Pines City Colleges

(Owned and operated by THORTON’S INTERNATIONAL STUDIES,

INC.)
Magsaysay Ave. Baguio City 2600
College of Nursing

CASE STUDY (PR WARD)

BSN 3 - SECTION 2
Group 2

SUBMITTED TO: Mr. Norman Sy

SUBMITTED BY: Cabfit, Shannon D.

November 21-23, 2022

Patient’s Profile
NAME: R.C
AGE: 66
GENDER: Male
RELIGION: Roman Catholic
NATIONALITY: Filipino
OCCUPATION: None
ADDRESS: FD 163 Pines Park, Balili, La Trinidad, Benguet
DATE OF ADMISSION: November 19, 2022
CHIEF COMPLAINT: Body Weakness and pain
ADMITTING DIAGNOSIS: Prostate Cancer Stage 4, Bone Metastasis, Anemia, Diabetes Type ll
FINAL DIAGNOSIS: Anemia, Prostate cancer with metastasis r/o UGIB gastric ulcer

HEALTH HISTORY:
A 66-year-old female patient was admitted to the 3rd-floor PR ward. He was admitted last November 19,
2022. Upon admission, the patient is conscious and shows body weakness but can move all extremities
without pain. His vital signs are as follows BP: 120/70, PR: 85, RR: 20, Temperature: 36.7 Celsius,
SPO2: 95%. The patient was taking Pantropazole, Rebamopide, Tramadol, Tamsulosin

HISTORY OF PRESENT ILLNESS:

A 66-year-old female patient was admitted to the PR ward and complains of body weakness. Upon
admission, the patient is conscious, and shows body weakness in all extremities but is able to move all
extremities with pain.

HISTORY OF PAST ILLNESS:

FAMILY HEALTH HISTORY

Mother Side: None
Father Side: Cancer and Asthma

13 AREAS OF ASSESSMENT

I. PSYCHOSOCIAL STATUS
Patient C.D is a 66 year old married man. He lives with his wife and 2 grand daughters and
presently residing at FD 163 Pines Park, Balili, La Trinidad, Benguet. Patient’s religious affiliation is
Roman Catholic and have no practices or beliefs which might affect providing health care. Sleeping and
having a conversation with his grand-daughter way of spending his leisure time. He has a light positive
outlook on life.

II. MENTAL AND ENVIRONMENTAL STATUS

The patient is conscious, awake, and in lying position. He is responsive to verbal stimuli, noise,
light, touch and pain stimuli. He is oriented to the current time, date, and place where he is. He acts
according to his age and is conversant. He has a good perception about his health. He is very cooperative
and prevents some things to further cause damage to his health. The patient responded that he was
interested in the question that I asked and able to respond to questions that is being asked. No fears or
anxiety were noted. Patient appears neat, nails are well-trimmed. He verbalized that he is not stressed but
very bored and that he wants to go home to have a dental check-up. He stated that she have a good
support from his family.

III. ENVIRONMENTAL STATUS

The patient is in the PR ward with his grand-daughter. Patient is well-oriented to the environment
and is familiar with the room set-up. Alcohol, food, and water were available at the right side table of the
patient; it is accessible for his needs. The room is adequately ventilated and proper lightning. Patient is
knowledgeable about his condition. The room is a little bit spacious and there are no other patients in the
room. No scattered rugs were seen.

IV. SENSORY STATUS

There is known visual deficit like cataract in both eyes, but doesn’t worn eye accessories such as
eyeglasses. He is able to move his eyes without tenderness, pain, and difficulty. Pupils are equal, round,
and reactive to light. Lens are cloudy and blurry vision. He can also distinguish voices even from a
distance, loud or soft. No corrective auditory deficits and no auditory device noted that is being used by
the patient. Ears were parallel, symmetrically proportional to the size of the head. No lumps or lesions
were seen. The patient’s nose is seen to be symmetrical, no lesions and no discharges were seen during
assessment. The patient is able to discriminate between an odor and smell from the other. The patient is
able to discriminate sweet, sour, salty and bitter taste from each other by the availability of foods that are
in their table and cabinet. With regards to the patient’s tactile status, he was able to discriminate between
sharp and light touch, able to perceive heat and cold in proportion to stimulus, and able to differentiate
common objects by touch by doing necessary procedures.

