INITAL INITIAL

September 05, 2019 September 06, 2019

32
I. Health Perception- Health
Management Pattern  Patient’s  The patient is
temperature elevated feeling better than
 He was able to take yesterday
 Feels good about all the due meds  Still feeling
himself  Assistance is still uncomfortable
 Does drink alcoholic needed by the because of the
drinks occasionally patient dressing on his neck
 He was hospitalized at  Still responsive  He was able to take
Holy Child Hospital for during the all the due
4 days due to persistent assessment medications
cough  The patient is
 Does not perform self- edematous
examination
 He has no known food
allergies
 A coin-sized lump was
noted last Aug. 10, 2019
 The patient rated his pain
as 10 on a scale of 0-10

33
II. Nutritional- Metabolic Pattern

 Breakfast: He usually  The patient is still on  Still on Full

eats 1 cup rice, 1 fried Full Diabetic Diet Diabetic Diet
fish, 1 fried egg, 1  He eats 2 white eggs  Eats 2 white eggs
bowl vegetable soup per meal per meal
anda glass of milk.  Meat and vegetables  Meat and
 Lunch:1 bowl vegetable with rice was given vegetables were
soup, 1 cup rice, 1 fried for lunch given again for
fish, 1 small banana.  Water intake: 1000 lunch
 Snacks: 1 glass milk, I ml
piece cooked banana.  Aminoleban intake:
 Dinner: 1 cup rice, 1 500 ml
bowl vegetable soup, 1
dried fish.
 He usually drinks 6
glasses of water
everyday

34
  He did not experienced
sudden weight loss for
the past 6 months
 Appetite is good
 No known for any food
allergies
 Coffee and sweets are
restricted
 Allowed to eat 1 cup of
rice per meal only
 Wounds and skin
lesions take time to heal

 He doesn’t wear

dentures
 He was 65 kg.

III. Elimination Pattern

 Did not experience  Urine output: 500 ml  The patient was able
elimination of bowl  The color of his to defecate
difficulty; moves bowel urine is yellow  He was able to void

35
 every day with soft,  He was able to  Urine output: 500ml
formed and brown stool. defecate twice @
 Did not experience during am shift
urinary elimination
difficulty, urinates at
least 1 liter a day with
yellow color urine

 Normally perspires when

doing strenuous
activities like household
chores.
IV. Activity-Exercise Pattern
 Rates energy level at 8 (0  Patient’s movement  He is able to sit in
being the lowest and 10 is still limited bed with the help of
is the highest) his SO
 Helping his wife in doing  Able to walk within
the household chores in the bed area only
the morning and sells
tocino in the afternoon as
his way exercise.

36
Feeding: 0 Grooming: 0
Bathing: 0 General mobility:
0
Toileting: 0 Cooking: 0
Bed mobility: 0
Dressing: 0

Functional Level Codes:

 Level 0 – full self-care

 Level I- requires use of equipment

or device
 Level II- requires assistance or
supervision from another person
 Level III- requires assistance or
supervision from another person and
equipment or device
 Level IV- is dependent and does not
participate

 Leisure: watching T.V. &

selling tocino

37
V. Sleep-Rest Pattern
 Wakes up at 5:00 a.am.  The patient was able  He was able to sleep
and goes to bed at8:00 or to sleep  No difficulty in
9:00 in the evening  He was able to rest sleeping
 Eats lunch usually at during wee hours
12:00 noon or earlier
than usual.
 Did not experience any
sleep problem.
 Feels rested upon
waking up
 Does not use any
sleeping aids

VI. Cognitive and Perception Pattern

 Visual: doesn’t wear
glasses.  The patient is  Very responsive
 Auditory: auditory is responsive and  He is able to clearly
exceptionally clear cooperative
 Olfactory: sense of smell  The patient is not
is excellent. wearing any

38
  Tactile: touch is eyeglasses and
sensitive. hearing aid
 Gustatory: can clearly
tastes salty, sour, bitter,
sweet and spicy.
 No memory gap
 Pain is felt in his neck
mass
VII. Self-Perception Self Concept
Pattern  “okay naman akong  The patient states
paminaw” stated by that he is feeling
 He is satisfied and the patient better
happy.  He is concerned on
 He felt changes as the wound on his left
lump on his neck gets anterior neck
bigger  Being sick makes
 He knows how to handle him very
emotions. unproductive

VIII. Role Relationship Pattern

39
  Currently living with his  The patient is  The patient is still
wife and 2 daughters in responsive responsive
Tandayag, Amlan.  He speaks clearly  He still able to
 Close relationship with and relevant to the answer questions
family and friends question being asked being asked.
 They communicate with  He cant help his wife
her siblings through anymore since he is
calling. in the hospital
 She also socializes with
neighbors and friends.
 Her live in partner is
working as maintenance
in the farm and he is
responsible for the
financial needs.

IX. Sexuality-Sexual Pattern

 There was really a  They are not into
change their sex life birth controls

40
  Verbalized that he is  They are not into because they are still
sexually active with his birth controls palnning for another
wife baby
 No sexual problems
 The relationship between
him and his wife is good

X. Coping-Stress Tolerance Pattern

 His stressors are  The patient has a  The patient usually
financial problem good coping talks to his daughters
 His coping mechanism mechanism in the phone for they
toward stress is by  He listens to music are his source of
making himself busy strength
 He usually talked and
shares his problems with
his wife.
 He does drink alcoholic
drinks occasionally but
he stopped smoking 7
months ago because he
made a promise to quit

41
 smoking when his wife
give birth to their
youngest
XI. Value-Belief Pattern
 He is happy and  He believes that he is  The patient prays all
contented with his life going to be okay real the time
 He does not go to church soon
often but does believe
God exist..
 Believes that healing
comes with prayer.
 The patient is a Roman
Catholic
 Does not have any
religious conflicts.

