CHAPTER I CASE OVERVIEW Introduction Hepatoma is the one of the most common cancer in the world with 1 Million

new cases diagnosed every year. Roughly 20,000 new cases are diagnosed every year in United States. It is more frequent in men and Oriental-Americans. The average age at the time of diagnosis is 60 years. Cancer of the liver can grow for a long time without causing any problems. Most patients are diagnosed in advanced stages. If left untreated, or if it fails to respond to treatment, liver cancer can spread to the rest of normal liver, causing liver failure, and also to lymph glands in the abdomen and lungs. This is the case of Ms. L. C., 88 years old, from Manjuyod, Negros Oriental, who was admitted due last to April on 12, 2011 at Negros Oriental Provincial Hospital edema lower extremities,

weakness and epigastric pain. She was diagnosed with Hepatoma Right Lobe Metastasis Lungs Right-side Hypertrophy by Dr. V. J. T. She was attended to, and medicated, and has underwent several laboratory exams yet her condition worsened due to poor prognosis. Though the case was personally given by the clinical instructor, the presenters find reasons to continue with the case. First, it is a unique and interesting case, knowing that it is about cancer which is a rare case a student nurse can encounter and handle. Secondly, health history of the patient is quite enough to support the diagnosis, especially the manifestations and laboratory results. And lastly, they take this as a challenge since they have not yet had any discussion on oncology in their year level that would hopefully help in the understanding and analysis of Hepatoma.

Objectives In this clinical paper, the presenters have the following goals: 1. Describe the of structure the of a cell and which the are process the of cell proliferation and differentiation, discuss the normal anatomy and physiology related systems respiratory, cardiovascular and systems and how their functions are altered in the presence of Hepatoma, Right Lobe Metastasis Lungs, and Rightsided Hypertrophy. 2. Show the current health status of the patient through thorough physical assessment, laboratory examinations, as well as diagnostic procedures of which the patient underwent. 3. Relate theories from books and other sources with the actual data gathered from the patient during interaction and assessment. 4. Create a comprehensive pathophysiology to trace the pathogenesis of the disease the processes clinical nursing starting from the to and that of precipitating and predisposing including 5. Formulate efficient interventions. SMART in care the plans are the effective patient and and enhancing well-being etiologic factors down the their complications, corresponding

manifestations

alleviating the progression of the disease, and prioritize them accordingly. 6. Justify all medical and nursing actions applied to the patient.

Scope The gathering of data and patient interaction was done for 4hours during the clinical exposure and on the final visit later in the afternoon of same day. Within this clinical paper is the discussion of the information related to the care and with condition their of of the patient during her present hospitalization; the contents include the physical assessment, the affected laboratory systems, results theoretical corresponding the admitting interpretations, background of the normal anatomy and physiology of background impression in connection to the patients status and manifestations, the pathophysiology designed to trace the progression of the disease process and the measures provided to solve each existing problems and manifestations, the effectiveness of these interventions reflected on the progress notes, and proposed discharge planning for the promotion of the patients well-being. Limitations In the
1.

process

of

making

this

clinical

paper,

the

group

encountered some limitations which are the following: No data about the patients grandparents were gathered because those people died before she was born and was not told by her parents about their causes of death. 2. Health history and other pertinent data were only limited to the patients responsiveness and SOs knowledge.
3.

Discussion on the pathology of the disease, particularly Hepatoma, is limited only to the presentors own understanding through researching since the topic cancer was not yet included in their classroom discussions.

4. Some laboratory exams were taken only once, so tracking of the disease progression is also limited.

CHAPTER II CASE DATA AND INFORMATION BIOGRAPHICAL DATA Name: L. C. Address: Manjuyod, Negros Oriental Age: 88 years old Gender: Female Birthplace: Manjuyod, Neg. Or., via home delivery Birth Date: August 10, 1922 Civil Status: Single Religion: Roman Catholic Nationality: Filipino Educational Attainment: Elementary Undergraduate Health care financing: none Date of Admission: April 12, 2011 at 10:26 PM Final Diagnosis: Hepatoma Right Lobe, Metastasis Lungs Right-sided Hypertrophy Physician: Dr. V. J. T. Source of information: Patient: SO: Patients chart: 20% 30% 50%__ 100% CHIEF COMPLAINT Abtik paman ni siya atong Enero-Pebrero, makalakaw-lakaw pa gud ni siya; nikalit lang man siya ug kaluya, dayon mao lagi ning iyahang dire (referring to the abdomen) nidako man, nisamot pud ang hubag sa iyang batiis, as verbalized by the patients sister. PRESENT HEALTH HISTORY One month prior to admission, patient started to experience swelling on lower extremities, epigastric pain and body weakness. She consulted a local physician and was medicated. By end week of March, her condition worsened. She became bed-ridden and her abdomen became bigger and harder. The edema on her lower extremities also worsened, and was associated with pitting. April 12, 2011, at around 9:00 in the evening, patient was brought to Bais District Hospital due to the worsening condition. She was received at the Emergency Department and was hooked with IVF of D5NS at 15gtts/min. She was then referred immediately to Negros Oriental Provincial Hospital via ambulance. She was then admitted at 10:26 PM in the said hospital.

