Ateneo de Davao UniversityCollege of Nursing

In Partial Fulfillment of the Requirements in Related Learning Experience

A Case Study On

RHABDOMYOSARCOMA

Submitted to:

Ms. Honeylet P. Villanueva, RN, MNClinical Instructor

Submitted by:

Jan Mikhail Louise Paolo FrascoJhon Bernand Hernandez

Angeline Nicole EspinoPatrick Antoni DerechoKlyde Louise JarabeloChristine Jay Domingo

Jenny Pearl EstuyaSheena Fe DanueLawrence CalvoPatrick Calanoy

August 2011

Table of Contents

I. Acknowledgement 01

II. Introduction 02

III. Objectives 04

IV. Patient’s Data 07

V. Genogram 09

VI. Family Background / Health History 10

VII. Developmental Data 14

VIII. Physical Assessment 22

IX. Definition of Complete Diagnosis 26

X. Anatomy and Physiology 31

XI. Etiology 39

XII. Symptomatology 41

XIII. Pathophysiology 43

XIV. Doctors Order 46

XV. Diagnostic Exam 54

XVI. Drug Study 77

XVII. Nursing Theories 101

XVIII. Nursing Care Plan 103

XIX. Prognosis 125

XX. Discharge Plan 128

XXI. Recommendation 131

XXII. Reference 133

ACKNOWLEDGEMENT

The researchers wish to express their deepest gratitude and warmest

appreciation to the following people, who, in any way have contributed and

inspired the researchers to the overall success of the undertaking:

To Mam. Li Derla for her guidance and support in the duration of the

study.

Mam Honeylet Villanueva for helping us and supporting us to find a

case during our duty. to the NOD at SPMC house of hope for the

accommodation and pure hospitality.

to our patient and his family, for their selfless cooperation and sharing

their precious time.

To our friends, who have been unselfishly extending their efforts and

understanding.

To our parents who have always been very understanding and

supportive both financially and emotionally.

And above all, to the Almighty God, who never cease in loving us and

for the continued guidance and protection.

The Researchers

INTRODUCTION

Rhabdomyosarcoma is a malignant tumor that starts in muscle, its

primarily a childhood tumor and occurs most often in children under 5 years of

age. Over 60% of cases show up before age 10. On rare occasions,

rhabdomyosarcoma affects adults.

Rhabdomyosarcoma can begin anywhere there is muscle including the

head and neck, arms and legs, genitourinary tract, and the trunk.

Treatment for rhabdomyosarcoma may involve surgery, radiotherapy or

chemotherapy. Usually two or three of these modalities of treatment are

employed. For example, a surgeon may first try to remove as much tumor as

possible. Then the patient may undergo several weeks of chemotherapy,

possibly followed by radiation therapy, and then more chemotherapy.

There are 2 main types of rhabdomyosarcomas. Embryonal

rhabdomyosarcoma (ERMS) is the most common type of rhabdomyosarcoma.

It usually affects infants and young children. The cells of ERMS look like the

developing muscle cells of a 6- to 8-week-old embryo. ERMS tends to occur

in the head and neck area, bladder, vagina, and in or around the prostate and

testicles. Alveolar rhabdomyosarcoma (ARMS) typically affects older children

or teenagers and occurs more often in large muscles of the trunk, arms, and

legs. ARMS cells look like the normal muscle cells seen in a 10-week-old

fetus. ARMS tends to grow faster than ERMS and usually requires more

intensive treatment.

About 3% of all childhood cancers are rhabdomyosarcomas. About 350

new cases of rhabdomyosarcoma occur each year in the United States. The

number of new cases has not changed much over the past few

decades.http://www.cancer.org/Cancer/Rhabdomyosarcoma/DetailedGuide/

rhabdomyosarcoma-key-statistics

We the researchers chose this case study because of the following

reasons. First, the researcher identified the case as a chance to study and

learn about the disease on why thus this illness increased globally. The

researchers aimed that the readers will have greater insights and more

understanding about this disease. And We also aim that this case study may

become a tool in improving care and in developing new medical technology in

relation to this disease. The researchers is aiming that this will help in

improving the quality of care given to patients suffering Rhabdomyosarcoma

With this study, it will also contribute and help the people involved

especially the nurse, by giving them enough knowledge to deal appropriately

with this disease. It will also help to let the client’s family understand the

disease condition and give them information or knowledge on how to care for

the client.

OBJECTIVES

A GENERAL:

Within our 3 days shift 3-11 shift span of duty we will be able to formulate a comprehensive case study about, which could essentially be a way of identifying and presenting all the accompanying characteristics and information contained in the patient’s condition including its prospective management. This would also able our group to:

B SPECIFIC

Cognitive:

—Discuss in details Acute Pyelonephritis in Sepsis for our case study so as to gain insight and knowledge.

—Gather necessary and pertinent data, concerning the client and family, as a baseline information about the ask data;

—Determine the degree of development in order to point out certain problems or foreseeable crisis that would affect the maintenance of health of my patient;

—Present the definition of complete diagnosis that would explain the illness of my client;

—Discuss the Anatomy and Physiology of the affected system (Urinary, Immune, Lymphatic and Hematologic Systems) of the disease;

—Present the Etiology and Symptomatology and trace the Pathophysiology of the disease with diagram;

—Present the diagnostic examinations undergone by the patient and know it's clinical significance;

—Present drug studies for all the medications prescribed by the physician administered to the patient such as; Cefuroxime, Domperidone, Paracetamol, Captopril, Ceftriaxone Sodium, Cefotaxime Sodium, Omeprazole, Eperisone, Tramadol and Diazepam.

—List all the actual medical management for the patient and interpret;

—Identify and Prioritize the need for our patient;

—Evaluate prognosis for my client with proper justification.

AFFECTIVE:

—Have a purposeful interaction with the client as well as her significant other.

—Establish rapport with our client and her family in order to gain cooperation and come up with a reliable information needed in this case study;

—Be able to relate the patient’s disease with the different nursing theories specifically those of Florence Nightingale (Environmental Theory), Jean Watson (Human Caring Theory), Lydia Hall(Care Core Cure theory) and Dorothea Orem’s (Self- care theory).

—Formulate a specific, measurable, attainable, realistic and time-bounded nursing care plan for the client

—Provide health teachings to the client and the family

—Outline recommendations based on the case study’s findings

PSYCHOMOTOR:

—Enhance the ability to identify and apply nursing interventions to provide a better care for the client with the said disease.

—Conduct a cephalocaudal assessment to our patient in order to note any alterations or deviations from the normal physical structures;

—Formulate an appropriate and realistic health teachings as part of the optimal and holistic care to achieve recovery;

—Provide the patient and family with proper discharge planning (M.E.T.H.O.D.)

Patient’s Data

Patient’s Name : Patient J

Gender : Male

Birthdate : August 5, 1996

Birthplace : Tagbilaran City, Bohol

Age : 14 years old

Number of Siblings : 7

Ordinal Rank : 5th Child

Address : Quarry 1, Villaverde Tagbina Surigao del sur

Nationality : Filipino

Civil Status : Single

Occupation : None

Religion : Catholic

Denomination : Roman Catholic

Educational Attainment : Grade 5

Admitting Data

Date of Admission : July 9, 2011

Time of Admission : 07:01 am

Hospital : Southern Philippines Medical Center

Ward : Orthopedic Male ward [Bed 25]

Vital Signs upon Admission

Blood Pressure 90/60 mmHg

Pulse Rate 100 beats per minute

Respiratory Rate 17 cycles per minute

Temperature 36.5 degree Celsius

Weight : 64 lbs

Height : 54cm

Body Mass Index : 1.1851852

Chief Complaint : Mass Right Deltoid

Admitting Physician : Dr. Chris George C. Pales

Admitting Diagnosis : Right Arm Mass Probably Sarcoma

Complete Diagnosis : Rhabdomyosarcoma, Right Shoulder

Source of Information : Patient and Patient’s chart and Patient’s Watcher

GENOGRAM

Paternal Side

Maternal Side

Ll

TTᶲ

Aa QQ KkBb RR

ᶲCc Ff IiHhGg

PPSS ᶲ

Dd

OO

JjEe Mm

ECA B D FPATIENT

Ʊ

ᶲDeceased

ƱRhabdomyosarcoma, @ Right Shoulder

Health History

Family Background

Patient J is the son of Mom QQ and Father RR. He was born on

August 5, 1996 in Tagbilaran City, Bohol. He is a 14 year old male and the

5th child among the seven siblings. According to Patient J, their

grandparents in the paternal side died due to old age and not of any kind of

disease. In the maternal side his grandparents are still alive and they were

not diagnosed of any sort of disease. His father who was 54 years old died

by committing suicide due to financial problem. His 47 year old mother is still

alive and not diagnosed of any sort of disease. Patient J studied at Villaverde

Elementary School. He loves to play with his friends and classmates and

watch television. He sometimes goes to the nearest river and play once a

week and every weekend he sometimes goes to terraces where his mother

works there as a peasant and helps her throughout the day.

In terms of familial relationship, Patient J is playful, funny and

sometimes hardheaded just like the other kids. He usually gets along with his

friends and classmates. He does not have any experience of having conflicts

with anyone of them. He usually wakes up at 6:00 am to prepare for his

morning class. With regards to their health condition Ms. QQ takes part in

making decision.

In terms of economic status, they belong to the lower class. His

Mother is a housewife. Aside from being a housewife she also works part-

time as a peasant at Surigao Del sur. His brother A is also contributing in

giving extra money to their mother. According to his brother, this helps in

their daily expenses. Their estimated monthly income is 2000 pesos. Their

monthly electricity bill is 400 pesos and their water bill is free because they

use safety tank where the rain drops are filtered. According to his brother

they have not gotten any disease from that tank. The school expenses are

1000 pesos annually for each child in a public school.

Patient J and most of his siblings are not engage in any kind of vices

except the 2nd brother who is Mr. B. Mr. B is a smoker. He smokes Philip

Morris and Hope and consumes more or less 3 sticks per day. Mr. A usually

gives his brother B advice regarding smoking. He wants him to stop because

it is dangerous to one’s health.

Client’s Lifestyle, Diet, and Activities of daily Living (ADL)

Patient J’s typical day starts with preparing himself and go to school.

During his free time, he watches television like cartoons and anime; he

always plays with his friends and classmates a “tumba lata”, “takyan” and

going to the river etc.

His diet is mainly fish such as “galong-gong”, “tulingan”, “bangus” and

“sari-sari”, vegetables that can be bought in the wet market and those that

they planted at their backyard themselves. He was able to have at least three

meals a day. During breakfast, lunch and dinner he eats fish and vegetables

and sometimes with a glass of milk. Patient J said that he doesn’t have any

usual routines for exercise but he considered his playtime as exercise. He

always wakes up early in the morning even during the weekends. He sleeps

at around 9:00 pm and wakes up at around 6:00 am. Every Sunday his family

goes to church to attend mass.

History of Past Illness

Patient J was born via Normal Spontaneous Vaginal Delivery at

Tagbilaran City, Bohol. According to his mother there were no complications

or abnormalities noted upon delivery. He said that he had a chicken pox at

the age of 3 and according to his mother she had him immunized and

completed it. He also experienced headache, fever and cough but able to

manage these through taking over-the-counter drugs such as Biogesic,

Neozep, and Tuseran.

According to Patient J, in January 2011, he noticed a painful tiny mass

on his right arm. Then, he and his mother decided to go to the Barangay

Health Center and a nurse adviced him to take antibiotic and analgesic which

is amoxicillin and mefenamic acid. After 1 month the tiny mass was gone.

History of Present Illness

However, on April 2011 the painful mass on his right arm came back.

Patient J just decided to take the antibiotic and analgesic again rather than

consulting a doctor because they don’t have enough money to pay for the

consultation fee. However, it came to the point that the tiny mass gone bigger

and painful. This time he was very eager to consult a doctor. When he finally

met the doctor he was recommended to undergo an operation to remove the

mass on his deltoid. On August 5, 2011 he had his amputation at Southern

Philippines Medical Center and was then admitted in Orthopedic Ward in the

same hospital and on September 1, 2011 where he had his Skin graft. Upon

admission, his vital signs were as follows: Blood Pressure = 90/60 mmHg,

Temperature =36.5 degree Celsius, Respiratory rate = 17 cycles per minute

and Pulse rate = 100 beats per minute.

Effects/ Expectations of Illness to Self/ Family

Patient J and his family are very religious and active to attend mass.

His current condition does have a great impact within their family. His

Mother, siblings and other relatives are there to support here emotionally and

financially. Even though they are tight on the budget, they still submit the

patient for better treatment and never lose hope for Patient J to be in good

health.

Medication Reconciliation

Medication Indication as

known by the

patient

Dosage Prescribing

health care

provider

Biogesic For fever and for

headache

250mg t.i.d

Neozep For colds 250mg t.i.d

Tuseran For cough 250mg t.i.d

Amoxicillin To treat and

prevent infections

500mg t.i.d Nurse

Mefenamic Acid Pain Reliever 500mg prn Nurse

Review of Systems

Prior to admission the patient complains pain at his right arm with a pain

scale of 7 out of 10. According to patient J it was painful and uncomfortable.

His vital signs upon admission are as follows. : Blood Pressure = 90/60

mmHg, Temperature =36.5 degree Celsius, Respiratory rate = 17 cycles per

minute and Pulse rate = 100 beats per minute.

DEVELOPMENTAL DATA

Developmental data contains records and analysis of an increase or

stagnancy in the complexity of function and skill progression. It manifests the

person’s capability and skills in adapting to a dynamic environment. It begins

in infancy stage and ends in the old age stage while attaining intelligence,

developing problem-solving ability and coping and adapting to the

environment in all aspects. Development is the behavioral aspect of growth

such as person’s ability to walk, talk, run and even feelings of sensation and

emotion. It proceeds from simple to complex such as from single acts to

integrated ones. In attempt to analyze a person’s developmental data a

developmental delay is monitored. A developmental delay is any significant

lag in a child's physical, cognitive, behavioral, emotional, or social

development, in comparison with norms.

Erikson’s Stages of Psychosocial Development

Erik Erikson, Erikson’s stages of psychosocial development describe eight

stages through which a healthy developing human should surpass from

infancy to late adulthood. In each stage, a person faces and hopefully

masters new challenges. These challenges may come back as problems in

the future if these are not successfully completed from each stage.

Stage Description Result Justificationfidelity - Identity vs.

Role ConfusionTeens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of

unachieved Patient J has not successfully achieved this

stage because he is in constant confusion on

what will be his role in the

society. He is still dependent on his older siblings and

self. mother emotionally.

Havighurst’s Developmental Task

Havighurst (1972) defines a developmental tasks 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 identifies three sources of

developmental tasks (Havighurst, 1972).

o Tasks that arise from physical maturation

o Tasks that arise from personal values

o Tasks that have their source in the pressures of society

Havighurst also identified Six Major Stages in human life covering birth to old

age which are the following:

Infancy & early childhood (Birth till 6 years old)

Middle childhood (6-12 years old)

Adolescence (13-18 years old)

Early Adulthood (19-30 years old)

Middle Age (30-60years old)

Later maturity (60 years old and over)

Our client belongs to the 3rd stage which is the adolescence, Tasks

that arise from personal values: Choosing an occupation, socializing with

same age group, figuring out ones philosophical outlook.

The following are the developmental task that a adolescence adult must fulfill

or achieve:

DEVELOPMENTAL

TASK

ACHIEVED OR NOT

ACHIEVED

JUSTIFICATION

Achieving new and more Achieved Patient J was able to

mature relations with

age mates of both

sexes.

achieve this. He was active

with interacting with his

classmates at school.

 Achieving a masculine

or feminine social role.

Achieved He was able to achieve it

since he is willing to help his

mother on the farm. He

accepts the responsibility of

being a male in his family by

helping his younger siblings

and helps with the

maintenance of the house.

Accepting one’s

physique and using the

body effectively

Achieved Patient J achieved this since

he has already accepted

that his arm is amputated.

He was able to adapt with

his present condition by

doing alternative measures

in his ADL’s.

Achieving emotional

independence from

parents and other adults.

Achieved Patient J achieved this since

he has emotional stability in

his present condition and

does not depend on his

mother.

Achieving assurance of

economic independence

and selecting and

preparing for occupation

Unachieved Patient J has not achieved

this since he only finished 5th

grade and with his present

condition he will have a hard

time landing a job.

Preparing for marriage

and family life.

Unachieved Patient J has not achieved

this since he is still not

financially capable of

supporting a family. He says

he is not thinking of

marriage as of the moment.

Developing intellectual

skills and concepts

necessary for civic

competence;

Unachieved Patient J has not achieved it

since he only finished 5th

grade. With his present

condition which requires

admittance in the hospital

and financial situation, he

was not able to develop the

skills necessary for civic

competence.

Desiring and achieving

socially responsible

behavior.

Achieved Patient J was able to

achieve this since he has

the desire to be responsible

and help in little ways in the

family prior to his sickness

like helping in farm and

babysitting his younger

siblings.

Acquiring a set of values

and an ethical system as

a guide to behavior

Achieved Patient J was able to

achieve this since he was

taught by his mother and

older sibling’s good conduct.

He says he follows the rules

set by his mother in the

house.

Kohlberg's Stages of Moral Development

This theory specifically addresses moral development in children and

adults. The morality of an individual’s decision was not Kohlberg’s concern;

rather, he focused on the reasons an individual makes a decision.

Stage Description Result Justification

Conventional

Stage (Law

and Order

Orientation)

The conventional level of

moral reasoning is typical of

adolescents and adults.

In this stage, it is important

to obey laws, dictums and

social conventions because

of their importance in

maintaining a functioning

society. Right is being good,

with the values and norms of

family and society at large.

The self enters society by

filling social roles; therefore

society must learn to

transcend individual needs.

A central ideal or ideals often

prescribe what is right and

wrong, such as in the case

of fundamentalism. If one

person violates a law,

perhaps everyone would—

thus there is an obligation

and a duty to uphold laws

and rules. When someone

does violate a law, it is

morally wrong;

responsibility is thus a

significant factor in this stage

as it separates the bad

domains from the good

ones. Most active members

of society remain at stage

ACHIEVED In this stage of Kohlberg's Moral

Development theory, it is a must

for the client to pursue the laws

in order to continue a good

functioning in the society as a

good citizen. Patient J also

expressed that as a member of

this society, one must follow

rules or else your gonna be

punished. Because of his young

age, he was not able to expound

his ideas regarding the

questions. Patient J was raised

by his mother with the proper

values that is acceptable in our

society. He believes that there is

order if one follows the rules as

he gives anologies in their

household.

four, where morality is still

predominantly dictated by an

outside force

DEFINITION OF COMPLETE DIAGNOSIS

(Rhabdomyosarcoma, Right Shoulder)

Rhabdomyosarcoma (rab’do-mi-o-sark-ko’mah)

A malignant neoplasm derived from skeletal (striated) muscle; characterized

in adults by poorly differentiated oblong, as well as rounded and bizarre, cells

with large hyperchromatic nuclei; the cytoplasm is usually granular and

structures that resemble cross striations may be observed.

Illustrated stedman’s medical dictionary 24th edition,1982. P. 1230.

USA: Williams and wilkins.

a sarcoma containing striated muscle fibers

DORLAND'S ILLUSTRATED MEDICAL DICTIONARY. 23RD

EDITION.: L., Et al. (eds.) Brainerd

Rhabdomyosarcoma is a fast-growing, highly malignant tumor which

accounts for over half of the soft tissue sarcomas in children. Less frequently,

other soft tissue sarcomas are found in children: fibrosarcoma,

mesenchymoma, synovial sarcoma, and liposarcoma.z`

Blakistons new gould medical dictionary 8th edition page 1024 USA

RIGHT

Toward or on the right.

Daniels, R., Nosek, L., Nicoll, L. Contemporary Medical Surgical

Nursing. 2007. p. 1780. USA: Thomas Delmar Learning.

 the condition of having the right side distinct or different from the left.

Tamparo, Carol. Diseases of The Human Body. (2005) Davis

Company. ISBN: 0-8036-1245-1.

location near or direction toward the right side

Late, P. (2009). Seeley’s Principle of Anatomy and Physiology. (p.

616) McGraw Hill; New York, NY 10020

Shoulder

The lateral portion of the scapular region, where the scapula joins with the

clavicle and humerus and is covered by the rounded mass of the deltoid

muscle.

Illustrated stedman’s medical dictionary 24th edition,1982. P. 1282.

USA: Williams and wilkins.

