You are on page 1of 31

I.

Introduction

Brief Description of the Disease Condition The body is made up of many types of cells. Normally, cells grow, divide and die. Sometimes, cells mutate (change) and begin to grow and divide more quickly than normal cells. Rather than dying, these abnormal cells clump together to form tumors. If these tumors are malignant (cancerous), they can invade and kill your body's healthy tissues. From these tumors, cancer cells can metastasize (spread) and form new tumors in other parts of the body. By contrast, benign (noncancerous) tumors do not spread to other parts of the body. Nasopharyngeal (say: "nay-zo-fair-in-gee-al") cancer is a malignant tumor that develops in the nasopharynx (say: "nay-zo-fair-inks"). The nasopharynx is the area where the back part of your nose opens into your upper throat. This is also where tubes from your ears open into your throat. Nasopharyngeal cancer is rare. It most often affects people who are between 30 and 50 years of age. Men are more likely to have nasopharyngeal cancer than women. You are most likely to get this cancer if you or your ancestors came from southern China, particularly Canton (now called Guangzhou) or Hong Kong. You are also more likely to get this cancer if you are from a country in Southeast Asia, like Laos, Vietnam, Cambodia or Thailand. No one knows for sure what causes nasopharyngeal cancer. Eating salt-preserved foods (like fish, eggs, leafy vegetables and roots) during early childhood may increase the risk of getting this form of cancer. The EpsteinBarr virus may also make a person more likely to get nasopharyngeal cancer. This is the same virus that causes infectious mononucleosis (also called "mono"). You may also inherit a tendency to get nasopharyngeal cancer. Reason for Choosing the Case Nasopharyngeal Cancer is one of the unusual terms for a lay person and a rare case that a nurse would encounter. Acquisition of cognitive knowledge regarding the topic would enable the researchers in providing optimum care for clients suffering such and in delivering appropriate interventions that would promote health and wellness for the client.

1

Statistics (Global and Local) Cancer of the nasopharynx is a rare neoplasm in most countries. However, it occurs at high frequencies in China and Southeast Asia. The highest incidence rates in the SEER regions occur among the Chinese. Rates are also high in Vietnamese and Filipino men, two groups that include persons of Chinese heritage. Incidence rates of nasopharyngeal cancer are also available for black, Hispanic and white men and for white women in the SEER areas. There were too few nasopharyngeal cancers diagnosed between 1988 and 1992 in the other racial/ethnic groups to provide meaningful incidence rates. The average annual age-adjusted incidence rate of nasopharyngeal cancer in Chinese men, 10.8 per 100,000, is 1.4 times greater than that of Vietnamese men and nearly 2.8 times greater than that of Filipino men. In fact, the rate among Filipino men, although relatively high, is the same as that for Chinese women. Rates of one per 100,000 and lower occur in black men, Hispanic and non-Hispanic white men and non-Hispanic white women. The United States mortality rates for cancer of the nasopharynx reflect patterns similar to those for SEER incidence rates. Mortality is highest in Chinese, lower in Filipinos and lowest among blacks, Hispanics and non-Hispanic whites. No mortality rates are currently available for Vietnamese. Incidence-to-mortality rate ratios vary, with Chinese and Filipinos having higher incidence relative to mortality (2.3 for men in both groups and 3.2 for Chinese women) than other groups (ranging from about 1.7 for white Hispanic men to two for non-Hispanic white men). Incidence and mortality rates for nasopharyngeal cancer increase through the oldest age group, although the small number of cases precluded the calculation of reliable rates for many populations. The major modifiable risk factor identified for cancer of the nasopharynx is the consumption of Cantonese salted fish, which is a common food item eaten from early infancy onward by groups with high risk of this disease. Other possible risk factors include extensive exposures to dusts and smoke and regular consumption of other fermented foods. The role of Epstein-Barr virus in the development of nasopharyngeal cancer continues to be explored.

2

Nurse-centered Objectives: The group aims: • • • • to have a better understanding about the causes of nasopharyngeal cancer. to determine the medical and surgical treatment that has given to the disease entity. to perform well our role as student nurses in the treatment and achieving the optimum level of health of the patient. to enhance our nursing skills most importantly focusing on promotive and preventive nursing measures.

3

II.

