I. INTRODUCTION A.

Overview of the study

Colon cancer ranks 6th overall leading cause of cancer-related deaths in the Phillipines , 5th among males and 7th among females. An estimated 2,963 new cases, 1,548 in males 1,415 in females, together with 1,567 deaths will be seen in 1998. Colon cancer increases markedly after age 50. A malignancy in the colon or rectum can be referred to as colorectal cancer. Strictly speaking, a malignancy in the colon is colon cancer and a malignancy in the rectum is rectal cancer. Most colon cancers occur on the left side in the sigmoid region. The colon is a muscular tube approximately 6 feet long connecting the small intestine to the rectum. The right side of your body has the “ascending colon” which receives waste from the small intestine. This ascends upward to the “transverse colon” which crosses over the small intestines and descends on the left side of the body as the “descending colon”. At the bottom the colon again crosses the belly toward the rectum as the “sigmoid colon”. Finally, the sigmoid colon empties into the 8-inch rectum. When the cells that line the colon or rectum start to proliferate in an uncontrolled manner it is called a tumor. It is common to find a benign type of growth called polyps. These are small and produce few, if any, symptoms. However, over time these polyps can grow and develop into cancer.

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B. Objectives and Purpose of the Study As a student nurse, it is indeed my vocation to adjoined hands with the health care team for the promotion of wellness of our clients. My main goals for this study are the following: · To establish rapport · To identify chief complaints of clients to give its specific interventions · To determine the family and personal history of the client that many affect client’s present condition · To identify the cause and effect the main problem through the correct analysis of the pathophysiology of the case · To determine the medical management given through identifying doctor’s order and its rationale · To make nursing care plans for the different health problems encountered by the client · To evaluate the effectiveness of the actual nursing care plan that was established C. Scope and Limitation of the Study Specifically this study is more concerned with the care of one patient in Polymedic General Hospital, Medical Ward. I performed physical assessment to the patient to properly identify the nursing problems, which requires necessary and direct interventions and medical regimen. I had 2 days duty or 16 hours care for the patient and some limited informants.. Thus this care study focuses on the particular case of the patient. The study of the medications and doctor’s order are limited to our chosen patient, a case of Colon Cancer.

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II. HEALTH HISTORY A. Patients Profile Name of Patient: RF Sex: Male Age: 73 Birthday: May 31, 1938 Birthplace: Misamis Oriental Religion: PIC Civil Status: Married Educational Attainment: CollegeLevel Occupation: OFW Number of Siblings: 5 Nationality: Filipino Date Admitted: July 5, 2011 Time Admitted: 5:15 pm Informant: Daughter Blood Pressure: 110/60 mmHg Temperature: 36.7O C Pulse Rate: 82 bpm Respiration: 21 cpm Allergy: No known allergy Attending Physician: Dr. O Admitting Diagnosis: T/C Colon Cancer

B. Past Health History Mr. RF verbalized he has been confined due to gastritis but he already forgot about the date he was admitted. He has no allergy to any foods or other stuffs.

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C. Chief Complains and History of Present Illness Patient RF, &3 years old, from Lapasan, CDOC, few days prior to admission he already experienced poor appetite and severe generalized body weakness and due to this instance,he was brought to PGH by his daughter last July 5, 2011 with the admitting diagnosis of T/C Colonic cancer. the initial vital signs of: temperature- 36.7 ˚C, respiratory rate- 44 cpm, and a pulse rate of 138 bpm.

III. DEVELOPMENT DATA A. Erik Erikson’s Stages of Psychosocial Development Theory Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Each of Erikson's stages of psychosocial development are marked by a conflict, for which successful resolution will result in a favourable outcome and by an important event that this conflict resolves itself around. In the Eriksons 8th stage of psychosocial Development theory which is Senior: Integrity vs. Despair (65 years onwards). Integrity means moral soundness, whole or completeness of a person, Despair means being hopeless. When it comes to my patient he was loosing hope that his illness will be cure, it is because he feels that he was really old and he don’t have the capabilities of living the way it should be. But still, because of the support of the family little by little he was trying to understand his situation tried to think on positive side and for himr to live longer for his family that still need him as a father, as a grandfather and as a husband. B. Sigmund Freud’s Psychosexual Development Theory According to Freud, people enter the world as unbridled pleasure seekers. Specifically, people seek pleasure through from a series of