The part of the body between the neck and the upper arm

Dorlands illustrated medical dictionary 23rd edition p. 1184 press of

W.B. sanders company USA

The region where the arm joins the trunk formed by the meeting of the

clavicle and scapula and the overlying soft parts.

Blakistons new gould medical dictionary 8th edition page 929 USA

Rhabdomyosarcoma, Right Shoulder

A rhabdomyosarcoma is a type of cancer, specifically a sarcoma (cancer of connective tissues), in which the cancer cells are thought to arise from

skeletal muscle progenitors. It can also be found attached to muscle tissue, wrapped around intestines, or in any anatomic location. Most occur in areas

naturally lacking in skeletal muscle, such as the head, neck, and genitourinary tract. Rhabdomyosarcoma is a relatively rare form of cancer.

PHYSICAL ASSESSMENT

Date of Assessment: 15 Sept. 2010

Time of Assessment: 7:00 pm during Physical Assessment

General Sur-vey

Received lying on bed, at supine position, awake, conscious, coherent, alert, & oriented. He has wounds at right thigh (3) & right shoulder (1). Appears thin, height of 48”, weight of 64 lbs., relaxed, bent posture, unsteady gait; coordinated movement, dominantly uses left foot in standing, able to sits up straight, and walks at moderate speed, clean, unkempt appearance, presence of purulent wound odor, withdrawn, able to follow instructions, affect is appropriate to situation, speech is understandable, moderate pace; clear tone & inflection; exhibits thought association, relevance & organization of thought has relevant s sequence; makes sense; has sense of reality. BMI=14.3

Integument

Nails

Convex curvature; angle of nail plate about 160 degrees, smooth texture, highly vascular & pink, intact epidermis, prompt return of pink or usual color.

Hair

Evenly distributed, thin, silk, resilient, no infection or infestation, variable amount.

Skin

Color is light brown, generally uniform except in areas exposed to the sun, no edema, wound size at right shoulder is 12” x 6” 4 mm deep at most, wounds sizes at thigh are 1 x 1”; 4 x 2”; 4 x 4”; itchy, 2 mm deep at most, uniform temperature; within normal range, when pinched then skin springs back to previous state.

Head

Skull & Face

Vital Signs Results

Blood Pressure 80/50 mmHg

Pulse rate 84 BpM

Respiratory rate 32 CpM

Temperature 37.7 degrees Celsius

Rounded (normocephalic and symmetric with frontal, parietal, and occipital prominences); smooth skull contour, smooth uniform consistency; absence of nodules or masses, almost symmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds, symmetric facial movements.

Eye structures & visual acuity

Visual acuity

Able to read newsprint

Extraocular Muscle Tests

Light falls symmetrically on both pupils, uncovered eye does not move on cover test

Visual Fields

When looking straight ahead, client can see objects in the periphery, both eyes coordinated, move in unison, with parallel alignment

External Eye Structures

Eyebrows hair evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement, equally distributed eyelashes; curled slightly outward, eyelid skin is intact; no discharge; no discoloration, lids close symmetrically, approximately 15 to 20 involuntary blinks per minute; bilateral blinking, when lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered, Transparent bulbar conjunctiva; capillaries sometimes evident; sclera appears white, shiny, smooth, and pink palpebral conjunctiva, no edema or tenderness over 3 mm in diameter; round, smooth border, iris flat & round lacrimal gland, no edema or tearing on the lacrimal sacs & nasolacrimal ducts, transparent, shiny, & smooth cornea; details of the iris are visible, client blinks when the cornea is touched, transparent anterior chamber, no shadows of light on iris, depth of about 3 mm, pupils are black in color; equal size, 3 mm in diameter; round, smooth border, iris flat & round, illuminated pupil constricts (direct response), nonilluminated pupil constricts (consensual response), Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose.

Ears & Hearing

Gross Hearing Acuity Tests

Normal voice tones audible, able to hear ticking in both ears.

External Ear Canal and Tympanic Membrane

Distal third contains glands, dry cerumen, and tan color, tympanic membrane has pearly gray color, semitransparent.

Auricles

Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye; about 10 degrees from vertical, mobile, firm, & not tender; pinna recoils after it is folded.

Nose & Sinuses

Nose

Symmetric & straight, no discharge, uniform color, not tender; no lesions, air move freely as the client breathes through the nares, mucosa pink, clear, watery discharge, no lesions, nasal septum intact & in midline.

Facial Sinuses

Not tender

Mouth & Oropharynx

Lips & Buccal Mucosa

Outer lips has a uniform pink color, soft, moist, smooth texture, symmetry of contour, able to purse lips, inner lips & buccal mucosa has uniform pink color, moist, smooth, glistening, & elastic texture

Teeth & Gums

30 teeth, white, stained tooth enamel, pink gums, no retraction of gums.

Tongue/Floor of the Mouth

Tongue is at the center, pink color, smooth lateral margins; no lesions, raised papillae, moves freely; no tenderness, tongue base has prominent veins

Salivary Glands

Same as color of buccal mucosa & floor of mouth

Palates & Uvula

Soft palate is light pink, lighter pink hard palate, more irregular texture, uvula is positioned in midline of soft palate

Oropharynx & Tonsils

Pink & smooth posterior wall, pink & smooth tonsils, no discharge, of normal size: Grade 1 (normal), present gag reflex.

Neck

Neck Muscles

Muscle equal in size; head centered, head movement is coordinated, smooth movements with no discomfort, head flexes 45 degrees, hyperextends 60 degrees, laterally flexes 40 degrees, laterally rotates 70 degrees, muscle strength is equal when turning head, equal when shrugging shoulders

Lypmh Nodes

Not palpable

Trachea

Centrally placed in the midline of neck; space are equal on both sides

Thyroid Gland

Not visible on inspection, gland ascends during swallowing but is not visible, lobes cannot be palpated, absence of bruit.

Chest, Lungs and Axilla

Thorax & Lungs

Anterior Thorax

Quiet, rhythmic, & effortless respirations, costal angle is less than 90 degrees & the ribs insert into the spine at approximately 45 degrees angle, vocal fremitus is the same as posterior thorax; vocal fremitus decreased over heart & breast tissue, percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas bone, dull on areas over the heart & the liver, & tympanic over the underlying stomach, bronchial and tubular breath sounds are heard on the trachea, bronchovesicular & vesicular breath sounds are heard on the bronchi between over the sternum and the clavicles

Cardiovascular & Peripheral Vascular Systems

Heart & Central Vessels

No pulsations in the aortic & pulmonic areas, no pulsations; lift in the tricuspid area, no lift or heave in the apical area, aortic pulsations at the epigastric area, S1: heard at all sites, S2: heard at all sites, systole: silent interval; slightly shorter duration than diastole, diastole: silent interval; slightly longer duration than systole

Carotid Arteries

Symmetric pulse volume, full pulsations, thrusting quality, quality remains the same when client breathes, turns head, & changes from sitting to supine position, elastic arterial wall, no sound heard on auscultation

Jugular Veins

Veins not visible

Peripheral Vascular System

Symmetric pulse volumes, full pulsations,

Peripheral Veins

Symmetric pulse volumes, full pulsations

Peripheral Veins

Limbs not tender, symmetric in size

Peripheral Perfusion

Skin color pink, skin temperature not excessively warm or cold, no edema.

Buerger’s Test

Original color returns in 10 sec.; veins in feet or hands fill in about 15 sec.

Capillary Refill Test

Immediate return of color=< 2 sec.

Breast & Axillae

Flat, muscles not yet developed, skin uniform in color, smooth & intact, areola are oval & bilaterally the same, dark brown, nipples are round, everted, equal in size; similar in color; both point in the same direction, no discharge, axillary, subclavicular, supraclavicular lymph nodes are not tender, no masses, breast has no masses, tenderness, nodules, discharge

Abdomen

Inspection

Unblemished skin, uniform color, flat, no evidence of enlargement of liver or spleen, symmetric contour, symmetric movements caused by respiration, no visible vascular pattern

Auscultation

Absence of friction rub, Audible bowel sounds, Absence of arterial bruits

Percussion

Tympany over the stomach; dullness especially over the liver & spleen

Percussion of the Liver

2.5” in the mid-clavicular line; 1.5” at the midsternal line

Palpation

No tenderness; relaxed abdomen with smooth, consistent tension

Palpation of the Liver

Not palpable

Palpation of the bladder

Not palpable

Genito-Urinary

Pubic Hair

Pt. denies assessment & does not answer directly.

Penis

Pt. denies assessment but states that there is no problem & he is circumcised.

Scrotum

Pt. denies assessment but states that there is no problem.

Inguinal Area

Pt. denies assessment but states that there is no problem.

Rectum & Anus

Pt. denies assessment but states that there is no problem.

Back

Posterior Thorax

Anteroposterior to transverse diameter in ratio of 1:2, chest symmetric, spine vertically aligned, spinal column is straight, right & left shoulders & hips are at same height, skin intact, uniform temperature, chest wall intact, Full and symmetric chest expansion, bilateral symmetry of vocal fremitus, fremitus is heard most clearly at the apex of the lungs, Percussion notes resonates; except over left scapula, Lowest point of resonance is at the diaphragm, percussion on a rib elicits dullness, vesicular & bronchovesicular breath sounds present.

Upper extremities

Muscles

No contractures, no tremors, normally firm, smooth coordinated movements, equal strength on each body side, no right arm muscles.

Bones

No right scapula, no tenderness, no radius, no ulna, no humerus.

Joints

No swelling, no tenderness, no crepitating sounds, no nodules, joints move smoothly, normal range of motion

Lower Extremities

Muscles

No contractures, no tremors, normally firm, smooth coordinated movements, equal strength on each body side.

Bones

No tenderness, no deformities.

Joints

No swelling, no tenderness, no crepitating sounds, no nodules, joints move smoothly, normal range of motion.

Anatomy & Physiology

I. Upper limb

Front of right upper extremity.

Back of right upper extremity.

Latin: Membrum Superius

Gray's: subject #289 1325

System: Musculoskeletal

MeSH: Extremity Upper Extremity

A. The upper limb or upper extremity is the region extending from the deltoid region to the hand, including the arm, axilla and shoulder.

B. Anatomy

1. The muscles of the upper limb can be classified by origin, topography, function, or innervation. While a grouping by innervation reveals embryological and phylogenetic origins, the functional-topographical classification below reflects the similarity in action between muscles (with the exception of the shoulder girdle, where muscles with similar action can vary considerably in their location and orientation.

2. Musculoskeletal system

a) Shoulder girdle

(1) Bones of the shoulder girdle

(i) The shoulder girdle or

pectoral girdle, composed of

the clavicle and the scapula,

connects the upper limb to the axial

skeleton through

the sternoclavicular joint (the only

joint in the upper limb that directly

articulates with the trunk), a ball and

socket joint supported by

the subclavius muscle which acts as

a dynamic ligament. While this

muscle prevents dislocation in the

joint, strong forces tend to break the

clavicle instead.

The acromioclavicular joint, the joint

between the acromion process on

the scapula and the clavicle, is

similarly strengthened by strong

ligaments, especially the

coracoclavicular ligament which

prevents excessive lateral and

medial movements. Between them

these two joints allow a wide range

of movements for the shoulder

girdle, much because of the lack of

a bone-to-bone contact between the

scapula and the thoracic cage.

The pelvic girdle is, in contrast,

firmly fixed to the axial skeleton,

which increases stability and load-

bearing capabilities. 

(ii) The mobility of the shoulder

girdle is supported by a large

number of muscles. The most

important of these are muscular

sheets rather than fusiform or strap-

shaped muscles and they thus

never act in isolation but with some

fibres acting in coordination with

fibres in other muscles.

(2) Muscles of shoulder girdle excluding the glenohumeral joint

(a) Migrated from head

(i) Trapezius, sternocleidomastoideus, omohyoideus

(b) Posterior(i) Rhomboideus major, rhomboideus minor, levator scapulae

(c) Anterior(i) Subclavius, pectoralis minor, serratus anterior

b) Shoulder joint

(1) Shoulder joint with ligaments

(2) The glenohumeral joint (colloquially called

the shoulder joint) is the highly mobile ball and

socket joint between the glenoid cavity of the

scapula and the head of the humerus. Lacking the

passive stabilisation offered by ligaments in other

joints, the glenohumeral joint is actively stabilised

by the rotator cuff, a group of short muscles

stretching from the scapula to the humerus. Little

inferior support is available to the joint and

dislocation of the shoulder almost exclusively

occurs in this direction. 

(3) The large muscles acting at this joint

perform multiple actions and seemingly simple

movements are often the result of composite

antagonist and protagonist actions from several

muscles. For example, pectoralis major is the

most important arm flexor and latissimus dorsi the

most important extensor at the glenohumeral

joint, but, acting together, these two muscles

cancel each other's action leaving only their

combined medial rotation component. On the

other hand, to achieve pure flexion at the joint

the deltoid and supraspinatus must cancel the

adduction component and the teres minor

and infraspinatus the medial rotation component

of pectoralis major. Similarly, abduction (moving

the arm away from the body) is performed by

different muscles at different stages. The first 10°

is performed entirely by the supraspinatus, but

beyond that fibres of the much stronger pectoralis

major are in position to take over the work.

Furthermore, to achieve the full 180° range of

abduction the arm must be rotated medially and

the scapula must be rotate about itself to direct

the glenoid cavity upward. c) Muscles of shoulder joint proper

(1) Posterior(a) Supraspinatus, infraspinatus, teres minor, subscapularis, deltoideus, latissimus dorsi, teres major

(2) Anterior(a) Pectoralis major, coracobrachialis

d) Arm

(1)

(a) Superficial muscles of the arm

(2) The arm proper (brachium), the region between the shoulder and the elbow, is composed of the humerus with the elbow joint at its distal end.

(3) The elbow joint is a complex of three joints 

(a) The humeroradial, humeroulnar, and superior radioulnar joints 

(i) The former two allowing flexion and extension whilst the latter, together with its inferior namesake, allows supination and pronation at the wrist. Triceps is the major extensor and brachialis and biceps the major flexors. Biceps is, however, the major pronator and while performing this action it ceases to be an effective flexor at the elbow. 

(4) Muscles of the arm

(a) Posterior

(i) Triceps brachii, anconeus

(b) Anterior

(i) Brachialis, biceps brachii

e) Forearm

(1) Ventral superficial muscles of the forearm

(a) The forearm

(antebrachium) composed of

the radius and ulna; the latter is the main

distal part of the elbow joint, while the

former composes the main proximal part of

the wrist joint.

(2) Most of the large number of muscles in the

forearm are divided into the wrist, hand, and

finger extensors on the dorsal side (back of hand)

and the ditto flexors in the superficial layers on

the ventral side (side of palm).

(a) These muscles are attached to

either the lateral or medial epicondyle of

the humerus. They thus act on the elbow,

but, because their origins are located close

to the centre of rotation of the elbow, they

mainly act distally at the wrist and hand.

Exceptions to this simple division are 

(i) brachioradialis 

(a) a strong elbow flexor 

(ii) palmaris longus 

(a) A weak wrist flexor

which mainly acts to tense

the palmar aponeurosis. The

deeper flexor muscles are

extrinsic hand muscles;

strong flexors at the finger

joints used to produce the

important power grip of the

hand, whilst forced extension

is less useful and the

corresponding extensor thus

are much weaker. 

(b) Biceps is the major supinator (drive

a screw in with the right arm) and 

(c) pronator teres and pronator

quadratus the major pronators

(unscrewing) 

(i) The latter two role the radius

around the ulna (hence the name of

the first bone) and the former

reverses this action assisted

by supinator. Because biceps is

much stronger than its opponents,

supination is a stronger action than

pronation (hence the direction of

screws). (3) Muscles of the forearm

(a) Posterior

(i) (Superficial) extensor

digitorum, extensor digiti

minimi, extensor carpi ulnaris,

(deep) supinator, abductor pollicis

longus, extensor pollicis

brevis, extensor pollicis

longus, extensor indicis

(b) Anterior

(i) (Superficial) pronator

teres, flexor digitorum

superficialis, flexor carpi

radialis, flexor carpi ulnaris, palmaris

longus, (deep) flexor digitorum

profundus, flexor pollicis

longus, pronator quadratus

(c) Radial

(i) Brachioradialis, extensor

carpi radialis longus, extensor carpi

radialis brevis

f) Wrist

(1) The wrist (carpus), composed of the carpal

bones, articulates at the wrist joint (or radiocarpal

joint) proximally and the carpometacarpal

joint distally. The wrist can be divided into two

components separated by the midcarpal joints.

The small movements of the eight carpal bones

during composite movements at the wrist are

complex to describe, but flexion mainly occurs in

the midcarpal joint whilst extension mainly occurs

in the radiocarpal joint; the latter joint also

providing most of adduction and abduction at the

wrist. 

(2) How muscles act on the wrist is complex to

describe. The five muscles acting on the wrist

directly  

(a) flexor carpi radialis, flexor carpi

ulnaris, extensor carpi radialis, extensor

carpi ulnaris, and palmaris longus 

(b) Are accompanied by the tendons of

the extrinsic hand muscles (i.e. the

muscles acting on the fingers). Thus, every

movement at the wrist is the work of a

group of muscles; because the four

primary wrist muscles (FCR, FCU, ECR,

and ECU) are attached to the four corners

of the wrist, they also produce a secondary

movement (i.e. ulnar or radial deviation).

To produce pure flexion or extension at the

wrist, these muscles therefore must act in

pairs to cancel out each other’s secondary

action. On the other hand, finger

movements without the corresponding

wrist movements require the wrist muscles

to cancel out the contribution from the

extrinsic hand muscles at the wrist. g) Hand

h)

(1) Bones of the hand

(a) The hand

(manus), the metacarpals (in the hand

proper) and the phalanges of the fingers,

form the metacarpophalangeal

joints (MCP, including the knuckles)

and interphalangeal joints (IP).

(b) Of the joints between the carpus

and metacarpus, the carpometacarpal

joints, only the saddle-shaped joint of the

thumb offers a high degree of mobility

while the opposite is true for the

metacarpophalangeal joints. The joints of

the fingers are simple hinge joints. 

(c) The primary role of the hand itself is

grasping and manipulation; tasks for which

the hand has been adapted to two main

grips — power grip and precision grip. In a

power grip an object is held against the

palm and in a precision grip an object is

held with the fingers, both grips are

performed by intrinsic and extrinsic hand

muscles together. Most importantly, the

relatively strong thenar muscles of the

thumb and the thumb's flexible first joint

allow the special opposition movement that

brings the distal thumb pad in direct

contact with the distal pads of the other

four digits. Opposition is a complex

combination of thumb flexion and

abduction that also requires the thumb to

be rotated 90° about its own axis. Without

this complex movement, humans would not

be able to perform a precision grip. 

(d) In addition, the central groups of

intrinsic hand muscles give important

contributions to human dexterity. The

palmar and dorsal interossei abduct and

adduct at the MCP joints and are important

in pinching. The lumbricals, attached to the

tendons of the flexor digitorum

profundus (FDP) and extensor digitorum

communis (FDC), flex the MCP joints while

extending the IP joints and allow a smooth

transfer of forces between these two

muscles while extending and flexing the

fingers. (e) Muscles of the hand

(i) Metacarpal

(a) Lumbricals, dorsal

interossei, palmar introssei

(ii) Thenar

(a) Abductor pollicis

brevis, adductor

pollicis, flexor pollicis

brevis, opponens pollicis

(iii) Hypothenar

(a) Abductor digiti

minimi, flexor digiti

minimi, opponens digiti

minimi, palmaris brevis

3. Neurovascular system

a) Innervation

(1) Branches of brachial plexus

(2) The motor and sensory supply of the upper

limb is provided by the brachial plexus which is

formed by the ventral rami of spinal nerves C5-

T1. In the posterior triangle of the neck these rami

form three trunks from which fibers enter the axilla

region (armpit) to innervate the muscles of the

anterior and posterior compartments of the limb.

In the axilla, cords are formed to split into

branches, including the five terminal branches

listed below. The muscles of the upper limb are

innervated segmentally proximal to distal so that

the proximal muscles are innervated by higher

segments (C5–C6) and the distal muscles are

innervated by lower segments (C8–T1). 

(3) Motor innervation of upper limb by the five

terminal nerves of the brachial plexus:

(a) The musculocutaneous

nerve innervates all the muscles of

the anterior compartment of the arm.

(b) The median nerve innervates all the

muscles of the anterior compartment of the

forearm except flexor carpi ulnaris and the

ulnar part of the flexor digitorum profundus.

It also innervates the three thenar muscles

and the first and second lumbricals.

