I.

INTRODUCTION

This Case Study is focused on the concept of Acute Biologic Crisis. Acute
Biologic Crisis is understood as the turning point of a disease when an important
change takes place, indicating either recovery or death.

Among the cases to chose, from we chose a client with the diagnosis of Diffuse
Large B Cell Lymphoma. It is a type of Non Hodgkin’s Lymphoma specifically of the B
cell wherein cancer develops as the B cell matures.

Internationally, an estimated 14.1 million new cases of cancer occurred

worldwide. Malignant lymphoma encompasses a wide variety of distinct disease
entities. It is generally more common in developed countries and less common in
developing countries. The East Asia region has one of the lowest incidence rates of
malignant lymphoma (Cancer Research UK 2012). The incidence of malignant
lymphoma around the world has been increasing at a rate of 3-4% over the last 4
decades. Nationally, Cancer remains a national health priority in the country with
significant implications for individuals, families, communities, and the health system. 
Cancer is the third leading cause of morbidity and mortality in the country after diseases
of the heart and the vascular system (Philippine Health Statistics 2009).  Furthermore,
189 of every 100,000 Filipinos are afflicted with cancer while four Filipinos die of cancer
every hour or 96 cancer patients every day, according to a study conducted by
the University of the Philippines’ Institute of Human Genetics, National Institutes of
Health. Lastly, locally, malignant neoplasms of all forms is still the third leading cause of
mortality in all ages (Health Research Priorities by Dr. Victoria Lupase).

Our client presented in this case study is Mr. Roslinda, a 55-year old male in
Cubicle 8 of the Intensive Care Complex at San Pedro Hospital. He experienced loss of
sensorium and was recently diagnosed with Diffuse Large B Cell Lymphoma, Hypoxic
and Metabolic Anemia of Chronic Disease and Mixed Encephalopathy. We chose him
as our client to be presented because his illness puts him at high risk for Acute Biologic
Crisis.
 I believe that this case study in Nursing education impacts greatly on our clinical
reasoning which enhances our ability to develop nursing care plans for our clients with
Acute Biologic Crisis. With Nursing practice, our skills will be honed to deliver our care
plans with the needed care and attention in dealing with patients. Lastly, the
significance of this case in nursing research is that it provides basis in the development
of new interventions and testing its efficacy.

II. GOALS AND OBJECTIVES

GENERAL OBJECTIVE:

That in our 4-week Acute Biologic Crisis Rotation in the Intensive Care Unit of
San Pedro Hospital, we will be able to apply what we learned in real life cases or
situations and execute interventions for clients in Acute Biologic Crisis.

SPECIFIC OBJECTIVES:

To achieve our general objective, we specifically aim to:

A.) choose a client whose case is related to the subject of study,

B.) secure all the consents needed,

C.) explain the purpose of our assessment to the client,

D.) describe the client through a well- written introduction,

E.) formulate specific, measurable, attainable, realistic and time bound objectives,

F.) gather necessary data through an interview that will serve as the baseline
information for the case study,

G.) present the Data Base of the client,

H.) perform a comprehensive cephalocaudal Physical,

I.) define Diffuse B Cell Lymphoma, Hypoxic and Metabolic Anemia of Chronic
Disease

J.) review the Anatomy and Physiology of the Lymphatic System, Immune System,
Nervous System and Skeletal System

K.) trace the pathophysiology of the disease,

L.) justify the Medical management,

M.)formulate a Nursing Care Plans,

N.) present a Discharge Plan,

O.) choose a Nursing Theory appropriate for our client,

P.) supply the references used that helped for the formulation of this case study
following the APA format;

Q.) present the case study in a comprehensive manner.

III. DATA BASE

A. Demographic Data
NAME: Roslinda, Zosimo
 GENDER: Male
AGE: 55 y/o
BIRTHDAY: March 6, 1983
ORDINAL RANK: 3rd out of 4 siblings
BIRTHPLACE: Bohol
NATIONALITY: Filipino
ADDRESS: Park 5 Salvacion Panabo City
RELIGION: Catholic
CIVIL STATUS: Married
SPOUSE: Minda Robin Roslinda
NUMBER OF CHILDREN: 3
EDUCATIONAL LEVEL: College
OCCUPATION: Chemical Engineer
AVERAGE INCOME: Not Disclosed

SOCIAL STATUS: Not Disclosed

B. Clinical Data
CHIEF COMPLAINT: Change in sensorium
DATE OF ADMISSION: August 20, 2018
TIME OF ADMISSION: 4:20 pm
MANNER OF ADMISSION: Per wheelchair
WARD: ICU
ROOM/BED NUMBER: 9
TENTATIVE DIAGNOSIS: Mixed Encephalopathy
Hypoxic and Metabolic Anemia of Chronic
Disease
Diffuse Large B-Cell Lymphoma stage 4
ATTENDING PHYSICIAN: Dr. A. Lui
DATE OF DISCHARGE: N/A
FINAL DIAGNOSIS: Diffuse Large B Cell Lymphoma stage 4

C. Past Health History

The client was delivered via NSVD according to his son. When asked
about his immunizations, his son claimed that he completed it. We checked for
 BCG scar and it is present on his right arm. The client is hypertensive but the
date of diagnosis in unrecalled. He was a smoker and can consume 1 pack of
cigarettes per day for 30 years.

D. Present Health History

The client works as a chemical engineer for more than 20 years and was
exposed to different chemicals. On July 2017, he experienced loss of appetite,
weight loss, bloatedness and some epigastric pain. He did not consult this to a
physician and did not take any medication. On November 2017, he experienced
back pain and dysuria. He consulted this and was given medications and was
relieved. On April 2018, he underwent colonoscopy and found hypoplastic
polyps. On May 13,2018, a paravertebral mass was found and underwent a CT
guided biopsy at PGH. On July 2018, he underwent CT scan and saw multipl
matted abdominal lymph adenopathies with vascular encasement and masses
on the left adrenal gland, spleen and vertebral metastases. Four days prior to
admission, the client started having changes in sensorium and decreased level of
consciousness according to his son, which prompted admission.

Family Health History

CR AR

BR
MR SR
65 ZR
60 53
55
 Legend:

Paitent Pancreatic Cancer

Girl Lymphoma

Boy Hypertension

Deceased
Narrative

The client’s grand parents were unrecalled by the client’s son. The client’s
parents are CR and AR. CR died from pancreatic cancer and her wife AR died of
unknown cause. They have four children namely BR, MR, ZR, and SR. They are all still
alive and has currently no known diseases except for our client ZR who has
hypertension and diffused large B cell lymphoma.

IV. DEVELOPMENTAL TASK

Growing is a lifelong progression of physical, behavioral and emotional growth.

Developing a person’s attitude, values and understanding are just part for an individual
to grow. In Robert Havighurst Developmental Task Theory and Erik Erikson
Psychosocial Theory during this process each stage, the person experiences a
psychosocial crisis, which could have a positive or negative outcome of personality
development. A person must go through and achievable different stages for him grow.

Crisis Result Rationale

Generativity vs. Passed our patient’s son verbalized that his
stagnation father income is enough to provide for
their family.
Developmental Task Result Rationale
Achieving adult civic and Achieved ZR achieved his adult civic
social responsibility  and social responsibility as
he is an officer in the
Disaster team in their
community.
Establishing and Achieved Client ZR is a chemical
maintaining an economic engineer, work in Saudi
standard of living  and Singapore for more
than 20 years. He is also
into farming and cock
breeding.
Assisting teenage children Achieved They spend their time
to become responsible and together, through visiting
happy adults  their farm and sometimes
they being brought to his
workplace as verbalized by
his son.
Developing adult leisure- Achieved Client ZR has a lot friends,
time activities  especially in their
community. An active
member of their Chapel as
verbalized by his son JR.
Relating oneself to one’s Achieved Client ZR has been
spouse as a person  married for thirty years to
his wife, JR, his son
observed that both his
parents are in a good
relationship, they fight but
manage to talk and solved
their problems
 Accepting and adjusting to
the physiologic changes or
middle age  observed that client ZR is
Adjusting to aging parents
Partially Achieved We rate him as partially
achieved because we
still trying his best to fight
and his family are there
supporting him.
Achieved It is achieved because our
client’s parent has long
gone and he was able to
core with the loss as
verbalized by his son JR

V. PHYSICAL ASSESSMENT

General Survey

We conducted the physical assessment of our patient on August 28, 2018 at

8am. With a body built of endomorph, an estimated body weight of 65 kg. The client
was well groomed but was drowsy. With an NGT French 14 inserted in his right nares.
An IVF of PNSS 1Liter + 60meq KCl @ 80 cc/hour and another line of Dopamine
400/250 @ 9.7cc/hour @ right metacarpal vein. PNSS 1l @ 383cc/hour and another
line of PNSS 50cc+ Albumin 20cc + Furosemide 100 @ 5cc/hour infusing at his left
thumb. A blood transfusionline of PNSS 1L @KVO rate infusing at his left brachial vein.
He also has a condom catheter attached to a urometer draining clear yellow urine.

VITAL SIGNS RESULT NORMAL RANGE REMARKS

TEMPERATURE 36.7 35.6-37.2 NORMAL
BLOOD 90/60 – 110/80 90/60-130/90 NORMAL
PRESSURE
RESPIRATORY 11-13 12-20 NORMAL
RATE
CARDIAC RATE 90-105 80-120 NORMAL

Skin
 Skin is uniform tan in color, smooth and warm to touch with good skin turgor.
Skin is dry with well-trimmed nails and has pale pink nail beds noted. Capillary refill test
done with less than 2 seconds. BCG scar is present at his right arm. Edema on his left
arm with blisters and bipedal pitting edema was also noted. Bed sores on his sacrum
was also noted upon assessment.

Head

The head is rounded, normocephalic with closed fontanelles. The skull is

symmetrical and upon inspection scalp is free from dandruff, lice or lesions and upon
palpation the head has no nodules or masses and depressions. Hair is normal in
distribution.  The face of the client appeared smooth  with no presence of nodules or
masses. There are symmetric facial features.

Eyes

Eyebrows are aligned with symmetrical movements. Lids are symmetrical and
lashes are curled upward. The lacrimal duct is not inflamed with smooth cornea and
lens and with pale palpebral conjunctiva. The bulbar conjunctiva appeared transparent
with few capillaries evident and sclera appeared white and is anicteric while the pupil is
isochoric. Both eyes are brisk upon reaction to light. The pupils of the eyes are black
and equal in size. The iris is flat and round, PERRLA.

Ears

The pinna of the patient’s ears is symmetrical and its color is uniform with the
facial skin and aligned with the outer canthus of the eye. Tenderness, lesions and
masses were not noted. The pinna recoils after it was folded. Hearing acuity is not
good.

Nose & Sinuses

The nose of the patient was at the midline and has the same color with the face.
Discharges, lesions or flaring was not noted and it was non-tender upon palpation.
Nasal septum was in midline. Nasal mucosa was pinkish in color was not swelling.
Maxillary and frontal sinuses were also non-tender when palpated.

Mouth

Patients’ lips were pale in color and dry in texture. The oral mucosa was firm and
moist, without any congenital defects and masses upon inspection. The gums and
buccal mucosa were pinkish in color without ulcerations and lesions. The tongue was in
the midline. The salivary ducts have the same color as the buccal mucosa and floor of
the moth and no inflammation and lesions noted. The soft and hard palate were pinkish
without any lesions noted. The uvula is at the midline. Tonsils were pink in color smooth
with no inflammation noted.

Pharynx

The uvula is located in the midline, pinkish mucosa and no inflamed tonsils noted
and with positive Gag Reflex.
Neck

Neck muscles were symmetrical. A mass was noticed at the right side of the
midline of the neck near the adam’s apple. Lymph nodes were palpable. Trachea was in
the midline and spaces were equal on both sides. The thyroid gland of the patient was
not enlarged, and Jugular Vein Distention was not present.

Thorax

The thorax was symmetrical, with anterior-posterior transverse diameter ratio of

1:2. The spinal alignment was vertically aligned. There were no bulges and tenderness
noted. There was full and symmetric chest wall expansion upon assessment. Quiet,
unlabored respirations with no use of accessory muscles noted. Upon palpation, tactile

fremitus was normal. There we also no adventitious sound noted upon auscultation.

Heart

The precordium was not having any abnormal pulsation, heaves or lifts upon
assessment. Point of maximal impulse was at the apex of the heart, located at the fifth
intercostal space left of midclavicular line. Distinct S 1& S2, Cardiac rate was normal and
regular in rhythm while Pulse was strong, pounding, and regular.

Breast & Axillae

Nipples are equal and brown in color with no obvious difference. No lesions,
masses, and tenderness noted. Both areolas and nipples were darker than the
surrounding skin. The axilla was dry and no discoloration was noted on both axilla, with
hair noted; foul odor, rashes, lesions, and masses were also not observed.

Abdomen

The stomach is intact and globular has an unblemished skin and is uniform in
color. A dressing was noted beside the navel. The abdomen has a symmetric contour.
There were symmetric movements caused associated with client’s respiration. With
normoactive bowel sounds but it was firm and distention was noted upon palpation.
Bladder distention was not noted upon palpation.

Genito-Urinary

Upon assessment the patient is wearing diaper with a condom catheter attached
to a urometer. The patient’s penis is well developed but has a wound on the shaft. The
Meatus is in the midline but the scrotum was enlarged and with no pubic hair.

Extremities

The extremities are symmetrical in size and length but edema was noted on the
left arm and both legs. The extremities are symmetrical in size and length. The muscles
are not palpable with the absence of tremors.

NEUROLOGICAL ASSESSMENT

The patient was drowsy with GCS of 10. His orientation was not assessed.His
eye opening was to speech and his speech was incomprehensible. He could move his
extremities but with noticeable weakness.

VI. DEFINITION OF DIAGNOSIS

Hypoxic + Metabolic anemia of chronic disease

Anemia of chronic blood disease (ACD) develops because of chronic disorder such as
cancer, infection, inflammation, heart failure, diabetes, and stroke. It is particularly common
among elderly patient, as they often have one or more chronic disease.

Reference: Capriotti, T., Frizzel, J.K(2016) Pathophysiology.F.A Davis Company. Philadelphia

Anemia is a common consequence of chronic disease. The most common chronic

disease associated with anemia are cancer, chronic kidney failure, autoimmune disoreder and
infectious disease. In cancer anemia is reported in 30% to 90 % of patient ( Knight, Wade, &
Balducci,2004). Fatigue and malaise indicative of anemia are sometimes dismissed by health
care providers as psychosocial consequence of chronic disease.
Reference: Hannon, R.A., Pooler, C., Porth, C.M.(2010) Porth Pathophysiology. Lippincott
Williams & Wilkins

Anemia of chronic disease is seen in the setting of chronic infection, inflammation, or

malignancy. This is characterized by low serum iron, reduced transferrin saturation, reduced
iron binding capacity, reduced red cell survival and inadequate erythropoietin response.

Reference: Wahed, A.,Dasgupta,A.(2015) Hematology and Coagulation: A Comprehensive

Review for Board Preparation, Certification and Clinical Practice. Elsevier Health Science

Encephalopathy

Encephalopathy 1.1% of adults in the general population age 55 years old and above.is
a clinical syndrome of global cognitive impairment characterized by impaired arousal,
inattention, and disorientation. Causes of encephalopathy can be tumor of the central nervous
system, metastatic, and metabolic disturbances.