PAST HEALTH HISTORY Childhood illness: fever, common cough and colds Childhood immunization: no knowledge about patients immunizations Hospitalizations: present is the first hospitalization Surgeries: has not undergone any surgery, both minor and major Allergies: no known allergy to foods Accidents and Injuries: no history of accidents and injuries Serious Illnesses: no known serious illnesses by history Medications: uses herbal medicines like mayana, decoction of guava leaves, heated atis leaves and pound malunggay cloves Recent Travel: no other travel outside Negros Oriental than transportation from Manjuyod to Dumaguete for hospitalization FAMILY HEALTH HISTORY Legend: - female - male - patient AW LP + OA Hem HTN OD JP - alive and well - Liver Problem - deceased - Old Age - Hematemesis - hypertension - occasional dyspnea - joint pain

93,+ LP

105,+ OA

82,+ Hem Interpretation:

80,AW

78,JP, HTN

78,OD

Patients mother died at the age of 93 due to liver problem. Her father died at 105 years old due to old age. She has 4 siblings. Her sister next to her died at the age of 82. They do not know the exact problem, yet they claimed that she vomited blood. The only male among

her siblings has been experiencing joint pain and hypertension. The youngest has been having difficulty in breathing occasionally. Data about the patients grandparents were not taken due to her limited ability to speak and SO has no knowledge about such. PSYCHOSOCIAL PROFILE Health Practices and Belief: Usually bruises, hilots. Typical Day: Patient usually wakes up at around 5:00 in the morning and drinks coffee with bread for breakfast. Then she walks around the house, and does her gardening activity. After which, she goes to market with a nigo filled with dried tobacco leaves for business. She takes pot-pot as her transportation to get there. She goes home for lunch at around 12:00 and takes her rest after eating for about 30 minutes to an hour. She goes to market again to continue selling. She arrives home at around 5:00 in the afternoon. She eats her dinner with her niece, who lives with her as her adopted, at around 6:00-7:00 in the evening. She watches TV at night and retires to bed sometimes at 9:00PM, but usually by 8:00PM. By March, she started to become weak and eventually went into being bed-ridden. Nutritional Patterns: Patient usually eats vegetables in a menu of law-oy and fish, most often, dried salty fish and ginamos. She eats corn, not rice. She has a regular eating pattern and complete 3 meals a day, no snacks in between. She uses spoon for eating. She can consume a maximum of 2 glasses of water after meal. She started to loss her appetite when she became ill. She can barely consume her food served on a plate. She also started to lose weight. Activity and Exercise: her She goes up and down from their room by a 5step stair and walks around the house every morning and does gardening. She does not walk anywhere else, she just ride pot- pot for transportation. By the time she became weak, she seldom go downstairs, until she became bedridden. Elimination Pattern: She urinates 2-3 times a day with dark colored urine, about a glass in quantity, and defecates usually once a day and sometimes never at all. When she became bedridden, she wears diaper. She seldom defecates, usually every other day. She uses 2-3 diapers a day, and gets changed by the help of her use herbal Patient believes in the effectiveness to cure illnesses like cough, of herbal medicine and that prayers can heal sickness/illnesses. medicines and wounds. She also believes in quack doctors and

adopted daughter. Sleep/rest: She usually gets 9hours of sleep at night time and 30minutes to an hour at noon. She has no sleep disturbance; she only wakes when she urinates. During the occurrence of the problem, her sleeping pattern changed. She cannot sleep well at night. She complains of abdominal pain associated with difficulty in breathing. Personal Habits: She is neither a smoker nor an alcoholic, yet she Her income in selling for their daily experienced drinking once when she was adolescent. Occupational and Socioeconomic Health Pattern: tobacco is their major source of money

consumptions. Her nieces and nephews sometimes give her money or goods. Her siblings also share some food to her when they have enough. When she became weak, she stopped selling; her other family members supports her in the needs and expenses. Environmental Health Patterns: She lives in a separate house just beside her sisters. With her is her adopted daughter, her niece, who helps around. The house is a small 2-storey hut, with a sinibit roof. The stair leading to their bed room has 5 steps made of bamboo. She sleeps on a wooden bed, covered with a banig, beside her adopted daughter. The surrounding is a noncemented land with few trees and plants. Their source of water is flowing where they connected a hose directly towards their household. They use pour flush as their toilet facility. The house location is just near the street, with other neighboring houses. The market is about 15meters away. Cultural influences and religious/spiritual influences: She believes in quack doctors and hilots, but she believes most in God. Their family has a tradition of not taking a bath on Wednesdays and Fridays because for them this may cause illnesses and death of a family member. She goes to Church on Sundays with her adopted and sometimes with her sister. Sexual pattern: suitors and Patient never got married, but experienced having boyfriends during her adolescence. (Detailed

information about this was not taken due to limited ability to speak, and her sister has no knowledge about it). Social Support: She is well-loved by her siblings, nieces and nephews. She receives all types of support from her family, may it be physiological, emotional, or spiritual. They share with one another what they have and solve problems immediately.

