NCP Format

Easter College
DEPARTMENT OF NURSING
Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483
E-mail: ndcon2013@gmail.com
Website: www.eastercollege.ph
A Case Study on Neck Mass Infection
Area of Rotation:
Medical 5 Ward
Inclusive Dates:
September 22-24, 2022
Submitted by:
Rafael, Diana c
BSN 3C
Submitted to:
Sir David Jezer Reyes
09/28/2022
VISION
Glocally renowned school of nursing
MISSION
Pursue excellence in shaping and transforming learners into spiritually upright and competent servant-professionals
OBJECTIVES
The BSN program desires to develop culturally- responsive nursing professionals advocating advanced nursing knowledge, ethical principles and clinical excellence consistent with Christian character traits and quality nursing education and practice. It aims to produce a fully functioning nurse who is able to perform the competencies under each of the key
areas of responsibility:
safe and quality nursing care, management of resources and environment, health education, legal responsibility ,personal and professional development, quality improvement, research, record management, communication, and collaboration and teamwork
Easter College
Phone: (074) 424-5483
I. Patient’s Profile:
Name: Edmundo Mojar
Age: 63 years old
Address: 112 Purok 3, Asin road Baguio City, Benguet
Gender: Male
Ethnicity: Pangasinense
Language/ dialect spoken/ understood: Tagalog, Ilocano
Religion: Roman Catholic
Occupation: Dependent
Educational Attainment: N/A
Area of Confinement: Medical Ward
Admission Date: August 26, 2022
Admission Time: 1:56 AM
Admitting Physician: Habiling, Kavin B.
Attending Physician:
Chief Complaint: Difficulty of breathing
Medical Diagnosis: Infected Neck Mass
II. History of Present Illness:
Patient is a known case of laryngeal SCCA s/p bilateral laryngectomy with neck dissection last July 2022.Patient offered chemotherapy but has lost to
follow up. 1 week pta, patient noted progression of neck mass with noted ulcerated wound on the mass with noted foul smelling discharge prompted
consult and subsequent admission.
III. History of Past Illness:
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
IV. Family History of Illness:

V. Social and Environmental Status:
VI. Physical Assessment:
General Survey ● Edmundo Mojar , 63 yrs. old, male, at station 2 D6

Initial V/S: BP: 110/80 mmhg
HR: 99 bpm
RR: 16 cpm
TEMP: 36.0
SPO2: 95 %
Skin ● AS, PPC, (-) pallor, (-) cyanosis, (-) jaundice, (-) warm to touch, (-) good skin turgor, (-) rashes.
Head ● (-) gross deformities, (-) trauma, (-) neck vein engorgement, (-) CLAD,
Eyes ● (+) anicteric sclerae, pink palpebral conjunctiva, (-) sunken eyeballs, (-) periorbital edema
Ears ● (-) deformed ears, (-) discharges, (-) impacted cerumen, (-) intact tympanic
Nose ● (-) discharge, (-) congestion, (-) alar flaring
CHEST & LUNGS (Breast, Heart) ● Subsegmental atelectasis both lower lobes, atherosclerotic aorta, degenerative thoracic spondylosis
GASTROINTESTINAL ● Soft non-tender
GENITO-URINARY ● (-) difficulty in urination, urine is yellow in color and consistency is clear.
Peripheral / Vascular ● Normal capillary refill time, no carotid bruits, sensation in the lower limbs is soft, no abnormal pulsations in
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
the abdomen.
Musculoskeletal ● Size and normal shapes, arms, and wrist are symmetrical, no redness or swelling. Elbows have no
deformities.
Neurologic ● awake, (-) active, (-) conversant
Hematologic ● No clotting or bleeding, no enlargement of spleen and liver.
Endocrine ● High temperature (-) excessive sweating, (-) cardiac irregularity
Psychiatric ● Normal
VII. Prioritization of Identified Nursing Diagnoses:
List of Identified Nursing Diagnoses Guide/ Basis Justification
Fluid volume excess r/t retained fluid on interstitial The patient has fluid retention on both hands Fluid volume excess is also known as fluid
spaces where veins are having trouble transporting overload, is a condition where you have too
enough blood all the way to the hands and much fluid volume in your body. Body fluids,
back to the heart. like blood and water, are important to keep
your organs functioning. People with heart and
kidney conditions and people who are pregnant
often experience hypervolemia.
Impaired Skin Integrity r/t Biological injuring agent The mass on the neck of the patient has a Good skin integrity is vital to good health
secondary to neck mass infection foul smelling and purple colored. Neck because the skin acts as a barrier to microbes
abscess is a collection of pus from an infection and toxins, as well as physical stressors such
in spaces between the structures of the neck. as sunlight and radiation. It is well known that
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
As the amount of pus increases, the soft the skin loses integrity with the ageing process,
tissue spaces expand and push against the and this makes older adults susceptible to
structures in the neck, such as the throat, pressure injury.
tongue, and, in extreme cases, the trachea.
Risk for Deficient Fluid Volume r/t haemorrhage It was observed that blood comes out from It is a state or condition where the fluid output
the tracheostomy valve as the patient cough exceeds the fluid intake. The body loses both
or release phlegm. water and electrolytes from the ECF in similar
proportions. Common sources are the
gastrointestinal tract, polyuria, and increased
perspiration.
VIII. Drug Study:
Drug/ Classification Dose/Route/Frequency Mechanism of action Common Side Effects Nursing responsibilities
Tramadol 50-100 mg every 4-6 Tramadol is a centrally -Constipation.  Be alert for excessive sedation or somnolence.
hours IV / IM acting μ-opioid receptor -discouragement.  Notify physician or nurse immediately if patient is
agonist and SNRI -drowsiness. unconscious or extremely difficult to arouse.
(serotonin/norepinephrine -feeling of warmth.  Monitor other changes in mood and behavior,
reuptake-inhibitor) that is -feeling unusually cold. including euphoria, confusion, malaise, nervousness,
structurally related and anxiety.
-itching or skin rash.
to codeine and morphine.
-loss of strength or
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
Tramadol binds weakly to weakness.  Notify physician if these changes become

