VISION A premier university in historic Cavite recognized for excellence in the development of morally upright and globally competitive

individuals.

MISSION

Republic of the Philippines CAVITE STATE UNIVERSITY Don SeverinoDelas Alas Campus Indang, Cavite

College of Nursing

Cavite State University shall provide excellent, equitable and relevant educational opportunities in the arts, science and technology through quality instruction and relevant research and development activities. It shall produce professional, skilled and morally upright individuals for global competitiveness.

Acute Lymphocytic Leukemia

Presented by: Baliguat, Andrea Mariz B. Cedron, Arianne Rose S. Cubilla, Princess Claudine L. Lopez, Don Rafael V. Masenas, Ayr Hershel Mendoza, Kimberly Ann Musni, Michelle Marie V. Puedan, Jenivic E. Supnet, Javern M. Unico, Dan Leo L. BSN 2-1/GROUP II

Presented to: Prof.CzarGenreigh G. Genuino, RN, MAN Prof.KarenLouela R. Rint, RN, MAN Prof. Sunny Rose M. Ferrera, RN, MAN Prof.Reymund Kristopher M. Samonte, RN, MAN LEVEL II CLINICAL INSTRUCTORS

Date: March 13, 2013 In Partial Fulfillment of the Requirement in NURS 55 for the Degree of Bachelors of Science in Nursing

I.

DEMOGRAPHIC DATA:

Initials Client Name: R.P.C. Address: TreceMartirez City

Date of Admission: February 21, 2013 Time of Admission: 1:50 PM Date of Interview: February 26, 2013

Age: 16 years old Birth Date: September 14, 1996 Birth Place: Valenzuela City Gender: Male Civil Status: Single Religion: Roman Catholic

Primary Informant: Patient Secondary Informant:Mother Other Date Sources:Patients Chart

Highest Educational Attainment: High school Undergraduate Occupation: N/A Monthly Income/ Budget: N/A

II.

REASON FOR SEEKING HEALTH CARE The primary reason why Patient RC seeks for health care is for his Second dose of chemotherapy. He was admitted last February 21, 2013 at KPFP to receive the drug for chemotherapy ( Doxorubicin) but unfortunately the drug was not available so he has to stay at the hospital until the drug will be available again. The drug was administered to him last February 27, 2013 and it is his second dose of Chemotherapy.

III.

HISTORY OF PRESENT ILLNESS When Patient RC was First Year High School, he had a fever for about a

week and since it is almost a week her mother decide to ask medical advice from a physician to find out the real cause of her sons condition The physician found out that Patient RC has a tonsillitis (inflammation of the palatine tonsils) and prescribed patient RC some antibiotics and to come back after 1 week if symptoms still persist. Patient RC and his mother do not obey the physicians order to come back after a week. A month has past until they notice that Patient RCs neck swells and when they palpate it they can feel nodules on it. They panic by that time and decide that they have to consult a physician immediately. After several laboratory test performed to Patient RC the doctor diagnosed Patient RC with ALL( Acute Lymphocytic Leukemia) He had been hospitalized starting January 1 to 22 2013 because his condition got worst. He had facial edema, enlargement of the cervical lymph nodes. Then his first chemotherapy was January 20, 2013 and have undergone to Lumbar Puncture that reveals the presence of blast cells in the CSF. The result of the Lumbar puncture is NO BLAST. His second chemotherapy was last February 27, 2013.His medications are Prednisone, Calcium Gluconate, KaliumDurule, Allopurinol and Furosemide IV. PAST MEDICAL HISTORY According to Patient R.C. he was fully immunized. During his childhood, he had experienced common diseases such as, colds, cough and fever. Patient RC admitted that when he was young he was very prone to injury and he always got wound though he doesnt know where it came from. At the age of 9, he suffers from air borne disease such as measles, he also had mumps and boils but he cant remember his age that time. When he was 12 years old, he had also chickenpox for a week. In the same year, the client had also experienced injury in his foot because his foot was hooked in the tricycle. Patient RC has no known allergies to food or medication. He verbalized that he was circumcised when he was in 4th grade and he remember still the pain it brought to him.

V.

DEVELOPMENTAL HISTORY A. Jean Piagets Cognitive Development STAGE SPECIFIC TASK EVIDENCES OF MILESTONE ACHIEVEMNT

Formal Operational Thought

Can solve hypothetical problems with scientific reasoning: understands causality and can deal with past, present, future. Adult or mature thought.

Patient RC thinks rational and he accepts the reality that any moment he may die because of his condition though he is still frightened about death. He thinks what could happen to himthe moment he cannot able to afford or avail the chemotherapy. But still he is not withholding any possibility that he will live longer.

B. Erik Eriksons Psychosocial Development STAGE SPECIFIC TASK EVIDENCES OF MILESTONE ACHIEVEMENT Identity vs. Role Confusion Provides opportunities for an adolescent to discuss 12 to 18 years old feelings about events important to him or her. Offer support and praise for Though he is weak at this moment he does not closes the possibility that he as a son of his parents and a brother to his siblings will

decision making

help them in the future in terms of financial aspect because he believe this is his role.

C.Sigmund Freuds Psychosexual Development STAGE SPECIFIC TASK EVIDENCES OF MILESTONE ACHIEVEMENT Genital Stage Adolescent develops sexual maturity and learns established satisfactory relationship with opposite sex Patient RC enjoys the company with her two girlfriends. He verbalized that his girlfriends were very caring, loving and supportive. He was happy and contented with an opposite sex company.

D. Lawrence Kohlberg Moral Development STAGE SPECIFIC TASK EVIDENCES OF MILESTONE ACHIEVEMENT Post Conventional ( Level III) Adolescent can be responsible for self-care because they view this as a Patient RC now appreciates how beautiful it is to live with a healthy lifestyle.

standard of adult behaviour. Before he admitted that he smokes and can consume 2-3 sticks a day but now since he is fighting with ALL

he is guilty from what he is doing before. Before he is not eating vegetables and instead he prefers to eat street foods and ihawihaw but now he appreciates and verbalized that eating plenty of fruits and vegetables will aid you to be healthy.

VI.

HEREDO FAMILIAL HISTORY

A. Genogram Paternal Side C.CM.CF.P 70 68 A&W A.C L.CR.CD.S B.P A.TE.V C.A P.RM.AC.S 49 45 42 36 50 48 45 A&W 59 58 A&WA&W A.P Maternal Side

40

37

33

30

A&WA&WA&WA&WA&WA&WA&WA&WA&WA&W

R.CR.CR.CR.CR.CR.Cjr 1316 14 E Interpretation:

13 ALL

11 2 A&W A&WA&WA&W LEGEND: A&W Alive and Well - female

The genogram shows the familial history of Patient R.C. In the paternal side, there is no history of diseases; his grandmother was died due to old age. The rest of the family including his father was all alive and well. In the maternal side, its just same; there is no history of diseases occurring in the family. They were both all alive and well. But as you look further, the eldest sister of Patient R.C. died because of epilepsy at the age of 13. Only his sister has VI epilepsy in the family. Then now, Patient R.C. diagnosed of having ALL or Acute Lymphocytic Leukemia and it is stage 4.

