Peritoneal Carcinomatosis Grand Case Study

ASCITES SECONDARY TO PERITONEAL TUBERCULOSIS, RULE OUT PERITONEAL CARCINOMATOSIS

____________________

A Case Study Presented to theCollege of Health Sciences Faculty

Notre Dame UniversityCotabato City

____________________

In Partial Fulfillment of the Requirements for the Degree of

BACHELOR OF SCIENCE IN NURSING

By

Alim, Suharto U.Ambolodto, Sandra Mae A.Cadungog, Evelyn Claire O.

Gorospe, Irish Kate A.Rubi, Beverly Joy A.

Sero, Valerie P.Sumampao, Diamond M.

Suyom, Jessieden E.

December 13, 2012

Ascites Secondary to Peritoneal ii

ACKNOWLEDGEMENT

This case study would not have been provided, done and studied if not for the

support of the people who unselfishly contributed their time, knowledge, skills, and

effort. With grateful heart and minds, the group would like to extend their gratitude to the

following:

The Almighty Father, source of strength, wisdom, and knowledge for giving them

hope and enlightenment, which they need to accomplish these study.

Their beloved parents, for providing them financial assistance that made possible

the compilation of their study and for inspiring, and giving them enough strength, and

courage in pursuing their study.

Lyreyann A. Cordero, RN for assisting and guiding the group in their case study

and checking their case written output.

The Cotabato Regional and Medical Center and staff of medicine ward for the

trust and time, thus, giving us enough time to gather relevant data to our patient and the

staff of emergency department for supervising us upon duty hours and assisted us on the

delivery of quality nursing service.

To our client and her family, for their trust, willing participation, and allowing the

group to render appropriate nursing service and conduct an interview, assessment and

study on her disease process.

To Maureen Laurice T. Cases, RN, their adviser for critiquing and checking their

work, sharing her expertise, comments, and suggestions which added to the group’s

knowledge improved the study.

Ascites Secondary to Peritoneal iii

TABLE OF CONTENTS

Page

TITLE PAGE ...................................................................................................................... iACKNOWLEDGEMENT..............................................................................................

CHAPTER I INTRODUCTION Overview of the Case........................................................ Incidence........................................................................ Rationale for Choosing the Case..........................................

CHAPTER II OBJECTIVES General Objective.......................................................... Specific Objectives.................................................................

CHAPTER III PATIENT’S HISTORY.............................................................

CHAPTER IV PHYSICAL ASSESSMENT...............................................................General Physical Survey.................................................Focus Assessment.............................................................

CHAPTER V REVIEW OF ANATOMY & PHYSIOLOGY............................

CHAPTER VI PATHOPHYSIOLOGY ………………..………………………Narrative Discussion.........................................................Schematic Diagram............................................................

CHAPTER VII COURSE IN THE HOSPITAL …………………………………

CHAPTER VIII NURSING CARE PLAN ……………………………….……..

CHAPTER IX DRUG STUDY…………………….……………………………

CHAPTER X LABORATORY STUDY...........…………………………………

CHAPTER XI PROGNOSIS …………………………………………………..

CHAPTER XII DISCHARGE SUMMARY PLAN …………………………..….

CHAPTER XIII BIBLIOGRAPHY ……………………………………………...

i ii

1 1 2

3 3

4

7 7 11

13

181819

21

28

36

45

59

62

65

CHAPTER I

INTRODUCTION

Peritoneal carcinomatosis (PC) is a type of secondary cancer that affects the lining

of the abdominal cavity, called the peritoneum. It occurs when cancer metastasizes from

another part of the body and implants into the lining. Peritoneal carcinomatosis most

commonly follows severe or untreated pancreas, ovarian, stomach, and colon cancer.

Symptoms can vary, but many people experience extreme fatigue and abdominal pain.

Quick, aggressive treatment in the form of medications and surgery is vital in preventing

fatal complications (Jeffress, 2012). Tumor growth on intestinal surfaces and associated

fluid accumulation eventually result in bowel obstruction and incapacitating levels of

ascites, which profoundly affect the quality of life for affected patients. Recently,

population-based studies have revealed that PC occurs relatively frequently among

patients with colorectal cancer (CRC). Risk factors for developing PC have been

identified: right-sided tumor, advanced T-stage, advanced N-stage, poor differentiation

grade, and younger age at diagnosis (Klaver et. al, 2012). Peritoneal carcinomatosis

represents a devastating form of cancer progression with a very poor prognosis

(Kusamura et. al, 2010).

In Germany, 66,000 new cases are diagnosed every year. Up to 25% of those

patients develop a peritoneal carcinomatosis (Sugarbaker et. al, 2007). Cytoreductive

surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are playing an

ever increasing role in the treatment of peritoneal carcinomatosis (Austin et. al, 2012).

Ascites Secondary to Peritoneal 2

Although survival benefit of this procedure has been reported in numerous literatures,

this treatment is still not widely accepted worldwide because of the necessity of long

learning curves for application of these techniques and high postoperative mortality and

morbidity rates (Mizumoto, 2012). Most patients with this condition will not live much

longer than two years without treatment. The shortest time they usually survive is only

six months. According to the peritoneal carcinomatosis survival rate statistics, 17% of the

patients who received treatment died after surgery (Peritoneal Health, 2010). The most

common cause of peritoneal carcinomatosis in women is ovarian cancer. Two-thirds of

women with ovarian cancer present with abdominal dissemination of disease, the

standard management of which comprises surgical debulking followed by chemotherapy

(Johnson, 1993).

The researchers chose this case because they wanted to know more about this type

of cancer since this case has long been considered a fatal clinical entity, rarely seen and

treated palliatively, thus it will help and add additional learning’s from what they had

already learned from their past concept, thus, this study will help them give appropriate

health teachings for their future clients with the same cancer called peritoneal

carcinomatosis.

CHAPTER II

OBJECTIVES

General Objective:

This case study aims to understand the disease process of Peritoneal

Carcinomatosis and to learn about its aftermath in the human body; thereby helping us,

the student nurses to be guided on how to deal with clients with the said condition,

especially the implementation of nursing care.

Specifically, the study aims to:

1. Organize patient’s data to establish good background information.

2. Review the health history.

3. Understand the definition of Peritoneal Carcinomatosis.

4. Determine the signs & symptoms and complications manifested by the patient.

5. Discuss the normal functioning of the Gastrointestinal System.

6. Present the pathophysiological basis of the disease.

7. Study the different laboratory and diagnostic tests.

8. Understand the significance of specific medications given to the patient.

9. Formulate and prioritize different nursing care plans.

10. Impart appropriate health teachings to the patient and as well as to the family.

11. Discuss discharge plan and prognosis for the continuity of care.

12. Assist future researches that they may use the output as basis for further research.

CHAPTER III

PATIENT’S HISTORY

NAME: Ms. Bella

AGE: 23 years old

SEX: Female

CIVIL STATUS: Single

NATIONALITY: Filipino

ADDRESS: RH 4, Cotabato City

DATE OF BIRTH: November 30, 1989

RELIGION: Roman Catholic

OCCUPATION: Housewife

_____________________________________________________________________________________

DATE/TIME OF ADMISSION: December 5, 2012 / 11:10 am

PREVIOUS ADMISSION: November 22-30, 2012

ATTENDING PHYSICIAN: Nelson P. Gilapay, MD

ADMITTING V/S: T: 36.5°C HR: 98bpm RR: 25 bpm BP: 120/90 mmHg Ht: 5’1 Wt: 42 kg

CHIEF COMPLAINT: Abdominal distention

ADMITTING DIAGNOSIS: Ascites secondary to Peritoneal Tuberculosis, rule out

Peritoneal Carcinomatosis


Past Illness History

Long before, the patient was living a simple and happy life. She experienced

childhood illness such as German measles during her fourth grade. She loves chicken so

much and does not necessarily do exercise.

She formerly worked as a clerk. Years passed by, this young lady turns into a

lovely maiden, August 2012; she was admitted and delivered her first child, a baby girl,

via Normal Spontaneous Vaginal Delivery at Cotabato Regional and Medical Center. She

claimed to have regular prenatal visit in the same institution. She had no extraordinary

qualms during her pregnancy.

Two months after her delivery, she noticed to have constipation for few days and

took one dose of laxative (Dulcolax). However, constipation persists and abdominal

distention was observed by her and her family. Despite of these manifestations, they did

not immediately seek any medical attention. One month prior to admission, patient

consulted a private physician and requested for abdominal CT scan but failed to comply.

Last November 22, 2012, she was admitted with chief complaints of constipation

and abdominal distention. She was diagnosed with peritoneal carcinomatosis. She was

then discharged last November 30, 2012, with take home medications of Furosemide

40mg 1 tablet once a day, Spironolactone 25mg 1 tablet for twice a day, Vitamin B

complex + Folic acid + Ferrous sulfate 1 capsule twice daily, and Vitamin C (Poten cee)

1 tablet twice a day, Ciprofloxacin 500mg 1 tablet twice daily, and Domperidone 1 tablet

three times a day, and was encouraged to increase fiber in the diet.


Present Illness History

She was supposed to come back for follow up checkup on December 5, 2012 but

a day before her follow up checkup, she was hurriedly brought to the same hospital due

to progressive abdominal distention and difficulty of breathing, and was admitted.

Family History

On the client’s mother side, she claimed a positive history of hypertension, and

her uncle died a year ago from liver cirrhosis, but no idea about the health history on her

father side.

CHAPTER IV

PHYSICAL ASSESSMENT

Appearance and Behavior

1. Age, Sex, and Race -23 years old, Female, Asian

2. Body Build -Ectomorphic; emaciated

3. Posture and Gait -Coordinated movement when sitting and

walking with difficulty.