V. MOTOR STATUS
Motor strength is assessed. His body movements in all extremities are weak but without pain. No
prosthetic device was noted present with the patient and all his extremities are intact. He verbalized that
his grand-daughter can assist him whenever he needs something or to urinate.

VI. NUTRITIONAL STATUS

The patient's food is being served in the hospital and she is on a BM diet. The patient's appetite is
good and can eat properly without the help of his grand-daughter. There is no change in the appetite in
eating during the hospitalization and health deviation. The patient is not using dentures. The skin is
smooth, warm, sweaty and fair skin. The nails were neat and well-trimmed. There is no cultural or
religious dietary restriction reported by the patient. The patient is able to swallow his food and
medications without pain. The patient denied any indigestion, diarrhea, and vomiting. The patient was
eating orally by himself.

VII. ELIMINATION STATUS

When the patient was asked how many times he urinated and defecated from morning until the
end of shift, he reported that he urinated four times and no defecate at my shift. No pain was reported to
be felt during urination. She drinks water for about 1 to 1.5 liters per day. The patient claimed the absence
of special problems like urinary and bowel retention, and urinary incontinence. The patient denies feeling
of thirst.  

VIII. FLUID AND ELECTROLYTE STATUS

The patient usually drinks 1 to 1.5 liters of water daily and urinates regularly.  The patient denies
feeling thirsty. His skin turgor is normal and he has a moist mouth and lips. The patient capillary refill is
2 seconds.

IX. CIRCULATORY STATUS

The pulse rate during the shift is 85 beats per minute which are in the normal range. The pulse
was strong in the radial pulse with a regular rhythm. The patient’s blood pressure is 120/70 mmHg. This
was taken while the patient is lying down in bed while awake and conscious.

X. RESPIRATORY STATUS
Her respiratory rate is 20 breaths per minute with no use of accessory muscles and oxygen. There
are no abnormal breath sounds heard. The patient's lips color is pinkish.

XI. TEMPERATURE STATUS

The patient’s temperature is 36.7 C using a gun thermometer. There is a sign of sweating in both
arms. The environmental temperature is warm in the morning but cold in the afternoon and the patient is
comfortable with it.

XII. INTEGUMENTARY STATUS

Skin color is fair and has a good skin turgor at 2 seconds. There were no wounds, lesions, bruises,
edema, pallor, jaundice, or skin breakdown noted and as reported by the patient. Hair is well-kept by the
patient. There are no odorous secretions or oily secretions.

XIII. COMFORT AND REST STATUS

The patient claims that normally she sleeps 4-5 hours a day. His sleep was now only 30 minutes
to 1 hour during hospitalization. He claims he is not comfortable enough with his sleep even if he is in the
private ward because of the change of environment.

LABORATORIES

A. HEMATOLOGY 
NORMAL RESULT  INTERPRETATION  INDICATION
 VALUE 

Hematocrit  (Male) 0.42 0.40 Normal Indicates that the

– patient’s body is
0.53 making enough RBC

(Female)
0.36 –
0.46

Hemoglobin  155 +/- 20 133 g/L Normal Has normal

g/L Hemoglobin count is a
140 +/- 20 g/L normal protein that the
red blood cells
carry oxygen to her
body’s organs and
tissues and
transports carbon
dioxide from her
organs and tissues back
to his lungs, it
means it is functioning
well. It does not indicate
the occurrence
of anemia.

WBC Count  5-10 / L 3.40 x 10^9 Decreased An inadequate

/L production of white
blood cells is typically
indicated by a low
white blood cell
count. The chance of
developing infections
may increase as a
result.

