A Case Study on Thyroid Cancer Stage IV

In Partial Fulfillment of the Requirements in

Related Learning Experience 116

Submitted to:

Ms. Laverne F. Palencia, RN

Clinical Instructor

Submitted by:

Sittie Ranyah P. Lantud;

Evamie L. Etor;

Marielle Melrose M. Hondrado;

Angel Gabrelle B. Jotojot;

Val Christian Ronel C. Joya;

Trisha Jane P. Labton;

Clifford Kristian L. Lagsa;

Paulo Miguel A. Lorea;

Ryan Greg L. Molina;

March 2023
Title: A CASE STUDY ON THYROID CANCER STAGE IV

Authors: Sittie Ranyah P. Lantud;

Evamie L. Etor;

Marielle Melrose M. Hondrado;

Angel Gabrelle B. Jotojot;

Val Christian Ronel C. Joya;

Trisha Jane P. Labton;

Clifford Kristian L. Lagsa;

Paulo Miguel A. Lorea;

Ryan Greg L. Molina;

ABSTRACT

This is a case study of a 56-year-old female diagnosed with Thyroid Cancer Stage
IV and admitted to Capitol University Medical Center (CUMC). Thyroid cancer is the most
common endocrine-related malignancy in the Philippines. Worldwide, an estimated
586,202 people were diagnosed with thyroid cancer in 2020. It is important to conduct
this case study to investigate the pathophysiology of the disease as this will be helpful to
nursing practice to establish the appropriate nursing interventions necessary to provide
holistic care to the patient and promote optimal wellness and recovery.
In this case, the patient underwent thyroidectomy but a twice recurrence of the
tumor happened. Another procedure tumor debulking was performed and a
tracheostomy is attached to the patient to maintain airway clearance. During the time of
duty, the patient was unable to speak properly because of a tracheostomy. She is being
monitored and was advised to comply with medication for fast recovery.

Keywords: thyroid tumor, thyroidectomy, tumor debulking, tracheostomy, radioactive

iodine therapy
TABLE OF CONTENTS

ABSTRACT
ACKNOWLEDGMENT
I. Introduction ........................................................................................................ 1
Background of the Study ...................................................................................... 1
Objectives of the Study ........................................................................................ 2
The Significance of the Case Study ..................................................................... 2
Nursing Education ..................................................................................... 2
Nursing Practice ........................................................................................ 3
Scope and Limitations of the Study...................................................................... 3
Definition of terms ................................................................................................ 3

II. Patient’s Profile.............................................................................................................. 4

Demographic Profile............................................................................................. 4
Nursing Health History ........................................................................................ 4
Chief Complaint......................................................................................... 4
History of Present Illness........................................................................... 4
Family History ........................................................................................... 4
Lifestyle ..................................................................................................... 4
Vital Signs ............................................................................................................ 4
Physical Assessment ........................................................................................... 5
Health Perception and health management pattern .................................. 5
Nutritional and Metabolic Lifestyle Pattern ................................................ 5
Elimination Pattern .................................................................................... 5
Activity and Exercise Pattern..................................................................... 5
Sleep and rest Pattern .............................................................................. 5
Cognitive and Perceptual Pattern .............................................................. 5
Self-perception and self-concept Pattern .................................................. 6
Roles and Relationship Pattern ................................................................. 6
Sexuality and reproduction Pattern .......................................................... 6
Coping and Stress Tolerance Pattern........................................................ 6
Value-belief Pattern................................................................................... 6
Anatomical Model ..................................................................................... 6
Patient’s Developmental Stage ........................................................................................... 7
Sigmund Freud’s Psychosexual Development ............................................... 7
Erik-Erikson’s Psychosocial Development....................................................... 7
Jean Piaget's Stages of Cognitive Development ....................................... 8
Lawrence Kohlberg's Stages of Moral Development ................................. 9

III. Theoretical and Conceptual Framework .......................................................... 9

IV. Anatomy and Physiology ................................................................................ 10
V. Diagnostic Tests and Laboratory Tests ......................................................... 11
VI. Pathophysiology ............................................................................................. 13
Schematic Diagram ................................................................................. 13
Narrative Form ........................................................................................ 15
VII. Medical-Surgical Management........................................................................ 16
Medical-Surgical Procedures ............................................................................. 16
Ideal Procedures ..................................................................................... 16
Actual Procedures ................................................................................... 17
Drug Study

VIII. Nursing Management

IX. Discharge Plan
X. Results and Discussion
XI. Conclusions
XII. References
LIST OF TABLES

Table 1.1. Vital Signs ....................................................................................................... 4

Table 1.2. Intake and Output ........................................................................................... 5
Table 1.3. Activities of Daily Living/Mobility Status .......................................................... 5
Table 1.4. CBC Result (March 9, 2023) ......................................................................... 12
Table 1.5 CBC Result (March 5, 2023) .......................................................................... 12
Table 1.6 CBC Result (March 9, 2023) .......................................................................... 13
ACKNOWLEDGEMENT

To the group’s clinical instructor, Ms. Laverne F. Palencia, RN, it would not be
possible without your help and guidance. Thank you for sharing your knowledge and
expertise and for the unending patience and support throughout the course of our duties.

To our patient and her significant others, for allowing the researchers to assess
and for sharing the information required for the fulfillment of this study. The time you have
shared, and the willingness to help the researchers by providing all the necessary data
are highly appreciated from the time of assessment until the actual nursing care during
duty days.

To the Capitol University Medical Center - Medical Ward Staff, thank you for
providing us with the necessary information and for entertaining and answering all our
inquiries. Thank you for being accommodating and for providing the necessary support
to us during the duration of our duty.

To our families and friends who have been the source of our strength and
inspiration to work hard toward achieving our goals, we thank them for motivating and
providing the support we need in all our endeavors.

Most especially, we give thanks to God Almighty, who is the source of our
knowledge, strength, wisdom, energy, and all the necessary faculties required to
accomplish our tasks and overcome the challenges we have encountered along the way.
I. INTRODUCTION

Background of the Study

Thyroid cancer is the most common endocrine-related malignancy in the

Philippines. Thyroid cancer starts when cells begin to grow out of control. Papillary thyroid
cancer, which is the most common type of thyroid cancer, makes up about 80% of all
cases of thyroid cancer. Although risk factors for papillary thyroid cancer include radiation
exposure and a family history of thyroid cancer, it is important to note that the majority of
patients have no risk factors at all. Up to 20% of patients will have involved lymph nodes
at the time of diagnosis. However, unlike other cancers where involved lymph nodes
means a very poor prognosis, in thyroid cancer involved lymph nodes usually have almost
no impact on survival. Involved lymph nodes may increase the chance of recurrence (i.e.
cancer coming back), but they do not change the prognosis. Most patients with papillary
thyroid cancer will not die of this disease.

