LEVEL II SECTION 2 GROUP 6

MEDICAL FORBES
I. Introduction

A. Background of the Study

Cancer (medical term: malignant neoplasm) is a class of diseases in which a group of cells display uncontrolled growth (division beyond the normal limits),

invasion (intrusion on and destruction of adjacent tissues), and sometimes metastasis (spread to other locations in the body via lymph or blood). These three malignant properties

of cancers differentiate them from benign tumors, which are self-limited, and do not invade or metastasize. (http://en.wikipedia.org/wiki/Colorectal_cancer)

Colorectal cancer, also called colon cancer or large bowel cancer, includes cancerous growths in the colon, rectum and appendix. Tumors of the colon and rectum are

growths arising from the inner wall of the large intestine. Benign tumors of the large intestine are called polyps. Malignant tumors of the large intestine are called cancers. Benign

polyps do not invade nearby tissue or spread to other parts of the body. Benign polyps can be easily removed during colonoscopy and are not life-threatening. If benign polyps are

not removed from the large intestine, they can become malignant (cancerous) over time. Most of the cancers of the large intestine are believed to have developed from polyps.

Cancer of the colon and rectum (also referred to as colorectal cancer) can invade and damage adjacent tissues and organs. Cancer cells can also break away and spread to other

parts of the body (such as liver and lung) where new tumors form. The spread of colon cancer to distant organs is called metastasis of the colon cancer. Once metastasis has

occurred in colorectal cancer, a complete cure of the cancer is unlikely. Factors that increase a person's risk of colorectal cancer include high fat intake, a family history of

colorectal cancer and polyps, the presence of polyps in the large intestine, and chronic ulcerative colitis. (http://www.medicinenet.com/colon_cancer/article.htm)

Globally, cancer of the colon and rectum is the third leading cause of cancer in males and the fourth leading cause of cancer in females. The frequency of colorectal

cancer varies around the world. It is common in the Western world and is rare in Asia and Africa. In countries where the people have adopted western diets, the incidence of

colorectal cancer is increasing. Colorectal cancer ranks second to lung cancer as the overall most common cause of cancer mortality. In Asian 46.9 per 100,000 men and 34.6 per

100,000 women have incidence rates of colon cancer. The April 15th, 2009 release of the Cancer Statistics Review (1975-2006) does not include cancer mortality statistics because

the latest mortality file with 2006 deaths from the National Center for Health Statistics, Division of Vital Statistics has not been released.

(http://seer.cancer.gov/csr/1975_2006/index.html)
 B. Rationale for the study

The researchers decided to choose this study because they wanted to know more about Colorectal Cancer and its cause. Why Colorectal cancer is rapidly growing not only

in the western population but also in the eastern population. They wanted to use the acquired knowledge in promoting awareness to the people especially to the poor in slum

because they are the most vulnerable. The researchers also wanted to focus on the preventive measure. Presently in our country Colon Cancer is rapidly gain momentum as one of

the disease due to lifestyle.

C. Significance of the study

This study will help the nursing profession in providing information about the proper management and care of patients with colon cancer. It will also educate the people

especially those with colon cancer to seek medical care in order to prevent much more major complication. It will come to awareness the importance of healthy habits and lifestyle

to maintain wellbeing.

D. Scope and Limitation of the study

This study is the focus on the nursing aspects of care of patients diagnose with colon cancer. This study will also be used in the nursing profession. The researchers

only focus their attention on the medication, diagnosis, care plan, pathophysiology. This study will be limited for the colon cancer patients and for those who are interested in colon

cancer.
II. Clinical Summary

A. General Information

Name: Pebenito, Revelina Caballes Room/ Bed No.: 205-D

Age: 46 years old Gender: Female Civil Status: Married Nationality: Filipino

Religion: Roman Catholic Date of Birth: February 19, 1963 Place of Birth: Biñan

Occupation: Housewife Educational Attainment: Tertiary

Residence: 1019 Ibarra St., Sampaloc, Manila

Father’s name: Eduardo Caballes Mother’s name: Elena Caballes

Date /Time Admitted: May 17, 2009/ 3:10 PM

Attending Physician: Dr. Chan/ Dysangco/ Cuenza

B. Chief Complaint

*Abdominal Pain

C. History of Present Illness

o Five days PTA, the patient complained continuous abdominal pain that was graded 6/10.

o Four days PTA, patient noted persistence of abdominal pain. And she also noted decrease urine output.

o Three days PTA, the patient still have persistence of abdominal pain. Patient had a paracentesis done on the same day. Patient now complained of the passage of

loose watery stools, 2 episodes, ¼ cup per episode.

 o Two days PTA, patient complained of abdominal pain and passage of loose watery stools persisted, there was uncontrolled passage of stool during urination. Felt

febrile, for which she self-medicated with Paracetamol, which lysed the fever.

o One day PTA, patient complained of the persistence of abdominal pain, loose watery stool, and uncontrolled passage of stool during urination. And she self-

medicated paracetamol due to fever.

o Persistence of symptoms prompted consultation the following days hence this admission.

D. Past Medical History

Allergies: none

Illnesses: Colonic CA

Operations: January 2008- Sigmoidectomy, Appendectomy, TAH-BSO

Transfusions: January 2008 (2 transfusion)