Reference: Ferri, F.F.(2015) Ferri’s Clinical Advisor 2015 E-Book. Elsevier Health Science

Encephalopathy, the attention and cognitive functions such as perception, thinking and
memory are affected. Alertness tends to fluctuate between agitation and lethargy. Numerous
endogenous conditions, including cancer, nutritional and hypoxic disorder, and fluid and
electrolytes disorder may be responsible for encephalopathy in critically ill patient.

Reference: Baue, A.E., Berlot, B., Vincent, L.J(2013) Sepsis and Organ Dysfunction: The
Challenge Continues

Encephalopathy encompasses a spectrum of neuropsychiatric abnormalities. The

spectrum includes personality changes, impaired mental function, motor abnormalities
(asterixis, tremor, hyperactive reflexes) and altered consciousness.

Reference: Vincent, J.L., Abraham, E., Kochanek, P. etc(2011) Textbook of Critical Care E-
Book. Elsevier Health Science

Diffuse large B-cell lymphoma

 lymphoma are solid tumor of lymphoid cells, and the most common type of blood cancer
in the United State, lymphoma falls into two major categories: Hodgkin's lymphoma and Non-
Hodgkin Lymphoma. Non-Hodgkins can be caused by cancerous B-cell, T-cell, or NK cells and
are classified according to cells type and aggressiveness. They usually develop among middle
age and older adults and are 50% more frequent in men than women. Children and young
adults are occasionally diagnosed with NLH; in these patients, the lymphomas are more
aggressive. Stage 4 (widespread or disseminated disease): lymphoma is outside the lymph
nodes and spleen and has spread to another area or organ such as bone marrow, bone, or
central nervous system.

Reference: Capriotti, T., Frizzel, J.K(2016) Pathophysiology.F.A Davis Company. Philadelphia

Diffuse large B-cell lymphomas are heterogenous group of aggressive germinal or post
germinal centre neoplasm. The disease occurs in all age group but is most prevalent between
60 and 70 years of age. The cause of diffuse large B- cell lymphoma is unknown. It is rapidly
evolving, multifocal, nodal and extra nodal tumor.

Reference: Hannon, R.A., Pooler, C., Porth, C.M.(2010) Porth Pathophysiology. Lippincott
Williams & Wilkins

The World Health Organization classification defines diffuse large B-cell lymphoma as a
group of proliferations of large B-cell lymphoid cells with a diffuse growth pattern. DLBCL is the
most common hematopoietic malignancy, accounting for one-third of mature B-cell neoplasm.

Reference: Younes, A., Coiffier,B.(2013) Lymphoma: Daignosis and treatment. Vol.43 of

Current Clinical Oncology. Springer Science & Business Media

VII. ANATOMY AND PHYSIOLOGY

Lymphatic System

The key functions of the lymphatic system:

  Drains excess fluids and proteins from tissues all around the body and returns
them back into the bloodstream.
 Removes waste products produced by cells.
 Fights infections.
 Absorbs fats and fat-soluble vitamins from the digestive system and transports
these into the bloodstream.

Lymph
Lymph is a fluid that circulates throughout the body in the lymphatic system. It
forms when tissue fluids/blood plasma (mostly water, with proteins and other
dissolved substances) drain into the lymphatic system. It contains a high
number of lymphocytes (white cells that fight infection). Lymph that forms in the
digestive system called chyle, this contains higher levels of fats, and looks milky
white.

Lymph vessels
Walled, valved structures that carry lymph around the body

Lymph nodes
Small bean-shaped glands that produce lymphocytes, filter harmful substances
from the tissues, and contain macrophages, which are cells that digest cellular
debris, pathogens and other foreign substances. Major groups of lymph nodes
are located in the tonsils, adenoids, armpits, neck, groin and mediastinum.

Thymus
The thymus is a specialized organ of the immune system, located between the
breast bone and heart. It produces lymphocytes, is important for T cell
maturation (T for thymus-derived).

Spleen
The spleen is an organ in the upper left abdomen, which filters blood, disposes
of worn-out red blood cells, and provides a 'reserve supply' of blood. It contains
both red tissue, and white lymphatic tissue. Different parts of the the spleen
 specialize in different kinds of immune cells.

The major (encapsulated) lymphatic organs are the lymph nodes, thymus and
spleen. In addition the lymphoid tissues include:

Mucosa-associated lymphoid tissue (MALT)

These are . These nodules contain lymphocytes and macrophages which defend
against invading bacteria and other pathogens that enter these passages along
with food, air, or urine. These nodules can be solitary or grouped together in
clusters.

Major clusters of lymphatic nodules include:

 Tonsils: these are clusters of lymphatic tissue under the mucous

membrane lining of the nose, mouth, and throat. Lymphocytes and
macrophages in the tonsils provide protection against foreign substances
and pathogens that enter the body through the nose or mouth.
 Adenoids: A cluster of lymphatic tissue that hangs from the upper part of
the back of the nasal cavity. Adenoids get bigger after birth but usually
stop growing by the age of 7. Like the Tonsils, they can be removed
without significantly increased risk of infections.
 Peyer's patches: these are clusters of lymphatic nodules in the mucosa
that lines the ileum of the small intestine. They play an important role in
defending against the large number of pathogens that enter the
gastrointestinal system.

Circulation of tissue fluids

Fluid in the spaces between tissues is called interstitial fluid, or 'tissue fluid'. This
provides the cells of the body with nutrients (via the blood supply) and a means of waste
removal. Lymph is formed when the interstitial fluid is collected through tiny lymph
capillaries (see diagram), which are located throughout the body. It is then transported
through lymph vessels to lymph nodes, which clean and filter it. Lymph then flows on to
the lymphatic ducts, before emptying into the right or the left subclavian vein, where it
mixes back with blood.

Blood is enriched with oxygen (by the respiratory system) and nutrients (by the digestive
system), which are circulated all around the body (by the cardiovascular system). Some
fluid (blood plasma) leaks out into the tissues via tiny capillaries, contributing to
interstitial fluid, which eventually drains back into the lymphatic system.

Immune System

The immune system includes a variety of defenses against viruses, bacteria, fungal
infections, and parasites (such as thread worms). The lymphatic system is part of the
broader Immune System.

Innate immune system

This are the non-specific, unchanging lines of defenses which include:

 Physical and chemical barriers to pathogens.

 Producing cytokines and other chemical factors to recruit immune cells to
sites of infection.
 Activates the complement cascade to identify bacteria, activate cells and
to promote clearance of dead cells or antibody complexes.
 Identifies and removes foreign substances present in organs, tissues, the
blood and lymph, by specialized white blood cells.
 Activation of the adaptive immune system, through a process known
as antigen presentation.

Adaptive immune system

 Adaptive (or acquired) immunity is where immunological memory is made after
an initial response to a new pathogen, leading to an enhanced response to future
exposure to that same pathogen. This process of acquired immunity is the basis
of vaccination. This is essential because bacteria and viruses are continually
adapting and evolving in an 'arms race' with our immune systems. Features of
the adaptive immune system include:

 Recognition of specific "non-self" antigens, during the process of antigen

presentation.
 The generation of responses tailored to destroy specific pathogens or
pathogen-infected cells.
 Development of immunological memory, in which each pathogen is
"remembered" by signature antibodies or T cell receptors. These memory
cells can be called upon to quickly eliminate a pathogen should
subsequent infections occur.

Cells of the Immune System

There are many different cell types and sub-types involved in the immune
system. Some of the main types include:

 Lymphocytes: are white cells which circulate between blood and lymph.
They play an important role in fighting infection. There are many kinds of
lymphocytes; the main types are T cells, B cells and natural killer cells.
Lymphocytes initially develop in the bone marrow. Some migrate to the
thymus, where they mature into T cells ; others mature in the bone marrow
as B cells.

B Cell Development

In the bone marrow, the Common lymphoid precursor turns into the Pre-B
lymphoblast then Naive B-cell. The Naive B-cell is then transported to the
 Lymph nodes where it becomes a Germinal Cell. These germinal cells or
centroblasts will then be differentiated to a specific type of B cell.

 Neutrophils: are the most abundant type of white blood cells and are an
important part of the innate immune system. Neutrophils are a type
of phagocyte (cells which engulf and then digest, cellular debris and
pathogens). They are normally found in the blood stream, but are quickly
recruited to the site of injury or infection following chemical signals such as
Interleukin-8.
 Macrophages: are another type of phagocyte and have a role in both the
innate and adaptive immune systems. They attack foreign substances,
infectious microbes and cancer cells. Macrophages also stimulate
lymphocytes and other immune cells to respond to pathogens.
 Dendritic cells: are antigen-presenting cells which act as messengers
between the innate and adaptive immune systems. They are usually
located in tissues in contact with the external environment such as the
skin, linings of the nose, lungs, stomach and intestines. In response to
pathogens they migrate to the lymph nodes where they interact with T
cells and B cells to initiate the adaptive immune response.

Antigens and Antibodies

Antibodies (also known as an immunoglobulins) are Y-shaped proteins produced
by B-cells,that bind to specific antigens on the surface of foreign objects such as
bacteria and viruses. This identifies and 'tags' the foreign object as 'non-self',
signalling other immune cells to attack them.

Hormones and the Immune System

 There are several hormones generated by the immune system. These hormones
are generally known as lymphokines. Steroids and corticosteroids (components
of adrenaline) suppress the immune system.

Skeletal System

Vertebrae
Vertebrae are the 33 individual bones that interlock with each other to form the spinal column.
The vertebrae are numbered and divided into regions: cervical, thoracic, lumbar, sacrum, and
coccyx . Only the top 24 bones are moveable; the vertebrae of the sacrum and coccyx are
fused. The vertebrae in each region have unique features that help them perform their main
functions.

Cervical (neck) - the main function of the cervical spine is to support the weight of the head (about
10 pounds). The seven cervical vertebrae are numbered C1 to C7. The neck has the greatest
range of motion because of two specialized vertebrae that connect to the skull. The first
vertebra (C1) is the ring-shaped atlas that connects directly to the skull. This joint allows for the
nodding or “yes” motion of the head. The second vertebra (C2) is the peg-shaped axis, which
has a projection called the odontoid, that the atlas pivots around. This joint allows for the side-
to-side or “no” motion of the head.

Thoracic (mid back) - the main function of the thoracic spine is to hold the rib cage and protect the
heart and lungs. The twelve thoracic vertebrae are numbered T1 to T12. The range of motion in
the thoracic spine is limited.

Lumbar (low back) - the main function of the lumbar spine is to bear the weight of the body. The
five lumbar vertebrae are numbered L1 to L5. These vertebrae are much larger in size to absorb
the stress of lifting and carrying heavy objects.

Sacrum - the main function of the sacrum is to connect the spine to the hip bones (iliac). There
are five sacral vertebrae, which are fused together. Together with the iliac bones, they form a
ring called the pelvic girdle.

Coccyx region - the four fused bones of the coccyx or tailbone provide attachment for ligaments
and muscles of the pelvic floor.

Nervous System

Brain
  
The brain is an organ that’s made up of a large mass of nerve tissue that’s protected within the
skull. It plays a role in just about every major body system.

Some of its main functions include:

 processing sensory information

 regulating blood pressure and breathing

 releasing hormones

Cerebrum

The cerebrum is the largest part of the brain. It’s divided into two halves, called hemispheres.
The two hemispheres are separated by a groove called the interhemispheric fissure. It’s also
called the longitudinal fissure.

Each hemisphere of the cerebrum is divided into broad regions called lobes. Each lobe is
associated with different functions:

 Frontal lobes. The frontal lobes are the largest of the lobes. As indicated by their
name, they’re located in the front part of the brain. They coordinates high-level
behaviors, such as motor skills, problem solving, judgment, planning, and attention.
The frontal lobes also manage emotions and impulse control.
 Parietal lobes. The parietal lobes are located behind the frontal lobes. They’re
involved in organizing and interpreting sensory information from other parts of the
brain.

 Temporal lobes. The temporal lobes are located on either side of the head on the
same level as the ears. They coordinate specific functions, including visual memory
(such as facial recognition), verbal memory (such as understanding language), and
interpreting the emotions and reactions of others.

 Occipital lobes. The occipital lobes are located in the back of the brain. They’re
heavily involved in the ability to read and recognize printed words, along with other
aspects of vision.

Cerebellum

The cerebellum is located in the back of the brain, just below the occipital lobes. It’s involved
with fine motor skills, which refers to the coordination of smaller, or finer, movements, especially
those involving the hands and feet. It also helps the body maintain its posture, equilibrium, and
balance.X

Diencephalon

The diencephalon is located at the base of the brain. It contains the:

 thalamus

 epithalamus

 hypothalamus

The thalamus acts as a kind of relay station for signals coming into the brain. It’s also involved
in consciousness, sleep, and memory.

The epithalamus serves as a connection between the limbic system and other parts of the brain.
The limbic system is a part of the brain that’s involved with emotion, long-term memory, and
behavior.

The hypothalamus helps maintain homeostasis. This refers to the balance of all bodily functions.
It does this by:
 maintaining daily physiological cycles, such as the sleep-wake cycle

 controlling appetite

 regulating body temperature

 controlling the producing and release of hormones

Brain stem

The brain stem is located in front of the cerebellum and connects to the spinal cord. It consists
of three major parts:

 Midbrain. The midbrain helps control eye movement and processes visual and
auditory information.

 Pons. This is the largest part of the brain stem. It’s located below the midbrain. It’s
a group of nerves that help connect different parts of the brain. The pons also
contains the start of some of the cranial nerves. These nerves are involved in facial
movements and transmitting sensory information.

 Medulla oblongata. The medulla oblongata is the lowest part of the brain. It acts as

the control center for the function of the heart and lungs. It helps regulate many
important functions, including breathing, sneezing, and swallowing.

VIII. PATHOPHYSIOLOGY

A. Etiology
Predisposing Factors

Factor Present/Absent Rationale

 1. Age Lymphoma is most
common in people over
60. However, some
types are more common
in children and infants.

2. Gender Women are more likely

to develop non-
Hodgkin’s lymphoma.

3. Race White Americans in the

United States are more
likely to develop some
types of lymphoma than
African-Americans or
Asian-Americans.

4. Family History Passing of defective

genes and adaptation of
lifestyle especially of
immediate family
members.

Precipitating Factors

Factor Present/Absent Rationale

1. Exposure to Have carcinogenic
certain chemicals agents that can
and drugs transform proto-
(nicotine, oncogenes to
insecticides, oncogenes.
herbicides)

2. Radiation Have carcinogenic

agents that can
transform proto-
oncogenes to
oncogenes.

3. Weakened Weakened thus more

immune system susceptible to mutation.
(HIV)

4. Autoimmune Anomalies of the cell

Disease make it more at risk of
mutating

5. Viral Infections Destroys cells which

(HIV, EBV) makes them more
susceptible to mutation
B. Symptomatology

Symptom Present/Absent Rationale

1. Painless, swollen Infiltration with malignant
lymph nodes cells (metastases)
brought to the node with
the lymph flowing from
an area 

2. Abdominal pain Lymphomas that start or

grow in the abdomen
(belly) can cause swelling
or pain in the abdomen.
This could be from
lymph nodes or organs
such as the spleen or
liver enlarging, but it can
also be caused by the
build-up of large
amounts of fluid. 
3. Loss of appetite An enlarged spleen
might press on the
stomach, which can
cause a loss of
appetite and feeling full
after only a small meal.

4. Persistent fatigue Malignant cells make

use of the body’s energy
supply to proliferate

5. Fever It is because of a release

of chemicals into the
blood that raise your
body temperature
(similar to when you
have an infection)
 6. Night sweats
It is the body’s reaction
to your temperature
rising to above a normal
level (fever). Night
sweats may also be a
response to some of the
abnormal hormones and
proteins produced by the
lymphoma cells.