REVIEW OF SYSTEMS
Assessment (April 16, 2011 at 8AM) General Survey Pt. is 88 years old, female, oriented to place and person only, appears emaciated, awake and responsive to verbal communication, with slurred speech in a low tone voice, but unable to maintain eye contact; scratching on elbows noted; wearing adult diaper; with ongoing IVF of D5NM 1L running at KVO rate, infusing well at left metacarpal vein, with a level of 800mL; O2 therapy of 2-4L/min via nasal cannula, and NGT passing into the right nostril. Vital signs of: 36. 2 C, afebrile; 87 bpm, regular but weak; 22 cpm, deep, with use of accessory muscles; 110/70 mmHg INTEGUMENTARY SYSTEM Skin -Inspection: jaundice noted on palms and soles, sagging skin on upper extremities, shiny skin surfaces on edematous lower extremities noted; visible muscle wasting -Palpation: rough skin texture on upper extremities, smooth on lower extremities; warm to touch; pitting noted on lower extremities edema of grade 2 Hair -Inspection: body hair noted all over, but with less hair growth on lower extremities Nails -Inspection: pale, intact, firm, adhere well to nail bed, and absence of clubbing; cuticles are pale as well as nail beds; -Palpation: poor capillary refill of 3 seconds on upper extremities, (lower extremities 8 ---SAME-----SAME----SAME-- Assessment (April 16, 2011 at 4AM) General Survey Condition worsened associated with rigidity on upper lip, inability to open eyes, blood stains noted in oral area, inability to speak, unresponsive to verbal command; still with ongoing IVF of D5NM 1L running at KVO rate, infusing well at left metacarpal vein, with a level of 300mL; O2 therapy of 24L/min via nasal cannula, and NGT passing into the right nostril. Level of orientation not assessed due to inability to speak Vital signs of: 38.9 C, febrile; 96 bpm, regular but weak; 28 cpm, deep, use of accessory muscles; 90/60 mmHg

not assessed due to presence of nail polish) HEENT Head and face -Inspection: head size appropriate to age, white hair evenly distributed on scalp; less facial movements upon communication, -Palpation: scalp slightly mobile, no lessions Eyes -Inspection:pallor conjunctivae noted (visual acuity, accommodation and extraoccular movement not assessed due to patients inability to maintain eye opening) Nose -Inspection: nose located midline with symmetrical nares, nasal flaring noted, no drainage, with O2 cannula connected, and NGT inserted into right nares Neck and Throat -Inspection: lips midline, symmetrical, appears dry with cracks noted; has 6 teeth, yellow discoloration noted; neck erect and midline; (gag reflex not assessed due to inability to open mouth widely, and tolerance to procedures) -Palpation: no lumps or masses on neck RESPIRATORY SYSTEM -Inspection: trachea located midline, no deviation; bulging of chest on right side noted, use of accessory muscles noted upon breathing, nasal flaring noted, with O2 therapy of 24L/min via nasal cannula; with 9 Additional: breathing through mouth noted; with RR of 28 cpm, deep, use of accessory muscles ---SAME-----SAME--Additional: rigidity on upper lip noted, with blood stains in the oral area ---SAME-----SAME--Additional: jaw jutting noted ---SAME---

RR of 22 cpm, deep, with use of accessory muscles Auscultation:Diminished peripheral sounds on right lung field CARDIOVASCULAR SYSTEM -Inspection: visible carotid pulsation, observable neck vein distention, positive pulsation at epigastric area noted, visible blood vessels on extremities -Palpation: bounding heart beat on apex, weak peripheral pulses, pulse on lower extremities nonpalpable; with a pulse rate of 87 bpm, regular but weak -Auscultation: loud heart beat, no extra heart sound heard; with a BP reading of 110/70 mmHg ABDOMEN -Inspection: Caput medusa noted extending from the umbilicus; umbilicus midline and inverted with no discharges;positive pulsation noted, rounded abdomen with assymetrical contour -Auscultation: hypoactive bowel sounds on all quadrants: 1 on LLQ, 2 on RLQ, 1 on RUQ, and 1 on LUQ -Palpation: hard and rigid MUSCULOSKELETAL SYSTEM -Inspection: measurement of extremities are the following: Right arm length of 69 cm with a circumference of 17.5 cm; Left arm length of 69 cm with a circumference of 18 cm; Right leg is 80cm in length and 42.5cm in circumference; Left leg is 81cm in length and 41cm in circumference; asterixis noted on both arms and hands -Palpation: pitting noted on Additional: 0 muscle strength on both upper and lower extremities, no active range of motion & no palpable muscle contraction (paralysis) ---SAME-----SAME---with a PR of 96 bpm, regular but weak; with a BP of 90/60 mmHg ---SAME---