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erogenous zones. These erogenous zones are only part of the story, as the social relations learned when focused on each of the zones are also important. Freud's theory of development has 2 primary ideas: One, everything you become is determined by your first few years - indeed, the adult is exclusively determined by the child's experiences, because whatever actions occur in adulthood are based on a blueprint laid down in the earliest years of life (childhood solutions to problems are perpetuated) Two, the story of development is the story of how to handle anti-social impulses in socially acceptable ways. My patient belongs to the genital stage which begins at puberty involves the development of the genitals, and libido begins to be used in its sexual role. However, those feelings for the opposite sex are a source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted from all that. C.Robert J. Havighurst’s Developmental Task Theory Havighurst categorized the tasks, in first category are the tasks, which has to be completed in certain period, and the second are the tasks that continue for a long, sometimes for a lifetime.So what happens if the task is not completed in that stage or completed in a later date? Havighurst reply to that it is critical that the tasks should be completed during the appropriate stage, otherwise result will be the failure to achieve success in future tasks. D. Jean Piaget’s Theory of Development According to Piaget, development is driven by the process of equilibration. Equilibration encompasses assimilation (i.e., people transform incoming information so that it fits within their existing schemes or thought patterns) and accommodation (i.e., people adapt their schemes to include incoming information). My patient belongs to the formal operational stage. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations. The abstract quality of the adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving ability. The logical quality of

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the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as a scientist thinks, devising plans to solve problems and systematically testing solutions. They use hypothetical-deductive reasoning, which means that they develop hypotheses or best guesses, and systematically deduce, or conclude, which is the best path to follow in solving the problem.

IV. MEDICAL MANAGEMENT A. DOCTORS ORDER Order 7/5/11  Please admit under the service of Dr. O

 Secure Consent to care

 Monitor or V/S q 4

 Start venodysis w/ D5NSS IL @ 15 gtts/min  LAB’S: -CBC -Urinalysis -Chest x-ray PA -Serum Na+, K+ creatinine  MEDS - Vamin 500 cc for 12 hours  I & O q shift  Refer accordingly

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7/6/11  NaCl 1 tab TID  Iterax  tramal 7/7/11  hold iterax  Morphine 10g 1 tab q 8o  D/C tramal once Morphine is started 7/8/11  continue meds 7/9/11  Paracetamol 500g 1 tab q 4 PRN for fever  D/C vamin when consumed  Flanax 275 g 1 tab BID  IVF to ff D5NSS1L @ 15 gtts/min 7/10/11  d/c flanax  refer to Dr. RY for colonoscopy & Biopsy - if for colonoscopy pls. do 1. CXR 2. ECG 12 leads 7/11/11  may change FBC in AM per request 7/12/11  follow – up CXR result  for possible colo this am depending on response of bowel prep  give morphine 10 mg 1 tab now  increase IVF rate to 25 gtts/min 7/13/11  give flanax 1 tab  sched for colo @ 9 am tomorrow - do the routine bowel prep - refer to Dr. G 7/14/11  suggest surgical consult  colostomy schedule noted  resume previous diet  resume vamin 500 cc to run for 12 hours  refer to Cr. RY for evaluation if ok w/ family  plan : Diverting loop colostomy ?& debarment of perineal abcess 7/15/11  request CBC, serum Nat, Kt, Crea, SGPT  secure unit of PRBC for possible transfusion  pls. facilitate hot sitz bath for 15 min 3 x a day for 2 -3 days  provide bedside commode  pls. transfuse 2 units of PRBCof blod type @ 20 gtts/min  please close main IVF line once BT is ongoing 7