DIAGNOSTIC LABORATORY RESULTS

42
 LYMPHOCYTE 5 1.0 - 5.1

EOSINOPHIL 0 0.0 - 0.5

MONOCYTE 7 0.0 - 0.8

BASOPHIL 0 0.0 - 0.2

PLATELET COUNT 161 150 - 400

RBC 5.40 4.40 - 6.00

MCV 77 80 - 100

MCH 27 27.0 - 33.0

MCHC 34.48 31.0 -36.0

CREATININE 61.88

URIC ACID 368.78

SODIUM 125.60 135 - 145

43
POTASSIUM 3.80 3.5 - 5.0

HDL .28

LDL .36

pH 6.6

GENOGRAM OF GABITO

44
 M.G. S.G. E.Q. A.Q
Sr. 91 89 88 89

LEGEND:

M.G. P.G. patient

Jr. 63 61

deceased
L.G. B.G.
39 38
Diabe
tic

P.Q. L.G.
G 41 30 fem
ale

male
MGG MRG
Nursing Care Plan for P.Q.G. 4 7mos

Cues & Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

45
SUBJECTIVE: Altered comfort: Pain Within my 6 hours Independent At the end of my 6 hours
related to presence of nursing care, the patient nursing care, the patient was
“Okay na siya (wound neck mass at left will be able to: 1. Monitor and  Monitor the condition able to:
anterior neck record vital signs of the patient
in his neck) karon. Di
strictly
na kaayo sakit
 Report pain is 2. Monitor skin  To identify any  Report pain is
kompara sa una…” as relieved or color & changes of the patient relieved or controlled
verbalized by the controlled temperature = MET
patient.  Follow 3. Perform  To determine any
prescribed assessment of pain management  Followed prescribed
pharmacological pain to needs and pharmacological
OBJECTIVE: regimen characteristic, effectiveness of it regimen = MET
 PR: 98  Regain strength location and
 B/P: 110/70 and normal gait severity (scale of  Regain strength and
 The patient has  Verbalize sense 0-10) gait = UNMET
limitations upon of control of 4. Note location of  This can influence
turning his head response to surgical the amount of pain  Verbalized sense of
acute situation procedure control of response
and positive 5. Assess for and positive outlook
outlook for the referred pain for the future = MET
future
Dependent
6. Administer pain  This helps to lessen
reliever as the pain
prescribed by the
physician

Nursing Care Plan for P.Q.G.

Cues & Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

46
SUBJECTIVE: Impaired physical Within my 6 hours Independent At the end of my 6 hours
mobility secondary to nursing care, the patient nursing care, the patient was
“Di ra kaayo ko nerve injury will be able to: 1. Position the patient  To facilitate able to:
in a Fowler’s breathing and
mulingi ky basin
position promote comfort
matandog and tahi…”  Verbalize  Verbalized comfort
as verbalized by the comfort and 2. Monitor the patients  Monitor the condition and relief of pain =
patient. relief of pain vital signs of the patient and MET
obtain baseline data
 Attains maximal 3. Assess the patient  Attained maximal
OBJECTIVE: mobility in rising or in lying  To prevent stress on mobility = MET
 The patient has in bed the patient
limitations upon  Be able to move  Able to move safely
turning his head safely 4. Monitor any  This is to decrease = MET
 The patient needs potential the risk of
assistance in rising  Identify and use complications such complications  Identified and used
and lying in bed appropriate as bleeding appropriate support
support system system = MET

Dependent
7. Administer pain  This helps alleviate
reliever as the pain
prescribed by the
physician

Collaborative
8. Making sure that  To decrease the risk
the patient is of postoperative
eating the complications
appropriate diet

47
 CUES & NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
EVIDENCES DIAGNOSIS
INDEPENDENT:
SUBJECTIVE: Ineffective airway After my 6 hours of After my 6 hours of nursing
clearance related to nursing intervention the  Position the patient  To facilitate intervention the patient was
“gitagaan ko ug obstruction by mucus, patient will be able to: in a semi Fowler’s breathing and able to:
salbutamol ky bleeding or edema position when in promote
usahay mag apas  Maintain airway bed comfort  Maintained airway
kos akong ginhawa. patency patency = UNMET
”as verbalize by the
 Experience  Encourage deep  Experienced lessened
patient” lessened difficulty breathing exercises difficulty of
of breathing as  Promote chest breathing as
OBJECTIVES: manifested by  Monitored expansion manifested by
decreased in RR respiratory patterns decreased in RR from
 Shortness of from 26-40 cpm to including rate, 26-40 cpm to 20 cpm
breath 20 cpm with the depth, and effort  Assess the with the absence of
 Rapid shallow absence of nasal condition of nasal flaring, and
breathing flaring, and DEPENDENT the patient presence of calm
 RR: 26-40 cpm presence of calm  Administer breathing = UNMET
 Nasal flaring breathing. bronchodilators as
 Use of accessory prescribe by the  Demonstrated
muscles  Demonstrate physician  Induced behaviors to improve
behaviors to bronchoconstri airway patency =
improve airway ction MET
patency

48
 PATHOPHYSIOLOGY

Predisposing Precipitating

Age - 41 Pneumonia

Male Tobacco Use

Alcohol

Environmental Inhalants

Inflammatory or
infectious condition

Single course of broad-

spectrum antibiotic

Chest radiogram & PPD

tuberculin skin test

Negative PPD test result

Wide local incision

49
Deep space neck infection

Broad spectrum antibiotics

v
Cervical infection

Incision drainage and

debridement

50
 DRUG STUDY

Generic name: PANTOPRAZOLE

Brand name: PANTOLOC
Classifications: ANTISECRETORY DRUG; PROTON PUMP INHIBITOR

Therapeutic Effects: Gastric-acid pump inhibitor; supresses gastric secretion by specific inhilation of the hydrogen-potassium ATPase enzyme system at the secretory
surface of the gastric parietal cells; blocks the final step of acid production.