10

lower extremities edema of grade 2; muscle strength on lower extremities is 0, no active range of motion & no palpable muscle contraction (paralysis); 2 on upper extremities, reduced active range of motion & no muscle resistance (posture, gait, balance and coordination not assessed due to patients inability to stand and walk) NEUROLOGIC SYSTEM Cerebral Functions -awake, responsive to verbal communication, with slurred speech in a low tone voice -GCS score of 11/15 (Moderate brain injury): Additional: unconscious, unresponsive to any command -GCS score of 3/15 (severe brain injury): Eye = 1, no eye opening Verbal= 1, no verbal response Motor= 1, no motor response ---SAME---

Eye = 4, eye opens

spontaneously

Verbal = 2, incomprehensible Motor= 5, localizes to pain

Cranial Nerves (not assessed due to patients limited response and tolerance) REPRODUCTIVE SYSTEM (not assessed due to wearing of diaper) --SAME

11

Diagnostic Imaging Studies Taken on April 13, 2011 CHEST X-RAY (PA) This is to visualize the physical structure of the lungs to rule out abnormalities, specifically consolidation on the lung parenchyma. Result: Massive right sided hydrothorax noted. Hidden pulmonary mass cannot be ruled out Interpretation: This result shows that there is the passage of ascites from the peritoneal to the pleural cavity through small diaphragmatic defects. Patients with advanced cirrhosis and portal hypertension have abnormal extracellular fluid volume regulation that in most cases results in accumulation of fluid, typically in the abdominal cavity (ascites) or lower extremities (edema). The negative intrathoracic pressure generated during inspiration favors the passage of fluid from the intra-abdominal to the pleural space. April 13, 2011 ULTRASOUND WHOLE ABDOMEN The liver is enlarged with multiple echogenic masses seen in the right lobe. Minimal free fluid noted in the hepatic recess. The pancreas, spleen, and kidneys are sonographically normal The gallbladder and urinary bladder with normal wall thickness and echofree The uterus and ovaries are technically difficult to imague due to bowel gas

Remarks: 1. Solid hepatic masses. Consider primary new growths 2. Non-visualization of uterus and ovaries due to bowel gas. -Suggest: Transvaginal or transrectal ultrasound for better visualization

12

3. The other visualized organs are sonographically unremarkable Interpretation: Cancer starts with damage to DNA (a nucleic acid that contains the genetic instructions used in the development and functioning of all known living organisms ). This damage causes changes in these instructions. Liver cancer also occurs as metastatic cancer, which happens when tumors from other parts of the body spread (metastasize) to the liver. In the liver cancer, some cells begin to grow abnormally. One result is that cells may begin to grow out of control and eventually form a tumor/mass of malignant cells.

Laboratory Examinations April 12, 2011 Hepatitis B surface antigen (HBsAG) - Protein that is present on the surface of the virus; will be present in the blood with acute and chronic HBV infections Often used to screen for and detect HBV infections; earliest indicator of acute hepatitis B and frequently identifies infected people before symptoms appear; undetectable in the blood during the recovery period; it is the primary way of identifying those with chronic infections. Result: Reactive Interpretation: This result shows that patient is positive for hepatitis B. Hepatitis B virus has three antigens for which there are commonly-used tests the surface antigen (HBsAg), the core antigen (HBcAg) and the e antigen (HBeAg). Markers found in the blood can confirm hepatitis B infection and differentiate acute from chronic infection. These markers are substances produced by the hepatitis B virus (antigens) and antibodies produced by the immune system to fight the virus.

TUBE METHOD: FORWARD AND REVERSE TYPING RH TYPING Anti-A 0 Type B+ Anti-B 4+ Anti-D 4+ Known A 2+ Known B 0

13

April 12, 2011, 12:50 am RANDOM BLOOD SUGAR TEST

Random blood sugar (RBS) measures blood glucose regardless of when the person last ate. Several random measurements may be taken throughout the day. Random testing is useful because glucose levels in healthy people do not vary widely throughout the day. Blood glucose levels that vary widely may mean a problem. This test is also called a casual blood glucose test.
RBS Result 76 mg/dl Normal Range 45-130 mg/dl

April 12, 2011, 2:08 am Complete Blood Count

The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood
Results 12.4 g% 40.4 vol% 6.600 T/cumm Normal Range 12-14 g% 37-44 vol% 5-10 T/cumm Remark Normal Normal Normal

Hemoglobin Hematocrit WBC Count Differential Count:

Neutrophil Seg Lymphocytes Monocytes Eosinophils Basophils Platelet Count

78% 17% 4% 1% 188,000

55-60% 20-35% 1-6% 1-4% 0-0.5% 150-400 T/cumm

Increased Decreased Normal Normal Normal Normal

Interpretation: A high neutrophil count can be caused by cancer spreading in the body. Cancer is a group of diseases in which symptoms are due to an abnormal and excessive growth of cells in one of the body organs or tissues. A cell is the smallest, most basic unit of life, that is capable of existing by itself. Abnormal values of the differential count suggest infection or may be altered process of cellular differentiation.