Thyroid cancer is considered the most common endocrine cancer in the

Philippines. Recent data show that thyroid cancer is the 9th most common cancer in the
world for both sexes, with an incidence of 586,202 cases in 2020 alone. In the Philippines,
thyroid cancer is the 6th most common cancer with a 5-year prevalence of 19,260 cases,
and it ranks 21st in terms of mortality as of 2020. Thyroid cancer affects more women of
reproductive age than other population groups. Its incidence increases every year, noted
especially in females and in the reproductive age group. Considering the burden of thyroid
cancer in the Philippines, the Department of Health (DOH) called for the development of
a national guideline on thyroid cancer that could address the needs of patients afflicted
with this malignancy and aid the physician in his/her clinical decision making for these
patients.

The House Committee on Health has approved for plenary deliberation the bill
declaring the 4th week of September of every year as the National Thyroid Cancer
Awareness Week. Under House Bill 5307, the National Thyroid Cancer Awareness Week
shall coincide with the international celebration of Thyroid Awareness Month. In
Committee Report No. 529, the panel said the objective of the bill is to increase the level
of public awareness through education and information campaign. To ensure a
meaningful observance of the National Thyroid Cancer Awareness Week, the bill provides
for the implementation of a comprehensive public education and awareness program to
discuss the causes, consequences, diagnosis, treatments and prevention of thyroid
cancer.

The National Integrated Cancer Control Act (NICCA) or the Republic Act No.
11215, has been signed into law in February of 2019 by President Rodrigo Duterte. This
was implemented to ensure provision of quality health services for Filipino cancer
patients. This law further envisions to strengthen the cancer control in the country,
increase cancer survivorship and reduce the burden on families and cancer patients

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 especially on the financial aspect. The implementation of the NICCA law with formation
of the council shall make a great leap in cancer care in the Philippines. This will make
cancer care better, more accessible, and affordable to our patients. This shall realize the
thrust for a healthy Philippines.

OBJECTIVES OF THE STUDY

General Objectives

This case presentation aims to improve the student's understanding of the disease
process of Thyroid Cancer Stage IV, in undergoing thyroidectomy, with a soft diet, low fat
and low salt, to review the current approach to the diagnosis and treatment of patients
with thyroid cancer. The nursing plan of care, and the nursing intervention.

Specific Objectives:

The group aims to:

1. Discuss, explain, and elaborate on the nature of the disease process thoroughly.
2. Provide appropriate and proper nursing diagnoses in accordance with the client’s
medical condition, and skillfully develop nurse care plans for the problems
identified.

3. Institute appropriate nursing interventions and apply the proper management

necessary for the patient‘s condition.

SIGNIFICANCE OF THE STUDY

Nursing Practice

This case study can be used as a tool in nursing practice because it provides
nursing interventions for patients with Thyroid Cancer Stage IV. This study can provide a
good introduction to the disorder so that an established nursing action can be quickly
implemented. By discovering and rediscovering innovative interventions and facilitation
of this condition, a more advanced nursing management can be developed. Important
information on this illness has been acquired because of this study, which will assist
researchers to gain better knowledge of the disease.

Nursing Education

This study can be used as a resource for students for research on Thyroid Cancer
Stage IV, making it an effective teaching tool for nursing education. Through the use of this
case study, students will gain knowledge on how to evaluate patients with Stage IV thyroid
cancer and provide the necessary nursing care and management. 5 The students will learn
about nursing interventions and develop an understanding of how their actions are justified.
If they encounter a similar or identical situation, they may apply these interventions. This
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increases their understanding of the illness, which they can use to enhance their abilities as
student nurses and future nurses. It might open the door to a new era in the provision of
top-notch healthcare.

Scope and Limitations of the Study

The focus of this case study is thyroid cancer in stage IV. It also includes the
patient's profile, health story, and vital signs taken in addition to basic ideas, concepts, and
studies related to the specified ailment. Also, the pathophysiology of the illness, its
anatomy, and its associated variables are all examined in this study. Also provided are the
nurse interventions, discharge plans, and other relevant information.
The scope of the plan comprises the course of duty in CUMC Surgical Ward
Rotation March 9, 2023.
Discussions of thyroid cancer stage IV and the standard of nursing care provided to
the patient are the only topics of relevance.

Definition of Terms

● Thyroid tumor - a cancer that forms in the thyroid gland (an organ at the base of
the throat that makes hormones that help control heart rate, blood pressure, body
temperature, and weight).

● Thyroidectomy - is the surgical removal of all or part of your thyroid gland.

Surgeons perform thyroidectomies to remove goiters and thyroid nodules and to
treat thyroid cancer.

● Tumor debulking - surgical removal of as much of a tumor as possible. It is a

reduction of as much of the bulk or volume of a tumor without the intention of a
complete eradication. l.

● Tracheostomy - is a surgical airway management procedure which a surgeon

makes a hole on the front aspect of the neck and opening a direct airway through
an incision in the trachea.

● Radioactive iodine therapy - is used to treat hyperthyroidism and thyroid cancer.

It is usually given in a special radiology department called nuclear medicine, either
at an outpatient clinic or in the hospital. It can be taken by mouth as a pill or liquid
or injected into a vein.

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 II. PATIENT’S PROFILE

Demographic Profile

Patient X is a 56-year-old female, born on 1967. She is a Filipino citizen, Roman

Catholic, and a resident of Opol Misamis Oriental. She is legally married. She is a college
graduate and a successful businesswoman. In terms of finances, her husband provides
it.

Nursing Health History

Chief Complaint: The patient complaint shortness of breath.

History of Present Illness:

Patient X was diagnosed with a case of thyroid cancer stage IV (unrecalled specific
type) last 2005, underwent total thyroidectomy (2013), and resection of tumor
recurrence (2015), s/p RAI (2013, 2015). Patient X was maintained on Thydin 150 mg 1
tab OD and Carvid 25 mg ½ tab OD.