(c) The ulnar nerve innervates the

muscles of the forearm and hand not

innervated by the median nerve.

(d) The axillary nerve innervates

the deltoid and teres minor.

(e) The radial nerve innervates the

posterior muscles of the arm and forearm

(4) Collateral branches of the brachial plexus:

(a) The dorsal scapular

nerve innervates rhomboid

major and minor.

(b) The long thoracic

nerve innervates serratus anterior.

(c) The suprascapular

nerve innervates supraspinatus and infrasp

inatus

(d) The lateral pectoral

nerve innervates pectoralis major

(e) The medial pectoral

nerve innervates pectoralis

major and minor

(f) The upper subscapular

nerve innervates subscapularis

(g) The thoracodorsal

nerve innervates latissimus dorsi

(h) The lower subscapular

nerve innervates subscapularis and teres

major

(i) The medial brachial cutaneous

nerve innervates the skin of medial arm

(j) The medial antebrachial cutaneous

nerve innervates the skin of medial forearm

II. Prokaryotic cells

A. Diagram of a typical prokaryotic cell

B. Nuclear material of prokaryotic cell consists of a single

chromosome that is in direct contact with cytoplasm. Here, the

undefined nuclear region in the cytoplasm is called nucleoid.

A prokaryotic cell has three architectural regions:

1. On the outside

a) flagella 

(1) A tail-like projection that protrudes from the

cell body and functions in locomotion.

b) and pili

(1) Pili connect a bacterium to another of its

species, or to another bacterium of a different

species, and build a bridge between the interior of

the cells. This enables the transfer

of plasmids between the bacteria.

c) Project from the cell's surface. These are

structures (not present in all prokaryotes) made of

proteins that facilitate movement and communication

between cells;

2. Enclosing the cell is the cell envelope

a) covering a plasma membrane

(1) The protective envelope that separates the

inside of the cell from its surroundings. It contains

specialized receptors that detect chemical

messages, as well as pumps and pores that

regulate the flow of substances into and out of the

cell. The membrane also anchors the cells to the

surrounding tissues and links adjacent cells at

specialized junctions, to form tissues

b) The envelope gives rigidity to the cell and

separates the interior of the cell from its environment,

serving as a protective filter.

3. Inside the cell is the cytoplasmic region

a) A transparent, gel-like region outside the nucleus,

in which the organelles are suspended

b) that contains

(1) The cell genome (DNA) and ribosomes

and various sorts of inclusions...

(2) Though not forming a nucleus, the DNA is

condensed in a nucleoid.

(3) Prokaryotes can carry extrachromosomal

DNA elements called plasmids, which are usually

circular.

(a) Plasmids enable additional

functions, such as antibiotic resistance.

(4) Microfilaments

(a) Fine thread-like fibers made from a

protein called actin. These form part of the

cell’s internal skeleton, allowing the cell to

change shape and move by ‘rolling’ or

‘crawling’ along a surface

(5) Centrioles

(a) Are small cylinders, at right angles

to one another, made up of nine sets of

microtubules. They are involved in the

formation and elongation of the cell’s

microtubules,

(6) Lysosomes

(a) Small vesicles containing that

powerful acids and enzymes that

breakdown worn-out organelles, and digest

bacteria and foreign substances taken up

by the cell.

(7) Golgi Apparatus

(a) The cell’s processing & transport

area. It stores, sorts and modifies products

made within the cell, and transports them

to other organelles or to the cell surface in

vesicles. Most cells need only one Golgi

apparatus, but some have more

(8) Peroxisome

(a) Small vesicles that detoxify alcohol,

hydrogen peroxide and other toxins that

may be present within a cell.

(9) Rough Endoplasmic Reticulum

(a) An internal network of flattened

sacs, studded with ribosomes, which is

involved in packaging proteins

(10) Mitochondria

(a) Batteries of a cell. They use oxygen,

glucose and fatty acids to release energy

plus waste carbon dioxide gas. It contains

its own genetic material, and is believed to

have evolved from symbiotic bacteria that

combine with single-celled organisms at

the dawn of life on earth.

(11) Ribosomes

(a) Small units that assemble the amino

acid chains that form proteins. Some

ribosomes move freely within the

cytoplasm, while others are attached to the

rough endoplasmic reticulum, which

funnels newly formed proteins to the Golgi

apparatus.

(12) Smooth Endoplasmic Reticulum

(a) An internal network of branching

tubes involved in the production of fatty

acids, steroids and the storage and release

of Ca.

(13) Microtubules

(a) Hollow tubes, made from a protein

called tubulin, which form part of the cell’s

internal skeleton, maintaining its shape and

assisting with cell division, movement of

organelles within the cell and transport of

vesicles

(14) The nucleus is separated from the rest of

the cell by the nuclear envelope.

(i) The membrane that

separates the nucleus from the rest

of the cell. Chemicals can move to

and from the nucleus to the

cytoplasm via holes in the envelope

known as nuclear pores

(b) Nucleus

(i) The largest organelle. It is the

cell’s control centre and contains the

chromosomes.

(a) A circular molecule

(ii) Most cells have only one

nucleus, a few specialized skeletal

muscle cells have several nuclei and

mature red blood cells and the clear

cells found in the crystalline lens of

the eye have none.

III. DNA

A.

B. Contains a human’s full genetic blueprint stored as

1. Chromosomes

a) There are 23 pairs. One of each pair was

inherited from an individual’s mother, the other from the

father. 44 of these chromosomes contain genes

(1)

(2) That provides the code for proteins

involved in the structure & function of every cell.

(3) The stretch of DNA that provides all the

coding needed to make a single protein.

Scientists from around the world have

collaborated in the human Genome Project to

decode the sequence of genes that make up a

human being. They have determined that each

own about 40,000 genes-a figure originally

thought to be considerably higher.

(4) The genes within every cell in a person are

identical, but, depending on the type of cell,

different genes are switched on and off, so the

cell can make the particular proteins it requires.

That is why liver cells, muscle cells, skin cells &

fat cells are all so different from 1 another.

(5) Each gene exists in many different forms

within the population, according to the exact order

of it’s A and T or C and G sub-units. A man

inherits 23 chromosomes from each parent.

Although everyone inherits the same number and

types of genes, the subtle difference within them

make each person unique from the other 6.5

billion on this planet. Some of the genes that a

man inherits determine his visible features, such

as his skin, hair & eye colour, while others

determine how his metabolism functions and

whether or not he is at risk of developing medical

problems such as high blood pressure, diabetes

or cancer.

b) The remaining pair of sex chromosomes contains

information that determines an individual’s male (Y) &

female (X) characteristics.

c) The DNA molecules are loosely wound around

special proteins (histones), which form a spaghetti-like

complex called chromatin. Before a cell divides, each

molecule of DNA is copied & condenses to form a

duplicated chromosome. Each duplicated molecule

chromosome contains 2 identical strands of DNA,

referred to as sister chromatids. The chromatids remain

attached at a point called telomeres, which never copy.

After duplication, the DNA molecules condense again to

form copies of the X-shaped structures known as

duplicated chromosomes.

d) 46 highly coiled molecules, made up of 2 chains

of units called

(1) Nucleotides, which roll around each other

to form a long, spiral shaped, double helix.

(a)

(b) Each nucleotide consists of a

phosphate group, the sugar deoxyribose

and one of 4 chemicals called bases:

adenine (A), thymine (T), cytosine (C) or

guanine (G). These bases face inwards

and pair up to form the rungs of the

double-helix ladder. Importantly, A always

pairs with T, and C always pairs with G.

(c) The DNA provides the code needed

for cells to make proteins, which are

formed from a chain of amino acids. The

code depends on the order in which the

bases occur along 1 strand-known as the

sense strand-of the DNA helix. Each run of

3 bases-called a triplet-provides the code

for a particular amino acid. This code tells

each cell the order in which place amino

acids in a protein chain.

Date/Time Doctor’s Order Rationale Remarks7/9/117AM

Please admit under GS 2 S. West

Admission is required to assess and observe the patient further. This is also to monitor patient's condition and provide necessary care and interventions related to diagnosis.

Done

Secure consent to care

Patient has the right to be consented in all procedures to be done.

Done

DAT Diet as tolerated to maintain nutritional status of patient.

Done

Monitor VS q4 To monitor vital signs so that any unusualities will be referred as follows.

Done

IVF: D5LR @ 100cc/hr

For fluid replacement. Done

Labs: CBC PC CBC with PC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.

Done

Serum calcium electrolyte

Serum calcium indicates whether there is a calcium deficit or an abnormal increase of calcium level in the blood stream.

Done

X-ray ® arm To see whether a bone has been fractured or a joint dislocated. It is also used to check for an injury or damage from conditions such as an infection, arthritis, bone growths (tumors), or other bone diseases.

Done

Blood transfusion Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.

Done

Chest X-ray Ordered for symptoms of  shortness of breath, cough,

Done

or chest pain. 

Meds: Mefenamic acid 250mg, q6, take with meals

For relief of pain including muscular, traumatic, fever, and headache.

Done

For referral to consultant

This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

4PM STAT Ketorolac 30mg q8

Effective in the management of moderately severe acute pain.

Done

7/10/11 Continue meds Compliance with meds will avert any complications.

Done

For transfer service to GS 1

For specialized care and management.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/11/11 For referral to consultant

This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/12/118AM

Continue meds Compliance with meds will avert any complications.

Done

For referral to consultant

This may create a collaborative treatment among the client and health providers; thus it

Done

also makes a good coordination in the treatment of the client.

11AM To secure 1 unit of PRBC & transfer once with cross

matching

RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.Cross matching is done to determine if the donor's blood is compatible with the blood of an intended recipient.

Not done

Start cefuroxime 750mg IVTT q8

ANST

For the treatment of many different types of bacterial infections.

Done

For CT scan of chest include shoulder with

contrast

CT scans allow doctors to inspect the inside of the body without having to operate or perform unpleasant examinations including the affected part which is the shoulder.

Not done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/15/1112PM

Still to secure blood RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.

Not done

For compliance of medicine

Compliance with meds will avert any complications.

Done

Defer CT scan Not done

For MRI of ® arm to include shoulder

MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor. 

Not done.

Refer to Anesthesia For pain management. DoneRefer This may create a

collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

4:10PM May start Tramadol- Ketorolac drip,

Tramadol 250mg + Ketorolac 90mg in

500cc D5W @ 20cc/hr x 1 cycle

Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.

Done

Give Ketorolac 30mg IVTT

For pain reliever. Done

Give Tramadol 40mg IVTT prior to

drip then q6 PRN for severe pain

For severe pain. Done

Metoclopromide 10mg IVTT PRN for

vomiting

It is commonly used to treat nausea and vomiting, to facilitate gastric emptying.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/16/116AM

Continue Tramadol-Ketorolac drip

Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.

Done

Still for MRI MRI can find changes in the structure of organs or other

Not done

tissues. It also can find tissue damage or disease, such as infection or a tumor. 

Still to secure blood RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.

Not done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/17/116PM

Still for MRI MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor. 

Not done

Continue Tramadol-Ketorolac drip

Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.

Done

Still to secure blood RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.

Not done

7/18/11 For repeat CBC today

CBC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells.

Not done

To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.

To secure 1 unit of PRBC & transfer

after cross matching

RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.Cross matching is done to determine if the donor's blood is compatible with the blood of an intended recipient.

Not done

To secure another 4 unit of PRBC for OR

use

For blood loss replacement during the operation.

Done

Continue Meds Compliance with meds will avert any complications.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/20/1112:30AM

Give Paracetamol 500mg tab now then

after q4 PRN for fever

It is commonly used for the relief of fever, headaches, and other minor aches and pains. Given every hours for 24 hours. And as needed if temperature is greater than 38° C.

Done

9AM Still for MRI MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor. 

Not done

Still for repeat CBC CBC determines the quantity of each quantity of blood cell in a given

Not done

specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.

Continue Meds Compliance with meds will avert any complications.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/21/118:45AM

Still for repeat CBC CBC with determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.

Done

Continue Meds Compliance with meds will avert any complications.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the

Done

treatment of the client.

Refer to Ortho and possible transfer

service

For evaluation. Not done

7/23/1111:10PM

Follow up: Serum Calcium

Serum calcium indicates whether there is a calcium deficit or an abnormal increase of calcium level in the blood stream.

Done

Alkaline Phosphatase

Used to help detect liver disease or bone disorders.

Done

ESR To help detect conditions associated with acute and chronic inflammation, including infections, cancers, and autoimmune diseases.

Done

Continue blood transfer

Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.

Done

7/24/1110AM

For re-cross matching prior to

transfusion

To determine if the donor's blood is compatible with the blood of an intended recipient.

Not done

Continue meds Compliance with meds will avert any complications.

Done

Continue Tramadol-Ketorolac drip

Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/25/116AM

S/F re-cross matching

To determine if the donor's blood is compatible with the blood of an intended recipient.

Done

Continue Tramadol-Ketorolac drip

Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.

Done

S/F transfer to Ortho service

For evaluation. Done

ReferThis may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/26/113:24PM

May transfer to Ortho once cleared

by GS

Transfer to Orthopedic ward for further evaluation.

Done

Transfuse 2 units available blood of

patient’s blood type properly secure 2nd cross

matched.

Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.

Done

Give Diphenhydramine

50mg IVTT once BT starts

To limit allergic reactions to blood products.

Done

7/27/111PM

Cleared from GS Patient is ready to be transferred to Ortho Ward.

Done

Transfer to Ortho ward

Orthopedic ward caters patients with skeletal or bone problems such as fracture and dislocation.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

7/29/11 To secure 4 units of For correction of anemia. Done

blood of patient’s blood type.Pressure sore

precaution on shoulder mass ®

To avoid infection. Done

7/31/119:16Am

Please transfuse available blood of

patient’s blood type and after proper

cross matching as previously ordered

RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.Cross matching is done to determine if the donor's blood is compatible with the blood of an intended recipient.

Done

Decrease IVF to KVO rate while BT

To prevent circulatory overload.

Done

For referral on pedia onco tomorrow

Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

8/1/1111AM

Repeat CBC post 2 units of transfusion

To check for hemoglobin level.

Done

2PM Verbal order: To give paracetamol 300mg IVTT now

It is commonly used for the relief of fever, headaches, and other minor aches and pains. Given every hours for 24 hours. And as needed if temperature is greater than 38° C

Done

8/3/119:30AM

S/F correction of anemia

RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical

Done

problems, and are one of the most important blood components used in transfusion medicine.

Follow up referral to pedia onco for evaluation and

clearance

Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.

Done

Continue meds Compliance with meds will avert any complications.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

2:50PM Please transfuse 2 units available blood

of patient’s blood type after properly

cross matched

Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.

Done

Decrease IVF rate to KVO once in BT

To prevent circulatory overload

Done

Give Diphenhydramine 50mg IVTT once transfuse starts

To limit allergic reactions to blood products.

Done

Watch out for fever, dyspnea, pruritus

and others

These are signs and symptoms of transfusion reaction.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

8/4/118AM

Please schedule patient for STAT OR 3rd table other room tomorrow

8/5/11

In preparation for the planned operation.

Done

Plan Fore Quarter Amputation

A major surgical procedure in which the upper extremity and a variable portion of the supporting shoulder girdle is amputated, to treat either advanced malignancy.

Done

NPO @ 3AM To avoid aspiration during operation.

Done

Cefazolin 2g IVTT 1 hour prior to OR, 1g

q8 there after

Cefazolin is given 1 hour prior to OR to reduce the incidence of certain postoperative infections in patients undergoing surgical procedures which are classified as contaminated or potentially contaminated.

Done

Inform OR/AR OD For reservation of table in the Operating room and endorsement of patient.

Done

Secure pedia onco clearance for

surgery

Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.

Done

3PM Ranitidine 30 mg IVTT 1 hour prior

Ranitidine reduces preoperative gastric fluid acidity and volume.

Done

To secure 4 units PRBC

PRBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.

Done

To secure 2 unit Fresh Frozen

Plasma, Patient’s blood type properly

retype

Used for patients with a coagulopathy who are bleeding or at risk of bleeding. FFP should be blood type-matched to ensure compatibility.

Done

Refer accordingly This may create a Done

collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Follow up repeat RBC port Blood

Transfusion

Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.

Done

4PM NPO post midnight To avoid aspiration during operation.

Done

To secure pedia ICU reservation

For possible post-op use. Done

Adequate hydration To keep the stomach and intestines clear, limit strain to the digestive system, but keep the body hydrated prior to or recover from a medical procedure.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

8/5/117PM

S/P Fore Quarter Amputation under

GETA

Operation done to the patient.

Done

To PACU until stable then to Ortho

ward

Post-op patients are transferred to PACU for close monitoring and to watch out for any unusualities and complications after undergoing a surgery.

Done

May have soft diet until fully awake with

aspiration precaution

The digestive system tolerates softer foods better after surgery so cramps and abdominal pain can be avoided.

Done

Monitor VS q15 until stable then hourly

To monitor vital signs so that any unusualities will be referred as follows.

Done

Q15 since patient is post-op and there is a higher risk for complications to occur after surgery.

Continue venoclysis with PLR @ KVO

rate

For fluid resuscitation. Done

Continue blood transfusion @

80cc/hr – Left arm

Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.

Done

Terminate IV line @ R arm

Right arm was amputated. Done

Meds: Morphine drip: D5W 500ml +

10mg Morphine with 20mgtts/min, may

give 1.5mg PRN for severe pain

To reduce pain. Done

Meds: Ketorolac 15mg q6 IVTT x 8 doses then shift to

Mefenamic acid 500mg cap 1 cap q6

PO after meals

Switching from intravenous (IV) to oral (PO) therapy as soon as patients are clinically stable can reduce the length of hospitalization and lower associated costs.

Done

Meds: Ranitidine 35mg q8 IVTT x

2days

Treatment and prevention of heartburn, acid indigestion, and sour stomach.

Done

Meds: Metoclopromide

10mg tablet, 1tab q6 PO, PRN for pain

It is commonly used to treat nausea and vomiting, to facilitate gastric emptying.

Done

Meds: Furosemide 20mg IVTT post-BT

Furosemide is a "water pill" (diuretic) that causes you to make more urine.

Done

MHBR Allows greater lung expansion and prevent compression on the diaphragm from prolong

Done

bed rest.Thermo regulate

patientTo check for fever. Done

O2 inhalation @ 6L/min face mask

To alleviate dyspnea. Done

Monitor I&O qhour and record

To monitor the elimination status of the patient and the kidney function as well as for any complications and unusualitiesQhour since patient is post-op.

Done

For CBC post BT @ ward

To check for RBC, WBC, and Platelet count of the patient.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

11:05PM IV rates: PLR @60cc/hr, PNSS @ 10cc/hr, Morphine

drip 20cc/hr =90cc/hr

To replace fluid loss. Done

8/6/119PM

Continue Antibiotics Compliance with meds will avert any complications.

Done

8/7/111AM

Phone order: O2 inoculation via nasal

cannula @ 2Lpm

To relieve dyspnea and other problems in breathing.

Done

9:05AM May remove Foley catheter

To void freely. Done

Monitor I&O q shift To monitor the elimination status of the patient and the kidney function as well as for any complications and unusualities

Done

Cont. VS monitor qhour

To monitor vital signs so that any unusualities

Done

will be referred as follows. Q1hour since patient is post-op and complications usually occur hours after a surgery.

Tramadol 35mg q6 IVTT PRN

To give as needed for severe pain.

Done

9:55AM Maintain 1 IV line, D/C other IV lines

To correct electrolyte imbalances, to deliver medications, for blood transfusion or as fluid replacement to correct, for example, dehydration.

Done

Wound dressing To avoid wound infection. DoneContinue antibiotics Compliance with meds will

avert any complications. Done

DAT Diet as tolerated to maintain nutritional status of patient.

Done

Refer to pedia onco for post-op co-management

Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.

Done

8/8/1112PM

Follow up referral to pedia onco

Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.

Done

8/9/11 For dressing of wound

To avoid wound infection. Done

Cont. meds Compliance with meds will avert any complications.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

8/10/119:45AM

For wound dressing To avoid wound infection. Done

Discontinue antibiotics IVTT

Antibiotics will be given PO.

Done

Start Cefuroxime Cefuroxime is used for Done

500mg/cap; 1tab BID PO

treatment of serious infections of the lower respiratorytracts.

8/12/11 For wound dressing today

To avoid wound infection. Done

Cont. meds: Cefuroxime:PO

Amikacin: IV-D/C

Cefuroxime is used for treatment of serious infections of the lower respiratorytracts..