4. Hygiene and Grooming -Slightly clean and neat, unfixed hair,

untrimmed nails

5. Dress -Appropriate for age, place and climate

6. Odor of the body and breath -Slight foul smell noted on body and breath

7. Signs of distress -Mild respiratory distress

8. Apparent state of health -Use accessory muscles when breathing,

anxious, pain scale of 6/10.

9. Attitude -Cooperative with treatment

10. Affect and mood -Cooperative with treatment, expresses

feelings regarding her condition

11. Speech -Understandable, moderate pace, clear tone

12. Thought Process -Conscious, oriented, coherent, follows

direction


Skin

Fair skin. Has smooth skin texture, no presence of wounds. Hair is well

distributed on both parts of the body, nails are untrimmed. Skin returns back after 3-4

seconds when doing skin turgor; warm to touch.

Head

Skull is oval, smooth skull contour, uniform consistency, no tenderness palpated,

absence of nodule or mass with symmetrical facial features and movements.

Eyes

Eyebrows are evenly distributed, symmetrically aligned, equal movements of the

eye; eyelashes are equally distributed, curved and slightly outward. Eyelids skin is intact,

closes symmetrically, bilateral blinking, bulbar conjunctiva is clear with tiny vessel, and

palpebral conjunctiva is pink with no discharge. Sclera appears moist.

Ears

Ears are symmetrical, color same as face, firm and not tender; Pinna coils after it

folded. Presence of mass, lesions, lacerations, bruises, swelling was not seen upon

inspection. No unusual discharge noted.

Mouth

Slightly dry lips, yellowish teeth, pale gums, no swelling noted; Tongue is pink in

color, no lesions, no tenderness, no palpable nodules, uvula is position on midline of soft

palate. Tonsils are not inflamed, slight halitosis noted upon assessment.


Nose

Nose is symmetrical and straight, without nasal discharge, uniform in color, not

tender, no lesions; nasal septum is intact and located in the midline. External surface of

the patient’s nose is smooth and oily.

Neck

Patient can move his neck freely without any difficulty. No lesions, masses,

deformities noted upon inspection. No neck vein enlargement.

Chest/Lungs

Chest and lung expansion symmetry are equal, with mild respiratory distress,

intercostals spaces are equal but labored; respiratory, rhythm and depth are even,

respiratory rate of 25 breaths/min, evident use of accessory muscles when breathing.

Abdomen

Patient’s abdomen is distended. Abdominal girth is 93 cm. Scars noted on her

right lower quadrant of the abdomen due to paracentesis, and left lower quadrant of the

abdomen due to biopsy procedure. Have palpable masses at all quadrants of the abdomen.

Genito-urinary

Has regular urination. No indwelling catheter present.

Upper extremities

Patient’s upper limbs, shoulders and arms were symmetrical but thin. No


deformities and swelling noted. No tenderness on the bones of the wrists and fingers and

no structural deviations.

Lower extremities

Patient’s lower limbs are symmetrical but thin. No deformities and swelling

noted.


FOCUS ASSESSMENT

Abdominal Assessment

A. INSPECTION

1. Skin

Color of the abdomen is same with other parts of the body; smooth and

shiny in texture with visible veins observed.

2. Umbilicus

Flat, centrally located at the midline; pale in color.

3. Contour

Distended and round in contour.

4. Symmetry

Abdomen is symmetrical upon inspection.

5. Enlarged organs

No enlarged organs based on diagnostic tests.

6. Peristalsis

No peristalsis noted upon inspection.

7. Pulsation

No pulsation noted upon observation.

B. AUSCULTATION

1. Bowel sounds

Hypoactive bowel sounds heard in all four quadrants upon auscultation.


C. PERCUSSION

1. Entire Abdomen

Dullness noted in all quadrants of the abdomen.

D. PALPATION

1. Measure Abdominal Girth

93cm

E. Special Maneuvers

1. Assess for possible ascites

Has visible veins observed upon inspection; ascites noted.

2. Testing for shifting dullness

Positive for shifting dullness, dullness of percussion shifts as patient was

turned from side to side.

3. Testing for fluid wave

Positive fluid wave transmitted from one abdominal wall side to the other

side upon placing a hand on one side of the abdomen, then pressing the opposite

side of the abdomen with the other hand, shifting the fluid.

CHAPTER V

REVIEW OF ANATOMY & PHYSIOLOGY

The Abdomen and the Gastrointestinal System

The abdomen (commonly called the belly) is the body space between the thorax

(chest) and pelvis. The diaphragm forms the upper surface of the abdomen. At the level

of the pelvic bones, the abdomen ends and the pelvis begin.

The abdomen contains all the digestive organs, including the stomach, small and

large intestines, pancreas, liver, and gallbladder. These organs are held together loosely

by connecting tissues (mesentery) that allow them to expand and to slide against each

other. The abdomen also contains the kidneys and spleen. Many important blood vessels

travel through the abdomen, including the aorta, inferior vena cava, and dozens of their

smaller branches. In the front, the abdomen is protected by a thin, tough layer of tissue


called fascia. In front of the fascia are the abdominal muscles and skin. In the rear of the

abdomen are the back muscles.

Abdominal organs

Digestive tract: Stomach, small intestine, large intestine with cecum and appendix

Accessory organs of the digestive tract: Liver, gallbladder and pancreas

Urinary system: Kidneys and ureters - but technically located in retroperitoneum -

outside peritoneal membrane

Other organs: Spleen

Introduction to the gastrointestinal system

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from

the oral cavity, where food enters the mouth, continuing through the pharynx,

oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There

are various accessory organs that assist the tract by secreting enzymes to help break down

food into its component nutrients. Thus the salivary glands, liver, pancreas and gall

bladder have important functions. Food is propelled along the length of the GIT by

peristaltic movements of the muscular walls.

The primary purpose of the gastrointestinal tract is to break food down into

nutrients, which can be absorbed into the body to provide energy. First food must be

ingested into the mouth to be mechanically processed and moistened. Secondly, digestion

occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates

are chemically broken down into their basic building blocks. Smaller molecules are then

http://en.wikipedia.org/wiki/Spleen

http://en.wikipedia.org/wiki/Retroperitoneum

http://en.wikipedia.org/wiki/Ureters

http://en.wikipedia.org/wiki/Kidney

http://en.wikipedia.org/wiki/Pancreas

http://en.wikipedia.org/wiki/Gallbladder

http://en.wikipedia.org/wiki/Liver

http://en.wikipedia.org/wiki/Appendix_(anatomy)

http://en.wikipedia.org/wiki/Cecum

http://en.wikipedia.org/wiki/Large_intestine

http://en.wikipedia.org/wiki/Small_intestine

http://en.wikipedia.org/wiki/Stomach


absorbed across the epithelium of the small intestine and subsequently enter the

circulation. The large intestine plays a key role in reabsorbing excess water. Finally,

undigested material and secreted waste products are excreted from the body via

defecation (passing of faeces).

The Peritoneum

The peritoneum is the serous membrane that forms the lining of the abdominal

cavity or the coelom—it covers most of the intra-abdominal (or coelomic) organs -

in amniotes and some invertebrates (annelids, for instance). It is composed of a layer

of mesothelium supported by a thin layer of connective tissue. The peritoneum both

supports the abdominal organs and serves as a conduit for their blood and lymph vessels

and nerves.

The abdominal cavity (the space bounded by the vertebrae, abdominal

muscles, diaphragm and pelvic floor) should not be confused with the intraperitoneal

space (located within the abdominal cavity, but wrapped in peritoneum). The structures

within the intraperitoneal space are called "intraperitoneal" (e.g. the stomach), the

structures in the abdominal cavity that are located behind the intraperitoneal space are

called "retroperitoneal" (e.g. the kidneys), and those structures below the intraperitoneal

space are called "subperitoneal" or "infraperitoneal" (e.g. ththe bladder).

The peritoneal membrane is a semi-permeable membrane that lines the abdominal

wall (parietal peritoneum) and covers the abdominal organs (visceral peritoneum). The

membrane is a closed sac in males. The fallopian tubes and ovaries open into the

peritoneal cavity in females. The size of the membrane approximates the body surface

http://en.wikipedia.org/wiki/Coelom

http://en.wikipedia.org/wiki/Abdominal_cavity

http://en.wikipedia.org/wiki/Abdominal_cavity

http://en.wikipedia.org/wiki/Serous_membrane

http://en.wikipedia.org/wiki/Kidney

http://en.wikipedia.org/wiki/Retroperitoneal

http://en.wikipedia.org/wiki/Stomach

http://en.wikipedia.org/wiki/Pelvic_floor

http://en.wikipedia.org/wiki/Diaphragm

http://en.wikipedia.org/wiki/Abdominal_muscles

http://en.wikipedia.org/wiki/Abdominal_muscles

http://en.wikipedia.org/wiki/Vertebrae

http://en.wikipedia.org/wiki/Nerves

http://en.wikipedia.org/wiki/Lymph

http://en.wikipedia.org/wiki/Blood

http://en.wikipedia.org/wiki/Connective_tissue

http://en.wikipedia.org/wiki/Mesothelium

http://en.wikipedia.org/wiki/Annelid

http://en.wikipedia.org/wiki/Amniote


area (1-2 m2). There are about 100 cc of transudate that is contained in the cavity in

normal individuals.

A. Blood Supply

The parietal peritoneum derives its blood supply from the arteries in the

abdominal wall. This blood drains into the systemic circulation. The visceral

peritoneum is supplied by blood from the mesenteric and celiac arteries which

drain into the portal vein.

