LICEO DE CAGAYAN UNIVERSITYCollege of Nursing

A Case StudyOn

IN PARTIAL FULFILLMENT OF NCM501204

SUBMITTED TO:

Ms. Christine D. Paderange, R.N

SUBMITTED BY:

Borja, Mary Karen Rose T.Cimacio, May Grace

Casinillo, Vincent Chris L.Cortez, Elmar Bonniday M.

July 2009

I. Introduction

A. Brief Description of the Disease Condition

The body is made up of many types of cells. Normally, cells grow, divide and

die. Sometimes, cells mutate (change) and begin to grow and divide more

quickly than normal cells. Rather than dying, these abnormal cells clump

together to form tumors. If these tumors are malignant (cancerous), they can

invade and kill your body's healthy tissues. From these tumors, cancer cells can

metastasize (spread) and form new tumors in other parts of the body. By

contrast, benign (noncancerous) tumors do not spread to other parts of the

body. Nasopharyngeal (say: "nay-zo-fair-in-gee-al") cancer is a malignant tumor

that develops in the nasopharynx (say: "nay-zo-fair-inks"). The nasopharynx is

the area where the back part of your nose opens into your upper throat. This is

also where tubes from your ears open into your throat.

Nasopharyngeal cancer is rare. It most often affects people who are between 30

and 50 years of age. Men are more likely to have nasopharyngeal cancer than

women. You are most likely to get this cancer if you or your ancestors came

from southern China, particularly Canton (now called Guangzhou) or Hong

Kong. You are also more likely to get this cancer if you are from a country in

Southeast Asia, like Laos, Vietnam, Cambodia or Thailand. No one knows for

sure what causes nasopharyngeal cancer. Eating salt-preserved foods (like fish,

eggs, leafy vegetables and roots) during early childhood may increase the risk

of getting this form of cancer. The Epstein-Barr virus may also make a person

more likely to get nasopharyngeal cancer. This is the same virus that causes

infectious mononucleosis (also called "mono"). You may also inherit a tendency

to get nasopharyngeal cancer.

Reason for Choosing the Case

Nasopharyngeal Cancer is one of the unusual terms for a lay person and a rare

case that a nurse would encounter. Acquisition of cognitive knowledge regarding

the topic would enable the researchers in providing optimum care for clients

suffering such and in delivering appropriate interventions that would promote

health and wellness for the client. Since our rotation is about EENT, this

condition can also be acceptable.

Statistics (Global and Local)

Cancer of the nasopharynx is a rare neoplasm in most countries. However, it

occurs at high frequencies in China and Southeast Asia. The highest incidence

rates in the SEER regions occur among the Chinese. Rates are also high in

Vietnamese and Filipino men, two groups that include persons of Chinese

heritage. Incidence rates of nasopharyngeal cancer are also available for black,

Hispanic and white men and for white women in the SEER areas. There were

too few nasopharyngeal cancers diagnosed between 1988 and 1992 in the other

racial/ethnic groups to provide meaningful incidence rates.

The average annual age-adjusted incidence rate of nasopharyngeal cancer in

Chinese men, 10.8 per 100,000, is 1.4 times greater than that of Vietnamese

men and nearly 2.8 times greater than that of Filipino men. In fact, the rate

among Filipino men, although relatively high, is the same as that for Chinese

women. Rates of one per 100,000 and lower occur in black men, Hispanic and

non-Hispanic white men and non-Hispanic white women.

The United States mortality rates for cancer of the nasopharynx reflect patterns

similar to those for SEER incidence rates. Mortality is highest in Chinese, lower

in Filipinos and lowest among blacks, Hispanics and non-Hispanic whites. No

mortality rates are currently available for Vietnamese. Incidence-to-mortality rate

ratios vary, with Chinese and Filipinos having higher incidence relative to

mortality (2.3 for men in both groups and 3.2 for Chinese women) than other

groups (ranging from about 1.7 for white Hispanic men to two for non-Hispanic

white men). Incidence and mortality rates for nasopharyngeal cancer increase

through the oldest age group, although the small number of cases precluded the

calculation of reliable rates for many populations.

