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Our Lady of Fatima University

College of Nursing
Valenzuela Campus

Nasopharyngeal
Carcinoma
Undifferentiated Type
Stage IVA
A Case Study

February 10, 2015

TABLE OF CONTENTS

I. Introduction
II. Objectives
III. Patients Profile
IV. Anatomy and Physiology
V. Pathophysiology
VI. Laboratory Examination Results
VII. Gordons Assessment
VIII. Nursing Care Plans
IX. Drug Study
X. Discharge Planning

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 Epstein-Barr
virus may also make a person more likely to get nasopharyngeal cancer. This is
the same virus that causes infectious mononucleosis (also called "mono"). You
may also inherit a tendency to get nasopharyngeal cancer.
Reason for Choosing the Case
Nasopharyngeal Cancer is one of the unusual terms for a layperson and a rare
case that a nurse would encounter. Acquisition of cognitive knowledge regarding
the topic would enable there searchers in providing optimum care for clients

suffering such and in delivering appropriate interventions that would promote


health and wellness for the client.
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.
II. OBJECTIVES
Nurse-Centered
After the completion of this case study, the nurse will be able to:
1. Understand the current statistics and latest trend regarding Nasopharyngeal
Carcinoma Undifferentiated Type Stage IVA
2. Describe factually, the personal and pertinent family history of the patient and
relate it to the present condition.
3. Perform comprehensive physical assessment.
4. Trace the book-based and client-centered pathophysiology of
Nasopharyngeal Carcinoma Undifferentiated Type Stage IVA
5. Determine the predisposing and precipitating factors and the signs and
symptoms and relate to the disease process.
6. Enumerate and describe the diagnostic and laboratory procedures as well as
the nursing responsibilities in relation to the disease condition
7. Enumerate the different treatment modalities and their indication specifically
for the patients condition.
8. Identify the pharmacologic treatment provided to the patient, relate the
actions of each drug with the disease process and evaluate the patients
response to the medications given.

9. Identify nursing diagnoses, formulate short-term and long-term goals, carry


out appropriate interventions and evaluate the plan.
10. Appraise the effectiveness of medical and surgical nursing management in
treating the patient.
11. List the preventive measure for the occurrence of Nasopharyngeal
Carcinoma Undifferentiated Type Stage IVA for the benefit of the general
public.
Patient Centered
After the completion of this case study, the patient will be able to:
1. Report understanding of the disease process.
2. Understand the indications of the different diagnostic procedures and medical
management involved in her care.
3. Cooperate with the necessary medical and nursing interventions.
4. Adhere with the health teachings provided.
5. Understand the different ways of health promotion and prevention in relation to
the disease condition.
6. Demonstrate improved conditions as evidenced by absence of further
complications.

III. PATIENTS PROFILE


Name: Mrs. Ilong
Age: 31 years old
Birthday: July 9, 1983
Nationality: Filipino
Religion: Baptist
Civil Status: Married
Date Admission: February 1, 2015
Time of Admission: 8:30 AM
Chief Complaint's: Consultation for Radiotherapy
Initial Diagnosis: Nasopharyngeal Carcinoma Undifferentiated Type Stage IVA
(T2N2MX) s/p 7 sessions of Radiotherapy.
Final Diagnosis: Nasopharyngeal Carcinoma Undifferentiated Type Stage IVA
(T2N2MX) s/p (28 sessions); s/p Chemotherapy
HISTORY OF PAST ILLNESS