κ- and δ-opioid receptors -muscle aches and pains. problematic.
and to the μ-opioid
receptor with 6000-fold
less affinity than
morphine.
Vancomycin 5 mg/ solution IV every Inhibits cell wall - Reddish rash on face  Assess any back or neck pain to rule out
6 hours synthesis by binding to and upper body musculoskeletal pathology; that is, try to determine if
the D-Ala-D-Ala terminal (intravenously: red neck pain is drug induced rather than caused by anatomic
or red man syndrome,
of the growing peptide or biomechanical problems.
related to infusion rate),
chain during cell wall low blood  Monitor for signs of eosinophilia (fatigue, weakness,
synthesis, resulting in pressure accompanied by myalgia) or leukopenia (fever, sore throat, signs of
inhibition of the flushing, nausea, infection).
transpeptidase, which vomiting, chills, drug
prevents further fever, high levels of white
elongation and cross- blood cells (eosinophilia),
rash, fatigue, swelling of
linking of the
hands and feet.
peptidoglycan matrix (see
glycopeptide pharm)
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
IX. Pathophysiology:
NECK MASS INFECTION
SIGNS AND
RISK FACTORS SYMPTOMS
- Shortness of
- Bacterial / viral breath.
infections - Nasal
congestion.
-flu, mono, or
NURSING DIAGNOSIS - Stiff neck.
strep throat
-Burning or pain
- Fluid Volume excess r/t retained with urination
fluids o interstitial spaces.
- Impaired Skin Integrity r/t

biological Injuring agent
secondary to neck infection.
LAB TESTS
- Risk for deficient fluid volume
r/t haemorrhage. - CBC
-Radiotherapy
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
X. Nursing Care Plan Proper:
ACTUAL
DATA GOALS/ Expected ACTION/ NURSING RATIONALE RESPONSE &

outcomes INTERVENTIONS EVALUATION
Subjective findings: Dxtc: STG:
STG: After 1 hour of NI the patient was able to to
“May lumalabas na dugo ● Check and monitor ● To obtain a maintain balanced intake and output and
minsan ‘pag umuubo, Within 1 hour of NI the vital signs baseline data stable weight normal vital signs.
tapos ganayan nadin patient will be able to
dalawang kamay nya” as maintain balanced ● Monitor input and ●Dehydration may be
verbalized intake and output and output closely the result of fluid
stable weight and shifting even if overall STG: FULLY MET
Objective findings:
normal vital signs. fluid intake is
 Vital signs adequate LTG :
BP: 110/80 mmhg Txc: Within 8 hours of NI the patient was able to
LTG
HR: 99 bpm
Within 8 hours of NI ● Established rapport
● To gain trust and clear lung sounds as manifested by absence of
RR: 16 cpm
the patient will be able approach pulmonary crackles
TEMP: 36 ºC
SPO2: 95% to clear lung sounds as
 Presence of edema manifested by absence ● Restriction of
● Limit sodium intake LTG: PARTIALLY MET
on both hands and of pulmonary crackles. sodium aids in
as prescribed.
bruises due to decreasing fluid
radiotherapy.
● Ensured safety by ● To prevent from
raising the side rails falling.
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
Focus/ Nursing Dx:

(PE/S)
● Reposition the client ● To promote optimal
Fluid Volume Excess r/t in a comfortable or patient comfort and
retained fluids on prefered position. reduce restlessness.
interstitial spaces
Edx:
● Instructed to ● To determine any

verbalize concern underlying factors and
symptoms
● Instruct patient,
caregiver, and family ● Information and
members regarding knowledge about
fluid restrictions, as condition are vital to
appropriate. patients who will be
co-managing fluids.
ACTUAL