The major modifiable risk factor identified for cancer of the nasopharynx is the

consumption of Cantonese salted fish, which is a common food item eaten from

early infancy onward by groups with high risk of this disease. Other possible risk

factors include extensive exposures to dusts and smoke and regular

consumption of other fermented foods. The role of Epstein-Barr virus in the

development of nasopharyngeal cancer continues to be explored.

B. Objectives of the study

The main concern of this study is: to have a better understanding about the causes of nasopharyngeal

cancer.

to determine the medical and surgical treatment that has given to the

disease entity.

to perform well our role as student nurses in the treatment and achieving

the optimum level of health of the patient.

to enhance our nursing skills most importantly focusing on promotive and

preventive nursing measures.

C. Scope and Limitations

The scope of the study are as follows:

The patient must be admitted at Cagayan de Oro Medical Center.

The patient must have an informant.

The student must have the consent coming from the family to make the

client as a subject of the study.

The scope of the study includes the patient’s profile, the developmental

data, the health history of the patient, the history of present illness, the

nursing assessment, the anatomy and physiology of the involved

structures, the pathophysiology of the condition, the patient’s diagnosis,

the diagnostic exams, the nursing management, the medical management

and the recommendation and the patient’s prognosis as evaluated by the

student nurse conducting this study.

The different references were also part of this study, which encompasses

the use of the different pathophysiology books, nursing care plan books

and other sources which served as guide throughout the study.

 The limitations of the study are as follows:

Interaction with the client was limited to 2 days of care only. The first

interaction was on July 6, 2009 at Cagayan de Oro Medical Center during

the first day of duty and July 7, 2009 for our last duty. The interaction was

limited only on the days the patient was confined to the Hospital.

The information gathered were based on the legal informants, and the

client himself who may still be subjected for further critique in terms of

validity and reliability.

The discussion on the pathophysiology is focused on the principal

diagnosis and the signs and symptoms manifested by the client.

II. HEALTH HISTORY

A. Patient’s Profile

Name: Egberto Villanueva

Age: 70 years old

Address: Lot 7 Block 14 Phase 2, Miguel Manolo Fortich

Bukidnon

Sex: Male

Civil Status: Married

Birthdate: April 24, 1939

Birthplace: Manolo Fortich Bukidnon

Nationality: Filipino

Occupation: Retired Supervisor in Del Monte Philippines

Religion: Roman Catholic

Educational Attainment: Graduate of Agricultural in Central Mindanao

University

Date of admission: July 6, 2009

Allergies: No known allergies to food and drugs

Temperature: 36.8 º C

Pulse Rate: 70 bpm

Respiratory Rate: 23 cpm

Blood Pressure: 130/80 mmHg

Height: 5’5”

Weight: 125 pounds

Attending Physician: Dr. Abas

Diagnosis: Nasopharyngeal Carsinoma

Chief complaint: For chemotherapy 4th patient was diagnosed with

Nasopharyngeal carcinoma there started 1st chemotherapy his march 2009

B. HISTORY OF PRESENT ILLNESS and CHIEF COMPLAINT

Last March 2009, the patient has been in session of Chemotherapy.

and last March was his first. The patient is also having a Diabetic and has a

maintenance of the following medication : Galdos tab OD and Litizak 500mg Tab

OD.

The patient was admitted for his 4th session and scheduled on

Chemotheraphy under Doctor Abas. Was admitted 6:30 am, July 6, 2009.

III. DEVELOPMENTAL DATA

Psychosocial TheoryOur personality traits come in opposites. We think of ourselves as

optimistic or pessimistic, independent or dependent, emotional or unemotional,

adventurous or cautious, leader or follower, aggressive or passive. Many of these

are inborn temperament traits, but other characteristics, such as feeling either

competent or inferior, appear to be learned, based on the challenges and support

we receive in growing up.

Erik Erikson organized life into eight stages that extend from birth to death

(many developmental theories only cover childhood). Since adulthood covers a

span of many years, Erikson divided the stages of adulthood into the experiences

of young adults, middle aged adults and older adults. While the actual ages may

vary considerably from one stage to another, the ages seem to be appropriate for

the majority of people.