Indications: oral: short-term ( 8 wk or less) and long -term treatment of GERD. Maintenance healing of erosive esophagitis.
Unlabeled use: treatment of duodenal ulcer
Contraindications: contraindicated with hypersensitivity to any proton pump inhibitor or any drug components use cautiously with pregnancy, lactation

Adverse Effects:
 CNS: Headache, dizziness, tremors. CV: Palpitation, angina, tachycardia, flushing, paradoxical pressor response. Overdose: arrhythmia, shock.
 Dermatlogic: Rash, inflammation uritacaria, pruritus, alopecia, dry skin
 GI: diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophy
 Respiratory: URI symptom, cough, epistaxis.
 Other: Cancer in preclinical studies back pain, fever, vit. B12 deficiency

NURSING IMPLICATIONS

 Take the drugonce or twice a day. Swallow the tablets whole - do not chew, cut or crush them
 Arrange to have regular medical follow-up care while you are using this drug
 Maintain all of the usual activities and restrictions that apply to your condition. If this becomes difficult, consult your health care provider
 Report severe headache, worsening of symptoms, feve, chills, blurred vision, preorbital pain

51
Generic name: FUROSEMIDE
Brand name: Lasix
Classifications: Loop Diuretic

Actions: inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle, leading to a rch sodium diuretics

Indications: - edema associated with CHF, cirrhosis, renal disease

- acute pulmonary edema (IV)
- hypertension (oral)

Contraindications: contraindicated with allergy to furosemide, sulfonamides, allergy to tatrazine, electrolyte depletion; anuria, severe renal failure; hepatic coma. Use
caustiously with SLE, gout, diabetes mellitus

Adverse Effects:
 CNS: Dizziness, vertigo, paresthiasis, xanthopsia, weakness, headache, drowsiness
 CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias
 Dermatlogics: Photosensitivity, rash, pruritus
 Urogenital: Polyuria, nocturia, glycosuria
 GI: Nausea, Anorexia, vomiting, oral and gastric irritation
 Hematologic: Leukopenia, anemia
 Other: Muscle cramps and muscle spasms

NURSING IMPLICATIONS
 Record intermittent therapy on a calendar or dated envelope, when possible take the drug early so increased urination will not disturbed sleep.
 Take with food or with meals.
 Weigh yourself on a regular basis at he same time and in the same clothing and record the weight
 Report loss or gain of more than 3 lb in 1 day

52
Generic name: CIPROFLOXACIN
Brand name: Ciloxan, Cipro I.V. , Cipro XR
Classifications:Antibacterial
Fluroquinolone

Mechanism of actions: Bactericidal; interferes with DNA replication in susceptible bacteria preventing cell reproduction
Uses: For the treatment of infections caused by susceptible gram-negative bacteria, including Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter,
Proteus vulgaris, proteus rettgeri, morganella morgani, pseudomonas aeruginosa, Citrobacter freundii, staphylococcus aureus, staphylococcus epidermidis, group D
streptococci
 Treatment uncomplicated UTI’s caused by E. coli, K. Pneumoniae as a one-time dose in patients at low risk of nausea, diarrhea
 Otic; treatment of acute otitis externa
 Treatment of chronic bacterial prostatitis
 IV: Treatment of nosocomial pneumoniae caused by Haemophilles influenzae, K. pneumoniae
 Oral: typhoid fever, STD’s caused by Neisseria gonorrhea
 Prevention of anthrax following exposure to anthrax bacilla
 Acute sinusitis; caused by E.coli, Klebsiella, Enterobacterial species, P. mirabilis
 Unlabeled use: cystic fibrosis in patients who have pulmonary exacerbations, gastroentiritis in children myobacterial infection

Contraindications: contraindicated with allergy to ciprofloxacin, norfloxacin or other fuoraquinolones use cautiously with renal impairment, seizures, tendinitis or tendon
rupture associated with fluoroquinolone use.

Adverse Effects:
 CNS: Dizziness, insomnia, somnolence, depression, blurred vision, hallucinations, ataxia, nightmares
 CV: Orthostatic hypotension, angina, cardiac arrhythmias
 GI: Nausea, vomiting,dry mouth, diarrhea, abdominal pain
 Hematologic:elevated BUN, AST, ALT, serum creatinine and alkaline phosphatase; decreased WBC count neutrphil count, HCT
 GU: Renal failure
 Other: Fever rush

53
NURSING IMPLICATIONS

 History: Allergy tp ciprofloxacin, norflaxacin or other quinolones, renal impairment; seizures, lactation
 Physical: skin color, lesions; T; orientation, reflexes affect; mucuos membranes, bowel sounds, LFTs renal function tests
 If an antacid is needed take it

54
Generic name: ACETAMINOPHEN, PARACETAMOL
(a-seat-a-mee'noe-fen)
Classifications: CENTRAL NERVOUS SYSTEM AGENT; NONNARCOTIC ANALGESIC, ANTIPYRETIC
Availability

80 mg, 120 mg, 125 mg, 300 mg, 325 mg, 650 mg suppositories; 80 mg, 160 mg, 325 mg, 500 mg tablets; 80 mg/0.8 mL, 80 mg/2.5 mL, 80 mg/5 mL, 120 mg/5 mL,
160 mg/5 mL, 500 mg/5 mL liquid

Actions

Produces analgesia by unknown mechanism, perhaps by action on peripheral nervous system. Reduces fever by direct action on hypothalamus heat-regulating center
with consequent peripheral vasodilation, sweating, and dissipation of heat. Unlike aspirin, acetaminophen has little effect on platelet aggregation, does not affect
bleeding time, and generally produces no gastric bleeding.

Therapeutic Effects

It provides temporary analgesia for mild to moderate pain. In addition, acetaminophen lowers body temperature in individuals with a fever.

Uses

Fever reduction. Temporary relief of mild to moderate pain. Generally as substitute for aspirin when the latter is not tolerated or is contraindicated.

Contraindications

Hypersensitivity to acetaminophen or phenacetin; use with alcohol.

Cautious Use

55
Children <3 y unless directed by a physician; repeated administration to patients with anemia or hepatic disease; arthritic or rheumatoid conditions affecting children
<12 y; alcoholism; malnutrition; thrombocytopenia. Safety during pregnancy (category B) or lactation is not established.