7. Unexplained Malignant cells make

weight loss use of the body’s energy
supply to proliferate

C. Schematic Diagram
Predisposing Factors Precipitating Factors
Age Exposure to chemicals

Gender Carcinogenic agent Radiation

Race Autoimmune Disease

Family History Normal B-cell Weakened immune system

Viral infection
DNA damage

Activation of growth Inactivation of tumor Alteration in genes that

promoting oncogenes suppressor cells control apoptosis

Cell mutation

Fatigue and weight Mutated B-cells

loss are vascularized

Enlarged lymph nodes

Invasion into lymph nodes and epigastric pain
and blood vessels (splenomegaly)

Transportation and with

other blood elements

Arrest in capillary
bed of organs

Adherence of
cancer cells

Escape from
vessels
 Establish microenvironment and
growth into organ

Brain Bone

Impaired brain
function Vertebrae (T11, Bone marrow
T12, L1

Encephalopathy Reduced
DOB, impaired production of RBC
bladder and bowel and WBC
Changes in movement
sensorium and
seizures

Hypoxia Infection

Shock Sepsis

If treated If not treated

Maintenance of Multiple organ

physiological failure
function

Poor prognosis Death

D. Narrative

The predisposing and precipitating factors will lead to the exposure of the cell, in
this case, the B-cell, to carcinogenic agents. These carcinogenic agents will then cause
DNA damage which will result to activation of growth promoting oncogenes, inactivation
of tumor suppressor genes and alteration in genes that cause apoptosis. This will then
cause the B-cell to mutate. These mutated B-cells will then be vascularised and
eventually invade into the lymph nodes and blood vessels. This causes swelling of
lymphnodes and epigastric pain because of the splenomegaly. Once these mutated B-
cells invade the lymph nodes and blood vessels these becomes a medium of
transportation to them thus they are able to interact with other blood elements. They will
then arrest in capillary beds of a random organ and adhere to the cells of these organs.
Once they escape from vessels they can finally establish a microenvironment and
growth in the organ into metastases. In our patient’s case, his lymphoma has
metastasized to the bone specifically the vertebrae as well as the brain but it has not yet
been confirmed. Bone metastasis can result to different dysfunctions depending to
where the metastasis is but in our client’s case the metastasis has lead to the bone
marrow being unable to produce enough RBC and WBC as evidenced by his laboratory
exams. The low RBC can put the patient at risk for hypoxia and eventually shock while
the decreased WBC can put him at risk of infection, especially pneumonia, and
eventually sepsis. Metastasis to the vertebrae specifically T11, T12 and L1 can also
cause difficulty of breathing, impaired bowel or bladder function because they play a
part in these physiological processes. On the other hand, brain metastasis, which has
not yet been confirmed, could cause brain damage which leads to encephalopathy and
is manifested through our client’s change in sensorium and seizures.

IX. MEDICAL ORDER

August 20, 2018 Pls. admit under Dr. Lui
 Secure consent
 DAT
 PNSS1L @ 140 cc/hour fast drip
200 cc now
 VS every 4 I&O every shift
 Labs
1. CBC, blood type now
2. Creatinine now
3. Electrolytes + Mg now
4. Albumin now
5. CBG now
6. ECG now
7. Blood CS x2 site now
8. VA once
9. Chest x-ray AP
10. ABG with electrolyte
 O2 at 2L/min nasal cannula
 Secure 2 units blood
 Transfuse once available after
cross matching
 Increase IV rate to 160cc/hour
 Please facilitate movement of
blood transfusion and transfuse
once available
August 21, 2018
8 am Conferred with Dr. Lui
 Repeat serum creatinine + ionized
calcium
 Refer ionized calcium, do serum
calcium

12:20pm  Repeat creatinine as ordered

 Review of PNSS1L x 6 hour,

please give furo 40 mg IV after
every cycle of PNSS

 Facilitate blood transfusion of at

least 2 units pack RBC

 Fast drip 500cc

 Repeat serum creatinine and

calcium
  Albumin 20 % 50 cc IV infusion
every 12 each for 4 hours
 For pre & post albumin and BT
assessment
 For close I & O monitoring
 Decrease IVF to KVO rate on BT
 For assessment prior to increase
VS every hour for now
 I&O every 4 hour
 Hydration round every 4 hour
 Increased IVF rate 160cc/ hour x 4
hours
 Fast drip 200cc now and recheck
BP
 Maintain IVF at 160cc/ hour after
fast drip x 4 hours then reassess
 May proceed with BT of available
pack RBC

 Decrease IVF to KVO while in BT

3:45 pm

10:30 pm
August 22, 2018
3am  Facilitate repeat serum creatinine
this 5 am

5am  Follow up s. electrolyte and s.

creatinine result this 6:30am
  Strictly no dairy in diet
 No food supplements
 IVF rate of PNSS of 160cc/hour
7:57am decrease D5W to KVO
 Reassess after 1 hour

 May give furo 40 mg IV now

 Increase IVF PNSS to 160cc/ hour

 Facilitate Blood Transfusion

8am  Decrease IVF to KVO once
ongoing Blood Transfusion
 For post BT assessment
 Measure I & O accurately

3pm  Continue hydration at 110cc while

not hooked to BT
 Discontinue KCl tab confirmed by
Dr. Leano

 Increase IVF rate to 200 cc/hour

3:45 pm

 Fast drip 200cc now and recheck

blood pressure
 Maintain IVF at 160cc/hour after
fast drip x 4 hours then reassess
 Facilitate giving furo, may give furo
as long as systolic BP >100
 Dr. Jen Togonon (nephron) pls.
7:30 pm refer
 Nephrology
1. Repeat electrolyte today STAT
include Mg
10:30pm 2. Strict I&O every shift
3. Increase IVF rate to 180cc/ hour
4. Get full minute of heart rate
 5. Reassess IVF after
 For repeat serum creatinine

 Start D5H2O 40cc/hour as side

drip then give furo IVTT

 Repeat serum Mg

 Include serum creatine

11:20 pm
August 23, 2018
11:45  Repeat serum creatinine

August 24,2018
5am  Please insert 3-way catheter
 Repeat s. creatinine and calcium
conferred by Dr. Lui

 Conferred Dr. Leano

6am
 Monitor I & O accurately

 Rounds with Dr. Hereda

 Suggest to hold Bisulfate for now

9am due to worsening of renal function

 Maintain hydration

 Please insert NGT and start OF

feeding
  Maintain IVF at 300cc

Conferred with Dr. Lui

 Dr. Roa out please refer to Dr.

Brato for evaluation

August 25, 2018

 Maintain 300cc x 4
 Start OF 2,00 kcal/ day
 Conferred with Dr. Lui
 Please carry out Dr. Brato suggest
 For repeat chest x-ray today
 CBG every 8 hour

 Albumin 20% 50 cc + Furo 100g +

PNSS 50 cc at 10cc/ hour
10:10
 Discussed the need of internal
jugular catheter insertion for
adequate hydration and
monitoring, possible for
hemodialysis

 Please transfer service back to Dr.

Leano

 For serum ionized calcium – HOLD

 Continue albumin at 10 cc/hour

 Maintain IVF rate of 300cc
reassess 2 hours after

9:45 pm
ICU
August 26, 2018
9:30 Rounds with Dr. Leano
 Transfer patient to ICU

 Please transfer patient to ICU

9:41
 Secure consent

 Monitor every hour

 O2 at 3L/ min via nasal cannula

 OF 2,000 kcal

 Still for stool exam x 3

 Follow-up serum electrolyte + Mg

1. PNSS1L at 340cc/ hour

2. PNSS 50 cc + Albumin 20
% 50 cc + Furo 100mg at 5
cc/hour
3. D5W500 at KVO
 CBG every 8 hours
 Will inform for Dr. Lui, Leano

August 27, 2018

12:50 am  Shift D5W500 to PNSS1L + 60
meq KCl at 80 cc/hour
 Decrease PNSS to 280 cc/ hour
 Review of IVF
1. PNSS at 280cc/hour
2. PNSS + 60 meq KCl at 80
cc/hour
3. PNSS + Albumin 20 % 50
cc + furo 100mg at 5 cc/
hour
4. Cumulative of 367.4 cc/
hour
5. Dopamine 400/250 at 1
mkd (2.4 cc/hour)
  Start MgSO4 500 mg + 30 cc
PNSS slow IV push every 6 hours
x 2 doses

8am  Increase O2 4L/ min via nasal

cannula

9:30  Repeat CBC

 Discontinue Dexamethasone oral

 For repeat serum potassium and

2:30pm calcium

 Blood CS x 2 sites now

3pm
 Sputum GSCS

 Dr. Lui informed and updated

 Secure 1unit pack RBC of patient

blood type and transfuse once
properly cross match

Rounds with Dr. Leano

 For routine ionized calcium
tomorrow
 Increased cumulative IVF
400cc/hour
 For serum electrolyte + Mg at 12
noon tomorrow ( routine)
 Hold repeat serum potassium and
5:30pm calcium tomorrow
 Do serum electrolyte as ordered

Conferred with Dr. Leano

 Hold ionized calcium
7pm
August 28, 2018
4am  Please shift to calcium/ dairy free
OF
 Free water flushing of 140cc
 Repeat serum sodium at 12pm
today

7am  Transfuse 1unit pack RBC at 12

noon after repeat sodium is
extracted

 Pre & post BT assessment

Rounds with Dr. Togonon

2pm  May transfuse available blood unit
available as ordered
 Agree with repeat serum creatinine
Review of fluids
1. Dopamine 400/250 at 5 mkd (12.2
cc/ hour)
2. PNSS at 383cc/hour
3. PNSS 50cc + 20% albumin +
100mg furo at 80cc/ hour
4. PNSS at KVO (10 cc/hour)
Total: 413.2 cc/hour
 Plan to decrease IVF rate to 250
cc/hour if okay with AP
 Continue free PO flushing 140 cc
every hour until further order
 Repeat serum sodium tomorrow
am include CBC

9:30 pm
Conferred with Dr. Togonon
 Decrease IVF cumulative rate to
300
 Increase Furo drip to 10 cc/hour
10pm
August 29,2018
8:18am  Repeat serum sodium at 12 noon
 Continue free H2O flushing until 12
noon
Rounds with Dr. Lui
9am  Include serum albumin in next
blood extraction
 Bed sore precaution
Conferred with Dr. Togonon
 Revise free H2O flushing to 130 cc
q hourly for 10 hours
10:04am  Include serum calcium in next
blood extraction
 Decrease IVF cumulative rate to
200cc/hour
Confirmed with Dr. Togonon
 Decrease IVF rate to 140 cc/ hour
 Repeat serum calcium tomorrow

Rounds with Dr. Togonon

 Free water flushing 200 cc now per
6:20 pm NGT
 Cycle albumin cocktail

8pm

August 30, 2018

6:30am  Include repeat serum potassium in
today’s blood extraction
 Decrease O2 at 2L/ min via nasal
cannula, maintain O2sat > 95%
9am  Maintain IV cumulative rate of
140cc/hour

Rounds with Dr. Lui

  May not reinsert NGT
9:49am  May have soft diet
 Ready for transport to room of
choice

 Start KCl DRIP 40 meq KCl +

PNSS at 80cc/hour x 2 cycle

 Repeat serum potassium after 2nd

10:14 am cycle

 Maintain IVF cumulative rate of

140cc/hour

Conferred with Dr. Leano

 For correction of hypokalemia – no
clearance nephron
 Observe strict aspiration
precaution

Rounds with Dr. Togonon

 Add 6 scoop of Beneprotein to
10:22 lugaw/ rice per meal

4:30pm
August 31, 2018
7am  Include CBC in today’s lab

 Incorporate 100mg Furo + albumin

10am drip at succeeding drops at
10cc/hour

 New prep. 200mg Furo + 1 vial

albumin + 50 cc PNSS at 10cc/
hour

 Facilitate repeat serum potassium

post 2nd unit KCl drip as ordered
  Decrease furo to 5cc/hour

Conferred with Dr. Leano

11am  Decrease IVF to 80cc/hour,
incorporate 40 meq KCl to present
fluid
 Repeat serum electrolyte with Mg
11:55 tomorrow AM include CBC, SGPT,
APTT
September 1,2018
5:45am  Maintain albumin and Furo cocktail
at 5cc/hour
 Maintain BP >100/60

Rounds with Dr. Leano

 Include serum creatinine in lab.
1:30 pm today

 Continue KCl drip x 2 more cycle

2pm  MgSO4 2g + 20cc D5W x 24 hours

 Repeat potassium and Mg

 Cranial CT-Scan with contrast now

 Increase cumulative to 180cc/hour

 Creatinine 48 hours post scan

2:45 pm

9pm
September 2,2018
6am  Creatinine 48 hours post CT Scan,
include CBC, Sodium, Potassium,
Magnesium, Calcium, Albumin
 Chest X-ray tomorrow
 Insert NGT, start of 2000 kcal in 7
divided feeding

 Electrolyte and Mg now

 Include ammonia in next blood

10am extraction – hold

 Delay electrolyte and Mg

12
Rounds with Dr. Togonon
 Add 6 scoops of Beneprotein to
feeding

6:30pm
September 3, 2018
6am  Labs for today CBC, serum
electrolyte + Mg, albumin,
creatinine and Chest X-ray

Round with Dr. Leano

11:20am
 ABG now

Dr. Anuta informed

 Secure 1 unit of pack RBC of
1:35pm patients blood type and transfuse
once available

 Secure clearance from all services

for lumbar tap

2pm  For bleeding and clotting time

2:40pm
September 4, 2018
12:40  PBS smear
 CBG to BID

Rounds with Dr. Anuta

1pm  If lumbar puncture can’t be done
 For cranial MRI + contrast
 CBC with pH count now

 Facilitate cranial MRI with contrast

3:25pm  Secure 1 unit pack RBC of patient
blood type transfuse after proper
cross matching with same BT
5pm order

 FOBT

 Increase albumin + Furo to

10cc/hour

 IVF cumulative at 40cc

September 5, 2018
7:15 am Rounds with Dr. Lui
 For MRI today
 Trans out to room per request

Rounds with Dr. Leano

 Remove catheter
11:45 am  For transfer to private room

Procedure

Capillary blood glucose Blood glucose monitor blood glucose

changes, testing allows for quick
response to high blood sugar or low blood
sugar
Arterial Blood Gas ABG is done for our client, mainly to
evaluate gas exchange and to determine
the acid-base level of the blood.
Electrocardiography Routinely used to assess the electrical
and muscular function of the heart
Blood Transfusion Blood transfusion is performed to client
ZR to treat anemia and to make sure that
there is enough oxygen.
 Foley Catheter catheterization is a medical procedure
used to drain and collect urine from the
bladder. It is inserted to our client to
prevent urinary retention and measure
accurately his output.
Nasogastric Intubation Used for feeding and administering oral
drugs.
Peripheral Blood Smear The Peripheral Smear test is done for our
client to measure the level of Parasite
Growth in the blood and also to detect
Anemia and Blood Cancer 
Magnetic Resonance Imaging A scanning technique for creating
detailed images of the internal body
structure and to measure brain structure
and function
Intake and Output Fluid balance monitoring is the recording
of intake and output of fluid. These
measurements are important to help
evaluate client ZR fluid and electrolyte
imbalance, to suggest various diagnoses
and allow prompt intervention to correct
any imbalances.
Vital Sign Monitoring the pulse, respiratory rate,
blood pressure, and temperature are
essential to us in identifying deterioration
in our client

X. Medical Management

A. Actual Diagnostic and Laboratory Tests

Hematology – These are series of tests of the peripheral blood that gives information
about the hematologic system and many other organ systems. This test may be
particularly helpful in determining whether you have too few red blood cells, which
causes anemia.