Mrs. Ilongs did not have any problems at the time of her birth. Her
immunization record is complete. According to Mrs. Ilong she is not allergic to
any drugs, foods or other environmental agents. She never experienced allergic
rhinitis. As stated by Mrs. Ilong, her last check-up was done last March 2014
when she experienced hearing loss. Two weeks after her check-up she
experienced epistaxis and difficulty in breathing. She undergone biopsy and it
was shown that she has tumor in the nose and it is stage II. Mrs. Ilong, did not
take any medications in the month of June. Due to the persistence of the
symptoms, she sought consultation last September 23, 2014, when she was first
admitted at the nearest hospital in Western Visayas, with a chief complaint of
difficulty in breathing and hearing. Prior to this, she undergone Radiotherapy last
December 8, 2014 and Chemotherapy last January 23, 2015.
HISTORY OF PRESENT ILLNESS
Mrs. Ilong is not known hypertensive, not known diabetic. History of
present illness started six months ago prior to admission when patient
experienced hearing loss, bilateral. No other associated signs and symptoms
noted. Due to persistence of the symptoms patient sought consultation at a
private hospital in Iloilo, where patient was noted to have nasopharyngeal mass.
Biopsy was done revealing nasopharyngeal carcinoma. Mrs. Ilong underwent
seven sessions of Radiotherapy. Then she was referred to the Institution for
completion of radiotherapy.
PHYSICAL ASSESSMENT
Physicians Physical Assessment done by the Resident on Duty (February 1,
2015, lifted from the patient's chart)
Height: 50 (160cm)
Weight: 38 kg
Vital Signs as follows:

T: 36.7 C

PR: 92bpm

RR: 18cpm

BP: 100/60 mmHg

SAO2: 97

PHYSICAL ASSESSMENT:
GENERAL SURVEY
Mrs. Ilong, Assessed/received patient lying on bed, awake, conscious,
responsive, and coherent. With the following vital signs:
Temperature: 37 C
Heart rate: 92 bpm
Respiratory rate: 20 bpm
Blood Pressure: 100/60 mmHg
SAO2: 98
NUTRITIONAL STATUS
Upon admission, Mrs. Bu Cool was placed on a regular diet.
SKIN
> Pallor noted.
> Good skin turgor in both upper and lower extremities; the skin returns to its
previous state immediately after being tented.
> warm moist skin, no active dermatoses.

HAIR
> Hair is black and is evenly distributed.
> Silky and smooth hair.
> No areas of hair loss noted.
> Thick hair strands.
NAILS
> Trimmed clean nails.
> Concave shaped; with a nail plate angle of about 160 degrees.
> Smooth in texture.
> Intact epidermal lining around the nails.
> Capillary Refill Test less than 3 seconds.
SKULL AND FACE
> Rounded (normocephalic and symmetrical with frontal, parietal and occipital
prominences).
> Head size is appropriate to body size.
> No nodules or masses upon palpation.
EYES AND VISION
> Eyebrows and eyelashes are evenly distributed.
> Eyelids are intact.

> Sclera appears white.


> Pale conjunctiva.
> No discharges and discoloration noted.
> Blink reflex intact.
EARS AND HEARING
> Ears are symmetrical in size and in line with the outer canthus of the eyes.
> Color of ears is the same with the facial skin.
> No discharges and foul odor noted upon inspection.
> Pinna and ear canal are clean.
> Auricles are firm and recoil to previous state when folded.
> No nodules or masses noted upon palpation.
NOSE AND SINUSES
> Symmetric and straight.
> No watery discharges.
> Has a slow uneven breathing pattern.
> No tenderness masses and pain noted upon palpation.
> Oxygen inhalation attached.
OROPHARYNX (Mouth and Throat)
> Dry and pale lips noted upon inspection.

> Tongue is able to move freely


>slightly difficulty swallowing
> Good oral hygiene.

NECK
> Jugular vein is not visible.
> Muscles are equal in size with the head centered.
> Slow muscle movement.
> Lymph nodes are not palpable.
CARDIOVASCULAR AND PERIPHERAL SYSTEM
> Skin color of palm of the hand and feet is pink.
> Pink nail beds upon inspection.
> Symmetric pulse volumes, full pulsations of peripheral pulses.
> Heart rate is 92 beats per minute.
> Blood Pressure is 110/70 mmHg.
> (Vital signs taken during the time of assessment on February 2, 2015 at
7:00 am).
Respiratory System
> Chest is symmetric.