Late Adulthood: 55 or 65 to Death

Ego Development Outcome: Integrity vs. DespairBasic Strengths: Wisdom

Erikson felt that much of life is preparing for the middle adulthood stage

and the last stage is recovering from it. Perhaps that is because as older adults

we can often look back on our lives with happiness and are content, feeling

fulfilled with a deep sense that life has meaning and we've made a contribution to

life, a feeling Erikson calls integrity. Our strength comes from a wisdom that the

world is very large and we now have a detached concern for the whole of life,

accepting death as the completion of life.

On the other hand, some adults may reach this stage and despair at their

experiences and perceived failures. They may fear death as they struggle to find

a purpose to their lives, wondering "Was the trip worth it?" Alternatively, they may

feel they have all the answers (not unlike going back to adolescence) and end

with a strong dogmatism that only their view has been correct.

The significant relationship is with all of mankind—"my-kind."

As of for our client we thought that he had reached this stage and

overcome it positively. There are problem’s that he successfully overcome with

his own strength and knowledge.

Developmental Task Theory Robert Havighurst defines a developmental task as one that arises at a

certain period in our lives, the successful achievement of which leads to

happiness and success with later tasks; while leads to unhappiness, social

disapproval, and difficulty with later tasks. He recognized that each human has

three sources for developmental tasks. They are:

Tasks that arise from physical maturation: Learning to walk, talk, control of

bowel and urine, behaving in an acceptable manner to opposite sex,

adjusting to menopause.

Tasks that arise from personal values: Choosing an occupation, figuring

out ones philosophical outlook.

Tasks that have their source in the pressures of society: Learning to read,

learning to be responsible citizen.

The developmental tasks model that Havighurst developed was age dependent

and all served pragmatic functions depending on their age.

Age 60 and over (Late Maturity)

Adjusting to decreasing physical strength and health. Adjusting to retirement

and reduced income.  Establishing an explicit affiliation with one’s age group.

Adopting and adapting social roles in a flexible way. Establishing satisfactory

physical living arrangements.

IV. Medical Management

A. Medical orders and rationale

7/6/09

6:00 am RATIONALE

Pls. admit to station 4

IVF: 0.9 NaCl 1L at 30gtts/min

For CBC in AM

Endorsement of patient to the station

To maintain patients fluid balance

to

To determine, evaluate and diagnose pt. condition and to visualize if there are abnormalities.

7/7/09 RATIONALE

For chemothrapy

Continue IV hydration

Cover iv tubing with black tape

Refer accordingly

shrink tumors , destroy cells that have spread to other parts of the body or control tumor growth.. Chemotherapy works by interfering with the growth and reproductive process of cancer cells.

To maintain patients fluid balance

This is not to alter the chemicals use in chemotherapy

to check appropriate order

Laboratory Results

CBCRESULT NORMAL RANGE INTERPRETATION

WBC 8,200 5,000-10,00 /MM3 Normal

RBC 3.4 4.35-5.90 /MM3 Low red blood cells

Hgb 10.7 13.7-167 g.Dl Bone marrow insufficiency

Hct 33.1 40.5- 49.7 VOLS %indicates anemia

PLATELET 348,000 144,000-372,000 normalMCV 96.0 79.7-97.06 normalMCH 32.4 26.1-33.3 pq normal

MCHC 33.5 32.2-35.0 q/dl normalDIFF. COUNT

Neutrophils 69 43.4-76.2% normalLymphocytes 19 17.4-46.2% normal

Monocytes 10 4.5-10.5%

Decreased ability to regulate immune function and repair body tissues

Eosinophil 1.4 2-3% normalBasophil 0.2 0-0.5% normal

V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

Anatomy and Physiology of the Human Respiratory System

The respiratory system consists of all the

organs involved in breathing. These

include the nose, pharynx, larynx, trachea,

bronchi and lungs. The respiratory system

does two very important things: it brings

oxygen into our bodies, which we need for

our cells to live and function properly; and it

helps us get rid of carbon dioxide, which is

a waste product of cellular function. The

nose, pharynx, larynx, trachea and bronchi

all work like a system of pipes through which the air is funneled down into our

lungs. There, in very small air sacs called alveoli, oxygen is brought into the

bloodstream and carbon dioxide is pushed from the blood out into the air. When

something goes wrong with part of the respiratory system, such as an infection

like pneumonia, it makes it harder for us to get the oxygen we need and to get rid

of the waste product carbon dioxide. Common respiratory symptoms include

breathlessness, cough, and chest pain.