B. Lymphatics

Subdiaphragmatic lymphatics are responsible for 80% of the drainage

from the peritoneal cavity. The drainage is then absorbed into the venous

circulation through the right lymph duct and the left thoracic lymph duct. A

balance of solutes and fluid in the interstitial tissue is maintained by absorption of

fluid from the peritoneal cavity. The average lymphatic rate of absorption in the

PD patient is 0.5-1.0 ml/min. Factors that affect the rate of absorption are

respiratory rate, posture, and intra-abdominal pressure.

Layers

Although they ultimately form one continuous sheet, two types or layers of

peritoneum and a potential space between them are referenced:

The outer layer, called the parietal peritoneum, is attached to the abdominal wall.

The inner layer, the visceral peritoneum, is wrapped around the internal organs

that are located inside the intraperitoneal space.

The potential space between these two layers is the peritoneal cavity; it is filled

http://en.wikipedia.org/wiki/Peritoneal_cavity

http://en.wikipedia.org/wiki/Abdominal_wall


with a small amount (about 50 mL) of slippery serous fluid that allows the two

layers to slide freely over each other.

The term mesentery is often used to refer to a double layer of visceral peritoneum.

There are often blood vessels, nerves, and other structures between these layers.

Subdivisions

There are two main regions of the peritoneum, connected by the epiploic

foramen (also known as the omental foramen or foramen of winslow):

The greater sac (or general cavity of the abdomen), represented in red in the

diagrams above.

The lesser sac (or omental bursa), represented in blue. The lesser sac is divided

into two "omenta":

- The lesser omentum (or gastrohepatic) is attached to the lesser curvature of

the stomach and the liver.

- The greater omentum (or gastrocolic) hangs from the greater curve of the

stomach and loops down in front of the intestines before curving back

upwards to attach to the transverse colon. In effect it is draped in front of the

intestines like an apron and may serve as an insulating or protective layer.

The mesentery is the part of the peritoneum through which most abdominal organs are

attached to the abdominal wall and supplied with blood and lymph vessels and nerves.

http://en.wikipedia.org/wiki/Lymph

http://en.wikipedia.org/wiki/Blood

http://en.wikipedia.org/wiki/Mesentery

http://en.wikipedia.org/wiki/Colon_(anatomy)

http://en.wikipedia.org/wiki/Intestines

http://en.wikipedia.org/wiki/Greater_curve_of_the_stomach

http://en.wikipedia.org/wiki/Greater_curve_of_the_stomach

http://en.wikipedia.org/wiki/Greater_omentum

http://en.wikipedia.org/wiki/Liver

http://en.wikipedia.org/wiki/Lesser_curvature_of_the_stomach

http://en.wikipedia.org/wiki/Lesser_curvature_of_the_stomach

http://en.wikipedia.org/wiki/Lesser_omentum

http://en.wikipedia.org/wiki/Lesser_sac

http://en.wikipedia.org/wiki/Greater_sac

http://en.wikipedia.org/wiki/Epiploic_foramen

http://en.wikipedia.org/wiki/Epiploic_foramen

http://en.wikipedia.org/wiki/Mesentery

http://en.wikipedia.org/wiki/Serous_fluid

CHAPTER VI

PATHOPHYSIOLOGY

Narrative Explanation:

Peritoneal Carcinomatosis is a broad description in which multiple tumors

develop in, and line the peritoneal abdominal cavity and linings.

This description is used in conjunction with cancers and conditions of appendix,

colon, gall bladder, ovaries, mesothelioma, pancreas, Pseudomyxoma Peritonei, rectal,

sarcomas, small bowel, and stomach. When tumor develops from the peritoneum, it is

referred to as Primary Peritoneal Surface Malignancy. Occasionally, a tumor far from

the abdomen or a bone cancer can result in peritoneal carcinomatosis after cancerous

cells invade lymph nodes and the bloodstream.

Symptoms of Peritoneal Carcinomatosis may initially be detected by appearing

on as a diffused thickening of the peritoneum on a CT scan. The appearance of ascites

refers to the accumulation of fluid within the peritoneal cavity and may occur for a

variety of conditions including post operative inflammation or to cancer. The most

common symptoms of peritoneal carcinomatosis include acute or chronic aches,cramps,

bloating, and full-body fatigue. Many symptoms are caused when excess fluid

accumulates in the abdominal cavity, a direct consequence of nearby tumor activity.

Other problems such as breathing difficulties, digestive problems, and chest pains may be

present as well, depending on the extent and location of the original cancer.

http://www.wisegeek.com/what-are-cramps.htm


Schematic Diagram:

Predisposing Factors Age (23 yrs. old) Gender (Female) Heredity

Precipitating Factors Environmental conditions Lifestyle Other health conditions

Damage to DNA in cell nucleus

Cell death

Cell Cycle Alteration

Imbalance between production and

absorption of fluid

Increased production and proliferation of enzymes and hormones

Tumor implants compress the bowel

by their volume

Carcinogenesis

New and rapid growth

Ascites (Abdominal distention: Girth-93cm)

Bowel obstruction

Compression and elevation of the diaphragm

DOB

Pain

Damaged to surrounding tissues and nerve

compression as tumor grows

Dissemination from the primary tumor

Invasion in the GIT

Paracentesis

Mechanical effects:

Palpable masses on the

abdomen


Systemic effects:

Cachexia(muscle wasting)

Body cannot synthesize amino

acids

Altered protein metabolism

Weight loss(From 50 kg to 42 kg)

Peritoneal Carcinomatosis

CHAPTER VII

COURSE IN THE HOSPITAL

DATE & TIME

SIDE NOTES ORDERS RATIONALE

December 5, 2012

11:10 am

Problem: Ascites secondary to Peritoneal TB, r/o Peritoneal carcinomatosis

Admit with consent under the service of green team.

Monitor vital signs every hour and record.

Small frequent feedings.

MIO every 4 hours and record.

IVF: D5LR 1L @ KVO (microset)

Laboratory:

CBC, BT

AFB peritoneal fluid

-Admission for referral of care.

-For close monitoring and to watch out for any unsualities.

-To prevent gastrointestinal reflux.

-Provides information about fluid status, circulating volume and replacement needs.

-Replacement therapy; to support fluids and electrolytes in the body.

-To use as baseline information in comparison to next repeated laboratory exams.

-A screening test to provide information about the cellular components of the patient’s blood; to determine presence of any abnormalities or disorders.

-Acid- fast bacilli, to identify pathogenic organisms present in the peritoneal fluid, as well as,

December 5, 20125:00 pm

(-) obstruction seen

Surgical notes;Thank you for the referral seen and examined

A/P carcinomatosis vs. PTB

Medications: Ceftriaxone 1mg

IVTT every 12 hours ANST

Ranitidine 50mg IVTT every 8 hours

Metoclopramide 10mg IVTT every 8 hours PRN for vomiting

Multivitamins + Amino acid 1 capsule once a day

For paracentesis, secure consent

Continue medication management

Refer

For: CEA

TSH

to identify the antimicrobial therapy that is best suited for the particular micobacteria identified.

-An antibiotic Cephalosphorin, for treatment of susceptible infection.

-An H2 receptor antagonist, used to decrease gastric secretion.

-An antiemetic, for management of nausea and vomiting associated with various GI disorders.

-To prevent low levels of vitamins, folic acid, and amino acids in the body.

-Secure consent, because the procedure to be done is an invasive procedure.

-Carcinoembryonic antigen, a test performed when cancer is suspected but not yet diagnosed and especially when doctor suspects that cancer has metastasized.

-Thyroid stimulating hormonetest, is a test that measures the amount of



CHAPTER VIII

NURSING CARE PLAN # 1

HRP NSG. Dx

AMB PATHO-PHYSIOLOGY

CLIENT OUTCOME

NURSING INTERVENTIONS

RATIONALE EVALUATION

EXCHANGING

Ineffective breathing pattern r/t decreased lung compliance secondary to ascites

(Dec.7, 2012)

Subjective: -“Medyo nahihirapan akong huminga, malaki kasi tong tiyan ko”, as verbalized.

Objective:-RR: 25 bpm-Nasal flaring noted-DOB noted-Uses accessory muscles-Abdominal distention noted due to ascites-Abdominal girth of 93 cm

The accumulation of fluid may cause breathing difficulties by compressing the diaphragm.A person with ascites has a swollen, rounded stomach. The skin on the abdomen is tight. The size of the abdomen is related to the amount of fluid present.Ascites may extend as far as the chest cavity. The presence of the fluid adds pressure to the lungs and may cause the individual to experience difficulty breathing.

Within the shift, patient will breathe with minimal difficulty as evidenced by not using accessory muscle and RR within normal range.

1. Monitor vital signs.

2. Place on semi-fowler’s position with arms supported with pillows.

3. Maintain calm attitude while dealing with client and to significant others.

4. Encourage adequate rest and sleep periods between activities.

5. Instructed to avoid overeating/ gas-forming foods.

-To watch out for abnormalities, assess condition.

-To relieve pressure on the diaphragm.

-To limit the level of anxiety.

-To limit fatigue and preserve energy.

-They can cause abdominal distention, thus, will aggravate difficulty of breathing.

Goal not met, patient’s respiratory rate was 27 bpm, evident use of her accessory muscles when breathing.



HRP NSG. Dx


CLIENT OUTCOME

NURSINGINTERVENTIONS


EXCHANGING

Deficient fluid volume r/t active fluid volume loss (ascites: third spacing)

(Dec.7, 2012)

Subjective: “Kadalasan talaga gusto kong tubig.”

Objective:

-Abdominal distention (ascites)

- Muscle weakness

-Poor skin turgor

Ascites is the accumulation of fluid in the peritoneal cavity. Third spacing occurs when too much fluid moves from the intravascular to interstitial space causing a reduced blood volume in intravascular space.

Within the shift, the patient will able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill.