Nursing Assessment

Personal Data Mr. Split, 74 years old, married and a father of 7 children. Offspring of Mr. and Mrs. Choco Split, he was born on December 31, 1934 in Angeles Pampanga, and at this point in time, he resides in Timog Park, Angeles. He is a Filipino-born citizen. He was admitted last September 18, 2008 in Angeles Medical Center (AMC). Mr. Split is a jeepney operator and he is the sole provider for their means of living. His children, mostly married, some are presently unemployed and contribute to the burden on financial matters to the family of orientation. Mr. Split has a lifestyle of eating food that should or not allowed to him such as foods that are high amounts in sugar and low density cholesterol. Besides that Mr. Split is also attached to cigarette smoking. He also worked as a painter of houses for living for the past 20 years. History of Past Illness Mr. Split’s last check-up was done 3 years ago and was diagnosed to have nasopharyngeal cancer. Prior to this, he has also been diagnosed to have Diabetes Mellitus Type 1 and Pulmonary Tuberculosis. According to his daughter, his first admission in the hospital was September 18, 2008. History of Present Illness One (1) month PTA, Mr. Split experienced difficulty of breathing, and anorexia lasting for 1 week. A week PTA, he still experienced difficulty of breathing, and anorexia associated plus muscle weakness with easy fatigability but still he did not seek medical attention. A day PTA, he still experienced the same signs but this time he decided to seek medical attention.

4

Family Health Illness History

Mr. Split Legend: = Male = Female = Diabetes Mellitus = Cancer = Tuberculosis = Deceased

5

III.Physical Examination
Angeles Medical Center (AMC) (September 18, 2008) Upon admission: • (+) body weakness accompanied by difficulty of breathing and anorexia.

Physical Examination: • Drowsy, coherent, afebrile, in respiratory distress, pale palpable conjunctiva, (+) irregular mass on nasal area, (+) rales, no murmur, normal abdominal bowel sounds, pale nail bed, weak pulses. 1st Assessment (September 20, 2008) General Appearance: Received pt in a fowler’s position with contraptions. Pt is with body odor and with minimal foul breath odor. Pt’s speech is slightly incomprehensive. Vital Signs: T: 36.4 °C PR: 87 bpm Physical Assessment: Integument • • • • • Head • • Hair generally white Presence of patches of hair loss 6 Noted dryness Presence of tattoo in the right arm Poor skin turgor Capillary refill test: delayed return in pink color (3 seconds) Presence of scars on the lower extremities RR: 29 cpm BP: 120/80 mmHg

• Eyes • • • • Ears • • • • • • • • • • • • • • • •

Noted thinning of eyebrows

Pale palpebral conjuctiva Anicteric sclera Unable to read newsprint within reading distance Reactive to light accomodation

Symmetrical Presence of cerumen

Nose and Sinuses Presence of neoplasm

Mouth and Throat Gums grayish in color Presence of halitosis 2 sets of teeth left on frontal portion of the mandible Brown discoloration of the enamel of the teeth Noted difficulty in uttering words Presence of cough

Breast and Axillae Absence of discharge Absence of signs of edema

Respiratory/Chest Chest is symmetric Presence of tachypnea Presence of chest pain

Gastrointestinal/Abdomen Flat contour of the abdomen Liver is non-palpable 7

Urinary • • Pt in foley catheter Urine light yellow in color

8

IV.Diagnostic and Laboratory Procedures
Procedures done to the Client
Diagnostic/ Laboratory Procedures Blood Chemistry Date Ordered/ Date Result(s) Released 09/18/08 Indication(s)/ Purposes(s) To assess a wide range of conditions and the function of organs. Often, blood tests check electrolytes, the minerals that help keep the body's fluid levels in balance, and are necessary to help the muscles, heart, and other organs work properly. To assess kidney function and blood sugar, blood tests measure other substances. Result(s) Hct > 32.7 Platelet Count > 759 Hgb (Hemoglobin)>9.5 WBC (White Blood Cells)>27.9 Lymhocytes > 10 Granulocytes > 90% Normal Values (units used in the hospital) @m: 40.0 – 54.0 @m: 140 - 440 @m: 14 – 18 g/dl @m: 4.3 – 10.0 x 1/l @m: 28.0 – 48.0 @m: 44.2 – 80.2(x 10/1) Analysis and interpretation of results Hematocrit level as shown are below the standard values. Platelet count is above the average level. Hemoglobin level is lower than the established normal values. White blood cells are higher than the usual amount. Lymphocytes are below the average levels. Granulocytes are beyond the normal values.