The Upper Airway and Trachea

When you breathe in, air enters your body

through your nose or mouth. From there, it

travels down your throat through the larynx (or

voicebox) and into the trachea (or windpipe)

before entering your lungs. All these structures

act to funnel fresh air down from the outside

world into your body. The upper airway is

important because it must always stay open for

you to be able to breathe. It also helps to

moisten and warm the air before it reaches

your lungs.

The Lungs

The lungs are paired, cone-shaped organs which take up most of the space in

our chests, along with the heart. Their role is to take oxygen into the body, which

we need for our cells to live and function properly, and to help us get rid of

carbon dioxide, which is a waste product. We each have two lungs, a left lung

and a right lung. These are divided up into 'lobes', or big sections of tissue

separated by 'fissures' or dividers. The right lung has three lobes but the left lung

has only two, because the heart takes up some of the space in the left side of our

chest. The lungs can also be divided up into even smaller portions, called

'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other by

membranes. There are about 10 of them in each lung. Each segment receives its

own blood supply and air supply.

Air enters your lungs through a system of pipes called the bronchi. These pipes

start from the bottom of the trachea as the left and right bronchi and branch many

times throughout the lungs, until they eventually form little thin-walled air sacs or

bubbles, known as the alveoli. The alveoli are where the important work of gas

exchange takes place between the air and your blood. Covering each alveolus is

a whole network of little blood vessel called capillaries, which are very small

branches of the pulmonary arteries. It is important that the air in the alveoli and

the blood in the capillaries are very close together, so that oxygen and carbon

dioxide can move (or diffuse) between them. So, when you breathe in, air comes

down the trachea and through the bronchi into the alveoli. This fresh air has lots

of oxygen in it, and some of this oxygen will travel across the walls of the alveoli

into your bloodstream. Travelling in the opposite direction is carbon dioxide,

which crosses from the blood in the capillaries into the air in the alveoli and is

then breathed out. In this way, you bring in to your body the oxygen that you

need to live, and get rid of the waste product carbon dioxide.

Blood Supply

The lungs are very vascular organs, meaning they receive a very large blood

supply. This is because the pulmonary arteries, which supply the lungs, come

directly from the right side of your heart. They carry blood which is low in oxygen

and high in carbon dioxide into your lungs so that the carbon dioxide can be

blown off, and more oxygen can be absorbed into the bloodstream. The newly

oxygen-rich blood then travels back through the paired pulmonary veins into the

left side of your heart. From there, it is pumped all around your body to supply

oxygen to cells and organs.

The Pleurae

The lungs are covered by smooth

membranes that we call pleurae. The pleurae

have two layers, a 'visceral' layer which sticks

closely to the outside surface of your lungs,

and a 'parietal' layer which lines the inside of

your chest wall (ribcage). The pleurae are

important because they help you breathe in

and out smoothly, without any friction. They

also make sure that when your ribcage

expands on breathing in, your lungs expand

as well to fill the extra space.

The Diaphragm and Intercostal Muscles

When you breathe in (inspiration), your muscles need to work to fill your lungs

with air. The diaphragm, a large, sheet-like muscle which stretches across your

chest under the ribcage, does much of this work. At rest, it is shaped like a dome

curving up into your chest. When you breathe in, the diaphragm contracts and

flattens out, expanding the space in your chest and drawing air into your lungs.

Other muscles, including the muscles between your ribs (the intercostal muscles)

also help by moving your ribcage in and out. Breathing out (expiration) does not

normally require your muscles to work. This is because your lungs are very

elastic, and when your muscles relax at the end of inspiration your lungs simply

recoil back into their resting position, pushing the air out as they go.

The Respiratory System and Ageing

The normal process of ageing is associated with a number of changes in both the

structure and function of the respiratory system. These include:

Enlargement of the alveoli. The air spaces get bigger and lose their

elasticity, meaning that there is less area for gases to be exchanged

across. This change is sometimes referred to as 'senile emphysema'.

The compliance (or springiness) of the chest wall decreases, so that it

takes more effort to breathe in and out.

The strength of the respiratory muscles (the diaphragm and intercostal

muscles) decreases. This change is closely connected to the general

health of the person.