Route & Dosage

Mild to Moderate Pain, Fever

Adult: PO 325–650 mg q4–6h (max: 4 g/d) PR 650 mg q4–6h (max: 4 g/d)
Child: PO 10–15 mg/kg q4–6h PR 2–5 y, 120 mg q4–6h (max: 720 mg/d); 6–12 y, 325 mg q4–6h (max: 2.6 g/d)
Neonate: PO 10–15 mg/kg q6–8h

Administration
Oral

 Administer tablets or caplets whole or crushed and give with fluid of patient's choice.
 Chewable tablets should be thoroughly chewed and wetted before they are swallowed.
 Do not coadminister with a high carbohydrate meal; absorption rate may be significantly retarded.
 Store in light-resistant containers at room temperature, preferably between 15°–30° C (59°–86° F).

Rectal

 Insert suppositories beyond the rectal sphincter.

Adverse Effects ( 1%)

Body as a Whole: Negligible with recommended dosage; rash. Acute poisoning: Anorexia, nausea, vomiting, dizziness, lethargy, diaphoresis, chills, epigastric or
abdominal pain, diarrhea; onset of hepatotoxicity—elevation of serum transaminases (ALT, AST) and bilirubin; hypoglycemia, hepatic coma, acute renal failure (rare).
Chronic ingestion: Neutropenia, pancytopenia, leukopenia, thrombocytopenic purpura, hepatotoxicity in alcoholics, renal damage.

56
Diagnostic Test Interference

False increases in urinary 5-HIAA (5-hydroxyindoleacetic acid) by-product of serotonin; false decreases in blood glucose (by glucose oxidase–peroxidase procedure);
false increases in urinary glucose (with certain instruments in glucose analyses); and false increases in serum uric acid (with phosphotungstate method). High doses
or long-term therapy: hepatic, renal, and hematopoietic function (periodically).

Interactions
Drug: Cholestyramine may decrease acetaminophen absorption. With chronic coadministration, BARBITURATES, carbamazepine, phenytoin, and rifampin may
increase potential for chronic hepatotoxicity. Chronic, excessive ingestion of alcohol will increase risk of hepatotoxicity.
Pharmacokinetics
Absorption: Rapid and almost complete absorption from GI tract; less complete absorption from rectal suppository. Peak: 0.5–2 h. Duration: 3–4 h. Distribution:
Well distributed in all body fluids; crosses placenta. Metabolism: Extensively metabolized in liver. Elimination: 90–100% of drug excreted as metabolites in urine;
excreted in breast milk. Half-Life: 1–3 h.

Nursing Implications

Assessment & Drug Effects

 Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have ingested alcohol over
prolonged periods; poisoning, usually from accidental ingestion or suicide attempts; potential abuse from psychological dependence (withdrawal has been
associated with restless and excited responses).

Patient & Family Education

 Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage
and other toxic effects.
 Do not self-medicate adults for pain more than 10 d (5 d in children) without consulting a physician.
 Do not use this medication without medical direction for: fever persisting longer than 3 d, fever over 39.5° C (103° F), or recurrent fever.
 Do not give children more than 5 doses in 24 h unless prescribed by physician.
 Do not breast feed while taking this drug without consulting physician

57
Generic name: AMPICILLIN SODIUM AND SULBACTAM SODIUM
(am-pi-sill'in/sul-bak'tam)
Classifications: ANTIINFECTIVE; ANTIBIOTIC; AMINOPENICILLIN
Prototype: Ampicillin

Availability

1.5 gm, 3 gm vials

Actions

Antibiotic agent with activity resulting from beta-lactamase inhibition. Sulbactam inhibits beta-lactamases most frequently responsible for transferred drug resistance.
Because of this action, a wide range of beta-lactamases found in organisms resistant to penicillins and cephalosporins have their growth inhibited.

Therapeutic Effects

Effective against both gram-positive and gram-negative bacteria including those that produce beta-lactamase and nonbeta-lactamase producers. Ampicillin without
sulbactam is not effective against beta-lactamase producing strains.

Uses

Treatment of infections due to susceptible organisms in skin and skin structures, intraabdominal infections, and gynecologic infections.

Contraindications

Hypersensitivity to penicillins; mononucleosis.

58
Cautious Use

Hypersensitivity to cephalosporins; pregnancy (category B) or lactation.

Route & Dosage

Systemic Infections
Adult/Child: IV/IM 40 kg, 1.5 (1 g ampicillin, 0.5 g sulbactam) to 3 g (2 g ampicillin, 1 g sulbactam) q6h (max: 4 g sulbactam/d)
Child: IV 1 y, 300 mg/kg/d (200 mg/kg ampicillin and 100 mg/kg sulbactam) divided q6h

Administration
Intramuscular

 Reconstitute solution with sterile water for injection by adding 6.4 mL diluent to a 3 g vial. Each mL contains 250 mg ampicillin and 125 mg sulbactam.
 Give deep IM into a large muscle. Rotate injection sites.

Intravenous

PREPARE: Direct/Intermittent: Reconstitute each 1.5 g with 3.2 mL of sterile water for injection to yield 375 mg/mL (250 mg ampicillin/125 mg sulbactam); further
dilute with NS, D5W, D5/NS, D5W/0.45NS, or RL to a final concentration within the range of 3–45 mg/mL.

ADMINISTER: Direct/Intermittent : Give slowly over at least 15 min. • With solutions of 100 mL or more, set rate according to amount of solution but no faster than
direct IV rate. • Convulsions may be induced by too rapid administration. • Use only freshly prepared solution; administer within 1 h after preparation.

INCOMPATIBILITIES Solution/additive: Do not add to a dextrose-containing solution unless entire dose is given within 1 h of preparation. Y-site: Amiodarone.

59
  Store powder for injection at 15°–30° C (59°–86° F) before reconstitution. Storage times and temperatures vary for different concentrations of reconstituted
solutions; consult manufacturer's directions.