Glucose (FBS) > 138.6 BUN > 13.72 Creatinine > 0.78 Potassium > 3.6 Sodium > 143

@76 - 111 mg/dl @7 - 21 mg/dl @0.5 - 1.69 mg/dl @3.5 - 5.0 @136 - 145 mmo/L

09/19/08

Glucose levels in the patient’s body are within normal values. Results show that BUN is at average levels. Result shows that creatinine are at normal values. Potassium is at the normal values. Result shows that sodium levels are within regular values.

Nursing responsibilities: 9

• • • • •

inform patient on the procedure to be done. Explain the details on what and how the procedure is going to be administered. let client sign a waiver or a consent before starting the procedure. provide the best possible nursing care for the patient who is to undergo a procedure. inform patient that the test would be done for the better of the patient’s condition. inform the patient with the results of the procedure done, explain the implications of each result, client has the right to know.

Diagnostic/ Laboratory Procedures Chest X-ray

Indication(s)/ Purposes(s) Commonly used to detect abnormalities in the lungs, but can also detect abnormalities in the heart, aorta, and the bones of the thoracic area. Metallic objects, such as jewelry are removed from the chest and neck areas for a chest x-ray to avoid interference with x-ray penetration and improve accuracy of the interpretation.

Normal Values (units used in the hospital)

Analysis and interpretation of results Minimal Pulmonary Tuberculosis on left lateral portion of the lungs

Nursing Responsibilities: • • • • Inform the patient about the procedure Ask the patient to remove any radiopaque objects (jewelry, belts, or metal buttons). Assist patient to wear a gown. Assist patient when positioning. 10

Note pertinent findings—such as the presence of a pacemaker or an artificial joint.

11

V. The Patient and His Illness
Anatomy and Physiology of the Human Respiratory System The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain. The Upper Airway and Trachea When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voicebox) and into the trachea (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs.

12

The Lungs The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply. Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide. Blood Supply The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so 13

that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs. The Pleurae The lungs are covered by smooth membranes that we call pleurae. The pleurae have two layers, a 'visceral' layer which sticks closely to the outside surface of your lungs, and a 'parietal' layer which lines the inside of your chest wall (ribcage). The pleurae are important because they help you breathe in and out smoothly, without any friction. They also make sure that when your ribcage expands on breathing in, your lungs expand as well to fill the extra space. The Diaphragm and Intercostal Muscles When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in, the diaphragm contracts and flattens out, expanding the space in your chest and drawing air into your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not normally require your muscles to work. This is because your lungs are very elastic, and when your muscles relax at the end of inspiration your lungs simply recoil back into their resting position, pushing the air out as they go. The Respiratory System and Ageing The normal process of ageing is associated with a number of changes in both the structure and function of the respiratory system. These include: 14

Enlargement of the alveoli. The air spaces get bigger and lose their elasticity, meaning that there is less area for gases to be exchanged across. This change is sometimes referred to as 'senile emphysema'.

• •

The compliance (or springiness) of the chest wall decreases, so that it takes more effort to breathe in and out. The strength of the respiratory muscles (the diaphragm and intercostal muscles) decreases. This change is closely connected to the general health of the person.

All of these changes mean that an older person might have more difficulty coping with increased stress on their respiratory system, such as with an infection like pneumonia, than a younger person would.

15

Pathophysiology (Book-based and Client-centered) Definition of the Disease Nasopharyngeal cancer is a disease in which malignant (cancer) cells form in the tissues of the nasopharynx. Predisposing Factors • People who are between 30 and 50 years of age • Men are more likely to have nasopharyngeal cancer than women • Chinese or Asian ancestry • Hereditary Precipitating Factors • Eating salt-preserved foods (like fish, eggs, leafy vegetables and roots) during early childhood • Cigarette smoking • Alcohol abuse • Poor Oral Hygiene • Long Term Sun Exposure • Occupational Exposure (chemicals esp. asbestos) Signs and Symptoms with Rationale • Anorexia – is a decreased sensation of appetite caused by the complications of compression of the esophagus. • Atelectasis – is a collapse of lung tissue affecting part or all of one lung because of presence of fluid in the lungs. • Chest pain – pain caused by the obstruction of the vena cava. • Chest wall pain – pain caused by the invasion of the pleural cavity irritating nerve fibers. • Chronic Cough – caused by sputum production brought by the irritation of the bronchioles. 16