All of these changes mean that an older person might have more difficulty coping

with increased stress on their respiratory system, such as with an infection like

pneumonia, than a younger person would.

Pathophysiology (Book-based and Client-centered)

Definition of the Disease

Nasopharyngeal cancer is a disease in which malignant (cancer) cells form in the

tissues of the nasopharynx.

Predisposing Factors

People who are between 30 and 50 years of age

Men are more likely to have nasopharyngeal cancer than women

Chinese or Asian ancestry

Hereditary

Precipitating Factors

Eating salt-preserved foods (like fish, eggs, leafy vegetables and roots)

during early childhood

Cigarette smoking

Alcohol abuse

Poor Oral Hygiene

Long Term Sun Exposure

Occupational Exposure (chemicals esp. asbestos)

Signs and Symptoms with Rationale

Anorexia – is a decreased sensation of appetite caused by the

complications of compression of the esophagus.

Atelectasis – is a collapse of lung tissue affecting part or all of one lung

because of presence of fluid in the lungs.

Chest pain – pain caused by the obstruction of the vena cava.

Chest wall pain – pain caused by the invasion of the pleural cavity irritating

nerve fibers.

Chronic Cough – caused by sputum production brought by the irritation of

the bronchioles.

Difficulty in swallowing – condition caused by the compression of the

esophagus.

Distended neck veins – caused by the obstruction of the vena cava.

Dyspnea – caused by the invasion of the pleural space.

Facial, arm, and trunk swelling – caused by the obstruction of the vena

cava.

Hemoptysis – is the expectoration of blood caused by lesions in the blood

vessels.

Hoarseness of voice – caused by the irritation of the laryngeal nerve.

Hyperglycemia – a manifestation caused by Cushing’s syndrome.

Hyperkalemia – a manifestation caused by Cushing’s syndrome.

Hypertension – a manifestation caused by Cushing’s syndrome.

Hypervolemia – a manifestation caused by Cushing’s syndrome.

Immunosupression – a manifestation caused by Cushing’s syndrome.

Osteoporosis – caused by high levels of cortisol.

Pneumonia – condition caused by the invasion of the pleural space and it is

characterized by inflammation and abnormal alveolar filling with fluid.

Shortness of breath – caused by the irritation and obstruction of airway.

Venous stasis – caused by the obstruction of the vena cava.

Weight loss – caused by dysphagia and the metastases in the liver.

Note: Items marked in RED were experienced by the client.

Schematic Diagram (Book-based)

Predisposing Factors: People who are between 30 and 50 years of age Men are more likely to have nasopharyngeal cancer

than women Chinese or Asian ancestry Hereditary

Precipitating Factors: Eating salt-preserved foods (like fish, eggs, leafy

vegetables and roots) during early childhood Cigarette smoking Alcohol abuse Poor Oral Hygiene Long Term Sun Exposure Occupational Exposure (chemicals esp. asbestos)

Nasopharyngeal Cancer/ Lung Cancer

Chronic cough

Osteoporosis

Atelectasis

Chest wall

Irritation and obstruction of airway

Cushing’s Syndrom

Immunosupression

Hypertension

Hyperglycemi

Hypervolemia

Hyperkalemia

Pleural Effusion

Squamous Cell Carcinoma Small Cell Carcinoma Adenocarcinoma Large Cell Carcinoma

Sputum production

Invasion of the pleural cavity

Pneumonitis

Hemoptysis

Pneumonia

Anorexia

Formation of benign bronchial epithelium tissue

Transformation benign tissue to neoplastic

Weight

Shortness of breath

Wheezing

Lesions erode to the blood vessels

Compression of the esophagus

Difficulty in swallowing

Hoarseness of voice

Irritation of the laryngeal

Metastases to the liver

Triggering of pain receptors

Shortness of breath

Dyspnea

Vena cava

Facial, arm, and trunk swelling

Distended neck veins

Chest pain

Venous stasis

Synthesis of bioactive products

Invasion of the mediastinum

Schematic Diagram (Client-centered)