Component

Normal Range

Rationale

Result
(08-20-18)

Result
(09-05-18)

Interpretation/

Significance

Nursing Responsibilities

Hemoglobin

120-160 g/L

‘This is a test to measure the total amount of hemoglobin, and thus the iron status and oxygen-
carrying capacity of the blood

83 g/L
110g/L

Low

-A Low hemoglobin level indicates anemia, recent hemorrhage, or fluid retention, causing
hemodilution

Prior:

 Explain the purpose and what to expect.

 No food or fluid restrictions.
 Check the doctor's order.
During:

 Do not take the blood sample from hand or arm with receiving IVF.
 The tourniquet should be less on a minute.
 Do not squeeze the punctured site rightly.
 Wipe away the first drop of blood.
After:

 Label the specimen.

 Secure the results.
 Note for inflammation of punctured site.
 Render health teachings such as to:
a. eat foods rich in in iron, folic acid or vitamin B12 such as green leafy vegetables, seafood and
beans.

Red Blood Cells

4.0-5.0 10^12/L

The red blood cell count is an important test because the number of red blood cells (RBCs) you
have can affect how much oxygen your tissues receive.

3.2710^12/L
3.9710^12/L

Low

-A depressed count may indicate anemia, fluid overload, or hemorrhage beyond 24 hours

MCH

28-33 pg

Mean Corpuscular Hemoglobin. The MCH test measures the amount of hemoglobin in the
average red blood cell.

25.4 pg

27.8 pg

Low

-A Low MCH level may indicate anemia

 MCV

82-98 fl

Mean Corpuscular Volume. The MCV test measures the size of the average red blood cell.

77.6 fl

84 fl

In Aug. 20 the result is low which indicate anemia

MCHC

33-36 g/L

Mean Corpuscular Hemoglobin Concentration. Measures average hemoglobin concentration

within 100ml or 1 dl of packed RBCs

32.7 g/L
 31
g/L

In Aug. 20 the result is Decreased which Indicates hemoglobin deficiency

White Blood Cells

4.8-10.8 10^9/L

It is used to detect infection or inflammation and to monitor a client’s response to adverse

effects of therapies.

6.3
10^9/L

7.7
10^9/L

Normal

Neutrophil

40-70%

These neutrophils are an integral part of our immune system and through a process called
chemotaxis, they reach any place where an infection has occurred.

 Neutrophils are powerful white blood cells that destroy bacteria and fungi

62%

89%
 High

- If a person has heightened levels of neutrophils in their body, the disorder is known as
neutrophilic leukocytosis. This condition is a normal physical response to an event, such as
infection, injury, inflammation, some medications, and certain types of leukemia

Lymphocyte

19-48%

This test measures the number of lymphocytes (a type of white blood cell) in blood. It is used to
evaluate and manage disorders of the blood or the immune system.

21%

4%

Low
decrease lymphocyte counts can occur after a cold or another infection, or be caused by intense
physical exercise.

Monocyte

3-9%

A second line of defense, increasing in chronic infections. Monocytes are responsible for
attacking and breaking down germs or bacteria that enter a person's body.

16%
 6%

High
-It indicates that An increased number of monocytes in the blood (monocytosis) occurs in
response to chronic infections, in autoimmune disorders, in blood disorders, and in certain
cancers.

Eosinophil

2-8%

 Phagocytic, destroy antigen-antibody complexes before they can harm the body.
Eosinophils are responsible for destroying parasites and cancer cells, and they are part of an
allergic response.
1%

1%

Low

-may be decreased by stress response; due to trauma, shock, burns, surgery, mental distress,
Cushing's Syndrome
 Basophil

0-0.5%

A type of WBC that fights parasitic reactions, prevents blood clots, mediates allergic reactions.

0%

0%

Normal

Hematocrit

0.37-0.45%

The hematocrit shows the oxygen-carrying capacity of the blood. This value also tells whether
the blood is too thick or too thin.

Useful as a measurement of red blood cells only if the hydration of the client is normal.

0.25%
0.33%

Low

-Low Hematocrit suggests anemia, hemodilution, or massive blood loss

Platelet Count

150-400 10^9/L

A platelet count may be used to screen for or diagnose various diseases and conditions that
affect the number of platelets in the blood. It may be used as part of the workup of a bleeding
disorder, bone marrow disease, or excessive clotting disorder, to name just a few.

158 10^9/L

38
10^9/L

Low
 - it indicates thrombocytopenia

Chemistry (Serum Creatinine, BUN, Sodium, Potassium, Calcium, Albumin)- it can

help determine if there's an electrolyte imbalance in the body

Componen Normal Result Result Nursing

Rationale 09/03/18 Responsibilties
ts Values 8/23/18
Creatinine 49.0-115.0 The 129.38 Prior:
umol/L kidneys umol/L  Explain the
maintain increases procedure.
the blood  Explain the
creatinine purpose and what
in a to expect.
normal  No food or fluid
range. restrictions.
Creatinine  Check the doctor's
has been order.
found to  Notify the
be a fairly laboratory and
98.93
reliable umol/L physician of
Normal
indicator medications the
of kidney patient is taking
function that may affect test
 results; they may
be restricted.
During:
 Do not take the
blood sample from
hand or arm with
receiving IVF.
 The tourniquet
should be less on
a minute.
 Do not squeeze
the punctured site
tightly.
 Wipe away the first
drop of blood.
After:
 Label the
specimen.
 Secure the results.
 Note for
inflammation of
punctured site.
 If a hematoma
develops at the
venipuncture sire,
apply warm soaks.
 For hypokalemia,
encourage the
patient to eat
foods rich in
potassium such as
 banana and green
vegetables
 For high
creatinine, instruct
patient to limit
foods rich in
sodium and
phosphorus.
 For low calcium,
encourage patient
to eat foods rich in
calcium and
vitamin D
For low albumin,
encourage patient to
eat foods rich in
protein such as nuts,
egg, and dairy
products.
Sodium 136-145 Sodium 136
mmol/L testing is mmol/L
a part of Normal
the
routine
lab
evaluation
of most
people as
part of an
electrolyte
144
panel or a
mmol/L
basic Normal
metabolic
 panel.
These
may be
ordered
during an
annual
physical
or when
someone
has non-
specific
health
complaint
s.
Potassium 3.6-5.1 Your 3.3
mmol/L doctor mmol/L
may want decreased
you to get Potassium
a blood level may
test to indicate
check for kidney
potassium disease and
levels if diabetic 4
mmol/L
she ketoacidosis
Normal
suspects
you’re
having
health
issues like
kidney
disease,
 high blood
pressure,
diabetic
ketoacido
sis (a
serious
complicati
on of
diabetes),
any
condition
treated
with
diuretics
(drugs
that force
the body
to shed
water and
sodium
and cause
you to
pee a lot
Calcium 2.12-2.52  To
evalua
mmol/L 2.96
te
endocr mmol/L
ine Decreased
functio
n, - A low
calciu calcium
m
metab level may
olism, result from
and
 acid- 1.94
base mmol/L
balanc
e.
 To
guide
therap
y in a problem
patient
s with with the
renal parathyroid
failure,
renal glands, as
transpl well as from
ant,
endocr diet, kidney
ine disorders,
disord
ers, or certain
cardia drugs
c
diseas
e and
skeleta
l
disord
ers.
Magnesiu 0.74-1.03 To 0.73
m mmol/L evaluate (aug 20,
the level 2018)
of mmol/L
magnesiu decrease 0.68
mmol/L
m in your it indicates
blood and damage decrease
it
to help kidneys
indicates
determine damage
kidneys
the cause
of
abnormal
levels of
 magnesiu
m, calciu
m and or
potassium
 amount
of this
21 g/L
protein in - Low
albumin
the clear
levels
liquid can also
be seen
portion of
in
the blood inflammat
ion,
shock,
and
malnutriti
on. They
may be
seen with
August condition
s in
29,2018 which the
35-50g/L
Albumin 17.56g/L body
does not
decrease properly
absorb
and
digest
protein,
such as
Crohns
disease
or celiac
disease,
or in
which
large
volumes
of protein
are lost
from the
intestines
Ammonia 11-32 To detect Sept 2 2018
 an
elevated
level of
ammonia
in the
blood; to 41.30umol/L
help High
investigat elevated
e the level of
cause of ammonia in
changes the blood
umol/L
in that may be
behavior caused by
and severe liver
conscious disease
ness; to ,kidney
support failure
the
diagnosis
of
hepatic en
celopathy
Procalciton <0.5 ng/ ml Procalcito
0.19
in nin is a
Normal
substance
produced
by many
types of
cells in
the body,
often in
 response
to infectio
ns but
also in
response
to tissue
injury

Urinalysis – reveals a significant amount of preliminary information about the kidneys

and metabolic processes

Date component Normal Interpretation Nursing

Range Rationale Result and Responsibili
Significance ties
Augus  Explain
t 21, Urine flowcytometry to the
2018 patient
about
the test,
its
purpose
and how
it is
done.
• Inform
the
patient
that the
test will
Collecting of
urine
specimen.
-Do it mid
stream
clean catch.
 Follow up
the
High
An increased
The number
number of
of WBCs in
WBCs seen in
urine
the urine under
sediment is
a microscope
normally low
and/or positive
0-17 WBCs can
WBC 45 ul test for
uL be a
leukocyte
contaminant,
esterase may
such as
indicate an
those from
infection or
vaginal
inflammation
secretions
somewhere in
the urinary tract
Normally, a
few RBCs
0-11
RBC are present 30 ul High
uL
in urine
sediment
Normally, in
men and
women, a
few epithelial
cells can be
found in the
urine
sediment. In
urinary tract
conditions 5 ul Normal
0-11
Epith. cells such as
uL
infections,
inflammation,
and
malignancies
, an
increased
number of
epithelial
cells are
present.
cast 0-1 Casts are 1 + coarse
cylindrical Granular,
particles Hyaline
 sometimes
found in urine
that are
formed from
coagulated
protein
released by
kidney cells.
In healthy
people, the
bacteria 0-111 9 Normal
urinary tract
is sterile
Physical Exam
Normal urine
color is due
to the
presence of a
Yellow pigment
(light/pale called
color to urochrome. Yellow Normal
dark/deep Urine color
amber) varies based
on the urine
concentration
and chemical
composition.
Hazy It is observed in
patient who
have
Clear or
Clarity UTI,Lesion of
cloudy
kidney, urethra
and Gouty
Arthritis
Reaction 4.5-8 5 Normal
This test
simply
indicates how
concentrated
Specific 1.005-
the urine is
gravity 1.025
and reflects 1.015 Normal
the hydration
status of the
client.
Chemical Analysis
Glucose Glucose is
normally not
 present in
urine. When
glucose is negative Normal
present, the
condition is
called
glucosuria.
The protein
test pad
-this is often a
provides a
sign of kidney
rough
disease.
estimate of
Healthy kidneys
the amount
do not allow a
of albumin in
significant
the urine.
amount
Albumin
of protein to
makes up
pass through
protein about 60% of Tace
their filters. But
the total
filters damaged
protein in the
by kidney
blood.
disease may
Normally,
let proteins suc
there will be
h as albumin
no protein or
leak from the
a small
blood into the
amount of
urine.
protein in the
urine.

Arterial Blood Gas can be used to assess gas exchange and acid base status and can
determine electrolytes level

Componen Normal Nursing

Rationale
Date t Range Result Responsibilities
08/29/18 PH 7.35- pH is a Pretest
7.45 measurement  Explain
the test
of the 7.57
procedur
acidity/alkalinit this may e and
the
y of the blood, indicate to
purpose
reflecting the kidney failure,
 UTI, of the
number of test.
Respiratory
hydrogen ions  Assure
Alkalosis and the
present. . patient
Vomiting
that
35-45 mmhg
arterial
pCO2 (partial 35 mmhg puncture
pressure of is similar
Normal
carbon to other
dioxide) reflect blood
PCO2 s the amount tests
of carbon she or
dioxide gas he might
dissolved in have
the blood.  had.

PO2 (partial Intratest

pressure of  .Adhere
to
oxygen) reflect
standar
s the amount d
precauti
of oxygen gas
ons.
dissolved in
the blood. It 56.7 mmhg Posttest

80-100 primarily Low  Monitor

PO2 the
mmhg measures the punctur
effectiveness e site
every 5-
of the lungs in 10min
pulling oxygen for at
least 30
into the blood min
stream from followin
g the
the test for
atmosphere. bleeding
HCO3 21-28 Bicarbonate is .
 Check
mmol/L a primary for signs
substance that of nerve
impairm
influences the ent
 acid-base distal to
32.6 the
balance of
punctur
mmol/L
body fluids. It e.
high  Apply
is considered
pressur
a strong buffer e for at
least 5-
when
10 min
examining the to the
arterial
arterial gases
punctur
and is an e site.
accurate  Explain
that
indicator of the some
conditions bruising,
discomf
involving the ort, and
regulation of swelling
may
the pH of the appear
body fluids. at the
site and
Total CO2 that
content is a warm
moist
measurement compre
of all the CO2 sses
can
in the blood.  alleviate
23-30 33.7 this.
TCO2 Most of this is  Monitor
mmol/L mmol/L
in the form of for signs
High of
bicarbonate infection
(HCO3), .

controlled by
the kidney. 

B.E. (-2)–(+2) Base

mmol/L excess (BE) is
the mmol/L of
base that
 needs to be 10.7 mmo/L
removed to high
bring the pH. It
is used as an
indicator of the
degree of
metabolic
disturbance. 
Oxygen
saturation
(SO2) measur
es the
70-
O2 Sat. percentage of 93 %
100%
hemoglobin normal
which is fully
combined with
oxygen. 
Sodium 138-146 Sodium
mmol/L testing is a
part of the
routine lab
evaluation of
most people
as part of an
electrolyte
panel or a 129
basic mmol/L
metabolic Low sodium
panel. These may indicate
may be endocrine or
ordered during metabolic
an annual disorders
 physical or
when
someone has
non-specific
health
complaints.
Potassium 3.5-4.5 Your doctor 3
mmol/L may want you mmol/L
to get a blood decreased
test to check Potassium
for potassium level may
levels if she indicate
suspects kidney
you’re having disease and
health issues diabetic
like kidney ketoacidosis
disease, high
blood
pressure,
diabetic
ketoacidosis
(a serious
complication
of diabetes),
any condition
treated with
diuretics
(drugs that
force the body
to shed water
and sodium
 and cause you
to pee a lot
To evaluate 1.63 mmol/L
endocrine high calcium
function,
1.15-
calcium
Calcium 1.33
metabolism,
mmol/L
and acid-base
balance.

Glucose Is 105 mg/dl

carried to the high glucose
74-100 blood stream
Glucose
mg/dl to provide
energy to all
cell
Hct 38-51 % The
hematocrit
shows the
oxygen-
carrying
capacity of the
blood. This
value also tells
whether the
blood is too 24 %
thick or too low
thin.
Useful as a
measurement
of red blood
cells only if the
 hydration of
the client is
normal
Chromogranin 8.2 g/dl
B is a low
12-17 emerging
cHgb
g/dl biomarkers for
in heart failure
patient
To help 1.65 mmol/L
0.56-
investigate the high
LAC 1.39
cause of a
mmol/L
blood clot
The kidneys 1.96 mg/dl
maintain the high creatinine
blood level signifies
creatinine in a impaired
normal range. kidney
0.51-
Creatinine has function or
Creatinine 1.19mg/
been found to kidney
dl
be a fairly disease
reliable
indicator of
kidney
function.