Injuries: ----

Medications: Metronidazole, Hyoscine-N-butylbiomide, Paracetamol

Adverse Drug Reaction: none

E. Familial History

Eduardo Caballes Elena Caballes

Father: Mother
Deceased Deceased
RENAL FAILURE GOUT/OTHER ARTHRITIS
HYPERTENSION

Revelina Caballes Pebenito

Patient: Colon cancer

PHYSICAL ASSESSEMENT

AREA TECHINIQUE NORMS FINDINGS ANALYSIS & INTERPRETATION

A. SKULL
1. Size, shape and Inspection Rounded (normocephalic and Rounded (normocephalic); normal
symmetry of the skull Palpation symmetrical, with frontal, Smooth skull contour
parietal, and occipital
prominences); Smooth skull
contour
2. Presence of nodules, Palpation Smooth, uniform consistence; No tenderness, masses or Normal
masses or depressions Inspection absence of nodules or masses nodules
3. Facial Features Inspection Symmetric or slightly asymmetric Symmetrical; palpebral Normal
Palpation facial features; palpebral fissures fissures equal in size;
equal in size; symmetric symmetric nasolabial folds
nasolabial folds
4. Presence of edema and Inspection No edema and hollowness no edema or haollowness Normal
hollowness of the eye.
C. HAIR
1. Evenness of growth, Inspection Evenly distributed and covers the Has signs of hair loss Hair loss or alopecia can be signs to some disease or
thickness, or thinness of Palpation whole scalp; maybe thick or thin because of medication such as radiation therapy or
hair chemotherapy.
2. Texture and oiliness Inspection Silky; resilient hair Dry hair Maybe cause of underlying disease process or by poor
over the scalp Palpation hygiene
3. Presence of infection Inspection No infection and infestation No infection and infestation normal
and infestation Palpation
D. FACE
Facial features, symmetry Inspection Symmetric or slightly asymmetric Symmetrical; palpebral Normal
of facial movements facial features; palpebral fissures fissures equal in size;
equal in size; symmetric symmetric nasolabial folds
nasolabial folds
IV. EYES
A. EYEBROWS
Hair distribution, Inspection Symmetrical and in line with each Symmetrical and in line with Normal
alignment, skin quality other; maybe black, brown or each other; black; evenly
and movement blond depending on race; evenly distributed
distributed
B. EYELASHES
Evenness of distribution
and direction of curl
C. EYELIDS
Surface characteristics
and position (in relation to
the cornea, ability to blink,
and frequency of blinking)
D. CONJUNCTIVA
1. Color, texture, and the
presence of lesions in the
bulbar conjunctiva
2. Color, texture, and the
presence of lesion in the
palpebral conjunctiva
E. SCLERA
Color and clarity
F. CORNEA
Clarity and texture
G. IRIS
Shape and color
H. PUPILS
1. Color, shape, and
symmetry of size
2. Light reaction and
accommodation
Inspection Evenly distributed; turned
Palpation outward
Inspection Upper eyelids cover the small
portion of the iris, cornea, and
sclera when eyes are open;
eyelids meet completely when the
eyes are closed; symmetrical
Inspection Pinkish or red in color; with
palpation presence of small capillaries;
moist; no foreign bodies; no
ulcers
Inspection Pinkish or red in color; with
Palpation presence of small capillaries;
moist; no foreign bodies; no
ulcers
Inspection White in color; clear; no
yellowish discoloration; some
capillaries maybe visible
Inspection No irregularities on the surface;
looks smooth; clear or transparent
Inspection Anterior chamber is transparent;
no noted visible materials; color
depends on the person’s race
Inspection Color depends on the person’s
race; size ranges from 3-7mm,
and are equal in size; equally
round
Inspection Constrict briskily/sluggishly
when light is directed to the eye,
Evenly distributed; turned Normal
outward
Upper eyelids cover the small Normal
portion of the iris, cornea, and
sclera when eyes are open;
eyelids meet completely when
the eyes are closed;
symmetrical
Pale pink; with presence of Abnormal: pale conjunctiva may be related to low
small capillaries; moist; no RBC level of the patient.
foreign bodies; no ulcers
Pale pink Abnormal: pale conjunctiva may be related to low
RBC level of the patient.
White in color; clear; no Normal
yellowish discoloration; some
capillaries are visible
No irregularities on the normal
surface; looks smooth; clear or
transparent
Anterior chamber is Normal
transparent; no noted visible
materials; black color
Black; 2-3mm and are equal in Normal
size; equally round
Reactive to light Normal
 both directly and consensual
I. VISUAL ACUITY
1. Near vision Inspection Able to read newsprint Able to read Normal
J. LACRIMAL GLAND
Palpability and tenderness Palpation No edema or tenderness over the No edema or tenderness over Normal
of the lacrimal gland lacrimal gland the lacrimal gland
K. EXTRAOCULAR
MUSCLE
Eye alignment and Inspection Both eyes coordinated, move in Both eyes coordinated, move Normal
coordination unison, with parallel alignment in unison, with parallel
alignment
L. VISUAL FIELDS
Peripheral visual fields Inspection When looking straight ahead, When looking straight ahead, Normal
client can see objects in the client can see objects in the
periphery periphery
V. EARS
A. AURICLES
1. Color, symmetry of size Inspection Color same as facial skin; Symmetrical Normal
and position symmetrical; auricle aligned with
outer canthus of the eye, about 10
degrees from vertical
2. Texture, elasticity and Palpation Mobile, firm and not tender; Mobile, firm and not tender; Normal
area of tenderness pinna recoils after it is folded pinna recoils after it is folded
C. HEARING ACUITY
TEST
1. Client’s response to Inspection Normal voice tones audible Normal voice tones audible Normal
normal voices tones
VI. NOSE
1. Any deviation in shape, inspection Symmetric and straight; no Symmetrical Normal
size, or color and flaring discharge or flaring; uniform
or discharge from the color
nares
2. Nasal septum (between Inspection Nasal septum intact and in Nasal septum intact Normal
the nasal chambers) Palpation midline
3. Patency of both the Inspection Air moves freely as the client No obstruction Normal
nasal cavities breathes through the nares
4. Tenderness, masses and Palpation Not tender; no lesions Not tender; no lesions Normal
displacement of the bone
and cartilage
VII. SINUSES
Identification of the
sinuses and for tenderness
VIII. MOUTH
A. LIPS
Symmetry of contour,
color and texture
B. BUCCAL MUCOSA
Color, moisture, texture
and presence of lesions
C. TEETH
Color, number and
condition and presence of
dentures
D. GUMS
Color and condition
E. TOUNGUE/FLOOR
OF THE MOUTH
1. Color and texture of the
mouth floor and frenulum.
2. Position, color and
texture, movement and
base of the toungue
3. Any nodules, lumps, or
excoriated areas
F. PALATES and UVULA
1. Color, shape, texture
and the presence of bony
prominences
2. Position of the uvula
and mobility (while
Inspection Not tender Not tender Normal
Palpation
Inspection Uniform pink color; soft, moist, Moist; pale pink Normal
Palpation smooth texture; symmetry of
contour; ability to purse lip
Inspection Uniform pink color; moist, pale pink color; moist, Abnormal: pale may suggest low RBC
smooth, soft glistening and elastic
texture
Inspection 32 adult teeth; smooth, white, 30 adult teeth; intact dentures Loss of teeth may suggest poor proper hygiene
shiny tooth enamel; smooth,
intact dentures
Inspection Pink gums; no retraction pale pink gums; no retraction Low RBC
Inspection Pink color; moist; slightly rough; Pink color; moist; slightly Normal
Palpation thin whitish coating; moves rough; thin whitish coating;
freely; no tenderness moves freely; no tenderness
Inspection Central position; pink color; Central position; pink color; Normal
smooth tongue base with smooth tongue base with
prominent veins prominent veins
Palpation Smooth with no palpable nodules, Smooth with no palpable Normal
Inspection lumps or excoriated areas nodules, lumps or excoriated
areas
Inspection Light pink, smooth and soft Light pink, smooth and soft Normal
Palpation palate; lighter pink hard palate, palate; lighter pink hard palate,
more irregular texture more irregular texture
Inspection Positioned in the midline of soft Positioned in the midline of Normal
palate soft palate
examining the palates)
G. OROPHARYNX and
TONSILS
1. Color and texture Inspection Pink and smooth posterior wall ink and smooth posterior wall Normal
2. Size, color, and Inspection Pink and smooth; no discharge; of Pink and smooth; no Normal
discharge of the tonsils normal size discharge; of normal size
3. Gag reflex Inspection Present Present Normal
X. THORAX
A. ANTERIOR THORAX
1. Breathing patterns Inspection Quiet, rhythmic and effortless Quiet, rhythmic and effortless Normal
respiration respiration
2. Temperature, Palpation Skin intact; uniform temperature; Skin intact; uniform Normal
tenderness, masses chest wall intact; no tenderness; temperature; chest wall intact;
no masses no tenderness; no masses
3. Anterior thorax Auscultation Bronchovesicular and vesicular Bronchovesicular and Normal
auscultation breath sounds vesicular breath sounds
B. POSTERIOR
THORAX
1. Shape, symmetry, and Inspection Anteroposterior to tranverse Anteroposterior to tranverse Normal
comparison of Palpation diameter in ratio 1:2; chest diameter in ratio 1:2; chest
anteroposterior thorax to symmetric symmetric
transverse diameter
2. Spinal alignment Inspection Spine vertically aligned Spine vertically aligned
3. Temperature, Palpation Skin intact; uniform temperature; Skin intact; uniform Normal
tenderness, and masses chest wall intact; no tenderness; temperature; chest wall intact;
no masses no tenderness; no masses
7. Posterior thorax Auscultation Vesicular and bronchovesicular Vesicular and Normal
auscultation breath sounds bronchovesicular breath
sounds
XI. CARDIOVASCULAR
A. AORTIC and Auscultation No pulsation No pulsation Normal
PULMONIC AREAS
B. TRICUSPID AREA Auscultation No pulsation; no lift or heave No pulsation; no lift or heave Normal
C. APICAL AREA Auscultation Pulsation visible in 50% of adult Pulsation felt Normal
and palpable in most PMI in fifth
LICS at or medial to MCL
D. EPIGASTRIC AREA Auscultation Aortic pulsation Pulsation felt
E. CARDIOVASCULAR Auscultation S1: Usually heard at all site Weak heart sounds Decrease cardiac input
AREAS
AUSCULTATION Usually louder at the apical area

S2: Usually heard at all sites

Usually louder at the base of the

heart

Systole: silent interval; slightly

shorter duration than diastole of
normal heart rate (60 to 90
beats/min)

Diastole: silent interval; slightly

longer duration than systole at
normal heart rates

S3: in children and young adults

S4: in many older adult

XII. CAROTID
ARTERIES
1. Carotid artery Palpation Symmetric pulse volume; full Weak pulsation Decrease cardiac input
palpation pulsation, thrusting quality;
quality remains the same when
the client breathes, turns head,
and changes from sitting to
supine position; elastic arterial
wall
XIV. AXILLAE Normal
1. Axillary, subclavicular, Inspection No tenderness, masses or nodules No tenderness, masses or Normal
and supraclavicular lymph nodules
nodes
XV. ABDOMEN
1. Skin integrity Inspection Unblemished skin; uniform color scar Due to operation
2. Abdominal contour Inspection Flat, rounded (convex) or Abdominal distention Enlargement of organs
scaphold (concave)
3. Enlargement of liver or
spleen
4. Symmetry of contour
5. Abdominal movements
associated with
respiration, peristalsis or
aortic pulsation
6. Vascular pattern
XVI.
MUSCULOSKELETAL
SYSTEM
A. MUSCLES
1. Muscle size and
comparison on the other
side
2. Fasciculation and
tremors in the muscles
3. Muscle tonicity
4. Muscle strength
C. JOINT
1. Joint swelling
EXTREMITIES
G. Patterns of Functioning
The researchers utilized the Gordon’s typology in assessing the pattern of functioning of our patient in her life. How does she manages and takes care of herself
based on Eleven Patterns.
Prior to Hospitalization
Health perception – Health Management
Inspection No evidence of enlargement of There is an enlargement of the Cause by underlying conditions.
liver or spleen liver
Abdominal girth:105cm
Inspection Symmetric contour Symmetric contour normal
Inspection Symmetric movements caused by Peristalsis not visible Not visible because of abdominal distention
respiration; visible peristalsis in
very lean people; aortic pulsation
in thin persons at epigastric area
Inspection No visible vascular patterns No visible vascular patterns Normal
Inspection Proportionate to the body; even in Proportionate to the body; Normal
both sides even in both sides
Inspection No fasciculation and tremors No fasciculation and tremors Normal
Palpation Even and firm muscle tone Even and firm muscle tone Normal
Palpation Has equal muscular strength on Has equal muscular strength Normal
both sides on both sides
Inspection No swelling; no warmth, redness, No swelling; no warmth, Normal
no pain, no crepitus redness, no pain, no crepitus
Inspection No swelling, no warmth, no No swelling, no warmth, no Normal
Palpation redness, no pain redness, no pain
Functional Health Pattern
Norms and Standards
 Measure for personal cleanliness and grooming, called personal hygiene, promote physical and
 The patient receives incomplete immunization. She lacks
psychological well-being. Various studies have confirmed that improved personal hygiene practices reduce
1 dose of measles vaccine, 3 doses of Hepa-B, and 1 dose
illness rates. (Larson, 2002 ; Larson and Aiello, 2001)
of BCG. The patient’s salience regarding immunization is
Personal hygiene practices vary widely among people. The time of the day one bathes and how often
low, hence, she do not intend to complete her
one shampoo or changes the bed linens, and sleeping garments are relatively unimportant. What is important
immunizations. In addition to this, financial constraints
is that personal care be carried out conveniently and frequently enough to promote personal hygiene.
are also a consideration.
Illness, hospitalization and institutionalization generally require modifications in hygiene practices. In
 Prior to knowing her medical diagnosis, she often consults
these situations, the nurse helps the patient to continue some hygiene practices, and can teach the patient and
“manghihilot” regarding her abdominal pain.
family members, when necessary, regarding hygiene. Nurses assist the patient with basic hygiene must
 The patient was hospitalized thrice, and had underwent
respect individual patient preferences, providing only the care that patients cannot or should not provide for
several medical procedures like sigmoidectomy,
themselves. (Fundamentals of Nursing 5th edition by Taylor, page 1005)
appendectomy and TAH-BSO.
The main purpose of washing hands is to cleanse the hands of pathogens (including bacteria and
 The patient shows no allergies to any food or drugs.
viruses) and chemicals which can cause personal harm or disease, particularly diarrhea and pneumonia. To
 The patient’s diet is tolerated and has no any other
maintain good hygiene, hands should always be washed after using the toilet, changing diaper, tending to
precautions to eating habits.
someone who is sick, or handling raw meat, fish or poultry, or any other situation leading to potential
 Whenever the patient feels abdominal pain, she usually
contamination. Hands should also be washed before eating, handling or cooking food. Conventionally, the use
resorts to herbal medicines like guava leaves and other
of soap and warm running water and the washing of all surfaces thoroughly, including under fingernails is
“tapal techniques”. If the patient has cough, she usually
seen as necessary. Alcohol rub sanitizers kill bacteria, multi-drug resistant bacteria (MRSA and VRE),
drinks decoction of lagundi, oregano, or Yerba Buena.
tuberculosis and viruses (including HIV, herpes, RSV, rhinovirus, vaccine, influenza and hepatitis) and
 The patient’s point of view regarding health is that being
fungus. (http://en.wikipedia. org/wiki/Hand-washing)
healthy is being fat and free from sickness.
Malnutrition is the lack of sufficient nutrients to maintain healthy bodily functions and is typically
 The patient had never experienced any accidents.
associated with extreme poverty in economically developing countries. Most commonly, malnourished
 The patient has a regular schedule of medical visits but
people either do not have enough calories in their diet, or are eating a diet that lacks protein, vitamins, or trace
then, laboratory tests and other procedures were not done
minerals. Medical problems arising from malnutrition are commonly referred to s deficiency diseases.
on a regular basis.
Deficiency in micronutrients such as Vitamin A reduces the capacity of the body to resist disease. Deficiency
 The patient immediately consults her physician whenever
in iron, iodine and Vitamin A is widely prevalent and represent a major public health challenge. An array of
 needed. afflictions ranging from stunted growth, reduced intelligence and various cognitive abilities, reduced
 The patient has a habit of washing her hands before sociability, reduced leadership and assertiveness, reduced activity and energy, reduced muscle growth and
eating. strength, and poorer health overall are directly implicated to nutrient deficiencies.
 The patient takes a bath once daily and brushes her teeth (http://en.wikipedia. org/wiki/Malnourishment)
once daily.
Herbalists treat many conditions such as asthma, eczema, premenstrual syndrome, rheumatoid
arthritis, migraine, menopausal symptoms, chronic fatigue, and irritable bowel syndrome, among others.
Herbal preparations are best taken under the guidance of a trained professional. Be sure to consult with your
doctor or herbalists before self-treating. Some common herbs and their uses are discussed below. Please see
our monographs on individual herbs for detailed descriptions of uses as well as risks, side effects, and
potential interactions. (http://www.umm.edu/altmed/articles/herbal-medicine-000351.htm)