Predisposing Factors: People who are between 30 and 50 years of age Men are more likely to have nasopharyngeal cancer

than women Chinese or Asian ancestry Hereditary

Precipitating Factors: Eating salt-preserved foods (like fish, eggs, leafy

vegetables and roots) during early childhood Cigarette smoking Alcohol abuse Poor Oral Hygiene Long Term Sun Exposure Occupational Exposure (chemicals esp. asbestos)

Nasopharyngeal Cancer/ Lung Cancer

Formation of benign bronchial epithelium tissue

Transformation benign tissue to neoplastic

Chronic cough(September 20, 2008)

Irritation and obstruction of airwaySputum production

Shortness of breath

Wheezing

Anorexia(August 2008)

Weight

Compression of the esophagus

Difficulty in swallowing

Hoarseness of voice(September 20, 2008)

Irritation of the laryngeal

Invasion of the mediastinum Chest wall pain

(September 20, 2008)

Invasion of the pleural cavity

Triggering of pain receptors

VI. NURSING ASSESSTMENT

*********NURSING REVIEW CHART********

Name: Egberto VillanuevaVital Signs:Pulse: 70bpm BP: 130/80mmhg Temp: 36.8ºC Respi: 23cpm Weight: 125 pounds Height: 5’5” EENT : impaired vision blind pain X hard of hearing reddened drainage gums deaf burning edema lesion teeth no problem

RESP: asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea laboredX wheezing pain cyanotic no problem

CARDIO VASCULAR arrhythmia tachycardia numbness diminished pulses edema fatigue irregular bradycardia murmur tingling absent pulses painX no problem

GASTRO INTESTINAL TRACT obese distention mass dysphagia rigidity painX no problem

GENITO-URINARY and GYNEpain urine color / vaginal bleeding hermaturia / discharge noctoriaX no problem

NEURO paralysis stuporous unsteady seizures lethargic comatose vertigo tremors confused vision grip X no problem

MUSCULOSKELETAL and SKIN appliance stiffness X itching petechiae hot drainage prosthesis swelling lesion X poor turgor cool deformity wound X rash skin color flushed atrophy pain ecchymosis X dry no problem

Hearing loss reported

Change in appetite and horseness of voice

Wheezing sound

Alopecia

Constipation reported

Muscle pain reported and itchiness skin with poor skin turgor.

Rashes noted

Afebrike 36.8 ºCBP 130/80 mmHg

Polyuria

Generalized weakness and weight loss

Muscle pain in lower extremities reported and itching skin with poor skin tuger

IV site : 0.9 NaCl @ 30gtts/min

**********NURSING ASSESSMENT II********SUBJECTIVE OBJECTIVE

COMMUNICATION: “ sukad atong nasakit ko halapþ Hearing Loss na ako pananaw og ga glasses lisod ko ug dungog kayþ visual changes naay nag tubo sa akodenied dalunggan” as verba- lized by th pt.

þ glasses languages contact lens hearing aide

R LPupil size _2-3mm_ speech difficultiesReaction _PERRLA_

OXYGENATION: Comments: dyspnea “kani adto ga sigarilyo, smoking history karon wala nah, dugay___20 yrs ago___ na kaau, 20 yrs ago” cough as verbalized by the sputum pt.þ denied

Resp. regular þ irregularDescription ___patient has irregular respiration –23 cpm with normal range of (16-29)

R SymmetricalL Symmetrical

CIRCULATION Comments : “ usahay mag þ chest pain sakit akong dughan karon leg pain lang wala ka naa man þ numbness of tambal ug sakit akong extremities kalawasan or luya kung denied mag tindog ko” as ver- balized by the pt.

Heart Rhythmþ regular irregularAnkle edema _____NONE_______________

Pulse Car Rad DP FemR ______√_____70bpm_ _√__ _√____________L ______√_____70bpm √__ _√____________Comments: ___All pulses are palpable

NUTRITIONDiet : Diabetic diet Comments: “wala jud ko gana N V mukaon permi kay Character lain man akong þ recent change in pan lasa, tu-ig nani weight, appetite siya mao dili ko swallowing nahan kaon usahay” difficulty verbalized by the denied patient

dentures þ none

Full Partial With Patient

Upper Lower

ELIMINATION:Usual bowel pattern urinary frequency ___once a day _ _5 times a day_____þ constipation urgency remedy dysuria____________ hematuria Date of last BM Incontinence _____ July 4, 2009 __ þ polyuria diarrhea foley in place character denied