Patient X noted 2nd tumor recurrence last 2021 at the left anterior aspect of the
neck, approx. to a calamansi-sized, and was referred for resection and ff up with
oncology service at COMC for chemotherapy, but was apprehensive to undergo repeat
surgery and was lost to ff up.

The thyroid gradually grew in size to approximate the size of a tennis ball, with the
onset of dysphagia, some dyspnea, and dysphonia. 7 3 mos PTA, sought consultation
with an internist and was given salbutamol-ipratropium MDI 1 puff as needed for an
episode of dyspnea, and salmeterol-fluticasone 2 puffs BID as maintenance. Dyspnea
was still present, but tolerable.

1 month PTA, with exacerbation of dyspnea and onset cough. Sought off up and
was prescribed Azithromycin, NAC, levocetirizine, prednisone for 1 week, and
multivitamins.

2 hours of PTA noted sudden onset of severe dyspnea as the patient was gasping
for air. No noted allergenic food intake. Only took 2 doses of salbutamol-ipratropium
which provided no relief. Due to persistence of symptoms, patient X was rushed to the
ER and was advised for admission.

Patient Health History:

Patient X was diagnosed with thyroid cancer stage IV last 2005 and underwent total
thyroidectomy last 2013 and resection of tumor recurrence in 2015.

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 Family Health History: None

Lifestyle: The patient is a non-smoker, non-alcohol drinker and does not use illicit
drugs..

Vital Signs

The initial assessment was done last March 08, 2023. The vital signs were as
follows: Pulse Rate: 99 bpm, Respiratory Rate: 19 cpm, Temperature: 35.8 degrees
Celsius, Blood Pressure: 110/70 mmHg, 02 sat: 98%. She stands 162.56 cm and weighs
116 pounds.

Table 1.1: Vital Signs

DATE TIME. SHIFT PR RR TEMP BP O2
(7-3) SAT

3/08/23 8 AM 84 20 36.7 110/80 95

3/08/23 12 PM 91 20 37.0 110/70 95

3/09/23 8 AM 99 19 35.8 110/70 99

3/09/23 12 PM 99 19 36.7 110/80 96

Table 1.2: Intake and Output

Date ORAL IV TOTAL URINE STOOL TOTAL

03/08/2023 720 360 1080 240 1 240

(12 pm)

03/09/2023 1080 340 1420 720 2 720

(12 pm)

PHYSICAL ASSESSMENT

Health Perception and Health Management: The patient maintains compliance with
her medication.

Nutritional and Metabolic Lifestyle Pattern:

Prior to admission: The patient had a good appetite. She consumes 1-2 cups of rice
in each meal. She loves to eat vegetables, fish, and pork. She loves to drink water and
consumes 10 to 12 glasses of water per day.
During admission: The patient still has a good appetite. However, she is on a soft
diet, low sat after she has surgery

Elimination Pattern:
Prior to admission: Patient X defecated twice a day without any problems. During
admission: Patient X can defecate 2-3 times a day,

5
Activity-Exercise Pattern:
During admission, Patient X can do ADLs with a person’s assistance.
Activities of Daily Living/Mobility Status
ACTIVITIES OF DAILY LIVING PATIENT FUNCTIONAL ABILITIES SCORE

Feeding Assist with person 2

Bathing Assist with person 2

Dressing Assist with person 2

Meal Preparation Assist with person 2

Cleaning Assist with person 2

Laundry Assist with person 2

Toileting Assist with person 2

Bed mobility Assist with person 2

Chair-toilet transfer Assist with person 2

Ambulation Assist with person 2

ROM Assist with person 2

Sleep-Rest Pattern:
Prior to admission: Patient X sleeps between 5 to 6 hours every night. He does
have sleeping problems, there are external stimuli that can interfere with sleep, such as
a noisy environment.
During admission: Patient X is uncomfortable during his sleep due to environmental
factors.

Cognitive Perceptual Pattern:

The patient is conscious, alert, and oriented to date, time, place, and person. She
has no difficulty in hearing, or any visual problems experienced.

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Self-Perception and Self-Care: The patient describes herself as a friendly, caring, and
thoughtful person. However, she felt differently about herself during admission since she
is unable to go outside and be with her peers.

Role Relationship Pattern:

Prior to admission: Patient X is currently living with her husband and children in
Citihomes Opol, CDO Misamis Oriental. They are very supportive and provide
emotional support for her needs.
During admission: Since her admission, her husband and their children attend to all
the things she needed.
Sexuality and Reproduction Problems: The patient reports no changes in sexual
relation.

Stress Tolerance Coping:

Prior to admission: Patient X has been anxious because of her thyroid. The patient
said that her source of stress reliever is her family and looks forward to the day she will
be okay.
During admission: The patient appeared worried because of her thyroidectomy
surgery. With the help of her family, she remained calm for her upcoming surgery.

Values/Belief Pattern: The patient and her family are Roman Catholics. They attend
mass on Sundays.

Anatomical Model

March 8, 2023 to March 9, 2022.

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Patient’s Developmental Stage

Sigmund Freud’s Psychosexual Development

Genital Stage (Puberty to Adult)

Sigmund Freud believed that life was built round tension and pleasure. Freud also
believed that all tension was due to the build-up of libido (sexual energy) and that all
pleasure came from its discharge. In describing human personality development as
psychosexual, Freud meant to convey that what develops is the way in which sexual
energy of the id accumulates and is discharged as we mature biologically.

The genital stage at the age range: Puberty to adult. The onset of puberty causes
the libido to become active once again. During the final stage of psychosexual
development, the individual develops a strong sexual interest in the opposite sex. This
stage begins during puberty but last throughout the rest of a person's life. Where in earlier
stages the focus was solely on individual needs, interest in the welfare of others grows
during this stage. The goal of this stage is to establish a balance between the various life
areas. Unlike many of the earlier stages of development, Freud believed that the ego and
superego were fully formed and functioning at this point. Younger children are ruled by
the, id which demands immediate satisfaction of the most basic needs and wants. Teens
in the genital stage of development are able to balance their most basic urges against the
need to conform to the demands of reality and social norms.

Patient X in this stage of psychosexual development by Sigmund Freud. The

patient is in the genital stage at the age range of puberty to adult. Patient X has passed
sexual experimentation, the successful resolution of which is settling down in a loving
one-to-one relationship with another person. This stage has been completed successfully,
the patient is well-balanced, warm, and caring.