Component Normal Rationale

 Date Range Result
09/03/18 pH is a measurement of
the acidity/alkalinity of
PH 7.35-7.45 the blood, reflecting the 7.43
number of hydrogen Normal
ions present. .
35-45 mmhg
pCO2 (partial pressure 39.5 mmhg
of carbon
Normal
PCO2 dioxide) reflects the
amount of carbon
dioxide gas dissolved in
the blood. 

PO2 (partial pressure of

oxygen) reflects the
amount of oxygen gas
dissolved in the blood.
80-100
PO2 It primarily measures 97.7 mmHg
mmhg
the effectiveness of the Normal
lungs in pulling oxygen
into the blood stream
from the atmosphere.
HCO3 21-28 Bicarbonate is a
mmol/L primary substance that
influences the acid-
26
base balance of body
mmol/L
fluids. It is considered a
Normal
strong buffer when
examining the arterial
gases and is an
accurate indicator of the
conditions involving the
regulation of the pH of
 the body fluids.
Total CO2 content is a
measurement of all the
CO2 in the blood. 
23-30 27.2
TCO2 Most of this is in the
mmol/L mmol/L
form of bicarbonate
Normal
(HCO3), controlled by
the kidney. 

Base excess (BE) is the

mmol/L of base that
needs to be removed to
(-2)–(+2)
B.E. bring the pH. It is used
mmol/L
as an indicator of the 2.1 mmol/L
degree of metabolic elevated
disturbance. 
Oxygen saturation
(SO2) measures the
percentage of
O2 Sat. 70-100%
hemoglobin which is 98.2%
fully combined with normal
oxygen. 

Coagulation Test - Coagulation tests measure your blood’s ability to clot, and how long
it takes to clot. Testing can help your doctor assess your risk of excessive bleeding or
developing clots (thrombosis) somewhere in your blood vessels.
 Result Nursing Responsibilities
Exam
Date
09/03/1 Clotting time 4 min 45  Assess the site for redness,
8 seconds bruising and phlebitis
Bleeding time 2  If phlebitis is present apply
minutes warm compress for treatment
3o Follow the physician’s advice
seconds regarding your medication
Protime 12
Control seconds
Protime 15.4
seconds
INR 1.24
% activity 76.3%
APTT control 31.4
seconds
APTT 35.6
seconds

Chest PA/Lateral- A chest radiograph, colloquially called a chest X-ray, or chest film, is
a projection radiograph of the chest used to diagnose conditions affecting the chest, its
contents, and nearby structures.

Type Rationale Result Result Result Interpre Nursing

of tation/ Responsibilities
(8/21/18 (8/28/18) (9/03/18)
Test Signific
) ance
Chest It is a - -Pulmonary - no Indicate Pre-test:
PA common Pneumo congestion significant s that
-Check the
procedure nia with and/ edema change in patient
used to pleural - Bilateral pulmonary has a medical order
demonstrat perfusio pleural congestion pulmon
-Properly identify
e the n effusion and ary
appearance ,bilateral considered pneumonia proble the patient.
of the lungs, - pleural m thus
-Explain the
mediastinu thickening needs
m, bony treatme purpose and
thorax, nt
procedure of
diaphragm,
chest wall, obtaining a chest
cardiac
x-ray and assure
silhouette,
and thyroid the patient that
gland
the test is
painless.
-Instruct the
patient to remove
clothing to the
waist and to put
on a hospital
gown.
-Instruct patient
to remove all
metal objects like
jewellery and
pins.
-Inform the
patient that no
discomfort is
associated with
chest
radiography.
Intra-test
-Tell the patient
that he or she
will be asked to
take a deep
breath and hold it
while the x-ray
films are
obtained.
Post-test
-Document the
date and time the
test was done.
 -Give health
teachings such
as to:
a. get plenty of
rest;
b. drink plenty of
fluids; and
c. practice proper
cough etiquette

Stool Exam- A stool analysis is a series of tests done on a stool (feces) sample to help
diagnose certain conditions affecting the digestive tarct These conditions can include
infection (such as from parasites,bascteria,virus), poor nutrient absorption, or cancer.

Result Result Significance

8/26/18 8/29/18
Having too much fat in your stool is called
Color Brown Greenish steatorrhea. If you have too much fat in
Brown your stool, it may be a sign that food is
moving through your digestive system
Consistenc Soft Soft without being broken down and absorbed
y properly. This is called malabsorption.
-No - Fat globules Having a fecal fat test is the best way to
Others parasite (++) find out if you have malabsorption.
seen
CT scan of the Head/ Brain,Abdomen, - A cranial CT scan is a diagnostic tool used
to create detailed pictures of features inside your head, such as your skull, brain,
paranasal sinuses, ventricles, and eye sockets.

Date TEST IMPRESSION NURSING INTERVENTIONS

August CT scan of -Mediastinal Before procedure

20, Chest/ Lymphadenoma  Instruct to remove
2018 Thorax > aortic and coronary jewelries and any metal
arteries objects
>mixed osteoblastic and  Check for any allergies.
lytic vertebral  Instruct client not to eat
metastases of T11,T12 8 hours before the
and L1 laboratory test
 09/01/1 CT scan of - Negative Cranial CT
8 the Head / Scan
Brain
09/03/1 CT Scan -Multiple matted
8 Of whole Abdominal
Abdomen Lymphadenoma and
vascular encasement
-Minimally enhancing
Masses, Left Adrenal
Gland and Spleen
Metastatic Foci
-Mild Splenomegaly
-Mixed Osteolytic and
Blastic Vertebral
Metastases of T11,T12
and L1
During procedure
 Instructed that he may
be ask to hold his breath
After Procedure
 Increase Oral Fluid as
tolerated
 Instruct to report for
delayed reaction such as
rashes, hypertension,
palpitations

Fecal Occult Blood Test - The fecal occult blood test (FOBT) is a lab test used to check stool
samples for hidden (occult) blood.Occult blood in the stool may indicate colon cancer or polyps
in the colon or rectum though not all cancers or polyps bleed.

Date

Rationale

Result

09/05/18

It can be a sign of a problem in your digestive system such as a growth, or polyp, or cancer in the
colon or rectum

Positive

Possible Laboratory and Diagnostic Tests

>Joint Fluid Analysis- It can be used to draw fluid out of the affected joint and examining
it

>MRI or magnetic resonance imaging is a radiology techinque scan- that uses

magnetism, radio waves, and a computer to produce images of body structures.

XI. DRUG STUDY

Date ordered August 29, 2018
Generic Name Pregabalin

Brand Name Lyrica

Drug Anticonvulsant, antineuralgic, analgesic
Classification
Mechanism of Binds to calcium channel sites in CNS tissue, inhibiting excitatory
Action neurotransmitter release. Exerts antinociceptive, anticonvulsant
activity.
Therapeutic Effect: Decreases symptoms of painful peripheral
neuropathy; decreases frequency of partial seizures.
Actual Dosage 75 mg 1 tab every other day
Suggested PO: ADULTS, ELDERLY: Initially, 50 mg 3 times/day. Maximum: 300
Dosage mg/day, increased dose based on efficacy and tolerability.
Indication Adjunctive therapy in treatment of partial-onset seizures.
Management of neuropathic pain associated with diabetic peripheral
neuropathy or spinal cord injury. Management of postherpetic
neuralgia. Management of fibromyalgia.
Contraindicatio None known.
n HF, renal impairment, cardiovascular
disease, diabetes, history of angioedema,
pts at risk for suicide.
Side Effects Dizziness, drowsiness, ataxia, peripheral edema.Weight gain, blurred
vision, diplopia, difficulty with concentration, attention, cognition;
tremor, dry mouth, headache, constipation, asthenia. Abnormal gait,
confusion, incoordination, twitching, flatulence, vomiting, edema,
myopathy
Adverse Abrupt withdrawal increases risk of seizure frequency in pts with
Effects seizure disorders; withdraw gradually over a minimum of 1 wk
Drug DRUG: Alcohol, barbiturates, narcotic
Interactions analgesics, other sedative agents may increase sedative effect.

Nursing 1. Do not crush or chew caps

Responsibilitie 2. Give without regards to meal
s 3. Provide increase fluid, bulk in diet for constipation
4. Avoid activities that requires alertness
5. Tell patient to avoid alcohol

Date ordered August 29, 2018

Generic Name Dexamethasone
Brand Name Dexticort
Drug Long acting glucocorticoid. Corticosteroid
Classification
Mechanism of Suppresses neutrophil migration, decreases production of
Action inflammatory mediators, reverses increased capillary permeability.
Decreases inflammation. Suppresses normal immune response.
Actual Dosage 10mg IV q8
Suggested Prophylaxis of nausea and vomiting associated with cytotoxic therapy
Dosage Adult: Prevention: 10-20 mg 15-30 minutes before admin of
chemotherapy on each treatment day. For continuous infusion
regimen: 10 mg every 12 hr on each treatment day. For midly
emetogenic regimen: 4 mg every 4-6 hr
Indication Used primarily as an anti-inflammatory or immunosuppressant agent
in a variety of diseases (e.g., allergic, inflammatory autoimmune).
Antiemetic, treatment of croup, dexamethasone suppression test
(indicator consistent with suicide and/or depression), accelerate fetal
lung maturation. Treatment of acute mountain sickness, high altitude
cerebral edema.
Contraindicatio Hypersensitivity; active untreated infections; ophthalmic use in viral,
n fungal disease of the eye
Side Effects Inhalation: Cough, dry mouth, hoarseness, throat irritation. Intranasal:
Burning, mucosal dryness. Ophthalmic: Blurred vision. Systemic:
Insomnia, facial edema (cushingoid appearance [“moon face”]),
moderate abdominal distention, indigestion, increased appetite,
nervousness, facial flushing, diaphoresis. Occasional: Inhalation:
Localized fungal infection (thrush). Intranasal: Crusting insidenose,
epistaxis, sore throat, ulceration of nasal mucosa. Ophthalmic:
Decreased vision; lacrimation; eye pain; burning, stinging, redness of
eyes; nausea; vomiting. Systemic: Dizziness, decreased/ blurred
vision. Rare: Inhalation: Increased bronchospasm, esophageal
candidiasis. Intranasal: Nasal/pharyngeal candidiasis, eye pain.
Systemic: Generalized allergic reaction (rash, urticaria); pain,
redness, swelling at injection site; psychological changes; false sense
of well-being; hallucinations; depression.
Adverse Long-term therapy: Muscle wasting (esp. arms, legs), osteoporosis,
Effects spontaneous fractures, amenorrhea, cataracts, glaucoma, peptic ulcer
disease, HF. Ophthalmic: Glaucoma, ocular hypertension, cataracts.
Abrupt withdrawal following long-term therapy: Severe joint pain,
severe headache, anorexia, nausea, fever, rebound inflammation,
 fatigue, weakness, lethargy, dizziness, orthostatic hypotension.
Drug DRUG: Amphotericin may increase hypokalemia. May increase
Interactions digoxin toxicity caused by hypokalemia. CYP3A4 inducers (e.g.,
carbamazepine, phenytoin, rifampin) may decrease concentration.
CYP3A4 inhibitors (e.g., ketoconazole), macrolide antibiotics may
increase concentration. May decrease effects of oral antidiabetic
agents. Live virus vaccines may decrease pt’s antibody response to
vaccine, increase vaccine side effects, potentiate virus replication.
HERBAL: Cat’s claw, echinacea may increase immunosuppressant
effect. FOOD: Interferes with calcium absorption. LAB VALUES: May
increase serum glucose, lipids, sodium levels. May decrease serum
calcium, potassium, thyroxine, WBC.
Nursing 1. Observe 10 rights of drug administration
Responsibilitie 2. Monitor Intake and Output, weigh daily.
s 3. Observe for peripheral edema
4. Assess patient for level of consciousness
5. Monitor respiratory and lung sounds
6. Monitor serum electrolytes
7. Administer with meal to prevent gastric irritation

Date ordered August 29, 2018

Generic Name Calcium Carbonate

Brand Name Calvit

Drug Calcium Supplement
Classification
Mechanism of Essential for function, integrity of nervous,
Action muscular, skeletal systems. Plays an
important role in normal cardiac/renal
function, respiration, blood coagulation,
cell membrane and capillary permeability.
Assists in regulating release/storage
of hormones/neurotransmitters. Neutralizes/
reduces gastric acid (increases pH).
Actual Dosage 1 tab OD at night
Suggested 1-2 tablet daily
Dosage
Indication Prevention & treatment of osteoporosis, OA & osteomalacia; Ca
insufficiency & as dietary supplement during pregnancy & lactation,
pre- & postmenopause.
Contraindicatio All preparations:
n Calcium-based renal calculi, hypercalcemia,
 ventricular fibrillation. Calcium
chloride: Digoxin toxicity. Calcium gluconate:
Neonates: Concurrent IV use
with ceftriaxone
Side Effects PO: Chalky taste. Parenteral: Pain, rash, redness, burning at injection
site; flushing, nausea, vomiting, diaphoresis, hypotension. PO: Mild
constipation, fecal impaction, peripheral
edema, metabolic alkalosis (muscle pain, restlessness, slow
respirations, altered taste). Calcium carbonate: Milkalkali
syndrome (headache, decreased appetite, nausea, vomiting, unusual
fatigue).Urinary urgency, painful urination
Adverse Hypercalcemia: Early signs: Constipation, headache, dry mouth,
Effects increased thirst, irritability, decreased appetite, metallic taste, fatigue,
weakness, depression. confusion, drowsiness, hypertension,
photosensitivity, arrhythmias, nausea, vomiting, painful urination.
Drug Hypercalcemia may increase digoxin toxicity. Oral form may decrease
Interactions absorption of biphosphonates (e.g., risedronate), calcium channel
blockers, tetracycline derivatives, thyroid products.
Nursing 1. Assess for milk-alkali syndrome
Responsibilitie 2. Assess for hypercalcemia
s 3. Assess for constipation
4. Avoid enteric coated tablets within 1 hour
5. Tell patient to have an adequate intake of vitamin D

Date ordered August 29, 2018

Generic Name Paracetamol

Brand Name Biogesic

Drug Central analgesic. Non-narcotic analgesic, antipyretic.
Classification
Mechanism of Paracetamol exhibits analgesic action by peripheral blockage of pain
Action impulse generation. It produces antipyresis by inhibiting the
hypothalamic heat-regulating centre. Its weak anti-inflammatory
activity is related to inhibition of prostaglandin synthesis in the CNS.
Actual Dosage 500mg 1 tab q4 prn for fever
Suggested 0.5-1 g 4-6 hrly. Max: 4 g daily.
Dosage
Indication Mild to moderate pain and fever
Contraindicatio Hypersensitivity to
n sulfonamides, severe renal/hepatic disease,
adrenal insufficiency, hypochloremic
 acidosis, hypokalemia, hyponatremia,
long-term administration in pts
with chronic noncongestion angle-closure
glaucoma.
Side Effects Hypersensitivity reaction.
Adverse Anorexia, nausea, diaphoresis, fatigue
Effects within first 12–24 hrs. Later Signs
of Toxicity: Vomiting, right upper quadrant
tenderness, elevated hepatic function
tests within 48–72 hrs after ingestion.
Drug May reduce serum levels w/ anticonvulsants (e.g. phenytoin,
Interactions barbiturates, carbamazepine). May enhance the anticoagulant effect
of warfarin and other coumarins w/ prolonged use. Accelerated
absorption w/ metoclopramide and domperidone. May increase serum
levels w/ probenecid. May increase serum levels of chloramphenicol.
May reduce absorption w/ colestyramine w/in 1 hr of admin. May
cause severe hypothermia w/ phenothiazine.
Nursing 1. Monitor temperature of patient.
Responsibilitie 2. Monitor CBC, liver and renal functions for toxicity.
s 3. Instruct watcher to have the patient take with food or milk to
minimize GI upset.
4. Instruct watcher to not coadminister with a high carbohydrate meal;
absorption rate may be significantly retarded.
5.Assess allergic reactions: rash, urticaria; if these occur, drug may
have to be discontinued.
6. Instruct watcher to report nausea and vomiting, cyanosis, shortness
of breath and abdominal pain as these are signs of toxicity.
7. Report paleness, weakness and heart beat skips, abdominal pain,
jaundice, dark urine, itchiness or clay-colored stools.
8. Tell watcher to avoid using multiple preparations containing
acetaminophen. Carefully check all OTC products.
9. Tell watcher to notify for fever lasting for more than 3 days
10. Assure that N-acetylcysteine should be available as a specific
antidote.