7/16/11  secure another units of FWB for possible BT  repeat CC result 7/17/11  absolute NPO  once vamin glucose is consumed; start kabiverl 2,000 kcal to run for 24 hours  decrease IVF rate to 10 gtts/ min when kabivern is started  repeat CBC result  request for ECG 12 leads  for possible sigmoid coop colostomy @ 1 pm 7/18/11  hold all meds  transfuse: 1 unit of available FWB @ 20 gtts/min  start O2 @ 2 L/min  check 02 sat  proceed scheduled sigmoid loop colostomy @ 1 pm 7/19/11  monitor V/S q 15 min  I & O q shift  Incorporate 20 meq kCl to ongoing IVF of D5NSS 1L regulated @ 20 gtts/min 7/20/11  d/c tramadol  decrease O2 inhalation to 2 L/min  soft diet  sinecoid forte 1 tab TID  terminate D5NSS line 7/21/11  full diet 7/22/11  off O2 inhalation  fluimucil 2m/sachet 7/23/11  repeat CBC 7/24/11  start tsenam 500mg IV drip q 8 h  encourage deep breathing exercise  d/c fluimucil 7/25/11  follow – up biopsy result 7/26/11  continue tsenam 7/31/11  V/S monitoring q 4  Transfer in ICU  Increase Dopa to 3cc.hr

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8/1/11  decrease ivf rate to 15 ggts/min 8/2/11  decrease O2 inhaltion to 2 l/min 8/3/11  start dopamine via syringe pump  meds FeSO4 1 tab OD 8/4/11  full diet  continue vital signs 8/5/11  v/s q hourly  I & O q shift 8/7/11  decrease dopamine rate to 9cc/hr  decrease IV rate into 15 ggts/min 8/8/11  decrease dopamine rate to 5cc/hr  encourage deep breathing exercises 8/9/11 > decrease dopa to 4 cc/hr > consume stock tsenam

B. LABORATORY TEST

Test Creatinine

Normal Range

Result

Interpretation Low

Significance Due muscle disease to small mass , stature decreased some

71.0-133.0 60.4 mmol/L

debilitation,

complex cases of hepatic Potassuim 3.50-5.10 4.41 mmol/L Normal

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CHEST XRAY 1. Consider atelectasis versus pneumothorax, right lung 2. Pneumonia, bilateral 3. Consider cardimegally 4. Atherosclerotic aorta 5. Minimal pleural effusion and or/ thicking, bilateral V. PATHOPHYSIOLOGY & ANATOMY AND PHYSIOLOGY A. PATHOPHYSIOLOGY COLON CANCER

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B. ANATOMY AND PHYSIOLOGY COLON

The colon is also called the large intestine. The ileum (last part of the small intestine) connects to the cecum (first part of the colon) in the lower right abdomen. The rest of the colon is divided into four parts: • The ascending colon travels up the right side of the abdomen. • • The The transverse descending colon colon runs travels across down the the left abdomen. abdomen.

• The sigmoid colon is a short curving of the colon, just before the rectum. The colon removes water, salt, and some nutrients forming stool. Muscles line the colon's walls, squeezing its contents along. Billions of bacteria coat the colon and its contents, living in a healthy balance with the body.

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VI. NURSING REVIEW CHART IV. PHYSICAL ASSESSMENT NURSING SYSTEM REVIEW CHART Name: RF Date: August 8, 2011 Vital Signs: Pulse: 82 bpm BP: 110/60

Temp:

36.3

Respi: 20 cpm

EENT [X] impaired vision [] blind [] pain reddened [] drainage [] gums [] hard of hearing [] deaf [] burning [] edema [] lesion teeth [] asses eyes, ears, nose [] throat for abnormality [] no problem RESPIRATION [] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing [] pain [] cyanotic [] assess resp rate, rhythm, depth, pattern [] breath sounds, comfort []no problem GASTRO INTESTINAL TRACT [] obese [] distention [] mass [] dysphagia [] rigidly [] pain [] asses abdomen, bowel habits, swallowing [] bowel sounds, comfort [X]no problem GENITO-URINARY and GYNE [] pain [] urine color [] vaginal bleeding [] hematuria [] discharge [] nocturia [] assess urine freq., control, color, odor, comfort [] grip, gait, coordination, speech, [X]no problem NEURO [] paralysis [] stuporous [] unsteady [] seizure [] lethargic [] comatose [] vertigo [] tremors [] confused [] vision [] grip [] assess motor function, sensation, LOC, strength [] grip, gait, coordination, speech, [X]no problem 2 MUSCULOSKELETAL and SKIN

Blurry vision

With pitting edema

Abdominal pain noted with the scale of 5/10

Generalized weakness

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[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage [] prosthesis [] swelling [] lesion [] poor turgor [] cool [] deformity [] atrophy [] pain [] ecchymosis [] diaphoretic [] assess mobility, motion, gait, alignment, joint function [] skin color, texture, turgor, integrity [x] no problem