Erik-Erikson’s Psychosocial Development

Generativity vs Stagnation (Middle Adulthood: 40 to 65 years)

Erik Erikson believed that in middle adulthood needs to create or nurture things
that will outlast them, often by having children or creating a positive change that benefits
other people. Success leads to feelings of usefulness and accomplishment, while failure
results in shallow involvement in the world.

Care is the virtue achieved when this stage is handled successfully. Being proud
of your accomplishments, watching your children grow into adults, and developing a
sense of unity with your life partner are important accomplishments at this stage.

Patient X is in this stage of psychosocial development. She has successfully

achieved generativity and was able to develop the virtue of care. She is happily married

8
with three children. With the help of their business, they were able to finish their children's
education. During her stay in the hospital, Patient X’s husband was her primary
caregiver/watcher. He looks after her and provides for her needs.

III. THEORETICAL AND CONCEPTUAL FRAMEWORK

Nursing is defined by Lydia Hall as involvement in the care, core, and cure
components of patient care, where the care is the primary responsibility of nurses, but the
core and cure are shared with other members of the health team. The care explains the
function of nurses and focuses on the noble work of nurturing patients, providing comfort
measures, patient education activities, and assisting patients in meeting their needs
where assistance is required. The core is the patient receiving nursing care. The core
sets his or her own goals rather than those set by others and acts in accordance with his
or her feelings and values. This focuses on the patient's social, emotional, spiritual, and
intellectual requirements in relation to family, institution, and community. This entails the
therapeutic use of one's own body, and it is discussed with other members of the health
team. The cure is the component of nursing that involves the administration of
medications and treatments, as well as interventions and actions aimed at treating the

9
patient for whatever ailment or disease he or she is suffering from. This theory relates to
our patient who is considered as the core. Providing care should be centered to the
patient’s overall needs may it be socially, emotionally, spiritually, and intellectually.
Providing care to the patient requires us to provide nursing care and carry out our nursing
functions, ensuring that we can meet the patient’s needs holistically.

IV. ANATOMY AND PHYSIOLOGY

Thyroid Gland

A butterfly-shaped organ, the thyroid gland is located anterior to the trachea, just
inferior to the larynx. The medial region, called the isthmus, is flanked by wing-shaped
left and right lobes. Each of the thyroid lobes are embedded with parathyroid glands,
primarily on their posterior surfaces. The tissue of the thyroid gland is composed mostly
of thyroid follicles. The follicles are made up of a central cavity filled with a sticky fluid
called colloid. Surrounded by a wall of epithelial follicle cells, the colloid is the center of
thyroid hormone production, and that production is dependent on the hormones’ essential
and unique component.

The thyroid gland is a vital hormone gland: It plays a major role in the metabolism,
growth and development of the human body. It helps to regulate many body functions by
constantly releasing a steady amount of thyroid hormones into the bloodstream. If the
body needs more energy in certain situations – for instance, if it is growing or cold, or
during pregnancy – the thyroid gland produces more hormones.

Thyroid produces and releases the following hormones:

● Thyroxine (T4): This is the primary hormone your thyroid makes and releases.
Although your thyroid makes the most of this hormone, it doesn’t have much of an

10
 effect on your metabolism. Once your thyroid releases T4 into your bloodstream,
it can convert to T3 through a process called deiodination.
● Triiodothyronine (T3): Your thyroid produces lesser amounts of T3 than T4, but
it has a much greater effect on your metabolism than T4.
● Reverse triiodothyronine (RT3): Your thyroid makes very small amounts of RT3,
which reverses the effects of T3.
● Calcitonin: This hormone helps regulate the amount of calcium in your blood.

In order to make thyroid hormones, your thyroid gland needs iodine, an element found in
food (most commonly, iodized table salt) and water. Your thyroid gland traps iodine and
transforms it into thyroid hormones. If you have too little or too much iodine in your body,
it can affect the level of hormones your thyroid makes and releases.

V. DIAGNOSTIC AND LABORATORY TEST

● Thyroid function blood tests. Tests that measure blood levels of thyroid-
stimulating hormone (TSH) and hormones produced by your thyroid gland might
give your health care team clues about the health of your thyroid.

● Ultrasound imaging. Ultrasound uses high-frequency sound waves to create

pictures of body structures. To create an image of the thyroid, the ultrasound
transducer is placed on your lower neck.

● Biopsy. The only way to confirm if a lump on the thyroid is cancer is to take a
biopsy. This is where a small sample of cells are removed and studied under a
microscope. A biopsy of the thyroid is usually done by inserting a thin needle into
the lump.T

● An imaging test that uses a radioactive tracer. A radioactive iodine scan uses
a radioactive form of iodine and a special camera to detect thyroid cancer cells in
your body. It's most often used after surgery to find any cancer cells that might
remain. This test is most helpful for papillary and follicular thyroid cancers.

11
COMPLETE BLOOD COUNT:

Date Released: Mar-09-2023

Table 1.3.

TEST RESULT UNIT NORMAL VALUES

Hemoglobin 10.10 g/dL 11.7 – 14.5

Hematocrit 30.30 gm% 34.1 – 44.3

WBC Count 6,000 cells/mm3 5000 – 10000

DIFFERENTIAL COUNT

Segmenters 69 % 45 – 70

Lymphocyte 15 % 18 – 45

Monocyte 6 % 4–8

Eosinophil 2 % 2–3

Platelet Count 305,000 cells/mm3 150,000 – 450,000

Red Blood Cell 3.36 10°5/ul 4.2 – 5.4

MCV 90.20 fL 80 – 96

MCH 30.10 Pg 27 – 31

MCHC 33.30 g/dL 32 – 36

RDW 13.40 % 10.0 – 15.0

CONVENTIONAL UNIT:

Date Released: Mar-05-2023

Table 1.4.

TEST RESULT UNIT REFERENCE

VALUE

Sodium 138.00 meq/L 135 – 148

Potassium 4.00 meq/L 3.5 – 5.3

Creatinine 0.61 mg/dL 0.52 – 1.04

LIVER PROFILE

SGPT/ALT 45.00 U/L 9 – 52

Albumin 3.70 g/dL 3.5 – 5.0

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Date Released: Mar-09-2023

Table 1.5.

