RLE – MODULE FOR CASE STUDY

Course Code NCM 104

Course Title CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND

IMMUNOLOGIC RESPONSE AND PERCEPTION AND COORDINATION

Level Offering 1st Semester AY 2020-2021

Clinical area of assignment Surgical Ward

Date of Exposure December 21-23,2020

No. of hours 24 hours

CASE STUDY for Surgery

CONGRATULATIONS! For you are a few steps away of pursuing your dream of becoming a “nurse”.

INSTRUCTIONS:
Read the case of a patient whom you are to provide nursing care. Take time to analyze and process the information
provided, before answering the activities following each section of your module.
You may take a break, as necessary. You can ask your friends, classmates, parents, or any person whom you think can
help you understand but remember a greater amount of output should come from you, as you are the LEARNER here.
Of course, you can ask me, your clinical instructor, for clarification on areas you do not seem to understand and do not
know what to do. Would be thankful and gladly help you on your learning needs. You can contact me through my number
Messenger/ Mobile number/ Email address at ___________________.

For you to conduct all the requirements for this rotation, we may follow the schedule below:
Online:
Day 1: AM: read on your patient’s case and answer the given activity. In the afternoon we shall process 1
nursing problem (actual).
Day 2: AM: processing of 2nd nursing problem (actual/potential), PM – partial or full processing of concept map
Day 3: AM: processing of case study module and rotational exam (20 points)
Modular: Remember that you are given 3 days to finish this task.

ENDORSEMENT: You are on duty at the Surgery ward on a 7- 3 shift to a male patient, Antonio.

DAY 1: Endorsing a male client, 55y/o, at Surgery ward, bed 1, with a chief complaint of dry cough and weight loss.
Scheduled at 7:00 a.m. for a lung resection to remove a malignant tumor under general anesthesia.
▪ With an IVF PNSS 1-liter x 12 hrs.
▪ NPO post-midnight
▪ Monitor vital signs q 2⁰
▪ Initial V/S as follows: T – 37.2°C PR – 79 BPM RR– 20 CPM BP – 140/90mmHg SP02- 95%

OR report: Following induction of general anesthesia by the anesthesiologist, the patient is placed in the lateral position
with warming blankets over his legs and upper body. The patient maintains normothermia throughout the procedure. His
baseline systolic blood pressure (SBP) is 148 mmHg and was recorded by the anesthesia professional as low as 135
mmHg during the surgery. The patient’s position remains stationary throughout the four-hour surgical procedure. After
removal of the surgical drapes, the patient’s skin appears dry and no moisture is observed by the perioperative team
members. The patient is extubated by the anesthesiologist and the patient is transferred to a gurney for transport to the
PACU. The estimated blood loss for the procedure is recorded at 200 mL.

Day 2: 8:00AM transferred from PACU with a chest tube placed intraoperatively, and is noted to have 50 mL of
sanguineous fluid in the collection chamber
Post op Meds: Paracetamol 500mg for > T- 37. 8°C
Cefazolin1g per IV every 8 hours
Celecoxib 400mg for PRN for pain
IVF to follow: PNSS 1 liter x 12 hrs.
V/S every 1 hr.
On liquid diet.
Change dressing, check for bleeding
Monitor I and O.
Check CTT for drainage and consistency.
V/S as follows: T – 38.1 °C PR – 88 BPM RR– 25 CPM BP – 140/80mmHg SP02- 94%

Day 3: Continue with current management

Log rolling every 2 hrs.
On soft diet.
Watch out for signs of infection.
Refer accordingly.
V/S as follows: T – 37.7 °C PR – 90 BPM RR– 28 CPM BP – 140/90mmHg SP02- 95%

HISTORY:
Patient has a dry cough for the past two months with no consultation done. He is a heavy smoker for 30 years.
He is 5’10”, 250 lbs. (BMI of 35.9) and leads a sedentary lifestyle. When he arrives in the preoperative unit two hours in
advance, he states that his weight has remained constant over the last five years.