1. Note possible condition that may create a fluid volume deficit such as fluid restriction, vomiting or use of diuretics.2. Monitor vital signs, noting low blood pressure—severe hypotension, rapid heartbeat, and thready peripheral pulses.3. Compare usual and current weight.

4. Measure abdominal girth.

5. Instruct the client to avoid foods very high in sodium content.

6. Monitor Intake and output accurately.

7. Instruct patient to avoid drinks containing caffeine e.g. beverages and coffee.8. Change position frequently.

-Help identify and prevent further fluid deprivation.

-Changes in vital signs are associated with fluid volume loss and/or hypovolemia.-To note for any significant fluid gain or loss.-To note for the extent of fluid retention in the abdomen.-To avoid excessive water retention and further fluid shifting (ascites).-To note for significant fluid loss and gain.

-To reduce effects of diuresis.

-To reduce pressure on fragile skin and tissues.

Goal partially met. The patient was able to maintain fluid volume at a functional level as evidenced by good vital sign, but skin turgor was still poor (3-4 sec).



HRP

NSG. Dx


CLIENT OUTCOME

NURSING INTERVENTONS


FEELING

Acute pain r/t abdominal

fullness secondary to

ascites

(Dec.8,2012)

Subjective: “Masakitangtiyan ko ngayon” as verbalized-pain scale of 6/10

Objective:-pale and weak looking

-with limited movements noted

-facial grimace noted

-diaphoresis noted

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress.

Within the shift, client will report

pain is relieved or controlled

and demonstrate

use of relaxation skills and

diversional activities.

1. Allow patient to verbalize pain.

2. Provide non-pharmacologic comfort measures such as repositioning, back rub and diversional activities such as listening to music and conversing about pleasant things.

3. Encourage use of stress management skills or complementary therapies such as guided imagery and therapeutic touch.

4. Observe or monitor signs and symptoms associated with pain, such as BP, HR, temp., color and moisture of skin, restlessness, and ability to focus.

5. Provide rest periods to facilitate comfort, sleep, and relaxation.

-Pain is subjective that can only be felt by the person affected.

-Promotes relaxation and helps refocus attention.

-Enables patient to participate actively in nondrug treatment of pain and enhances sense of control.

- Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.

- Pain may result in fatigue, which may result in exaggerated pain and exhaustion.

Goal met, client appears calm and relaxed,

pain was decreased from

6/10 to 3/10; verbalized,

“Medyo hindi na masakit ngayon”.



HRP NSG. Dx


CLIENT OUTCOME



EXCHANGING

Altered bowel elimination: Constipation r/t decreased motility of GI tract

(Dec. 8, 2012)

Subjective: -“Hindi parin ako nakakabawas simula ng naadmit ako” as verbalized.-Reports decreased frequency of bowel movement

Objective:-Abdominal distention noted due to ascites-Abdominal girth of 93 cm-Limited fluid intake of 1000mL-Inadequate fiber intake due to loss of appetite

Constipation is a condition characterized by infrequent or hard bowel movements, or having difficulty passing bowel movements. Also known as irregularity, Constipation can include pain when having a bowel movement, an inability to “go” after trying for more than ten minutes or having no bowel movement after more than three days.

Within the shift, patient will be able to establish or regain an elimination pattern as evidenced by bowel movement with at least normal consistency, thus, participate and understand the appropriate interventions or solutions in order to relieve self from constipation.

INDEPENDENT:1. Auscultate abdomen for

presence and location of bowel sounds and its characteristics.

2. Note color, odor, consistency, amount, and frequency of previous stool.

3. Identify factors (eg. Medications, bedrest, diet) that may cause or contribute to constipation.

4. Encourage on high fiber foods, and suggest warm stimulating fluids.

5. Encourage on light exercises as tolerated.

DEPENDENT:6. Administer laxative or stool

softeners as ordered.

-This reflects the bowel activity.

-This provides baseline comparison, promotes recognition of changes.

-Assessing causative factor is an essential first step in teaching and planning for improved bowel elimination.

-To improve consistency of stool and facilitate passage.

-Influences bowel elimination by improving muscle tone and stimulating peristalsis.

-May be necessary to gently stimulate peristalsis/ stool evacuation.

Goal not met, patient was still unable to regain her bowel movement.



HRP NSG. Dx


CLIENT OUTCOME



EXCHANGING

Imbalanced nutrition less

than body requirements

related to feeling of

being full and mal-

absorption

(Dec.11, 2012)

Subjective: “Hanggang apat na kutsara lang kaya kong kainin kasi feeling ko wala ng mapaglagyan pagkain sa tyan ko” as verbalized.

Objective: -Weakness noted-Poor muscle tone-Decreased subcutaneous fat/ muscle mass

The client perceived that there is no space in her stomach that’s why she didn’t take lots of food. Her nutritional needs was very high due to poor eating habits. She seems to have poor nutritional status.

Within 8 hours of nursing interventions the client will be able to regain weight and verbalize understanding of causative factors when known and necessary inteventions

Assess weight, age, body build, strength, activity/ rest level

Auscultate bowel sounds. Note characteristics of stool.

Weigh weekly and document results.

Encourage to verbalize feelings and concerns

Discuss eating habits including food preferences, intolerance, aversions

Determine psychological factors

-Use as comparative baseline

-To identify if bowel movement is present for peristalsis

-To monitor effectiveness of dietary plan

-To know the real concern/ feeling of the client.

-To appeal to client likes/ desires.

-To assess body image and congruency with reality

Goal partially met, the client’s nutritional status enhances as evidenced by verbalization of “Medyo naging okay na ako ngayon, may lakas na ako” and having an energy during the conduct of assessment and during or within the activity period.



HRP NSG. Dx


CLIENT OUTCOME



FEELING

Mild anxiety related to threat/ changes in health status secondary to peritoneal tuberculosis

(Dec.8, 2012)

Subjective:“Kinakabahan ako sa kalagayan ko ngayon”, as verbalized.

Objective:- -Awake with

blank stare- -Focus on self

- Pale and weak looking-Limited movements noted-Diaphoresis noted

Mild anxiety speaks for itself. Basically your body's natural warning system telling you to go on alert when there is no actual cause for alarm.Even though mild anxiety is slighter in terms of effects, it still can be a heavy baggage especially if it occurs more often than you think. On the case of our client she was anxious about her current condition, if there will be a good prognosis or not. Those suffering from mild anxiety will usually only suffer from the physical and mental symptoms.

Within the shift, client will be able to appear relaxed and report anxiety is reduced to a manageable level.

1. Explore client’s feelings.

2. Allow/ encourage client to speak openly about fears and concerns.

3. Establish a therapeutic relationship, conveying empathy and unconditional positive regard

4. Acknowledge anxiety or fear. Do not deny or reassure that everything will be alright

5. Monitor and record vital signs.

-To know what/ how does client really feels.

-To let him express what are those he think that makes him worry.

-To let patient feel that he’s not alone and to avoid the contagious effect or transmission of anxiety.

-Not to let client assure herself and blame anyone if something happen.

-To identify physical responses associated with both medical and emotional conditions.

Goal met, client was able to expressed feelings and concerns; appears relaxed and verbalized, “Mas okay sa ngayon kesa kanina”.



HRP NSG. Dx


CLIENT OUTCOME



FEELING

Anticipatory grieving related to perceived potential death

(Dec.11, 2012)

Subjective: “Malala na daw tong sakit ko”, as verbalized.

Objective:-Weakness noted- Alterations in sleep pattern

Grieving is an intellectual and emotional responses and behaviors by which the individual and family work through the process of modifying self concept based on the perception of potential loss. Since patient’s illness has a poor prognosis, and chance of survival is minimal, it is normal that the patient and family mourn.

Within the shift, the client will be able to identify and express feelings appropriately.

1. Establish rapport to the client.

2. Provide open, nonjudgmental environment. Use therapeutic communication skills.

3. Encourage verbalization of thoughts/concerns and accept expressions of sadness, anger, rejection. Acknowledge normality of these feelings.

4. Reinforce teaching regarding disease process and treatments and provide information as requested/appropriate about dying. Be honest; do not give false hope while providing emotional support.

5. Identify positive aspects of the situation.

-To establish trust and cooperation to the client.

- Promotes and encourages realistic dialogue about feelings and concerns.

- Patient may feel supported in expression of feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation.

- Patient/SO benefit from factual information. Individuals may ask direct questions about death, and honest answers promote trust and provide reassurance that correct information will be given.

-Possibility of remission and slow progression of disease and/or new therapies can offer hope for the future.

Goal met, client and family were able to verbalize understanding of the dying process and feelings of being supported in grief work.



HRP NSG. Dx


CLIENT OUTCOME



MOVING

Self-care deficit r/t lack of motivation in performing good hygiene.

(Dec.7, 2012)

Subjective: “Hindi ko na magawang maligo at mag-ayos ng katawan ko dahil sa sakit ko”, as verbalized.

Objective:-discomfort noted

-dry skin

-slight unpleasant body odor noted

Self-care deficit is described as an impaired ability to perform complete feeding, bathing/ hygiene, dressing and grooming or toileting activities.Since the patient has weakness, it’s hard for her to move and do daily activities that’s why self-care is often depleted.

Within the shift, the client will be able to cooperate in the practice of good and proper hygiene.

1. Establish rapport to the client.

2. Encourage to verbalize feelings and concerns.

3. Assist on adaptation to accomplish activities of daily living.

4. Provide communication among those who are involved in caring for assisting the client.

5. Allow sufficient time for the client to accomplish task to fullest extent of ability.

-To establish trust and cooperation to the client.

-To discover barriers to participation.

-To encourage client and build on successes.

-Enhances coordination and continuity of care.

-To enhance client’s capabilities and promote independence.

Goal met, client and family were able to participate in promoting good hygiene to the patient by giving him a bed bath.