> Skin and chest wall are intact and has uniform temperature.
> No tenderness and masses noted upon palpation.
> Regular breathing pattern
> Presence wheezing and crackles sound upon auscultation.
> Full and symmetric chest wall expansion.
BREAST AND AXILLAE
> Breasts are symmetrical in size; color is the same as with the abdomen.
> Both nipples are symmetrical in size.
> No discharges noted.
> No tenderness, masses, and nodules noted upon palpation.
ABDOMEN
> Abdominal skin is intact.
> Distended abdomen noted.
> Audible bowel sound upon auscultation.
> Abdominal dullness upon percussion.
MUSCULOSKELETAL
> Posture is good, able to stand straight and can walk alone properly but
slowly.
> Movement of muscles is weak.

> Muscles in the upper extremities are weak.


NEUROLOGIC
> Patient has times of looking in the distance and is slow in response when a
question asked.
> Patient was able to answer well when asked of her complete name, birth
date and age.
URINARY SYSTEM
> Patient usually urinates 5 times a day.
REPRODUCTIVE SYSTEM
> The patient refused to be assessed with her external reproductive organ but
she verbalized that she has minimal vaginal bleeding and complain of pain
when secretions are expelled.
REVIEW OF SYSTEM
Integumentary System
The patient has no history of bruises in both upper and lower extremities.
Head
The patient had no history of any form of head injuries.
Eyes
Patient had no history of any eye problems.
Ears and Hearing

Patient had no history of smelly discharges on both ears, and no complaints


of hearing impairment.
Breast and Axillae
The patient had no history of breast nodules, no enlargement, no tenderness,
no pain and unusual discharges.
Respiratory System
The patient experienced slow irregular breathing patterns.
Cardiovascular System
The patient has a history of hypertension.
Genitourinary System
The patient had no history of any genital problems. Usually urinates 5 times a
day.
Gastrointestinal System
The patient had no history of difficulty in defecation.
Musculoskeletal System
Patient has no history of joint pain.
Neurologic System
Patient had no history of any major mental problems but had episodes of
mental absences.

IV.ANATOMY AND PHYSIOLOGY


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

symptoms
breathlessness,

respiratory
include

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 voice box) and into
the trachea (or windpipe) before entering your lungs. All these structures act to
funnel fresh air down from the outside world into your body. The upper airway is
important because it must always stay open for you to be able to breathe. It also
helps to moisten and warm the air before it reaches your
lungs.
The Lungs
The lungs are paired, cone-shaped organs which take up most of the
space in our chests, along with the heart. Their role is to take oxygen into the
body, which we need for our cells to live and function properly, and to help us get
rid of carbon dioxide, which is a waste product. We each have two lungs, a left
lung and a right lung. These are divided up into 'lobes', or big sections of tissue
separated by 'fissures' or dividers. The right lung has three lobes but the left lung
has only two, because the heart takes up some of the space in the left side of our

chest. The lungs can also be divided up into even smaller portions, called
'broncho pulmonary segments'. These are pyramidal-shaped areas which are
also separated from each other by membranes. There are about 10 of them in
each lung. Each segment receives its own blood supply and air supply.
Air enters your lungs through a system of pipes called the bronchi. These
pipes start from the bottom of the trachea as the left and right bronchi and branch
many times throughout the lungs, until they eventually form little thin-walled air
sacs or bubbles, known as the alveoli. The alveoli are where the important work
of gas exchange takes place between the air and your blood. Covering each
alveolus is a whole network of little blood vessel called capillaries, which are very
small branches of the pulmonary arteries. It is important that the air in the alveoli
and the blood in the capillaries are very close together, so that oxygen and
carbon dioxide can move (or diffuse) between them. So, when you breathe in, air
comes down the trachea and through the bronchi into the alveoli. This fresh air
has lots of oxygen in it, and some of this oxygen will travel across the walls of the
alveoli into your bloodstream. Travelling in the opposite direction is carbon
dioxide, which crosses from the blood in the capillaries into the air in the alveoli
and is then breathed out. In this way, you bring in to your body the oxygen that
you need to live, and get rid of the waste product carbon dioxide.
Blood Supply
The lungs are very vascular organs, meaning they receive a very large
blood supply. This is because the pulmonary arteries, which supply the lungs,
come directly from the right side of your heart. They carry blood which is low in
oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can
be blown off, and more oxygen can be absorbed into the bloodstream. The newly
oxygen-rich blood then travels back through the paired pulmonary veins into the
left side of your heart. From there, it is pumped all around your body to supply
oxygen to cells and organs.