Comments : Has audiblebowel sound when aus-cultate the abdomen partof the pt., the usual bowelsound hashypoactivethat is extremely soft andinfrequent

MGT. OF HEALTH ILLNESS:alcohol þ denied(amount, frequency) “kaniadto kato mayo pa ako lawas” SBE Last Pap Smear : N/A LMP: N/A

Briefly describe the patient’s ability to follow treatments (diet, meds, etc) for chronic problems (if present)_______________N/A______________________________________________________________

Bowel sounds hypoactive

Abdominal distention Present [] yes [] no Urine*(color, consistency, odor) no foley bag catheter in place *if they are in place? ____none________

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY: Comments : þ dry “ ga katol ni ako panit lagi, taga kalot nako akoþ itching likod kay murag ma paksi na panit” as ver- other balized by the pt.

denied

þ dry cold þpale flushed warm moist cyanotic* rashes, ulcers, decubitus (describe size, location, drainage) : presence of rashes noted at the right lower quadrant at the back extremities of the pt.

ACTIVITY/SAFETY Comments: “ ala man kani convulsion lang mag tindod og dizziness tanaw ko sa kasakit limited motion sa ako lawas hasta of joints murag akong bukog Limitation in ga apil ug sakit” ability to as verbalized by the þ ambulate pt. bathe self other denied

LOC and orientation Awake, conscious, and coherent_. Oriented to date, time and place.______________________________ Gait: Walker Cane Other steady unsteady __________________ sensory and motor losses in face orextremities:NONE_________________________ ROM limitations _Patient has no limits on range of motion_______

COMFORT/SLEEP/AWAKE: pain Comments: (location, “All mayo man pud Frequency akung pag tulog mao remedies) na ako amapay ron” nocturia as verbalized by the sleep difficulties patient.þ denied

þ facial grimaces guarding other signs of pain_Generalized_____ weakness_______________________________________________________þ side rail release form signed ( 60 + years)________no side rail________________

COPING:Occupation _____None___________000Members of household __2 members___ Most supportive person: Irene Villanueva (daughter).

Observed non-verbal behavior _patient is responsive during our interview The person and his phone number that can beReached any time __none________________

Date Oredered

Diagnostic/Laboratory Exams

Date DoneDate

OrderedIV Fluids/Blood Date Disc.

7/76/09 HGT test 7/6/09 7/6/09 PNSS

7/6/09 Creatinine 7/6/09

7/6/09 CBC 7/06/09

VII. NURSING MANAGEMENT

**********IDEAL NURSING CARE PLAN********

Fatigue

Assessment Nursing Diagnosis Objectives Nursing Interventions Rationale

Subjective cues:“maglisod jud ko ug tindog”, as verbalized by the patient.

Objective cues: appears weak decreased ability in

performing activities with compromised

concentration

Fatigue related to poor physical condition as manifested by the patient appears weak, a decreased ability in performing activities, and compromised concentration.

After 3 hours of nursing intervention, the patient will verbalize an understanding regarding the health teachings on how to conserve energy as evidenced by the patient appears strong, an increase in the ability to perform activities, and has the ability to concentrate fully.

Establish rapport

Monitor and record vital signs

Encourage pt. to sit instead of standing in performing activities

Advise pt. to have adequate rest

Encourage pt. to perform ROM exercises

Encourage pt. to eat carbohydrates-containing food

Encourage pt. to do focus breathing

to gain cooperation for baseline data

to conserve energy

to regain strength

to reduce fatigue

to increase energy level

to promote energy

Disturbed Energy Field

Assessment Nursing Diagnosis Objectives Nursing Interventions Rationale

Subjective cues:“Mao nang maglisod ko ug tindog, dayon mag lakaw2x”, as verbalized by the patient.

Objective cues: appears weak low tone speech compromised

concentration

Disturbed energy field related to slowing of energy flow as manifested by the pt. appears weak, with low tone speech, and with compromised concentration secondary to illness.