Adverse Effects ( 1%)

Body as a Whole: Hypersensitivity (rash, itching, anaphylactoid reaction), fatigue, malaise, headache, chills, edema. GI: Diarrhea, nausea, vomiting, abdominal
distention, candidiasis. Hematologic: Neutropenia, thrombocytopenia. Urogenital: Dysuria. CNS: Seizures. Other: Local pain at injection site; thrombophlebitis.

Interactions
Drug: Allopurinol increases incidence of rash; effectiveness of the AMINOGLYCOSIDES may be impaired in patients with severe end stage renal disease;
chloramphenicol, erythromycin, tetracycline may reduce bactericidal effects of ampicillin—this interaction is primarily significant when low doses are used;
ampicillin may interfere with the contraceptive action of ORAL CONTRACEPTIVES—female patients should be advised to consider nonhormonal contraception
while on antibiotics.

Pharmacokinetics
Peak: Immediate after IV. Duration: 6–8 h. Distribution: Most body tissues; high CNS concentrations only with inflamed meninges; crosses placenta; appears in
breast milk. Metabolism: Minimal hepatic metabolism. Elimination: Excreted in urine. Half-Life: 1 h.

Nursing Implications

Assessment & Drug Effects

 Determine previous hypersensitivity reactions to penicillins, cephalosporins, and other allergens prior to therapy.
 Lab tests: Baseline C&S tests prior to initiation of therapy; start drug pending results.
 Report promptly unexplained bleeding (e.g., epistaxis, purpura, ecchymoses).
 Monitor patient carefully during the first 30 min after initiation of IV therapy for signs of hypersensitivity and anaphylactoid reaction (see Appendix F). Serious
anaphylactoid reactions require immediate use of emergency drugs and airway management.

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  Observe for and report symptoms of superinfections (see Appendix F). Withhold drug and notify physician.
 Monitor I&O ratio and pattern. Report dysuria, urine retention, and hematuria.

Patient & Family Education

 Report chills, wheezing, pruritus (itching), respiratory distress, or palpitations to physician immediately.
 Do not breast feed while taking this drug without consulting physician.

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Generic name: TRAMADOL HYDROCHLORIDE
(tra'ma-dol)
Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; ANALGESIC; NARCOTIC (OPIATE) AGONIST
Prototype: Morphine sulfate

Availability

50 mg tablets; 50 mg orally disintegrating tablets

Actions

Centrally acting opiate receptor agonist that inhibits the uptake of norepinephrine and serotonin, suggesting both opioid and nonopioid mechanisms of pain relief. May
produce opioid-like effects, but causes less respiratory depression than morphine.

Therapeutic Effects

Effective agent for control of moderate to moderately severe pain.

Uses

Management of moderate to moderately severe pain.

Contraindications

Hypersensitivity to tramadol or other opioid analgesics; patients on MAO inhibitors; patients acutely intoxicated with alcohol, hypnotics, centrally acting analgesics,
opioids, or psychotropic drugs; substance abuse; patients on obstetric preoperative medication; abrupt discontinuation; alcohol intoxication; pregnancy (category C);
lactation; children <16 y.

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Cautious Use

Debilitated patients; chronic respiratory disorders; respiratory depression; older adults; liver disease; renal impairment; myxedema, hypothyroidism, or hypoadrenalism;
GI disease; acute abdominal conditions; increased ICP or head injury, increased intracranial pressure; history of seizures; patients >75 y.

Route & Dosage

Pain
Adult: PO 50–100 mg q4–6h prn (max: 400 mg/d), may start with 25 mg/d if not well tolerated, and increase by 25 mg q3d up to 200 mg/d
Geriatric: PO 50–100 mg q4–6h prn (max: 300 mg/d), may start with 25 mg/d if not well tolerated, and increase by 25 mg q3d up to 200 mg/d

Renal Impairment
Clcr <30 mL/min: decrease to 50–100 mg q12h
Hepatic Impairment
Cirrhosis decrease to 50–100 mg q12h

Administration
Oral

 Note: Dosage reduction is recommended for patients with renal insufficiency and hepatic impairment.
 Store at 15°–30° C (59°–86° F).

Adverse Effects ( 1%)

CNS: Drowsiness, dizziness, vertigo, fatigue, headache, somnolence, restlessness, euphoria, confusion, anxiety, coordination disturbance, sleep disturbances, seizures.
CV: Palpitations, vasodilation. GI: Nausea, constipation, vomiting, xerostomia, dyspepsia, diarrhea, abdominal pain, anorexia, flatulence. Body as a Whole: Sweating,
anaphylactic reaction (even with first dose), withdrawal syndrome (anxiety, sweating, nausea, tremors, diarrhea, piloerection, panic attacks, paresthesia, hallucinations)
with abrupt discontinuation. Skin: Rash. Special Senses: Visual disturbances. Urogenital: Urinary retention/frequency, menopausal symptoms.

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Diagnostic Test Interference

Increased creatinine, liver enzymes; decreased hemoglobin; proteinuria.

Interactions
Drug: Carbamazepine significantly decreases tramadol levels (may need up to twice usual dose). Tramadol may increase adverse effects of MAO INHIBITORS.
TRICYCLIC ANTIDEPRESSANTS, cyclobenzaprine, PHENOTHIAZINES, SELECTIVE SEROTONIN-REUPTAKE INHIBITORS (SSRIs), MAO INHIBITORS
may enhance seizure risk with tramadol. May increase CNS adverse effects when used with other CNS DEPRESSANTS. Herbal: St. John's wort may increase
sedation.
Pharmacokinetics
Absorption: Rapidly absorbed from GI tract; 75% reaches systemic circulation. Onset: 30–60 min. Peak: 2 h. Duration: 3–7 h. Distribution: Approximately 20%
bound to plasma proteins; probably crosses blood–brain barrier; crosses placenta; 0.1% excreted into breast milk. Metabolism: Metabolized extensively in liver by
cytochrome P450 system. Elimination: Excreted primarily in urine. Half-Life: 6–7 h.