Platelet   150-450 / L 284 x Normal Indicates that the patient

Count 10^9 / L has no bleeding and has
no clotting

Schilling’s  
Differential  
Count

NORMAL RESULT INTERPRETATION INDICATION

VALUE

Neutrophilic 0.43-0.76 0.83 Increased This is a sign that the

Segmenters body has an infection
 Neutrophilic Sta 0.00-0.05
b

Lymphocytes  0.17-0.48  0.13 Decreased The blood doesn't

have enough white
blood cells. A low
white blood cell
count usually is
caused by Viral
infections that
temporarily disrupt
the work of bone
marrow.

Eosinophils  0.00-0.04

Basophils  0.00-0.01

NORMAL RESULT  INTERPRETATION  INDICATION

VALUE 

Monocytes  0.04-0.10 0.04 Normal Normal to help to

defend the body from
germs and play a role
in inflammation

Atypical  
Cells

RBC Morphology:  Normocytic, Normochromic

MCV:  90.9 fL (NV: 80-100 fL) MCH: 30.9 pg (NV: 27-23

pg) MCH: 333 g/L (NV: 334-355 g/L)

B. CLINICAL CHEMISTRY
TESTS RESULTS NORMAL INTERPRETATION INDICATION
VALUE
Creatinine 0.88 mg/dL 0.5-1.7 mg/dL Normal This indicates that
the patient may
have no  
complications.

Sodium 138.4 mmol/L 135-148 mmol/L Normal This indicates that

the patient may
have no  
complications.

Potassium 3.67 mmol/L 3.5-5.3 mmol/L Normal The patient may

indicate no
complications.

C. BT TEST
VITAL SIGNS PRE-TRANSFUSION DURING POST TRANSFUSION
TRANSFUSION
 Blood Pressure 120/80 110/80 100/70
Pulse Rate 87 88 82
Temperature 36.8 36.7 36.8
Respiration Rate 20 20 20

Hour Minute/s AM PM
Time Blood Transfusion Started 12 00 /
Time Blood Transfusion Ended 5 00 /

D. RADIOGRAPHIC REPORT
Finding:
Follow-up since September 09, 2022 still shows the blastic metastases at the thoracic rib cage and spine.
There are prominent interstitial lung markings present may relate to lymphangitic spread. Atherosclerotic
aortic arch is noted.

IMPRESSION:
BLASTIC METASTASES OF THE THORACIC CAGE AND SPINE.
POSSIBLE LYMPHANGITIC METASTASIS OF THE LUNGS.
CARDIOMEGALY WITH ATHEROSCLEROTIC AORTIC ARCH.

PATHOPHYSIOLOGY

CANCER

Blood loss Cytokines Tumor necrosis Hemolysis Microangiopathy

Immune effector mechanisms DIC
Malnutrition
Bone marrow metastasis Bone
Renal dysfunction Immune system marrow necrosis red cell
Activation aplasia

Blunted EPO production

Cytokines Hemophagocytosis
Myelosuppressive
Anti-neoplastic therapy Increased hepcidin

Erythropolesis suppression Iron sequestration

Hypoproliferative anemia

PRIORITIZATION

Cues Nursing Diagnosis Rank Justification

SUBJECTIVE Ineffective Tissue Perfusion 1 This has been the prioritized problem
DATA: related to decreased because it is an actual problem and it
“maululawak” hemoglobin levels leading to involves respiratory function problems,
as verbalized Lack of oxygen transport to its main function is to transport oxygen.
by the patient tissue So, if red blood cells decreased the patient
OBJECTIVE could experience anemia and need for the
DATA: cooperation of the patient on the
Patient was interventions that will be performed.
seen lying on
the bed with a
weak presence.
Vital sign taken
as follows:
Temp: 36.8 C
PR: 94
RR: 22
BP: 110/60
SPO2: 95%
SUBJECTIVE Acute urinary retention 2 This has been the second priority
DATA: related to mechanical nursing diagnosis because it is also
“Marigatan ak obstruction of an enlarged an actual problem that needs to be
umisbo. Uray prostate as evidenced by addressed. If left untreated it can
nu maka is isbo bladder distention cause health complications such as heart
ak ngem bassit problems. Order to avoid health
latta ti complications.
rumwar”, as
verbalized by
the patient
OBJECTIVE
DATA:
Dysuria
Distended
abdomen upon
palpation
Urine output of
200 mL in 8
hours
Vital sign taken
as follows:
Temp: 36.7 C
PR: 85
RR: 20
BP: 120/70
SPO2: 95%