14

April 13, 2011, 2:02 am

ELECTROLYTES The electrolyte panel is frequently ordered as part of a routine physical, either by itself or as components of a basic metabolic panel or comprehensive metabolic panel. It is used to screen for an electrolyte or acid-base imbalance and to monitor the effect of treatment on a known imbalance that is affecting bodily organ function. Since electrolyte and acid-base imbalances can be present with a wide variety of acute and chronic illnesses, the electrolyte panel is frequently ordered for hospitalized patients and those who come to the emergency room.
Sodium Potassium 140.6 mmol/L 3.44 mmol/L 135-148 mmol/L 3.5-5.3 mmol/L

April, 14, 2011 - 9:51:45 am BLOOD CHEMISTRY - SERUM Assays BUN Creatinine Uric Acid Cholesterol Triglycerides Chol-HDL Chol-LDL SGPT Results 61 mg/dl 1.08 mg/dl 7,2 mg/dl 202 mg/dl 61 mg/dl 9 mg/dl 181 mg/dl 96 U/L Normal Range 11-36 mg/dl 0.57-0.9 mg/dl 2.5-6.8 mg/dl 0-200 mg/dl 0-250 mg/dl 45-65 mg/dl 0-150 mg/dl 0-36 U/L Details High High High High Normal Low High High

Interpretation: properly.

most results

are

high

which

indicate

dysfunctional

liver, probably liver failure. Liver fails to do its normal functions

15

CHAPTER III LITERATURE REVIEW Normal Anatomy and Physiology Cells make up the smallest level of a living organism such as yourself and other living things. The cellular level of an organism is where the metabolic processes occur that keep the organism alive. That is why the cell is called the fundamental unit of life. Cells are sacs of fluid surrounded by membranes. Inside the fluid float chemicals and organelles. An organism contains parts that are smaller than a cell, but the cell is the smallest part of the organism that retains characteristics of the entire organism. For example, a cell can take in fuel, convert it to energy, and eliminate wastes, just like the organism as a whole can. But, the structures inside the cell cannot perform these functions on their own, so the cell is considered the lowest level. Therefore, cells not only make up living things; they are living things. The most important characteristic of a cell is that it can reproduce by dividing. If cells did not reproduce, you or any other living thing would not continue to live. Cell division is the process by which cells duplicate and replace themselves. The cell-division cycle is a vital process by which a singlecelled egg develops into a mature organism, as well as the process by which hair, skin, blood cells, and some internal organs are renewed. Cell Division: Interphase Time between divisions Protein synthesis carried out Chromatin present Nucleolus present DNA replicated towards division time Prophase Chromatin thickens into chromosomes Nuclear membrane disintegrates Centriole pairs move to opposite ends of the cell Spindle fibers begin to form

16

Metaphase

Guided by the spindle fibers, the chromosome pairs line up along the center of the spindle structure

Anaphase

The chromosome pairs Telophase (sisters) begin to pull apart Once separated, they are called daughter chromosomes Due to pull, many chromosomes bend Groove in plasma membrane present

Chromosomes return to chromatin Spindle disintegrates Nuclear membrane takes shape again Centrioles replicate Membrane continues to pinch inward (in plant cells a new cell wall is laid)

When the process is complete, each cell will have the same genetic material that the original cell had before replication. Each of the daughter cells is also identical to each other. Note that once telophase is complete, the cell returns to interphase. In either case it is the completion of the cell cycle that produces new organisms, a process that can go on throughout life by forming a group of cells to form a tissue that composed an organ, which comprises a system just like the respiratory system, Gastrointestinal system, that are responsible in maintaining homeostasis.

Cell Differentiation Within the bone marrow there is a pluripotent stem cell. This stem

17

cell is the Mother Cell or the originator of all blood cells. It has the ability to self-renew and create progenitor stem cell lines. They are naturally limited in number.

By reviewing the diagram, you can see that all cells come from the stem cell. An attack on the stem cell can theoretically affect all of them similarly. THE RESPIRATORY SYSTEM

The respiratory system is a group of organs and tissues that help you breathe. The main parts of this system are the airways, the lungs and
18

linked blood vessels, and the muscles that enable breathing. Respiratory system is divided into two tracts: upper respiratory tract (nose, pharynx, larynx, and trachea), and lower respiratory tract (bronchus, bronchioles, and alveoli). The Pathway

Air enters the nostrils passes through the nasopharynx, the oral pharynx through the glottis into the trachea into the right and left bronchi, which branches and rebranches into bronchioles, each of which terminates in a cluster of alveoli The lungs are the body's major organs of respiration. The two