Nursing Implications

Assessment & Drug Effects

 Assess for level of pain relief and administer prn dose as needed but not to exceed the recommended total daily dose.
 Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression.
 Discontinue drug and notify physician if S&S of hypersensitivity occur.
 Assess bowel and bladder function; report urinary frequency or retention.
 Use seizure precautions for patients who have a history of seizures or who are concurrently using drugs that lower the seizure threshold.
 Monitor ambulation and take appropriate safety precautions.

Patient & Family Education

 Exercise caution with potentially hazardous activities until response to drug is known.
 Understand potential adverse effects and report problems with bowel and bladder function, CNS impairment, and any other bothersome adverse effects to
physician.
 Do not breast feed while taking this drug.
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Generic name: ACETYLCYSTEINE
(a-se-til-sis'tay-een)
Classifications: SKIN AND MUCOUS MEMBRANE AGENT; MUCOLYTIC; ANTIDOTE
Availability

10%, 20% solution for inhalation; 20% solution for injection

Actions

Acetylcysteine probably acts by disrupting disulfide linkages of mucoproteins in purulent and nonpurulent secretions.

Therapeutic Effects

Acetylcysteine lowers viscosity and facilitates the removal of secretions.

Uses

Adjuvant therapy in patients with abnormal, viscid, or inspissated mucous secretions in acute and chronic bronchopulmonary diseases, and in pulmonary complications
of cystic fibrosis and surgery, tracheostomy, and atelectasis. Also used in diagnostic bronchial studies and as an antidote for acute acetaminophen poisoning.

Unlabeled Uses

As an ophthalmic solution for treatment of dry eye (keratoconjunctivitis sicca); as an enema to treat bowel obstruction due to meconium ileus; prevention of
radiocontrast-induced renal dysfunction.

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Contraindications

Hypersensitivity to acetylcysteine; patients at risk of gastric hemorrhage.

Cautious Use

Patients with asthma, older adults, severe hepatic disease, esophageal varices, peptic ulcer disease; debilitated patients with severe respiratory insufficiency, pregnancy
(category B), lactation.

Route & Dosage

Mucolytic
Adult: Inhalation 1–10 mL of 20% solution q4–6h or 2–20 mL of 10% solution q4–6h Direct Instillation 1–2 mL of 10–20% solution q1–4h
Child: Inhalation 3–5 mL of 20% solution or 6–10 mL of 10% solution 3–4 times/d
Infant: Inhalation 1–2 mL 20% solution or 2–4 mL of 10% solution 3–4 times/d

Acetaminophen Toxicity
Adult/Child: PO 140 mg/kg followed by 70 mg/kg q4h for 17 doses (use a 5% solution)
Adult/Adolescent: IV 150 mg/kg infused over 15 min, followed by 50 mg/kg over 4 h, then 100 mg/kg over 16 h; OR 140 mg/kg infused over 1 h, then, 4 h after the
loading dose, give 70 mg/kg q4h x 12 doses

Administration
Inhalation and Instillation

 Prepare dilution within 1 h of use; drug does not contain an antimicrobial agent. A light purple discoloration does not significantly impair drug's effectiveness.
 Dilute the 20% solution with NS or water for injection. The 10% solution may be used undiluted.
 Give by direct instillation into tracheostomy (1–2 mL of 10–20% solution).
 Instruct patient to clear airway, if possible, coughing productively prior to aerosol administration to ensure maximum effect.
 Store opened vial in refrigerator to retard oxidation; use within 96 h.
 Store unopened vial at 15°–30° C (59°–86° F), unless otherwise directed.

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Oral

 Dilute the 20% solution 1:3 with cola, orange juice, or other soft drink to make a 5% solution. If administered via a gastric tube, water may be used as the
diluent.
 Freshly prepare all diluted solutions and use within 1 hour of preparation.

Intravenous

PREPARE: IV Infusion: Acetylcysteine reacts with certain metals and rubber; use IV equipment made of plastic or glass. Dilute all required doses in D5W as follows:
for loading dose, add a dose equal to 150 mg/kg to 200 mL; for first maintenance dose, add a dose equal to 50 mg/kg to 500 mL; for second maintenance dose, add a
dose equal to 100 mg/kg to 1000 mL. Note: The total IV volume should be reduced for patients <40 kg and for those with fluid restriction. In small children,
individualize the total IV volume to avoid water intoxication and hyponatremia.

ADMINISTER: IV Infusion: Give loading dose over 15 min, maintenance dose 1 over 4 h, maintenance dose 2 over 16 h.

 Store reconstituted solution for up to 24 h at 15°–30° C (59°–86° F).

Adverse Effects ( 1%)

CNS: Dizziness, drowsiness. GI: Nausea, vomiting, stomatitis, hepatotoxicity (urticaria). Respiratory: Bronchospasm, rhinorrhea, burning sensation in upper
respiratory passages, epistaxis.

Pharmacokinetics
Onset: 1 min after inhalation or instillation. Peak: 5–10 min. Metabolism: Deacetylated in liver to cysteine and subsequently metabolized.

Nursing Implications

Assessment & Drug Effects

 During IV infusion, carefully monitor for fluid overload and signs of hyponatremia (i.e., changes in mental status).
 Monitor for S&S of aspiration of excess secretions, and for bronchospasm (unpredictable); withhold drug and notify physician immediately if either occurs.

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  Lab tests: Monitor ABGs, pulmonary functions and pulse oximetry as indicated.
 Have suction apparatus immediately available. Increased volume of respiratory tract fluid may be liberated; suction or endotracheal aspiration may be necessary
to establish and maintain an open airway. Older adults and debilitated patients are particularly at risk.
 Nausea and vomiting may occur, particularly when face mask is used, due to unpleasant odor of drug and excess volume of liquefied bronchial secretions.