Done

Refer to dietary For nutritional build-up. DonePls. include 3 egg whites per meal

Egg Whites provide an excellent source of amino acids for developing muscles.

Done

Follow up official biopsy result

A means of acquiring a tissue in order to make a definitive diagnosis.

Done

8/13/119:30AM

Dressing wound To avoid wound infection. Done

Cont. antibiotics Compliance with meds will avert any complications.

Done

8/14/113:50PM

Wound dressing To avoid wound infection. Done

For strict compliance of

antibiotics.

Compliance with meds will avert any complications.

Done

Follow up referral to dietary

For appropriate diet. Done

For compliance with 3 egg whites per

meal daily

Egg Whites provide an excellent source of amino acids for developing muscles.

Done

8/15/1111:50AM

For compliance with meds

Compliance with meds will avert any complications.

Done

Wound dressing To avoid wound infection. DoneFor compliance with

high albumin diet

High albumin diet is a combination of high calorie and high protein diet. It is important in regulating blood volume by maintaining the osmotic pressure of the blood compartment.

Done

Refer This may create a collaborative treatment among the client and

Done

health providers; thus it also makes a good coordination in the treatment of the client.

5:50PM Start Cloxacillin 500mg/cap q6

This is used to treat many different types of infections caused by staphylococcus bacteria. 500 mg orally every 6 hours for up to 21 days, depending on the nature and severity of the infection.

Done

Wound care To avoid wound infection. DoneHigh protein calorie

dietA high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness.

Done

8/16/119AM

Follow up biopsy result

To make a definitive diagnosis.

Done

Wound dressing To avoid wound infection. DoneStrict compliance of

oral antibioticsCompliance with meds will avert any complications.

Done

High protein calorie diet

A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness.

Done

8/17/117:10AM

Maintain high protein calorie diet

A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness.

Done

Strict compliance with antibiotic

Compliance with meds will avert any complications.

Done

Change dressing For hygienic purposes and to prevent infection.

Done

Follow up office of biopsy result

To make a definitive diagnosis.

Done

8/18/11 For compliance with meds

Compliance with meds will avert any complications.

Done

High protein calorie diet

A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness.

Done

Follow up biopsy result

To make a definitive diagnosis.

Done

8/19/115:10PM

Strict compliance with meds

Compliance with meds will avert any complications.

Done

Dressing done For hygienic purposes and to prevent infection.

Done

Refer for repeat CBC today

To check for hemoglobin, WBC, platelet count.

Done

8/20/118:52AM

Continue meds Compliance with meds will avert any complications.

Done

Wound dressing To prevent infection. DoneFor debridement of

wound

To remove patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.

Done

8/21/118:35AM

For wound care To prevent infection. Done

Please follow up debridement of

wound

To carry out the planned procedure.

Done

Continue meds Compliance with meds will avert any complications.

Done

8/22/1111:20AM

For wound care To prevent infection. Done

Continue meds Compliance with meds will avert any complications.

Done

8/23/118:40AM

Follow up biopsy result

To make a definitive diagnosis.

Done

Continue meds Compliance with meds will avert any complications.

Done

8/25/117:10AM

Refer back to Pedia onco

For further management. Done

Official biopsy: A type of cancer, specifically Done

Rhabdomyosarcoma

a sarcoma , in which the cancer cells are thought to arise from skeletal muscle progenitors.

Please inform pedia onco

Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.

Done

8/27/119:10AM

For wound dressing To prevent infection. Done

For repeat CBC PC CBC with PC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.

Done

Continue meds Compliance with meds will avert any complications.

Done

8/28/118:51Am

For wound dressing To avoid infection. Done

For OR schedule In preparation for a surgery.

Done

Plan debridement: Split Thickness Skin

Graft (STSG)

To remove patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.

Done

D/C: Loxacillin DoneContinue other

medsCompliance with meds will avert any complications.

Done

8/29/11 For wound dressing To avoid infection. DoneSecure blood and

OR materialIn preparation for the planned surgery.

Done

For STAT CX today To help diagnose symptoms such as shortness of breath, a bad or persistent cough, and chest pain or injury.

Done

8/30/117:30AM

For OR schedule In preparation for a surgery.

Done

8/31/119:50AM

Pls. schedule patient for OR tomorrow 2nd table.

In preparation for the planned operation.

Done

Plan STSG To remove patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.

Done

Inform ROD For reservation of table in the Operating room and endorsement of patient.

Done

Secure consent Patient has the right to be consented in all procedures to be done.

Done

NPO post midnight To avoid aspiration during operation.

Done

IVF D5LR 1L @ 100cc/hr

For fluid replacement and for administering IVTT meds.

Done

3:50PM To Ortho Ward once stable @ PACU

Orthopedic ward caters patients with skeletal or bone problems such as fracture and dislocation.

Done

Cont. Cefazolin 1gm IVTT q8

Treatment of bone and joint infection.

Done

Maintain dressing in ® hemi-thorax

To keep wound close and intact.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

9/1/1111:29AM

Maintain dressing in ® hemi-thorax

To avoid infection. Done

Cont. Cefazole 1gm IVTT q8

Treatment of bone and joint infection.

Done

Meds: Ascorbic acid 500mg, 1 tsp OD

Ascorbic acid helps produce collagen, a protein needed to develop

Done

and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels.

Meds: Mefenamic acid 500mg cap,

1cap q6 PO

For relief of pain including muscular, traumatic, fever, and headache.

Done

Cont. Tramadol + Ketorolac as

previously ordered

Tramadol with Ketorolac drip for clinical use has been shown to be an

effective balanced analgesic regimen in

alleviating moderate-to-severe pain.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

3:50PM S/P STSG, Right shoulder under

GETA

STSG surgical procedure is done.

Done

To PACU until stable then to ward

For close monitoring. Done

May have DAT when fully awake

with aspiration precaution

Patient should be closely supervised when eating.

Done

Monitor VS To monitor any unusualities.

Done

Meds: Tramadol 30mg

For pain reliever. Done

9/2/1112PM

Removal of Foley catheter

To void freely. Done

9/3/1110:20AM

Cont. IV antibiotics For treatment of infections. Done

DAT Diet as tolerated to maintain nutritional status of patient

Done

9/4/119AM

Cont. IV antibiotics For treatment of infections. Done

To secure 25% Albumin and

transfuse in 4 hours

Administered to patients with low albumin level.

Done

Maintain high protein diet

Protein is essential for tissue growth and regeneration.

Done

Advice 3 egg whites per meal daily

Egg Whites provide an excellent source of amino acids for developing muscles.

Done

9/5/1111:08AM

For change of dressing of recipient

site

To avoid wound infection. Done

Maintain high protein diet

Protein is essential for tissue growth and regeneration.

Done

For strict compliance of oral

antibiotics

Compliance with meds will avert any complications.

Done

Add 3 egg whites per meal daily

Egg Whites provide an excellent source of amino acids for developing muscles.

Done

Shift Cefazolin to Cefuroxime 500mg tab; 1tab BID PO

Cefuroxime is used for treatment of serious infections of the lower respiratorytracts.

Done

Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

9/7/119:40AM

For wound dressing today

To avoid wound infection. Done

Cont. PO antibiotics Compliance with meds will avert any complications.

Done

9/9/118:29AM

High protein/ caloric diet

Protein is essential for tissue growth and regeneration.

Done

Ascorbic acid 500mg tab BID

Ascorbic acid helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels.

Done

9/10/11 MGH- Ortho DoneRefer to pedia onco

for transfer of service

Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.

Done

Med: Ascorbic acid 500mg tab BID

Ascorbic acid helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels.

Done

Wound dressing as instructed

To avoid wound infection. Done

9/11/1110:31AM

Follow up referral to Pedia onco for

transfer of service

For specialized care and management.

Done

Transfer to pedia onco unit if obey to

mask secure for pedia onco to start

chemotherapy

For specialized care and management.

Done

9/12/11 Notify transfer to pedia onco unit for

chemotherapy

For specialized care and management.

Done

9/13/119:06AM

For chemotherapy Used to stop cancer cells from dividingso they stop growing or die.

Done

Refer to pedia for transfer of service

For specialized care and management.

Done

MGH to House of Hope

House of hope provides the psychosocial needs of children with cancer.

Not done

Cont. Ascorbic Acid Ascorbic acid helps Done

produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels.

For chemotherapy once with available

bed at the pedia onco ward

Used to stop cancer cells from dividingso they stop growing or die.

Not done

Photocopy all operative technique

and biopsy

To provide data to the House of Hope once patient is transferred.

Not done

July

28,

2011

Blood

Chemistry

Introduce

your name to

the patient

and establish

rapport.

Identify the

right client.

Discuss the

importance

and

purpose of

the

procedure.

Explain the

procedure

to the

patient.

Assess the

patient for

any factor

that will

probably

affect the

results of

the test.

Creatinine

53 – 115

umol/L

30.4

0Umol/L

(normal

)

Used to

evaluate renal

dysfunction.

Increased

creatinine

levels in the

blood suggest

diseases or

conditions that

affect kidney

function.

Blood Urea

Nitrogen

1.1 – 3.20

2.40

 measure of the

amount of urea

in the blood.

Urea forms in

the liver as the

end product of

protein

metabolism,

circulates in the

blood, and is

excreted

through the

kidney in urine.

The BUN,

determined by

a blood test, is

directly related

to the

metabolic

function of the

liver and the

excretory

function of the

kidney. Normal

findings (in

mg/dL) are 10

to 20 for adults,

5 to 18 for

children and

infants, 3 to 12

for newborns,

and 21 to 40 for

cord blood. In

the elderly, the

BUN may be

slightly higher

than the normal

adult range. A

critical value of

100 mg/dL

indicates

serious

impairment of

renal function.

Also

called urea

nitrogen, serum

urea nitrogen.

July

29,

2011

IPD hematology

ErythrocyteSedimentationRate

0.00-10.0mm/hr

60H

 the rate at which red blood cellssediment in a period of 1 hour. It is a common hematology test that is a non-specific measure of inflammation

July

09,

2011

Blood type

(ABO test)

A Blood typing in

the ABO

system, and

others, involves

the

identification of

specific

proteins that

are contained

in the blood.

Red Blood

Cells have

either antigen

(protein) A, B,

or AB or none,

on the surface

of the cells.

These

antigens,

(proteins) make

the blood of

each person

unique and

separate from

one another.

Blood typing

then,

categorizes

blood in

individuals

according to

these proteins

(ABO)

Blood type

B + RH

positiv

e

test for the Rh

factor protein

on the RBC,

Red Blood Cell.

Aug

ust

04,

2011

LDH

266 – 500.00

u/L

1580.0

H

Increase of LD activity in serum may occur in any injury that causes loss of cell cytoplasm. More specific information can be obtained by LD isoenzyme studies. Also, elevation of serum LD is observed due to in vivo effects of anesthetic agents, clofibrate, dicumarol, ethanol, fluorides, imipramine, methotrexate, mithramycin, narcotic analgesics, nitrofurantoin,

propoxyphene, quinidine, and sulfonamides.Decrease of serum LD is probably not clinically significant.There are two main analytical methods for measuring LD: pyruvate->lactate and lactate->pyruvate. Assay conditions (particularly temperature) vary among labs. The reference range for the assaying laboratory must be carefully studied when interpreting any individual result.Many European labs assay alpha-hydroxybutyrate dehydrogenase (HBD or HBDH), which roughly equates to LD isoenzymes 1 and 2 (the fractions found in heart, red blood cells, and kidney).

Aug

ust

27,

2011

Sodium

136-155

mmoL/L

136.10

mmol/L

(normal

)

Measures the

amount of

sodium in the

blood. It plays

a major role in

regulating the

amount of

water in the

body.

Sodium is a

mineral that is

vital to normal

body

processes,

which include

nerve and

muscle

functioning.

Too much

sodium can

increase the

chances of

high blood

pressure

Potassium

3.7 to 5.5

mmol/L.

3.94

(normal

)

This test

measures the

amount of

potassium in

the blood.

Potassium (K+)

helps nerves

and muscles

communicate.

It also helps

move nutrients

into cells and

waste products

out of cells.

Calcium

1.75 – 2.39Mmol/L

2.40L

a blood or urine test used to evaluate parathyroid function and calcium metabolism by directly measuring the total amount of calcium in the blood. It is used to monitor patients with renal failure, renal transplantation, hyperparathyroidism, and various malignancies, as well as to monitor calcium levels during and after large-volume blood transfusions.

September 02,2011

A/G Ratio

1.0 – 2.50

0.8

L

Globulin is increased disproportionately to albumin (decreasing the albumin/globulin ratio) in states characterized by chronic inflammation and in B-lymphocyte neoplasms, like myeloma and Waldenström's macroglobulinemia. More relevant information concerning increased globulin may be obtained by serum protein electrophoresis.Decreased globulin may be seen in congenital or acquired hypogammaglobulinemic states. Serum and urine protein electrophoresis may help to better define the clinical problem.

Total protein The total

64.00 – 83.00

g/L

57.40

g/L

L

protein test is a rough measure of all theproteins found in the fluid portion of your blood. Specifically it looks at the total amount of two classes of proteins: albumin and globulin.

Globulin

23.0 – 30.0

g/L

32.60g/

L

H

any of a class

of proteins

insoluble in

water, but

soluble in

saline solutions

(euglobulins),

or water-

soluble

proteins

(pseudoglobuli

ns); their other

physical

properties

resemble true

globulins

Albumin

35.00 – 50.00

g/L

24.80

(low)

Albumin is a

protein made

by the liver. A

serum albumin

test measures

the amount of

this protein in

the clear liquid

portion of the

blood.

SURGERY: Debridement, Split Thickness Skin Graft

DATE: September 5, 2011

HOSPITAL: SPMC – OR

SURGEON: Dr. Gabutan

ANESTHESIOLOGIST: Dr. Ranola

TYPE of ANESTHESIA: General Anesthesia TIME BEGAN: 2:15 PM – 4:15 PM

OPERATION DIAGNOSIS: Rhabdomyosarcoma right , status post forequarter amputation

OPERATION STARTED: 3:00 PM

OPERATION ENDED: 3:50 PM

Definition

Debridement is a medical procedure performed to remove damaged tissue from a patient to promote the development of healing in the underlying tissue. Surgical debridementis recommended when the tissue damage is so extensive that working on a conscious patient would be painful, as well as risky, as in the case of very deep or large wounds. This procedure can be done by a general surgeon or a specialist, depending on the location and nature of the damage.

Split Thickness Skin Graft is a skin graft including the epidermis and part of the dermis. Its thickness depends on the donor site and the needs of the patient. It can be processed through a skin mesher which makes apentures onto the graft, allowing it to expand up to nine times its size. Split-thickness grafts are frequently used as they can cover large areas and the rate of autorejection is low. You can take from the same site again after 6 weeks. The donor site heals by re-epitheliasation from the dermis and surrounding skin and requires dressings.

Procedure

The most important part of any skin graft procedure is proper preparation of

the wound. Skin grafts will not survive on tissue with a limited blood supply

(cartilage or tendons) or tissue that has been damaged by radiation

treatment. The patient's wound must be free of any dead tissue, foreign

matter, or bacterial contamination. After the patient has been anesthetized,

the surgeon prepares the wound by rinsing it with saline solution or a diluted

antiseptic (Betadine) and removes any dead tissue by débridement. In

addition, the surgeon stops the flow of blood into the wound by applying

pressure, tying off blood vessels, or administering a medication (epinephrine)

that causes the blood vessels to constrict.

Following preparation of the wound, the surgeon then harvests the tissue for

grafting. A split-thickness skin graft involves the epidermis and a little of the

underlying dermis; the donor site usually heals within several days. The

surgeon first marks the outline of the wound on the skin of the donor site,

enlarging it by 3–5% to allow for tissue shrinkage. The surgeon uses a

dermatome (a special instrument for cutting thin slices of tissue) to remove a

split-thickness graft from the donor site. The wound must not be too deep if a

split-thickness graft is going to be successful, since the blood vessels that

will nourish the grafted tissue must come from the dermis of the wound itself.

The graft is usually taken from an area that is ordinarily hidden by clothes,

such as the buttock or inner thigh, and spread on the bare area to be

covered. Gentle pressure from a well-padded dressing is then applied, or a

few small sutures used to hold the graft in place. A sterile nonadherent

dressing is then applied to the raw donor area for approximately three to five

days to protect it from infection.Indication

1. Debridement is indicated to our patient in preparation for split thickness skin graft.

2. An STSG is indicated in most wounds that cannot be closed primarily and when closure by secondary intention is contraindicated. It is also indicated for a relatively large wound (> 5–6 cm in diameter) that would take many weeks to heal secondarily. A skin graft provides more stable coverage for large wounds than the scar that results from secondary closure. A large wound also heals more quickly with a skin graft than with dressing changes alone. The wound must be clean. All necrotic tissue must be removed before skin grafting, and there should be no signs of infection in the surrounding tissues.

Anesthesia

General anesthesia puts the entire body to sleep by giving medicine. It is

often used during emergency surgery. It is also commonly used if a

procedure would make you uncomfortable if you were awaken

Position

When doing debridement the position of the patient should be side lying

position on the unaffected part.So that the surgical site is clearly expose and

for the convenience of the surgeon and the rest of the surgical team. Also in

doing the split thickness skin grafting, the position of the client is in supine

position.

InstrumentationKidney basin A bean-shaped basin used

for collection of bodily discharges or cleaning and irrigation.

Asepto syringe Used for intraoperative irrigation

Yankauer suction blood and fluids

Scalpel Used to cut

Abdominal Pack General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Operating sponge

General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Prosta Pack General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Mayo tray Sterile field which holds all surgical instruments used

Kelly clamps Used to clamp larger vessels and tissue

Needle Holder Facilitate use of suture

Army navy Used for tissue and bone retraction

Tissue forceps Grasps soft tissues and facilitates suturing of the site

Thumb forceps Used for grasping hard tissues

Mayo scissors Used to cut heavy tissue (fascia and muscle)

Metzenbaum scissors

Used to cut delicate tissue

Towel clips Holds towels in place around the surgical site

Water Saline solution

Irrigating surgical site and cleaning

Richardson Used for retraction

Straight mayo General purpose and suture cutting scissors

Allis forceps For grasping soft tissue

Bobcock for grasping soft tissue

Humby knife A knife with a roller and a calibration device to cut skin grafts of different thickness

Graft-meshing machine

a device used to make fine cuts in skin grafts

Padgett dermatome

was the first rotary drum manual dermatome to be devised

Bone curette A surgical instrument shaped like a scoop or spoon, used to remove tissue or growths from a body cavity.

Cotton tip applicator

For wound care

I. Nursing Responsibilities

Preoperative Phase

a. Assessment and Data Collection

The patient should be in best possible physical condition before

surgery. In emergencies, of course, this cannot be controlled, but

planned surgery might be postponed until the patient is physically

able to withstand the stress of anesthesia and the surgery.

First, the perioperative nurse gathers data specific to the surgical

procedure and postoperative course:

- health history and psychosocial assessment (what is the

reason for this surgery?)

- cultural assessment (what are your cultural customs regarding

privacy and blood transfusions?)

- spiritual assessment (do you have spiritual or religious

beliefs?)

- physical assessment (such as weight and vital signs)

- laboratory and diagnostic test data (note any abnormal

findings)

Any significant deviations from normal range should be brought to

the attention of the surgeon.

Second, the nurse assesses surgical risk factors. Carefully assess

the patient before surgery for risks of complications such as

advanced age with inactivity, obesity and cardiovascular problems,

excessive fear, substance abuse, respiratory disease, diabetes

mellitus and other chronic diseases.

b. General preoperative teaching

General information that almost all surgical patients should receive

includes information related to:

- Preoperative procedures: skin preparation, care of belongings,

restriction of food and fluid intake, time to come to hospital

- Technical information: anticipated surgical procedure, location

of incisions

- Day of surgery: time surgery is scheduled, time to arrive at

hospital, probable length of procedure, where family will wait

In addition, teaching the patient correct breathing, coughing,

turning and leg exercises is a high priority during the preoperative

period. Explain the importance of doing the exercises and show

the patient how to do each one and ask for a return demonstration.

c. The nurse checks that a consent form has been signed before

giving the preoperative medication. Before the surgeon can

perform an operation, written permission signed by either the

patient, her guardian, or whoever holds power of attorney must be

obtained.

Intraoperative Phase

Scrub nurse

The scrub nurse works directly with the surgeon within the sterile field,

passing instruments, sponges, and other items needed during the

procedure. Surgical team members who work within the sterile field have

scrubbed their hands and arms with special disinfecting soap and

generally wear surgical gowns, caps, eyewear, and gloves.