LUNGS vital parts that make up the lungs are located on each side of the chest within the rib cage. They are separated by the heart and other contents of the mediastinum. The top, or apex, of each lung extends into the lowest part of the neck, just above the level of the first rib. The bottom, or base, of each lung extends down to the diaphragm, which is the major breathing-associated muscle that separates the chest from the abdominal cavity. Each lung is divided into upper and lower lobes. The right lung is larger and heavier than the left lung, which is somewhat smaller in size because of the position of the heart. The root connects the lungs to the heart and the trachea (windpipe). Each root is made up of a main stem bronchus (large air passage connecting the windpipe to the right or left lungs), pulmonary artery (major artery that brings oxygen-poor blood back to the right or left lungs), pulmonary vein (major vein receiving oxygen-rich blood from the lobes of the right or left lungs), the bronchial arteries and veins, as well as nerves and lymphatic vessels. A clear, thin, shiny covering known as pleura, which covers the lungs. The inner, visceral layer of the pleura is attached to the lungs and the outer, parietal layer is attached to the chest wall. The trachea splits into right and left main stem bronchi. These are the major air passages from the trachea to the lungs and are similar to the trachea in tissue composition. The tracheobronchial tree conducts, humidifies, and heats air that is breathed in, or inspired. At its endpoints, the tracheobronchial tree connects with the blood vessels. The lining of the tracheobronchial tree is composed
19

of columnar epithelium (column-shaped surface cells) and glands that produce mucus and serous (clear plasma) fluid. The cilia (hair-like projections on columnar epithelium) move in a constant, beating motion to cleanse the airways of foreign bodies and infectious organisms. A watery "mucous blanket" - a gel-like liquid - covers and is moved by the cilia and aids the lungs' self-cleaning. Coughing triggers a highspeed flow of air that mobilizes the mucous blanket. The sputum produced by such mobilization contains mucus, nasal secretions, and saliva. The essential tissue of the lunglung parenchymais made up of clusters of spongy air sacs called lobules. Each lobule contains about 2,200 alveoli (air sacs and ducts) and have connective tissue coverings are called segmental bronchi. The smallest subdivisions, and do not have connective tissue coverings, are called bronchioles. The final branches of the bronchioles are called terminal bronchioles. The bronchioles end in irregular, swollen projections known as alveolar ducts (terminal branches composed of special gas-exchanging tissue) and alveolar sacs (blind passages of alveolar ducts). The alveolar sacs are tiny, thin-walled, cup-shaped structures are lined with a detergent-like substance known as surfactant, which reduces surface tension and prevents them from collapsing during breathing. Functions of the Respiratory System Providing large area for gas exchange between air and circulating blood. Moving air to and from the gas-exchange surfaces of the lungs. Protecting the respiratory surfaces from dehydration and temperature changes and defending against invading pathogens. Producing sounds permitting speech, singing, and non-verbal auditory communication. Providing olfactory sensations to the central nervous system for the sense of smell. How the Lungs Work The lungs expand upon inhalation, or inspiration, and fill with air. They then return to their resting volume and push air out upon exhalation, or expiration. These two movements make up the process of breathing, or respiration. The respiratory system contains several structures. When you breathe, the lungs facilitate this process: 1. Air comes in through the mouth and/or nose, and travels down through the trachea, or "windpipe." This air travels down the trachea into two bronchi, one leading to each lung. The bronchi then subdivide into smaller tubes called bronchioles. The air
20

finally fills the alveoli, which are the small air sacs at the ends of the bronchioles. 2. In the alveoli, the lungs facilitate the exchange of oxygen and carbon dioxide to and from the blood. Adult lungs have hundreds of alveoli, which increase the lungs' surface area and speed this process. Oxygen travels across the membranes of the alveoli and into the blood in the tiny capillaries surrounding them. 3. Oxygen molecules bind to hemoglobin in the blood and are carried throughout the body. This oxygenated blood can then be pumped to the body by the heart. 4. The blood also carries the waste product carbon dioxide back to the lungs, where it is transferred into the alveoli in the lungs to be expelled through exhalation. The Lungs' Protections Several lung parts and functions act as protective mechanisms to keep out irritants and foreign particles. The hairs and mucus in the nose prevent foreign particles from entering the respiratory system. The breathing tubes in the lungs secrete mucus, which also helps protect the lungs from foreign particles. This mucus is naturally pushed up toward the epiglottis, where is passed into the esophagus and swallowed. Mechanisms of breathing To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways. Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax). Gas Exchange Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveoli in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over. Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients.

21

CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane. THE LIVER The liver fills the right and center of the upper abdominal cavity just below the diaphragm. It has a larger right lobe and a smaller left lobe. The blood supply of the liver differs from that of other organs. The liver receives oxygenated blood by way of the hepatic artery. By way of the portal vein, blood from the abdominal digestive organs and the spleen is brought to the liver before being returned to the heart. This special pathway is called hepatic portal circulation and permits the liver to regulate blood levels of nutrients or to remove potentially toxic substances such as alcohol from the blood before the blood circulates to the rest of the body. The only digestive function of the liver is the production of bile by the hepatocytes (liver cells). Bile flows through small bile ducts, converges into larger ones, and leaves the liver by way of the common hepatic duct. The common hepatic duct joins the cystic duct of the gallbladder to form the common bile duct, which carries bile to the duodenum. Bile is mostly water and bile salts. Its excretory function is to carry bilirubin and excess cholesterol to the intestines for elimination in feces. The digestive function of bile is accomplished via bile salts, which emulsify fats in the small intestine. Emulsification is a type of mechanical digestion in which large fat globules are broken into smaller globules but are not chemically changed. Production of bile is stimulated by the hormone secretin, which is produced by the duodenum when acidic chyme enters the small intestine.