Nutritional Metabolic Pattern

Nutrition is a basic human need that changes throughout the life cycle and along the wellness-illness
 The patient indulge herself to eating grilled foods (e.g.
continuum.
isaw, barbeque, grilled eggplant and fish), kilawin, and
(Fundamentals of Nursing 5th edition by Taylor, page 1135)
doesn’t have varied food choices.
An adequate food intake consists of balance essentials nutrients: water, carbohydrates, fats, proteins,
 The patient eats three meals a day and often eats
vitamins and minerals. Habits about eating are affected by many factors like financial and health conditions.
junkfoods for snacks.
( Kozier et. Al, Fundamentals of Nursing 7th edition Page 1171, 1175)
 The patient drinks at least 9 to 10 glasses of water a day.
The middle aged adult should continue to eat a healthy diet, following the recommended portions of
 The patient doesn’t like to drink milk.
the 5 food groups, with special attention to protein, calcium and limiting consumption to cholesterol. Two to
three liters of fluid should be included in the diet. Pre menopausal women need to ingest sufficient calcium
and vitamin D to prevent osteoporosis. ( Kozier et. Al, Fundamentals of Nursing 7th edition Page 1180, 1181)
An adult individual needs to balance energy intake with his or her level of physical activity to avoid
storing excess body fat. Dietary practices and food choices are related to wellness and affect health, fitness,
weight management, and the prevention of chronic diseases such s osteoporosis, cardiovascular diseases,
 cancer and diabetes.
For adults (ages eighteen to forty-five or fifty), weight management is a key factor in achieving health
and wellness. In order to remain healthy, adults must be aware of changes in their energy needs, based on
their level of physical activity and balance their energy intake accordingly.
(http://www.faqs.org/nutrition/A-Ap/Adult-nutrition.html)
Inadequate nutrition is associated with marked weight loss, generalized muscle weakness, altered
functional ability, and increased susceptibility to infection, impaired pulmonary function and prolonged
length of hospitalization. (Kozier et. Al, Fundamentals of Nursing 7th edition page 1190)
Elimination
Elimination can be affected by a person’s developmental stage, daily patterns, the amount and quality
 The patient defecates at least 1 to 2 times daily and there
of fluid or food intake, the level of activity, lifestyle, emotional states, pathologic processes, medication, and
was uncontrolled passage of stool during urination.
procedures such as diagnostic test and surgery. Most people have individual pattern of elimination including
 The patient voids 7 to 8 times daily.
frequency, timing considerations, position and place. For most people defecation is a private affair
 The stool of the patient is dark brown in color and has soft
experienced easily only in the comfort of one’s own bathroom. Defecation may be difficult in shared hospital
consistency.
room with only a curtain for privacy. (Fundamentals of Nursing 5th edition by Taylor, page 1341)
The frequency of defecation is highly individualized, varying from several times per day to two to
three times per week. Sufficient bulk in the diet is necessary to provide fecal volume. Bland diets and low-
fiber diets are lacking in the bulk and therefore create insufficient residue of waste products to stimulate the
reflex for defecation. Low-residue foods such as rice, eggs and lean meats move more slowly through the
intestinal tract. (Kozier et. Al, Fundamentals of Nursing 7th edition page 1228).
Activity stimulates peristalsis, thus facilitating the movement of chime along the colon.
(Fundamentals of Nursing 5th edition by Taylor, page 1229)
A person’s urinary habits depend on social culture, personal habits and physical abilities. Urine
collects in the bladder contains between 250 to 450 ml of urine (Kozier et. Al, Fundamentals of Nursing 7 th
edition page 1256).
The excretory function of the kidney diminishes with age but usually not significant below normal
 levels unless disease intervenes. With age, the number of functioning nephrons decreases to some degree,
impairing the kidneys filtering abilities. The amount of flood intake affects the urinary frequency of n
individual. Foods high in sodium or fluids high in sodium can cause fluid retention because water is retained
to maintain the normal concentration of the electrolyte (Kozier et. Al, Fundamentals of Nursing 7 th edition
page 1258, 1259).

Activity and Exercise The human body was designed for motion, and regular exercise is necessary for its healthy
functioning. Individuals who choose inactive lifestyles or who are forced into inactivity by illness or injury
 The patient has sedentary lifestyle.
placed themselves at high risk for serious health problems. (Fundamentals of Nursing 5th edition by Taylor,
 The patient has no regular exercise.
page 1116)
 According to her, cleaning the house and doing light
Vigorous physical activity is not always needed to achieve positive result. (Fundamentals of Nursing
activities like walking from house to market is her own
5th edition by Taylor, page 1117).
way of exercise.
Lack of exercise, inactivity, or immobility related to illness, or injury place a person at high risk for
 The patient wasn’t aware that her activities weren’t
serious health problems. Immobility can affect the major body systems. Like the benefits, a person receives
enough to be considered good exercise because she
from exercise, complications resulting from immobility differ occurrence and severity based on the patients
believes that doing such activities like what she does is
age and overall health status. (Kozier et. Al, Fundamentals of Nursing 7th edition page 1118).
already good enough for her.
The wonderful tool of exercise can help teens become fit and healthy. Performing some form of
physical activity daily will significantly boost your “basal metabolic rate” – the number of calories your body
burns in order to keep you alive. By having a high metabolism, you burn calories 24 hours a day – even while
you sleep! You can literally turn your body into a fat-burning machine!
This has many benefits: with a strong metabolism comes a strong immune system. When you burn fat,
the toxins are released into the blood stream, and are quickly carried out of the body through sweat. This
inoculates you against the probability of developing cancerous and diseased cells. Therefore, hard exercise –
that makes you sweat – is very good for you.
Exercise also helps to regulate the mount of insulin released into the bloodstream. Insulin is
commonly referred to as “the fat-making hormone”. Its job is to metabolized blood sugar into energy. But too
 much insulin in the bloodstream keeps your body from burning stored fat. Years of an overworked pancreas-
the organ that produces insulin – can lead to “onset (type2) diabetes”. However, if you use –burn-more
calories than you consume, you significantly reduce chances of developing this disease.
Exercise can also help control other problems, such as sleep apnea, moodiness, stress, decreased
energy, cardiovascular disease, high cholesterol and others. There are too many benefits to list here. But be
assured that this tool can help you become a fit, stronger, disease free, and overall healthier person. The main
goal of aerobic exercise is to keep the heart elevated for an extended period of time for the purpose of
strengthening the heart and lungs. The most common aerobic exercise is walking. Running is the quickest
way to lose weight because it burns many calories. It also tones your calves and thighs. However, to avoid
extreme muscle aches or injuries, do not begin a running routine until you have performed two to three
months of aerobic walking.
(http://www.thercg.org/youth/articles/0201-toie.html)

Cognitive-perceptual Cognition is greatly affected by education. Those who study and develop their skills have better
cognitive performances because they have been provided with different information nod chances to develop
 The patient still has a good memory and was able to recall
their self. Perception is affected by the sensory diseases. Presence of any sensory abnormalities affects or
things that had happened in the past.
halters perception that would affect proper communication. (Black, Medical Surgical Nursing 7th edition, page
 The patient is literate.
1880)
 The patient can converse well.
Cognition involves a person’s intelligence, perceptual ability and ability to process information. It
 The patient is aware about the happenings in her
represents a progression of mental abilities from illogical to thinking, from simple to complex problem
surroundings.
solving and from concrete to abstract ideas. (Kozier et. Al, Fundamentals of Nursing 7th edition page 359).
 The patient is ill-tempered.