Major functions include:

- Gathers all equipment for the procedure

- Prepares all sterile supplies using sterile technique

- Gowns and gloves surgeons upon entry into operating room

- Assists with sterile draping of the patient

- Maintains sterility within the sterile field during surgery

- Maintains a neat instrument table

- Label and handles surgical specimens correctly

- Maintains an accurate count of sponges, sharps, and

instruments on the sterile field; verifies counts with circulating

nurse before and after surgery

- Monitors for breaks in sterile technique and points them out

- Cleans up after the surgery is over

Circulating nurse

The circulating nurse serves as the patient advocate while the patient is

least able to care for him or herself.

Functions include:

- Responsible for managing the nursing care of the patient within

the OR and coordinating the needs of the surgical team with

other care providers

- Observes the surgery and the surgical team from a broad

perspective

- Assists the team to create and maintain a safe and comfortable

environment for the patient

- Assesses the patient's condition before, during, and after the

operation to ensure an optimal outcome for the patient

Postoperative phase

The nurse checks the patient’s identity, settles the patient in bed, and

performs an initial postoperative assessment. Airway, breathing and

circulation are always the top priorities.

Monitoring for signs of the various complications that may occur as a

result of surgery is a major nursing responsibility.

Other responsibilities of the nurse towards the patient include:

- Maintaining ventilation: maintaining a patent airway is a priority

measure

- Maintain circulation and tissue perfusion

- Prevent injury and infection: use aseptic technique when caring

for postoperative patient. Good hand washing is the primary

means of preventing infection

- Maintain fluid balance

- Promote comfort: pain and discomfort interfere with rest and

inhibit the processes of healing and repair. Although analgesic

drugs are almost always prescribed for the postoperative

patient, comfort measures should also be used.

- Promote rest and activity

- Promote wound healing: adequate rest, sufficient blood supply,

and proper nutrition all promote wound healing

- Prevent postoperative complications such as wound infection

- Promote psychological adjustment: the patient may be

concerned about the ability to perform self-care post-

operatively

- The nurse assesses the graft area for signs of adequate blood

supply. She inspects the color of the graft area, which should be

the same color as the other skin on the patients body to see if

it has enough blood supply. The nurse also checks to make

sure the graft area is warm as this indicates sufficient blood

supply to the area.

- The nurse checks the patency of drains placed in the graft

area. She makes sure they are not blocked, so drainage can flow

out of the graft site instead of accumulating in it and potentially

causing an infection.

- The nurse ensures blood circulation to the graft area by

positioning the patient off the graft. Taking pressure off the

graft and skin surrounding it reduces the risk of decreased

blood supply to the area.

- The nurse may place the patient on a low pressure bed when

lying down or low pressure cushion for sitting down. The less

pressure exerted on the graft area, the more likely that it will

be adequately perfused. Low pressure beds and cushions

exert low pressure on the skin.

- Another nursing intervention for skin graft patients is to provide

an over the bed trapeze. The nurse makes sure that the patient is

aware of how to use it for moving around in bed. This

reduces the amount of shearing and friction that could occur

during movement and possibly displace the graft.

sources:

http://www.surgeryencyclopedia.com/Pa-St/Skin-Grafting.html

Dipietro, Luisa A., and Aime L. Burns, eds. Wound Healing: Methods and

Protocols. Totowa, NJ: Humana Press, 2003.

Herndon, David, ed. Total Burn Care , 2nd ed. London, UK: W. B. Saunders

Co., 2001.

Tura, A., ed. Vascular Grafts: Experiment and Modelling , 1st ed. Billerica,

MA: WIT Press/Computational Mechanics, 2003.

SURGERY: Forequarter Amputation

DATE: August 5, 2011

HOSPITAL: SPMC – OR

SURGEON: Dr. Penaranda/ Dr. Sabal/ Dr. Gabutan

ANESTHESIOLOGIST: Dr.Bermulo

TYPE of ANESTHESIA: General Anesthesia (GETA)TIME BEGAN: 3:20 PM – 6:45 PM

OPERATION DIAGNOSIS: to consider sarcoma right arm

OPERATION STARTED: 4:20 PM

OPERATION ENDED: 6:30 PM

Definition

Forequarter amputation (interscapulothoracic amputation) entails the surgical removal of the entire upperextremity and shoulder girdle, including the scapula and a portion of the clavicle.Traditionally forequarteramputations were most commonly performed for highgrade bone sarcomas of the proximal humerus andscapula . The proximal humerus is thethird most common site for osteosarcomas, and thesetumors are the most common primary malignancy of the proximal humerus. Chondrosarcomas and Ewing’s sarcoma tend to occur in the scapula.

Procedure

1. Posterior incision from medial end of clavicle, along clavicle over acromion and down lateral border of scapula, ending ~ 5 cm from midline at back. Anterior incision from mid clavicle, curving down just lateral and parallel with the deltopectoral groove, down over anterior axillary fold inferiorly and posteriorly to meet the posterior incision at the lower 1/3 of the axillary border of the scapula

2. Develop the posterior flap to expose the vertebral border of the scapula and divide trapezius, rhomboids, levator scapulae and latisimus dorsi from the scapula

3. Reflect scapula to divide attachment of serratus anterior and omo-hyoid

4. Allow arm to drop forward to bring plexus under tension and divide cords of the brachial plexus near the spine

5. Double ligation of subclavian artery and vein6. From the anterior incision divide clavicle near medial end7. Divide pectoralis muscles and insertion of latisimus dorsi to complete

the resection8. Perform a myoplastic closure and close skin over drains

Indication

The Forequarter amputation is indicated

1.Unresectable high-grade osteosarcoma (or any otherhigh-grade tumor) of the proximal humerus or the scapula (most commonly, chondrosarcoma).

2. Axillary soft-tissue sarcomas involving the brachial plexus.

3. Recurrent bone or soft-tissue sarcomas following a failed limb-sparing procedure.

4. Some radiation-induced sarcomas of the shoulder girdle.

5. Palliative amputation (primarily due to tumor fungation, infection, or bleeding).

6. Recurrent breast carcinoma involving the brachial plexus.

7. Pathological fracture through a high-grade sarcoma, especially if there is a poor response to induction chemotherapy.

Anesthesia

General anesthesia is a treatment that renders you unconscious during medical procedures, so you don't feel or remember anything that happens. General anesthesia is commonly produced by a combination of intravenous drugs and inhaled gasses (anesthetics).

The "sleep" you experience under general anesthesia is different from regular sleep. The anesthetized brain doesn't respond to pain signals or surgical manipulations.

The practice of general anesthesia also includes controlling your breathing and monitoring your body's vital functions during your procedure. General anesthesia is administered by a specially trained physician, called an anesthesiologist, often in conjunction with a certified registered nurse anesthetist.

Position

Intravenous lines are secured, and a Foley catheter is placed in the bladder. The patient is placed in a full lateral position and secured at the hips with tape. Alternatively, a VAC pack can be used to secure the torso. An axillary roll is placed under the axilla to allow full excursion of the chest, and a sponge-rubber pad is placed under the hip to prevent ischemic damage to the skin in this area. The skin is prepared, and the tumor-bearing extremity is draped free.

Instrumentation

Cautery cord and pencil

Uses electricity to cut or cauterize blood vessels.

Kidney basin A bean-shaped basin used for collection of bodily discharges or cleaning and irrigation.

Asepto syringe Used for intraoperative irrgation

Yankauer suction blood and fluids

Scalpel Used to cut

Abdominal Pack

General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Operating sponge

General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Prosta Pack General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Mayo tray Sterile field which holds all surgical instruments used

Kelly clamps Used to clamp larger vessels and tissue

Needle Holder Facilitate use of suture

Army navy Used for tissue and bone retractiob

Tissue forceps Grasps soft tissues and facilitates suturing of the site

Thumb forceps Used for grasping hard tissues

Mayo scissors Used to cut heavy tissue (fascia and muscle)

Metzenbaum scissors

Used to cut delicate tissue

Towel clips Holds towels in place around the surgical site

Water Saline solution

Irrigating surgical site and cleaning

Richardson Used for retraction

Straight mayo General purpose and suture cutting scissors

Allis forceps For grasping soft tissue

Bobcock for grasping soft tissue

Gigli saw a flexible wire saw used by surgeons for bone cutting. A gigli saw is used mainly for amputation surgeries, where the bones have to be smoothly cut at the level of amputation.

II. Nursing Responsibilities

Preoperative Phase

d. Assessment and Data Collection

The patient should be in best possible physical condition before

surgery. In emergencies, of course, this cannot be controlled, but

planned surgery might be postponed until the patient is physically

able to withstand the stress of anesthesia and the surgery.

First, the perioperative nurse gathers data specific to the surgical

procedure and postoperative course:

- health history and psychosocial assessment (what is the

reason for this surgery?)

- cultural assessment (what are your cultural customs regarding

privacy and blood transfusions?)

- spiritual assessment (do you have spiritual or religious

beliefs?)

- physical assessment (such as weight and vital signs)

- laboratory and diagnostic test data (note any abnormal

findings)

Any significant deviations from normal range should be brought to

the attention of the surgeon.

Second, the nurse assesses surgical risk factors. Carefully assess

the patient before surgery for risks of complications such as

advanced age with inactivity, obesity and cardiovascular problems,

excessive fear, substance abuse, respiratory disease, diabetes

mellitus and other chronic diseases.

e. General preoperative teaching

General information that almost all surgical patients should receive

includes information related to:

- Preoperative procedures: skin preparation, care of belongings,

restriction of food and fluid intake, time to come to hospital

- Technical information: anticipated surgical procedure, location

of incisions

- Day of surgery: time surgery is scheduled, time to arrive at

hospital, probable length of procedure, where family will wait

In addition, teaching the patient correct breathing, coughing,

turning and leg exercises is a high priority during the preoperative

period. Explain the importance of doing the exercises and show

the patient how to do each one and ask for a return demonstration.

f. The nurse checks that a consent form has been signed before

giving the preoperative medication. Before the surgeon can

perform an operation, written permission signed by either the

patient, her guardian, or whoever holds power of attorney must be

obtained.

Intraoperative Phase

Scrub nurse

The scrub nurse works directly with the surgeon within the sterile field,

passing instruments, sponges, and other items needed during the

procedure. Surgical team members who work within the sterile field have

scrubbed their hands and arms with special disinfecting soap and

generally wear surgical gowns, caps, eyewear, and gloves.

Major functions include:

- Gathers all equipment for the procedure

- Prepares all sterile supplies using sterile technique

- Gowns and gloves surgeons upon entry into operating room

- Assists with sterile draping of the patient

- Maintains sterility within the sterile field during surgery

- Maintains a neat instrument table

- Label and handles surgical specimens correctly

- Maintains an accurate count of sponges, sharps, and

instruments on the sterile field; verifies counts with circulating

nurse before and after surgery

- Monitors for breaks in sterile technique and points them out

- Cleans up after the surgery is over

Circulating nurse

The circulating nurse serves as the patient advocate while the patient is

least able to care for him or herself.

Functions include:

- Responsible for managing the nursing care of the patient within

the OR and coordinating the needs of the surgical team with

other care providers

- Observes the surgery and the surgical team from a broad

perspective

- Assists the team to create and maintain a safe and comfortable

environment for the patient

- Assesses the patient's condition before, during, and after the

operation to ensure an optimal outcome for the patient

Postoperative phase

The nurse checks the patient’s identity, settles the patient in bed, and

performs an initial postoperative assessment. Airway, breathing and

circulation are always the top priorities.

Monitoring for signs of the various complications that may occur as a

result of surgery is a major nursing responsibility.

Other responsibilities of the nurse towards the patient include:

- Maintaining ventilation: maintaining a patent airway is a priority

measure

- Maintain circulation and tissue perfusion

- Prevent injury and infection: use aseptic technique when caring

for postoperative patient. Good hand washing is the primary

means of preventing infection

- Maintain fluid balance

- Promote comfort: pain and discomfort interfere with rest and

inhibit the processes of healing and repair. Although analgesic

drugs are almost always prescribed for the postoperative

patient, comfort measures should also be used.

- Promote rest and activity

- Promote wound healing: adequate rest, sufficient blood supply,

and proper nutrition all promote wound healing

- Prevent postoperative complications such as wound infection

- Promote psychological adjustment: the patient may be

concerned about the ability to perform self-care post-

operatively

- Minimizing altered sensory perceptions- Promoting wound healing- Enhancing body image- Promoting independent self-care- Helping the patient to achieve physical mobility

Source:

http://www.sarcoma.org/publications/mcs/ch17.pdf

Dipietro, Luisa A., and Aime L. Burns, eds. Wound Healing: Methods and Protocols. Totowa, NJ: Humana Press, 2003

DRUG STUDY

Generic NameKetorolac

Brand NameToradol

Classification Nonsteroidal anti-inflammatory agents, nonopioid analagesics

Ordered DosageRoute: IVTT

Dosage : 15 mg

Dosage Frequency Q6 x 3 doses

Mechanism of

Action

It inhibits prostaglandin synthesis, producing peripherally

mediated analgesia. Also have antipyretic and anti-inflammatory

properties.

Therapeutic effect: Decreased pain

Indications For short term management of pain (not to exceed 5 days total for

all routes combined).

ContraindicationsContraindicated in patients with hypersensitivity cross-sensitivity

with other NSAIDS may exist, labor, delivery or lactation, pre- or

perioperative use and known alcohol intolerance (injection only).

Side effects and

Adverse Reactions

CNS:

1) drowsiness

2) abnormal thinking

3) dizziness

4) euphoria

5) headache-

RESP:

1) asthma

2) dyspnea

CV:

1) edema

2) pallor

3) vasodilation

GI:

1) GI Bleeding

2) abnormal taste

3) diarrhea

4) dry mouth

5) dyspepsia

6) GI pain

7) nausea

GU:

1) oliguria

2) renal toxicity

3) urinary frequency

DERM:

1) pruritis

2) purpura

3) sweating

4) urticaria

HEMAT:

1) prolonged bleeding time

LOCAL:

1) injection site pain

NEURO:

1) paresthesia

MISC:

1) allergic reaction, anaphylaxis

Nursing

Responsibilities

1. Ensure right patient, ask the patient his name and check

the ID band.

2. Check the drug label before preparing the drug.

3. Check the latest doctor prescribed dosage and asks

somebody for clarifications about the dosage.

4. Check latest doctor prescribed dosage frequency.

Administer on time.

5. Patients who have asthma, aspirin-induced allergy, and

nasal polyps are at increased risk for developing

hypersensitivity reactions. Assess for rhinitis, asthma, and

urticaria.

6. Assess pain (note type, location, and intensity) prior to and

1-2 hr following administration.

7. Ketorolac therapy should always be given initially by the IM

or IV route. Oral therapy should be used only as a

continuation of parenteral therapy.

8. Caution patient to avoid concurrent use of alcohol, aspirin,

NSAIDs, acetaminophen, or other OTC medications without

consulting health care professional.

9. Advise patient to consult if rash, itching, visual

disturbances, tinnitus, weight gain, edema, black stools,

persistent headche, or influenza-like syndromes

(chills,fever,muscles aches, pain) occur.

10.Effectiveness of therapy can be demonstrated by decrease

in severity of pain. Patients who do not respond to one

NSAIDs may respond to another.

Generic Name

Tramadol

Brand Name

Ultram

Classification

Analgesics

Ordered DosageRoute: IVTT

Dosage: 30 mg

Dosage Frequency Q6

Mechanism of Action

Physiologic Mechanism

• Decreased pain.

Pharmacologic Mechanism

• Binds to mu-opioid receptors.

• Inhibits reuptake of serotonin and norepinephrine in the

CNS.

Indications

Moderate to moderately severe pain

ContraindicationsHypersensitivity totramadol, opioids, orany component of

theformulation; opioid-dependent patients;acute

intoxicationwith alcohol,hypnotics, centrally-acting

analgesics,opioids, orpsychotropic drugs

Side effects and

Adverse Reactions

Side effects

Dizziness or vertigo

Nausea and Vomiting

Constipation

Headache

Dry mouth

Adverse Reactions

Respiratory depression

Seizures

Prolonged duration of action and cumulative effect may

occur in patients with impaired hepatic or renal function.

Nursing Responsibilities 1. Verify the identity of the patient

2. Inform the patient about the administration of drugs

and its purpose

3. Assess onset, type, location, and duration of pain.

4. Effect of medication is reduced if full pain recurs

before next dose.

5. Assess drug history especially carbamazepine, CNS

depressant medication, MAOIs.

6. Review past medical history, especially epilepsy or

seizures.

7. Assess renal or hepatic function laboratory values.

8. Give without regards to meals

9. Monitor pulse and blood pressure.

10.Assist with ambulation if dizziness or vertigo occurs.

11.Dry crackers or cola may relieve nausea.

12.Palpate bladder for urinary retention.

13.Monitor pattern of daily bowel activity and stool

consistency.

14.Sips of tepid water may relieve dry mouth.

15.Assess for clinical improvement and record onset of

relief from pain.

Generic Name

Mefenamic acid – Oral

Brand Name

Mefalth, Mefalth T, Ponstel, Ponstan, Ponstal, Parkemed,

Mafepain, Mefamed, Mephadolor, Meftal, Dyfenamic, Potarlon,

Dolfenal, Meyerdonal, Alfoxan, Fenagesic, Spiralgin.

ClassificationNon-steroidal anti-inflammatory drug.

Ordered DosageRoute: PO

Dosage:500 mg

Dosage Frequency Q6

Mechanism of Action Mefenamic acid binds the prostaglandin synthetase receptors

COX-1 and COX-2, inhibiting the action of prostaglandin

synthetase. As these receptors have a role as a major

mediator of inflammation and/or a role for prostanoid signaling

in activity-dependent plasticity, the symptoms of pain are

temporarily reduced.

Indications

Pain and inflammation.

ContraindicationsInflammatory bowel disease; peptic ulcer; neonates; pregnancy

(3rd trimester), lactation. Coronary artery bypass graft surgery,

severe renal impairment, and severe heart failure.

Side effects and

Adverse Reactions

Dependent on the dose and the duration of treatment, mefenamic acid frequently causes diarrhea. Long-term treatment can lead to enteritis or colitis (sometimes with steatorrhea). The drug can also cause nausea, vomiting and upper abdominal pain. Like other anti-inflammatory agents, it occasionally is the cause of peptic ulcers or even of bleeding or perforations.Mefenamic acid seems to cause hematologic problems (especially autoimmune hemolytic anemias) more often than other anti-inflammatory drugs. Several cases

of renal failure (partially without oliguria) have been observed. Vertigo, headaches and skin reactions can occur under mefenamic acid.

Nursing Responsibilities 1. Ensure right patient, ask the patient his name and check the ID band.

2. Check the drug label before preparing the drug.3. Check the latest doctor prescribed dosage and ask

somebody for clarifications about the dosage. 4. Check latest doctor prescribed dosage frequency.

Administer on time.5.  If patient have had a stomach ulcer or bleeding, tell

healthcare provider.6. Instruct patient to avoid alcohol (includes wine, beer,

and liquor) when taking this medicine since it can cause increases in stomach irritation.

7. Use caution if the patient has a weakened heart. It may cause increased shortness of breath or weight gain. Then recommend to talk with healthcare provider or its own physician.

8. Avoid aspirin, aspirin-containing products, other pain medicines, other blood thinners (warfarin, ticlopidine, clopidogrel), garlic, ginseng, ginkgo, and vitamin E while taking. Talk with healthcare provider.

9. If patient is allergic to any medicine, especially aspirin, or have asthma. Make sure to tell about the allergy and how it affected the patient by consulting its attending physician.

Generic Name

Cefuroxime

Brand NameAeruginox, Altacef, Ambixime, Bactipoz, Cefogen, Ceftin, Cefucil, Cefuzime, Zefur, Zinacef, and Zinnat. 

Classification

Second-generation Cephalosporin and antibiotic.

Ordered DosageRoute: PO

Dosage: 500mg

Dosage FrequencyBIP

Mechanism of

Action Cefuroxime binds to bacterial membranes. It inhibits synthesis of bacterial cell wall

IndicationsFor the treatment of many different types of bacterial infections such as bronchitis, sinusitis, tonsillitis, ear infections, skin infections, gonorrhea, and urinary tract infections

ContraindicationsCefuroxime is contraindicated in patients with known allergy to the cephalosporin group of antibiotics. Solutions containing dextrose may be contraindicated in patients with hypersensitivity to corn products.