Date ordered August 29, 2018

Generic Name Potassium Chloride

Brand Name Kalium

Drug Electrolyte supplement
Classification
Mechanism of Necessary for multiple cellular metabolic
Action processes. Primary action is intracellular.
Therapeutic Effect:╇ Required for
nerve impulse conduction, contraction of
cardiac, skeletal, smooth muscle; maintains
normal renal function, acid-base
balance
Actual Dosage 40meqs KCl+ pnss 1L 80cc/hr x2 cycles; KCl tab 1 tab BID
Suggested  PO Prophylaxis: 20 mEq/day. Treatment: 40-100 mEq/day in 2-4
Dosage divided doses. Max: 40 mEq/dose; 150 mEq daily. Dosage is
individualised based on serum K levels. IV Dose and rate of
administration are dependent upon the ECG and serum K levels.
Max: 2-3 mEq/kg/day
Indication Hypokalemia
Contraindicatio Severe renal impairment,
n adrenal insufficiency, hyperkalemia.
Side Effects Nausea, vomiting, diarrhea,
flatulence, abdominal discomfort with distention,
phlebitis with IV administration
(particularly when potassium concentration
of greater than 40 mEq/L is infused). Rash.
Adverse Hyperkalemia (more common in elderly,
Effects pts with renal impairment) manifested as
paresthesia, feeling of heaviness in lower extremities, cold skin,
grayish pallor,
hypotension, confusion, irritability, flaccid
paralysis, cardiac arrhythmias.
Drug Increased risk of hyperkalaemia with ACE inhibitors (e.g. captopril),
Interactions angiotensin II receptor antagonists, ciclosporin. May enhance
ulcerogenic effect of solid oral dosage forms of K chloride with
anticholinergic agents. May further decrease plasma K concentration
with glucose infusion.
Potentially Fatal: Increased risk of hyperkalaemia with potassium-
sparing diuretics (e.g. spironolactone, amiloride, triamterene)
Nursing 1. Monitor I&O ratio and pattern in patients receiving the
Responsibilitie parenteral drug. If oliguria occurs, stop infusion promptly and
s notify physician.
2. Lab test: Frequent serum electrolytes are warranted.
3. Monitor for and report signs of GI ulceration 
4. Monitor patients receiving parenteral potassium closely with
cardiac monitor. Irregular heartbeat is usually the earliest
clinical indication of hyperkalemia.
5. Be alert for potassium intoxication
Date ordered August 29, 2018
Generic Name Meropenem

Brand Name Meroget

Drug Anitbiotic
Classification
Mechanism of Binds to penicillin-binding proteins. Inhibits
Action bacterial cell wall synthesis.Bactericidal.
Actual Dosage 1g q 8 give up to 10 days
Suggested  IV Susceptible infections 0.5-1 g 8 hrly via IV inj over approx 3-5 min
Dosage or infused over approx 15-30 min. 
Indication Treatment of multidrug-resistant infections;
meningitis in children 3 mos and
older; intra-abdominal infections; complicated
skin/skin structure infections
caused by susceptible S. aureus, S. pyogenes,
S. agalactiae, S. pneumoniae, H.
influenzae, N. meningitidis, M. catarrhalis,
E. coli, Klebsiella, Enterobacter,
Contraindicatio Anaphylactic reaction
n to other beta-lactams
Side Effects Diarrhea, nausea,
vomiting, headache, inflammation at injection
site. Oral candidiasis,
rash, pruritus. Constipation, glossitis.
Adverse Antibiotic-associated colitis, other superinfections
Effects (abdominal cramps, severe
watery diarrhea, fever) may result from
altered bacterial balance in GI tract. Anaphylactic
reactions have been reported.
Seizures may occur in those with CNS
disorders (e.g., brain lesions, history of
seizures), bacterial meningitis, renal impairment.
Drug None significant.
Interactions
Nursing 1. Lab tests: Perform C&S tests prior to therapy. Monitor
Responsibilitie periodically liver and kidney function.
s 2. Determine history of hypersensitivity reactions to other beta-
lactams, cephalosporins, penicillins, or other drugs.
3. Discontinue drug and immediately report S&S of
 hypersensitivity
4. Report S&S of superinfection or pseudomembranous colitis
5. Monitor for seizures especially in older adults and those with
renal insufficiency

Date ordered August 29, 2018

Generic Name Tramadol

Brand Name Tramal

Drug Analgesic
Classification
Mechanism of Binds to mu-opioid receptors, inhibits
Action reuptake of norepinephrine, serotonin,
inhibiting ascending and descending
pain pathways. Therapeutic Effect:╇
Reduces pain
Actual Dosage 50mg 1 tab q8 RTC
Suggested  PO Moderate to severe pain 50-100 mg 4-6 hrly. Extended-release
Dosage tab: 50-100 mg 1-2 times/day. Max: 400 mg/day. 
Indication Management of moderate to moderately
severe pain. Extended-Release:
Around-the-clock management of moderate
to moderately severe pain for
extended period.
Contraindicatio Acute alcohol intoxication, concurrent
n use of centrally acting analgesics, hypnotics,
opioids, psychotropic drugs, hypersensitivity
to opioids. ConZip, Severe/
acute bronchial asthma, hypercapnia,
significant respiratory depression.
Side Effects Dizziness, vertigo, nausea, constipation, headache, drowsiness.
Vomiting,pruritus, CNS stimulation (e.g., nervousness,
anxiety, agitation, tremor, euphoria,mood swings, hallucinations),
asthenia,diaphoresis, dyspepsia, dry mouth, diarrhea.Malaise,
vasodilation,anorexia, flatulence, rash
Adverse Seizures reported in pts receiving tramadol within recommended
Effects dosage range. May have prolonged duration of action, cumulative
effect in pts with hepatic/renal impairment, serotonin
syndrome(agitation, hallucinations, tachycardia, hyperreflexia).
Drug Alcohol, other CNS depressants
Interactions may increase CNS depression. Carbmazepine decreases
concentration/effects. CYP2D6 inhibitors (e.g.,
paroxetine), CYP3A4 inhibitors (e.g., erythromycin), triptans, selective
serotonin reuptake inhibitors(SSRIs), tricyclic antidepressants
may increase risk of seizures, risk of serotoninsyndrome
Nursing Responsibilities

Observe 10 rights in administering a medication

Determine previous hypersensitivity reactions to penicillins, cephalosporins, and other allergens

prior to therapy.

Obtain specimens for culture and sensitivity prior to therapy. First dose may be given before
receiving results.

Assess bowel pattern before and during treatment as pseudomembranous colitis may occur

Report haematuria or oliguria as high doses can be nephrotoxic

Assess respiratory status

Date ordered August 30, 2018

Generic Name Dopamine

Brand Name Dopamine HCl

Drug Cardiac Stimulatant; Vasopressor
Classification
Mechanism of Stimulates adrenergic and dopaminergic
Action receptors. Effects are dose dependent.
Lower dosage stimulates dopaminergic
receptors, causing renal vasodilation.
 Higher doses stimulate both dopaminergic
and beta1-adrenergic receptors, causing
cardiac stimulation and renal vasodilation.
Actual Dosage 0.5mkd
Suggested  IV Initial: 2-5 mcg/kg/min, increased gradually up to 5-10 mcg/kg/min.
Dosage Seriously ill patient: Up to 20-50 mcg/kg/min
Indication Acute heart failure
Contraindicatio Pheochromocytoma,
n ventricular fibrillation. Hypersensitivity to
sulfites.
Side Effects Headache, arrhythmias, tachycardia,
anginal pain, palpitations, vasoconstriction,
hypotension, nausea, vomiting,
dyspnea. Piloerection
(goose bumps), bradycardia, widening
of QRS complex
Adverse High doses may produce ventricular arrhythmias.
Effects Pts with occlusive vascular
disease are at high risk for further compromise
of circulation to extremities,
which may result in gangrene. Tissue
necrosis with sloughing may occur with
extravasation of IV solution.
Drug May have increased effects
Interactions with vasopressors, vasoconstrictive
agents. COMT inhibitors may increase
level/effects.
Nursing 1. Monitor blood pressure, pulse, peripheral pulses, and urinary
Responsibilitie output at intervals prescribed by physician.
s 2. Report reduced urine flow rate in absence of hypotension;
ascending tachycardia; dysrhythmias; disproportionate rise in
diastolic pressure (marked decrease in pulse pressure); signs
of peripheral ischemia (pallor, cyanosis, mottling, coldness,
complaints of tenderness, pain, numbness, or burning
sensation).
3. Monitor vital signs and urine flow, other indices of adequate
dosage and perfusion of vital organs include loss of pallor,
increase in toe temperature, adequacy of nail bed capillary
filling.

Date ordered September 1, 2018

Generic Name Citicoline
Brand Name Kemodyn
Drug Dietary supplement
Classification
Mechanism of Citicoline increases blood flow and O2 consumption in the brain. It is
Action also involved in the biosynthesis of lecithin.
Actual Dosage 1g IV q6
Suggested  Up to 1 g/day
Dosage
Indication Acute ischemic stroke
Alzheimer's disease
Cerebral insufficiency
Other diseases of the brain
Contraindicatio Hypersensitivity
n
Side Effects Headache
Dizziness
Shaking of hands or feet
Sleeplessness
Change in pulse rate
Change in blood pressure
Diarrhea
Nausea
Stomach pain
Injection site pain
Blurred vision

Adverse
Effects
Drug None
Interactions
Nursing 1. May be taken with or without food
Responsibilitie 2. supplement should not be taken in the late afternoon or at night
s because it can cause difficulty sleeping.
3. Special attention should be paid for administration
4. Contact the physician immediately if allergic reaction such as
hives, rash, or itching, swelling in face or hands, mouth or throat,
chest tightness or trouble breathing are experienced.
5. Therapy should be started within 24 hours of a stroke.

Date ordered September 1, 2018

Generic Name Magnesium Sulfate

Brand Name MgSO4

Drug Anatacid; Anticonvulsant; Electrolyte; Laxative
Classification
Mechanism of  Magnesium sulfate increases peristaltic activity by causing osmotic
Action retention of fluids, thus resulting in bowel evacuation. 
Actual Dosage MgSo4 2g + 250cc D5W x 24 hrs

Suggested  1 g (8.12 mEq or 2 mL of the 50% solution) every 6 hr for 4 doses or

Dosage based on serum magnesium levels.
Indication Treatment/prevention of hypomagnesemia;prevention and treatment
of seizures in severe preeclampsia or eclampsia; pediatric acute
nephritis,
treatment of arrhythmias due to hypomagnesemia
Contraindicatio Appendicitis, symptoms of appendicitis, ileostomy, intestinal
n obstruction, severe renal impairment, HF, colostomy, hypersensitivity,
ileostomy, intestinal obstruction, undiagnosed rectal bleeding. Heart
block, myocardial damage, renal failure.
Side Effects Antacid: Chalky taste, diarrhea,
laxative effect.╇ Occasional:╇ Antacid:
Nausea, vomiting, stomach
cramps. Antacid, laxative: Prolonged
use or large doses in renal impairment
may cause hypermagnesemia (dizziness,
palpitations, altered mental status,
fatigue, weakness).
Adverse Magnesium as antacid, laxative has no
Effects known adverse reactions. Systemic use
 may produce prolonged PR interval,
widening of QRS interval. Magnesium
toxicity may cause loss of deep tendon
reflexes, heart block, respiratory paralysis,
cardiac arrest
Drug May decrease absorption of
Interactions quinolones, tetracycline, bisphosphonates.
May increase effects of antihypertensives.
Nursing 1. Check BP and pulse q10–15 min or more often if indicated.
Responsibilitie 2. Lab tests: Monitor plasma magnesium levels in patients
s receiving drug parenterally
3. Cardiac arrest occurs at levels in excess of 25 mEq/L. Monitor
calcium and phosphorus levels also.
4. Early indicators of hypermagnesemia include cathartic effect,
profound thirst, feeling of warmth, sedation, confusion,
depressed deep tendon reflexes, and muscle weakness.
5. Monitor respiratory rate closely.
6. Depression or absence of reflexes is a useful index of early
magnesium intoxication.
7. Check urinary output, especially in patients with impaired
kidney function.
8. Observe patients receiving drug for hypomagnesemia for
improvement in these signs of deficiency: Irritability, choreiform
movements, tremors, tetany, twitching, muscle cramps,
tachycardia, hypertension, psychotic behavior.
9. Drink sufficient water during the day when drug is administered
orally to prevent net loss of body water.

Date ordered September 1, 2018

Generic Name Spirinolactone

Brand Name Aldactone

Drug Potassium sparing Diuretic; Antihypertensive; Antihypokalemic
Classification
Mechanism of Interferes with sodium reabsorption by
Action competitively inhibiting action of aldosterone
in distal tubule, promoting sodium
and water excretion, increasing potassium
retention.
Actual Dosage 25 mg tab 1 tab
Suggested   As adjunct: Initially, 25 mg once daily to max 50 mg daily. May
Dosage reduce to 25 mg every other day if 25 mg once daily dose is not
tolerated.
Indication Management of edema associated with excessive aldosterone
excretion or with
HF; hypertension; cirrhosis of liver with edema or ascites,
hypokalemia, nephrotic
syndrome, severe HF; primary hyperaldosteronism.
Contraindicatio Acute renal insufficiency,anuria, hyperkalemia, Addison’s disease,
n concomitant use with eplerenone.
Side Effects Hyperkalemia (in pts with renal
insufficiency, those taking potassium supplements),
dehydration, hyponatremia,
lethargy. Nausea, vomiting,
anorexia, abdominal cramps, diarrhea,
headache, ataxia, drowsiness, confusion,
fever
Adverse Severe hyperkalemia may produce arrhythmias,
Effects bradycardia, EKG changes
(tented T waves, widening QRS complex,
ST segment depression). May proceed to
cardiac standstill, ventricular fibrillation.
Cirrhosis pts at risk for hepatic decompensation
if dehydration, hyponatremia
occurs
Drug ACE inhibitors (e.g., captopril), potassium-containing medications,
Interactions potassium supplements may
increase risk of hyperkalemia. May increase
half-life of digoxin. NSAIDs may
decrease antihypertensive effect.

Nursing 1. Check blood pressure

Responsibilitie 2. Lab tests: Monitor serum electrolytes (sodium and potassium)
s 3. Assess for signs of fluid and electrolyte imbalance, and signs
of digoxin toxicity.
4. Monitor daily I&O and check for edema
5. Weigh patient under standard conditions before therapy begins
and daily throughout therapy.
6. Observe for and report immediately the onset of mental
 changes, lethargy, or stupor in patients with liver disease.
7. Adverse reactions are generally reversible with discontinuation
of drug.