• Difficulty in swallowing – condition caused by the compression of the esophagus. • Distended neck veins – caused by the obstruction of the vena cava. • Dyspnea – caused by the invasion of the pleural space. • Facial, arm, and trunk swelling – caused by the obstruction of the vena cava. • Hemoptysis – is the expectoration of blood caused by lesions in the blood vessels. • Hoarseness of voice – caused by the irritation of the laryngeal nerve. • Hyperglycemia – a manifestation caused by Cushing’s syndrome. • Hyperkalemia – a manifestation caused by Cushing’s syndrome. • Hypertension – a manifestation caused by Cushing’s syndrome. • Hypervolemia – a manifestation caused by Cushing’s syndrome. • Immunosupression – a manifestation caused by Cushing’s syndrome. • Osteoporosis – caused by high levels of cortisol. • Pneumonia – condition caused by the invasion of the pleural space and it is characterized by inflammation and abnormal alveolar filling with fluid. • Shortness of breath – caused by the irritation and obstruction of airway. • Venous stasis – caused by the obstruction of the vena cava. • Weight loss – caused by dysphagia and the metastases in the liver. Note: Items marked in RED were experienced by the client.

17

Schematic Diagram (Book-based)
Predisposing Factors: • People who are between 30 and 50 years of age • Men are more likely to have nasopharyngeal cancer than women • Chinese or Asian ancestry • Hereditary Precipitating Factors: • Eating salt-preserved foods (like fish, eggs, leafy vegetables and roots) during early childhood • Cigarette smoking • Alcohol abuse • Poor Oral Hygiene • Long Term Sun Exposure

• Occupational Exposure (chemicals esp. asbestos)
Formation of benign bronchial epithelium tissue

Transformation benign tissue to neoplastic tissue

Nasopharyngeal Cancer/ Lung Cancer

Squamous Cell Carcinoma

Small Cell Carcinoma

Adenocarcinoma

Large Cell Carcinoma

Chronic cough

Sputum production Wheezing

Irritation and obstruction of airway

Lesions erode to the blood vessels Triggering of pain receptors Pleural Effusion

Hemoptysis

Shortness of breath

Invasion of the pleural cavity

Chest wall pain Atelectasis Dyspnea Pneumonitis

Invasion of the mediastinum

Synthesis of bioactive products Vena cava syndrome Cushing’s Syndrome Hyperglycemia Hypertension Hypervolemia Hyperkalemia Osteoporosis Immunosupression

Irritation of the laryngeal nerve

Compression of the esophagus

Shortness of breath Facial, arm, and trunk swelling Chest pain Distended neck veins Venous stasis

Pneumonia

Hoarseness of voice

Difficulty in swallowing

Metastases to the liver

Anorexia

Weight Loss

18

Schematic Diagram (Client-centered)
Predisposing Factors: • People who are between 30 and 50 years of age • Men are more likely to have nasopharyngeal cancer than women • Chinese or Asian ancestry • Hereditary Precipitating Factors: • Eating salt-preserved foods (like fish, eggs, leafy vegetables and roots) during early childhood • Cigarette smoking • Alcohol abuse • Poor Oral Hygiene • Long Term Sun Exposure

• Occupational Exposure (chemicals esp. asbestos)
Formation of benign bronchial epithelium tissue

Transformation benign tissue to neoplastic tissue

Nasopharyngeal Cancer/ Lung Cancer Chronic cough (September 20, 2008) Shortness of breath

Sputum production Wheezing

Irritation and obstruction of airway

Invasion of the pleural cavity

Triggering of pain receptors

Invasion of the mediastinum

Chest wall pain (September 20, 2008)

Irritation of the laryngeal nerve

Compression of the esophagus

Hoarseness of voice (September 20, 2008)

Difficulty in swallowing

Anorexia (August 2008)

Weight Loss

19

VI.The Patient and His Care
Medical Management a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy, etc.
Medical Management Treatment D5LRS Date Ordered, Date Performed, Date Changed/ D/C Date ordered: 09/18/08 Date started: 09/18/08 General Description Lactated Ringer's solution is a solution that is isotonic with blood and intended for intravenous administration. It is a nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply in a single dose container for intravenous administration. Isotonic sodium chloride with a 5% dextrose. It is typically the first fluid used when dehydration is severe enough to threaten the adequacy of blood circulation and is the safest fluid to give quickly in large volumes. mediacations, flush, maintain patency of intravenous access device Have a greater concentration of solutes than plasma. It is the solution that draw fluid out of the intracellular and interstitial compartments into the vascular compartment, expanding vascular volume Oxygen therapy is being prescribed for clients with mild or severe anemia because of their blood has a reduced capacity for oxygen Indication(s) or Purpose(s) Severe dehydration, hypovolemia, replace ECF loss, shock, diabetic ketoacidosis Client’s Response to the treatment Responded positively