Sleep and Rest For no known reasons, 8 hours of sleep at night has been the accepted standard for adults despite
  The patient’s usual time of sleep is around 10pm and obvious variation seen in the general population. It is important however that a person follows a pattern of
wakes up at around 7am. rest that maintains well-being. Many factors affect a person’s ability to rest. Illnesses and various life
 The patient usually takes a nap in the afternoon after situations that causes physiological stress tends to disturb sleep. Sleep quality is also influenced by certain
eating her lunch, then, chats to her neighbors. drugs. Some decreases REM sleep (barbiturates, amphetamines and anti-depressants) and some are seen to
 The patient considers sleeping as a necessary form of rest cause sleep problems (steroids, caffeine and asthma medications)
because it is when she regains her energy. The National Sleep Foundation in the United States maintains that eight to nine hours of sleep for adult
 Whenever the patient feels tired, she sits on the sofa for humans is optimal and that sufficient sleep benefits alertness, memory and problem solving, and overall
few minutes and then goes back to what she’s doing. health, as well as reducing the risk of accidents. A widely publicized 2003 study performed at the University
of Pennsylvania School of Medicine demonstrated that cognitive performance declines with fewer than eight
hours of sleep.
It has also been shown that sleep deprivation affects the immune system and metabolism. In a study by
Zager et al in 2007, rats were deprived of sleep for 24 hours. When compared with a control group, the sleep-
deprived rats’ blood tests indicated 20% decrease in white blood cell count, a significant change I the immune
system.
Scientists have shown numerous ways in which sleep is related to memory. In a study conducted by
Turner, Drummond, Salamat and Brown working memory was shown to be affected by sleep deprivation.
Working memory is important because it keeps information active for further processing, and supports
higher-level cognitive functions such as decision making, reasoning, and episodic memory. Turner et al.
allowed 18 women and 22 men to sleep only 26 minutes per night over a 4-day period. Subjects were given
initial cognitive tests while well rested and then tested again twice a day during the 4 days of sleep
deprivation. On the final test the average working memory span of the sleep deprived group had dropped by
38% in comparison to the control group. (http://enwikipedia.org/wiki/sleep)

Self-perception Self concept is one’s mental image of oneself. A positive self concept is essential to a person’s mental
and physical health. Individuals with a positive self concept are better able to develop and maintain
 The patient always senses that something is unusual with
interpersonal relationship and resist psychological and physical illness.
regards to her health condition.
  The patient has low self-esteem since she cannot fulfill her Self concept involves all of these self perceptions, that is, appearance, values and beliefs that
responsibilities as a wife and mother. influences behaviors and that are referred to when using the words I or me. Body image is who the person
 According to the patient, her family gives her the strength perceives the size, appearance and functioning of the body. If a person’s body image closely resembles one’s
and will-power to cope up with her condition. ideal body, the individual is more likely to think positively about the physical and non-physical concept of
 The patient doesn’t have any traumatic experiences in her self.
entire life. Self concept is also affected by role-strains. People undergoing role-strains are frustrated because they
feel or made to feel inadequate or unsuited to a role.
Illness and trauma can also affect the self-concept. People responds to different stressors such as illness
and alterations in function related to aging in a variety of ways: acceptance, denial, withdrawal and
depression are common. . (Kozier et. Al, Fundamentals of Nursing 7th edition page 957-962).

Role-relationship Relationship to another person is a developed manner in which there is the sharing of self, showing care
and putting trust. A healthy relationship affects an individual’s emotional development; it will facilitate the
 The client is the 3rd child among her 5 siblings.
channeling of the ideas, feeling of joy and others.
 She’s happily married to her husband, Herman.
An interpersonal relationship is a relatively long-term association between two or more people. This
 She’s a plain housewife.
association may be based on emotions like love and liking, regular business interactions, or some other type
 She actively participates in the barangay activities.
of social commitment. Interpersonal relationships take place in a great variety of contexts, such as family,
friends, marriage, acquaintances, work, clubs, neighborhoods and churches. They may be regulated by law,
custom, or mutual agreement, and are the basis of social groups and society as a whole. A relationship is
normally viewed s a connection between two individuals, such as a romantic or intimate relationship, or a
parent-child relationship.
All relationships involved some level of interdependence. People in a relationship tend to influence
each other, share their thoughts and feelings, and engage in activities together. Because of this
interdependence, anything that changes or impacts one member of the relationship will have some level of
impact on the other member. Psychologists have suggested that all humans have a basic, motivational drive to
form and maintain caring interpersonal relationships.
 According to attachment theory, relationships can be viewed in terms of attachment styles that develop
during early childhood. These patterns are believed to influence interactions throughout adulthood by shaping
the roles people adopt in relationships. (http://enwikipedia.org/wiki/intimate-relationship)

Sexuality-reproductive Sexuality is defined not only by a person’s genitalia but also by attitudes and feelings. It can also be
defined s learned behaviors in how a person reacts to his or her own sexuality and by how one behaves in
 The patient is already menopause at age 45.
relationships with others. (Fundamentals of Nursing 5th edition by Taylor, page 931).
 The patient has active sex life and engages herself to one
Sexuality is a crucial part of a person’s identity. Sex is central to who we are, to our emotional well-
sexual partner which is her husband.
being and to the quality of our lives. The world health organization defined sexual health as the integration of
 She’s also able to express her feminine attitudes.
the somatic emotional, intellectual and social aspect of sexual beings in ways that are positively enriching and
that enhance personality, communication and love. (Kozier et. Al, Fundamentals of Nursing 7 th edition page
957-973).
During the middle adulthood both men and women experience decreased hormone production causing
the climacteric, usually called menopausal in women. These events often affect the individual’s self-concept,
body image and sexual identity.
Women through the menopausal period experiences hot flushes, vasomotor instability, sleep
disturbances, vaginal dryness, genital tract atrophy, mood changes and skin, hair changes. The incidence of
osteoporosis and cardiovascular lipid changes also increases. The climacteric in males is not as dramatic in
the females: changes are more gradual.
Sexual response love and ply involved people’s emotional, psychological, physical and spiritual make
up, which plays a significant role in the satisfaction. A sexual desire fluctuates within each person and varies
from person to person. If people suppresses or block out conscious sexual desires they may not experienced
any physiological response. (Kozier et. Al, Fundamentals of Nursing 7th edition page 975,980).
Coping stress Coping mechanisms which are behaviors used to decreased stress and anxiety. Many coping behaviors
are learned, based on ones family past experiences, and socio-cultural influences and expectations.
 If the patient feels anxiety, she often watches movies or
(Fundamentals of Nursing 5th edition by Taylor, page 855).
telenovelas.
 If the patient is angry, she talks a lot and becomes
uncontrollable.
 She often sleeps or eats when she is stressed.
 She chats to her neighbors when she feels bored.
 She prefers to be alone on her room when she feels lonely.

Value-belief Spiritual well-being is the condition that exists when the universal spiritual needs for meaning and
purpose, love and belonging, and forgiveness are met. O’Briens conceptual model of spiritual well-being in
 She is a Roman Catholic.
illness identified three empirical referents of spiritual well-being: personal faith, religious practice and
 She attends mass every Sunday.
spiritual contentment. Spiritual beliefs are of special importance to nurses because of the many ways they can
 She often prays the rosary.
influence a patient’s level of health and self-care behaviors. (Kozier et. Al, Fundamentals of Nursing 7 th
 She believes in supernatural beings.
edition page 975,979).
 She often seeks God’s grace and providence in times of
Spiritual well being is manifested by a generally feeling of being alive, purposeful and fulfilled. People
trouble.
nurture or enhance their spirituality in many ways. Some focus on development of the inner self or world;
others focus on the expression of their spiritual energy with others or outer world. Relating to one’s inner self
or soul may be achieved through conducting an inner dialogue with a higher power or with one’s self through
prayer or medications. The expression of a person’s spiritual energy to others is manifested in loving
relationship with and service to others, joy and laughter and participation in religious services and associated
fellow gatherings and activities and by expression of compassion. (Kozier et. Al, Fundamentals of Nursing 7 th
edition page 996).
H. Activities of Daily Living

ASPECT PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION INTERPERTATION AND ANALYSIS

1. Nutrition The patient shows no allergies to
any food or drugs. The patient’s
diet is tolerated and has no any
other precautions to eating habits.
The patient receives soft diet as
ordered by her physician.
The patient’s diet is restricted only
to easily digestible foods that
include those that were mashed,
pureed, combined with sauce or
gravy, or cooked in soups.

2. Elimination The patient defecates at least 1 to 2 The patient defecates only twice The patient has irregular defecation
times daily and there was since her date of admission in the since she was not comfortable
uncontrolled passage of stool hospital and voids regularly using public toilets like in the
during urination. The stool of the everyday because of her diuretic hospital wards.
patient is dark brown in color and medications.
has soft consistency. The patient
 voids 7 to 8 times daily.
3. Exercise The patient has sedentary lifestyle.
According to her, cleaning the
house and doing light activities like
walking from house to market is
her own way of exercise.
4. Hygiene The patient has a habit of washing
her hands before eating. The patient
takes a bath once daily and brushes
her teeth once daily.
5. Substance use The patient is non-smoker and
doesn’t drink any alcoholic
beverages. She doesn’t use or
abuse any illicit drugs.
6. Sleep and Rest The patient’s usual time of sleep is
around 10pm and wakes up at
around 7am. The patient usually
takes a nap in the afternoon after
eating her lunch, then, chats to her
neighbors. The patient considers
sleeping as a necessary form of rest
because it is when she regains her
The patient cannot even do light
activities because she is always
lethargic from the time she was
admitted to the hospital.
The patient cannot take a bath and
only receives TSB from her
attending nurse or relative. The
patient was not able to brush her
teeth from the time she was
admitted to the hospital.
The patient is non-smoker and
doesn’t drink any alcoholic
beverages. She doesn’t use or abuse
any illicit drugs.
The patient is restless even though
she’s sleeping most of the time.
She’s lethargic and often got
bothered by different interruptions
to her sleep like medication time
and/or check up by her physician.
The patient cannot do her daily
routine since she is always lethargic
and weak.
The patient cannot take a bath
because she lacks energy and she is
very weak.
The patient doesn’t smoke, drink,
or use any illicit drugs.
The patient is having difficulty in
sleeping since the environment is
not conducive for rest (loud noise
from the outside, interruptions or
disturbances while trying to sleep).
 energy. Whenever the patient feels
tired, she sits on the sofa for few
minutes and then goes back to what
she’s doing.

7. Sexual Activity The patient has active sex life and Not applicable Not applicable
engages herself to one sexual
partner which is her husband. She’s
also able to express her feminine
attitudes.

I. Patients Concept about Health, Illness and Hospitalization

HEALTH ILLNESS HOSPITALZATION

The patient’s point of view regarding health is that, being According to her, illness is an uncomfortable feeling w/c She believes that hospitalization is only necessary when a

healthy is being fat and free from sickness. burdens her to do regular activities. certain disease is chronic and needs urgent cure.