Patient & Family Education

 Report difficulty with clearing the airway or any other respiratory distress.
 Report nausea, as an antiemetic may be indicated.
 Note: Unpleasant odor of inhaled drug becomes less noticeable with continued use.
 Do not breast feed while taking this drug without consulting physician.

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Generic Name: KALIGEN
Indications: treatment or prevention of low K levels
Dosage: K depletion 40-100 mEq in divided doses. Do not administer >20 meq as single dose.
Administration: should be taken with food: swallow whole w/a full glass of water, do not crush/chew.
Special precautions: cardiac disease or conditions predisposing to hyperkalemia eg. Renal or adenocortical insuffeciency, acute dehydration or extensive tissue
destruction as with severe burns.
Side effects: GI discomforts eg. Nausea, vomiting diarrhea and bleeding of digestive tract, uneven heartbeat, muscle weakness or limp feeling, severe stomach pain,
numbness or tingling in hands, feet or mouth

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 NURSING THEORY

According to Henderson’s Nursing Need theory, “ The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities
contributing to health or its recovery that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain
independence as rapidly as possible” (Henderson, 1966)

She emphasized the importance of increasing the patient’s independence so that progress after hospitalization would not be delayed. (Henderson, 1991) The
assumptions of Henderson’s Nursing Need Theory are: “Nurses care for patient can care for themselves once again. Patients desire to return to health, but this assumption
is not explicitly stated. Nurses are willing to serve and that “nurses will devote themselves to the patient day and night”.

Correlation: Virginia Henderson’s Nursing Need Theory focuses more on assisting individuals to gain independence in relation to the performance of activities
contributing to health or its recovery. (Henderson, 1966)

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 ANNOTATED READINGS

CHICAGO, IL —With the development of the Clinical Practice Guideline: Evaluation of the Neck Mass in Adults, published today in Otolaryngology–Head and
Neck Surgery and presented at the AAO-HNSF 2017 Annual Meeting & OTO Experience in Chicago, IL, the appropriate testing and physical examination of an adult
with a neck mass is addressed, with a specific goal to reduce delays in diagnosis of malignant disease and to optimize outcomes.

“Neck masses are common in adults, but the underlying cause is not always easily identified. This guideline is an important instrument for the early diagnosis and
treatment of potentially malignant growths, especially with the rise of HPV-related head and neck cancer. A neck mass may indicate a serious medical problem. It does
not mean the patient has cancer, but it does mean they need more medical evaluation to make a diagnosis,” said M. Boyd Gillespie, MD, MSc, guideline development
group assistant chair.

Most persistent neck masses in adults are neoplasms, new and abnormal growths, and malignant growths far exceed any other. While the traditional patient profile for
neck mass was an older adult, younger people infected with HPV are changing that expectation. If current trends continue, the incidence of HPV oropharyngeal (tonsil
and base of tongue) head and neck squamous cell carcinoma will surpass HPV-positive cancer of the uterine cervix by 2020.

Forty years ago, patients with a neck mass experienced an average of a five- to six-month delay from the time of initial presentation to the diagnosis of malignancy.
Today, studies continue to report delays as long as three to six months. The information in this guideline is targeted at anyone who may be the first clinician a patient
with a neck mass encounters. This includes clinicians in primary care, dentistry, and emergency medicine, as well as pathologists and radiologists.

"In addition to crafting a set of actionable statements relevant to diagnostic decisions in the workup of an adult patient with a neck mass, the guideline also seeks to
promote high quality and cost-effective care as well as educate patients about seeking medical attention when a neck mass presents," said Dr. Gillespie. The accompanying
materials provide patient information for adults with a neck mass.

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) guideline is endorsed to date by American Academy of Physician
Assistants (AAPA), American Academy of Emergency Medicine (AAEM), American Association of Oral and Maxillofacial Surgeons (AAOMS), American College of
Radiology (ACR), American Head and Neck Society (AHNS), American Society for Clinical Pathology (ASCP), Head and Neck Cancer Alliance, Society of
Otorhinolaryngology Head-Neck Nurses (SOHN), and Triological Society.

The guideline was chaired by Melissa A. Pynnonen, MD, with M. Boyd Gillespie, MD, MSc, and Benjamin R. Roman, MD, MSHP, serving as assistant Chair, and
Richard M. Rosenfeld, MD, MPH, as the methodologist, and David E. Tunkel, MD, as methodologist-in-training.

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What is the purpose of this guideline?

The primary purpose of this guideline is to promote the efficient, effective, and accurate diagnostic workup of neck masses to ensure that adults with potentially malignant
disease receive prompt diagnosis and intervention to optimize outcomes. Specific goals include:

Reducing delays in diagnosis of head and neck cancer

Promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies
Reducing inappropriate testing
Promoting appropriate physical examination when cancer is suspected
What is a neck mass?

A neck mass is an abnormal lump in the neck. Neck lumps or masses may be any size. They can be large enough to see or feel or very small. They can be a sign of an
infection or something more serious, such as cancer.

What causes a neck mass?

Neck masses are common in adults and can occur for many reasons. Adults may develop a neck mass due to a viral or bacterial infection. Ear or sinus infection, dental
infection, strep throat, mumps, or a goiter may cause a neck mass. If a neck mass is from an infection, it should go away completely when the infection goes away. A
neck mass could also be caused by a benign (noncancerous) tumor or a cancerous tumor. Cancerous, or malignant, neck masses in adults are most often due to head and
neck squamous cell carcinoma. Other cancers such as lymphoma, thyroid or salivary gland cancer, skin cancer, or cancer that has spread from somewhere else in the
body, may also cause a neck mass.

What is the prevalence of head and neck cancer?

 Head and neck squamous cell carcinoma has a worldwide annual incidence of 550,000 cases, representing five percent of all newly diagnosed cancers.
 From 1988 to 2004, the U.S. population experienced a 225 percent increase in HPV positive oropharyngeal (tonsil and base of tongue) head and neck squamous cell
carcinoma.
 If current trends continue, the incidence of HPV-positive oropharyngeal (tonsil and base of tongue) head and neck squamous cell carcinoma will surpass that of HPV
positive cancer of the uterine cervix by 2020 and constitute 50% percent of all head and neck cancer by 2030.