D5NSS

Date ordered: 09/18/08 Date started: 09/18/08

Replaced extracellular fluid volume, hyponatremia, diabetic ketoacidosis, diluent for

Responded positively

D5NM

Date ordered: 08-19-08 Date performed: 08-19-08

To supply fluid and electrolyte balance for the patient’s need. It is also used as a passage way in giving medication to the patient. Helps to prevent tissue hypoxia and lessens the workload of the heart as it struggles to compensate for the lower hb level

Complies positively

Oxygen therapy

Date ordered: 09-18-08 Date performed: 09-18-08 Changed: • 09-19-08 • 09-20-08

Complies positively

20

IVF Nursing Responsibilities: • • • • • • • • • Select venipuncture site. Clean site using circular motion from inner to outer with alcohol. Apply tourniquet. Anchor vein by stretching skin; insert bevel up to 20 – 30 degree angle. Watch for blood return in flashback chamber of the catheter. Advance needle another ¼ inch; then advance catheter into the vein until hub is at the venipuncture site. Stabilize the catheter and release tourniquet. Remove needle stylet and attach tubing or saline lock to catheter hub. Flush with saline to verify patency. Secure catheter and apply sterile dressing (gauze or transparent) to site.

Oxygen Therapy Nursing Responsibilities: • • • • • Explain the procedure to the patient. Check the doctor’s order. Monitor the client’s vital signs. Check equipment patency. Instruct the client and visitors about the hazard

21

b. Pharmacotherapy
Name of drugs Generic Name/ Brand Name Cefuroxime (Zegen) Date Ordered, Date taken/Given, Date Changed/ D/ C Date ordered: 09/18/08 Date started: 09/18/08 Dosage, Frequency and Route 750 mg IV q8 General Action, Mechanism of Action Haematopoietic Agents Second generation cephalosporins that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. Client’s Response to the Medication The client responded well to the medication

Nursing Responsibilities: • • Observe 10 R’s of drug administration. Before administration, ask patient if he is allergic to penicillins.

Name of drugs Generic Name/ Brand Name Piperacillin Na, Tazobactam Na (Piptaz)

Date Ordered, Date taken/Given, Date Changed/ D/ C Date ordered: 09/18/08 Date started: 09/18/08

Dosage, Frequency and Route 2.25 g IV infusion q8

General Action, Mechanism of Action Penicillin Inhibits cell-wall synthesis during bacterial multiplication.

Client’s Response to the Medication The client responded well to the medication

Nursing Responsibilities: • Observe 10 R’s of drug administration.

Name of drugs Generic Name/ Brand Name Human Insulin (Humulin R)

Date Ordered, Date taken/Given, Date Changed/ D/ C Date ordered: 09/18/08

Dosage, Frequency and Route 10 units SQ stat

General Action, Mechanism of Action Antidiabetics

Client’s Response to the Medication The client responded well to the medication

22

Date started: 09/18/08

Increases glucose transport across muscle and fat cell membranes and reduce glucose level. Helps convert glucose to glycogen; triggers amino acid uptake and conversion to protein in muscle cells; stimulates triglyceride formation and inhibits release of free fatty acids from adipose tissue; and stimulates lipoprotein lipase activity, which converts circulating lipoproteins to fatty acids.

Nursing Responsibilities: • Ask the patient if she/he ever had any allergic reaction with Tranexamic Acid.

Name of drugs Generic Name/ Brand Name Epoetin α (Renogen)

Date Ordered, Date taken/Given, Date Changed/ D/ C Date ordered: 09/19/08 Date started: 09/19/08

Dosage, Frequency and Route 4, 000 units SQ today

General Action, Mechanism of Action Haematopoietic Agent Mimics effect of erythropoietin. Functions as a growth factor and as a differentiating factor, enhancing RBC production.

Client’s Response to the Medication The client responded well to the medication

Nursing Responsibilities: • • Ask patient if he/she ever had allergy to Mefenamic acid Ask patient if he/she has a history of heart attack, stroke or blood clot.