TEST RESULT UNIT REFERENCE

VALUE

Potassium 3.70 meq/L 3.5 – 5.3

Creatinine 0.52 mg/dL 0.52– 1.04

VI. PATHOPHYSIOLOGY

Schematic Diagram

Pathophysiology of Thyroid Cancer Stage IV

Legend:

Factors Disease Process Complications Medications

Laboratory Test Nursing Diagnosis Surgical Diagnostic Test

Predisposing Factor:
• Genetics Factors Precipitating Factor:
• Family History • Exposure to
Radiation
• Gender (3x in
female) • Diet (Iodine)
• Age (30-50 years • Weight (Obese)
Etiology:
The cause is yet unknown, but the
risk factors has been linked to
increasing the risk of Papillary
Thyroid Cancer

Changes happen to the

DNA of thyroid gland cells

Mutation of BRAF protein

Mutation of TSH receptor

Activation of signaling pathways

(Nodule)

13
 ↑ Production of T4 and T3

• Changes in voice
• DOB
Cells grow fast abnormally • lump in the neck
(TUMOR) • difficulty swallowing
• sore throat that does not
go away
• neck pain and swollen
Papillary Thyroid Cancer
lymph nodes on the neck

Fine Needle Aspiration

Biopsy

Stage I Stage II Stage IV

Stage III
(Tumor is 2 cm in (Tumor is 2 to 4 cm in (Any size and
(>4 cm in size)
size) size) extended beyond
thyroid)

Started to grow outside thyroid Spread to nearby lymph

Spread to lymph nodes of
gland nodes
neck
(METASTASIZED)

(2005)
Diagnosed Stage IV Cancer

(2013) (2013)
Radioactive Iodine Thyroidectomy
(2015)
First Tumor recurrence

(2015)
(2015)
Tumor resection
Radioactive Iodine

(2021)
Second Tumor recurrence Referred for resection
- Left anterior aspect of the neck and chemotherapy
• Kalamasi-sized, hard, non- (Apprehensive to
movable, non-tender repeat surgery and was
lost to follow-up)
Tumor grew

• (-) dysphagia
• (-) dysphonia
• (-) dyspnea • Size of tennis ball

Home medication
• (+) dysphagia • salbutamol-
• (+) dyspnea ipratropium 1
• (+) dysphonia neb PO BID-
• 8am, 6pm

Home medication
(1 MONTH PTA)
• acetylcysteine
• (+) dyspnea
NAC- 1tab PO
• (+) cough OD-8pm

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 Admission at CUMC
(February 11, 2023)

Shortness of breath

(February 24, 2023)

Tumor debulking
• dexketoprofen (Leodex) -
1 tab PO BID -8am, 6pm • salbutamol-ipratropium
2 doses PO BID-8am,
6pm
(February 24, 2023)
Tracheostomy

Impaired verbal communication Fatigue related to Risk for aspiration related

related to presence of artificial decreased hemoglobin, to presence of
airway tracheostomy hematocrit, and RBC tracheostomy

(March 9, 2023)
• Low Hemoglobin
• Ferrous gluconate ➢ 10.10 g/dL
(Sangobion Iron) • Low Hematocrit
-1 tab PO OD- 8am ➢ 30.30 gm%
• Low RBC
➢ 3.36 10°5/ul

Narrative Form:

Predisposing Factors

● Genetic Factors - Some conditions, including cancer, come from the DNA you get
from your parents.
● Family History - For about 5 percent of people who develop papillary thyroid
cancer, the disease runs in the family.
● Gender - It is unclear why, but papillary thyroid cancer occurs about three times
more often in women than in men.
● Age – usually occur between 30-50 years old.

Precipitating Factors:

● Exposure to radiation - People who were exposed to high levels of radiation to

the head and have a higher chance of developing papillary thyroid cancer.
● Diet - Iodine is needed for normal thyroid function.
● Weight - Obesity appears to be a risk factor for thyroid cancer in women.

15
 Papillary thyroid cancer forms in follicular cells in the thyroid and grows in small finger-
like shapes. It has no known cause, but the identified risk factors have been linked to
increasing the risk of papillary thyroid cancer. Gene mutations are involved in papillary
thyroid cancer development. Thyroid cancer happens when cells in the thyroid develop
changes in their DNA. A cell's DNA contains the instructions that tell the cell what to do.
The changes are called mutations, it tells the cells to grow and multiply rapidly. The
mutation results in the activation of the BRAF protein (a gene that is involved in sending
signals in cells and cell growth) that causes cells to keep on dividing which increased
kinase activity. This results in the activation of signaling pathways that lead to increased
cell proliferation that forms a mass called a nodule/tumor. Not all lump growth is
cancerous, but the only way to confirm if a lump on the thyroid is cancer is to take a
biopsy. This is where a small sample of cells is removed and studied under a microscope.
A biopsy of the thyroid is usually done by inserting a thin needle into the lump. In Stage
I, the tumor size is 2 cm and started to grow outside thyroid gland; Stage II, tumor size 2
to 4 cm that also started to grow outside the thyroid gland; Stage III, the tumor size is >4
cm and spread to lymph nodes of the neck; Stage IV, the tumor is in any size that invades
nearby tissue and can spread (metastasize) to the lymph nodes in the neck. Sometimes
the cancer cells can spread beyond the neck to the lungs, bones, and other parts of the
body.

In this case, the patient was diagnosed with Papillary Thyroid Cancer Stage IV and
undergone thyroidectomy, a surgical removal of all or part of the thyroid gland. After
several years, the first tumor recurrence happened, and the patient undergone tumor
resection. Another second tumor recurrence grew, and the patient undergone tumor
debulking. Tracheostomy was also done to maintain the patient’s airway clearance.

VII. MEDICAL AND SURGICAL MANAGEMENT

Medical-Surgical Procedure
IDEAL:

● Thyroidectomy. A surgery to remove the thyroid gland. It is the most

common surgery for thyroid cancer.

● Hormone therapy. When thyroid cancer is present, specialists may

prescribe thyroid hormone therapy to prevent cancer cells from growing.
Increasing the amount of thyroid hormone in your blood tells your pituitary
gland to stop making TSH..

● External-beam radiation therapy. Uses high doses of radiation to destroy

cancer cells and shrink tumors. A large machine aims radiation at the
cancer. The machine moves around you, without touching you.

● Targeted therapy. A type of cancer treatment that targets proteins that

control how cancer cells grow, divide, and spread.