CHAPTER IX

DRUG STUDY # 1GEN.

NAMEBRAND NAME

DRUGCLASS

MODE OF ACTION

INDICATIONCONTRA-

INDICATIONACTUAL

DOSEUSUAL DOSE

SIDE EFFECTS

NURSING RESPONSIBILITIES

CEFTRIAXONE

ROCEPHIN

CEPHALOSPORIN

Inhibits bacterial wall synthesis, thus, promoting osmotic instability which eventually leads to bacterial cell death.

-Used to treat infection caused by staphyloco-ccus, streptococcus, E.coli, and other susceptible microorganism. Skin to skin structure infection and biliary tract infection.

Contra-indicated for patients who have known hypersensitive to cephalos-porins and any of its components.

Ceftriaxone 1gm q12 ANST ( )

Ceftriaxone 1-2 gms

once a day

Signs of allergy: skin rashes, fever.

Hematologic: leukopenia, reversible thrombo-penia

Digestive:nausea, vomiting, anorexia, diarrhea

1. Observe the 10R’s of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation).

2. Assess patient’s previous sensitivity reaction to cephalosporins.

3. Monitor for signs of allergic reaction.

4. Monitor vital signs before and after giving the drug esp. HR,RR,BP. Report changes.

5. Explain that the patient may experience the following side effects: nausea, diarrhea.

6. Encourage patient to report for signs of abnormalities.


DRUG STUDY # 2

GEN.NAME

BRAND NAME

DRUGCLASS

MODE OF ACTION

INDICATIONCONTRA-

INDICATIONACTUAL

DOSEUSUAL DOSE

SIDE EFFECTS


RANITIDINE

ZANTAC

Histamine (H2)

receptor antagonist

Inhibits the action of histamine at H2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion that stimulates by food, insulin, histamine, cholinergic agonist, gastrin, and pentagastrin.

-Short-term treatment of active duodenal ulcer; treatment of gastro-esophageal reflux disease; short-term treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions (postoperative hypersecretion); heartburn.

-Contra-indicated with allergy to ranitidine.Use cautiously with impaired renal or hepatic function.

Ranitidine 50mg

IVTT q8

Ranitidine 25-50mg

IV twice or thrice daily

CNS: Headache,malaise, dizziness

CV: Tachycardia,bradycardia

GI: Constipation,diarrhea, abdominal pain, hepatitis

Hematologic: Leukopenia, granulocytopenia, thrombocytopenia,pancytopenia

Local: Pain at IV site, phlebitis


2. Monitor vital signs and watch out for abnormalities such as tachycardia or bradycardia.

3. Monitor intake and output.

4. Explain to hat she may experience the following side effects: headache, malaise.

5. Check laboratory results for abnormalities and refer to the physician.

6. Check the insertion site for phlebitis.

7. Encourage to report immediately for any signs of abnormalities.


DRUG STUDY # 3

GEN.NAME

BRAND NAME

DRUGCLASS

MODE OF ACTION INDICATIONCONTRA-

INDICATIONACTUAL

DOSEUSUAL DOSE

SIDE EFFECTS


METOCLOPROMIDE

PLASIL

Anti-emetic

It binds to dopamine D2 receptors where it is a receptor antagonist, and is also a mixed 5-HT3 receptor antagonist/ 5-HT4 receptor agonist. The antiemetic action of metoclopramide is due to its antagonist activity at D2 receptors in the chemo- receptor trigger zone (CTZ) in the CNS—this action prevents nausea and vomiting triggered by most stimuli. At higher doses, 5-HT3 antagonist activity may also contribute to the antiemetic effect. The gastroprokinetic activity of metoclopramide is mediated by muscarinic activity, D2 receptor antagonist activity and 5-HT4 receptor agonist activity. The gastro-prokinetic effect itself may also contribute to the antiemetic effect.

-Disturbances of GI motility -For nausea andvomiting

-Contra-indicated withallergy to metoclopramide;GI hemorrhage; Mechanical obstruction or perforation; fluid overload, and renal impairment

Metoclo-promide

10mg IVTT q8 PRN for vomiting

Metoclo-promide1amp IV

q 6-8°

CNS: restlessness, drowsiness, fatigue, insomnia, dizziness, anxiety

CV: transient hypertension

GI: nausea and diarrhea


2. Check history: allergy to metoclopramide, GI hemorrhage, mechanical obstruction or perforation.

3. Monitor BP carefully during IV administration.


5. Tell patient that she may experience the said side effects: drowsiness, nausea, dizziness.


DRUG STUDY # 4

GEN.NAME

BRAND NAME

DRUGCLASS

MODE OF ACTION

INDICATIONCONTRA-

INDICATIONACTUAL

DOSEUSUAL DOSE

SIDE EFFECTS


MULTIVITAMINS

+

AMINO

ACIDS

NUTRI

WELL

Multi-vitamins

and supple-ments

Multivitamin is a combination

of many different

vitamins that are normally

found in foods and other natural

sources.Many act as

coenzymes or catalysts in numerous metabolic

processes. It also works by

providing extra vitamins, folic

acid, and amino acids to the

body when you need more than what you get in

your diet.

Treating or preventing low levels of vitamins, folic acid, and amino acids in the body.

-Contra-indicated if you are allergic to any ingredient in multivitamins with folic acid/amino acids and if you have high blood levels of arginine (argininemia).

Multi-vitamins +

Amino acids 1cap

OD

Multi-vitamins

1cap daily

Allergic reactions:Rash, hives, itching, difficulty breathing, tightness in the chest, swelling of the mouth, face, lips, or tongue


2. Take multivitamins with folic acid/amino acids by mouth with or without food. If stomach upset occurs, take with food to reduce stomach irritation.

3. Take multivitamins with folic acid/amino acids with a full glass of water (8 oz/240 mL).

4. Explain that she may experience the following side effects: rash, difficulty breathing.



DRUG STUDY # 5

GEN.NAME

BRAND NAME

DRUGCLASS

MODE OF ACTION

INDICATION CONTRA-INDICATION

ACTUAL DOSE

USUAL DOSE

SIDE EFFECTS


MULTIVITAMINS

+

MINERALS

SUPPLEMENTS

Multi-vitamins

and supple-ments

Multivitaminand minerals are used to provide vitamins and minerals that are not taken in through the diet. Multivitamin and minerals works by treating vitamin or mineral deficiencies caused by illness, pregnancy, poor nutrition, digestive disorders, certain medications, and many other conditions.

Dietary supplement for the treatment and prevention of vitamin and mineral deficiencies.

-Contra-indicated if you are allergic to any ingredient in multivitamins and minerals and any of its components.

Multi-vitamins + Minerals

(Supplements)1 vial OD x

12hours

Multi-vitamins + Minerals 1 vial once or twice a day

Less serious side effects:upset stomach,headache,unusual or unpleasant taste in your mouth

Allergic reaction: Hives, difficulty breathing, swelling of your face, lips, tongue, or throat.

1. Remember the 10R’s of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation).

2. Monitor for manifestations of hypersensitivity appearance promptly.

3. Do not take this medication with milk, other dairy products, calcium supplements, or antacids that contain calcium. Calcium may make it harder for your body to absorb certain ingredients of the multivitamin.

4. Check for nutritional deficiencies.



DRUG STUDY # 6

http://www.emedicinehealth.com/script/main/art.asp?articlekey=103281




GEN.NAME

BRAND NAME

DRUGCLASS

MODE OF ACTION

INDICATIONCONTRA-

INDICATIONACTUAL

DOSEUSUAL DOSE

SIDE EFFECTS


LACTULOSE

LILAC

Laxative

Ammoniareduction drug

Metabolism of lactulose by bacteria results in reduced colonic pH which stimulates peristalsis & decreases stool transit time. In turn, decreased water reabsorption from the feces further facilitates the passage of soft, well-formed stools. Increased osmotic pressure of fecal material secondary to an increase in colonic organic acids results in accum. of fluid from surrounding tissues, helping to soften stool mass.

Treatment of constipation.

Prevention and treatment of portal- systemic encephalo-pathy

-Contra-indicated to patients with allergy to lactulose, low-galactose diet.

-Use cautiously with diabetes, pregnancy and lactation.

Lactulose 30cc TID

Lactulose 30cc syrup

OD HS

GI: Transient flatulence,distention, intestinal cramps, belching, diarrhea, nausea

Other: Acid-base imbalance

1. Observe the 10R’s of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation).2. Instruct that this drug may be taken with fruit juice or milk to increase palatability.3. Do abdominal examination, check bowel sounds, and serum electrolyte levels.4. Do not administer if patient has already pass out stool especially if stool is liquid.5. Monitor intake and output.6. Tell patient that she may experience these side effects: flatulence, intestinal cramps, nausea)7. Report if unusualities occur.


DRUG STUDY # 7

GEN.NAME

BRAND NAME

DRUGCLASS

MODE OF ACTION

INDICATIONCONTRA-

INDICATIONACTUAL

DOSEUSUAL DOSE

SIDE EFFECTS


TRAMADOL

TRAMAL

Analgesic, opioid analgesic

Binds to –opiate receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of and response to pain; also inhibits the reuptake ofnorepinephrine and serotonin, which also modifies the ascending pain pathway.

Moderate to severe acute or chronic pain and in painful diagnostic or therapeutic measures.

Hypersensi-tivity to tramadol, opioids, or any component of the formulation; opioid-dependent patients; acute intoxication with alcohol, hypnotics, centrally-acting analgesics, opioids, or psychotropic drugs.

Tramadol drip: tramadol 100 mg 1amp + D5W 500cc x 24 hours

Tramadol 50 - 100 mg IV every

4 - 6 hours

●Dizziness●Nausea●Drowsiness●Dry mouth●Constipation●Headache●Sweating●Vomiting●Itching●Rash●Atelectasis


2. Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration.