“Ganyan po talaga ● Check and monitor ● To obtain a maintain balanced intake and output and
naaging resulta ng Within 2 hours of NI vital signs baseline data stable weight normal vital signs.
infection sa leeg nya, the patient will be able
malakas din yung amoy” to maintain intact skin ● Assess skin turgor,
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
as verbalized integrity as evidenced sensation, and ● Poor skin turgor,

by normal skin color. circulation decreased sensations STG: FULLY MET
Objective findings: and poor circulation
LTG increase the risk of LTG :
 Vital signs Within 8 hours of NI tissue damage.
BP: 110/80 mmhg the patient will be able Txc: Within 8 hours of NI the patient was able to
HR: 99 bpm to experience timely ● Established rapport
RR: 16 cpm ● To gain trust and experience timely healing of wounds and mass
healing of wounds and
TEMP: 36 ºC mass infection without approach infection without complications
SPO2: 95% ● Perform wound care
complications per guidelines and ● Wound care
 Present foul smelling
discharges orders differs depending on LTG: PARTIALLY MET
 Purple in color skin the type of skin
mass. breakdown, location
on the body, and size
of the wound.
Focus/ Nursing Dx: Inadequate or
(PE/S) incorrect wound care
delays healing and
Impaired skin Integrity r/t increases the risk for
biological injuring agent infection.
secondary to neck mass ● Repositioning and
infection support of boney ● Patients who cannot
prominences reposition themselves
should be turned in
bed on a schedule at
least every 2 hours.
Boney prominences
such as hips, knees,
heels, and elbows
should be supported
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
with pillows or devices

to allow for proper skin
Edx: perfusion.
● Instructed to
verbalize concern ● To promote optimal
patient comfort and
reduce restlessness.
● Encourage nutrition
and hydration ● Proper intake of fluids
increases oxygen and
nutrient delivery to the
wound bed by
increasing the blood
volume. Intake of high
protein foods and
supplements is
essential for repairing
body tissues.
POTENTIAL

“May lumalabas po na ● Check and monitor ● To obtain a remain normovolemic as evidenced by systolic
dugo ‘pag minsan  Within 2 hours of NI vital signs baseline data BP greater than or equal to 90 mm HG,
umuubo” as verbalized the patient will be absence of orthostasis, HR 60 to 100
VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
able to remain beats/min, urine output greater than 30 mL/hr

Objective findings: normovolemic as ● Assess skin turgor ● Poor skin turgor, and normal skin turgor.
evidenced by and oral mucous decreased sensations
 Vital signs systolic BP greater membranes for and poor circulation
BP: 110/80 mmhg than or equal to 90 signs of dehydration. increase the risk of
HR: 99 bpm mm HG, absence of tissue damage. STG: FULLY MET
RR: 16 cpm orthostasis, HR 60
TEMP: 36 ºC to 100 beats/min, LTG :
SPO2: 95% urine output greater
than 30 mL/hr and Txc: Within 8 hours of NI the patient was able to
Focus/ Nursing Dx: normal skin turgor. ● Established rapport ● To gain trust and
(PE/S) approach demonstrate lifestyle changes to avoid
LTG ● Urge the patient to progression of dehydration.
Risk for Deficient Fluid Within 8 hours of NI drink the prescribed ● Older patients LTG: FULLY MET
Volume r/t haemorrhage the patient will be able amount of fluid. have a decreased
to demonstrate lifestyle sense of thirst and
changes to avoid may need ongoing
progression of reminders to drink.
dehydration. Edx:
 Emphasize the
importance of oral ● A fluid deficit can
hygiene. cause a dry, sticky
mouth. Attention to
mouth care promotes
interest in drinking and
reduces the discomfort
of dry mucous
membranes.
 Encourage to drink ● A patient may have

VISION
MISSION
OBJECTIVES
Easter College
Phone: (074) 424-5483
bountiful amounts of restricted oral intake in

fluid as tolerated or an attempt to control
based on individual urinary symptoms,
needs. reducing homeostatic
reserves and
increasing the risk of
dehydration or
hypovolemia..
VISION
MISSION
OBJECTIVES

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Easter College

A Case Study on Neck Mass Infection

September 22-24, 2022

Sir David Jezer Reyes

II. History of Present Illness:

IV. Family History of Illness:

VI. Physical Assessment:

General Survey ● Edmundo Mojar , 63 yrs. old, male, at station 2 D6

VII. Prioritization of Identified Nursing Diagnoses:

List of Identified Nursing Diagnoses Guide/ Basis Justification

VIII. Drug Study:

Tramadol binds weakly to weakness.  Notify physician if these changes become

- Impaired Skin Integrity r/t

X. Nursing Care Plan Proper:

DATA GOALS/ Expected ACTION/ NURSING RATIONALE RESPONSE &

Focus/ Nursing Dx:

● Instructed to ● To determine any

DATA GOALS/ Expected ACTION/ NURSING RATIONALE RESPONSE &

as verbalized integrity as evidenced sensation, and ● Poor skin turgor,

with pillows or devices

DATA GOALS/ Expected ACTION/ NURSING RATIONALE RESPONSE &

able to remain beats/min, urine output greater than 30 mL/hr

 Encourage to drink ● A patient may have

bountiful amounts of restricted oral intake in

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