Side effects and

Adverse Reactions

Oral candidiasis (mouth and/or tongue sores)

Mild diarrhea

Mild abdominal cramping

Vaginal candidiasis

Nausea

Serum sickness reaction (joint pain, fever)

Allergic reactions

Thrombophlebitis

Nursing

Responsibilities

Ensure right patient, ask the patient his name and check the ID band.

1. Check the drug label before preparing the drug.2. Check the latest doctor prescribed dosage and ask

somebody for clarifications about the dosage. 3. Check latest doctor prescribed dosage frequency.

Administer on time.4. Question for history of allergies, particularly cephalosporins

and penicillins.5. Give without regards to meals. If GI upset occurs give with

food or milk.

6. Avoid crushing tablets due to bitter taste.7. Suspension must be given with food.8. Intramuscular injections must be administered deep IM to

minimize discomfort.9. Assess mouth for white patches on mucous membranes

and tongue.10.Monitor bowel activity and stool consistency carefully.11.Mild GI effects may be tolerable but increasing severity may

indicate onset of antibiotic-associated colitis.12.Monitor input and output and renal function reports for

nephrotoxicity.13.Be alert for superinfection: severe genital or anal pruritus,

abdominal pain, and severe mouth soreness, moderate to severe diarrhea.

14.Assess for hypersensitivity and other contraindications and current fluid intake and output record if present.

15.Check fluid intake and output and presence of side effects and adverse reactions.

16.Document drug administration and reactions if present. Record the administration in the medication sheet.

17.Assess and confirm if patient is having problems with regards to the medication and for reasons of refusing drug administration. Confirm from the patient and significant others on their view of the drug administration.

18. Instruct patient on proper drug compliance and report for signs of side and adverse effects. Orient the patient and significant other about the drugs action and effects.

Generic Name

Paracetamol

Brand Name

Common Brand names are Aeknil, Biogesic, Calpol, Neo-kiddielets, Tempra.

Classification

Analgesic (pain reliever) and Antipyretic (fever reducer)

Ordered Dosage Route: IVTT

Dosage: 300mg

Dosage FrequencyPTOR

Mechanism of

ActionThought to produce analgesic by pain impulses, probably by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to mechanical or chemical stimulation. It’s thought to relieve fever by central action in the hypothalamic heat-regulating center.

Indications

Fever, Relief of mild to moderate pain like headaches, muscular aches and pain, toothache, colds, earache, fever due to tonsillectomy, inoculations, and vaccinations.

Contraindications Contraindicated in patients hypersensitive to drug Use cautiously in patients with long-term alcohol use

because therapeutic doses cause hepatotoxicity in the patients.

Side effects and

Adverse Reactions

Side effects-Cramping-Heartburn-Abdominal distention can be experienced-Hypersensitivity reactions.

Adverse ReactionsAnorexia, nausea, diaphoresis (excessive sweating), generalized weakness within the first 12-24 hours. Liver damage, jaundice, hypoglycemia, rash, vomiting

Nursing

Responsibilities

1. Ensure right patient, ask the patient his name and check the ID band.

2. Check the drug label before preparing the drug, before administering intravenously, and after administration.

3. Check the latest doctor prescribed dosage and ask somebody for clarifications about the dosage.

4. Check latest doctor prescribed dosage frequency. Administer on time.

5. Inform patient about the drug and the purpose of administration

6. If to be given as analgesia, assess onset, type, location, duration of pain.

7. Can be given without regards to meals.8. Tablets can be crushed.9. Assess temperature directly before and 1 hour after giving

medication.10. If respirations are <12/min (<20/min in children), withhold

the medication and contact the physician.11.Evaluate for therapeutic response: relief of pain, stiffness,

swelling; increasing in joint mobility; reduced joint

tenderness; improve grip strength.12.Therapeutic blood serum level: 10-30 mcg/mL; toxic serum

level: >200 mcg/mL.13.Assess for hypersensitivity and other contraindications and

current fluid intake and output record if present.14.Check fluid intake and output and presence of side effects

and adverse reactions.15.Document drug administration and reactions if present.

Record the administration in the medication sheet.16.Assess and confirm if patient is having problems with

regards to the medication and for reasons of refusing drug administration. Confirm from the patient and significant others on their view of the drug administration.

17. Instruct patient on proper drug compliance and report for signs of side and adverse effects. Orient the patient and significant other about the drugs action and effects.

Patient Teaching - Consult physician for use in children less than 2 years old;

oral use more than 5 days for children, more than 10 days for adults, or fever more than 3 days.

- Do not crush or chew sustained-release or enteric-coated form.

- Report ringing in ears and persistent GI pain.- Severe, recurrent pain or high continuous fever may indicate

serious illness.

Generic Name

Diphenhydramine

Brand Name BENADRYL

Classification

Antihistamine

Ordered Dosage Route: IVTT

Dosage: 500 mg

Dosage Frequency Once blood transfusion started

Mechanism of

Action

Diphenhydramine competes with histamine at histamine receptor

sites. It inhibits central acetylcholine. It results in anticholinergic,

antipruritic, antitussive, and antiemetic effect. Diphenhydramine

produces antidyskinetic and sedative effect.

Indications Diphenhydramine is used to treat allergic reactions and

parkinsonism. It is also used in the prevention and treatment of

nausea, vomiting, and vertigo due to motion sickness.

Diphenhydramine is also an antitussive and can be used as a

short term treatment of insomnia. A topical form of

Diphenhydramine can be used to relieve pruritus, insect bites, and

skin irritations.

Contraindications Diphenhydramine is contraindicated in patients who are

hypersensitive to it or other antihistamines in its class. Because of

their anticholinergic activity, antihistamines should be used with

caution in patients with angle closure glaucoma, prostatic

hypertrophy, pyloroduodenal or bladder neck obstruction, and

COPD if mucosal secretions are a problem

Side effects and

Adverse ReactionsSide Effects :

Drowsiness Dizziness

Muscular weakness

Hypotension

Dry mouth, nose, throat, or lips

Urinary retention

thicknening of bronchial secretions

Sedation

Epigastric distress

Flushing

Visual or hearing disturbances

Paresthesia

Diaphoresis

Chills

Adverse Reactions:Dominant paradoxical reactions (restlessness, insomnia, euphoria, nervousness, and tremors)

Hallucinations

Seizures

Hypersensitivity reactions (eczema, pruritus, rash, cardiac disturbances, and photosensitivity)

CNS depression (sedation, apnea, hypotension, cardiovascular collapse, and death)

Nursing

Responsibilities

1. Verify the identity of the patient

2. Inform the patient about the administration of drugs and its

purpose

3. Assess onset, type, location, and duration of pain.

4. Give without regards to meals.

5. Scored tablets may be crushed.

6.  Do not crush capsules or film-coated tablets.

7. If patient is having acute allergic reactions, obtain history of

recently ingested food, drugs, environmental exposure, and

recent emotional stress.

8. Monitor rate, depth, rhythm, and type of respiration.

9. Monitor rate, depth, rhythm, and quality or rate of pulse.

10.Assess lung sounds for rhonchi, wheezing, rales.

11.Monitor blood pressure especially in elderly.

12.Monitor children closely for paradoxical reaction.

Patient Teachings

Tolerance to antihistamine effect generally does not occur; tolerance to sedative effect may occur.

Avoid tasks that require alertness and motor skills until response to drug is established.

Dry mouth, drowsiness, and dizziness may be an expected response of drug.

Avoid alcoholic beverages.

Generic Name

Cefazolin

Brand Name Ancef

ClassificationTherapeutic: Anti-infectivesPharmacologic:First generation cephalosphorins

Ordered Dosage Route: IVTT

Dosage: 1 g

Dosage Frequency Q8

Mechanism of

Action• Bind to bacterial cell wall membrane, causing cell death.• Active against many gram-positive cocci including: Streptococcus pneumoniae, Group A beta-hemolytic streptococci; Penicillinas-producing staphylococci.

Indications •Treatment of:Skin & skin structure infections; pneumonia; urinary tract infections; bone & joint infections

Contraindications •Hypersensitivity to cephalosporin. Serious hypersensitivity to penicillin.

Side effects and

Adverse Reactions• CNS:Seizures (high doses)• GI:Pseudomembranous colitis, diarrhea, nausea, vomiting, cramps• GU:Interstitial nephritis• DERM:Rashes, urticaria• HEMAT:Blood dyscrasias, hemolytic anemia• LOCAL:Pain at IM site, phlebitis at IV site• MISC:Allergic reactions including Anaphylaxis and Serum sickness, super infection

Nursing 1. Verify the identity of the patient

2. Inform the patient about the administration of drugs and its

Responsibilities purpose

3.  Assess patient for infection (vital signs; appearance of

surgical site, urine; WBC) at beginning and during therapy.

4. Before initiating therapy, obtain a history to determine

previous use of and reactions to penicillins or

cephalosphorins. Persons with a negative history of

penicillin sensitivity may still have an allergic response.

5. Obtain specimens for culture and sensitivity before

initiating therapy.

6. Observe patient for signs and symptoms of anaphylaxis

(rash, pruritis, laryngeal edema, wheezing). Discontinue

drug and notify physician or other health care professional

immediately if these problems occur. Keep epinephrine, an

antihistamine, and resuscitation equipment close by in case

of anaphylactic reaction.

7. Monitor site for thrombophlebitis (pain, redness, swelling).

Change sites every 48-72 hr to prevent phlebitis.

8. Instruct patient to report signs of superinfection (furry

overgrowth on the tongue, vaginal itching or discharge,

loose or foul-smelling stools) and allergy.

9. Instruct patient to notify health care professional if fever

and diarrhea develop, especially if diarrhea contains blood,

mucus, or pus. Advise not to treat diarrhea without

consulting healthcare professional.

Generic Name

Amikacin

Brand Name Amikin, Amikin Pediatric

Classification Amino glycoside

Ordered Dosage Route: IVTT

Dosage: 240 mg

Dosage Frequency Q12

Mechanism of

Action

Amikacin binds to 30S ribosomal subunits of susceptible bacteria,

thus inhibiting its protein synthesis.

Distribution: Detected in body tissues and fluids after inj; crosses

the placenta but does not readily penetrate the CSF. Significant

amounts penetrate the blood-brain barrier in children with

meningitis.

Excretion: Via the urine by glomerular filtration (within 24 hr); 2-3

hr (elimination half-life).

Indications Amikacin is indicated for the treatment of infections of: central

nervous system, urogenital system, biliary and intestinal tracts,

skin and subcutaneous tissues, intraabdominal infections,

pneumonia, caused by Gram-negative microorganisms, secondary

infections after combustion, bacterial septicemia, infections of the

bones and joints (caused by sensitive to Amikacin

microorganisms). 

Contraindications A history of hypersensitivity to amikacin is a contraindication for its

use. A history of hypersensitivity or serious toxic reactions to

aminoglycosides may contraindicate the use of any other

aminoglycoside because of the known cross-sensitivities of

patients to drugs in this class

Side effects and

Adverse Reactions

an allergic reaction (shortness of breath; closing of the throat; hives; swelling of the lips, face, or tongue; rash; or fainting);

little or no urine; decreased hearing or ringing in the ears; dizziness, clumsiness, or unsteadiness; numbness, skin tingling, muscle twitching, or seizures; or Severe watery diarrhea and abdominal cramps.

Nursing

Responsibilities 1. Ensure right patient, ask the patient his name and check

the ID band.

2. Check the drug label before preparing the drug.

3. Check the latest doctor prescribed dosage and asks

somebody for clarifications about the dosage.

4. Check latest doctor prescribed dosage frequency.

Administer on time.

5. Patients should be counselled that antibacterial drugs

including Amikacin should only be used to treat bacterial

infections.

6. · Patients should be told that although it is common to feel

better early in the course of therapy, the medication should

be taken exactly as directed.

7. · Skipping doses or not completing the full course of

therapy may:

Decrease the effectiveness of the immediate treatment and 

   Increase the likelihood that bacteria will develop resistance and will not be treatable by Amikacin or other antibacterial drugs in the future.

Generic Name Ranitidine Hydrochloride

Brand Name Zantac

Classification

Therapeutic: 

Anti-ulcer agents

Pharmacologic:

Histamine H2 antagonists

Ordered Dosage Route: IVTT

Dosage: 30 mg

Dosage Frequency Q8

Mechanism of

Action

• Inhibits the action of histamine at the H2 receptor site located

primarily in gastric parietal cells, resulting in inhibition of gastric

acid secretion.

• In addition, ranitidine bismuth citrate has some antibacterial

action against H. pylori.

Indications

•Treatment and prevention of heartburn, acid indigestion, and

sour stomach.

Contraindications •Hypersensitivity, Cross-sensitivity may occur; some oral liquids

contain alcohol and should be avoided in patients with known

intolerance.

Use Cautiously in:

• Renal impair

• Geriatric patients (more

susceptible to adverse CNS reactions)

• Pregnancy or Lactation

Side effects and

Adverse Reactions

Altered taste

Constipation

nausea

Nursing Responsibilities • Assess patient for epigastric or abdominal pain and frank or

occult blood in the stool, emesis, or gastric aspirate.

• Nurse should know that it may cause false-positive results for

urine protein; test with sulfosalicylic acid.

• Inform patient that it may cause drowsiness or dizziness.

• Inform patient that increased fluid and fiber intake may minimize

constipation.

• Advise patient to report onset of black, tarry stools; fever, sore

throat; diarrhea; dizziness; rash; confusion; or hallucinations to

health car professional promptly.

• Inform patient that medication may temporarily cause stools and

tongue to appear gray black.

Assess patient’s GI condition before starting therapy and

regularly thereafter to monitor the drug’s effectiveness.

Assess patient’s and family’s knowledge of drug therapy.

Be alert for adverse reactions and drug interactions.

Assess patient’s and family’s knowledge of drug therapy.

Patient teaching

Remind patient taking drug once daily to take at bed time.

Instruct patient to take drug with or without food.

Urge patient not to smoke cigarettes; smoking may increase

gastric acid secretions and worsen disease.

Generic Name

Metoclopramide

Brand Name Reglan

Classification

Function classification: Cholinergic and Antiemetic

Chemical classification: central dopamine receptor antagonist

Ordered Dosage Route: PO

Dosage: 10 mg 1 tab

Dosage Frequency Q6

Mechanism of

Action

Blocks dopamine receptors by disrupting CNS chemoreceptor

trigger zone, increasing peristalsis and promoting gastric

emptying

Indications Preventing nausea and vomiting induced by cisplatin and other

chemotherapy

Contraindications contraindicated in patients with hypersensitivity to the drug or to

sulfonamides; pheochromocytoma, because it it may induce

hypertensive crisis; and seizure disorders, renal failure, liver

failure, parkinson’s disease GI hemorrhage or intestinal

obstruction or perforation, because the drug may exacerbate

symptoms of these disorders . Do not use the drug for longer than

12 weeks.

Side effects and

Restlessness

Anxiety

Adverse Reactions Drowsiness

Fatigue

Lassitude

Insomnia

Headache

Dizziness

Nursing

Responsibilities

Obtain a baseline assessment of blood pressure, mental

status, GI status, and history of seizure disorder or

pheochromocytoma before therapy.

Be alter for adverse reactions or drug interactions during

therapy

Evaluate the patient’s and family’s knowledge about

metoclopramide.

Be aware that safety and effectiveness have not been

established for therapy that continues longer than 12 weeks

Monitor effectiveness by observing the patient for nausea

and vomiting

Monitor fluid balance.

Monitor Vital Signs

Observe for changes in mental status, moods, and

behavior.

Use safety precautions for patients who develop adverse

CNS reactions

If patient is alert, encourage adequate intake of fluids to

prevent fluid volume deficit.

Patient teaching

Warn patient to avoid activities requiring alertness for 2

hours after taking each dose.

Advise patient that changes in mood and behavior may

accompany therapy with metoclopramide.

Generic Name

Furosemide

Brand Name Lasix

Classification Diuretic

Ordered Dosage Route: IVTT

Dosage: 20 mg

Dosage Frequency Post BT

Mechanism of

Action

Enhances excretion of sodium, chloride, potassium by direct

action at ascending limb of loop of Henle and produces a diuretic

effect.

Indications Treatment of edema associated with congestive heart failure,

chronic renal failure, hepatic cirrhosis, and acute pulmonary

edema. It is also used for treatment of hypertension, alone or in

combination with other hypertensive. Can also be used for

treatment of hypercalcemia.

Contraindications Pronounced hyponatremia or hypovolemia and anuria.

Side effects and

Adverse ReactionsSide Effects Increase in urinary frequency or volume Nausea Gastric upset with cramping Diarrhea or constipation Electrolyte disturbances Dizziness or light headedness Headache Blurred Vision Paresthesia Photosensitivity Rash Weakness Bladder spasm Restlessness

Diaphoresis Flank or loin pain

Adverse Reactions Excessive diuresis may lead to increased water loss and

electrolyte depletion resulting to hypokalemia, hyponatremia, and dehydration.

Sudden volume depletion may result in increased risk f thrombosis, circulatory collapse, or sudden death.

Acute hypotensive episodes may occur, sometimes several days after beginning of therapy.

Ototoxicity manifested as deafness, vertigo, and tinnitus may occur especially in patients with severe renal impairment.

It can exacerbate diabetes mellitus, systemic lupus erthematosus, gout, and pancreatitis.

Blood dyscrasias have been reported.

Nursing

Responsibilities

1. Ensure right patient, ask the patient his name and check

the ID band.

2. Check the drug label before preparing the drug.

3. Check the latest doctor prescribed dosage and asks

somebody for clarifications about the dosage.

4. Check latest doctor prescribed dosage frequency.

Administer on time.

5. Give with food to avoid gastroinestinal upset, preferably

with breakfast (to prevent nocturia).

6. If given IM, temporary pain at injection site may be noted.

7. Check vital signs especially blood pressure for hypotension

prior to administration.

8. Assess baseline electrolyte, particularly check for low

potassium.

9. Assess edema, skin turgor, and mucous membranes for

hydration status.

10.Assess muscle strength and mental status.

11.Obtain baseline weight.

12. Initiate Input and Output monitoring.

13.Note extent of diuresis.

Generic Name

Cloxacillin

Brand Name Cloxapen, Tegopen

Classification antiinfective; antibiotic, natural penicillin; beta-lactam

Ordered Dosage Route: PO

Dosage: 500 mg per cup

Dosage Frequency Q6

Mechanism of

Action

Cloxacillin is resistant to degradation by penicillinases. It is

particularly useful against penicillinase-producing staphylococci.

Highly active against S aureus, S pyogenes, S viridans and S

pneumoniae.

Absorption: Incompletely absorbed from the GI tract with peak

plasma concentrations after 1-2 hr (oral); may be reduced in the

presence of food. Completely absorbed with peak plasma

concentrations after 30 min (IM).

Distribution: Pleural and synovial fluids and bone (therapeutic

concentrations), CSF (small amounts except when the meninges

are inflamed; crosses the placenta and enters the breast milk.

Protein-binding: 94%

Metabolism: Minimal metabolism.

Excretion: Via the urine by glomerular filtration and renal tubular

secretion (35% of an oral dose); via the bile (Up to 10%). Not

removed by dialysis; 0.5-1 hr (elimination half-life).

Indications Cloxacillin is effective against Penicillinase producing

Staphylococcus. It also acts against Strep Pyogenes,Strep

Viridans, Strep Pneumonia.

Contraindications Contraindicated in hepatic failure, Lactation, Hypersensitivity to

penicillin and pregnancy.

Side effects and Side effects

Adverse Reactions An allergic reaction Severe watery diarrhea Severe cramps Unusual bleeding Mild nausea White patches on the tongue Vaginal yeast infection Black, "hairy" tongue or sore mouth or tongue

Nursing

Responsibilities

1. Ensure right patient, ask the patient his name and check

the ID band.

2. Check the drug label before preparing the drug.

3. Check the latest doctor prescribed dosage and asks

somebody for clarifications about the dosage.

4. Check latest doctor prescribed dosage frequency.

Administer on time

5. Determine previous exposure and sensitivity to penicillins

and cephalosporins and other allergic reactions of any kind

before treatment is initiated.

6. Monitor for S&S of anaphylactoid reaction (see Appendix

G) or other signs or symptoms of hypersensitivity reaction

(see Appendix F) as with other penicillins.

7. Lab tests: Periodic assessments of renal, hepatic, and

hematopoietic function are advised in patients on long-term

therapy.

