SCENARIO-BASED QUESTION

NAME : Jam Mikka G. Rodriguez

DATE : March 22, 2021

SCENARIO:  At 8:30am, Mrs.  Cercan  come  in at the unit with her husband. They are bringing the referral
order from Dr. Sun. (See the referral order below from Dr. Sun).   

PHYSICIAN’S ORDER 

Respectfully referring to you Mrs. Leah Cercan, 55 years old, with the diagnosis of Ovarian CA Stage 3B
for chemotherapy. 

PROTOCOL: CISPLATIN  

Doctor’s orders: 

 Please refer to me results of assessment prior to initiation of treatment particularly concerning

the protocol 
 Hold Chemo if patient is at risk for or having neutropenia 
 Prior to Chemotherapy: 
o Start Plain NSS 1Liter  
o Inform me if started, additional orders will follow 

Short answered question: Discuss briefly the appropriate answers to the following questions:

 1.In dealing with this client, what are the important historical findings will evidence her medical
diagnosis?

1.Changes in bowel movements 3. Constipation 5. Increase abdominal girth

2. Bloating 4. Changes in appetite 6. Frequent need to urinate

2.Upon entering to the hema-onco unit, the assessment nurse and charge nurse will importantly
check/assess the following to proceed with the treatment:

1. Presence of actual 4. Laboratory results 7. Intake and output

infections

2. Height 5. Wearing of mask 8. History of medications

3. Weight 6. Check patient if having 9. vital signs

menstruation or menopause

4. Now that the medication nurse is done in the hydration order , she proceeded to the preparation of
premedications ordered by the physician. What are the nursing considerations of these drugs?
please give two (2).
Pre-medications Nursing considerations
1. Ranitidine a. Decrease does in renal and liver failure.

b. Monitor lab tests.

2. Benadryl a. Secure patient safety due to drug effect of drowsiness.

b. Avoid intake of alcohol.

3. Dexamethasone a. Monitor signs of allergic reactions.

b. Advise patient to avoid breastfeeding while taking drug.

4. Zofran a. Monitor fluid and electrolyte status.

b. Maintain adequate fluid intake.

4.After the pre-medications , the medication nurse is preparing for CISPLATIN administration. She should
now that:
Classification 2. Alkylating Agent
Considerations 3. Obtain baseline ECG and do cardiac monitoring

4. Do lab tests. (serum uric acid, serum creatinine, BUN, urinary creatinine
clearance. CBC and platelet counts are done weekly for 2 wk after each
course of treatment. Monitor periodically serum electrolytes and liver
function tests.)

5. Monitor intake and output.

Route 6. IV infusion
Contraindications 7. Pre-existing renal impairment

8. Myelosuppressed patients

9. Hearing impairment

10. Allergic reactions with cisplatin

Health Teachings 11. Do not breastfeed while taking the drug.

12. Continue hydration of at least 3000ml/day

13. Avoid sudden position changes.

14. Report tinnitus.

15. Report unusual fatigue, fever, sore mouth.

5. Upon administration, the patient experienced allergic effects to the drug so the patient experienced
shortness of breath. What are you going to do? For 2 points.

Nursing Interventions Rationale

1. Administer O2
2. Raise head of bed.
(Fowler’s/Semi-fowler’s)
Supplemental oxygen makes more oxygen available to the cells, even
though less air is being moved by the client, thereby reducing the work
of breathing.
Gravity allows for fuller lung expansion by decreasing pressure of
abdomen on diaphragm.

3. Check O2 saturation. It is used to detect hypoxemia or deficient oxygenation in the blood.

Per doctor’s order, what It is bronchodilator that relaxes the smooth muscle in the airways which
should be administered allows air to flow in and out of the lungs more easily and therefore it is
easier to breath.
4. Albuterol (Nebulizer)

6. Until the patient complains pain in the IV site. As the nurse in-charge, what are you going to assess?
2 points
Assessment findings Nursing Managements
1. Redness Apply warm, moist compresses to the area.

2. Swelling Elevate the site as much as possible to help reduce swelling. Apply a

warm or cold compress (depending on the fluid) for 30 minutes every 2-
3 hours to help reduce swelling and discomfort.

3. Burning sensation Apply cold compress to the area.

7. Give important ANTIDOTES to counteract the reaction of the medication.

4. Sodium Thiosulfate