Name of drugs

Date Ordered, Date taken/Given,

Dosage, Frequency

General Action, Mechanism

Client’s Response to the

23

Generic Name/ Brand Name Methyldopa hydrochloride (D50-50)

Date Changed/ D/ C Date ordered: 09/18/08 Date started: 09/18/08

and Route 1 vial IV

of Action Anti-Hypertensive Unknown. Thought to inhibit the central vasomotor centers, thereby decreasing sympathetic outflow to the heart, kidneys, and peripheral vasculature.

Medication The client responded well to the medication AEB a decrease in blood pressure from 140/90 to 120/80.

Nursing Responsibilities: • • • c. Diet
Type of Diet Diet as Tolerated Date Ordered/ Date Started/ Date Changed DO: 08-18-08 Indication(s) or Pupose(s) Maintaining dietary nutrition needed for the patient. General Description Is ordered when the patient’s appetite/ ability to eat and tolerated for certain foods may change. Client’s Response & or reaction to the Activity Complies positively

Ask patient if he/she is allergic to FeSO4 Ask the patient if he/she is taking any other drugs Ask the patient if he/she had multiple blood transfusions

Nursing Responsibilities: • • Provide oral hygiene before and after meal. Advise client to take nutritious foods especially foods rich in iron

24

VII.Nursing Care Plans
Ineffective Airway Clearance
Assessment Subjective cues: "Magkasakit ya knyan mangisnawa nang, lalu na pag sasabi ya" as verbalized by the SO Objective cues: • Dyspnea • Restlessness • Use of accessory muscle • Cough • Nasal flaring • Prolonged expiratory phase Nursing Diagnosis Ineffective airway clearance r/t tissue necrosis located in nasal area AEB dyspnea, restlessness, use of accessory muscle, cough, and nasal flaring. Scientific Explanation Ineffective airway clearance is the inability to clear secretions or obstruction from the respiratory tract to maintain a clear airway in which partial or complete blockage of the breathing tubes to the lungs. Obstruction of the airway can be due to different causes including foreign bodies, allergic reactions, infections, anatomical abnormalities and trauma. The onset of respiratory distress may be sudden with cough. There is often agitation in the early stage of airway obstruction. Objectives After 3 hours of NI, pt will be able to verbalize understanding of cause and therapeutic management regimen and demonstrate behaviors to improve or maintain clear airway. Nursing Interventions • Establish rapport Rationale • To get the trust of the pt. • To open or maintain open airway in at-rest or com promised individual • To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage • To maximize effort in expectorating secretions • Hydration can help liquefy viscous secretions and improve secretion clearance • To improve lung function Evaluation

• Position head to
facilitate airway

• Elevate head of
bed

• Encourage deepbreathing and coughing exercise • Increase fluid intake

• Support reduction/cessatio n of smoking

25

Impaired Physical Mobility
Assessment Subjective cues: “Magkasakit kung gagalo”, as verbalized by the patient. Objective cues: • with limited movements • limited ability to perform gross/fine motor skills • with difficulty turning • with slowed movements Nursing Diagnosis Impaired physical mobility related to decreased muscle strength a manifested by the patient’s limited movements, limited ability to perform gross/fine motor skills, difficulty turning, and slowed movements. Scientific Explanation Impaired physical mobility is limitation in independent, purposeful physical movement of the body or of one or more extremities. Mobility is also related to body changes from aging. Reduction in muscle strength and function, stiffer and less mobile joints affecting balance can significantly compromise the mobility of elderly patients. Restricted movement affects the performance of most activities of daily living (ADLs.) Objectives After 3 hours of nursing intervention, the pt. will be able to participate in ADLs and desired activities as evidenced by an increase in the pt.’s movements, ability to perform gross/fine motor skills, can turn easily, and an increase in motor agility. Nursing Interventions • establish rapport • monitor and record VS • advise pt. to have adequate rest • encourage pt to eat foods rich in carbohydrates • advise pt. to do deep breathing • advise pt. to take adequate fluid intake • encourage pt. to rest between activities • encourage pt. to engage in ROM exercise Rationale Evaluation

• to gain
cooperation • for baseline data • to regain strength • to increase energy level • to promote energy • to prevent dehydration • to promote energy and regain strength • to reduce fatigue