3. Assess BP & RR before and periodically during administration.

4. Assess bowel function routinely.

5. Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and pneumonia.

6. Instruct client to report any adverse reaction to the physician or nurse.


DRUG STUDY # 8

GEN.NAME

BRAND NAME

DRUGCLASS

MODE OF ACTION

INDICATIONCONTRA-

INDICATIONACTUAL

DOSEUSUAL DOSE

SIDE EFFECTS


ALBUMIN

ALBUMINAR

Plasma expanders

Blood derivatives

Provides increase in intravascular oncotic pressure and causes mobilization of fluids from interstitial into intravascular space.

For plasma volume expansion and maintenance of cardiac output in the treatment of certain types of shock or impending shock; may be useful for burn, ARDS, peritonitis, and ascites.Unless the condition responsible for hypoproteinemia can be corrected, albumin can only provide symptomatic relief of supportive treatment.

-Contra-indicated with allergy to albumin and any of its components, with severe anemia and

Albumin 25% 50cc + furose-mide 20mg x 2 hours q12hours

Albumin25% vials: 2-3 ml/ minute maximum

Fever Chills Flushing Hives, Skin Rash Itching Headache Nausea Breathing

Difficulty Rapid

Heart Rate


2. Monitor vital signs and watch out for abnormalities.


4. Explain to the parents that he may experience the following side effects: fever, chills, nausea.

5. Check laboratory results for abnormalities and refer to the physician.

6. Watch out for symptoms of overdose, such as: hypervolemia, CHF, pulmonary edema.



DRUG STUDY # 9

http://www.medicinenet.com/script/main/art.asp?articlekey=20628



GEN.NAME

BRAND NAME

DRUGCLASS

MODE OF ACTION

INDICATIONCONTRA-

INDICATIONACTUAL

DOSEUSUAL DOSE

SIDE EFFECTS


FUROSEMIDE

LASIX

Loop Diuretic

Inhibits sodium & chloride

reabsorption at the

proximal tubules, distal

tubules and ascending

loop of henle

leading to excretion of water together

with sodium, chloride

and potassium.

-Treatment of fluid accumulation such as ascites, edema associated with CHF,hepatic cirrhosis, renal disease.

- Hypersen-sitivity to furosemide, sulfonylureas, or any other drugs.

- Contraindicated in patients with anuria, hyponatremia or hypovolemia.

Albumin 25% 50cc + furose-mide 20mg x 2 hours q12hours

Furosemide20-40mg

IV everyday of one to

two times a day

●Low blood pressure●Dehydration and electrolyte depletion●Orthostatic HPN●Pruritus●Vertigo●Dizziness●Fever ●Nausea●Vomiting●Constipation●Oral and gastric irritation ●Diarrhea●Increased blood sugar and uric acid levels may also occur.


2. Check the BP first before administration.

3. Monitor Intake and Output of the patient.

4. Explain that she may experience these side effects: dizziness, nausea.

5. Instruct client to report any signs of side effects.

CHAPTER X

LABORATORY STUDY # 1

DETERMINATION ACTUAL VALUE NORMAL VALUE SIGNIFICANCE/INTERPRETATION NURSING RESPONSIBILTY

HEMATOLOGY(December 5, 2012)● WBC

● RBC

● HGB

HCT

PLT

MCV

MCH

MCHC

RDW

17.2 x 109/ L

4.51 x 1012/L

118 g/L

0.38

957 x 109/L

84.0 fL

26 pg

340g/L

12.1 %

4.0-10.0 x 109/ L

4.50-5.4 x 1012/L

115-155 g/L

0.36-0.47

100-300 x 109/L

86-100 fL

26-31 pg

310-375 g/L

11.6-13.7 %

Increased; indicative of impending infection or inflammation in the body due to disease process.

Normal; good oxygenation in the blood, may decrease because of disease process.

Normal; good circulation of oxygen in the blood.

Normal;there is good hydration status in the patient’s body; good oxygen supply.

Increased; or thrombocytosis, may result from iron deficiency anemia or inflammatory disorders.

Decreased; MCV measures the ratio of hematocrit to RBC count. May indicate iron deficiency anemia

Normal; MCH gives the hemoglobin to RBC ratio.

Normal: MCHC measures the ratio of hemoglobin weight to hematocrit.

Normal; RDW determines the measurement of RBCs.

Explain the procedure & purpose of performing the procedure, and that is to determine infection & its severity because of the disease. This test is very important as baseline data.

Tell patient as well as watcher that the test requires a blood sample and explain who will perform the venipuncture.

Give health teachings on patient’s diet and medication that may contribute to the result of the test.

Based on the result, instruct patient to eat nutritious foods especially rich in vitamins, minerals and iron, such as fish, vegetables, and fruits.

Advise to have adequate rest and sleep periods.

Stress out the importance of taking multivitamins as

Differential Count Neutrophils

Lymphocytes

Monocytes

Eosinophils

Basophils

80 %

10 %

9.0 %

1.0 %

0 %

40-70 %

19-42 %

3.0-9.0 %

2.0-8.0 %

0-5.0 %

Increased; may indicate infection, inflammatory processes during physical stress, or with tissue necrosis.

Decreased; may signal infection in the body and/or anemia.

Normal; may increase because of illness disease.

Decreased; signals infection because of illness.

Normal; aids in determining specific conditions.

prescribed by the physician.

Educate about the importance of medications and treatment regimen.

Note for any abnormalities on findings and refer the results to the physician.



DETERMINANTS ACTUAL VALUE

NORMAL VALUE

SIGNIFICANCE/ INTERPRETATION NURSINGINTERVENTIONS


CLINICAL CHEMISTRY(November 23, 2012) Creatinine

SGPT/ALT

SGOT/AST

ALP(Alkaline phosphatase)

Total Protein

Albumin

Globulin

73.4 umol/L

333.4 nKat/L

383.4 nKat/L

1300.3 nKat/L

62 g/L

33 g/L

53-97 mmol/L

0-517 nKat/L

0-517 nKat/L

700-1630 nKat/L

64-83 g/L

35-52 g/L

Normal; indicates that the kidneys are able to properly remove all creatinine. May increase if dehydrated or took certain medications.

Normal; indicates that liver and kidneys are functioning well. Low levels of ALT are normally found in the blood. But when the liver is damaged or diseased, it releases ALT into the bloodstream, which makes ALT levels go up. Most increases in ALT levels are caused by liver damage.

Normal; indicates no liver damage. High levels may indicate severe MI, severe infectious mononucleosis or alcoholic cirrhosis. Low levels indicate hemolytic anemia, metastatic hepatic tumors or fatty liver.

Normal;indicates no liver or bone disease. ALP test measures the amount of alkaline phosphatase released from the tissues into the blood and is a marker of the hepatobilary system function. Moderate increase indicates acute biliary obstruction. Low levels are linked to hypophosphatasia and protein or magnesium deficiency.

Decreased;may be indicative of certain diseases such as GI disease, protein deficiency, neoplastic disease, malnutrition or malabsorption.

Decreased; may indicate that not enough protein is being absorbed in the body, may also reflect diseases such as malnutrition or ascites.

Explain the procedure & purpose of performing the procedure, and that is to help diagnose the occurrence of disease and if there are complications, to test effectiveness of medications and find treatments for the disease.

Explain the procedure to the client that the medical technician will get sample of her blood for testing.

Give health teachings on patient’s diet and medication that may contribute to the result of the test.

Instruct patient to eat nutritious foods especially rich in vitamins, minerals and proteins, such as fish, vegetables, and fruits. Also, instruct to eat nutritious food that helps in cleansing the kidney.

Strictly monitor the intake and output.


Stress out the importance of


A/G Ratio

29 g/L

1.1

20-35 g/L

1.7-2.2

Normal;Globulin carries essential metals through the bloodstream and carries them to the various parts of the body and helps the body to fight infections. Globulin proteins include enzymes, antibodies and more than 500 other proteins. High levels indicate tuberculosis. Low levels indicate GI disease, malnutrition, or malabsorption.

Decreased;A low A/G ratio reflects overproduction of globulins, due to chronic infections, liver and kidney disease, fatty necrotic liver, rheumatoid arthritis, leukemia, increased amount of nonspecific protein, and autoimmunity disorders. On the other hand, a high A/G ratio suggests under production of immunoglobulin; this is seen in genetic deficiencies and in cases of nephrosis, liver dysfunction, acute hemolytic anemia, and hypogammaglobulinemia / agammaglobulinemia.

taking multivitamin and supplements as prescribed by the physician.

Note for any unusualities on findings and refer the results to the physician.




NORMAL VALUE

INTERPRETATION / SIGNIFICANCE NURSING RESPONSIBILITY

URINALYSIS(November 23, 2012) Color

Albumin

Sugar

Transparency

pH

Specific Gravity

Pus Cells

RBC

Amorphous Urates

Yellow

(+)

(-)

Cloudy

Acidic

1.025

0-2/hpf

0-2/hpf

111

Pale yellow to amber

None or 0-8mg/dL

None or 0.08mml/L

(0-25mg/dL)

Clear to slightly hazy

Acidic

1.003-1.060

Females: None or 5-10/hpf

None or 0-5/hpf

None

Normal; color may change due to diet and drugs.

Abnormal; an increase in urinary albumin excretion is indicative of increased permeability of the filters of the kidney called, glomerulus which due caused by some kidney damage.

Normal; normally, glucose is not present in the urine because it is reabsorbed from the renal tubules.

Abnormal; cloudy urine may be caused by crystal deposits, white cells, epithelial cells or fat globules.

Normal; pH measures how acidic or alkaline the urine is. Sometimes urine pH is affected by certain treatments.