The Pleurae
The lungs are covered
by smooth membranes that we
call pleurae. The pleurae have
two layers, a'visceral' layer
which sticks closely to the
outside surface of your lungs,
and a 'parietal' layer which lines
the inside of your chest wall
(ribcage). The pleurae are
important because they help
you breathe in and out
smoothly, without any friction.
They also make sure that when
your ribcage expands on
breathing in, your lungs expand as well to fill the extra space.
The Diaphragm and Intercostal Muscles
When you breathe in (inspiration), your muscles need to work to fill your
lungs with air. The diaphragm, a large, sheet-like muscle which stretches across
your chest under the ribcage, does much of this work. At rest, it is shaped like a
dome curving up into your chest. When you breathe in, the diaphragm contracts
and flattens out, expanding the space in your chest and drawing air into your
lungs. Other muscles, including the muscles between your ribs (the intercostal

muscles) Also help by moving your ribcage in and out. Breathing out (expiration)
does not normally require your muscles to work. This is because your lungs are
very elastic, and when your muscles relax at the end of inspiration your lungs
simply recoil back into their resting position, pushing the air out as they go.

The Respiratory System and Ageing


The normal process of ageing is associated with a number of changes in
both the structure and function of the respiratory system. These include:
Enlargement of the alveoli. The air spaces get bigger and lose their elasticity,
meaning that there is less area for gases to be exchanged across. This change is
sometimes referred to as 'senile emphysema'.
The compliance (or springiness) of the chest wall decreases, so that it takes
more effort to breathe in and out.
The strength of the respiratory muscles (the diaphragm and intercostal
muscles) decreases. This change is closely connected to the general health of
the person. All of these changes mean that an older person might have more
difficulty coping with increased stress on their respiratory system, such as with an
infection like pneumonia, than a younger person would.
Pathophysiology (Book-based and Client-centered)
Definition of the Disease
Nasopharyngeal cancer is a disease in which malignant (cancer) cells
form in the tissues of the nasopharynx.
Non-Modifiable 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
Modifiable 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.

Difficulty in swallowing condition caused by the compression of the


esophagus.

Chronic Cough caused by sputum production brought by the irritation of


the bronchioles.

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 Cushings syndrome.

Hyperkalemia a manifestation caused by Cushings syndrome.

Hypertension a manifestation caused by Cushings syndrome.

Hypervolemia a manifestation caused by Cushings syndrome.

Immunosuppression a manifestation caused by Cushings 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.

V. PATHOPHYSIOLOGY
Schematic Diagram (Book-based)

SCHEMATIC DIAGRAM (CLIENT-CENTERED)


MODIFIABLE FACTORS
NON-MODIFIABLE FACTORS

Eating salt-preserved foods (like fish, eggs, leafy

People who are between 30 and 50 years of age

Men are more likely to have nasopharyngeal

Cigarette smoking

vegetables and roots) during early childhood

cancer than women

Alcohol abuse

Chinese or Asian ancestry

Poor Oral Hygiene

Hereditary

Long Term Sun Exposure

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

Transformation benign tissue to neoplastic


tissue

Nasopharyngeal Cancer

Irritation and obstruction of airway


Wheezing
Invasion of
mediastinum
Shortness of
breath

Compression of the
esophagus
Difficulty in swallowing

Anorexia

Weight Loss

VI. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic /
Laboratory
Procedures

Date
Ordered

Indications or

Date

Purposes

1.