/ Deceased E Epilepsy ALL Acute Lymphocytic Leukemia Numbers- age Patient - male

VII. GORDONS 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception Health Management Pattern Before The hospitalization, Client R.C stated that he feels well and healthy. He does exercises like jogging every weekend together with his friends and also plays basketball after school. According to him, he doesnt like to eat vegetables but prefers to eat street foods. Mahiligakongkumainngmgafishball, squidball, kikiam, ihawihawyungisaw at mgadelata, as verbalized by the patient. The patient doesnt go to the clinic or hospital for consultation when simple illnesses arise like cough and colds.He used to take medication or herbal medicine like tawa-tawa and take a rest upon receiving the herbal medication. As of now, Client R.C stated that he feels pain in the left antecubitalwhen putting pressure on it started last February 26, 2013. As he rates the pain, using pain numeric rating scale, he answered 3 out of 10. He also experiences weakness during chemotherapy. When he undergone lumbar puncture, he also experienced pain and rates it 7 ouf of 10. Client R.C has a height of 163 cm, weight of 48 kg during hospitalization and BMI of 17, marked as underweight. During hospitalization, the clientlearned to eat vegetablesin order or him to become healthy. He alsotook hisvitamins like Ascorbic acid and medicines such as Prednisone, Calcium Gluconate, KaliumDurule, Allopurinol and Furosemidein order for him to feel better. His typical foods in the ward are fish, vegetables and bread. He also drinks 4-5 glasses of water a day. Client R.C eats on time and doesnt skip a meal.The client stated that he never tries to drink alcohol but he smokes and consumed three sticks of cigarette per day.Client R.C is fully immunized and had no known allergies. The client stated that he was prone to accidents until now such as falling in the floor due to dizziness. According to him, He usually eliminates 3 times a day every afternoon or morning. The feces characteristics are solid, moist, cylindrical in shape, aromatic odor, color brown with yellow and it doesnt have blood. Client RC also voids 6 times per day. The characteristics of urine are clear yellow in color and has faint aromatic odor. The client level of activity is sedentary active and his most valuable things are his family. Religion for him is very important because it give him strength to live longer. Client R.Chasstrong faith in God but believes in quack doctors

B. Nutritional Metabolic Pattern

According to client, before he was hospitalized, he had good appetite and always craves andeats street foods especially, isaw and canned goods without cooking or heating it. He said that he doesnt like to eat vegetables.He also stated that he lose weight, since he was thinner now compare before. His current weight is 48 kg compared to 55 kg before. As of now, the client said that his meals are composed of breakfast, lunch, snacks and dinner. Client R.C takes Ascorbic Acid every morning.He eats on time and doesnt skip meals. He stated that he learned to eat vegetables such as Ampalaya as he saidvegetables are good for his blood. Client R.C also experiences loss of appetite after a day his chemotherapy had ended it induced nausea and vomiting anddue to leaves him somewhat bitter after taste. According to him he eats 1 cup of rice every mealnot like before, he eats 2-3 cups of rice. His typical foods during hospitalization are bread, fishes and vegetables. He is also fond of eating junk foods that serve as his snack in the hospital. The clients diet was set Diet as Tolerated. He also drinks 4-5glasses of water a day. The client doesnt have eating discomfort except during chemotherapy and doesnt experienced dysphagia. Client R.C has dry skin, warm to touch and currently has 4 wounds in the lower extremities, due to dizziness he lost his balance. He stated that when he has a wound, its takes long time before it totally heals. The client also has Facial edema and a hematoma in right antecubital because ofsome Hematology test. The client also experiences bleeding gums while brushing his teeth. He has dry lips and doesnt have dental problems.
*3 Day Diet Recall (before) Meals Breakfast (7 and 9 am) Day 1 1 glass of milo, pancit canton Day 2 1 glass of milo, 2 pcs of pandesal, cup noodles Lunch (12 nn) 2 glasses of water, 2 cups of rice, 2 glasses of water, 2 cups of rice, Day 3 1 cup of milo, 1 cup of rice, san marino tuna 2 glasses of water, 3 cups of rice,

argentina corned beef Snack (3 pm) Piattos, softdrinks (8oz), 2 pcs of isaw, 2 pcs of dugo Dinner (7 pm) 3 cups of rice, 4 pcs. ofisaw, 2 pcs. of dugoihaw-ihaw, 3 glasses of water

Century tuna

sardines

10. Kikiam, 6 pcs. fishball, 1 glass of juice 2 cups of rice,3pcs of isaw, 5 pcs of kwekkwek, 2 glasses of water

1 pc of barbeque, 1 pc of hotdog, 1 glass of softdrinks 2 cups of rice, 1 pc of hotdog and 1 pc of isaw,2 glasses of water

Total Fluid Intake

1680 cc

1440 cc

1440 cc

*3 Day Diet Recall (during hospitalization) MEALS Breakfast DAY 1 2 pcs of pandesal, 1 glass of milo, and 125 ml of water Lunch 1 cup of rice, ginisangupo and 350 ml of water Dinner 1 cup of rice, fried fish (galunggung) and 350 ml of water Snack 1 glass of milo (240 ml) DAY 2 3 pcs of pandesal, 1 glass of milo, and 125 ml of water 1 cup of rice, DAY3 1 cup of lugaw, 1 glass of milo, and 120 ml of water 1 cup of rice,

ampalaya, 320 ml of munggo, 350 ml of water 1 cup of rice, fried fish (tilapia), and 280 ml of water Piattos, 280 ml of water water 1 cup of rice, fried chicken and 200 ml of water Cornic, 240 ml of water

Total Fluid Intake 1920cc 1440cc 1680cc The table represents the 3 day diet recall of the client before and during hospitalization. The client daily meals are composed of breakfast, lunch, dinner and snacks. His usual foods in the hospital are fishes, bread and vegetables unlike before that his typical foods are can goods and street foods which is not good to his health.Client R.C also takes 4-6 cups of rice per day while during hospitalization he can

only consumed 3 cups of rice per day. The client still drinks 4-5 glasses of water a day and advised diet as tolerated.

C. Elimination Pattern Before the client has been hospitalized, he stated that he defecate once a day, with color brown, hard solid form and had strongodour feces. The client had no hard time in defecating. He micturates3-5 times a day with color yellow urine. During hospitalization, his bowel movement is also normal. He usually defecates once a day every afternoon or morning. The feces characteristics are solid, moist, cylindrical in shape, color brown with yellow and it there is no blood present. He also stated that he doesnt use any laxatives to eliminate bowel. The client also doesnt experience any pain or difficulty when defecating. The client stated that he voids 6 times a day. The characteristics of urine are clear yellow in color and has faint aromatic odor unlike before he voids 3-4 times a day only with a yellow colored urine and strong aromatic odor. The client doesnt have trouble in holding urine when sneezing, coughing, and laughing. Client R.C excesses too much perspiration especially in the hands. The patient has no body odor. D. Activity Exercise Pattern Before, when he was still not diagnosed with ALL, the client stated he can do whatever he wants without any limitation. He can go and hang-out with his friends and deals to different kinds of activity. He was inclined to sport like basketball. Every weekend, he plays basketball throughout the day. He is also a dancer and competes with other dancers. During the weekdays, he goes to school and when his at home, he eats or does house chores. The clients activity level before is Moderately Active. During hospitalization, the patienthas no activity exercise, as he verbalized bawalakomapagod. He cannot dohis daily routines such as dancing,playingbasketball and going to school. The Client is now sedentary active. His usual activities in the hospital are reading books, texting, chatting with other patient, sleeping, resting, eating and do some personal hygiene such as bathing and brushing his teeth.During his chemotherapy, he wants to be relaxed and generally feel rested. As of now the patient still doesnt have sufficient

energy for desired activities. He also feels bored in the hospital. He wants to go home as verbalized by the patient. He frequently feels dizzy during chemotherapy. His mother is always at his side to guide and support him.
7 day Activity Table (before hospitalization) Time Day 1 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12nn 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12mn Day 2 Day 3 Days of the Week Day 4 Day 5 Day 6

Day 7

LEGENDS: - Sleeping Legend: Eating School time Doing household chores and Leisure Activities such as playing basketball and Dancing Studying, texting and watching television at night

The table above represents the 7 day activity table of the client before hospitalization. The client school time is 8:00 am to 4:00 pm. He usually watches television, studying and texting before going to sleep. He also plays basketball and do dancing every week ends. The client usually helps in household chores

During Hospitalization: Time Day 1 1 am 2 am 3 am 4 am 5 am 6 am 7 am 8 am 9 am 10 am 11 am 12 nn 1 pm 2 pm 3 pm 4 pm 5 pm 6 pm 7 pm 8 pm 9 pm 10 pm 11 pm 12 mn Day 2 Days of the Week & Date Day 3 Day 4 Day 5

Day 6

Day 7

Sleeping Reading books, listening to the music,texting, chatting with other patients, or visitors, do personal hygiene,resting eating

The table above shows 7 day activity table of the client during hospitalization, the client usually has 16-18 hours of sleep. His daily activities are reading books, listening to the music, chatting with other patients, do personal hygiene, resting and eating. These activities do not exert much energy.