Patient’s Profile:
Name: Jack Ammu
Age: 55 y/o
Sex: Male
Civil status: Married
Address: Camp 3, Tuba, Benguet
Occupation: Company Employee
Nationality: Filipino
Religion: R.C.
Date and time of Admission: Oct 5, 2020; 4:00 AM
Ward & Bed no. Surgery Ward, bed 9
Admitting Diagnosis: Metastatic lung cancer, Stage IV
Operation to be performed: Lung resection
Chief complaints: dry cough for two months, and weight loss for the last three months

HISTORY OF PRESENT ILLNESS:

⮚ Patient is a heavy smoker with a 30 pack-year history of cigarette smoking. He experienced dry cough for the
past two months and had a dramatic weight loss for the last three months. He came for a check-up and
laboratory test were performed such as: Chest-abdomen CT scan revealing a 5-mm nodule considered to be
lung metastasis detected in the left upper lobe. A thoracic puncture was done for the pleural effusion that led to a
diagnosis of adenocarcinoma, the tumor was classified as T4N0M1, stage IV. Another test: CEA is 97.4 ng/mL.
Hemoglobin 10.0 g/dL and hematocrit 31 %.
PAST MEDICAL AND SURGICAL HISTORY:
 ⮚ His past medical history includes type 1 diabetes mellitus and hypertension and is on maintenance dose of an
antihypertensive drugs.
FAMILY HISTORY:
⮚ The patient’s father is a deceased with prostate cancer and his mother is deceased with hypertension. His
brother has a hypertension.
SOCIAL, ENVIRONMENTAL AND HEALTH HISTORY:
⮚ The patient and his family lives independently. He is a company employee. His wife is a teacher and they have
three children, all are healthy and they are all in the middle school. The patient is also an occasional drinker and
been smoking for 30 years.

ACTIVITY 1: Underline using a red pen the pertinent positive and negative data or findings that you think are relevant in
the formulation of your nursing diagnoses

FEEDBACK: Congratulations! You can now proceed with the activity.

PHYSICAL EXAMINATION & REVIEW OF SYSTEMS

- Focused assessment on the organs/system affected and state pertinent findings appropriately (+/-)
General Survey
Skin
Head, Eyes, Ears, Nose,
Throat
Neck
Breast
Respiratory
Cardiovascular
Gastrointestinal
Urinary
Genital
Peripheral / Vascular
Musculoskeletal
Neurologic
Hematologic
Endocrine
Psychiatric

ACTIVITY 2: Recalling the concepts of health assessment, anatomy and physiology, you have to identify at least FIVE
pertinent PE findings that shows abnormality. Read your books or notes for you to elaborate on the cause of your
patient’s clinical signs and symptoms. In your own words, explain the condition by summarizing what you have read or
understood, this is highly encouraged. You must also supply the textbooks or materials that you have utilized as
references.

PERTINENT ABNORMAL PE/ROS EXPLANATION

1.
2.
3.
4.
5.
Reference/s:
FEEDBACK: You might find it easier, if you have your textbooks with you. Congratulations! You can now proceed with
the activity.

DIAGNOSTIC STUDIES:

ACTIVITY 3: Using a reference book (specify), you have to fill in the values that are asked. Indicate the appropriate
rationale for the diagnostic test done, its purpose, the abnormality and/or nursing intervention needed.
Laboratory test & Pertinent Reference/normal Result Interpretation What have caused the
Laboratory Result values abnormality/ Purpose/NI
1. CT scan 5-mm nodule
2. CEA 97.4 ng/mL
3. Hemoglobin 9.80 g/dL
4. Hematocrit 31 %
FEEDBACK: That’s the spirit keep going.
You might want to have a few minutes break before proceeding to the areas of the module.

MEDICAL/SURGICAL DIAGNOSIS:

ACTIVITY 4: Read about your patient’s diagnosis using your textbook (MedSurg/ specify). Focus on the description of the
disease, the etiology or cause, what are the signs and symptoms and why do they occur, what are the recommended
interventions and nursing interventions. Digest the information that you have obtained. Take time to process and analyze
them. Once you are ready, in 500 words or briefly answer the following questions.

Signs & Symptoms Signs & symptoms

(book)
Description of the Disease Etiology (patient)

Reference: Textbooks /Online resources allowed but should not come from blogs, Wikipedia,

FEEDBACK: KEEP UP THE GOOD WORK! What you are doing will keep you focused and enable to understand your
patient the best way possible. It may be hard on you at the start but doing it often, you will soon find it easier. Remember,
NO PAIN! NO GAIN.

PRESCRIBED THERAPEUTIC (MEDICAL/SURGICAL) MANAGEMENT, AND HEALTH PROMOTION PROGRAMS:

Activity 5: After reading your textbook or notes on pharmacology and/or med-surgical books, answer what are asked on
the following table.
Drug/ Dose/Route/ Mechanism of Common Side Nursing responsibilities
 Classification Frequency action Effects
1. Cefazolin
2. Paracetamol
3. Celecoxib

IVF Amount Infusion rate Purpose Nursing responsibilities

1. PNSS
Diagnostic Description Purpose Nursing Responsibilities
Procedure

1. Chest abdomen
CT scan
2. Thoracic
puncture
3. Blood chemistry
Reference/s: Textbooks /Online resources are allowed but should not come from blogs or Wikipedia

FEEDBACK: I hope you were not intoxicated by these drugs. Remember that these are important in saving your patient’s
life and it should be monitored for its therapeutic and side effects.