Results in
Date

Hematology

ordered:

test

Febuary

2,

the Blood Typing: O

of

Analysis and Interpretation of


results
The blood type of the patient is
Type O.

content in the
red blood cells

Results:
February

see

Normal Values

hemoglobin

2015
Date

to

Results

Rh: (+)
Hemoglobin:

The patient is Rh+.


90 120-160 g/L

gms/L

The result indicated that the


hemoglobin (the iron-containing

2,

part

2015

of

blood

that

carries

oxygen to cells) level of the


patient is very low, which may
lead to secondary anemia.

Hematocrit:
gms/L

0.30 0.37 0.43 g/L

WBC count:

4-10 x 10^9 /L

15.19 x 10^9/L

The level of white blood cell


count is very high since there
are invading pathogens due to
her condition.

Segmenters: 0.90

0.55 - 0.65

The number of Segmenters is


higher than the normal range.

Lymphocytes:

0.25 - 0.35

0.04
Monocytes: 0.06

The number of Lymphocytesis


very low than the normal level.

0.03 - 0.06

The number of monocytes is


within the normal range.

Eosinophils; 0.00

0.02 - 0.04

The eosinophils count is lower


than the normal range.

Basophils

0.00 - 0.01

The basophils count is on the


normal range

MCV: 76.6 fL

80 - 100 fL

MCH: 23.9 pg

26 - 32 pg

MCHC: 31

32 - 36 g/dL

RDW: 16.11

11.0 - 15.0

Platelet

count: 130.0 - 400.0 x The platelet count is within the

399 x 10^9 g/L

10^9 g/L

normal range; therefore, there


are no clotting complications
that may occur.

2. Urinalysis

to

Date
ordered:
February

determine Color:

signs
2,

infections

of Dark yellow
and

2015
Date

2015

Transparency:

bleeding.

Slightly turbid

of

Results:
February

abnormal

PH: 6
2,
SP Gravity:
1.010
Sugar: negative
Protein: negative
RBC: 2-5
Pus cells: 2-6
Epithelial cells:
few
Amorphous
Urates: few

Mucus threads:
few

VII. GORDONS ASSESSMENT


A. Health Perception and Management

Patient can recall being completely immunized

Visits a doctor for consultation

Takes OTC drugs and herbal medications

B. Nutrition/Metabolism

Eats more of fruits and vegetables

Eats dried /preserved fish

Eats her meals three times a day

No allergies on foods

C. Elimination

Voids usually five times a day

Urine color is dark yellow

Defecates usually once a day during morning

D. Activity/Exercise

Patient does household chores

Able to bathe herself

She does simple exercises such as arm exercises by means of shaking


and stretching

E. Sexuality/Reproductive

Married

A mother of 3 children

No history of STDs

F. Cognitive/Perceptual

Oriented to people, time and place

Responds to stimuli verbally and physically

Able to read and write

College graduate

In normal thought process

G. Roles/Relationship

Married

With 3 children

Well-supported by the family

Loves her family so much

H. Self Perception/Self-Concept

Hopeful to be relieve and treated

Manages to practice healthy lifestyle

I. Value/Belief

A Baptist

Has a strong faith in God

Attends Sunday mass

J. Coping/Stress

No traumatic events experienced before

Copes up with problems by talking about it with the family and finds ways
to resolve it together

K. Sleep/Rest

No difficulties in sleeping

Have enough rest intervals

L. Medication History

Herbal medications before admission

IX. NURSING CARE PLAN


1. Ineffective Airway Clearance

Assessment

ako clearance r/t tissue clearance is the NI, patient will rapport

huminga pag nag necrosis located in inability to clear be


sasalita

Nursing

Objectives

Explanation
Interventions
In effective airway Ineffective airway After 3 hours if 1. Establish

Subjective cues:
"Nahihirapan

Scientific

Nursing Diagnosis

ako"

as nasal

area

verbalized by the dyspnea,


patient.