- Health is defined as a state of complete physical, - Is disease, sickness or the condition of being in a - Placement of an individual in a hospital for

mental and social well-being and not merely the poor health, either physically or mentally. observation, diagnostic test, treatment for some

absence of disease or infirmity. WHO definition. (Blackwell’s Nursing Dictionary) diseases. (Blackwell’s Nursing Dictionary)

J. Laboratory and Diagnostic Examinations

DATE PROCEDURE RESULT NORMS INTERPRETATION AND

ANALYSIS
Sunday, May 17, 2009 Crossmatching for Blood “O” positive “O” positive The patient’s blood matched
Transfution with the blood donor.
Sunday, May 17, 2009 Crossmatching for Blood “O” positive “O” positive The patient’s blood matched
Transfusion with the blood donor
Sunday, May 17,2009 Coagulation Assay Prothrombin Time 15.8 SECS 10.3- 14.1 Patient’s prothrombin is higher
Normal Control 12.5 SECS than the normal range and her
Prothrombin Ratio 1.3 activated PTT ranges from
International Nomalized Ratio 1.3 normal.
Activated PTT 45.2 SECS 27. 0- 45.4
Normal Control 35.5
Sunday, May 17, 2009 Fecalysis Physical Characteristics: She had few muscle cells,
Color : dark brown starch granules and yeast cell.
Consistency : Soft But in the microscopic
Microscopic Findings: findings, there are so many
Muscle Cell FEW cystic parasites found in her
Vegetable Cell fecal specimen.
Vegetable Fiber
Starch Granules FEW
Yeast Cell FEW
Fat Globule
RBC
Pus cell
Macrophage
Mucus
Parasite Ova/ Cysts
Microscopic Findings
OVA AND PARASITES
Ascaris
 Trichuris
Hookworm
Entamoeba Histolytica
Cyst
Trophozoite
Entamoeba Coli
Cyst
Trophozoite
Blastocystis Hominis +++
Trichomonas Intestinalis
Giardia Lambia
Cyst
Trophozoite
Sunday, May 17, 2009 Blood Chemistry Urea Nitrogen 45.8 HIGH 9- 23 Patient Pebenito had high Urea
Creatinine 1.3 HIGH 0.5- 1.2 Nitrogen and creatinine but
Sodium 127 LOW 137- 147 low sodium and potassium.
Potassium 3.0 LOW 3.8- 5
Sunday, May 17, 2009 Urinalysis Physical Characteristics: Based on the UA exam of the
Color : yellow patient, there are many bacteria
Transparency : turbid present in her urine.
pH : 5.0
Specific Gravity : 1.025
Chemical Test
Albumin +
Sugar -
Cells:
 RBC 2-4/ hpf
Pus Cell 2-4/ hpf
Yeast Cell
Squamous Cell few
Renal Cell few
Transitionl Epithelial
Bacteria ++++
Mucus Threads ++
Crystals
Amorphous Urate +++
Uric Acid
Calcium Oxalate
Amorphous Phosphate
Triple Phosphate

Monday, May 17, 2009 Compete Blood Count (CBC) HGB 74 g/L 120-170 Based on the CBC done to
RBC 2.69 x 10ˆ12/L 4.0-6.0 patient Pebenito, it shows that
HCT 0.21 0.37- 0.54 there are significant deviations
MCV 79.50 uˆ3 87+ - 5 to several blood components
MCH 27.40 pg 29+ - 2 and only few are considered
MCHC 34.50 g/d L 34+ - 2 inclusive within the normal
RDW 15.90 11.6- 14.6 range.
MPV 7.20 fL 7.4 – 10.4
Platelet 342 x 10ˆg/L 150- 450
WBC 16.19 x 10ˆ g/L 4.5 – 10.0
 DIFFERENTIAL COUNT
Neutrophils 0.87 0.50- 0.70
Metamyelocytes
Bands 0.09 0.0-0.05
Segmented 0.78 0.50- 0.70
Lymphocytes 0.19 0.20- 0.40
Monocytes - 0.0-0.07
Eosinophils - 0.0-0.05
Basinophils - 0.0-0.01
Monday, May 18, 2009 Complete Blood Count (CBC) HGB 104 120- 170 Her HGB and HCT are below
HCT 0.31 0.37- 0. 54 from the normal range.
Monday, May 18, 2009 Clinical Microscopy Source : Ascitic Fluid Based on the clinical
Physical Characteristics microscopy of patient
Color: reddish Pebenito, it shows that there
Amount: 2mL were no noted changes in the
Transparency: Turbid physical characteristics and
Supernatant: reddish, clear red consistency of the ascites in the
precipitate peritoneal cavity.

RBC 190 x 10 g/L

WBC 600/ CUMM
Neutrophils 48%
Lymphocytes 52%
Wednesday, May 20, 2009 Complete Blood Count (CBC) HGB 100 g/L 120-170 Based on the CBC done to
RBC 3.54 x 10ˆ12/L 4.0-6.0 patient Pebenito, it shows that
HCT 0.29 0.37- 0.54 there are significant deviations
MCV 82.50 uˆ3 87+ - 5 to several blood components
 MCH 28.20 pg 29+ - 2 and only few are considered
MCHC 34.20 g/d L 34+ - 2 inclusive within the normal
RDW 16.40 11.6- 14.6 range.
MPV 7.80 fL 7.4 – 10.4
Platelet 331 x 10ˆg/L 150- 450
WBC 14.80 x 10ˆ g/L 4.5 – 10.0
DIFFERENTIAL COUNT
Neutrophils 0.87 0.50- 0.70
Metamyelocytes
Bands 0.07 0.0-0.05
Segmented 0.80 0.50- 0.70
Lymphocytes 0.12 0.20- 0.40
Monocytes - 0.0-0.07
Eosinophils 0.01 0.0-0.05
Basinophils - 0.0-0.01
Wednesday, May 20, 2009 Blood Chemistry Urea Nitrogen 16.8 mg/ dL 9- 23 Based on the Blood Chemistry
Creatinine 0.75 mg/ dL 0.5- 1.2 test done to patient Pebenito, it
Sodium LOW 135 mmol/L 137- 147 chows that her urea Nitrogen
Potassium LOW 2.9 mmol/L 3.8- 5 and creatinine is within the
normal range whereas her
sodium and potassium level is
noted to be lower than the
normal.
Friday, May 22, 2009 Sodium 132 LOW Patient’s sodium and
Potassium 3.7 LOW potassium are low.
Ultrasound Report

Name of Patient: Pebenito, Revelina C. Date: 5/7/2009

Age: 46 Date of Birth: 2/19/1963 Admission No. : OPO8LO1140

Room/ Bed No. : 205D Film No. : 3865

Request Physician: Dr. Pulido

Follow –up to 4/14/09 study shows the following findings.

The liver is enlarged. Solid nodules are again seen in both lobes of the liver, the largest at the left measures 6.3x5.1x5.8 cm (previous largest measurements were 3.7x4.9x3.9cm).

The boarder outlines of the most solid nodules are irregular. The intraheptic ducts are not dilated. There is increased parenchymal echopattern of the liver.

There s ascites.
The gallbladder measures 6.7x1.6cm. The intraluminal high level echo is again seen with acousting shadowing. The wall is not thickened.

The pancreas is normal in size and echopattern. Negative for mass in or at the region of the pancreas.

The spleen is not enlarged. Negative for intra-splenic mass.

The right kidney measures 10.2x4.7cm w/a cortical thickness of 1.4cm. The cortico modullary echo is intact. Negative for hydronephrosis, mass lesion or calculi.

The left kidney measures 11.0x6.0cm w/a cortical thickness of 1.6cm. There is still dilation of the central echo complex to a slightly greater degree since the last examination.

Negative for mass lesion.

The cystic nodule adjacent to the urinary bladder is again seen now measuring 9.7x7.2x7.9cm (previous measurement was 8.9x7.2x7.9cm). Still showing mural component and

appears to have increase in size. The other nodule adjacent to the cystic structure now measures 3.9x4.1x3.9cm, which s almost unchanged since the last examination.

K. Impression/Diagnosis

 Hepatogemaly with difuse parenchymal changes.

 Progression in sizes in most of the solid nodules in both lobes of the liver.

 Cholelithiasis

 Pancreas and spleen-negative

 Ascites and left preural effusion

 Grade II-III hydronephrosis, left but to a slightly greater degreethan the previous examination.

 Increased in size of the retrovesical fluid mass as well as the neural nodules.

L. Course in the Ward

 DATE MEDICAL PROCEDURES NURSING ASSESSMENT AND RATIONALE

FUNCTION
M. Ecologic Model
May 18-23, 2009 -History Taking Upon admission: Vital signs and Physical assessment
must be taken to obtain a baseline
-Physical Assessment -GCS E3 V5 M5 data.
Hypothesis
-Neurological Assessment -Vital signs BP-110/80 mmhg, PR: Ultrasound must be done to detect if
there is abnormalities in the abdominal
-Ultrasound 78bpm RR;18 breaths/min portion
The patient developed colon cancer thru a process that begins when an abnormal cell is transformed by genetic mutation of the cellular of the
DNA. body.
This disease
-IVF
might be because of heredity, environment of PNSS 1the
surrounding liter 20 gtts/min
patient and her to rundiet.Temp:36.7 C
food Giving medications are important to
immediately treat the disease.
for 12 hours -IV insertion done at the left arm,
Diet therapy is necessary for the
-Medications infusing well. improvement of the health condition of
the patient.
Agent  Metronidazole 500mg 1 tab TID -Due meds given

 Paracetamol 500 mg 1 tab Q6 -Ultrasound done

Colon Cancer is a not only a single disease with a single cause, rather it is a group of distinct diseases with different causes and different manifestations.
 Cefotxime 2g IV -History taking
Host
-Physical Assessment done
 Tramadol 50 mg 1 tab Q8
-Neurologic assessment done
 KCl 2 durules QID
-abnormal gait
 Lactulose 30 cc ODHS

 Buscopan 10 mg 1 tab RTC Q8

 STAT: dulcolax 1 suppository

-Received from ER to Medical Forbes
-Soft Diet
ward

-Patient was oriented

-Kept rested

-On soft Diet.

 o 46 years old
o Female
o Roman Catholic
o Filipino
o Highest educational attainment: College graduate
o Living together with family in Sampaloc Manila
o Housewife
o Incomplete immunization: DPT, OPV
o Practices hand washing
o Takes a bath once a day
o Brushes teeth once a day
o Regularly visiting her physician

Environment

The patient resides in a crowded community where street foods are usually sold. The environment where she resides is not polluted, however, people living

in this community are infected with various diseases that might contribute to infection.

WEB
Financial Insufficiency
Does not regularly take vitamins and minerals CAUSATION
Improper food preparations MODEL
Often eat street foods

Analysis

HOST
Lack of exercise
Exposure to low fiber and high fat diet Weakened immune
Doessystem
not eat food that is not cooked well.
Infected With Colon Cancer
 Cancer is a disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA. This abnormal cell forms a clone

and begins to proliferateofabnormally.

Degeneration Healthy cells Hereditary (transferred by genes)

Conclusions and Recommendations

Personal
Cancer of the colon can be prevented historywill
if people of colon cancerof their diet and their way of life. Considering precautions to the food we eat is necessary
be cautious

Does not havefora regular

us to monitor our exams
laboratory intake of nutrients and having a healthy lifestyle is also a good way to prevent chronic diseases. Regular medical check-up is also necessary
Improper food intake.
especially for those patients who have history of colon cancer.