Katz Index of Independence in Activities Daily Living Activities points (1-10) Independence =1 point no supervision ,direction or personal assistance needed 1 1 1 1 1 1 6 Dependence =0 point with super vision ,direction or personal assistance or total care

Bathing Dressing Toileting Transferring Continence Feeding Total Points

The table above shows the *KATZ Index of Independence in Activities of Daily Living.As manifested the clientcan do bathing, toileting, continence, transferring, and feeding with no supervision, direction or personal assistance needed.Total points: 6

E. Sleep Rest Pattern Before, Client R.C always sleeps late at night. He sleeps around 11:00-1:00 pm and wakes up at 6:00 am in the morning. He only gets 6-8 hours of sleep. At night time he usually studies, text on the phoneor watches television. Then on

theweekend he gets full sleep of 8 hours because he takes naps in the afternoon 3pm-pm. He also takes a bath and prays before sleeping. During hospitalization, He always wakes up at 8:00 in the morning and sleeps around 8:00- 10:00 in the evening. Client R.C also sleeps in the afternoon around 1:00 to 5:00 pm. The client stated that he has no problem in sleeping. As he verbalized,nagingantukinakoditosaospital, kasiwalaakomasyadomagawa. The client has usually 18 hours of sleep a day.At the hospital, he can sleep without his sleeping rituals. Heusually snores even thoughhe is not tired and talkswhile he sleeps. Sometimes he also had experienced dreams or night awakening. The client stated that he wants to be relaxed always.
7 Day Sleep Diary (before) Constructs Hours of Sleep Sleeping Time Waking Time Bedtime Rituals takes a bath and watching television takes a bath and watching television takes a bath and watching television takes a bath and watching television takes a bath and watching television Day 1 6hours Day 2 6 hours Day 3 6hours Day 4 6hours Day 5 5hours Day 6 9hours Day 7 8 hours 11 pm 11 pm 12 pm 12 pm 1 am 11 pm; 3pm 8 am; 4pm takes a bath and watching television 1 am; 3pm 8 am; 4pm takes a bath and watching television

6 am

6 am

6 am

6 am

6 am

Feeling upon waking up Problem Encountere d

sleepy

sleepy

Sleepy

sleepy

Sleepy

sleepy

sleepy

Vocalizing while sleeping and snoring

Vocalizing while sleeping and snoring

Vocalizing while sleeping and snoring

Vocalizing while sleeping and snoring

Vocalizin g while sleeping and snoring

Vocalizin g while sleeping and snoring

Vocalizin g while sleeping and snoring

*7 Day Sleep Diary (during hospitalization) Constructs Hours of Sleep Sleeping Time Day 1 8 hours 8 pm; 1 pm and 5 pm 9 pm; 1pm and 5 pm Day 2 8 hours Day 3 9 hours 8pm; 1pm and 5 pm Day 4 9 hours 10 pm; 1pm and 5 pm 8 am; 2 pm Reading bible sleepy Day 5 8 Hours 10 pm; 1pm and 5 pm 8 am; 2 pm Reading bible Sleepy Day 6 8 hours 10 pm; 1pm and 5 pm 8 am; 3 pm Reading bible sleepy Day 7 9 Hours 9 pm; 1pm and 5 pm 8 am; 3 pm Reading bible Sleepy

Waking Time Bedtime Rituals Feeling upon waking up Problem Encountered

8 am; 2 pm

8 am; 3 pm

8 am; 2 pm

Reading bible sleepy

Reading bible sleepy

Reading bible sleepy

Vocalizing while sleeping and snoring

Vocalizing while sleeping and snoring

Vocalizing while sleeping and snoring

Vocalizing while sleeping and snoring

Vocalizin g while sleeping and snoring

Vocalizin g while sleeping and snoring

Vocalizin g while sleeping and snoring

The 2 table above represents the 7 day sleep diary of the client before and during hospitalization. As manifested, before hospitalization the client always slept at night around 11pm to 1am and wakes up at 6:00 in the morning. He also sleeps in the afternoon every weekends at 3:00 to 4:00 pm. The client usually has 6 to 9 hours of sleep. His bedtime rituals are taking a bath and watching television. While during hospitalization the client sleeps around 8pm to 10pm and wakes up at 8:00am. It is much earlier that his usually sleep pattern. The client also sleeps in the afternoon but still feels sleepy after waking up. At the hospital his only bedtime ritual is reading the bible. His problem encountered aresnoring and vocalizing while sleeping.

F. Cognitive Perceptual The client said that he has difficulty in hearing because heis exposed to loud noiseand music in his daily life. The client also mentioned that he has difficultyseing in his right vision but he doesnt know the grade, because he never got his eyes check. He doesnt use eye glasses neither contact lenses nor hearing aids. He experienced it since he was in 2nd year high school. The client said that he has a hard time concentrating he has a good memory, the fact that he can still remember his childhood days. As of now, Client R.C stated that he feels pain in the left antecubital when putting pressure in it started last February 26. As he rates the pain, using pain numeric rating scale, he answered 3 out of 10. He also experiences pain during lumbar puncture and he rates it as 7 out of 10. Unlike before that he is fine and doesnt feel any comfortable and pain. According to him, he also experienced changes in taste of food during chemotherapy and it lasted for 1 and half day. Sense of his smell is still the same and wasnt affected. Decision making for the client is easy with the help and support of her parents and friends. The clients level of school completed is high school undergraduate and the easiest way for him to learn is to seek advice from others and through surfing in the internet. The client understood my questions and answered it in proper way without hesitation.

G. Self Perception- Self Concept Pattern

According to Client R.C, before he had been hospitalized, he describes himself

as a naughty person, good dancer and good basketball player. Even though a lot of
changes happened to him physically but his attitudes isquiet the same,as the client

verbalize, he is still joker, friendly, courteous, positive thinker and he became good person,. Most of the time, the client feels good about himself even though he is suffering from illness. He also feels excitedwhenever he was being chemotherapy because he believes that he will get better. The changes in his appearance which lead him to consciousness from other people are facial edema. The client also stated that when he gets better he is not going back to his old habits such as smoking.He also feels fear about his sickness and death but never feels lose hope even though he experienced a lot of problems in his life. He has strong Faith in Godbecause he gives him strengths and confidents. Family and friends also helps him and gives him support

H. Role Relationship Pattern

Client R.C currently lives with his parents, two brothers and two sisters. His elder sister passed away because of epilepsy. He handled it by accepting the truth, and having faith in God. According to the patient he has a good relationship with his family especially with his brothers. He mentioned that before, they usually watch T.V together, eats lunch and dinner together as a family. The client said that hes a respectful son to his parents. He helps out with the house chores and takes care of his brothers and sisters which he cannot donow due to his illness. The client stated that he feels safe and happy with his current relationships with his 2 girlfriends. His parents are the one who take care of the hospital bills. His mother is the one who usually visits him in the hospital and takes care of him. He said that whenever he has a problem, he talks to his siblings and parents who always gives him strength and confidents. As of now, the patient is not involved in any organizations or clubs. He is not active in his neighborhood or subdivision activities.

I. Sexuality Reproductive Pattern

Client R.C stated that his puberty started when he was 13 years old. He was circumcised at the age of 9 and doesnt have any problems with his genitals. He is not sexually active with his girlfriends and he has a good relationship with them. The client stated that Masaya akosa piling ngdalawakong girlfriend.

J. Coping Stress Tolerance Pattern As the client stated,his friends and siblings are the one who are always available in talking things over. The client stated that he is stressed because he cannot hang out with his friends. Before, Dancing for him is his stress relief and now he can only do is to listen to the music to relief or lessen his stress. As of now, he has 2 girlfriends and enjoys both companies, as he stated. When he was diagnosed of ALL and started chemotherapy there have been many changes occurred that made difficult for him to adjust. As said He cannot perform the usual activities that he had before. When it comes to problem, he tried to calm himself through prayers.