● Chemotherapy. A cancer treatment where medicine is used to kill cancer

cells. Chemotherapy is rarely used to treat thyroid cancer, but it's
sometimes used to treat anaplastic thyroid carcinomas that have spread to

16
 other parts of the body. It involves taking powerful medicines that kill
cancerous cells. It does not cure thyroid cancer, but it may help to control
the symptoms.

ACTUAL:

● Chemotherapy. A cancer treatment where medicine is used to kill cancer

cells. Chemotherapy is rarely used to treat thyroid cancer, but it's
sometimes used to treat anaplastic thyroid carcinomas that have spread to
other parts of the body. It involves taking powerful medicines that kill
cancerous cells. It does not cure thyroid cancer, but it may help to control
the symptoms.

● Thyroidectomy. Surgery to remove the thyroid gland. It is the most

common surgery for thyroid cancer.

● Radioactive iodine therapy. The thyroid absorbs almost all iodine that
enters the body. Therefore, a type of radiation therapy called radioactive
iodine (also called I-131 or RAI) can find and destroy thyroid cells not
removed by surgery and those that have spread beyond the thyroid.

● Tumor debulking. Surgical removal of as much of a tumor as possible.

Tumor debulking may increase the chance that chemotherapy or radiation
therapy will kill all the tumor cells. It may also be done to relieve symptoms
or help the patient live longer.

● Tracheostomy. Tracheostomy is a hole that surgeons make through the

front of the neck and into the windpipe (trachea). A tracheostomy tube is
placed into the hole to keep it open for breathing. A tracheostomy provides
an air passage to help you breathe when the usual route for breathing is
somehow blocked or reduced. A tracheostomy is often needed when health
problems require long-term use of a machine (ventilator) to help you
breathe. In rare cases, an emergency tracheotomy is performed when the
airway is suddenly blocked, such as after a traumatic injury to the face or
neck.

17
 CAPITOL UNIVERSITY
COLLEGE OF NURSING

VII. DRUG STUDY

DRUG ORDER NURSING

(Generic name, brand name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF RESPONSIBILITIES/
classification, dosage, route, ACTION THE DRUG PRECAUTIONS
frequency)
Generic name: calcium with • Calcium plays a • Calcium: as • Hypersensitivity • nausea and Assessment:
magnesium vital role in the Calcium carbonate vomiting • Lab tests: Determine
anatomy, which can help • increased thirst levels of calcium and
Brand name: CalMag Plus physiology, and maintain bone or urination phosphorus (tend to
biochemistry of health. • muscle pain or vary inversely) and
Classification: Vitamins and organisms and of • Vitamin D: to help weakness magnesium
minerals the cell, Calcium absorption • joint pain frequently, during
particularly in and needed for • confusion sustained therapy.
Dosage: 1 tab signal bone formation. • feeling tired or Deficiencies in other
transduction • Manganese: restless ions, particularly
Route: PO pathways. needed for helping • drowsiness, magnesium,
maintain bone and feeling light- frequently coexist with
Frequency: OD - 8am teeth strength. Zinc, headed. calcium ion depletion.
Copper, and Intervention/Evaluation
Manganese: • Monitor sign of toxicity
needed for helping
maintain bone Patient/Family Teaching
health. Usage: To • Milk products are the
help maintain bone best sources of calcium
health.

Issue: 05 April 2006 Revision Code :003

18
18
 CAPITOL UNIVERSITY
COLLEGE OF NURSING

DRUG ORDER NURSING

RESPONSIBILITIES/
(Generic name, brand name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS
PRECAUTIONS
classification, dosage, route, ACTION OF THE DRUG
frequency)
Generic name: dexketoprofen • It is a non- • To treat short- • Hypersensitivity to • Headache Assessment:
steroidal anti- term painful dexketoprofen,
• Dizziness • Lab tests: Monitor
inflammatory conditions aspirin, or other
baseline and periodic
Brand name: Leodex drug (NSAID) NSAIDs. • Flushing evaluations of
that reduces
prostaglandin • Hypotension hemoglobin, renal and
hepatic function.
Classification: Non-steroidal synthesis via • Nausea
anti-inflammatory inhibition of Intervention/Evaluation
cyclooxygena • Vomiting
se pathway • Monitor sign of toxicity
• Diarrhea
Dosage: 1 tab (both COX-1 Patient/Family Teaching
and COX-2) • abdominal pain
activity. • Stay in bed, dizziness
• dyspepsia may persist.
Route: PO
• dry mouth
• constipation,
Frequency: BID – 8am, 6pm
Issue: 05 April 2006 Revision Code :003

19
 CAPITOL UNIVERSITY
COLLEGE OF NURSING

DRUG STUDY
DRUG ORDER NURSING
(Generic name, brand name, INDICATIONS RESPONSIBILITIES/
classification, dosage, route, MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS
PRECAUTIONS
frequency) ACTION OF THE DRUG

Generic name: levothyroxine • Levothyroxine • Levothyroxine is • adrenal • Nausea Assessment:

sodium is a indicated as insufficiency • Diarrhea
synthetically replacement therapy • Hyperthyroidism • change in appetite, • Lab tests: Baseline and
prepared levo- in primary (thyroidal), headache periodic tests of thyroid
isomer of the secondary (pituitary) • tremors function.
Brand name: Thydine Intervention/Evaluation
thyroid and tertiary • palpitation
hormone (hypothalamic) • nervousness • Monitor pulse before
thyroxine (T4, a congenital or
Classification: Thyroid each dose during dose
tetra-iodinated acquired
Hormones adjustment. If rate is
tyrosine hypothyroidism. It is >100, consult physician.
derivative) that also indicated as an • Monitor for adverse
acts as a adjunct to surgery effects during early
Dosage: 150 mcg replacement in and radioiodine adjustment.
deficiency therapy in the Patient/Family Teaching
syndromes management of
Route: PO such as thyrotropin- • Thyroid replacement
hypothyroidism. dependent well- therapy is lifelong.
differentiated thyroid • Notify physician
cancer. immediately of signs of
Frequency: OD-8am toxicity.
 CAPITOL UNIVERSITY
COLLEGE OF NURSING

DRUG STUDY
DRUG ORDER
(Generic name, brand name,
classification, dosage, route, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE NURSING RESPONSIBILITIES/
frequency) ACTION EFFECTS OF PRECAUTIONS
THE DRUG