Cancer cells
 II. Clinical Discussion of the Disease

A. Anatomy and Physiology

DIGESTIVE SYSTEM

Made up of 30 feet of pipes and tubes and more than half a dozen organs, the digestive

system processes hundreds of pounds of food each year. As it moves food through the body,

the digestive system breaks down our meals into chemical compounds that can be absorbed

by the body’s cells. It also separates out unneeded materials and flashes them out of the

body.

Food travels through the body along the gastrointestinal (GI) tract, also called the alimentary canal. This 30-foot-long tube begins with the lips, where food

enters the body, and ends with the anus, where solid wastes are expelled.

Mouth

The digestive system begins here, where food is ground into pieces and prepped for delivery to the stomach. It then

enters the pharynx, or throat – muscular funnel that pushes the chewed food into the esophagus while simultaneously blocking

off the trachea (windpipe).

Esophagus
Is a 10-inch-long muscular tube that connects the pharynx to the stomach. When
food enters the esophagus, a wave of muscular contraction called peristalsis push and
pull the food to the stomach. Mucus secretions keep the lump of food, or bolus, sliding
along. The commute from the top of the esophagus to the stomach takes a mere four to
eight seconds.

Stomach Area
This muscular, expandable J-
shaped pouch is responsible for
holding and digesting food, as well
as removing its nutrients. When
food enters the stomach, its
muscular walls contract and churn
the food with powerful gastric
acids that kills bacteria and break
down proteins. The result is creamy
substance called chime, which the stomach stores until it is ready for release into the small
intestine.

Intestine

The small intestine measure about 20 feet in length and 1 inch in diameter. Thousands of

folds and millions of fingerlike projection called villi increase the surface area of the small

intestine, which absorbs 90% of nutrients and water the body will received from the digested

food. The large intestine absorbs the last bit of nutrients and water from indigestible foods,

compacts the remaining matter, and eliminates it as feces.

Small intestine

Duodenum – this is the first portion of the small intestine, where secretion from the liver and pancreas are received and most of the chemical digestion takes place.

Jejunum – this is the long, coiled middle portion of the small intestine that stretches from the duodenum to the ileum.

Ileum – this is the final portion of the small intestine, where remaining nutrients are absorbed and utilized.

Large intestine

Ascending colon – the large intestine surrounds the small intestine like an inverted U. the first

portion of the large intestine, the ascending colon, is suited vertically on the right side of the body. The

ascending colon extracts remaining moisture from food before its excretion.

Transverse colon – connecting the ascending and descending colons, this part of the large

intestine is suited horizontally above the small intestine.

Descending colon – found at the left side of the body, the descending, or left colon stores stool

that will be emptied into the rectum.

Rectum – only 5 inches long, the rectum sits just above the anal canal. Feces are stored here

briefly prior to defecation.

 Anus – this ring of muscle is the external opening of the rectum through which fecal matter is expelled. Peristaltic wave in the colon and contraction of the

abdominal muscles trigger defecation.

ACCESSORY ORGANS

Liver

Weighing in at 3 pounds, this wedge-shaped organ is the body’s largest gland. The liver is the accessory

organ of the digestive system. Among its many roles is detoxification of the blood. It also creates bile, which is

used to break down fats.

Gallbladder

This plum-size, green, muscular sac hangs from the liver. The gallbladder collects, stores, and concentrates bile from the liver.

Pancreas

This long organ, positioned behind the stomach, produces insulin and enzymes that aid digestion. The

Pancreatic enzymes help digest food in the small intestine, while insulin helps regulate the amount of sugar in the

blood.
DIGESTION

Digestion is the complex process of turning the food you eat into the energy you need to survive. The digestion process also involves creating waste to be eliminated.

Food's Journey

Stop 1: The Mouth

The mouth is the beginning of the digestive tract, and, in fact, digestion starts here before you even take the first bite of a meal. The smell of food triggers the salivary glands in

your mouth to secrete saliva, causing your mouth to water. When you actually taste the food, saliva increases.

Once you start chewing and breaking the food down into pieces small enough to be digested other mechanisms come into play. More saliva is produced to begin the process of

breaking down food into a form your body can absorb and use. In addition, "juices" are produced that will help to further break down food.

Stop 2: The Pharynx and Esophagus

Also called the throat, the pharynx is the portion of the digestive tract that receives the food from your mouth. Branching off the pharynx is the esophagus, which carries food to

the stomach, and the trachea or windpipe, which carries air to the lungs.

The act of swallowing takes place in the pharynx partly as a reflex and partly under voluntary control. The tongue and soft palate -- the soft part of the roof of the mouth -- push

food into the pharynx, which closes off the trachea. The food then enters the esophagus.

The esophagus is a muscular tube extending from the pharynx and behind the trachea to the stomach. Food is pushed through the esophagus and into the stomach by means of a

series of contractions called peristalsis.

Just before the opening to the stomach is an important ring-shaped muscle called the lower esophageal sphincter (LES). This sphincter opens to let food pass into the stomach and

closes to keep it there. If your LES doesn't work properly, you may suffer from a condition called GERD, which causes heartburn and regurgitation (the feeling of food coming

back up).

Stop 3: The Stomach and Small Intestine

The stomach is a sac-like organ with strong muscular walls. In addition to holding food, it serves as the mixer and grinder of food. The stomach secretes acid and powerful

enzymes that continue the process of breaking the food down and changing it to a consistency of liquid or paste. From there, food moves to the small intestine. Between meals the

non-liquefiable remnants are released from the stomach and ushered through the rest of the intestines to be eliminated.

Made up of three segments -- the duodenum, jejunum and ileum -- the small intestine also breaks down food using enzymes released by the pancreas and bile from the liver.

Peristalsis is also at work in this organ, moving food through and mixing it up with the digestive secretions from the pancreas and liver, including bile. The duodenum is largely

responsible for the continuing breakdown process, with the jejunum and ileum being mainly responsible for absorption of nutrients into the bloodstream.

A more technical name for this part of the process is "motility" since it involves moving or emptying food particles from one part to the next. This process is highly dependent on

the activity of a large network of nerves, hormones and muscles. Problems with any of these components can cause a variety of conditions.

While in the small intestine nutrients from food are absorbed through the walls of the intestine and into the bloodstream. What's leftover (the waste) moves into the large intestine

(large bowel or colon).

Everything above the large intestine is called the upper GI tract. Everything below is the lower GI tract.

Stop 4: The Colon, Rectum and Anus

The colon (large intestine) is a five- to seven -foot -long muscular tube that connects the small intestine to the rectum. It is made up of the ascending (right) colon, the transverse

(across) colon, the descending (left) colon and the sigmoid colon, which connects to the rectum. The appendix is a small tube attached to the ascending colon. The large intestine is

a highly specialized organ that is responsible for processing waste so that defecation (excretion of waste) is easy and convenient.
Stool, or waste left over from the digestive process, passes through the colon by means of peristalsis, first in a liquid state and ultimately in solid form. As stool passes through the

colon, any remaining water is absorbed. Stool is stored in the sigmoid (S-shaped) colon until a "mass movement" empties it into the rectum, usually once or twice a day.

It normally takes about 36 hours for stool to get through the colon. The stool itself is mostly food debris and bacteria. These bacteria perform several useful functions, such as

synthesizing various vitamins, processing waste products and food particles, and protecting against harmful bacteria. When the descending colon becomes full of stool it empties

its contents into the rectum to begin the process of elimination.

The rectum is an eight-inch chamber that connects the colon to the anus. The rectum:

 Receives stool from the colon

 Lets the person know there is stool to be evacuated

 Holds the stool until evacuation happens

When anything (gas or stool) comes into the rectum, sensors send a message to the brain. The brain then decides if the rectal contents can be released or not. If they can, the

sphincters relax and the rectum contracts, expelling its contents. If the contents cannot be expelled, the sphincters contract and the rectum accommodates so that the sensation

temporarily goes away.

The anus is the last part of the digestive tract. It consists of the muscles that line the pelvis (pelvic floor muscles) and two other muscles called anal sphincters (internal and

external).

The pelvic floor muscle creates an angle between the rectum and the anus that stops stool from coming out when it is not supposed to. The anal sphincters provide fine control of

stool. The internal sphincter is always tight, except when stool enters the rectum. It keeps us continent (not releasing stool) when we are asleep or otherwise unaware of the

presence of stool. When we get an urge to defecate (go to the bathroom), we rely on our external sphincter to keep the stool in until we can get to the toilet.
 B. Drug Study

GENERIC/B ACTION CLASSIFICATIO INDICATION CONTRAINDICATION SIDE EFFECTS NURSING INTERVENTIONS

RAND N
NAME
Cefotaxime Broad-spectrum Antiinfective; beta- Lower Hypersensitivity to BODY: Fever, nocturnal  Determine previous
semi-synthetic third- lactam antibiotic; respiratory tract cephalosporins and other perspiration, hypersensitivity reactions to
generation cephalosporin, third- infections, beta-lactam antibiotics; inflammatory reaction at cephalosporins and
cephalosporin generation Genitourinary pregnancy (category B). IV site, phlebitis, penicillins, and history of
antibiotic. infections, thrombophlebitis; pain, other allergies, particularly
Preferentially binds Gynecologic induration, and to drugs, before therapy is
to one or more of the infections, tenderness at IM site, initiated.
penicillin-binding Bacteremia/Septi superinfections. GI:  Lab tests: Perform culture
proteins (PBP) cemia, Skin and Nausea, vomiting, and sensitivity tests before
located on cell walls skin structure diarrhea, abdominal initiation of therapy and
of susceptible infections, Intra- pain, colitis, pseudo periodically during therapy
organisms. This abdominal membranous colitis, if indicated. Therapy may be
inhibits third and infections, Bone anorexia. instituted pending test
final stage of and/or joint SKIN: Rashes in skin and results. Serum creatinine,
bacterial cell wall infections, pruritus. creatinine clearance, BUN
synthesis, thus Central nervous should be evaluated at
killing the system infections regular intervals during
bacterium. therapy and for several
months after drug has been
discontinued. Perform
periodic hematologic studies
(including PT and PTT) and
 evaluation of hepatic
functions with high doses or
prolonged therapy.
 Monitor I&O rates and
patterns: Report change in
I&O in patients with
impaired renal function or
with chronic UTI or who are
receiving high dosages or an
aminoglycoside
concomitantly.
 Superinfection due to
overgrowth of
nonsusceptible organisms
may occur, particularly with
prolonged therapy.
 Report onset of diarrhea
promptly. Check for fever. If
diarrhea is mild,
discontinuation of
cefotaxime may be sufficient.