Upon interview, the client stated that he fears death despite of it, he shows an optimism and a positive outlook regardless of his illness. He stated that he tries his best to fight his illness. When the patient is asked how the family is dealing with his chemotheraphyfinancially, he stated that they have been seeking to public or private organizations such as Philhealth and PSO in order to obtain financial help.

K. Value Belief Pattern The patient is Roman Catholic. According to the him, the most valuable things in his life are his family. Client R.C wants a successful life in the near future. He said religion is very important, he prays every night before going to sleep and he has strong faith in God. He also learnedto go to the church every Sunday and to reads bible entitled AngBibliangDiyos from the time he was diagnosed with ALL but due to hospital admission he cannot go for a mass. Client R.C believes in superstition and in quack doctors but he most preferred to go to the hospital rather than in quack doctors.

IX. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs Date 2/26/13 Time 3:00 4:00 6:00 8:00 9:30 2/27/13 3:00 4:00 6:00 8:00

Date/ time of Exam: BP 100/60 100/60 100/70 100/60 100/60 100/70 110/60 110/60 110/80 PR 84 75 75 79 79 74 78 70 69 RR 15 17 17 19 20 18 20 16 16 T 36.2C 36.4C 36C 36.3C 36.3C 36.1C 36.4C 36.4C 36.3C

B. Anthropometric Data HEIGHT 163 cm WEIGHT 48 Kg BMI 18

C. General Appearance

Upon interview, the patient is thin with facialedema. The patient feels body weakness .He is tall with brownish hue to his skin color. RC sits in a relaxed manner but maintains a slightly slouched posture. He can stand alone without any other assistance as evidenced by the patient can go at the other patient to have small conversation. The patient is sometimes untidy and not well dressed. Upon observation of his finger nails, they are quite long and dirty. His clothes are not so clean. He has no body odoreven though he didnt take a bath. During the interview, patient R.C was friendly and approachable. He was able to cooperate with us. The patient gave appropriate answers to all the questions being asked.
1. Body build and height-weight proportionality

Patient R.C.s body is average and proportion to his height. But his weight is not proportionally to his height, because his BMI is 18. 2. Posture and Gait

RC sits in a relaxed manner but maintains a slightly slouched posture.

3. Over-all hygiene and grooming

The patient is sometimes untidy and not well dressed. He didnt take a bath
but he changes his clothes every day.The patient is sometimes untidy and

not well dressed. Upon observation of his finger nails, they are quite long and dirty. His clothes are sometimes not so clean.
4. Body and breath odor The patient has no breath odor because he do toothbrush three times a day. He also doesnt have body odor even though he didint take a bath, because he changes his clothes every day. 5. Obvious sign of distress / illness The patient was very evident that he has poor health. He feels body weakness. He just lying in the bed and have rest especially during his chemotherapy. 6. Mental Status Patient R.C has a positive outcome in life even though he is sick. Hes very confident and has strong beliefs that he will be able to overcome the problem that he encounters. 7. Attitude The patient behavior was good.He is sociable and cooperates well. 8. Affect/mood; appropriateness of response Upon the interview the client was able to response clearly without hesitating in our questions. The client was cheerful, friendly, approachable and not irritable. 9. Quantity and quality of speech During the interview, Client R.C is courteous. He always says po and opoHe has Understandable type of speech. 10. Relevance and organization of thoughts Patient RC knows how to organize and use each word properly.

D. Focused Assessment Body Part Examined INTEGUMENTARY Skin Actual Finding skin color is brown (+) lesions dry (+) edema (+) hematoma in antecubital thin follicle hair warm to touch smooth Hair color black thin hair evenly hair distributed no dandruff smooth hair silky Nail nail plate is 160 short nails pail bed nail dirty smooth texture Normal Finding Clinical Significance

Varies from light to deep brown; from ruddy pink to light pink; from yellow overtone to olive. No edema; freckles; some birthmarks, some flat nevi; no abrasions or other lesions.

According to Kozier and ErbsFundamental of Nursing these findings: lesions, edema, dry and hematoma are abnormal findings.

Evenly distributed hair, no infection, variables, silky, resilient hair, thick hair

According to Kozier and Erbs Fundamental of Nursing these findings:Evenly distributed hair; no infections, variables, silky, resilient hair, thick hair is normal

Convex curvature; angle of nail plate about 160; smooth texture

According to Kozier and Erbs Fundamentals of Nursing these findings: Pail bed nail is abnormal.

HEAD Skull and Face

normocephalic facial edema

Rounded( norm cephalic and

According to Kozier and Erbs

 (+) nodules (+) masses

symmetric, with frontal, parietal, and occipital prominence); smooth skull contour; uniform consistency; absence of nodules and masses;

Fundamentals of Nursing these findings: Facial edema, nodules and masses are abnormal.

Eyes and Vision

eyebrows: equal distribution thin color black

Hair evenly distributed; skin intact Eyebrows symmetrically aligned; equal movement Eyelashes curled

According to Kozier and Erbs Fundamentals of Nursing these findings: Evenly distributed; align; Equal movement According to Barbarito these findings are normal because length and curliness of

eyelashes: not curly short eyelashes

slightly outward.length and curliness of eyelids varies

eyelids: Intact

Skin intact; no discoloration; lids close symmet-rically; Transparent, capillaries sometimes

eyelids varies. According to Barbarito these finding are normal Skin intact; no discharge; lids close symmetrically

Conjunctiva pale pink

evident; sclera appears white (darken or yellowish) and with small brown macules in darkskinned clients); shiny, smooth and

According to Barbarito pale pink conjunctiva is abnormal: Conjunctiva should be

pink or red;

No edema or tenderness over lacrimal gland; no tearing

Lacrimal gland, sac, nasolacrimal duct: presence of edema normal tearing

pink with no tenderness or irregularities. Palor may indicate low RBC and haematocrit count.

Sensitive,clear, transparent part of the sclera

Cornea Sensitive

According to Barbarito Health and Physical exam in nursing these findings are abnormal: there should have No edema; no tenderness.
According to Barbarito Health and Physical exam in Nursing this findings are normal because if one or both eyes does not respond there could be a problem with cranial nerve V, VII or both.

transparent pupils: black equal round direct reaction Pupillary: constrict in the same eye consensual reaction papillary: constriction in the opposite eye

Arcussenilis may be evident; client blinks when the cornea is touched;

Ears and Hearing

Auricles Noskin lesion symmetrical in Size external canal: Small cerumen Inside

Color same as facial skin; symmetric; auricle aligned with the outer canthus of the eye about 10 from vertical; mobile, firm and not tender;

According to Kozier and Erbs Fundamentals of Nursing these findings:

Same as facial skin; symmetric; auricle pinna recoils after it is aligned with the outer canthus of the eye; folded; firm; no tenderness Able to hear the ticking in both ears

*Watch Tick Test no problem in Hearing Can heard the tick

of the clock from a distance of 6cm

. Nose and Sinuses nose: symmetric and straight no tenderness

Symmetric and straight; no discharge;No flaring; uniform in color; no tenderness; no lesions Air moves freely as

According to Kozier and Erbs Fundamentals of Nursing these findings: Symmetric; straight; no discharge; unison in color are normal.

nasal mucosa: no swelling no tenderness no masses

the client breathes through the nares; mucosa pink; clear , watery discharge; no Air moves freely in both nares

nasal patency maxillary and frontal sinuses: notenderness Mouth / Oropharynx lips: pale red no lesions

lesions; nasal septum intact and in midline

Uniform pink in color; soft, moist, smooth texture;

According to Kozier and Erbs Fundamentals of Nursing these findings: Uniform in color; soft and moist; has the ability to purse lips

teeth: complete teeth properly Aligned tooth Discoloration no dental filings and caries gums: pinkish no swelling no lesions tongue: position properly whitish tongue

Symmetry of contour; ability to purse lips; With dentures; smooth and shiny; tooth 32 adult teeth enamel

Pink

gums;

moist,

firm; no retraction of gums; smooth intact dentures. No bleeding, retraction, swelling and lesions central pink and

Tongue position; smooth;

lateral According to Barbarito margins; no lesion; Health and Physical

raised papillae (taste exam in Nursing these buds) moves freely, no tenderness; Light,
uvula: properly Aligned at the midline findings are normal Centrally aligned; moves freely; with prominent smooth veins;

pink

palate; lighter pink, No nodules; no swelling hard palate, more

irregular texture

According Barbarito Pink

tonsils: pinkish in color

to Health

and

smooth

and Physical exam in Nursing these

posterior wall Tonsils pink and

findings are normal smooth;no discharge Positioned midline palate of in soft

no swelling

According to Barbarito Health and Physical Examination In

Nursing this findings are normal there

should be pinkish color of posterior walls and there should have no presence of discharge.