Normal; this checks the amount of substance in the urine. When you drink lots of fluid your specific gravity becomes low. When you are dehydrated your specific gravity becomes high.

Normal; there should be no yeast cells and bacteria or parasites in the urine, if present; it means that there is infection.

Normal; normally, there is no blood in the urine. One of the common causes of RBC in the urine is infection or inflammation of the urinary tract itself (cystitis).

Increased; Amorphous Urates indicates uric acid crystals in the urine. Higher than acceptable levels of uric acid crystals in urine

1. Instruct patient to void into a clean, dry container.

2. Sterile disposable container should be used always.

3. Cover all specimens tightly, label properly and send immediately to the laboratory.

4. Observe standard precaution when handling the specimen.

5. Avoid the specimen to be exposed to extreme temperature such as sunlight or heat.

6. The specimen should be preserved if not to send to laboratory to have accurate results.

7. Note for any unusualities on findings and refer the


Epithelial Cells

11 None to few

can be caused by gout, cardiovascular disease, diabetes, uric acid stone, urolithiasis, and metabolic syndrome.

Increased; may suggest inflammation within the bladder, but they may also originate from the skin and could be contaminated. Sometimes, it is normal not to have any epithelial cells present in a urine sample or to have occasional numbers of any of the three cell types. Large numbers of squamous cells may indicate contamination of the urine specimen, but large numbers of either the transitional or renal tubular cells may indicate a serious disease process.

results to the physician.




NORMAL VALUE

INTERPRETATION / SIGNIFICANCE NURSING RESPONSIBILITY

PERITONEAL FLUID ANALYSIS(November 26, 2012) Glucose

Lactate dehydrogenase

Total protein

Albumin

Globulin

7.40 mmol/L

2025 U/L

6.6

4.20 g/dL

2.40g/dL

4.2-6.2 mmol/L

36-229.1 U/L

7.3-21.1 g/dL

< 1.1 g/dL

2.4-4.5 g/dL

Increased; may indicate tuberculosis and/or malignancy; could be low in malignant ascites

Increased; Elevated levels of LDH and changes in the ratio of the LDH isoenzymes usually indicate some type of tissue damage. LDH levels typically will rise as the cellular destruction begins, peak after some time period, and then begin to fall.

Decreased; may be indicative of a symptom of a disease, infection or an underlying condition. When there is inadequate protein intake, the body begins to breakdown muscle to obtain enough amino acids for the synthesis of serum albumin.

Increased; to distinguish exudates and transudates. Values above 1.1 g/dL are considered evidence of a transudate.

Normal; Globulins are proteins that include gamma globulins (antibodies) and a variety of enzymes and carrier/transport proteins. Low globulin levels signify a type of protein deficiency; high levels mean chronic infections.

Explain the procedure & purpose of performing the procedure, and that is to help distinguish between types of peritoneal fluid and help diagnose the cause of fluid accumulation (ascites).

Explain that in this procedure, a local anesthetic is applied to the area of operation and then a catheter is routed from the skin into the peritoneal cavity. As soon as this is done, the peritoneal fluid will start to flow out.

Monitor vital signs prior to the procedure.

Advise to empty the bladder first before the procedure becausethis is a lengthy test.

Note for any unusualities on findings and refer the results to the physician.



DETERMINANTS ACTUAL NORMAL SIGNIFICANCE/

VALUE VALUE INTERPRETATION NURSINGINTERVENTIONImmunology

CA 12-5

(November 28, 2012)

127 U/ml 0.35 U/ml Increased: indicates that the cancer antigen is increased in colon, upper gastrointestinal (GI), ovarian, and other gynaecologic cancers: pregnancy, peritonitis.

Explain the procedure and the purpose of performing such procedure, and that is to determine infection because of the disease, that this test is very important as baseline data.


Give health teachings on patient’s diet that may contribute to the result of the test.

Based on the result, instruct the patient to eat nutritious foods especially rich in iron, such as fish, vegetables, and fruits.


Stress out the importance of taking multivitamins as prescribed by the physician.




NORMAL VALUE

SIGNIFICANCE/INTERPRETATION NURSINGINTERVENTION

Immunology(December 6, 2012) Free T4

TSH

CEA(Carcinoembryonic

Antigen)

0.95

4.08

531.12

0.58-1.64 ug/dl

0.34-5.60 µ U /ml

0-3 ng/ul

Normal; indicates that thyroid hormone feedback system is functioning well. This test was done to evaluate thyroid function. The free T4 test is a newer test that is not affected by protein levels. Since free T4 is the active form of thyroxine, the free T4 test is thought by many to be a more accurate reflection of thyroid hormone function.

Normal; indicates normal functioning of the thyroid. T4 will be ordered along with a TSH to give a more complete evaluation of the adequacy of the thyroid hormone feedback system. These tests are usually ordered when a person has symptoms of hyper or hypothyroidism.

Increased; can indicate possible cancerous activity. Increased CEA levels may also indicate some non-cancer-related conditions, such as some forms of inflammation, cirrhosis, and peptic ulcer. A CEA test is ordered when the patient’s symptoms suggest the possibility of cancer. CEA is an embryonic protein which could be secreted in adult as well, if there is any abnormality in protein producing organs, especially liver, but similar protein can also be secreted if there is a presence of cancer.

Explain the procedure and the purpose of performing such procedure, and that is to evaluate thyroid function, determine possibility of cancer, diagnosis of certain illness or to monitor the effectiveness of treatment.


Give health teachings on patient’s diet that may contribute to the result of the test.

Educate on the importance of strict compliance to medication and treatment regimen.


Advise to eat nutritious foods necessary to improve health and to hasten recovery.



DETERMINANTS ACTUAL

VALUE

NORMAL VALUE

SIGNIFICANCE/INTERPRETATION NURSINGINTERVENTION

http://labtestsonline.org/glossary/feedback

http://en.wikipedia.org/wiki/International_unit

http://en.wikipedia.org/wiki/Micro-

Electrolytes(December 11, 2012) Serum Na

Serum K

Serum Ca

126.6

3.91

1.02

135-148 mmol/L

3.5-5.3 mmol/L

1.13-1.32 mmol/L

Decreased; indicates an electrolyte disturbance in which the sodium concentration in the serum is lower than normal. Sodium is the dominant extraellular cation and cannot freelycross the cell membrane. Hyponatremia is most often a complication of other medical illnesses in which excess water accumulates in the body at a higher rate than can be excreted (for example in congestive heart failure, syndrome of inappropriate antidiuretic hormone, SIADH or polydipsia.

Normal; Potassium testing is frequently ordered, along with other electrolytes. The most common cause of hyperkalemia is kidney disease, but many drugs can decrease potassium excretion from the body and result in this condition. Hypokalemia can occur if someone has diarrhea and vomiting or if is sweating excessively. Potassium can be lost through the kidneys in urine; in rare cases, potassium may be low because someone is not getting enough in their diet.

Decreased; indicates an electrolyte imbalance. Hypocalcaemia either occurs as a result of too much calcium loss or insufficient calcium intake through food. Early symptoms of low serum calcium include frequent muscle cramps and joint pains. In addition to this, inability to perform tiresome activities, fatigue, brittle nails, and yellowness of teeth also occur as a result of abnormally low level of calcium in the blood stream.

Explain the procedure and the purpose of performing such procedure, and that is to determine electrolyte imbalance in the body due to disease process


Because of electrolyte imbalance, initial treatment consists of slow correction of the hyponatremia via fluid restriction.

To restore calcium to a normal level, advise patient to eat calcium-rich foods or calcium supplements on a regular basis or as prescribed.

Advise to eat nutritious foods necessary to improve health and to hasten recovery.


DIAGNOSTIC TESTS

ABDOMINAL ULTRASOUND (November 23, 2012)

http://en.wikipedia.org/wiki/Congestive_heart_failure

http://en.wikipedia.org/wiki/Blood_serum

http://en.wikipedia.org/wiki/Sodium

The liver is normal in size and echopattern. The intrahepatic ducts are not dilated. There are no focal mass lesions

seen.

The gallbladder is distended. There are no intraluminal stones seen. Wall is not thickened. The common duct is not

dilated.

The pancreas and spleen are normal in size and echopattern. There are no solid nor fluid-filled mass lesions seen.

The right kidney measures 11.0 x 3.4 cms while the left measures 10.0 x 4.2 cms. The cortical echoes exhibit normal

echogenicity and show good distinction of its corticomedullary junctions. The pelvocalyceal systems are intact. No ectasia

norlithiasis seen. There are no focal renal mass lesions detected.

The uterus is not dilated. The urinary bladder is distended without intravesical lithiasis seen.

The uterus is normal in size with an intact endometrium. No abnormal uterine/adnexal mass seen.

Fluid collection is seen in the peritoneal cavity. There are omental cakes and thickening of the peritoneal lining.

Impression: Omental cake / Peritoneal thickening, consider peritoneal carcinomatosis vs. peritoneal tuberculosis

Massive ascites

Normal sonogram of the liver, gallbladder, pancreas, spleen, kidneys, urinary bladder and uterus.


ABDOMINAL CT SCAN (November 27, 2012)

Multiple plain & contrast enhanced axial CT images of the whole abdomen show the following findings:

The liver, gallbladder, pancreas, spleen and adrenals are normal. There are no enhancing mass lesions seen. The

intrahepatic and pancreatic ducts are not dilated.

Both kidneys exhibit good excretory functions. No ectasia, masses nor lithiasis seen.

The ureters and urinary bladder are opacified and maintains its normal course and configurations.

There are distended fluid-filled intestinal loops seen. However, no evident intraluminal masses are seen. There are

thickening noted in the peritoneal lining seen in the left.