Dulcolax Expands intestinal Gastrointestinal Constipation. Acute surgical abdomen, Rarely, abdominal  Evaluate periodically
fluid volume by agent; laxative, Preparation for nausea, vomiting, discomfort and diarrhea patient's need for continued
increasing epithelial stimulant radiography; abdominal cramps, use of drug;
 permeability antepartumand intestinal obstruction,  Monitor patients receiving
post-partum care; fecal impaction; use of concomitant anticoagulants.
preparation for rectal suppository in Indiscriminate use of
sigmoidoscopy presence of anal or rectal laxatives results in decreased
or proctoscopy, fissures, ulcerated absorption of vitamin K.
colonoscopy. hemorrhoids, proctitis.
 Add high-fiber foods slowly
to regular diet to avoid gas
and diarrhea. Adequate fluid
intake includes at least 6–8
glasses/d.
 Do not breast feed while
taking this drug without
consulting physician.

Lactulose Reduces blood Gastrointestinal Constipation Low galactose diet; GI: Flatulence,  In children if the initial dose
ammonia; appears to agent; laxative, associated with pregnancy (category C). borborygmi, belching, causes diarrhea, dosage is
involve metabolism hyperosmotic pediatric Safe use in lactation or abdominal cramps, pain, reduced immediately.
of lactose to organic problems, post- children is not established. and distention (initial Discontinue if diarrhea
acids by resident op; pregnancy dose); diarrhea persists.
intestinal bacteria. and post natal (excessive dose); nausea,  Promote fluid intake (≥1500–
period; bedridden vomiting, colon 2000 mL/d) during drug
and geriatric accumulation of therapy for constipation;
patients; surgical hydrogen gas; older adults often self-limit
procedures; hypernatremia. liquids. Lactulose-induced
painful rectal osmotic changes in the bowel
&anal support intestinal water loss
 conditions; and potential
laxative hypernatremia.
dependence; drug
 Advice the patient and
induce
family that Laxative action is
constipation
not instituted until drug
reaches the colon; therefore,
about 24–48 h is needed.
 Advise the patient and
family that do not self-
medicate with another
laxative due to slow onset of
drug action.
 Advise the patient and
family tonotify physician if
diarrhea (i.e., more than 2 or
3 soft stools/d) persists more
than 24–48 h. Diarrhea is a
sign of overdosage. Dose
adjustment may be
indicated.

Metronidazo Synthetic compound Antiinfective; Acute intestinal Blood dyscrasias; active hypersensitivity (rash,  Discontinue therapy
le
with direct antitrichomonal; amebiasis and CNS disease; first urticaria, pruritus, immediately if symptoms of
trichomonacidal and amebicide; antibiotic amebic liver trimester of pregnancy flushing), fever, fleeting CNS toxicity (see Appendix
amebicidal activity abscess. joint pains, overgrowth of F) develop. Monitor
as well as Symptoms and (category B), lactation. Candida. Vertigo, especially for seizures and
antibacterial activity asymptomatic headache, ataxia, peripheral neuropathy (e.g.,
against anaerobic trichomoniasis, confusion, irritability, numbness and paresthesia of
bacteria and some giardiasis depression, restlessness, extremities).
gram-negative weakness, fatigue,  Lab tests: Obtain total and
bacteria. drowsiness, insomnia, differential WBC counts
paresthesias, sensory before, during, and after
neuropathy (rare). therapy, especially if a
Nausea, vomiting, second course is necessary.
anorexia, epigastric  Monitor for S&S of sodium
distress, abdominal retention, especially in
cramps, diarrhea, patients on corticosteroid
constipation, dry mouth, therapy or with a history of
metallic or bitter taste, CHF.
proctitis. Polyuria,  Monitor patients on lithium
dysuria, pyuria, for elevated lithium levels.
incontinence, cystitis,  Report appearance of
decreased libido, candidiasis or its becoming
dyspareunia, dryness of more prominent with
vagina and vulva, sense therapy to physician
of pelvic pressure. Nasal promptly.
congestion. ECG changes  Repeat feces examinations,
(flattening of T wave). usually up to 3 mo, to ensure
that amebae have been
eliminated.
KCl Principal Electrolytic balance Dryness of the Severe renal impairment; Nausea, vomiting,  Monitor I&O ratio and
intracellular cation; and water balance mouth of any severe hemolytic diarrhea, abdominal pattern in patients receiving
essential for agents; replacement origin, reactions; untreated distension. Pain, mental the parenteral drug. If
maintenance of solution particularly in Addison's disease; crush confusion, irritability, oliguria occurs, stop infusion
intracellular radiogenic syndrome; early listlessness, paresthesias promptly and notify
isotonicity, sialadenitisand postoperative oliguria of extremities, muscle physician.
transmission of for the (except during GI weakness and heaviness  Lab test: Frequent serum
nerve impulses, maintenance of drainage); adynamic ileus; of limbs, difficulty in electrolytes are warranted.
contraction of oral hygiene. acute dehydration; heat swallowing, flaccid  Monitor for and report signs
cardiac, skeletal, and cramps, hyperkalemia, paralysis. Oliguria, of GI ulceration (esophageal
smooth muscles, patients receiving anuria. Hyperkalemia. or epigastric pain or
maintenance of potassium-sparing Respiratory distress. hematemesis).
normal kidney diuretics, digitalis Hypotension,  Monitor patients receiving
function, and for intoxication with AV bradycardia; cardiac parenteral potassium closely
enzyme activity. conduction disturbance. depression, arrhythmias, with cardiac monitor.
Plays a prominent or arrest; altered Irregular heartbeat is
role in both sensitivity to digitalis usually the earliest clinical
formation and glycosides. ECG changes indication of hyperkalemia.
correction of in hyperkalemia: Tenting  Be alert for potassium
imbalances in acid– (peaking) of T wave intoxication (hyperkalemia,
base metabolism. (especially in right see S&S, Appendix F); may
precordial leads), result from any therapeutic
lowering of R with dosage, and the patient may
deepening of S waves be asymptomatic.
and depression of RST;
 prolonged P-R interval,
widened QRS complex,
decreased amplitude and
disappearance of P
waves, prolonged Q-T
interval, signs of right
and left bundle block,
deterioration of QRS
contour and finally
ventricular fibrillation
and death.
Tramadol Centrally acting Analgesics&antipyre Moderate to -Hypersensitivity to CNS: Drowsiness,  Assess for level of pain relief
opiate receptor tics severe acute tramadol or other opioid dizziness, vertigo, and administer prn dose as
agonist that inhibits &chronic pain, analgesics fatigue, headache, needed but not to exceed the
the uptake of painful somnolence, restlessness, recommended total daily
-patients on MAO
norepinephrine and diagnostic euphoria, confusion, dose.
inhibitors
serotonin, suggesting procedures & anxiety, coordination  Monitor vital signs and
both opioid and surgery disturbance, sleep assess for orthostatic
-patients acutely
nonopioid disturbances, seizures. hypotension or signs of CNS
intoxicated with alcohol,
mechanisms of pain CV: Palpitations, depression.
hypnotics, centrally acting
relief. May produce vasodilation. GI:  Discontinue drug and notify
analgesics, opioids, or
opioid-like effects, Nausea, constipation, physician if S&S of
psychotropic drugs
but causes less vomiting, xerostomia, hypersensitivity occur.
respiratory -patients on obstetric dyspepsia, diarrhea,  Assess bowel and bladder
depression than preoperative medication abdominal pain, anorexia, function; report urinary
morphine. flatulence. Body as a frequency or retention.
 Whole: Sweating,  Use seizure precautions for
-lactation.
anaphylactic reaction patients who have a history
(even with first dose). of seizures or who are
Skin: Rash. Special concurrently using drugs
Senses: Visual that lower the seizure
disturbances. Urogenital: threshold.
Urinary  Monitor ambulation and
retention/frequency, take appropriate safety
menopausal symptoms. precautions.

Buscopan Anti-flatulents and -Acute GI -glaucoma -constipation

anti-inflammatory -biliary & - myasthenia gravis -dry mouth
genitourinary - paralytic ileus -photophobia
spasm, including - pyloric stenosis -flushing
biliary & renal - prostatic enlargement -skin rash.
colic. - porphyria -may also cause urinary
Parenterally also urgency and urinary
as an aid in retention.
diagnostic &
therapeutic
procedures eg
gastroduodenal
endoscopy,
radiology.
Paracetamol Analgesics and -pain -Nephropathy -Hypersensitivity
antipyretics -fever reactions
-headache, -predominantly skin
-toothache allergy (itching and
-mild and rash), may appear.
moderate -Long-term treatment
postoperative with high doses may
and injury pain cause a toxic hepatitis
-high with following initial
temperature symptoms: nausea,
-infectious vomiting, sweating, and
diseases and discomfort.
chills (acute -Occasionally a
catarrhal gastrointestinal
inflammations discomfort may be seen.
of the upper
respiratory
tract, flu, small-
pox, parotitis,
etc.).
*IV FLUID

TREATMENT/ INFUSION CLASSIFICATION INDICATION CONTRAINDICATION NURSING RESPONSIBILITIES

- Hypobolemia -Do not connect flexible plastic
PNSS 1L Isotonic - Heart- related emergencies -CHF containers of intravenous solution in
- Freshwater drowning series , i.e., do not piggybank
- Diabetic ketoacidosis (DKA) connections. Such use could result in
air embolism due to residual air being
drawn from one container before
administration of the fluid from a
secondary container is completed.
- Pressurizing intravenous solutions
contained in flexible plastic containers
to increase flow rates can result in air
embolism if the residual air in the
container is not fully evacuated prior to
administration.
-Use of a vented intravenous
administration set with the vent in the
open position could result in air
embolism. Vented intravenous
administration sets with the vent in the
open position should not be used with
 flexible plastic contain.