NECK

Neck and Muscles

INSPECTION 6 nodules in both neck masses lymph nodes (+)enlargement

Muscles equal in size; head centered; Coordinated smooth movement with no discomfort;

According to Kozier and Erbs Fundamentals of Nursing these findings are abnormal there should not have a presence of nodules and the neck should not be enlarged.

Muscles equal in size; coordinated movement

BREAST & AXILLAE breast flat no lumps or lesions Areolae round color brown Axilla 6 nodules in both axila nipple no discharge ABDOMEN flat abdomen smooth skin umbilicus is in the center of the abdomen. It should be symmetrical smooth skin no presence of bulges or masses. According to Barbarito Health and Physical Examination in Nursing this findings are normal because presence of bulges or masses could The breast feels like a male thin disk of tissue under a flat nipple and areola. Flat breast and free from lesions and lumps.

According to Kozier and ErbsFundamentals of Nursing these findings are normal Flat, no lesions or lumps And free of discharges.

indicate tumor ,cysts or hernias. GENITALS Normal distribution of pubic hair no presence of infestations. Circumcised penis Inguinal lymph nodes are palpable and enlarged. The amount distribution and texture of pubic hair vary according to patients age Circumcision varies with race Penis should have no presence of discharge and lesions. Some of the inguinal lymph nodes are palpable but they should not be larger than 0.5cm According to Barbarito Health and Physical Exam in Nursing this findings are normal except the inguinal lymph nodes are palpable and enlarged, tenderness in this area suggests infection of the scrotum or groin area.

X. DIAGNOSTIC TEST HEMATOLOGY REPORT

Patient ID: 234345/119 --------------------------------------------------------------------------------------------------------------------Patient Name R.C. Referring Doctor SAMPLE ID 0000000000AM 24 AGE SEX EXAM DATE 16 MALE 02/25/2013 09:56 AM ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------TEST RESULT UNIT REFERENCE ROOM PED A

White Blood Cell Red Blood Cell Hemoglobin Hematocrit MCV MCH MCHC PLATELET Neutrophil (%) Lymphocyte (%) Monocyte (%) Eosinophil (%) Basophil (%) RDW-CV MPV RETICULOCYTE COUNT ERTHROCYTE SEDIMENTATION RATE CLOTTING TIME BLEEDING TIME

24.67 3.69 119.0 34.9 94.6 32.2 34.1 99 12.0 37.0 5.8 0.0 0.2 19.5 8.3

10^3/uL 10^6/uL G/L % fL pg g/dL 10^3/uL % % % % % % fL % MM/HR M/N M/N

5.0-10 M 4.7-6.1 F 4.0-5.5 M 135-180 F 120-160 M 42.0-52.0 F 37.0-47.0 M 80-94 F 81-99 27.0-31.0 33.0-37.0 150-450 50.0-70.0 25.0-40.0 3.0-11.0 1.0-0.4 0.0-1.0 11.5-14.5 7.2-11.1 ADULT 1-2 INFANT 4-8 M 0-10 F 0-20 2-4 2-4

REMARKS: immature cells: 45%

The table above represents Complete Blood Count result of the client. It shows that the client has elevated WBC , decrease of RBC,Hematocrit, hemoglobin and platelet count. Decreaseof WBC suggests diabetes mellitus ,anemias ,following cancer chemotherapy while Increase in WBC suggests acute infections ,trauma , malignant disease , cardio-vascular disease. Decrease in Hemoglobin may indicates anemia , hyperthyriodism , liver cirrhosis , severe haemorrhage, while Decrease in haematocrit indicates anemia , leukemia , cirrhosis and hyperthyroidism and Decrease in platelets indicates anemias ,allergic condition ,during cancer chemotherapy.

HEMATOLOGY REPORT

Patient ID: 234345-175 --------------------------------------------------------------------------------------------------------------------Patient Name ROOM SAMPLE ID R.C. PED-ANX PM 18 Referring Doctor AGE SEX EXAM DATE DR. AGUINALDO 16 MALE 02/21/2013 04:31 PM -------------------------------------------------------------------------------------------

--------------------------

--------------------------------------------------------------------------------------------------------------------TEST RESULT UNIT REFERENCE White Blood Cell 151.85 10^3/uL 5.0-10 Red Blood Cell 3.86 10^6/uL M 4.7-6.1 F 4.0-5.5 Hemoglobin 125.0 G/L M 135-180 F 120-160 Hematocrit 36.5 % M 42.0-52.0 F 37.0-47.0 MCV 94.6 fL M 80-94 F 81-99 MCH 32.4 pg 27.0-31.0 MCHC 34.2 g/dL 33.0-37.0 PLATELET 128 10^3/uL 150-450 Neutrophil (%) Lymphocyte (%) Monocyte (%) Eosinophil (%) Basophil (%) RDW-CV MPV RETICULOCYTE COUNT ERTHROCYTE SEDIMENTATION RATE CLOTTING TIME BLEEDING TIME 11.0 3.0 0.0 0.0 0.0 20.7 8.1 % % % % % % fL % MM/HR M/N M/N 50.0-70.0 25.0-40.0 3.0-11.0 1.0-0.4 0.0-1.0 11.5-14.5 7.2-11.1 ADULT 1-2 INFANT 4-8 M 0-10 F 0-20 2-4 2-4

The table above still represents the Complete Blood Count of the patient. It still shows that the client has elevated WBC, decrease hemoglobin, haematocrit and platelet count. This table also shows that the client has an abnormal growth of lymphocyte precursors which indicates ALL.

Name: R.C. Age/Sex: 16/M Birth date:

Ward: MED-KP Hospital No.: 310986 Case No. : 234345

Date: 25 Feb.13 Control No.: 119 Physician: DR. FABIAN

CLINICAL CHEMISTRY Cobas Integra 400 Plus Generated Result

Test

Result

Reference Range

SODIUM

123.0

135-148 mmol/L

POTASSIUM

2.45

3.6-5.5 mmol/L

IONIZED CALCIUM

0.88

1.13-1.31 mmol/L

The table above shows that the client has decrease sodium, ionized calcium and potassium.

Name: R.C. Age/Sex: 16/M Birth date:

Ward: PED-A Hospital No.: 310986 Case No. : 234345

Date: 25-Feb-13 Control No.: 36 Physician:

URINALYSIS MACROSCOPIC: Color: YELLOW Transparency: CLEAR MICROSCOPIC: Pus Cells: 0-2 / hpf RBC: 0-1 / hpf Epithelial Cells: FEW Amorphous Urates /: _____ Phosphate: _____ Mucus Threads: _____ Bacteria: _____ Renal Cells: _____

Reaction/ph: 6.0 Sp. Gravity: 1025

Albumin: Sugar:

+1 NEGATIVE

CRYSTALS:

CAST:

PREGNANCY TEST

Time Received: 10:20 AM Time Released: 11:20 AM

The Normal, fresh urine is pale to dark yellow or amber in color and clear. Normal urine volume is 750 to 2000 ml/24hr. Turbidity or cloudiness may be caused by excessive cellular material or protein in the urine or may develop from crystallization or precipitation of salts upon standing at room temperature or in the refrigerator. Clearing of the specimen after addition of a small amount of acid indicates that precipitation of salts is the probable cause of tubidity.