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Functions of the Liver The liver is involved in a great variety of metabolic functions, most of which involve the synthesis of specific enzymes. For the sake of simplicity, these functions may be grouped into categories. CARBOHYDRATE METABOLISM. The liver regulates the blood glucose level by storing excess glucose as glycogen and changing glycogen back to glucose when the blood glucose level is low. The liver also changes other monosaccharides such as fructose and galactose to glucose, which is more readily used by cells for energy production. AMINO ACID METABOLISM. The liver regulates the blood levels of amino acids based on tissue needs for protein synthesis. Of the 20 amino acids needed for the production of human proteins, the liver is able to synthesize 12, called the nonessential amino acids, by the process of transamination. The other eight amino acids, which the liver cannot synthesize, are called the essential amino acids. Essential amino acids are required in the diet. Excess amino acids (those not needed for protein synthesis) undergo the process of deamination in the liver; the amino group is removed and the remaining carbon chain is converted to a simple carbohydrate that is used for energy production or converted to fat for energy storage. The amino groups are converted to urea, a nitrogenous waste product that is removed from the blood by the kidneys and excreted in urine. LIPID METABOLISM. The liver forms lipoproteins for the transport of lipids in the blood to other tissues. The liver also synthesizes cholesterol and excretes excess cholesterol into bile to be eliminated
23

in feces. The liver is also the main site of the process called beta oxidation, in which fatty acid molecules are split into twocarbon acetyl groups. These acetyl groups may be used by the liver to produce energy, or they may be combined to form ketones to be transported to other cells for energy production. SYNTHESIS OF PLASMA PROTEINS. The liver synthesizes albumin, clotting factors, and globulins. Albumin, the most abundant plasma protein, helps maintain blood volume by pulling tissue fluid into capillaries. Clotting factors produced by the liver include prothrombin and fibrinogen, which circulate in the blood until needed for chemical clotting. The globulins synthesized by the liver become part of lipoproteins or act as carriers for other molecules in the blood. PHAGOCYTOSIS BY KUPFFER CELLS. The fixed macrophages of the liver are called Kupffer cells (or stellate reticuloendothelial cells). They phagocytize worn blood cells and pathogens that circulate through the liver. Many of the bacteria that enter the liver come from the colon, after being absorbed along with water. Portal circulation brings this blood to the liver before entering circulation throughout the remainder of the body. These bacteria are normal flora of the colon but would be harmful elsewhere. FORMATION OF BILIRUBIN. The fixed macrophages of the liver phagocytize worn red blood cells (RBCs) and form bilirubin from the heme portion of their hemoglobin. The liver also removes from the blood the bilirubin formed in the spleen and red bone marrow and excretes it into bile to be eliminated in feces. STORAGE. The liver stores the minerals iron and copper; the fatsoluble vitamins A, D, E, and K; and the water soluble vitamin B12. DETOXIFICATION. The liver synthesizes enzymes that alter harmful substances to less harmful ones. Alcohol and medications are examples of potentially toxic chemicals. The liver also converts ammonia from the colon bacteria to urea, a less toxic substance. ACTIVATION OF VITAMIN D. The skin, kidneys, and liver each perform a different role in providing the body with activated vitamin D.

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Theoretical Background Primary Liver Cancer Primary liver cancer develops from the benign tumors. It is the most common type of cancer. Most of the growths in the liver such as hemangiomas, focal nodular hyperplasia, hepatic adenomas are usually benign, that is, non-cancerous. Chronic kidney disease, hepatitis B or C, some toxins, viral infections of the liver can cause primary liver cancer. It is further divided into three types.

Hepatocellular Carcinoma or Hepatoma Cholangiocarcinomas or Bile Duct Cancer Angiosarcomas and Hemangiosarcoma

Hepatocellular carcinoma is the most common primary liver cancer. it is an uncontrolled growth of hepatocyte cells in the liver results in hepatocellular carcinoma. About 80% of people with primary liver cancer have cirrhosis of the liver. Hepatitis C infection is responsible for about 50% to 60% of all liver cancers, and hepatitis B is responsible for approximately 20%. Metastatic carcinoma or the liver is more common than primary carcinoma. The liver is a common site of metastatic growth because of its high rate of blood flow and extensive capillary network. Cancer cells in other parts of the body are commonly carried to the liver via the portal circulation. Cancer cells cause the liver to be enlarged and misshapen. Hemorrhage and necrosis in the liver are common. Lesions may be singular or numerous and nodular or diffusely spread over the entire liver. Some tumors infiltrate into other organs such as the gallbladder or into the peritoneum or diaphragm. Primary liver tumors commonly metastasize to the lung. Secondary Liver Cancer Secondary cancer is caused by the spread of cancerous cells, which are located outside the liver. It can spread from gastrointestinal organs like stomach, pancreas and colon, as the blood flows from these organs to the liver or it can also spread through the lymphatic system. Secondary liver cancer is also called as metastatic cancer. In most of the cases, it is a result of primary liver cancer. It can be a result of advanced breast cancer, colorectal cancer, lung cancer, kidney cancer or some other types of cancers.