Generic name: ferrous • combines in one • Treatment of • Hypersensitivity • Diarrhea, Assessment:

gluconate capsule anemia • decreased kidney • Constipatio • Obtain Lab tests: Hemoglobin,
haematopoietic caused by function n hematocrit.
Brand name: Sangobion substance in well iron deficiency • diarrhea • Abdominal Intervention/Evaluation
Iron balanced Pain • Lab tests: Monitor Hemoglobin level
proportion. • Nausea • Monitor bowel movements as
Together with other and constipation is a common adverse
Classification: Vitamins and
haematopoietic vomiting effect.
minerals
factors and iron • Advise patient to take iron
absorption supplements an hour before meals
Dosage: 1 tab
enhancing factors, for maximum absorption
Sangobion Patient/Family Teaching
Route: PO replenishes iron • Be aware that milk, eggs, or caffeine
stores and corrects beverages when taken with the iron
Frequency: OD-8am haemoglobin deficit preparation may inhibit absorption.
by increasing • Be aware that iron preparations
haemoglobin levels cause dark green or black stools.
in the body. • Report constipation or diarrhea to
physician.
 CAPITOL UNIVERSITY
COLLEGE OF NURSING

DRUG STUDY
DRUG ORDER NURSING RESPONSIBILITIES/
(Generic name, brand name, INDICATIONS PRECAUTIONS
classification, dosage, route, MECHANISM OF CONTRAINDICATIONS ADVERSE
frequency) ACTION EFFECTS OF THE
DRUG

Generic name: salbutamol- • relaxes the • relieve coughing • Hypersensitivity • Headache Assessment:
ipratropium smooth muscles of and shortness of • High blood pressure • Dizziness
breath • Drowsiness • Check heart rate
all airways, from
Brand name: Duavent neb the trachea to the • Dry mouth
Classification: terminal Intervention/Evaluation
Bronchodilator bronchioles
• Monitor heart rate
Dosage: 1 neb • Monitor patient response to the
drug.
Route: PO • Back tapping and allow patient to
Frequency: BID-8am, 6pm cough after to expectorate
secretions

Patient/Family Teaching
• rinse mouth after medication
puffs to reduce bitter taste.
• Take medication only as directed
 CAPITOL UNIVERSITY
COLLEGE OF NURSING

DRUG STUDY
DRUG STUDY

DRUG ORDER NURSING RESPONSIBILITIES/

(Generic name, brand name, INDICATIONS PRECAUTIONS
classification, dosage, MECHANISM OF CONTRAINDICATIO ADVERSE
route, frequency) ACTION NS EFFECTS OF THE
DRUG
Generic name: acetylcysteine • Acetylcysteine's • to relieve chest • Heart failure • Nausea and Assessment:
sulfhydryl groups congestion due • Hypertension vomiting
Brand name: NAC may hydrolize to thick or • Flushing • Assess respiratory rate,
• renal disease. depth, and rhythm
Classification: Mucolytic disulfide bonds abnormal
within mucin, mucous Intervention/Evaluation
Dosage: 1 tab breaking down the secretions in • Monitor respiratory rate,
oligomers, and people with lung depth, and rhythm
Route: PO
making the mucin conditions Patient/Family Teaching
Frequency: OD-8pm less viscous.
• Adequate hydration is
important for therapy
• Proper coughing and
deep breathing
technique

Issue: 05 April 2006 Revision Code :003

 CU-QMS-NURSING-0017

CAPITOL UNIVERSITY
COLLEGE OF NURSING

VIII. NURSING CARE MANAGEMENT

Priority #1
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) RATIONALE
Subjective: Impaired verbal Short-term: Independent: ● After 2-3 hours
• “galisud pa siya ug storya, communication related to • After 2-3 hours of ● Encourage the patient to use of nursing
dili pa niya kaya mu-storya” presence of artificial airway nursing an available mobile intervention, the
as verbalized by the tracheostomy possibly interventions, the application that can help with goal was met,
daughter. evidenced by difficulty patient will be able communication. and the patient
peaking. to learn to use a Rationale: can help the learned to use
Objective: form of patient express ideas and communication
• Tracheostomy attachment communication to communicate needs. materials
• Difficulty speaking noted get needs met ● Allow the client time to
and to relate communicate his or her ● After 1-2 days of
effectively with needs. nursing
persons and the Rationale: To let the client intervention, the
environment. practice her communication goal was
Long-term skills. partially met,
● After 1-2 days of ● Involve family and significant and the patient
nursing others in plan of care as was able to nod
intervention, the much as possible. the head and
patient will be Rationale: Enhances say “yes” or
able to nod the participation and commitment “no”.
head and say, to plan.
“yes or no”

24
24
 ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) RATIONALE
Dependent:
● Collaborate with the
healthcare provider and
speech therapist on the
possible use of a “taking”
tracheostomy tube as
indicated.
Rationale: It is a group that
works together to make
decisions regarding the
treatment of individual
patients and service users.
Also, Primary healthcare
providers play an
indispensable role in the
healthcare system to prevent
and manage common health
conditions. They may guide
patients to make healthy
decisions and recommend
treatment depending on the
symptoms of diseases that
present.
 CU-QMS-NURSING-0017

CAPITOL UNIVERSITY
COLLEGE OF NURSING

VIII. NURSING CARE MANAGEMENT

Priority #1
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) RATIONALE
Subjective: Fatigue related to decreased Short-term: Independent: ● After 2-3 hours
• hemoglobin, hematocrit, and • After 2-3 hours of ● Encourage the patient to use of nursing
Objective: RBC possibly evidenced by nursing an available mobile intervention, the
• Lack of energy the laboratory resul interventions, the application that can help with goal was met,
• Laboratory test patient will be able communication. and the patient
➢ Hemoglobin: ↓10.10 to learn to use a Rationale: can help the learned to use
g/dL form of patient express ideas and communication
➢ Hematocrit: ↓30.30 communication to communicate needs. materials
gm% get needs met ● Allow the client time to
➢ RBC:↓3.36 10°5/ul and to relate communicate his or her ● After 1-2 days of
effectively with needs. nursing
persons and the Rationale: To let the client intervention, the
environment. practice her communication goal was
Long-term skills. partially met,
● After 1-2 days of ● Involve family and significant and the patient
nursing others in plan of care as was able to nod
intervention, the much as possible. the head and
patient will be Rationale: Enhances say “yes” or
able to nod the participation and commitment “no”.
head and say, to plan.
“yes or no”

26
 ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) RATIONALE
Dependent:
• Instruct the client about
medications that may
stimulate RBC production in
the bone marrow as
prescribed by the physician.
• Rationale: Recombinant
human erythropoietin
(rHuEPO), a hematological
growth factor, increases
hemoglobin and decreases
the need for RBC
transfusions.
Collaborative:
• Refer the client and family to
an occupational therapist.
Rationale: The occupational
therapist can teach the client
about using assistive devices.
The therapist also can help
the client and family evaluate
the need for additional
energy-conservation
measures in the home
setting.