After 3 hours of nursing intervention, the pt. will verbalize a sense of relaxation as evidenced by the pt. appears strong, high toned speech and the ability to concentrate.

establish rapport

monitor and record VS advise pt. to have

adequate rest encourage pt. to eat

foods rich in carbohydrates

advise pt. to do deep breathing

advise pt. to take adequate fluid intake

encourage pt. to rest between activities

allow pt. to have period of independency

to gain cooperation for baseline data

to regain strength

to increase energy level

to promote energy

to prevent dehydration

to promote energy and regain strength

to strengthen own inner resources

S“ga luya akong lawas murag apil ang bukod, hago au mag lihok” as verbalized by the patient.

O- Generalized weakness noted upon moving- decreased pertinence in an activity- increase in physical complaints

AFatigue related to altered body chestry(chemotherapy)

PAt the end of 2 days, the client will be able to verbalize improved sense of energy

I

1. Determine level of ability to stand, move about and the amount of assistance necessary

2. Provide environment conducive to improvement of fatigue

3. Provide diversional activities4. Encourage pt. to develop assertiveness skills

prioritizing goals/activity5. Encourage independence in performing activities

EAt the end of 2 days, objective met, client reported improved sense of energy.

S“katol akong likod sa bukton” as complained by the patient

O- Distension of skin surface- Destruction of skin layers- Invasion of body structure

ASkin integrity impaired related to radiation

PAt the end of 2 days, the client will be able to verbalize feeling of increased in self-esteem and to damage situation.

I

Independent:1. Palpate skin lesions for size, shape, consistency,

texture, temperature and hydration.2. Expose lesions/ulcer to air and light as indicated3. Monitor for sign of complications in wound healing,

infection4. Check for proper fit clothing5. Identify safety factors for use of equpment

Dependent: 6. Apply medication as indicated (cream)

EAt the end of 2 days, objective met, patient verbalized feeling of increased self-esteem and ability to manage stimulation

SReported altered sensation

O- loss of weight with low food intake- show no interest in food noted

ANutrition altered, less than body requirement related to sudden change in appetite.

PAt the end of 2 days, the client will demonstrate behavior, lifestyle changes to regain appropriate weight.

I

Independent:1. Note food intolerance2. Auscultate bowel sounds and pts. oral hygiene3. Note total calorie intak; maintain dietary intake, time

and pattern of eating4. Promote adequate intake of fluid5. Weigh daily and document result

Dependent: 6. Administer medication agent

EAt the end of 2 days, objective met, patient demonstrated behavior, life style changes to regain weight.

************HEALTH TEACHING**********

MEDICATION Instruct the patient to follow the medication regimen as indicated to promote pharmacological effects. It should be prescribed by the doctor.

EXERCISEInstruct the patient to have a ROM exercises daily as tolerated. Which increases energy level and anxiety of the patient.

TREATMENT

Instruct the patient to properly do an oral hygiene 3xdaily to increase food appetite and to maintain hygiene. Patient also is advised not to drink hot fluids that may irritate the pharynx and esophagus. Encourage to drink water 8 glasses per day.

OUTPATIENTEncouraged patient to have a follow-up check up 1 week after discharged. Under supervision of Dr. Abas. This to monitor the condition of the patient.

DIET Encouraged patient to maintain the diabetic diet which is low sugar content . Increase fluid intake and nutritious foods.

VIII. REFERRALS AND FOLLOW-UP

The patient was referred to Dr. Abas.. The significant others of the

patient was also advised to continue medication at home and was also advised

to keep back dry always to prevent from worsening the disease. And also the

client was instructed to come back for follow up check up a week after

discharged.

IX. PROGNOSIS AND EVALUATION

Criteria Good Prognosis Poor Prognosis

A. Onset of Illness √

B. Duration of illness

C. Precipitating

Factors

D. Attitude towards

taking medications

and treatment

E. Financial

F. Family Support

On the criteria listed above it shows that the prognosis of the patient is

good because the majority of the criteria falls under good prognosis. His onset of

illness was poor because it was in late stage and cannot be treated with

medications and duration of illness was also good. Precipitating factors was also

good because the author has identified the said factors that contributed to the

client’s disease condition. Attitude towards taking medication and treatment were

also good because the patient exhibits interest in taking religiously his

medications as well as following the doctor’s indicated treatment regimen. Family

support was good because the significant others were always there in the

hospital supporting him.