SUBJECTIVE Risk for Infection 3 Although the risk for infection is a

DATA: potential problem, it needs to be
“haanak py nag prioritized first because if it is not treated,
digdigos” as managed, and monitored properly can lead
verbalized by to more serious problems which then be
the patient harder to manage and increase discomfort
OBJECTIVE to the patient.
DATA:
Decreased
WBC count
Increased
Neutrophilic
segmenters

Vital sign taken

as follows:
Temp: 36.6 C
PR: 83
RR: 20
BP: 120/70
SPO2: 95%

NCP

ASSESSMENT NURSING PLANNIN IMPLEMENTATI RATIONAL EVALUATIO

DIAGNOS G ON E N
IS

SUBJECTIVE Ineffective After 6-7 -Assess vital signs -To monitor Patient
DATA: Tissue hours of and oxygen the baseline improved
Dyspnea Perfusion nursing saturation data and tissue
Dizziness related to intervention identify perfusion as
Body weakness decreased , patient will complication evidenced by
Lethargy hemoglobin be able to: s the absence of
“maululawak” levels Demonstrat pallor and a
as verbalized by leading to e increased -Administer IV fluids - To maintain normal
the patient Lack of perfusion as the fluid capillary refill
oxygen evidenced status and time and vitals
OBJECTIVE transport to by absence improve sign.
DATA: tissue of edema tissue
Capillary refill Verbalize perfusion
time prolonged understandi
respiratory rate ng of risk -Advice patient to -To increase
increased and factors or take foods rich in hemoglobin
deep breathing condition, iron and vitamins and RBC
Hemoglobin therapy levels in the
decreased regimens, blood
Vital sign taken side effects
as follows: of -Advice the client to -To prevent
Temp: 36.8 C medication, prevent injury by blood loss
PR: 94 and when to avoiding sharp and further
RR: 22 contact objects and falls decrease
BP: 110/60 healthcare
tissue
SPO2: 95% provider
perfusion
-Assess the blood -To increase
grouping and Rh hemoglobin
typing of the patient levels and
and transfuse as
improve
prescribed
tissue
perfusion.

ASSESSMENT NURSING PLANNING IMPLEMENT RATIONALE EVALUATIO

DIAGNOSI ATION N
S

SUBJECTIVE Acute Goal: -Monitor vital -Observe for After 8 of

DATA: urinary After 8 hours signs, input and hypertension nursing
“Marigatan ak retention of nursing output and fever intervention,
umisbo. Uray nu related to intervention, the patient’s
maka is isbo ak mechanical the patient -Weigh daily -Increase weigh urine output
ngem bassit latta obstruction will be able may indicate was 450mL in
ti rumwar”, as of an to achieve a decrease fluid 8 hours.
verbalized by enlarged regular elimination Patient was
the patient prostate as voiding able to achieve
evidenced pattern a regular
OBJECTIVE by bladder -Encourage -May minimize voiding
DATA: distention patient to void urinary pattern.
Dysuria every 2-4 hours retention
Distended when urge is distension of
abdomen upon noted the bladder
palpation
Urine output of -Encourage to -Increased
200 mL in 8 increase oral circulating
hours fluid intake up to fluid maintains
2-3 L for 24 renal perfusion
Vital sign taken hours, within and flushe the
as follows: cardiac kidneys,
Temp: 36.7 C tolerance, if bladder, and
PR: 85 indicated ureters of
RR: 20 “sediment and
BP: 120/70 bacteria”
SPO2: 95%
-Provide -Reduces risk
perineal care of ascending
infection