AEB secretions

to

or verbalize

obstruction

restlessness, use of the

able

from understanding

airway

in management

flaring

partial of regimen

Dyspnea

Restlessnes

complete

blockage of the behaviors


breathing tubes to improve

Use
accessory
muscle

Cough

of

which

the
airway

be

have verbalized an

maintain

understanding
the

facilitate airway

at

therapeutic

3. Elevate head of

rest

or

cause

compromised

management

individual

regimen

3.To

take

of
and

and

demonstrate
behaviors

to

gravity

improve

or

to

decreasing

maintain

clear

or

pressure on the

lungs. maintain clear


can

of the patient.

open airway in

and bed
demonstrate

Obstruction of the airway.

The patient shall

2. Position head to

respiratory of cause and

cough, and nasal clear

1.To get the trust

2.To

accessory muscle, tract to maintain a therapeutic


Objective cues:

Evaluation

Rationale

advantage

diaphragm
enhancing
drainage.

of

and

airway.

Nasal flaring

due to diffecrent

4.To

Prolonged

causes including

effort

expiratory

foreign

phase

allergic reactions,

With

Vital

Signs taken:
BP:100/60
mmHg
PR: 92bpm
RR: 18cpm
T: 36.7 C
SAO2: 97

bodies,

infections,

expectorating

deep breathing

secretions

and caughing
exercise.

5.Hydration can

anatomical

help

abnormalities and

viscous

trauma. The onset


of

respiratory

liquefy

5. Increase fluid

secretions

intake

improve

and

secretion

distress may be
sudden

in

4. Encourage

clearance.

with
6.To

caugh. There is

improve

lung function

often agitation in
the early stage of
airway

6. Support

obstruction.

reduction/cessatio
n of smoking

2. Impaired Physical Mobility

maximize

Assessment
Subjective cues:
"Ang

sakit

katawan

physical

ko

by patient's

Objective cues:
with

gross/fine

limited skills,

movements

limited purposeful

movements, limited physical


ability to

turining,

nursing rapport

the

For desired

and

activities

participate

data.

an increase in the

in signs
and

patient's

difficulty more extremities. activities

as patient to have

also evidenced by adequate rest

movements, ability
3. To regain to
strength.

skills,

from the

easily,

patient's 4. Encourage

motor skills

in

with difficulty

strength

and perform

turning

function,

stiffer gross/fine

muscle ability

and less mobile motor


affecting can

patient to eat
to food rich in

turn patient to do

can
and

motor
turn
an

4. To increase increase in motor


energy level.

carbohydrates.
skills, 5. Advise

perform

gross/fine

body an increase in

aging. Reduction movements,

joints

ADLs

as evidenced by

gross/fine

movements

2.

participated

baseline

3. Advise

is

have

will be able to record vital

motor body or of one or desired

limited ability slowed movements. related to


changes
to
perform

with slowed

cooperation

in

patient. 2. Monitor and

perform movement of the ADLs

and Mobility

Evaluation
Rationale
1. To gain The patient shall

in intervention,

ako." manifested by the independent,

the patient.

is of

pag muscle strength a limitation

verbalized

Nursing

Objectives

Explanation
Interventions
mobility Impaired physical After 3 hours 1. Establish

ng related to decrease mobility

gumagalaw
as

Scientific

Nursing Diagnosis

5. To promote
energy.

agility.

With Vital Signs

balance

can easily, and an deep breathing.

take:

significantly

increase

BP:100/60

compromise

the motor agility.

mmHg

mobility of elderly

patient to have

PR: 92bpm

patients.

adequate fluid

RR: 18cpm

Restricted

intake.

T: 36.7 C

movements

SAO2: 97

affects

in

6. To prevent
6. Advise

dehydration.