8. Be sure to let healthcare provider know if your child has any

allergies or reactions to medicine, food preservatives, or

dyes. Make sure to tell about the allergy and how it affected

your child. This includes telling about rash; hives; itching;

shortness of breath; wheezing; cough; swelling of face, lips,

tongue, or throat; or any other symptoms involved.

Patient & Family Education

Take medication around the clock, do not miss a dose, and continue taking the medication until it is finished.

Report to physician the onset of hypersensitivity reaction (see Appendix F) and superinfections.

Check with physician if GI adverse effects (nausea, vomiting, diarrhea) appear.

Do not breast feed while taking this drug.

Generic Name

Ascorbic Acid

Brand Name CELIN(Glaxo), CHEWCEE(Wyeth Lederie), CELL -C (Sarabhai),

CECON DROPS (Abbott),

Classification Vitamins

Ordered Dosage Route: PO

Dosage: 500mg

Dosage Frequency BID

Mechanism of

Action

Assists in collagen formation, tissue repair; involved in oxidation reduction reactions, other metabolic reactions.Vitamin C is involved in metabolism; carbohydrate utilization; synthesis of lipids, proteins, carnitine. It also preserves blood vessel integrity.

Indications Vitamin C is a compound that is necessary for proper growth and

health. They are needed in small amounts only and are usually

available in the normal foods that are ingested. Ascorbic

acid( vitamin C) is necessary for wound healing. Vit C plays a

major role in many oxidative and other metabolic reactions

essential for formation and stabilization of collagens,conversion of

folic acid to folinic acid, synthesis of adrenal steroids and

catacholamines.It is very important for maintanance of intracellular

tissue.

Contraindications Use of sodium ascorbate in patients on sodium restriction; use of

calcium ascorbate in patients receiving digitalis. Ascorbic acid may

be contraindicated in patients with hemolytic anemia.

Side effects and

Adverse ReactionsSide Effects

Abdominal cramps

Nausea

Vomiting

Diarrhea

Increased urination with doses exceeding 1 gram

Flushing

Headache

Dizziness

Sleepiness or insomnia

Adverse Reactions Urine acidification that may lead to crystalluria

Nursing

Responsibilities

Nursing Considerations

May give without regard to food.

Assess for clinical improvement (improved sense of well-being and sleep patterns).

Observe for reversal of deficiency symptoms (gingivitis, bleeding gums, poor wound healing, digestive difficulties, joint pain).

Patient Teachings

Abrupt vitamin C withdrawal may produce rebound deficiency.

Generic Name

25 % Albumin vial

Brand Name Commonly used brand name(s): Albuminar-25; Albuminar-5; Albutein 25%; Albutein 5%; Buminate 25%; Buminate 5%; Plasbumin-25; Plasbumin-5.

Classification

Ordered Dosage Route: IVTT

Dosage: 25% albumin vial

Dosage Frequency Transfuse in 4 hours

Mechanism of

Action

Blood volume expander—Albumin is an important regulator of the

volume of circulating blood. It accounts for 70 to 80% of the colloid

oncotic pressure of plasma. An infusion of albumin 5% is

oncotically equivalent to an equal volume of human plasma and

increases blood volume by an amount approximately equal to the

volume of albumin infused; albumin 25% is oncotically equivalent

to approximately 5 times the volume of human plasma and draws

into the circulation an amount of fluid approximately 3.5 times the

volume of albumin infused. Albumin provides a

temporary increase in blood volume, which reduces

hemoconcentration and blood viscosity.

IndicationsAlbumin (Human), Human Albumin Grifols® 25% is indicated:

a. For the prevention and treatment of hypovolemic shockb. in conjunction with exchange transfusion in the treatment of

neo-natal hyperbilirubinemiac. Concentrated Albumin (Human) solutions (e.g., 25%) have

also been used successfully to induce diuresis in some patients with acute nephrosis who were refractory to other forms of treatment. However, Albumin (Human) has no role in the management of chronic nephrosis.

d. More dilute Albumin (Human) solutions (e.g., 5%) have been used as pump priming fluids during cardiopulmonary bypass. However, an adequate blood volume can also be maintained during bypass with crystalloid as the only priming fluid without a significant difference in the clinical outcome achieved.

ContraindicationsContraindicated in patients with severe anemia or cardiac failure in the presence of normal or increased intravascular volume.The use of Human Albumin Grifols® 25% is contraindicated in patients with a history of allergic reactions to albumin.

Side effects and

Adverse ReactionsRare- Nausea, fever, chills, flushing, hives, skin rash, itching, headache, breathing difficulty, rapid heartbeat or allergic reactions may occasionally occur.Potentially Fatal : Anaphylactic shock.

Nursing

Responsibilities

1. Ensure right patient, ask the patient his name and check

the ID band.

2. Check the drug label before preparing the drug.

3. Check the latest doctor prescribed dosage and asks

somebody for clarifications about the dosage.

4. Check latest doctor prescribed dosage frequency.

Administer on time

5. This product is usually given in a hospital setting.

6. Inform patients being treated with Albumin (Human) 20%

about the potential risks and benefits with its use

7. Discontinue immediately if allergic symptoms occur (e.g.

skin rashes, hives, itching, breathing difficulties, coughing,

nausea, vomiting, fall in blood pressure, increased heart

rate).

8. Inform patients that Albumin (Human) 20% is a derivative of

human plasma and may contain infectious agents that

cause disease (e.g., viruses, and theoretically, CJD agent).

9. Inform patients that the risk that Albumin (Human) 20%

may transmit an infectious agent has been reduced by

screening plasma donors for prior exposure for certain

viruses, by testing the donated plasma for certain virus

infections and by inactivating and/or removing certain

viruses during manufacturing .

Nursing Theory Definition Rationale

1. Florence Nightingale

(Environmental theory)

She stated in her

nursing notes that

nursing "is an act of

utilizing the environment

of the patient to assist

him in his recovery"

(Nightingale

1860/1969), that it

involves the nurse's

initiative to configure

environmental settings

appropriate for the

gradual restoration of

the patient's health, and

that external factors

associated with the

patient's surroundings

affect life or biologic and

physiologic processes,

and his development.

Nurses should assist the

client during his/her recovery. If

ever they are not able to give him

the most ideal environment there

is, it is the nurse’s duty to give

him the comfort as part of our

care. Such ways include the good

sanitation where the client stays;

it includes cleaning the area

always, attending to her

immediate needs, and keeping

environment suitable for client’s

recovery.

2. Adaptation Model

(Callista Roy)

The major concepts are

the person or group as

an adaptive system; the

environment as internal

and external stimuli;

health as being and

becoming whole and

integrated; and nursing

The theory is applicable to the patient

since it is focused to the adaptation

ability of the patient that can greatly

affect the recovery of the patient. In the

patient’s condition, it is very important

that he’ll be able to have a fast recovery

because recovering would mean that the

patient will be able to go back to the

things that he used to do before his

admission and be able to continue on

as the art and science of

promoting adaptation.

The philosophic and

scientific assumptions

are basic underlying

concepts. The model

aims to direct nursing

practice, research and

education. The

widespread us of the

model in each of these

areas is well

documented, for

example, in all areas of

practice, all levels of

education, and in

quantitative and

qualitative research.

with his life. However, the patient has

already accepted his condition and is

slowly trying to live a normal life despite

of his condition.

3. Core, Care, Cure

Theory

(Lydia E. Hall)

Hall’s theory of

nursing involves three

interlocking circles, each

representing one aspect

of nursing. The care

aspect represents

intimate bodily care of

the patient. The core

aspect deals with the

innermost feelings and

motivations of the

patient. The cure aspect

tells how the nurse

helps the patient and

The patient cannot fully do the

things he usually does when he

still has both arms and somehow

needs the assistance of the

nurse. The support coming from

his family motivates him to

comply with the therapy. While

we nurses did our part by

providing him the care that he

needs including the therapeutic

communication, body language

that he deserves.

family through the

medical aspect of care.

The main tool the nurse

uses to help the patient

realize her or her

motivations and to grow

in self-awareness is that

of reflection.

DATE &

TIME

CUES NEED NURSING

DIAGNOSIS

OBJECTIVES OF

CARE

NURSING INTERVENTIONS EVALUATION

September

15,

2011

@

4:00 PM

SUBJECTIVE:

“sakitakoangsugatdi

risatiil”, as

verbalized by the

patient.

OBJECTIVE:

patient

complains of

pain at the

right thigh;

post skin

graft;

grimace face

noted;

guarding

behavior at

the site of

C

O

G

N

I

T

I

V

E

P

E

R

C

E

P

T

U

Pain related to post

surgical procedure

secondary to Skin

Grafting

®Pain is a subjective

state which varies on

how the client

perceives it as well as

on the client’s level of

pain threshold. Pain

is commonly

observed in client’s

who undergone

surgery since trauma

is being induce to the

client couple with

breakage in the

continuity of the

different levels of

That within our 2

hours span of care

our patient will be

relieve from pain as

evidenced by:

a. Pain scale will

be reduce from

moderate to mild

or absence of

pain;

Pain scale:

0 Absent:

1 to 3 Mild;

4 to 7 Moderate

7 to 10 Severe

b. Demonstrate

techniques that

can help to

1. Medicate patient with the

prescribed analgesics as ordered

such as Ketorolac and Tramadol;

evaluate and document patient’s

response through the pain scale.

®Drug administration of analgesics

will aid in relieving the pain, thus

decreasing the severity of the pain.

2. Perform comfort measures passive

range of motion of the hands and

the like.

®These measures reduce muscle

spasm, redistribute pressure on

body parts and help patient focus

on non-pain related subjects.

3. Plan activities with the patient to

provide distraction, such as

reading, talking, and other

September 15, 2011

@

6:00 pm

GOAL MET

After rendering different

sets appropriate,

comprehensive and

systematic nursing

interventions our client was

able to relieve from pain as

evidenced by:

a. pain scale of 1 out of 3

which signifies reduction

of pain intensity from

moderate to mild;

b. able to perform

pain;

motion is

done in a

slow manner;

Pain

Characteristic

s:

Severity: 4

Pain Scale

o Mild: 1

to 3

o Moder

ate: 4

to 6

o Sever

e: 7 to

10

Location:

Right thigh

Duration:

Continuous

A

L

P

A

T

T

E

R

N

body’s tissues. In due

to this existence our

body’s normal

reaction to this

situation is pain.

Bibliography:

Smeltzer,S.,Bare,B,.

et al Brunner and

Suddarths Textbook

of Medical Surgical

Nursing

Bare,B.,RN,MSN,

Cheever, K,

K, PhD, RN,

Hinkle, J.,

PhD, RN,

alleviate pain

such as deep

breathing

exercises.

distraction techniques.

®These heighten one’s

concentration upon non-painful

stimuli to decrease one’s

awareness and experience of pain.

4. Eliminate additional stressors or

sources of discomfort whenever

necessary or possible.

®Patient may experience an

exaggeration in pain or a

decreased ability to tolerate painful

stimuli if the environmental,

intrapersonal and intra-psychic

factors are further stressing them.

5. Teach the patient on relaxation

exercises, breathing exercises or

even music therapy.

®Techniques are used to bring

about a state of physical and

mental awareness and tranquility.

The goal of these techniques is to

relaxation techniques

such as deep breathing

exercises which helps in

alleviating pain.

Quality:

Burning

with

medication/s

of: Ketorolac;

and Tramadol

for pain.

reduce tension, subsequently

reducing pain.

6. Provide rest periods especially to

the client after performing those

activities which may aid in

alleviating the pain.

®This facilitates comfort, sleep and

relaxation. In a cyclic fashion,

feeling of pain may lead towards

the occurrence of fatigue and even

exhaustion, thus resting period is

very much essential.

7. Help the patient in a comfortable

position, and use pillows to splint or

support painful areas as

appropriate.

®This aid in reducing spasm at the

site of pain, preventing worsening

of painful stimulation and

experience.

8. Provide anticipatory instruction on

pain causes, appropriate prevention

and relief measures.

®Knowledge about what to expect

can help the patient develop

effective coping strategies for pain

management.

9. Instruct patient to report existence

or feeling of pain.

®Relief measures to be instituted

as early as possible.

10. Instruct the patient to evaluate and

even report effectiveness of

measures used.

®Pain relief strategies can be

modified, to promote more

satisfactory comfort levels.

DATE &

TIME

CUES NEED NURSING

DIAGNOSIS

OBJECTIVES OF

CARE

NURSING INTERVENTIONS EVALUATION

September

15,

2011

@

3:00

PM

S/O:

Hiding altered

body part with

the use of

clothing.

Refusal to talk

about the

altered body

part.

Changes in

social

behavior.

When asked

about his

amputated

S

E

L

F

P

E

R

C

E

P

T

I

O

N

Body Image

Disturbance related

to Permanent

Alterations in

structure and

function.

® Amputation is a

reconstructive

procedure that alters

the patient's body

image. The nurse

encourages the

patient to look at, feel

and care for the

altered body part.

Within our 8 hours

span of nursing care,

our patient will be able

to demonstrate

enhanced body image

as evidenced by:

Ability to look

at, touch and

talk about

the altered

body part.

Able to

enhance self

esteem.

1. Note sign of grieving/indicators of

severe or prolonged depression.

®To evaluate need for counseling

and/or medications.

2. Observe interaction of patient with

significant others.

®Distortion in body image may be

unconsciously reinforced by family

members.

3. Listen to patient’s comments and

responses to the situation.

®Different situations are upsetting

to different people, depending on

individual coping skills.

4. Note withdrawn behavior and the

September 15, 2011

@

11:00 pm

GOAL PARTIALLY MET

After our 8 hours span of

nursing care, our patient

was able to demonstrate

enhanced body image as

evidenced by:

Able to look at,

touch and talk about

the altered body

arm, he

avoids the

topic.

He would feel

irritated when

interviewed

about his

amputated

arm compared

to other

topics.

-

S

E

L

F

C

O

N

C

E

P

T

P

A

T

T

E

The loss of an

extremity may come

as a shock even if the

patient was prepared

preoperatively. The

patient's behavior

and expressed

feelings reveal how

the patient is coping

with the loss and

working through the

grieving process.

the patient who is

accepted as a whole

person is more

readily able to

resume responsibility

for self care, self

concept improves

and body image

changes as accepted.

Bibliography:

Verbalize

understandin

g of body

changes.

use of denial.

®may be normal response to

situation or may be indicative of

mental illness.

5. Visit patient frequently and

acknowledge the individual as

someone who is worthwhile.

®Provides opportunities for

listening to concerns and

questions.

6. Assist in correcting underlying

problems.

®To promote optimal

healing/adaptation.

7. Encourage verbalization of and role

– play anticipated conflicts.

®To enhance handling of potential

situations.

8. Set limits on maladaptive behavior

and assist patient to identify

positive behaviors.

part.

Able to enhanced

self esteem.

Patient was not able

to verbalized

understanding of

body changes.

R

N

Brunner &Suddarth’s

Textbook of Medical

– Surgical Nursing

11th edition

®To aid in recovery.

9. Help patient to select and use of

clothing.

®To minimize body changes and

enhance appearance.

10. Provide information at patient’s

level of acceptance.

®To allow for easier assimilation.

DATE &

TIME

CUES NEED NURSING

DIAGNOSIS

OBJECTIVES OF

CARE

NURSING INTERVENTIONS EVALUATION

September

17,

2011

@

3:00

PM

SUBJECTIVE:

“Katolakoangsugat”

as verbalized by

the patient.

OBJECTIVE:

Open wound

Not covered

with dressing

Redness,

Swelling and

purulent

discharges

noted.

N

U

T

R

I

T

I

O

N

A

L

M

E

T

A

B

O

L

I

C

P

A

T

T

E

R

N

Impaired Skin

Integrity related to

humidity and

moisture secondary

to STSG

®The integument

acts as a

protective barrier

from

environmental

insults including

trauma, radiation,

harsh

environmental

conditions and

infection. 

Bibliography:

Brunner'sand

Suddarth's

Textbook of

Medical-Surgical

Nursing(2008)

.

Within our 5 hours

span of care the

patient will be able to

improve skin integrity

as evidenced by:

a. Demonstrate

behaviors to

promote healing

and prevent

complication.

b. Absence of

discharges in the

wound.

c. Cope with the

activities of daily

living.

1. Discuss Importance of

adequate nutrition especially,

Increase intake of fluids,

proteins and vitamins.

®These provide patient

information how nutrition

could elevate his chances of

a faster recovery and wound

healing.

2. Instruct not to scratch the

wound.

®This provides patient a

guide towards a proper skin

management technique

minimizing more skin trauma.

3. Emphasize principles of

asepsis especially hand

washing.

®To avoid possible infection

thus hindering the wound

healing process

4. Demonstrate wound care

technique such as wound

cleansing and dressing

changing.

®To provide the patient on

the correct procedures and

techniques of wound caring.

5. Reinforce initial dressing/

September 17, 2011

@

8:00 PM

GOAL PARTIALLY MET

At the end of 5 hours span of

care the patient was able to

improve skin integrity as

evidenced by:

a. Demonstrated

behavior to promote

healing and prevent

complications such not

touching the wound.

b. There were minimal

discharges noted.

c. Able to cope with ADL.

DATE &

TIME

CUES NEED NURSING

DIAGNOSIS

OBJECTIVES OF

CARE

NURSING INTERVENTIONS EVALUATION

September

16,

2011

@

S/O:

Open

wound at

right leg.

H

E

A

L

Risk for infection

related to surgical

procedure secondary

to Fore Quarter

Amputation

Within our 5 hours

span of nursing care,

my patient will be free

from infection as

evidence by:

1. Administer antibiotics such as

Cefazolin as ordered.

®To kill microorganisms that

may predispose infection.

September 16,

2011

@

8:00 pm

3:00

PM

WBC of

23.67

Redness,

swelling

and

purulent

discharge

s at

incision.

Meds:

Cefazolin

T

H

P

E

R

C

E

P

T

I

O

N

-

H

E

A

L

T

H

® Surgery

traumatizes the body

by disrupting

protective

mechanisms and

homeostasis.

Bibliography:

Brunner &Suddarth’s

Textbook of Medical

– Surgical Nursing

11th edition

Verbalize

interventions

that may

prevent

infection.

Absences of

redness,

swelling and

purulent

discharges at

post-op site.

2. Wash hands before and after

handling the client.

®To deter the spread of

microorganism.

3. Wear gloves when handling

patient.

®Using gloves does not just

protect the health worker but

also prevent contamination to

the wound.

4. Monitor the wound for redness,

swelling, pain, discharges and

heat.

®This may signify that an active

inflammatory response to local

area is present

5. Clean and dry surrounding

tissue of lesion.

®Adjacent areas that are

unclean may potentiate skin

breakdown.

GOAL MET

After our 5 hours

span of nursing

care, our patient

was free from

infection as

evidenced by:

Verbaliz

ed:

“walanankog

inagunitanak

oangsugatug

nagahugasn

apudkougka

mot.”

Absenc

e of

redness

,

swelling

M

A

N

A

G

E

M

E

N

T

P

A

T

T

E

R

N

6. Replace soiled linens in contact

with lesions

®Soiled linens are good medium

for microbial growth

7. Instruct to avoid scratching the

healing lesions

®Healing wound is usually itchy.

8. Avoid unnecessary contact with

the lesion

®It decreases the potentiality of

acquiring infection

9. Monitor vital signs

®Increase in vital signs,

especially temperature may

indicate inflammatory response.

10. Provide/encourage balanced

diet, emphasizing proteins to

feed the immune system.

®Immune function is affected by

protein intake, the balance

between omega-6 and omega-3

and

dischar

ges at

post-op

site.

fatty acid intake, and adequate

amounts of vitamins A, C, and E

and the minerals zinc and iron. A

deficiency of these nutrients

puts the client at an increased

risk of infection.

11. Review individual nutritional

needs, appropriate exercise

program, and need for rest.

®Enhance immune system

function and healing.

DATE &

TIME

CUES NEED NURSING

DIAGNOSIS

OBJECTIVES OF

CARE

NURSING INTERVENTIONS EVALUATION

September

17,

2011

@

4:00

PM

SUBJECTIVE:

“Ayawgunitiangako

angsugatkaybasig”

As verbalized by

patient.

OBJECTIVE:

presence of

wound at

right thigh

appears

worried

guarding

behavior

S

E

L

F

-

P

E

R

C

E

P

T

I

O

N

S

E

L

F

-

C

O

N

C

E

P

T

P

A

Fear related to

physical threat

secondary surgical

procedure (Skin

Grafting)

® Fear is a strong

and unpleasant

emotion caused by

the awareness or

anticipation of pain,

or danger. The

factors that

precipitate fear are

fear of pain; bodily

injury and surgical

complication are

common to most

people.