A red or red-brown (abnormal) color could be from a food dye, eating fresh beets, a drug, or the presence of either hemoglobin or myoglobin. If the sample contained many red blood cells, it would be cloudy as well as red. Specific gravity between 1.002 and 1.035 on a random sample should be considered normal if kidney function is normal. Since the sp gr of the glomerular filtrate in Bowman's space ranges from 1.007 to 1.010, any measurement below this range indicates hydration and any measurement above it indicates relative dehydration.

Name: R.C.

Age/Sex: 16/M

Hospital No.: 310986

Date: 2/21/13

BODY FLUIDS QUALITATIVE EXAMINATIONS: Color: COLORLESS Volume: approx. 1.5 ml pH: ALKALINE (8.0) Specific Gravity: 1.010 Normal Value: ________cu /mm ________ % polymorphonuclear ________ % mononuclear ________ mg/dl

QUANTITATIVE EXAMINATIONS: WBC Count Differential Count

PROTEIN

SUGAR

_________ mg/dl

Time Received: 6:45 AM Time Released: 9:30 AM Requesting Physician: Birth Date: Case No.: 234345 Ward: PED-ANX

XI. REVIEW OF SYSTEM

Neurologic Pulmonary Cardiovascular Hematologic Immunologic Gastrointestinal Renal Musculoskeletal Reproductive Integumentary

Kapagtinakpankoangkaliwangmatako, malaboangpaninginngkanangmatako. Nahihirapanakohumingadatikasi may bukolsailongkosa may daluyannghininga. Hindi namannaninikipangdibdibko. Mababaangdugokongayon kaya pinapakainakongampalaya. Namamagaangleegko. Hindi namanakonahihirapanglumunokngpag-kain. Walanamanakongsakitsabato. Masakityungbandangbrasoko, kinuhaankasiakongdugodiyan. Walanamangproblema, hindinamanmasakit, may bukollangakosa may singit. Maramiakongmgasugatkasinadapaako at may pasa din sabandangbraso.

Acute Lymphoblastic Leukemia Pathophysiology

Precipitating Factors: Predisposing Factors: Age Gender Race Family HIstory Activate oncogene/ deactivate tumorsupppresor gene Somatic mutations in the DNA

ETIOLOGY: Unknown

exposure to radiation and certain chemicals having a sibling with leukemia HTLV-1 virus genetic abnormalities chromosomal translocations

Malignant transformation of lymphoid stem cells s/sx: Uncontrolled proliferation of lymphoblast in the bone marrow bone pain joint pain

Treatment: Analgesic

Diagnostic Test: BM aspiration

BM biopsy

Lymphoblast replace the normal marrow elements

Treatment: Remission Induction Therapy Consolidation and Maintenance Therapy BM Transplantation CNS prophylaxis

Decreased production of normal blood cells

Diagnostic Test: CBC

Leukopenia (4.36 x 10 9/L)

Decreased production of normal blood cells

s/sx: presence of petechiae bruise & bleed easily anemia fatigue dizziness palpitations dyspnea

Treatment: Blood transfusion Epoetin and hemapoetic stimulants

s/sx: fever, chills seizure

Infection

Spillage of lymphoblast into the bloodstream

Organ infiltration
If not treated

If treated: Antibiotic Ig
Leukapheresis

Septicemia

Prevention of complications

Death

Kidneys s/sx: Renal failure Little/ no UO RR Flank pain Restless n/v legs and feet swelling uremia azotemia

Diagnostic Test: MRI

Treatment: Intrathecalchem otherapy

CNS

leukocyte cells impairs the circulation of CSF

s/sx: h/a, weakness, blurred vision, balance difficulty, vomiting, lethargy s/sx: CSF leukocytes s/sx: cranial nerve palsies confusional states optic neuropathy cerebellar dysfunction papilledema

Liver / Spleen

Diagnostic Test: Ultrasonography

Extra cells cause the liver/spleen to rupture bleeding

s/sx: hepatomegal y splenomegaly elevated ALT (81 u/L) s/sx:

Diagnostic Test: Spinal Tap/Lumbar Puncture

leukocyte cells compresses spinal/ cranial nerves Progress to coma

Hypovolemic shock

hypotension
tachypnea tachychardia

Overgrown thymus

Compress the Superior Vena Cava SVC syndrome

s/sx: shortness of breath cough suffocation

Physical Exam Diagnostic test: Lymph node biopsy

Lymph nodes

Mediastinal lymphadenopathy

s/sx: lymphadenopathy

Bronchial/tracheal obstruction Esophageal compression

Treatment: s/sx: swelling of head, neck and arms obstruction of blood flow O2 administration Bronchodilators

s/sx: cough, wheezes, respiratory tract obstruction

s/sx: dysphagia

Erosion of node into a bronchus/ trachea

s/sx: hemoptysis

Severe hypoxia

DEATH

XIII. Case Management A. Medical 1. Pharmacologic Intervention

Drug Features

Therapeutic Indication Contradiction Contraindicated with allergy to allopurinol, blood dyscrasias Use cautiously with liver disease, renal failure, lactation and pregnancy.

Side Effects CNS: headache, drowsiness, peripheral neuropathy, neuritis, paresthesias Dermatologic: rashesmaculopapular, scaly or expoliative- sometimes fatal GI: nausea, vomiting, diarrhea, abnominal pain gastritis, hepatomegaly, hyperbilirubinemia, cholestatic jaundice. GU: exacerbation of gout and renal calculi, renal failure

Nursing Responsibilities Administer drug following meals. Encourage patient to drink 2.5-3 L/day to decrease the risk of renal stone development. Check urine alkalinity-urates crystallize in acid urine; sodium bicarbonate or potassium citrate may be ordered to alkalize urine. WARNING Discontinue drug at first sign of skin rash; severe to fatal skin reactions have occurred. Arrange for regular medical

Brand/ Generic Name Allopurinol

Classification Anti-gout drug Purine Analogue Prescribe Dosage 300mg tab

Management of the signs and symptoms of primary and secondary gout Management of patients with leukemia, lymphoma and malignancies that result in elevations of serum and urinary uric acid Management of patients with recurrent calcium oxalate calculi whose daily uric acid excretion exceeds 800 mg/day (male)

Route Oral

Frequency Every 8hrs

or 750 mg/day (females) Orphan drug use: treatment of Chagas disease; cutaneous and visceral leishmaniasis Unlabeled uses: Amelioration of granulocyte suppression with 5FU; as a mouthwash to prevent 5FUinduced stomatitis

Hematologic: Anemia, leukopenia, agranulocytosis, thrombocytopenia, aplastic anemia, bone marrow, depression

follow-up and blood tests.

Drug Features

Therapeutic Indication Contradiction Contraindicated with allergy to furosemide, sulfonamides: allergy to tartrazine(in oral solution); anuria, severe renal failure; hepatic coma; pregnancy; lactation

Side Effects CNS: dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss CV: orthostatic hypotension, volume depletion, cardiac arrhythmias, thrombophlebitis Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura , expoliative dermatitis, erythema multiforme GI: nausea, anorexia, vomiting, oral and gastric irritation, constipation, diarrhea, acute pancreatitis, jaundice GU: polyuria, nocturia, glycosuria, urinary bladder spasm Hematologic: leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalance, hyperglycemia, hyperpurisemia Others: muscle crumps

Nursing Responsibilities Administer with food or milk to prevent GI upset. Reduce dosage if given with other anti hypertensive, readjust dosage gradually as BP responds Give early in the day so that increased urination will not disturb sleep.