27
IX. DISCHARGE PLAN
Long-term goals:
● The patient and her loved ones will have a thorough understanding of the
prognosis, as well as further home management and therapies, in order to provide
the care she requires.
● The patient and her close friends and family will be able to prevent problems and
aid in the recovery of the patient's condition.
Medications:
● Instruct the patient and significant others to take the prescribed drugs exactly as
prescribed by the doctor for the first several months after discharge.
● Instruct the patient and people who are close to them about the necessity of taking
drugs exactly as prescribed in terms of dosage and timing.
Environmental.
● Instruct family members to maintain a quiet environment as much as possible to
avoid disturbed sleep patterns and for fast recovery.
Treatment/ therapy:
● Teach the patient and anybody else who cares about them the necessity of
keeping follow-up appointments.
● Explain to them the significance of taking their prescriptions at home as directed
by their doctor. - Informing the patient and significant others about the need of
continuing and finishing all medications at home, as well as when and how to
administer them.
Health Teaching:
● Emphasize the importance of following the doctor's prescription for medications or
medication. Premature treatment termination can lead to infection and other injury
problems.
● Make a point of emphasizing the patient's need for good nutrition.
● To avoid the transmission of pollutants that could infect the patient's wound, proper
personal hygiene and hand washing should be practiced.
Outpatient:
● Instruct the patient and other important people in the patient's life about the
necessity of regular check-ups and any follow-up visits to any health care provider.
To keep a constant eye on the patient's condition.

29
Diet:
● Diet recommended by the physician such as low sodium, and low fat should be
followed and optimally balanced nutrition such as fish and vegetables should be
promoted.
Spiritually:
● Explain to the patient and significant others that spiritual care is equally as vital as
physical treatment.
● Encourage the patient to continue practicing her religion once she has been
discharged. Spiritual care is critical because it gives the patient hope and belief
that she will fully recover from her condition.
X. RESULTS AND DISCUSSION
The patient underwent Thyroidectomy last 2013 and resection of the first tumor
recurrence last 2015. Noted second tumor recurrence last 2021. Another procedure tumor
debulking was performed and a tracheostomy is attached to the patient to maintain airway
clearance. However, the patient is unable to speak properly because of the tracheostomy.
Medication was given for the relief of pain after the surgery. In the two-day care of the
patient, there are no indications of respiratory problems. The patient has low RBC,
hemoglobin, and hematocrit level as shown in her laboratory result. She was given
medication to treat her low RBC, hemoglobin, and hematocrit level.

XI. CONCLUSION
The most typical kind of thyroid cancer is papillary thyroid cancer. This case study
enables the student nurses to obtain knowledge of the patient's disease process and
discover the relationships between the treatment plan, medical-nursing interventions, and
the disease itself, which strengthened and enhanced our understanding of Thyroid
Cancer Stage IV. This was completed by a thorough physical examination and family
history investigation. Throughout the clinical exposure nursing interventions were
implemented and proper management was applied to help elevate the patient’s condition

30
VII. REFERENCES

Cherry, K. (2022). Piaget's 4 Stages of Cognitive Development Explained Background

and Key Concepts of Piaget's Theory. Verywell Mind.
https://www.verywellmind.com/piagets-stages-of-cognitive-development-2795457

Cherry, K. (2022). Kohlberg's Theory of Moral Development. Verywell Mind.

https://www.verywellmind.com/kohlbergs-theory-of-moral-development-
2795071#:~:text=Kohlberg's%20theory%20of%20moral%20development%20is%
20a%20theory%20that%20focuses,on%20seeking%20and%20maintaining%20ju
stice.

Cherry, K. (2023). Freud's Stages of Human Developmen: The 5 Psychosexual Stages

of Development by Age.Verywell Mind. https://www.verywellmind.com/freuds-
stages-of-psychosexual-development-2795962

Cleveland Clinic. (n.d.). Thyroid Cancer: Types, Symptoms, Causes & Treatment.
https://my.clevelandclinic.org/health/diseases/12210-thyroid-cancer

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide [Book]. In
Diagnoses, prioritized interventions, and rationales (15th ed., Vol. 1). F.A. Davis
Company

House of Representatives Press Releases. (2015). House of Representatives.

https://www.congress.gov.ph/press/details.php?pressid=8483

Mcleod, S. (2023). Freud’s Psychosexual Theory And 5 Stages Of Human Development.

Simply Psychology. https://simplypsychology.org/psychosexual.html

Mcleod, S. (2023). Kohlberg’s Stages Of Moral Development. Simply Psychology.

https://simplypsychology.org/kohlberg.html#:~:text=Kohlberg%20suggested%20t
hat%20people%20move,preconventional%2C%20conventional%2C%20and%20
postconventional

Mcleod, S. (2023). Jean Piaget’s Theory And Stages Of Cognitive Development. Simply
Psychology. https://simplypsychology.org/piaget.html

Nguyen, Q. T., Lee, E. J., Huang, M. G., Park, Y. I., Khullar, A., & Plodkowski, R. A.
(2015). Diagnosis and Treatment of Patients With Thyroid Cancer. PubMed
Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415174/

Shi, G. (2019). LearnOncology. LearnOncology.

https://www.learnoncology.ca/modules/thyroid-cancer

Susman, D. (2022). Erikson’s Stages of Development. VeryWell Mind.

https://www.verywellmind.com/erik-eriksons-stages-of-psychosocial-
development-2795740

Toney-Butler, T. J., & Unison-Pace, W. J. (2022). Nursing Admission Assessment and

Examination - StatPearls - NCBI Bookshelf. Nursing Admission Assessment and
Examination - StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK493211/

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