What are the common symptoms in patients with a neck mass at high risk for cancer?

 The mass lasts longer than two to three weeks

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 The mass gets larger
 The mass gets smaller but does not completely go away
 Voice changes
 Trouble or pain with swallowing
 Trouble hearing or ear pain on the same side as the neck mass
 Neck or throat pain
 Unexplained weight loss
 Fever > 101 degrees Fahrenheit

Why is the guideline for evaluation of neck mass in adults important?

Currently, there is only one evidence-based clinical practice guideline to assist clinicians in evaluating an adult with a neck mass. Additionally, much of the available
information is fragmented, disorganized, or focused on specific etiologies. In addition, although there is literature related to the diagnostic accuracy of individual tests,
there is little guidance about rational sequencing of tests in the course of clinical care. This guideline strives to bring a coherent, evidence-based, multidisciplinary
perspective to the evaluation of the neck mass with the intention to facilitate prompt diagnosis and enhance patient outcomes. The information in this guideline is targeted
at anyone who may be the first clinician whom a patient with a neck mass encounters. This includes clinicians in primary care, dentistry, and emergency medicine, as
well as pathologists and radiologists who have a role in diagnosing neck masses.

SIGNIFICANT POINTS MADE IN THE GUIDELINE:

1. Avoidance of Antibiotic Therapy

Clinicians should not routinely prescribe antibiotic therapy for patients with a neck mass unless there are signs and symptoms of bacterial infection.

2a. Stand-alone Suspicious History

Clinicians should identify patients with a neck mass who are at increased risk for malignancy because the patient lacks a history of infectious etiology and the mass has
been present for two weeks or greater without significant fluctuation or the mass is of uncertain duration.

2b. Stand-alone Suspicious Physical Examination

Clinicians should identify patients with a neck mass who are at increased risk for malignancy based on one or more of these physical examination characteristics: fixation
to adjacent tissues, firm consistency, size greater than 1.5 cm, and/or ulceration of overlying skin.

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2c. Additional Suspicious Signs and Symptoms

Clinicians should conduct an initial history and physical examination for adults with a neck mass to identify those patients with other suspicious findings that represent
an increased risk for malignancy.

3. Follow Up of the Patient Not at Increased Risk

For patients with a neck mass who are not at increased risk for malignancy, clinicians or the designees should advise patients of criteria that would trigger the need for
additional evaluation. Clinicians or their designees should also document a plan for follow up to assess resolution or final diagnosis.

4. Patient Education

For patients with a neck mass who are deemed at increased risk for malignancy, clinicians or their designees should explain to the patient the significance of being at
increased risk and explain any recommended diagnostic tests.

5. Targeted Physical Examination

Clinicians should perform, or refer the patient to a clinician who can perform, a targeted physical examination (including visualizing the mucosa of the larynx, base of
tongue, and pharynx) for patients with a neck mass deemed at increased risk for malignancy.

6. Imaging

Clinicians should order a neck computed tomography (or magnetic resonance imaging) with contrast for patients with a neck mass deemed at increased risk for malignancy.

7. Fine Needle Aspiration (FNA)

Clinicians should perform FNA instead of open biopsy, or refer the patient to someone who can perform FNA, for patients with a neck mass deemed at increased risk for
malignancy when the diagnosis of the neck mass remains uncertain.

8. Cystic Masses

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For patients with a neck mass deemed at increased risk for malignancy, clinicians should continue evaluation of patients with a cystic neck mass, as determined by FNA
or imaging studies, until a diagnosis is obtained and should not assume the mass is benign.

9. Ancillary Tests

Clinician should obtain additional ancillary tests based on the patient’s history and physical examination when a patient with a neck mass is at increased risk for malignancy
and/or does not have a diagnosis after FNA and imaging.

10. Examination under Anesthesia of the Upper Aerodigestive Tract before Open Biopsy

Clinicians should recommend examination of the upper aerodigestive tract under anesthesia, before open biopsy, for patients with a neck mass who are at increased risk
for malignancy and without a diagnosis or primary site identified with FNA, imaging, and/or ancillary tests.

Where can I get more information?

Patients and health care providers should discuss all evaluation, testing, and follow-up options and find the best approach for the patient. There are printable patient
handouts and materials that further explain neck mass evaluation in adults that can help with discussions between patients and providers. For more information on
evaluation of the neck mass in adults, visit www.entnet.org/NeckMassCPG.

About the AAO-HNS/F

The American Academy of Otolaryngology—Head and Neck Surgery, one of the oldest medical associations in the nation, represents about 12,000 physicians and allied
health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves
its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and
socioeconomic issues. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology-head and neck surgery through education,
research, and lifelong learning. The organization's vision: "Empowering otolaryngologist-head and neck surgeons to deliver the best patient care."

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 REFERENCES
Books
Hall, et al (2017). Fundamentals of Nursing. Volume I. 9th ed. Singapore, Singapore 239519: Elsiever Inc.
Kelly, J. W. (2007). Health Assessment in Nursing. Philadelphia: Lippincott Williams and Wilkins.
Brunner & Suddarth (2014). Medical-Surgical Nursing. Volume I. 13th ed. Philadelphia, PA 19103: Lippincott Williams & Wilkins.
Skidmore-Roth, L. (2015). Mosby's Nursing Drug Reference. St. Louis, Missouri: Elsevier Inc.

Internet
Iintegumentary system. (2018, may 15). Available at: www.myvmc.com: https://www.myvmc.com/anatomy/integumentary-system/
Lumenlearning, 2017. Integumentary. Available at: https://courses.lumenlearning.com/wm-biology2/chapter/integumentary-system/
neckmass. (2018, november 16). Available at: www.mayoclinic.org: https://www.mayoclinic.org/diseases-conditions/neckmass/symptoms-causes/
https://www.verywellmind.com/generativity-versus-stagnation-2795734

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