26

Fatigue
Assessment Subjective cues: “Medyu mangalambut ku”, as verbalized by the patient. Objective cues: • appears weak Nursing Diagnosis Fatigue related to poor physical condition as manifested by the patient appears weak, a decreased ability in performing activities, and compromised concentration. Scientific Explanation An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level Fatigue is a subjective complaint with both acute and chronic illnesses. In an acute illness fatigue may have a protective function that keeps the person from sustaining injury from overwork in a weakened condition. As a common symptom, fatigue is associated with a variety of physical and psychological conditions. Objectives After 3 hours of nursing intervention, the patient will verbalize an understanding regarding the health teachings on how to conserve energy as evidenced by the patient appears strong, an increase in the ability to perform activities, and has the ability to concentrate fully. Nursing Interventions • Establish rapport • Monitor and record vital signs • Encourage pt. to sit instead of standing in performing activities • Advise pt. to have adequate rest • Encourage pt. to perform ROM exercises • Encourage pt. to eat carbohydratescontaining food • Encourage pt. to do focus breathing Rationale Evaluation

• to gain
cooperation • for baseline data • to conserve energy

• decreased ability
in performing activities • with compromised concentration

• to regain strength • to reduce fatigue • to increase energy level • to promote energy

27

Chronic Pain
Assessment Subjective cues: "Mahigit neng pilan banwa ing keng arung na" as verbalized by the SO Objective cues: • Facial mask • Self-focusing • Reduced interaction with people • Guarding behavior • restlessness Nursing Diagnosis Chronic pain r/t Chronic physical disability AEB facial grimace, selffocusing, guarding behavior and restlessness Scientific Explanation Chronic pain is unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage, constant or recurring without an anticipated or predictable end and duration of greater than 6 months. Chronic pain may be classified as chronic malignant pain or chronic nonmalignant pain. In the former, the pain is associated with a specific cause such as nasopharyngeal cancer. A tumor that presses on bones, nerves, or organs can cause pain. Objectives After 4 hours of NI, the patient verbalizes acceptable level of pain relief and ability to engage in desired activities. Nursing Interventions • Establish rapport • Evaluate pain behaviors • Encourage pt to take medicine religiously • Note lifestyle effect of pain such as depression • Assist client to learn breathing techniques Rationale Evaluation

• to gain
cooperation • to determine client's response to chronic situation • to lessen pt's suffering from his chronic pain • to know the contributing factor of his chronic pain condition • to assist in muscle and generalized relaxation

28

Disturbed Energy Field
Assessment Subjective cues: “Balamu pane kung mapagal panamdaman”, as verbalized by the patient. Objective cues: • appears weak • low tone speech Nursing Diagnosis Disturbed energy field related to slowing of energy flow as manifested by the pt. appears weak, with low tone speech, and with compromised concentration secondary to illness. Scientific Explanation Disruption of the flow of energy surrounding a person’s being that results in a disharmony of the body, mind, and/or spirit. Objectives After 3 hours of nursing intervention, the pt. will verbalize a sense of relaxation as evidenced by the pt. appears strong, high toned speech and the ability to concentrate. Nursing Interventions • establish rapport • monitor and record VS • advise pt. to have adequate rest • encourage pt. to eat foods rich in carbohydrates • advise pt. to do deep breathing • advise pt. to take adequate fluid intake • encourage pt. to rest between activities • allow pt. to have period of independency Rationale Evaluation

• to gain
cooperation • for baseline data • to regain strength • to increase energy level • to promote energy • to prevent dehydration • to promote energy and regain strength • to strengthen own inner resources

• compromised
concentration

29

VIII.Discharge Plan
Topic: How to achieve health and wellness. Time allotment: 1 hour Venue: At the Eastwing of AMC; room 207
Objective After 1 hour of health teachings, the patient will be able to verbalize understanding regarding topics that are given. Content Teaching patient: • the right nutritious food especially the importance of taking iron with regards to her present condition. • to have an adequate exercise every day to have a proper hygiene to promote wellness. Time Allotment Teaching Strategy Discussion 20 mins. Evaluation ----------

15 mins.

15 mins.

30

IX.Learning Derived
Comparatively, our rotation in Angeles Medical Center is much different from the previous rotations we had. Since it is a private hospital, all of us experienced the so called “culture shock” because we just had our duties from government/district hospitals. The setting in AMC is much ideal considering the more advanced facilities and equipments it has. The hospital staff is able to balance consideration and appropriate interventions to each and every patient. We have learned that the client’s status in life should not be the basis of our fullness in rendering services to them. After all, everyone deserves a fair treatment whatever aspect it may be.

31