Date ordered September 2, 2018

Generic Name Ivrabadine

Brand Name Coralan

Drug Anti Anginal
Classification
Mechanism of Heart rate lowering agent that works through selective and specific
Action inhibition of the cardiac pacemaker If current that controls the
spontaneous diastolic depolarisation in the sinus node and regulates
heart rate.
Actual Dosage 5 mg tab 1 tab BID
Suggested Initially, should not exceed 5 mg bid. Increase if necessary to 7.5 mg
Dosage bid after 3-4 wk. Titrate downward to as low as 2.5 mg bid, if patient
develops bradycardia symptoms (e.g. dizziness, fatigue) or resting
heart rate is persistently <50 beats/min.
Indication Angina Pectoris; Chronic Heart Failure; CAD
Contraindicatio Resting heart rate <70 beats/min prior to treatment, cardiogenic
n shock, acute MI, severe hypotension (<90/50 mmHg), sick sinus
syndrome, SA block, unstable or acute heart failure, pacemaker
dependent, unstable angina, 3rd degree AV block. Severe hepatic
impairment.
Side Effects Bradycardia, hypertension, atrial fibrillation, and temporary vision
disturbance (flashes of light). dizziness, weakness, or fatigue
Adverse Luminous phenomena in the visual field (phosphenes), blurred vision,
Effects bradycardia, other cardiac arrhythmias, syncope, hypotension,
asthenia, fatigue, headache, dizziness, nausea, constipation,
diarrhoea, dyspnoea, muscle cramps, skin reactions, angioedema,
hyperuricaemia, eosinophilia, elevated blood-creatinine
concentrations.
Drug QT prolongation may be exacerbated by heart rate reduction w/ QT-
Interactions prolonging drugs (e.g. quinidine, disopyramide, pimozide,
ziprasidone). Concentration may be reduced w/ CYP3A4 inducers
(e.g. rifampicin, barbiturates, phenytoin) and may require ivabradine
dose adjustment.
Nursing 1. Caution should be exercised in patients with abnormal heart
Responsibilitie rhythm, high blood pressure, stroke.
s 2. Monitor regularly for atrial flutter occurrence while taking this
 medication. 
3. May cause blurred vision, do not drive a car or operate
machinery while taking this medication

Date ordered September 2, 2018

Generic Name Levetiracetam

Brand Name Keppra

Drug Pyrrolidine derivative; Anticonvulsant
Classification
Mechanism of Exact mechanism unknown. May inhibit
Action voltage-dependent calcium channels; facilitate
GABA inhibitory transmission; reduce
potassium current; or bind to synaptic
proteins that modulate neurotransmitter
release.
Actual Dosage 10 mL BID
Suggested Initially 500 mg bid, may be increased up to 1,500 mg bid. Dose may
Dosage be increase or decrease to 500 mg bid every 2-4 wk.
Indication Adjunctive therapy of partial onset, myoclonic,
and/or primary generalized tonicclonic
seizures
Contraindicatio Hypersensitivity to levetiracetam or other pyrrolidone derivatives.
n
Side Effects Drowsiness, asthenia, headache, infection, dizziness, pharyngitis,
pain,depression, anxiety, vertigo, rhinitis, anorexia. Amnesia,
emotional lability, cough, sinusitis, anorexia, diplopia.
Adverse Acute psychosis, seizures have been reported.
Effects Sudden discontinuance increases
risk of seizure activity. Serious dermatological
reactions, including Steven-Johnson
syndrome and toxic epidermal necrolysis
have been reported.
Drug None known
Interactions
Nursing 1. Assess patient duration, location and characteristic of seizure
Responsibilitie activity
s 2. Monitor patient behavior
3. Monitor for dizziness or nausea
4. May administer without regards to meals
5. Do not crush, break or chew.

Date ordered September 2, 2018

Generic Name 0.9 % Sodium Chloride

Brand Name Plain Normal Saline Solution (PNSS)

Drug Isotonic Intravenous Solution
Classification
Mechanism of  
Action The osmolality is entirely contributed by electrolytes, the solution
remains within the ECF, does not cause red blood cells to shrink or
swell and it expands the ECF volume
Actual Dosage 1 liter @ 58cc/hr
Suggested Individualized dosage
Dosage
Indication Used for hydration and preventing hypovolemic shock or hypotension,
replace extracellular fluid
Contraindicatio Heart failure, pulmonary edema, renal impairement, sodium retention
n
Side Effects Irritation or swelling where the shot was given, pain
Adverse Febrile response, infection at the site, venous thrombosis,
Effects extravasation, hypovolemia
Drug Corticosteroid- increase in sodium and water retention
Interactions Lithium- increase renal elimination of lithium
Nursing 1. Do not administer if container is damaged
Responsibilitie 2. Properly label the IV
s 3. Be alert for fluid overload
4. Check for the presence of bubbles in the IV
5. Observe aseptic technique in changing IV fluid
6. Monitor signs of infiltration
7. Monitor signs of phlebitis and infection
8. Check the condition of the tubing
9. Check the level of the IV
10. Check and regulate the drop rate
Date ordered September 3, 2018
Generic Name Furosemide

Brand Name Lasix

Drug Diuretic
Classification
Mechanism of Enhances excretion of sodium, chloride, potassium by direct action at
Action ascending
limb of loop of Henle. Produces diuresis, lowers B/P.
Actual Dosage 40mg post BT IV

Suggested 20-50 mg via IM or slow IV inj, may increase by increments of 20 mg

Dosage 2 hrly. Doses >50 mg must be given via slow IV infusion. Max: 1,500
mg daily.
Indication Treatment of edema associated with HF and renal/hepatic disease;
acute pulmonary edema. Treatment of hypertension,
either alone or in combination with other antihypertensives.
Contraindicatio Anuria
n
Side Effects Increased urinary frequency/ volume. Nausea, dyspepsia, abdominal
cramps, diarrhea or constipation, electrolyte disturbances.Dizziness,
light-headedness, headache, blurred vision, paresthesia,
photosensitivity, rash, fatigue, bladder spasm, restlessness,
diaphoresis.Flank pain.
Adverse Vigorous diuresis may lead to profound
Effects water loss/electrolyte depletion, resulting in hypokalemia,
hyponatremia, dehydration.Sudden volume depletion may result in
increased risk of thrombosis, circulatory collapse, sudden death.
Acute hypotensive episodes may occur, sometimes several
days after beginning therapy. Ototoxicity (deafness, vertigo, tinnitus)
may occur, esp. in pts with severe renal impairment. Can
exacerbate diabetes mellitus, systemic lupus erythematosus, gout,
pancreatitis. Blood dyscrasias have been reported.
Drug Amphotericin B, nephrotoxic, ototoxic medications may increase
Interactions risk of nephrotoxicity, ototoxicity. May increase risk of lithium toxicity.
Other medications causing hypokalemia may increase risk of
hypokalemia.
Nursing 1. Observe patients receiving parenteral drug carefully; closely
Responsibilitie monitor BP and vital signs.
s 2. Monitor for S&S of hypokalemia
3. Monitor BP during periods of diuresis
4. Sudden alteration in fluid and electrolyte balance may
precipitate significant adverse reactions.
5. Lab tests: Obtain frequent blood count, serum and urine
electrolytes, CO2, BUN, blood sugar, and uric acid values
6. Monitor I&O ratio and pattern.
7. Monitor urine and blood glucose & HbA1C closely in diabetics
and patients with decompensated hepatic cirrhosis.
8. Excessive dehydration is most likely to occur in older adults

Date ordered September 3, 2018

Generic Name Albumin

Brand Name Albumax

Drug Plasma Protein Faction
Classification
Mechanism of Blood volume expander. Provides increase in intravascular
Action oncotic pressure, mobilizes fluids into intravascular
space.
Actual Dosage Albumin + Furo to 10cc IVF comminuted @ 40cc
Suggested Initially 2 mL/kg, a subsequent dose of 1 mL/kg, may be repeated
Dosage after 15-30 min if initial dose is inadequate.
Indication Used for plasma volume expansion,maintenance of cardiac output in
treatmentof shock or impending shock. May be useful in treatment of
severe burns, adult respiratory distress syndrome(ARDS),
cardiopulmonary bypass, hemodialysis.
Contraindicatio None
n
Side Effects Hypotension. High dose in repeated therapy: altered vital
signs, chills, fever, increased salivation, nausea, vomiting, urticaria,
tachycardia.
Adverse Fluid overload may occur, marked by increased B/P, distended neck
Effects veins. Pulmonary edema may occur, evidenced by labored
respirations, dyspnea, rales, wheezing, coughing. Neurologic changes
that may occur include headache, weakness, blurred vision,
 behavioural changes, incoordination, isolated muscle twitching.
Drug None known
Interactions
Nursing 1. Monitor BP, pulse and respiration, and IV albumin flow rate.
Responsibilitie 2. Lab tests: Monitor dosage of albumin using plasma albumin
s 3. Observe closely for S&S of circulatory overload and pulmonary
edema
4. If S&S appear, slow infusion rate just sufficiently to keep vein
open, and report immediately to physician.
5. Observe for bleeding points that did not bleed at lower BP with
injuries or surgery and as BP rises.
6. Monitor I&O ratio and pattern.
7. Report changes in urinary output

Date ordered September 5, 2018

Generic Name Omeprazole

Brand Name Acifre

Drug Proton pump Inhibitor
Classification
Mechanism of Inhibits hydrogen-potassium adenosine triphosphatase (H1/K1 ATP
Action pump), an enzyme on the surface of gastric parietal cells.
Actual Dosage 40mg q12 AC
Suggested 40 mg once daily infused over 20-30 min or slow inj over 5 min until
Dosage oral admin is possible
Indication Short-term treatment (4–8 wks) of erosive esophagitis (diagnosed by
endoscopy), symptomatic gastroesophageal reflux disease (GERD)
poorly responsive to other treatment. H. pylori–associated
duodenal ulcer (with amoxicillin and clarithromycin). Long-term
treatment of pathologic hypersecretory conditions,treatment of active
duodenal ulcer or active benign gastric ulcer. Maintenance healing of
erosive esophagitis.
Contraindicatio Hypersensitivity to other proton pump inhibitors
n
Side Effects Headache.Diarrhea, abdominal pain,
nausea. Dizziness, asthenia (loss of strength, energy), vomiting,
constipation, upper respiratory tract infection, back pain, rash, cough.
Adverse Pancreatitis, hepatotoxicity, interstitial nephritis occur rarely.
Effects
Drug Increased risk of hypomagnesaemia w/ diuretics. May increase INR
Interactions and prothrombin time w/ warfarin. Increased risk of digoxin-induced
cardiotoxic effects. May increase plasma concentration
benzodiazepines (e.g. diazepam), clarithromycin and methotrexate.
Decreased absorption of itraconazole, ketoconazole, posaconazole,
dasatinib, iron salts. May prolong elimination of diazepam, cilostazol,
phenytoin and ciclosporin. May reduce the antiplatelet effect of
clopidogrel. Potentially Fatal: May decrease plasma concentrations
and pharmacological effects of rilpivirine, nelfinavir and atazanavir. 
Nursing 1. Consider 10 rights of drug administration
Responsibilitie 2. Monitor therapeutic effectiveness and adverse reactions
s 3. Assess GI system, bowel sounds for pain and swelling
4. Report for occurrence of headache
5. Instruct to limit activities that do not require alertness

Date ordered September 5, 2018

Generic Name Rebamipide

Brand Name Mucosta

Drug Antacid
Classification
Mechanism of Rebamipide is a mucosal protective agent and is postulated to
Action increase gastric blood flow, prostaglandin biosynthesis and decrease
free oxygen radicals
Actual Dosage 1tab TID
Suggested 100 mg tid, in the morning, evening and before bedtime
Dosage
Indication Treatment of gastric mucosal lesions (erosion, bleeding, redness &
edema) in acute gastritis & exacerbation of chronic gastritis; gastric
ulcer. Prevention of NSAID-induced gastropathy.
Contraindicatio Pregnancy and lactation. Elderly
n
Side Effects Rarely hypersensitivity reactions; GI disturbances; increased SGOT,
SGPT, γ-glutamyl transferase, alkaline phosphatase & BUN levels;
leukopenia; mammary gland expansion, nonpuerperal lactation,
menstrual disorder, dizziness, edema & foreign body feeling in the
pharynx.
Adverse Dizziness, drowsiness, dry mouth, constipation, diarrhoea, abdominal
Effects distention, nausea, vomiting, eructation; ALT, AST and BUN
elevation, oedema, hyperbilirubinaemia; gynaecomastia, induction of
 lactation, menstrual disorders, hot flushes; leucopenia, leucocytosis,
thrombocytopenia; rash, urticaria, eczema
Drug None known
Interactions
Nursing 1. Monitor for adverse reactions
Responsibilitie 2. Administer drug with meals
s 3. Check BP after administering drug

Date ordered September 5, 2018

Generic Name Silver Sulfadiazine

Brand Name Flammazine

Drug Topical Antibiotic
Classification
Mechanism of Acts only on the cell membrane and cell wall to produce its
Action bactericidal effect. A specific mechanism of action has not been
determined.
Actual Dosage Flammazine cream on Left arm
Suggested Applied directly to the wound in a layer of at least 2-3 mm thick
Dosage
Indication Prevention & treatment of infections in burns & other types of wounds
& infected skin lesions
Contraindicatio Hypersensitivity. Liver damage & oliguria.
n
Side Effects Leukopenia, Skin rash
Adverse Leukopenia, Skin rash
Effects
Drug None known
Interactions
Nursing 1. Clean burn wound first before applying
Responsibilitie 2. Change dressing every 2-3 days
s 3. Reapply cream every 24 hours.
XII. NURSING MANAGEMENT

A.NURSING CARE PLAN

Patient’s Name: ZR Age/Gender: 55/M Room: ICU 9

CC: Changes in Sensorium AP: Dr.A. Lui

Diagnosis: Diffused Large B-cell Lymphoma

DATE CUES NE NURSING OBJECTIVE OF NURSING EVALUATION

/TIME ED DIAGNOSIS CARE INTERVENTIONS
S Subjective: C Altered After 30 minutes 1. Monitor Vital Signs Sept. 03 2018
E Objective: O Comfort:Pain of nursing R: if the Blood pressure, @ 8:30 pm
P -Grimace Face G related to interventions the Heart rate and GOAL
T -Restlessness N compression of client will be free temperature increases it PARTIALLY
E -Non Labored I Metastasis of from pain as indicates pain MET
M breathing T Spinal nerves. evidenced by: 2. Provide a quiet After 30
B -Bedsore on the I Rationale: a Normal Vital environment. minutes of
E back V Spinal nerves t11, Signs R: Additional stressors nursing
R -medication: E T 12 and L1 are b restless can intensify patient’s interventions
Tramadol100 mg 1 P responsible for c. absence of perception and tolerance the client is
03, tab , Flammazine E protecting the grimace face of pain. free from pain
Cream R spinal cord which 3. Administer Pain as evidenced
2 -CT Scan result of C helps vertebrae medication as prescribed by;
0 Mixed Osteoblastic E support the R: to Aid in the patients a. Normal Vital
1 and Lytic P weight.When there pain Signs
8 Metastases of T11, T is compression it 4. Change position q2 Temp: 37.1
T12 and L1 U puts pressure in the R: To prevent further HR: 82 bpm
@ Vital signs of: A bones thus having pressure thus causing RR:13cpm
Temp: 36.8*C L pain and altered pain BP: 90/60
8PM HR: 90bpm comfort is present mmHg
RR: 11cpm b. calm
BP: 90/60mmHg c.still presence
of grimace face