III. Nursing Process

Problem List:

Cues Nursing Problem Rank Justification

Subjective cues: Hyperthermia related to elevated body 1 - This demands immediate
- “Mainit po ang aking temperature due to underlying infection as treatment/care and subsequent
pakiramdam” as verbalized by evidenced by elevated WBC count medical attention as they can result
the patient to many other complications like
Objective cues: dehydration, convulsion or
- T = 38.5 hyperplexia, and increased cardiac
- Flushed face output.
- With body malaise
- With chills sensation
- Warm to touch (skin)
- With dry skin, lips, mucous
- Restlessness
- Irritability to fall asleep
- PR = 120
- RR = 25
- WBC = 331 X 100 g/l

Subjective cues: Acute pain related to inflammation of the 2 - This condition may have a life
- “Masakit ang akin tiyan” as liver at the right upper quadrant as threatening condition that warrants
 verbalized by the patient. manifested by abdominal surgery or may have something
Objective cues: enlargement/distention simple as constipation or even just
- Coherent, conscious gas in the bowel (wind).
- With abdominal pain at the
RUQ.
- Pain score: 7
- With facial grimace
- With abdominal tenderness
- Abdominal girth measures
105cm

Subjective cues: Increased fluid volume in the lower 3 - a fluid overload with normal saline
- “Namamanas ang mga binti ko.” extremities related to excess sodium intake and/or 5% dextrose can cause
As verbalized by the patient. as manifested by weight gain in a short similar problems but for different
Objective cues: period of time and decrease urine output. reasons. When the body is
- Edema scale +3 functioning normally it is almost
- Numbness impossible to produce an excess of
- Fatigue total body water. However this can
- Pallor occur during IV treatment w/
- oliguria normal saline or 5% dextrose. The
effect can be overload of both salt
and water or just salt or dilutional
low sodium.
Subjective cues: Imbalanced nutrition less than body 4 - Adequate nutrition is necessary to
- “wala akong ganang kumain” as requirement related to increase metabolic meet the body’s demands. During
verbalized by the patient needs caused by disease processes as times of illness, adequate nutrition
Objective cues: manifested by weight loss. plays an important role in healing
- Weight loss and recovery.
- Generalized weakness
- Hyperactive bowel sounds
- Thinning/loss of hair

Subjective cues: Fatigue related to altered body chemistry 5 - The patient with chronic illness
- “Nanghihina ang pakiramdam – side effects of pain or other medication experiencing fatigue may not be
ko at parang lagi akong pagod” such as chemotherapy as manifested by able to participate in their own care
as verbalized by the patient. drowsiness and inability to restore energy and fulfill role responsibilities.
Objective cues: after sleep. Moreover, it can result to chronic
- Disinterest in the surrounding. fatigue syndrome characterized by
- Lethargy prolonged debilitating fatigue,
- Pallor neurologic pattern, general pain,
- Dizziness GI problems and flu-like
- BP: 120/80 symptoms.
- PR: 90
- RR: 22
- Temp: 37.3

Assessment Nursing Background of Goals and objective Nursing intervention Rationale Evolution
Diagnosis Knowledge
Subjective cues: Hyperthermia Etiology - Within the end Independent - At the end of the
- “Mainit po ang related to of the shift/ after shift, patient’s body
aking elevated body Immediate 8 hrs. of duty, - Monitor the - Temperature of 38.9
 pakiramdam” temperature due cause: patients body patient’s vital – 41.1 C suggest temperature was
as verbalized to underlying temperature will signs. Give infectious disease reduced to 37.5
by the patient infection as Inflammatory reduced or particular attention process. Fever may from 38.5.
Objective cues: evidenced by response of the maintained to
to the temperature. aid in diagnosis. - Goal was met.
- T = 38.5 elevated WBC body against normal range.
- Flushed face count microorganisms.
- With body
malaise Intermediate
- With chills cause:
sensation - Asses for presence - Note for further care
- Warm to touch Elevated WBC
of posturing or given
(skin)
- With dry skin, Root cause: seizures. - Oliguria and/or renal
lips, mucous - Monitor/record all failure may occur
- Restlessness Weakened fluid loss such as during hypotension,
- Irritability to immune system urine. dehydration.
fall asleep - Note - Evaporation is
- PR = 120 Health presence/absence decreased by
- RR = 25 implication:
of sweating as environmental
- WBC = 331 X
100 g/l Fever of 40 C or body attempts to factors of high
higher demand increase heat loss humidity and low
immediate home by evaporation , ambient
treatment and conduction and temperature.
subsequent diffusion.
medical - Provide TSB;
attention, as they
avoid use of - May help reduce
can result in
delirium and alcohol fever
convulsion
particularly in
children. Dependent

- Administer
antipyretics as - Used to reduce lover
ordered by the by central action on
physician. the hypothalamus.
- Administer Fever may be
 replacement of beneficial in limiting
fluid and growth of
electrolytes microorganism and
- Provide high enhance destruction
calorie diet. of infected cell
- Provide use of - To support
supplemental circulating volume
oxygen and tissue perfusion
- To meet increase
metabolic demand.
Collaborative
- Discuss the - To offset increased
importance of oxygen demand and
adequate fluid consumption.
intake
- Identify
community
resources to
address specific - To prevent
need dehydration

- May help during

disaster/emergency.
 Assessment Nursing Diagnosis Background of Goals and objective Nursing intervention Rationale Evolution
Knowledge
Subjective cues: Acute pain related to Etiology - Within the end Independent - At the end of the
- “Masakit ang inflammation of the of the shift/ shift, patient’s
akin tiyan” as liver at the right upper Immediate after 8 hrs. of - Monitor the - Baseline data abdominal pain is
verbalized by quadrant as cause: duty, patient’s patient’s vital - alleviated.
the patient. manifested by abdominal pain signs.
Objective cues: abdominal Muscle will be . - Goal was met.
- Determine the
- Coherent, enlargement/distentio strain/trauma of alleviated. - To help determine
conscious n the abdominal possible path
possibility of
- With wall physiological
underlying
abdominal cause of pain.
condition or organ
pain at the Intermediate - Assess for
RUQ. cause: dysfunction.
referred pain
- Pain score: 7 - Use pain rating
- With facial Cause
scale
grimace inflammatory
- With response Dependent
abdominal
- To maintain
tenderness Root cause: - Administer
- Abdominal acceptable levels of
analgesic, as pain. Notify a
girth measures Parasite
105cm infection indicated, to physician if
(giardia lamblia) maximum dosage regimen is
as needed. inadequate to meet
Health pain control goal
implication:
Collaborative - When client is
in many patients - Ask others who unable to verbalize.
who are not know the client
treated, well to identify
infection can behaviors that
last for several may indicate pain
months to years
with continuing - Collaborate in
symptoms treatment of
children with underlying
chronic condition/disease
 infection my fail processes causing
to thrive. pain and proactive
management of
pain.

Assessment Nursing Background of Goals and objective Nursing intervention Rationale Evalution
Diagnosis Knowledge
Subjective cues: Increased fluid Etiology - Within the end Independent - At the end of the
- “Namamanas volume in the of the shift/ after shift, patient’s
ang mga binti lower Immediate 8 hrs. of duty, - Note presence of edema was
ko.” As extremities cause: patient will be medical/condition alleviated
verbalized by the related to excess able to that potentiate
patient. sodium intake as Excess enumerate -
fluid excess
Objective cues: manifested by interstitial fluid methods of
- Edema scale +3 weight gain in a relaxation - Note amount/rate
- Numbness short period of Intermediate technique such of fluid intake
- Fatigue time and cause: as destruction from all sources
- Pallor decrease urine technique, deep - Review intake of
- oliguria output.2l Decrease urine breathing sodium
output exercise, - Measure of
medication and - For changes that
abdominal girth
Root cause: prayer. may indicate
Dependent increasing
Excess sodium
retention/edema
intake - Administer
medication as
Health
implication: directed by the
physician
Excessive fluid - Restrict sodium
may be intake as indicated
manifested by - Weigh daily or on
venous regular schedule,
engorgement or - Provides
as indicated
edema comparative
 formation. baseline data and
Collaborative evaluate the
- Assist with effectiveness of
procedures as diuretic therapy
indicated.
- Consult dietician
as needed.

Assessment Nursing Background of Goals and objective Nursing intervention Rationale Evalution
Diagnosis Knowledge
Subjective cues: Imbalanced Etiology - Within the end of Independent - At the end of the
- “wala akong nutrition less the shift/ after 8 shift, patient was
ganang kumain” than body Immediate hrs. of duty, - Provide pleasant - Useful in promoting able to understand
as verbalized by requirement cause: patient will be atmosphere at appetite and the causative factor
the patient related to able to verbalize mealtime; remove reducing nausea
Objective cues: increase Chemotherapy understanding of and necessary
noxious stimuli intervention
- Weight loss metabolic needs causative factor
- Generalized caused by Intermediate when known and - Assist in oral -
- Clean moth enhances
weakness disease cause: necessary hygiene during
appetite
- Hyperactive processes as interventions meals if already
bowel sounds manifested by Malabsorption indicated
- Thinning/loss of weight loss. by the intestine - May lessen nausea
- Offer effervescent
hair of nutrients meals if already
from food
indicated
Root cause: Dependent
Intestinal - Consult with
obstruction;
dietician as
blockage of the
indicated; - Useful in
intestine by the
tumor advanced diet as establishing
tolerated. Restrict nutritional needs and
Health gas producing most appropriate
implication: foods. route.
 Underweight
teens and adult
can seriously
damage their
bone and put
themselves at
risk of
osteoporosis

Assessment Nursing Background of Goals and objective Nursing intervention Rationale Evaluation
Diagnosis Knowledge
Subjective cues: Fatigue related Etiology - Within the end of Independent - At the end of the
- “Nanghihina to altered body the shift/ after 8 shift, patient was
ang chemistry – side Immediate hrs. of duty, - Have the patient - Helps in developing able to improve a
pakiramdam ko effects of pain or cause: patient will be rate fatigue, using a plan to managed sense of energy.
at parang lagi other report improve numeric scale. fatigue.
akong pagod” as medication such Chemotherapy sense of energy.
- Encourage - Adequate intake is
verbalized by as
the patient. chemotherapy Intermediate nutritional intake necessary to meet
Objective cues: as manifested by cause: metabolic need.
Collaborative
- Disinterest in the drowsiness and
surrounding. inability to Growth of - Programmed daily
- Refer to physical
- Lethargy restore energy malignant exercise can help
- Pallor after sleep. tumor in the therapy.
the patient maintain
- Dizziness intestine.
and increase
- BP: 120/80
- PR: 90 Root cause: strength.
- RR: 22
Temp: 37.3 Intestinal
obstruction;
blockage of the
intestine by the
tumor

Health
implication:

can cause
prolonged
debilitating
fatigue,
neurologic
pattern, general
pain, GI tract
problems.