ACTIVITY 6: Applying the nursing process, integrate all the significant findings obtained in the analysis of the case and
formulate a nursing care plan for your patient. Use the given table/format presented.

DATA GOALS/ ACTION/ RATIONALE RESPONSE &

Expected outcomes NURSING EVALUATION
INTERVENTIONS
Subjective findings: STG: within ______hour/s Dxtc: After ______hr/s of NI, the
______________________ of NI the patient will be able patient was able to
______________
______________________ to _______________ ________________________
______________________ ______________ ________________________
______________________ _____________________ _______________
______________ as manifested by_________
______________________ _____________________ _______________
______________________ _____________________ ______________ ________________________
_______________
______________________ as manifested/evidenced ______________ _______________________
Txc:
______________________ by: ______________ STG: fully/partially/un MET
_______________
______________ _____________________ ______________
_______________
Objective findings: _____________________ ______________ After ______hr/s of NI, the
_______________
______________________ _____________________ patient was able to
______________
______________________ LTG: after ___days of NI _______________ ________________________
______________ ________________________
______________________ the patient will be able to: Edx:
______________ as manifested by _________
______________________ _____________________ _______________
_____________________ ______________ ________________________
______________________ _______________
_____________________ STG: fully/partially/un MET
Focus/ Nursing Dx: (PE/S) ______________
_______________
______________________ as manifested by: _______________ ______________
______________________ _____________________ _______________ ______________
_____________________ ______________

FEEDBACK: CONGRATULATIONS, you have just shown how prepared you are in meeting your patient’s needs. If this
continues, expect that a lot of your patient will be smiling and thanking you for saving their lives.

COLLABORATION
Activity 7: As a future nurse you should be able to work with your co-nurses and other health care professionals and form
a team sharing knowledge and resources to solve or provide patient care.
⮚ After administering the nursing and medical interventions, the patient claimed that he has chest pain and has
trouble breathing. As a nursing student what are you going to do next? (Limit you answers in 3-5 sentences only.)

ETHICO-MORAL-LEGAL CONCERNS
Activity 8: These principles concern the ethics of caring rather than 'curing' by exploring the everyday interaction between
you as a nurse and the person in your care.
⮚ In this situation what are the possible ethico-moral and legal concerns of your patient. Justify you answer in 3-5
sentences only.

FEEDBACK: WELL DONE! Now summarize what you have done by formulating the concept map/table.
ACTIVITY 9:
Incorporating all the data that had been presented to you and your readings, create in a diagram form the pathophysiology
of the patient’s disease/condition. Incorporate the risk factors present in your patient based on his/her history, the signs
and symptoms presented by your patient as shown on his/her PE and ROS, the lab results provided by the various
diagnostic exams. Group all cues together showing how you were able to arrive to a certain nursing diagnosis/es.
Lastly, include the various medications and or procedures. Do not forget to include the arrows to show connections and/or
relationships among the various concepts.

Study the given sample below for you to understand.

BE CREATIVE BUT KEEP IT SIMPLE GOOD LUCK!

⮚ Attach complete concept mapping here

COMMUNICATION
Activity 10: Your shift is about to end, using ISBAR (a patient safety communication structure that aids simplified,
effective, structured and anticipated communication between healthcare personnel). Fill in your end of shift report to help
guide the incoming student nurse.
Identify yourself: your name: _________________ role: student nurse ward/area: ________________
Situation: What is your patient’s name, age & gender, current situation/status (stable but in danger of deterioration,
unstable), concern or your observations, what needs to monitor/observe (ex; abnormal VS, labs, active clinical
signs/symptoms)
Background: Give the relevant details such as presenting problems and clinical history that will help the incoming
staff interpret the situation easily; may also include meds / procedures already administered.
Assessment: What is your assessment? (Base it on your observation on your patient during your shift what is his/her
current condition, risks & needs).
Recommendation: What do you recommend being done to correct the situation? Be clear about what you are
requesting. (e.g transfer/review/treatment? When should it happen?

Feedback: CONGRATULATIONS, you have carried out your task. I will be getting back to you after I have read your
output.

Prepared by: CHERRY G. KIM

Noted by: DR. GINA L. CASI, DEAN