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VII. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT PATIENT XY Patient: XY ASSESSMENT DIAGNOSIS objectives INTERVENTIO RATIONALE NS OUTCOME CRITERIA EVALUATION

Subjective: Pain related to After 4-6 hours of -Determine the -To evaluate The patient The goal has been “Sakit disease comprehensive location need for verbalizes minimal partially met ahungtiyan” as process(inflammatio nursing effectiveness retraction of pain verbalized by the n) secondary to intervention, the -Provide basic -To promote patient. rectal cancer as patient will be comfort measure relaxation and Objective: evidenced by patient able to verbalized like repositioning health refocus -seen patient lying facial appearance of a minimal -Encourage use attention in bed pain reduction of pain of stress -Enable patient to -Facial grimacing Scientific Basis: from score of 7 management like participate noted. Inflammation is the to 5 (at the pain relaxation actively and physical reaction of scale of 10 where techniques like enhance sense o -FBC attached to living tissues due to 1 is the lowest music. control UB infection. One of the and 10 is the - colostomy noted classical signs of highest) -Give medication -To relieve the -garded inflammation is pain. as ordered pain movement Source: -Monitor temperature -To detect http://medicalwhether the dictionary.thefreedict patient has fever ionary.com/Inflamati on

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ASSESSMEN DIAGNOSIS T
Subjective: -“wa koy gana mo kaon” as verbalized by the patient -coherent Objective: -sagging of skin -w/ on going IVF of D5 LR 1L @ 30 infusing well at the right arm -FBC attached to UB colostomy noted -sunken eyeballs -thin Imbalance nutrition less than body requirements related to pain secondary to colorectal cancer sensation as evidenced by patient sagging of the skin

PLANNING

INTERVENTI ONS
-Monitor daily food intake -Encourage patient to eat high calorie, nutrientrich w/ adequate fluid intake -Control environmental factor -Encourage use of relaxation techniques

RATIONALE

OUTCOME CRITERIA

ACTUAL EVALUATION

After 4-6 hrs. of comprehensive nursing interventions, the patient will be encouraged to eat even just a little in order to have something or the stomach to digest without triggering nausea and Scientific Basis: vomiting. Anorexia is lack or poor appetite which may affect the eating pattern and can cause imbalanced nutrition to the patient Source: Blackwell’s nursing dictionary, 2nd edition

-Encourage open communication regarding anorexia problem -Review laboratory studies as indicated

-Identifies nutritional The patient have The goal has been strength / deficiencies eaten a little without partially met -Metabolic tissue vomiting. needs as increases as will as fluid supplement can play on important rule in maintaining adequate calorie and protein intake -Can trigger nausea/vomiting response -May prevent onset or reduce severity of nausea, decrease anorexia and enable patient to increase oral intake -Often a source of emotional distress, especially for SO who want to feed rejected/frustrated -Help identify to degree of biochemical imbalance/malnutrition and influence choice of dietary interventions

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Patient: XY

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B. ACTUAL NURSING MANAGEMENT S “arang - arang na gani verbalized by the pt. O  cough  restlessness A  expelled white sputum Ineffective airway clearance related to increased amount of secretion akong ubo” as

P

At the end of 30 mins the patient will be able to expectorate secretions & improve / maintain airway clearance. > facilitate maintainace of patient upper airway by proper positioning - altered level of consciousness, sedation are some condition that alters pt. to project airways > assist w/ coughing/ deep breathing exercises position changes - for easy expectoration of secretions > increase fluid intake - oral fluid intake may liquefy secretion/ enhance expectorant >administer
-

I

Salbutamol

per

doctors

order 1 neb q 6o to improve ventilation & facilitate removal improved ventilation and of secretions Demonstrate

E

oxygenation of tissues by ABG within clients acceptable range.