Brand/ Generic Name Furosemide

Classification Loop diuretic

Oral, IV; Edema associated with heart failure, cirrhosis, renal disease IV: Acute pulmonary edema Oral: Hypertension

Prescribe Dosage 40mg SIVP

Route IV

Frequency Every 6hrs

and muscle spasm

Drug Features

Therapeutic Indication Contradiction Contraindicated with infections, especially tuberculosis, fungal infections, amebiasis, vaccinia, and varicella, and antibiotic resistant; lactation. Use cautiously with renal or liver disease, hypothyroidism , ulcerative colitis with pending perforation, diverculitis, active or latent peptic ulcer, inflammatory bowel disease, heart failure, hypertension, thromboemboli c disorders, osteoporosis, seizure

Side Effects CNS: Vertigo, headache, paresthesias, insomnia, seizures, psychosis, cataracts, increased IOP, glaucoma, euphoria, depression. CV:Hypotension, shock, hypertension and HF secondary to fluid retention, thromboembolism, thrombophlebitis, fat embolism, cardiac arrhythmias ELECTROLYTE IMBALANCE: Sodium and fluid retention, hypokalemia, hypocalcemia ENDOCRINE: Amenorrhea, irregular menses, growth retardation, decreased carbohydrate tolerance, diabetes mellitus, cushingiod state (long term-effect), increased blood sugar, increase serum cholesterol, decreased T3 and T4 levels, HPA suppression with systemic therapy longer that 5 days. GI: Peptic or esophageal

Nursing Responsibilities Administer once a day doses before 9 am to mimic normal peak corticosteroid blood levels. Increase dosage when patient is subject to stress. WARNING: *Taper doses when discontinuing high-dose or long-term therapy to avoid adrenal insufficiency. * Do not give live virus vaccines with immunosuppressive doesofcosticosteroids.

Brand/ Generic Name prednisone

Classification Corticosteroid (intermediate acting) Glucocorticoid Hormone

Prescribe Dosage 20mg/tab TID

Route

Replacement therapy in adrenal cortical insufficiency Hypercalcemia associated with cancer Short term management of various inflammatory and allergic disorders, such as rheumatoid arthritis, collagen disease(eg, SLE), dermatologic diseases (e.g, pemphigus), status asthmaticus, and autoimmune disorders Hematologic disorders: Thrombocytope nia purpura,

Oral Frequency Every 6hrs

erythroblastope nia Ulcerative colitis, acute exacerbations of MS and palliation in some leukemias and lymphomas Trichinosis with neurologic or myocardial involvement

disorders, diabetes mellitus, hepatic disease, pregnancy (monitor infants for adrenal insufficiency)

ulcer, pancreatic, abdominal distention, nausea, vomiting, increase appetite, weight gain (long-term therapy). HYPERSENSITIVITY:Hypersi nsitivity or anaphylactoid reactions MUSCULOSKELETAL: Muscle weakness, steroid myopathy, loss of muscle mass, osteoporosis, spontaneous fractures (long-term therapy) OTHER:Immunosupresion, aggravation or masking of infections, impaired wound healing; thin, fragile skin;petechiae, ecchymoses, purpura, striae, subcutaneous fat atrophy

Drug Features

Therapeutic Indication Contradiction/Cautions Contraindicated with allergy to calcium, renal calculi, hypercalcemia, ventricular fibrillation during cardiac resuscitation and patients with the risk of existing digitalis toxicity. Use cautiously with renal impairement, pregnancy, lactation.

Side Effects CV. Slowed heart rate, tingling beat waves;peripheral vasodilation, local burning, drop in BP LOCAL: Local irritation, severe necrosis, sloughing and abscess formation (IM, subcutaneous use of calcium chloride)

Nursing Responsibilities Before: > Make sure prescriber specifies form of calcium to be given; crash carts may contain both calcium gluconate and calcium chloride. > Tell patient to take oral calcium 1 to 1!/2 hours after meals if GI upset occurs. During: > Give I.M. injection ingluteal region in adults and in lateral thigh in infants. Use I.M. route only in emergencies when no I.V. route is available because of irritation of tissue by calcium salts. > Tell patient to take oral calcium with a full glass of water. After: > Monitor calcium levels frequently. Hypercalcemia may result after large doses in chronic renal failure. Report abnormalities

Brand/ Generic Name Calcium Gluconate Antacid Electrolyte

Dietary supplement when calcium intake is inadequate Treatment of calcium deficiency in tetany of the newborn, acute and chronic hypoparathyroi dism, psuedohypopar athyroidism, postmenopausa l and senile osteoporosis, rickets, osteomalacia Prevention of hypocalcemia during exchange transfusions Adjunctive therapy for insects bites of stings, such as black widow

spider bites; sensitivity reactions, particularly when characterized by utricaria; depression due to overdose of magnesium sulfate; acute symptoms of lead colic Combats the effect of hyperkalemia as measured by ECG, pending correction of increased potassium in the extracellular fluid. Improves weak or ineffective myocardial contractions when epinephrine fails in cardiac resuscitation, particularly after open

heart surgery Symptomatic relief of upset stomach associated with peptic ulcer, gastritis, peptic esophagitis, gastric hyperacidity, hiatal hernia. Prophylaxis of GI bleeding, stress ulcers, and aspiration pneumonia; possibly useful. Treatment of hypertension in some patients with indices suggesting calcium deficiency; treatment of premenstrual syndrome(calci um glubionate)

2. Dietary Prescription Patient RC was prescribed to be on a DAT or Diet As tolerated wherein there is no food restriction and the patient can eat whatever he wants no concerns if healthy or unhealthy.

3. Procedures a. Intravenous Fluids TYPE OF INTRAVENOUS FLUID D5NM 1000cc INDICATION

is indicated for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories from dextrose.Magnesium in the formula may help to prevent iatrogenic magnesium deficiency in patients receiving prolonged parenteral therapy.
Adriamycin (DOXOrubicin HCl) Injection, USP and Adriamycin (DOXOrubicin HCl) for Injection, USP have been used successfully to produce regression in disseminated neoplastic conditions such as acute lymphoblastic leukemia, acute myeloblastic leukemia, Wilms' tumor, neuroblastoma, soft tissue and bone sarcomas, breast carcinoma, ovarian carcinoma, transitional cell bladder carcinoma, thyroid carcinoma, gastric carcinoma, Hodgkin's disease, malignant lymphoma and bronchogenic carcinoma in which the small cell histologic type is the most responsive compared to other cell types.

PNSS 1000cc

Doxorubicin 1000cc

*Used to give intravenous fluids to the patients suffering from salt and water deprivation. *used in blood transfusion, hyponatremia,and burn victims *Used for irrigation during surgery, to dilute medications, and to clean wound outs *used because it has little to no effect on the tissues and make the person feel hydrated preventing hypovolemic shock or hypotension

B. Nursing Management 1. List of Nursing Problems a. b. c. d. e. Anemia

Risk for Infection Excessive fluid volume related to excess fluid intake

Fatigue
Disturbed Body Image

3. Plans of Nursing Action

NURSING CARE PLAN EXCESSIVE FLUID VOLUME Cues/Data Subjective: Hindi koalamkongbakitnamam agaangmukhako as verbalized by the patient. Excessive fluid volume related to excess fluid intake as manifested by decrease skin integrity in the right lateral portion of the leg Nursing Diagnosis Goals and Objectives GOAL: After Nursing Intervention the client will be able to know how to prevent the discomfort of edema in his lymph nodes and will lessen excess fluid volume Assess clients condition. Health teaching rendered on: To educate the client about the signs and symptoms of edema. To give the client about the risk factors of edema. To have the client To further assess information In general, the goal is partially met because the edema is still not subsiding. The client understood the health teaching about the causes of having edema and how to lessen or fully recovered from it by having answered 5 out 5 questions Intervention Rationale Evaluation

Objective: Decrease in skin integrity in the right lateral portion of the leg (+) Partially edema slight pitting/2mm,dis appear immediately

Signs and symptoms of edema.

Objectives: After 2 days of effective nursing intervention the client will be able to: Gain knowledge

Risk factors.

Complications

 Swelling eyelid, medial lateral part of the neck, splenius capitis, Latissimusdorsi, inguinal Fluid intake: 1200 cc/day Use of constrictive clothings

about individual risk factors and appropriate intervention of edema by answering at least 3 out 5 questions correctly.

might happen if edema grows up to the face.

the knowledge she needs about the further complicatio ns of having edema. To have the client proper knowledge of manageme nt and prevention of edema. To lessen the swelling that edema makes

correctly. She demonstrates how to elevate her leg and enumerate the time it must be elevated. The client do lifestyle changes as demonstrated of wearing proper shoes and did what she learned from health teaching.

Management and prevention of having edema.