7. To promote
the

7. Encourage

energy

of

patient to rest

regain

most activities of

between

strength.

daily living(ADLs.)

activities.

performance

and

8. To reduce
fatigue.
8. Encourage
patient to
engage in
ROM exercise.

3. Fatigue

Assessment

Nursing Diagnosis

"Nanlalambot ako." poor


verbalized

Objective cues:

Nursing

nursing rapport.

Evaluation
Rationale
1. To gain The patient shall
cooperation

as of exhaustion and intervention,


for verbalize

weak, a decreased physical


ability in performing mental

weak

activities,

decrease

compromised
in concentration.

an record vital

and understanding
work

and usual

is

For regarding

baseline

health

data.

on

how

the
teachings

how

conserve
3. Encourage

a teachings

subjective

signs.

2.

at regarding the

level. health

Fatigue

have verbalized an
understanding

the patient will 2. Monitor and

appears capacity

appears

ability

sense of

manifested by the decreased


patient

physical sustained

by condition

the patient.

Objectives

Explanation
Interventions
Fatigue related to An overwhelming After 3 hours 1. Establish

Subjective cues:
as

Scientific

to
energy

as evidence by the

on patient to sit

3.

to instead of

conserve

strong, an increase

energy

in the ability to

appears

performing

complaint on both conserve

activities

acute and chronic energy

as performing

perform activities,

with

illness,

by activities.

and has the ability

compromise

have

function

concentratio

keeps the person strong,

from

it

protective the

patient

that appears

to
4. Advise

an patient to have

sustaining increase in the adequate rest.

injury
With Vital Signs

may evidence

standing in

To patient

overwork

from ability
in

a perform

to
5. Encourage

fully.
4. To regain
strength.

concentrate

take:

weekend

activities, and patient to

BP:100/60

condition.

mmHg

common

PR: 92bpm

symptom, fatigue fully.

RR: 18cpm

is associated with

6. Encourage

T: 36.7 C

patient to eat

6. To increase

SAO2: 97

physical

carbohydrates

energy level.

As

variety

5. To reduce

a has the ability perform ROM

fatigue.

to concentrate exercise.

of
and

psychological

containing

conditions.

food.
7. Encourage

7. To promote

patient to do

energy.

focus
breathing.

X. DRUG STUDY
Name of drugs
Generic name
Brand name

Date Ordered,
Date taken,
date changes,

Route of Admin.
Dosage and
frequency of

General action

Indications/
purposes

Clients response to
medication with actual
side effect

Generic name:
Co-Amoxiclav
Brand name:
Amoclav

D/C
DO: 02/01/15
DT: 02/01/15

administration.
625 mg/cap 1 cap
BID PO

Inhibits enzymes
involve
information of
peptidoglycan
layer of bacterial
cell wall
No effect on
human cell wall
bactericidal; only
works on dividing
bacteria
Well absorb enter
ally

Use in
treating lower
respiratory
tract infection,
Otitis media,
sinusitis, skin
and soft
tissue
infection, and
UTI.

The patient is still within


medication course due to
her WBC result of 15.19.

Generic name:
EPO
Brand name:

DO: 02/01/15
DT: 02/01/15

XI. DISCHARGE PLANNING


MEDICATION:
Instructed to:

Take medications as prescribed by the physician


Ensure the right route in taking the medications
Take the medications on time and without lapse

EXERCISE:
Instructed to:

Do exercises within limits


Avoid the strenuous ones
Active range of motion exercises
Deep breathing exercise

TREATMENT:
Instructed to:

Follow the prescribed treatment regime


Comply with the laboratory examination
Comply with the diagnostic examinations

HYGIENE:

Encouraged to bathe daily


Instructed to do proper hand washing prior to and after handling the patient

OUTPATIENT ORDERS:

Encouraged to have frequent medical visits


Taught to report such as difficultly of breathing and decrease level of
consciousness
Provided with oral and written information regarding this discharge plan

DIET:
Instructed to:

Diet as tolerated
Low fat
Abide by the limited intake of salty foods
Consume high fiber diet in order to prevent constipation
Avoid processed foods
Increased fluid intake except coffee, alcohol and soda