Fluid density is seen in the abdominal cavity, with the uterus and ovaries floats within. There are no septations noted.

There are no enlarged intra abdominal / retroperitoneal nodes seen.

The mesentery, vascular and osseus structures are unremarkable.

Impression: Ascites with thickened peritoneal lining, left possibilities of inflammatory (Tuberculosis) vs.

Carcinomatosis are considered.


TRANSVAGINAL – TRANSABDOMINAL ULTRASOUND (November 29, 2012)

The uterus is anteverted with smooth contour and homogenous echopattern measuring 5.5 x 2.3 x 3.3 cm (The cervix

measures 2.6 x 19 x 1.3 cm with homogenous stoma and distinct endocervical canal).

The endometrium is hyperechoic measuring 0.2 cm thick with intact subendometrial halo.

The right ovary measures 3.0 x 1.7 x 1.8 cm.

The left ovary measures 2.5 x 1.8 x 1.8 cm.

There’s massive anechoic free fluid in the cul de sac.

The omentum is converted into a heterogenous mass measuring 18 x 10 cm.

Impression: Normal uterus

Thin endometrium

Normal ovaries

Consider GI pathology


CHEST AP (December 10, 2012):

There are no active lung infiltrates seen

Heart is not enlarged

Diaphragm is elevated

Bony thorax is unremarkable

Impression: Elevated Diaphragm

MISCELLANEOUS REPORT (November 25, 2012):

Specimen Submitted: Peritoneal Fluid

Final Report: No growth after 48 hours incubation

Gram Stain: No organism seen

AFB: None found

CHAPTER XI

PROGNOSIS

CRITERIAVERY GOOD

(5)GOOD

(4)FAIR

(3)POOR

(2)

VERYPOOR

(1)JUSTIFICATION

Severity/ Nature of disease

Ms. Bella’s disease is difficult to treat and is fatal. Onset of disease is rapidly progressive and for now, only supportive care can be rendered.

Financial Status

Though they are able to comply and provide financial support minimally, they are now referred to service consultant because of heavy expenses.

Family Support

The family of the patient’s partner supports her most of the time. Her parents seldom visit her and buy for her medicines.

Patient factor

The patient is cooperative and participative to treatment regimen, though weak and sometimes irritable.

Availability & accessibility of appropriate treatment

Most of the appropriate treatment and resources are available.


Respective Numerical Values:

Very Good= 5 Good = 4 Fair = 3 Poor = 2 Very Poor=1

Standard Rating:

Very Good = 4.20 – 5.00

Good = 3.41 – 4.20

Fair = 2.61 – 3.40

Poor = 1.81 – 2.60

Very Poor = 1.0 – 1.80

Formula:

Rate x Frequency No. of Criteria

Computaion:

Very Good: 5 x 0 = 0

Good: 4 x 1 = 4

Fair: 3 x 2 = 6

Poor: 2 x 1 = 2

Very Poor: 1 x 1 = 1 13 ÷ 5 criteria = 2.60 or POOR

General Prognosis:

Based on the criteria, Ms. Bella has poor prognosis with a result of 2.60. Specifically,

she has scores of zero (0) in very good; two (1) in good; two (2) in fair; one (1) in poor and

one (1) in very poor.


In general, the client has a poor prognosis due to the onset, severity and

progression of the disease and complications secondary to her health problems.

Peritoneal carcinomatosis represents a devastating form of cancer progression

with a very poor prognosis. It is the most common terminal feature of abdominal

cancers. peritoneal cancer can be hard to detect in the early stages. That's because its

symptoms are vague and hard to pinpoint. When clear symptoms do occur, the disease

has often progressed. Care at this time is focused on relieving symptoms and quality of

life issues post-treatment.

CHAPTER XII

DISCHARGE SUMMARY PLAN

I. MEDICATION

Instruct patient and watcher to administer the prescribed medications on a right

dose, frequency and time.

RATIONALE: To meet the therapeutic effect of the drug and prevent over

dosage of the medication.

Explain the purpose of the medication.

RATIONALE: This will provide information to both the client and the parent

as to why the patient needs to take the prescribed medication.

Explain the indication and possible side effects brought by each of the drug.

RATIONALE: This will give awareness on both the patient and the watcher

to prevent panic when side effects are experienced by the client.

Instruct the client and watcher that when adverse effect occurs and if there are

any unusualities consult the physician immediately.

RATIONALE: To prevent any complications and give appropriate

interventions

II. EXERCISE

Encourage client not to do strenuous activities and limit activities within own

capacity as possible.

RATIONALE: Activities that require great muscle strength should be

avoided to prevent injury and fatigue.


III. TREATMENT

Instruct to maintain the prescribed medication as regularly as ordered by the

physician.

RATIONALE: To have a pace of supportive care.

Let the patient and family know that they should maintain a conducive, peaceful,

and non-stressful environment.

RATIONALE: To promote relaxation and good palliative care.

Explain to the client and family the need for heightened quality of life until her

last days.

RATIONALE: To make the client and family aware that the care does not

end in the hospital and that their participation is a must in the continuation of care.

IV. HYGIENE

Encourage the client to observe proper hygiene like taking a bath everyday,

hand washing before and after performing activities especially when having

meals and brushing of teeth every after meal.

RATIONALE: Hygiene promotes comfort and cleanliness to the client

and it also increases the sense of wellness.

V. OUT PATIENT FOLLOW-UP

If possible, instruct the patient to follow physician’s order on when to consult

for checkup.

RATIONALE: To enable the physician to evaluate patient’s condition.


Advise the family to supervise the patient properly.

RATIONALE: To take note for any unusualities and can be referred

immediately.

VI. DIET

Inform the family that the patient must receive adequate & proper nutrition

(especially high fiber diet). Eat fruits and green leafy vegetables.

RATIONALE: To modify patient’s diet and prevent further complication.

VII. SEXUAL ACTIVITY

Instruct patient that sexual intercourse is not recommended.

RATIONALE: Care is focused on supportive and emotional care.

CHAPTER XIII

BIBLIOGRAPHY

Austin, F., Mavanur, A., Sathaiah, M., Steel, J., Lenzner, D., Ramalingam, L., Holtzman, M., Ahrendt, S., Pingpank, J., Zeh, H., Bartlett, D., & Choudry, H. (2012). Peritoneal Carcinomatosis. Retrieved December 11, 2012 from, http://pmppals.org/peritoneal-carcinomatosis.html

Brunner, L. S. &Suddarth’s D.S. (2008). Medical-Surgical Nursing 11th& 12th edition, Volume 1 & 2.

Doenges, M., Moorhouse, M., &Murr A. (2002). Nursing Care Plans: Guidelines for Individualizing patient care 6th edition.

Gould, B. (2007). Pathophysiology for the Health Professionals 3rd edition.

Gulanick, M., Klopp, A., Galanes, S., Gradishar, D., &Puzas, M. (1994). Nursing Care Plan 3rd edition.

Hoofnagle JH. Peritoneal Carcinomatosis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 151.

Jeffress, D. (2012). What Is Peritoneal Carcinomatosis? Retrieved December 10, 2012 from,http://www.wisegeek.com/what-is-peritoneal-carcinomatosis.htm

Johnson, RJ.(1993). Radiology in the management of ovarian cancer. Retrieved December 11, 2012 from, http://radiology.rsna.org/content/221/1/173.full

Karch, A. (2007). Lippincott’s Nursing Drug Guide.

Kusamura, S., Baratti, D., Zaffaroni, N., Villa, R., Laterza, B., Balestra, MR., & Deraco, M. (2010). Pathophysiology and biology of peritoneal carcinomatosis. Retrieved December 12, 2012 from,http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999153/

McCann, J. (2004). Handbook of Diseases 3rd edition.


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999153/

http://www.wisegeek.com/what-is-peritoneal-carcinomatosis.htm

Mizumoto, A., Canbay, E., Hirano, M., Takao, N., Matsuda, T., Ichinose, M., & Yonemura, Y. (2012). Gastroenterology Research and Practice Volume 2012Retrieved December 10, 2012 from, http://www.hindawi.com/journals/grp/2012/836425/

Peritoneal Health Guide (2010). Peritoneal Carcinomatosis Survival Rate. Retrieved December 11, 2012 from, http://peritoneal-health.info/peritoneal-carcinomatosis-survival-rate/

Sugarbaker, PH., Esquivel, J., & Sticca, R., (2007). Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin:a consensus statement. Retrieved December 11, 2012 from, http://www.ncbi.nlm.nih.gov/pubmed/17072675

Electronic resources:

http://bestpractice.bmj.com/bestpractice/monograph/750/basics/pathophysiology.

http://www.medicinenet.com/peritonealtuberculosis /page4.htm

http://www.streetdirectory.com/travel_guide/111734/medical_conditions/ peritoneal carcinomatosis _a_ in_history.html

http://www.who.int/mediacentre/factsheets/fs328/en/index.html - WHO 2012

http://www.ehow.com/list_6329814_signs-symptoms-peritoneal-carcinomatosis.html

http://www.ehow.com/list_6329814_signs-symptoms-peritoneal-

http://www.who.int/mediacentre/factsheets/fs328/en/index.html%20-%20WHO%202012

http://www.streetdirectory.com/travel_guide/111734/medical_conditions/%20%09peritoneal%20carcinomatosis%09_a_%09in_history.html

http://www.streetdirectory.com/travel_guide/111734/medical_conditions/%20%09peritoneal%20carcinomatosis%09_a_%09in_history.html

http://www.medicinenet.com/peritonealtuberculosis%20/page4.htm

http://bestpractice.bmj.com/bestpractice/monograph/750/basics/pathophysiology.

Peritoneal Carcinomatosis Grand Case Study

Documents

Transcript of Peritoneal Carcinomatosis Grand Case Study