-Administer
medications as
 indicated

ASSESSMENT NURSING PLANNIN IMPLEMENTATI RATIONAL EVALUATIO

DIAGNOS G ON E N
IS

SUBJECTIVE Risk for Short term: Dx (Assessment and

DATA: Infection The client monitoring) -To identify
“haanak py nag will be free • Monitor and report if infection
digdigos” as from any signs occur in
verbalized by infection, as and symptoms of order to
the patient evidenced infection immediately
by stable such as redness, give proper
OBJECTIVE vital signs, swelling, and treatment.
DATA: palpable elevated temperature.
Decreased WBC pulses, good
count capillary • Monitor if there -An
Increased refill, usual was an order abnormal or
Neutrophilic mentation, of laboratory test high WBC
segmenters individually such white count
adequate blood cell (WBC) indicates the
Vital sign taken and urinary count. body’s
as follows: output. efforts to
Temp: 36.6 C combat
PR: 83 Long Term: pathogens.
RR: 20 Patient will Tx (Actions)
BP: 120/70 verbalize • Assess for the -These
SPO2: 95% factors that presence, factors
would existence, and history represent a
increase the of the break in the
risk of common causes of body’s
infection. infection. normal
first line of
defense and
may indicate
an infection.

•Wash hands or -It reduces

perform hand the risk of
hygiene before transmitting
having contact pathogens.
with the patient.

Edx (Patient
Teachings)
• Ensure that any
- It reduces
articles used
are properly or eliminates
disinfected or germs.
sterilized before use.

•Educate the patient -To help

to avoid break the
crowded places. chain of
infection and
prevent
conditions
that may be
suitable for
 microbial
growth.

-To reduce
•Educate the patient
to take the risk of
nail care by the pathogen
fingernails transmission.
short and clean. Rough edges
or hangnails
can harbor
microorganis
ms.

DRUG STUDY

PANTROPAZOLE
DRUG MODE OF ACTION INDICATION

Generic Name: -Inhibits proton pump activity by -Maintenance of healing of erosive

Pantropazole binding to hydrogen-potassium esophagitis
Brand Name: adenosine triphosphatase, located at -Short-term treatment of erosive
Pantoloc the secretory surface of gastric esophagitis associated with GERD
Classification: parietal cells, to suppress gastric acid
Antiulcer Drug secretion
Route:
Oral
Dosage:
40mg BID

CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILITIES

-Contraindicated in patients with
hypersensitivity to any formulation
component
CNS: headache, - Low magnesium levels may result
dizziness, pain, vertigo from prolonged PPI use. Magnesium
CV: chest pain, edema levels should be checked both before
GI: abdominal pain, and throughout treatment.
diarrhea, nausea, - Keep an eye out for the patient's low
vomiting, constipation magnesium levels, which can cause
GU: urinary frequency fatigue, an upset stomach, and
Respiratory: Dyspnea, dizziness, as well as irregular heart
Increase cough rate.
- Inform the patient not to crush, split,
or chew the tablet and to take 1 glass
 of water with it.
- Encourage the patient to disclose any
negative effects and to identify and
report any indications of low
magnesium levels.
REBAMIPIDE
DRUG MODE OF ACTION INDICATION

Generic Name: Rebamipide, a mucosal -Gastric problems, gastroduodenal

Rebamipide protective drug, is thought to ulcers, and peptic ulcers can all be
Brand Name: improve prostaglandin treated with rabamipide.
Remapride production, boost gastric blood -It is indicated in cases of acute
Classification: flow, and reduce free oxygen gastritis and acute exacerbation of
Antiulcerant; Antacids radicals. chronic gastritis, which both involve
Route: bleeding, erosion, redness, and edema
Oral (all symptoms of gastric mucosal
Dosage: lesions).
100mg 1 tab TID -Rebamipide is a derivative of an
amino acid that acts by boosting the
body's mucosal defense mechanism
and scavenging free radicals.
-Recurrent oral ulcers in Behcet's
illness can be treated with rebamipide,
which is highly reliable and secure.

CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILITIES

- Rebamipide is Significant: Dizziness, -Ten Rights

contraindicated in patients
who are allergic to the
drug.
drowsiness, thrombocytopenia,
leucopenia, hypersensitivity, and
anaphylactoid reactions (e.g.
hives, rash, itching, eczema),
shock, jaundice. Rarely, liver
dysfunction.
Gastrointestinal disorders:
Constipation, dry mouth,
diarrhea, nausea, vomiting,
heartburn, abdominal pain,
belching, the sensation of
abdominal enlargement, and a
taste abnormality.
Investigations: Increased AST,
ALT, alkaline phosphatase, or
BUN levels.
-Do not give more than three tablets
per day of this medication.
-Ask the client to take in food that is
high in fiber to prevent constipation.
-Ask the client to wear lip balm or
place petroleum jelly on the lips to
prevent them from cracking since the
drug may cause dry lips.
-Ask the client to increase fluid intake
because the drug may cause dry mouth.
-Instruct the client to report the
presence of a rash.
-Encourage the client to verbalize relief
fromhyperacidity.8. Watch out for
abdominal distention.
-Monitor intake and output.
-Inform the client of the possible side
effects.

TRAMADOL
DRUG MODE OF ACTION INDICATION

Generic - Is able to bind to mu-opioid receptors. -The alleviation of mild to

Name: Prevents the CNS's reuptake of serotonin and moderately severe pain.
Tramadol norepinephrine.
Brand Name:
Ultram
Classification:
Opioid
Analgesic
Route:
Oral
Dosage: 
50mg 1tab TID

CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILITIES

- The drug-induced
hypersensitivity
- High intracranial pressure or
head injury
- Severely impaired kidneys
- Patients with a history of
epilepsy or risk factors for
seizures
CNS: Seizure, dizziness,
headache, anxiety, confusion,
nervousness, sleep disorder,
weakness CV: vasodilation
GI: constipation, nausea,
abdominal pain, anorexia,
diarrhea, dry mouth, vomiting
GU: urinary
retention/frequency
Skin: sweating
-Assess the type, location, and
intensity of pain before and 2-3
hours (peak) after administration.
-Assess bowel function routinely.
-Assess previous analgesic history.
-Tramadol is not recommended for
patients dependent on opioids or
who have previously received
opioids for more than 1 week; may
cause opioid withdrawal symptoms.
-Monitor the patient for seizures. -
May occur within the recommended
dose range

TAMSULOSIN
DRUG MODE OF ACTION INDICATION

Generic Name: Tamsulosin is a blocker of Treatment of the signs and symptoms

Tamsulosin alpha-1A and alpha-1D of benign prostatic hyperplasia (BPH)
Brand Name: adrenoceptors. About 70% of
Flomax Relief the alpha-1 adrenoceptors in the
Classification: prostate are of the alpha-1 A
Alpha-adrenergic subtype. By blocking these
blocker adrenoceptors, smooth muscle in
Route: the prostate is relaxed and
Oral
urinary flow is improved. The
Dosage:
blocking of alpha-1D
100mg 1 tab OD
adrenoceptors relaxes the
detrusor muscles of the bladder
which prevents storage
symptoms. The specificity of
tamsulosin focuses on the effects
on the target area while
minimizing effects in other
areas.

CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILITIES

Contraindicated with CNS: Somnolence, insomnia
hypersensitivity to CV: Orthostatic hypotension,
tamsulosin, prostate syncope
cancer, pregnancy, and GI: Nausea, dyspepsia
lactation. GU: Abnormal ejaculation,
decreased libido, increased
urinary frequency
Other: Cough, sinusitis, rhinitis
Interactions
-Take this drug exactly as prescribed,
once a day. Do not chew, crush, or
open capsules; capsules must be
swallowed whole. Use care when
beginning therapy; the chance of
dizziness or syncope is greatest at that
time. Change position slowly to avoid
increased dizziness. Take the drug 30
min after the same meal each day.