Atheana Joyce
Basillo, St. N

DATE CUES NE NURSING OBJECTIVE OF NURSING EVALUATION

/TIME ED DIAGNOSIS CARE INTERVENTIONS
S Subjective: A Ineffective tissue After 1 day of 1. Monitor Vital signs Sept. 4, 2018
E Objective: C perfusion: nursing R: Obtain baseline data. GOAL
P  O2 OF T peripheral related interventions the 2. Assist with position PARTIALLY
2L/min via
T I to reduced client will have changes. MET
nasal
E cannula V capability of the effective tissue R: Gently repositioning After 1 day of
M  (+) I bone marrow to perfusion as patient from a supine to nursing
weakness
B  (+) altered T produce red blood evidenced by; sitting/standing position interventions
E consciousne Y cells a. Absence of can reduce the risk for the client
ss
R  (+) weak - paleness, orthostatic BP changes. manifested
pulses on all E Rationale: b. Absence of Older patients are more effective tissue
extremities
03,  Pale skin X When malignant cold clammy skin, susceptible to such perfusion as
 Cold clammy E cells metastasize to c. Increased HgB, drops of pressure with evidenced by;
skin
2 R the bone, it impairs d. Maintain SPO2 position changes. a. Increased
 Edema on
0 lower C the bone marrow to within normal 3. Promote Hgb Of 97
extremities
1 I be able to produce range of 96-100% active/passive ROM b Maintained
and right
8 arm S WBC as well as e. Vital signs with exercises. SPO2 of 99%
 Presence of
E RBC thus reducing normal range of R: Exercise prevents however, there
slow healing
@ lesions on the vehicles to Temp: venous stasis and further was still
back
P deliver oxygen to HR: 60-100bpm circulatory compromise. c. Presence of
 HgB: 93
3PM  Metabolic A the other parts of RR: 16-20cpm 4. Administer paleness
Alkalosis T the body resulting PR: 60-100bpm medications as d. Presence of
 Transfused
PRBC T to ineffective tissue BP: 120/80- prescribed to treat cold clammy
 SPO2 of E perfusion. 140/90mmHg underlying problem. Note skin
98%
 Vital signs R the response. e. Vitals signs
 of: N R: These medications of
Temp: 36.8*C
facilitate perfusion for Temp: 37.1*C
HR: 90bpm
most causes of HR: 112bpm
RR: 11cpm
impairment. RR: 22cpm
PR: 88bpm
5. Provide oxygen PR:110bpm
BP: 90/60mmHg
therapy as necessary. BP:
R: This saturates 90/50mmHg
circulating hemoglobin
and augments the Allana Trebajo
efficiency of blood that is St.N
reaching the ischemic
tissues.
6. Position patient
properly in a semi-
Fowler’s to high-Fowler’s
as tolerated.
R:Upright positioning
promotes improved
alveolar gas exchange.
7. Elevate edematous
legs as ordered and
ensure that there is no
pressure under the knee.
R: Elevation improves
venous return and helps
minimize edema.
Pressure under the knee
limits venous circulation.
8. Apply support hose as
ordered.
R: Wearing support hose
helps decrease edema.
9. Observe for signs of
deep vein thrombosis,
including pain,
tenderness, swelling in
the calf and thigh, and
redness in the involved
extremity.
R: Thrombosis with clot
formation is usually first
detected as swelling of
the involved leg and then
as pain.
Date Ne Nursing
Cues Objective of Care Implementation Evaluation
Time ed Diagnosis
A O- N Fluid Volume That within 2 weeks 1.) Monitor vital signs GOAL PARTIALLY
U LABS: U Excess r/t span of nursing care, MET
G -CT Scan T Decrease albumin the patient will have R- to provide baseline data After 2 weeks span
U (7/5/18) R level decreased fluid and to especially assess of nursing care, the
S  Left Adrenal I retention as evidence sinus tachycardia and patient have
T gland mass T R: Albumin is by: increased BP decreased fluid
28  Spleen mass I responsible for the 2.) Monitory input and output retention as
2 (mild O oncotic pressure A. Balanced I and O closely evidenced by:
0 splenomegaly) N which helps A. Intake 1061cc
R- to detect the degree of
1  Mixed A maintain fluids in
B. VS within normal retention of the pt. Output 935cc
8 osteolytic & L the blood vessels.
range 3.) Auscultate lungs for (+126)(9/5/18)
7AM blastic - Reduced albumin
C. Maintain clear adventitious sounds
vertebral M levels will decrease
E oncotic pressure lung sounds B. VS:
metastases R-to assess for fluids
T and the fluids in the D. Decrease signs of
T11 T12 & L1 present in the lungs Temp:36.7
A blood vessels edema
4.) Elevate edematous CR:102
-Albumin B would go out and extremities RR:13
(8/29/18): O cause edema
BP:100/70
17.56g/L (35- L Reference: R-Elevation increases
50g/L) I Call, D.(2005). The venous return to the heart
C. Clear lung
-Edema on Left C role of albumin and and in turn decrease
sounds
arm and both fluids in the body. edema
D. No decrease
legs P Retrieved on 5.) Administer diuretics as
in edema
-Clear lung A September 10, prescribed
sounds T 2018. Retrieved at:
T http://www.vetfolio. R-Diuretics aids in the
Michael E.
Vital Signs: E com/veterinary- excretion of excess body
Puente,St.N
 Temp: 36.7 R practice-issues/the- fluids
BP: 90/60 N role-of-albumin- 6.) Administer and regulate
RR-12 and-fluids-in-the- Albumin drip
CR- 90 body
I and O: R-to help fluid stay within
I=2610cc vasculature and to
O=2310cc normalize the pt’s albumin
(+300) level
-IVF of PNSS 7.) Reposition client every 2
1Liter + 60meq hours
KCl @ 80
R-Repositioning prevents
cc/hour
fluid accumulation in
- PNSS 50cc+
dependent areas
Albumin 20cc +
Furosemide 100
@ 5cc/hour
Reference:
Wayne, G.(2016). Excess
fluid volume. Retrieved on
September 10, 2018.
Retrieved at
https://nurseslabs.com/excess
-fluid-volume/

DATE CUES NE NURSING OBJECTIVE OF NURSING EVALUATION

/TIME ED DIAGNOSIS CARE INTERVENTIONS
S Subjective: C Altered Level of After 1 day of 1. Assess level of Sept. 4, 2018
consciousness
E Objective: O consiousness nursing GOAL MET
and
P  weakness G related to increased interventions the neuromuscular After 1 day of
 (+) altered status, including
T N Calcium levels client will maintain nursing
consciousne muscle tone,
E ss; GCS I level of cognition strength, and interventions
M 9(Moderate T R: A high level of as evidenced by; movement. the client
disability calcium in the blood, R: Nerve and muscle
B I a. Free from maintained
 Restless activity is depressed.
called hypercalcemia, physical
E  weak pulses V Lethargy and fatigue can level of
harm
on all may become a progress to convulsions
R E b. Relax body cognition as
extremities medical emergency. or coma
movement
 Cold clammy 2. Review laboratory evidenced by:
This disorder is most and facial
skin values
03, P expression a. patient was
 Presence of commonly caused by R:assess
c. VS within
lesions on E contributing free from
cancer. normal
back factors of
2 R In the brain, calcium
range physical
 ABG 8/29/18 impairment
0 Hypercalcem C is thought to play a 3. Monitor Cardiac injuries
ia: 1.63 rate and rhythm
1 E particular significant b. calm and
mmol/L R: Overstimulation
8 Increased P role in both health of cardiac muscle relaxed
Creatinine level: occurs with
T and disease. In resultant c. VS:
1.96 mg/dL
normal amounts, dysrhythmias and Temp:36.7
@  SPO2 of U
ineffective cardiac CR:102
98% calcium apparently
A contraction. RR:13
 Vital signs
triggers signalling 4. Raise side rails BP:100/70
3PM of: L
pathways essential R: protect patient
Temp: 36.8*C
from occurring Hillary Jane
HR: 90bpm for certain type of injury
P R.Reginio, St.N
memory; in excess, 5. Assess I and O
RR: 11cpm
A R: Maintain fluid
calcium is thought to
PR: 88bpm and nutritional
T cause brain damage. balance
BP: 90/60mmHg
T Calcium is 6. Provide means of
 Edema on communication to
E intracellular
Left arm and patient
both legs R messenger capable R: promote normalization
of stimuli
 N of activating many Ref: Doengens,M. et al
cell functions. (2014). Sensory
perception. Nurses
Reference: Pocket Guide 13th
Agarwal, A. (2017, Company Philadelphia
October 3). The Pensylvania
Effects of too much
Calcium in the
Brain. Retrieved
from:
https://www.livestro
ng.com/article/3901
85-the-effects-of-
too-much-calcium-
in-the-brain/.
Retrieved on:
September 10,2018

DATE CUES NE NURSING OBJECTIVE OF NURSING EVALUATION

/TIME ED DIAGNOSIS CARE INTERVENTIONS
S Subjective: N Imbalanced That within 1 1.monitor and record GOAL
E Objective: U nutrition: less than week of nursing intake and output PARTIALLY
P T body requirement interventions the R: to determine MET
T - 65 kg R related to disease client will be able nutritional and After 1 week of
E -Pale skin I process to: elimination problems nursing
M -Cold clammy skin T Rationale: a) client 2. Note real, exact interventions
maintain
B -ectomorph I Adequate nutrition weight; do not estimate the client;
weight
E -1,800 kcal/ day O is essential to meet b) consume R: These a. maintained
adequate
R - Albumin17.5 g/L N the body’s anthropomorphic weight
nourishme
N: 35-50 g/L A demands. Cancer nt assessments are vital b. consumed
c) free of
03, -calcium 1.94 L cells also needs to that they need to be adequate
sign of
mmol/L - adapt their malnutritio accurate. These will be nourishment
n
2 N: 2.12-2.52 M metabolism to used as basis for c. free from
0 mmol/L E survive and multiply caloric and nutrient sign of
1 -hgt 335 mg/dL T under the requirements malnutrition
8 Vital signs of: A metabolically
Temp: 36.8*C B compromised 3. Promote proper
@ HR: 90bpm O conditions provided positioning
RR: 11cpm L by the tumor R: Elevating the head of
3PM PR: 88bpm I microenvironment. bed 30 degrees aids in
BP: 90/60mmHg C Tumor cells alter swallowing and reduces
P their metabolism to risk for aspiration with Maria Susan
A maintain eating Orlanes St. N
T unregulated cellular 4. Provide a pleasant
T proliferation and environment.
E survival, but this R: A pleasing
R transformation atmosphere helps in
N leaves them reliant decreasing stress.
on constant supply
of nutrients and
energy.
Reference:
Fadaka, A.,
Ajiboye, B.,Ojo, O.,
etc(2017) Biology
of glucose
metabolization in
cancer cells.
Elsevier Science
Direct
XIII. NURSING THEORY

Dorothea Orem (Self Care Deficit Theory)

Dorothea Orem’s theory is built on an idea

that when a patient is capable to care for
him/her, then they should. However, when
a patient is not capable to care for
him/her, then the nurse can provide
guidance. (Coldwell Foster & Janssen,
1990). According to Orem nursing is a
human service, it focus on one person
with the inabilities to maintain continuous
health care.

The theory is applicable to our patient because as our patient is diagnosed with Diffused
Large B cell Lyphoma Stage IV and as a student nurse it is our role to take care of the
patient who can’t perform the basic task in life and on the ways. We can suggests
interventions to the family on how they can take care of the patient

Margaret Jean Watson (Philosophy and Science of Caring

Her philosophy was on how

nurse’s expresses care to the
patient.
She adds that caring is central to
nursing practice.

We also choose the theory of

human caring because as what
Watson had said the disease might
be cures, but illness would remain
without caring and heath is not
attained or achieved. We can
provide comfort, privacy and safety precautions that can help them.
DISCHARGE PLANNING( METHOD)

 Instructed to comply medications at

home as ordered at the correct time
religiously.

 Pregabalin 75 mg 1 tab every other

day

 Calvit 1 tab OD @ night

 Paracetamol 500mg 1 tab q4 prn for

MEDICATIONS fever

 Tramadol 50mg 1 tab q8 RTC

 Aldactone 25 mg tab 1 tab

 Coralan 5 mg 1 tab BID

 Furosemide 40 mg 1 tab

 Omeprazole 40 mg q12 AC

 Mucosta 1 tab TID

 Flammazine cream on Left arm

 If any adverse reactions occur, contact

the physician immediately. Keep a list of
all the medicines taken and bring it all
the times.
 Instructed to perform low- impact
exercises that involves stretching and
passive range of motion, such as, arm
circling, leg raises, etc.
EXERCISE
 Advised to rest when the client feels it is
 needed.

 Suggested to maintain a healthy weight.

TREATMENT  Instructed to apply a bandage on skin
lesions to keep it moist and it would
promote faster healing
HYGIENE  Advised to observe proper hygiene
through observation daily routine
hygienic measures, such as taking a
bath regularly, keeping nails well
trimmed, washing hands thoroughly
especially before and after eating and
using the bathroom.
OUT- PATIENT  Attend follow- up check up at attending
physician’s clinic (Dr. Liu) at least within
one week after discharge, to monitor for
the progress of diagnosis.

 Advised to isolate from others who are

sick as the client is at risk for contracting
a severe infection.
DIET  Instructed the client to include food that
are rich in fiber, low fat, and rich in
vitamins and minerals, such as, fruits,
vegetables and meat for protein.

PROGNOSIS
 According to the National Cancer Institute, approximately 93% of the patients
diagnosed with regionally contained lymphoma survive for five years. More evolved
diagnostic methods and the latest findings in the field continue to increase patient
survival possibilities. About 65,500 new cases of lymphoma are diagnosed in the US
every year; about 20,000 die from the disease. The average age of death is 75;
women are more likely to survive than men. In stage 1, cancer is limited to a group of
lymph nodes, usually in the neck or armpits; in stage 2, usually more than two
groups of lymph nodes are involved. Stage 3 is diagnosed when cancer has spread
to a series of lymph node groups; and in stage 4, the cancer has already spread to
organs and bone marrow, in addition to the lymphatic system.

The International Prognostic Index (IPI) was first developed to help doctors determine the
outlook (prognosis) for people with fast-growing (aggressive) lymphomas. However, it has
proven useful for most other lymphomas as well (other than slow-growing [indolent] follicular
lymphomas, which are discussed below). The index depends on 5 factors:

 The patient’s age

 The stage of the lymphoma

 Whether or not the lymphoma is in organs outside the lymph system

 Performance status (PS) – how well a person can complete normal daily
activities

 The blood (serum) level of lactate dehydrogenase (LDH), which goes up with the
amount of lymphoma in the body

Good prognostic factors Poor prognostic factors

Age 60 or below Age above 60

Stage I or II Stage III or IV

 No lymphoma outside of lymph nodes, or Lymphoma is in more than 1 organ of
lymphoma in only 1 area outside of lymph the body outside of lymph nodes
nodes

PS: Able to function normally PS: Needs a lot of help with daily
activities

Serum LDH is normal Serum LDH is high

Our client falls under 4 out of 5 of the criteria for poor prognosis .With that, we
can conclude that our client has poor prognosis

REFERENCES

Books:

Capriotti, T. Frizzell, J. (2016) Pathophysiology introductory concepts

and clinical perspectives. F.A. Davis Company. 1915 Arch Street
Philadelphia, PA 19103

deWit, S. Kumagai, C. (2013) Medical- surgical nursing concepts and

practice 2nd edition. Elsevier Saunders. 3251 Riverport Lane St.
Louis, Missouri 63043