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S

“medyo sakit akong tiyan” As verbalized by the patient

O

A

>C pain scale of 7/10 >grimace noted >irritable >weakness noted Acute pain related to inflammatory response At the end of 30 mins the patient will be able to demonstrate relief from pain

P

I

Independent: >monitor v/s >Instructed tondeep breathing excersise >Encouraged to have Diversional activities like watching t.v. >Placed patient in a comfortable position >Encouraged to have adequate bed rest >Provided therapeutic touch Dependent: >Administered Ranitidine as ordered

E

> goal partially met, patient demonstrate relief from pain

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C. DRUG STUDY NAME OF DRUG DATE ORDER ED CLASSIFICATI DOSE/ ON FREQUEN CY/ ROUTE MECHANI SM ACTION SPECIFIC N CONTRAINDICAT SIDE ION EFFECTS NURSING PRECAUTI ON

OF INDICATIO

19

DUAVE NT

July 23, Brochodilator 2011

1 neb q 6

beta2Inhalation Contraindicated w/ adrenergic Solution is hypersensitivity to bronchodila indicated for the relief of salbutamol; tor bronchospa tachyarrytmias, sm. This drug relaxes tachycardia the smooth causes by digitalis muscle in the lungs and dilates airways to improve breathing.

Cases of urticaria, angioedema, rash, bronchospas m, hoarseness, oropharynge al edema, and arrhythmias (including atrial fibrillation, supraventric ular tachycardia, extrasystoles ) have been reported after the use of salbutamol SIDE EFFECTS

- Do not take any of these medications without consulting your doctor (even if you never had a problem taking them before). - Do not allow anyone else to take this medication.

NAME OF DATE DRUG ORDER ED

CLASSIFICAT ION

DOSE/ FREQUEN CY/

MECHANI SM ACTION

SPECIFIC N

CONTRAINDICA TION

NURSING PRECAUTI ON

OF INDICATIO

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Ceftriaxon e

July 23, Antibiotic 2011

ROUTE 3grams IVTT OD

Bactericid synthesis

Treatment caus strains shigella

Allergy

to CNS: Lethargy CV: heartfailure GI: gastritis Hypersensiti vity: Rashes, fever

>check of

IV

al; inhibits of infection cephalosporins of bacteria of wall causing cell death

site for signs thrombosis >cultureinfec ted area

on the cell salmonella, E.Coli, haemophillu s influenzae Serious Inhibits protein synthesis in susceptibl e neg. bacteria infection caused by pseumodo mas, E.coli, serios when causative gram infection With drug allergy to

500mg Metronidaz July 23, Antibiotic ole 2011 IVTT Q8H

>check reaction allegy CNS:Otoxicit drug y CV: Palpitaion GI: Hepatic toxicity

for of to

> check the site infection. of

appears to agent is not

21

disrupt functional integrity of bacterial cell membrane

known

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VIII. REFERRAL AND FOLLOW – UP Exercise/Economic Factor Practice deep breathing exercise and coughing exercises. Resume previous activities. Prevent extraneous work. Have a regular physical exercise like brisk walking for 30 minutes daily. For financial insufficiency, there are government drug stores available. The patient may continue her work in the factory. Treatment Follow faithfully the regimen for tuberculosis, especially the medications. Have a regular sputum test, as ordered by the doctor. Health Teaching You should practice hand washing regularly. Always cover the mouth and the nose when exposed to person who coughs or sneezes. You should not spit anywhere, instead spit in a single container to prevent transfer of M. Tuberculosis. Out patient Follow-up Always have a regular check up at your nearest health center, at least once a week to monitor the progress of the treatment. The client should report immediately to the physician if there is difficulty of breathing, there is productive cough more than 5 days and there is chest pain and experiencing fatigue. Diet The diet should be high caloric. Always drink a lot of water. Also eat fruits and vegetables. Don’t escape meals. If there are any food supplements available, consult it with the doctor. Eat vitamin c rich food to strengthen immune systems. Spiritual/Sexual Activities Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual IX. EVALUATION AND IMPLICATION At the end of our hospital duty, We were able to render care to our patient to help him resolve his health condition. Through observing the patient’s status, we able to identify priority problems related to his health. The patient was willing to pursue the medical therapy just to promote health and wellness for the betterment of her son’s condition. We have also made the patient’s wife realize the importance of completing the course of therapy by taking the medicines prescribed or ordered for him by his physician. In addition, eating healthy or nutritious foods that were prescribed to her by the health providers 23

was further been explained to her mother especially the benefits he will gain in eating those foods. Moreover, this several interventions given to the patient made her body conditioning normal and We can say that our patient has somehow recovered from his illness. X. DOCUMENTATION (None, we have no written consent that will allow us to take a picture/ photo of the said client.)

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