Bibliography:

Lewis,S.et al

(2007)Medical-

Surgical Nursing:

Assessmentand

Management of

Clinical Problem

Within our 2 hours span

of nursing care, patient

will be able to manifest

a reduction or absence

of fear as evidence by:

demonstrate

understanding

through use

of effective

coping

behaviors and

resources

and;

Appear relax.

1. Determine what the patient is

fearful of by careful and thoughtful

questioning.

® The external sources of fear can

be identified and current responses

can be assessed.

2. Determine the degree of fear and

the measures the patient uses to

cope with fear.

® This helps determine the

effectiveness of coping strategies

used by patient.

3. Reinforce the idea that fear is a

normal and appropriate response to

situations when pain, danger, or

loss of control is anticipated or

experienced.

® Knowledge serves to reduce

unrealistic expectations.

4. Assist the patient in identifying

strategies used in the past to deal

with fearful situations. These

measures may be helpful or

comforting.

® This helps the patient to focus on

fear as a real and natural part of life

that has been and can continue to

be dealt with successfully.

5. Discuss resumption of activity.

September 17,

2011

@

6:00 pm

GOAL MET

Within our 2

hours span of

nursing care,

patient was able

to manifest a

reduction of fear

as evidenced by:

a. Demonstrated

understanding

through the

use of

effective

coping

behavior

(relaxation

exercises)

b. appeared

relax;

DISCHARGE PLAN

Medications

Instruct patient to continue taking Ranitidine H2 inhibitor and Celecoxib an

NSAIDs drug

Inform client to take her medications on time, or as directed for the full course

of therapy.

Educate the patient about the side effects of Ranitidine such as; diarrhea,

headache, nausea, dizziness and constipation, Celecoxib such as;headache

and sore throat.

Instruct patient and significant others not to stop taking the prescribed

medications for the full course of therapy even if the patient already feels better

or unless being approved by the patient’s attending physician.

Instruct patient to check the labels of medicines before taking it.

Exercise

Explain to client the value of exercise in our body like active ROM.

Encourage the patient to have adequate rest and sleep.

Instruct the patient that exercises performed should be within normal limits.

Treatment

Instruct the client to continue drug therapy as ordered.

Discuss to the client the complications of her sickness.

Instruct the patient to report to the physician promptly any changes on health

condition. Such as allergic reactions, high blood pressure or all of the

unusualities that may happen to her.

Health Teachings

Instruct the patient to do daily hygiene and grooming, which includes daily body

bath and hand washing.

Teach the patient and family how to promote healthy lifestyle like regular

exercises and having adequate resting periods.

Educate the family about the importance of maintaining the cleanliness of their

surrounding environment.

Inform the family of the patient about his condition and the necessary information

for his treatment.

Advice the patient to avoid strenuous activities until full recovery is achieved.

Instruct patient’s significant others to provide emotional and social support to the

patient.

Teach patient how to do proper wound dressing.

Follow up check-up after a week.

Instruct patient the frequency of taking medications.

Outpatient Orders

Instruct patient and significant others to have follow-up check-up.

Encourage patient and significant other to notify the physician immediately if any

unusalities in the health status have occurred.

Encourage the patient to comply with all the regimen and instructions given to him.

Continue medication as ordered.

Diet

Inform the patient and significant others the importance of following a healthy diet

such as avoid drinking too much alcohol, low fatty foods, salty foods and increase

iron intake such as ampalaya, raisins and liver.

Instruct patient to increase oral fluid intake.

Instruct patient to minimize intake of goitrogenic foods such radish, and other

green leafy vegetables.

Spirituality

Encourage the patient to understand her situation whatever may happen .

Advice the patient to keep on praying and never lose hope if any negative results

will arise.

Sexuality

Advice the patient and significant other to refrain from doing sexual intercourse

for the first few weeks of post surgery.

PROGNOSIS

GOOD FAIR POOR JUSTIFICATION

Onset of the

illness

√ The onset of the illness was gradual as the

presence of mass on his right arm lasted for

3months. In terms of management, He was able to

consult his doctor about it and respond to

medications and surgery therefore had no delay

on proper medical consultation

Duration of illness √ For the past 3months the patient ignored his mass

on the right arm and did respond to treatment.

However, when he noticed that the mass is

beginning to grow larger and he has difficulty in

moving his arm because of it, he decided to

consult a doctor and undergoes a surgery.

Precipitating

factors

√ Lifestyle and diet, because the patient is lack of

nutrients and the patient is in low class. And he’s

living in the farm which is far from the city proper.

Willingness to take

medications and

treatment

√ The patient is willing to take proper treatments

accordingly since the surgery. They can afford the

medicines and treatment needed for the

improvement of her condition.

Age √ Age do have a direct effect in the condition

itself.However, the prevalence of

rhabdomyosarcomamost common in children ages

one to five, and is also found in teens aged 15 to

19. According to statistics, by 3% of all childhood

cancers are rhabdomyosarcomas.The patient is

14 years old.

Environmental

factors

√ He is living in a farm where He defines well. That

farm is far from the city proper. However there’s a

barangay health center near it, and far from

hospital but the patient chose to admit herself at

SPMC in Davao.

Family Support √ The patient’s family is very supportive throughout

the treatment regimen of the patient.He is also

frequently visited by his relatives to look out for his

condition.

Total 2 2 3

Computation:

Poor: (2*3)/7 = 0.86

Fair: (3*2)/7 = 6/7 = 0.86

Good: (3*2)/7 = 6/7 = 0.86

Total: 2.58

General Prognosis:

1-1.6 = POOR

1.7-2.3 = FAIR

2.4-3.0 = GOOD

General Prognosis:

As shown by the calculated results with their respective

points, the general prognosis of the client is GOOD. The

patient has a good chance of recovering from his condition

of having a rhabdomyosarcoma because of his age,

presence of only two precipitating factors, compliance to

some treatment regiment, and family support. Most

rhabdomyosarcomaoccurs at the age 15 to 19. They are

usually found by patients who feel a lump at their

arms,legs, and jaws or after undergoing a physical

examination. It is easily treated through surgery. As of now

the patient has improved in terms of his health as

evidenced by amputation

RECOMMENDATION

To the Patient

She must be wary of abnormalities that are developing in her body like in the event when she observed that there was a mongo sized growth in her neck then she must have sought a medical advice. She should be wearing protective equipment when handling hazardous substances and be fearful of the consequences of not doing so for this is one of the suspected factors that made her sick. The patient must realize that her condition is uncommon.

Hypocalcaemia must not be experienced by the client by taking calcium supplements as prescribed by the doctor. She can monitor apical pulse, blood pressure, & temperature at least every 4 hours. She must report palpitations, dyspnea, vertigo, or chest pain. She can keep her environment quiet & cool, change bed linens, & bath frequently.

She can elevate the head at night & use an eye lubricant. If photophobia is present, dark glasses or eye patches can be worn. If she cannot close the eyelids completely, she can tape the lids close with nonallergenic tape. If pressure behind the eye continues, she can undergo a doctor prescribed steroid therapy. She can take doctor prescribed diuretics to decrease edema around the eye.

The client must report if there is an increase or recurrence of symptoms. She must have a regular follow-up. The client must inspect the incision area and report if there is redness, tenderness, drainage, and swelling to a member of a healthcare team. She can expect mood changes as a result of hyperthyroidism.

To the pt.’s family

Her family must encourage her to visit a physician & support her financially. They can try to hide their financial incapability to avoid discouraging her from undergoing a treatment and warn her of the larger cost of treating a severe disease.

The family must be suspicious of recent weight loss & an increased appetite. The most important thing for them to watch out for is pt. diaphoresis even when the environmental temperature is comfortable for them.

To the Community

The community must promote a positive atmosphere despite of the advanced stage of the disease. They must contain the backing out from the treatment thoughts of the patient’s mind. Her surrender in the treatment program must be related by them to her as an avenue for the worsening of her condition. They must let her realize that her condition is uncommon but controllable. They must give employment that is healthy in order for the people to have lesser chances of working in environment with toxic chemicals.

REFERENCES

I. BOOKb. Ignativicius, Donna D., & Workman, M. Linda. (2002). Medical-Surgical

Nursing, Critical Thinking for Collaborative Care (pp.1422-1430). W.B. Saunders Company.

c. Hannon, Ruth A., Pooler, Charlotte., Porth, Carol Mattson., & Matfin, Glenn. (2010). Porth Pathophysiology, Concepts of Altered Health States (pp. 994-995). Wolters Kluwer Health | Lippincott Williams & Wilkins.

d. Nursing Care Plans: Nursing Diagnosis and Intervention 3rd Edition.By: Meg Gulanick, PhD, RN Audrey Klopp, PhD, RN, ET Susan Galanes, BS, RN Michelle Knoll Puzas, MHPE, RN, C.

e. Nurse’s Pocket Guide: Diagnoses, Interventions and Rationales: 8th

edition By: Marilynn E. Doenges Mary Frances Moorehouse Alice C. Geissler-Murr.

f. MOSBY’S POCKET DICTIONARY of Medicine, Nursing & Health Professions, 6th edition.2010

g. Tamparo, Carol. Diseases of The Human Body. (2005) Davis Company. ISBN: 0-8036-1245-1.

h. Daniels, R., Nosek, L., Nicoll, L. Contemporary Medical Surgical Nursing. 2007. p. 1780. USA: Thomas Delmar Learning.

i. Late, P. (2009). Seeley’s Principle of Anatomy and Physiology. (p. 616). McGraw Hill; New York, NY 10020

j. Smeltzer, Suzanne C., Bare, Brenda G., Hinkle, Janice L., Cheever, Kerry H. 2008. Brunner and studdarth’s textbook of medical surgical nursing. Lippincott Williams and Wilkins: 530 Walnut Street, Philadelphia, USA.

k. Crowley, Leonard V. An Introduction to Human Disease, 7 th Edition. 2007. p. 276. USA: Jones and Bartlett Publishers Inc.

l. Anatomy & Physiology. Patton, & Thibodeau.m. Scanlon, Valerie., & Sanders, Tina. (2007). Essentials of Anatomy &

Physiology 5th Edition. F.A. Davis Company.n. Marieb, Elaine N.. (2006). Essentials of Human Anatomy & Physiology 8th

Edition. Pearson Education South Asia Pte Ltd.

II. ELECTRONIC a. http://www.nlm.nih.gov/medlineplus/ency/article/007265.htmb. http://www.healthypinoy.com/health/articles/thyroid-nodules.htmlc. http://www.endocrineweb.com/conditions/thyroid/thyroid-nodulesd. http://www.endocrineweb.com/conditions/thyroid/thyroid-operations. Date

Retrieved: 21 Aug. 2011.e. http://www.4squarehealthcare.co.uk/ekmps/shops/4squarehealth/images/

safil-absorbable-sutures-1-2-circle-reverse-curve-cutting-21mm-needle-667-p%5Bekm%5D210x140%5Bekm%5D.jpg. Date Retrieved: 21 Aug. 2011.

f. http://www.apscan.com.au/Vet/surgical/Sutures/Monosyn.jpg. Date Retrieved: 21 Aug. 2011.

g. http://www.4squarehealthcare.co.uk/ekmps/shops/4squarehealth/images/safil-quick-sutures-1-2-circle-reverse-cutting-19mm-needle-678-p%5Bekm%5D210x140%5Bekm%5D.jpg. Date Retrieved: 21 Aug. 2011.

h. http://img.alibaba.com/wsphoto/v0/321168890/Free_Shipping_Air_Filter_Paper_Sponge_OS_87217.jpg_200x200.jpg. Date Retrieved: 21 Aug. 2011.

i. http://t3.gstatic.com/images?q=tbn:ANd9GcR-ZbdnJ7CeUt4ocF-fctZQqaunNqMb8dego9cdfX_LfADxm0VR. Date Retrieved: 21 Aug. 2011.

j. http://www.americansurgical.com/images/peanut-kittner.jpg. Date Retrieved: 21 Aug. 2011.

k. http://www.wireless-electronicspecifier.com/public/primages/pr26715a1.jpg. Date Retrieved: 21 Aug. 2011.

l. http://www.reliancemedical.co.uk/images/Products_large/Scissors.jpg. Date Retrieved: 21 Aug. 2011.

m. http://t1.gstatic.com/images?q=tbn:ANd9GcRV-_BBf6Xw9kjHEJMXRuXhMR7TAXp54JwWVvtI5YnTBPVzs9RT7Q. Date Retrieved: 21 Aug. 2011.

n. http://i01.i.aliimg.com/photo/v0/237188803/surgical_lap_sponge.jpg. Date Retrieved: 21 Aug. 2011.

o. http://t0.gstatic.com/images?q=tbn:ANd9GcQKBSFvR-mtngIuphOs-3ssB7CF_DcFpEcR8uk4_1C3YWGN99dz. Date Retrieved: 21 Aug. 2011.

p. http://www.nightscribe.com/Medical/reqd_thyroid_instruments.htm. Date Retrieved: 21 Aug. 2011.

q. http://static.patsnap.com/patent/image/small/US5059214&w=120. Date Retrieved: 21 Aug. 2011.

r. http://t3.gstatic.com/images?q=tbn:ANd9GcR_IOL6f0mWhyXBOfwvbqhCErswI2v4YuQQT317ekli0btou-aIOQ. Date Retrieved: 21 Aug. 2011.

s. http://server.selltec.com/go/diener/_ws/mediabase/_ts_1258871633000/generated/products/id/100x400/04-1390.17_l.jpg. Date Retrieved: 21 Aug. 2011.

t. http://t0.gstatic.com/images?q=tbn:ANd9GcQuIW0I0hJxBmJNqKS76hT5E1qHCMrMSyfUxJNmNjez8vh3Q3XJjQ. Date Retrieved: 21 Aug. 2011.

u. http://t2.gstatic.com/images?q=tbn:ANd9GcSts6m85_DMnB5uyDaj-p5ToLvKGtsbaczT7okK0xv7NMxHUlCi. Date Retrieved: 21 Aug. 2011.

v. http://t0.gstatic.com/images?q=tbn:ANd9GcThrM0DzlRTLstLNw1x5dSYPnlmYuzx6dTzuM3El96Mb8gmfi840w. Date Retrieved: 21 Aug. 2011.

w. http://t0.gstatic.com/images?q=tbn:ANd9GcQXjqCh-mv95okhA9KkwNJcGfCLk-eaYVaaFjoiQ3SdCHs15K8JFw. Date Retrieved: 21 Aug. 2011.

x. http://t3.gstatic.com/images?q=tbn:ANd9GcTsX-OpGnCdNfbKR6BqcU-k9_x81sCvJS4JiO-PL_lLUmsSb9HpjA. Date Retrieved: 21 Aug. 2011.

y. http://t2.gstatic.com/images?q=tbn:ANd9GcTHmmqCaoEh_3VVyjnQQ-Bkwvr0_6kyX63PMEO4e10Itgvy15I6. Date Retrieved: 21 Aug. 2011.

z. http://t1.gstatic.com/images?q=tbn:ANd9GcSKz7KNQy7cP7siHKVRnzjdTptDiIJEe6do7VcQz181OdjxUVEoBA. Date Retrieved: 21 Aug. 2011.

aa.http://t0.gstatic.com/images?q=tbn:ANd9GcSrVtkheEdF9qpQqiPEU67bzdCfYSCLuGtskv-WzktesWUxxCKy. Date Retrieved: 21 Aug. 2011.

bb.http://t0.gstatic.com/images?q=tbn:ANd9GcRxfTWxWQ-h4b-aoihfYmfOuAG7ytLIYhJELPeBLgvbo0HgBm59. Date Retrieved: 21 Aug. 2011.

cc. http://t0.gstatic.com/images?q=tbn:ANd9GcTU1UoepvH5IlBHF8ZaclhyJGGgMikfuhKVpFvG-g8ixj3k7hvs. Date Retrieved: 21 Aug. 2011.

dd.http://t2.gstatic.com/images?q=tbn:ANd9GcSzHVou49A8nqMQS3yjdyEFNKD5x7yLSudXG9GWr2XyOeOmy03m4g. Date Retrieved: 21 Aug. 2011.

ee.http://t0.gstatic.com/images?q=tbn:ANd9GcRxEh7vrgkAgoU7JoPTEzl_biAwJ3lSgI2WoUhHaFIhBRDX1NUy. Date Retrieved: 21 Aug. 2011.

ff. http://www.ellman.com/images/products/rf_suction_adenoid_probes.jpg. Date Retrieved: 21 Aug. 2011.

gg.http://t1.gstatic.com/images?q=tbn:ANd9GcSC2TMNxdZLWlXp82-xPcHQ0gpFAhg1eYdxV0_2_2Vd5IgvC0kz1A. Date Retrieved: 21 Aug. 2011.

hh.http://www.mpmmedicalsupply.com/media/catalog/product/cache/1/image/5e06319eda06f020e43594a9c230972d/r/i/richardson-east_lg.gif. Date Retrieved: 21 Aug. 2011.

ii. http://www.hnmmedical.com/media/catalog/product/cache/1/image/9df78eab33525d08d6e5fb8d27136e95/u/n/untitled-13_11.jpg. Date Retrieved: 21 Aug. 2011.

jj. http://t0.gstatic.com/images?q=tbn:ANd9GcQ3wktngUhyk59FdZHfSS-A9tDbzp9oGZL71xBNF7-znn9wJQew0g. Date Retrieved: 21 Aug. 2011.

kk. http://t2.gstatic.com/images?q=tbn:ANd9GcRRSHp6Tyl8hgCUjJQfx7j8mIeMTpVFQZu5Cj7wcFVYTVz6TgzkrA. Date Retrieved: 21 Aug. 2011.

ll. http://t1.gstatic.com/images?q=tbn:ANd9GcQ2wdpX5UgwUgEwMAZdP3OctYtn-ocDP29xF6NFJ3lq2z7vc401. Date Retrieved: 21 Aug. 2011.

mm. http://t1.gstatic.com/images?q=tbn:ANd9GcR8AHXPJMyJWPpP8RBaWBjpjtvDcWPQIcP9grMrstkuY2B2YKG1. Date Retrieved: 21 Aug. 2011.

nn.http://t3.gstatic.com/images?q=tbn:ANd9GcSUs4L9YrFWWSZOPGioBLRUqKhVT-v7nFtQRfaF7jU7GH7rvKvFzw. Date Retrieved: 21 Aug. 2011.

oo.http://t0.gstatic.com/images?q=tbn:ANd9GcRFP4qQCUp7DQ0F1SzaO4BCQzq-Y0n7HCQIKiCv7vmT2cQPSpRM. Date Retrieved: 21 Aug. 2011.

pp.http://t3.gstatic.com/images?q=tbn:ANd9GcRndWjfzx0Js44blQHcVHEcH5Cd2hG-QYjZqK5T-bjtLoBt81Qb. Date Retrieved: 21 Aug. 2011.

qq.http://www.bbs-int.com/surg1-1/786-51.jpg. Date Retrieved: 21 Aug. 2011.rr. http://t0.gstatic.com/images?q=tbn:ANd9GcSuBONJV_xrlC8XH-

Ic58qtdHfxNopqlQbJ0KTRkj5NEfIRZlUw. Date Retrieved: 21 Aug. 2011.ss. http://t0.gstatic.com/images?q=tbn:ANd9GcR4HZqZaJfoXoi1NBaUKIyK-

wa7-aYz6_bkmF-HXbG1yslryGSi. Date Retrieved: 21 Aug. 2011.tt. http://cdn.shopmedvet.com/images/uploads/14448_14668_thumb.jpg.

Date Retrieved: 21 Aug. 2011.uu.http://t2.gstatic.com/images?

q=tbn:ANd9GcR4ObG9XtYCJnkEeimnjE4YtqyyKjvB3tyGqqJN9SXvDPL5TKEn. Date Retrieved: 21 Aug. 2011.

Table of Contents

I. Acknowledgement 01

II. Introduction 02

III. Objectives 04

IV. Patient’s Data 07

V. Genogram 09

VI. Family Background / Health History 10

VII. Developmental Data 14

VIII. Physical Assessment 22

IX. Definition of Complete Diagnosis 26

X. Anatomy and Physiology 31

XI. Etiology 39

XII. Symptomatology 41

XIII. Pathophysiology 43

XIV. Doctors Order 46

XV. Diagnostic Exam 54

XVI. Drug Study 77

XVII. Nursing Theories 101

XVIII. Nursing Care Plan 103

XIX. Prognosis 125

XX. Discharge Plan 128

XXI. Recommendation 131

XXII. Reference 133