Demonstrate the proper elevation of lower extremities to lessen edema. Taught how to alleviate edema

Demonstrate behaviors or lifestyle changes to prevent development of edema.

DISTURBED BODY IMAGE Cues/Data Subjective: nahihiyaakonglumab asngbahayngayon, kasemagayungsa may leegko..as verbalized by the patient may bukol din akosa may leeg, kaya minsannagsusuotakon g scarf para di halatanakakahiyakase as verbalized by the patient Nursing Diagnosis Disturbed body image related to illness as manifested by swollen lymph nodes secondary to Acute Lymphocytic Leukemia (ALL) Goals and Objectives After rendering effective nursing intervention, the patient will verbalize acceptance of self in situation and verbalize relief of anxiety and adaptation to actual/alteredbody image. Intervention Assess patients condition Establish Rapport INDEPENDENT: Acknowledge and accept expressionof feelings of frustration, hostility.Note withdrawn behavior and use of denial. Rationale Serves as a baseline data To lessen patient anxiety Acceptance of this feeling as a normal response to what has occurred facilitates resolution. It is not helpful of possible to push patient ready to deal with situation. Denial maybe prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems Enhance trust andra pport between patient and nurse. Evaluation

The goal is PARTIALLY MET. The patient expressed his feelings about his condition

Objective: (+) pale conjunctiva (+) lump in the eyelid, medial lateral part of the neck, splenius capitis, Latissimusdors i, inguinal

The patient stated that he accept his condition and verbalized relief of anxiety and adaptation to actual altered body Image

Be realistic and positive during treatments in

 Swollen lymph nodes

health teaching and setting goals within limitations Provide hope within parameters of individual sit uation, do not give false reassurance

Promotes positi ve attitude and provides opportunity to set goals and plan for future based on reality.

Give positive reinforcement of progress and encourage endeavorstowar d attainment of rehabilitatio n

Words of encourageme nt can support development of positive coping behaviors.

Goals

Encourage family interaction with each other and with rehabilitation team

maintain open lines of communication and provides on ongoing support for patient and family.

Provide

support group for So. Give information about how so can behelpful to patient

Promotes ventilation of feelings andallow for more helpful responses to patient.

Role play social situation of concern to patient.

Prepares patient for reactions of others and anticipates ways to deal with them

Encourage patient to look at/ touch affected body part.

To begin to incorporate changes in body image

RISK FOR INFECTION Cues/Data Nursing Diagnosis Risk for infection related to inadequate primary and secondary defenseas manifested by open wounds secondary to ALL . Goals and Objectives Goal: After 8 hours of nursing intervention the client will be able to identify intervention to prevent/reduce risk of infection. Objective: After nursing intervention the client will be able to: Gain knowledge about the possible outcome of his condition. Demonstrate techniques, lifestyle Intervention Rationale Evaluation

Subjective: na-diagnose ako last January 1. na may ALL as verbalized by patient RC Objective: Low immune System due to chemothera py (+) Pallor (+) Leukemia cell Undevelope d WBC produced. (+) colds for 1 week Open wound

Assess the patients condition Observe for localized signs and symptoms of systemic infection Note risk factors for occurrence of infection Instruct client in techniques to protect the integrity of skin and prevention of spread of infection. Health teaching about his condition

To know the patients condition Fever, cough and colds may indicate infection. To evaluate presence/cha racter of infection. It serves as a first line of defense against infection To educate the client about the possible outcome of his condition.

In general, the goal is partially met because the infection is still not managed/ cured

in the anterior lateral portion of the leg

changes to promote safe environment . Verbalized understandi ng of individual causative/ris k factors

FATIGUE Cues/Data Nursing Diagnosis Goals and Objectives Intervention Rationale Evaluation

Subjective: Fatigue related to decreased metabolic energy production and increased energy requirements.

GOAL: >Monitor V/S signs After Nursing Intervention the client will be able to identify the measures to improve sense of energy >Plan interventions to allow patient adequate rest periods, schedule activities for periods when client has the most energy 3.Encourage patient to do whatever possible such as self-care, walking within war premises and interacting with family. 4.Instruct methods to conserve energy such as sitting when doing daily care or other activities,combining and simplifying activities and taking frequent short rest periods during 1.To evaluate fluid status and cardiopulmonary response to activity. 2.To maximize patient participation. 3.To manage patients limit of ability. 4.To conserve and maximize patients energy. 5. To protect client from injury.

Objective: >Lack of energy >Decrease activity performance >weakness

In general, the goal is partially met because the report improved sense of energy.

Objectives: After 2 days of effective nursing intervention the client will be able to: Gain knowledge about the possible outcome of

this condition

activities. 5. Assist patient in selfcare needs and with ambulation as needed

Demonstrate the ADLs

Report an improved sense of energy.

ACTIVITY INTOLERANCE Cues/Data Nursing Diagnosis Goals and Objectives Intervention Rationale Evaluation

Subjective: Minsan nahihilo ako as verbalized by patient R.C. Activity intolerance related to imbalance between oxygen supply and demand manifested by slow deep breathing.

GOAL: After Nursing Intervention the client will have no difficulty of breathing and will prevent other complication related to anemia. Objectives: After 2days of effective Nursing Intervention the client will be able to: Gain knowledge about individual risk factors and appropriate interventions related to anemia by answering 3 Assess clients condition. To know if there are any other complication related to anemia. In general, the goal is partially met because anemia cant be cure easily its a process that must be given full attention to recover and Mrs. E.P is now in process of recovery.

Objective: Pallor, pale conjunctiva, slightly pale hands and lips. Slow deep breathing Laboratory: hemoglobin count- 113g/L ( normal in female is 123156 g/L) V/S

Health teaching rendered on: Individual risk factors of anemia Potential problem might happen if anemia gets worst. Specific interventions about anemia.

PR= 90 RR= 18 BP= 100/70

Teaching how to prepare foods that are rich in

For the client to know risk factors and potential problem as well as interventions that can help her to lessen the risk of having anemia.

The client understands the health teaching regarding the cause and effects of anemia in a pregnant women by answering 5 out 5 questions

out of 5 questions. Prepare foods that are rich in iron , vitamins and minerals Monitor what she eats by eating foods that are rich in iron, vitamins and minerals to prevent development of anemia.

iron, vitamins and minerals. Alternative foods but has the same nutrient value. For the client to have skills on preparing foods that can help her to lessen the risk of having anemia. For budget friendly foods which has the same nutrient value of expensive foods.

correctly. She enumerated the thing that she must do and the food that she must eat and prepare. The client is monitored her diet by applying what she had learned from the health teaching.

Encouraged the client to eat nutritious foods rich in iron and other minerals.

To start the lifestyle change and prevent the other complications of anemia.

ANEMIA
Cues/Data Nursing Diagnosis Goals and Objectives Intervention Rationale Evaluation

Subjective: Minsan piling konahihiloako at nanghihina as verbalized by the patient Objective: CBC Result: Result: 3.86 (Norma Rangel: M 4.7-6.1) Fatigue Pallor Dizziness V/S taken as

Anemia related to decreased oxygen carrying capacity of blood as manifested by CBC result of RBD=3.86
(Normal Range: M 4.7-6.1)

After an hour of nursing intervention the client will:

Monitor V/S watching for changes in blood pressure, heart and respiratory rate.

To note significant changes that may be brought about by the disease.

Report a BP within patients normal range. Recommend a quiet atmosphere and bed rest 2. Promotes adequate rest, maintain energy level and alleviates strain on cardiac and respiratory rhythm. 2. Note reports of weakness, fatigue and difficulty in accomplishing tasks. Influence choice of interventions or needed assistance

Display laboratory values within acceptable range

After an hour of nursing intervention the goal was partially met: The patient improve or able to mobilize by doing walking outside the ward unlike before that he is just lying/ sitting on his bed and chat with his roommates.

Report an improve sense of energy

follows T: 36.2 P: 89 R: 22 BP: 90/60

Identify or implement energy saving technique like sitting while doing a task

3. Elevate the head of the patient

3. Enhances lung expansion to maximize oxygenation

Encourages patient to do as much as possible, while conserving limited energy and preventing fatigue