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Risk Factors for Liver Cancer The exact cause of primary liver cancer is still unknown. In adults, however, certain factors are known to place some individuals at higher risk of developing liver cancer. These factors include:

Gender. The male/female ratio for hepatoma is 4:1. Age over 60 years. Environmental exposure to carcinogens (cancer causing substances). Examples of environmental carcinogens are aflatoxin, substance produced by a mold that grows on rice and peanuts; thorium dioxide, used at one time as a contrast dye for x rays of the liver; and vinyl chloride, used in manufacturing plastics.

Use of oral estrogens for contraception (birth control). Hereditary hemochromatosis. Hemochromatosis is a disorder characterized by abnormally high levels of iron storage in the body. It often progresses to cirrhosis.

Cirrhosis. Hepatomas appear to be a frequent complication of cirrhosis of the liver. Between 30-70% of hepatoma patients also have cirrhosis. It is estimated that a patient with cirrhosis has 40 times the chance of developing a hepatoma than a person with a healthy liver. Cirrhosis usually results from alcohol abuse or chronic viral hepatitis.

Exposure to hepatitis B (HBV) or hepatitis C (HBC) viruses. In Africa and most of Asia, exposure to hepatitis B is an important factor; in Japan and some Western countries, exposure to hepatitis C is associated with a higher risk of developing liver cancer. In the United States, nearly 25% of patients with liver cancer have evidence of HBV infection. Hepatitis B and C are commonly found among intravenous drug abusers.

Clinical Manifestations It is difficult to diagnose and differentiate liver cancer from cirrhosis in its early stages because of their similar clinical manifestations (e.g., hepatomegaly, splenomegaly, jaundice, weight loss, peripheral edema, ascites, portal hypertension). Other common manifestations of liver cancer include dull abdominal pain in the epigastric or right upper quadrant region, anorexia, nausea and vomiting, increased abdominal girth. Patients frequently have pulmonary emboli.

Underlined words signify the clinical manifestations exhibited by the patient

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Medical Management Administer oxygen inhalation at 2-4 LPM via nasal cannula Chemotherapy o Chemotherapy is used for patients with hepatocellular cancer who are not likely to benefit from other procedures (e.g., surgery, transplantation, ablation). A variety of chemotherapeutic agents (e.g., 5-fluoracil [5-FU] and leucovorin) administered either systemically or regionally have been used to treat liver cancer. Sorafenib (Nexavar), a targeted therapy, is used to treat metastatic liver cancer. It inhibits tyrosine kinases, some of which are involved in promoting new blood vessel growth to tumors.

Surgical Management Radiofrequency Ablation Treatment o A thin needle is inserted through the skin and into the core of the tumor. Then electrical energy is used to create heat in a specific location for a limited amount of time. The end result is destruction of tumor cells. This procedure can be done percutaneously, laparoscopically, or through an open incision. This therapy, although not ideal for all patients, can be used both for tumors (<5cm in size) that are considered resectable and for palliative purposes. Complications are not common but can include infection, bleeding, dysrhythmias, and skin burn. Chemoembolization o A catheter is placed in the arteries to the tumor and an embolic agent is administered, often mixed with a chemotherapeutic agent(s). the embolic agent reduces the blood supply, thus allowing greater exposure of liver cells to the chemotherapy drugs.

Nursing Management Give analgesics as ordered and encourage the patient to identify care measures that promote comfort.
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Provide patient with a sodium, fluid, and protein restricted diet and that prohibits alcohol. Elevate the patients legs to increase venous return and decrease edema. Monitor and treat fever. Provide meticulous skin care. Turn the patient to sides frequently and keep bed linens from wrinkles to prevent pressure ulcers. Provide comprehensive care and emotional assistance towards the patient and to the significant others as well. Monitor the patient for fluid retention and ascites. Monitor respiratory function. Explain the treatments to the patient and his family, including adverse reactions the patient may experience.

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CHAPTER IV CASE ANALYSIS AND INTERVENTIONS Pathophysiology:

Etiology Precipitating: -nutrition Legend: Italics - manifestations Arrows Disease Process ALL CAPS - Complications

Predisposing: -age -familial hx of liver problem -HBV

Injury to liver

Inflammation (hepatitis)

Healing, scarring

(prolongation)
Constant necrosis & proliferation cycle Chronic liver disease

Proliferation arrest, stellate cell activation

Extensive scarring Disorganized nodular regeneration

Liver cirrhosis

Obstructs biliary, vascular channels

Moderate genomic instability, acted by HBV DNA Blood bypasses liver + ammonia in bld reaches brain HEPATIC ENCEPHALOPATHY *coma *asterixis Portal hypertension

Increased pressure in mesenteric tributaries of portal vein Increased hydrostatic pressure Fluid shifts out of vessels Decreases intravascular vol Less bld supply to renal system

Obstructive jaundice

Obx of bile canaliculi

Bile duct obx Conjugated bilirubin enters bld stream, reabsorpt ion of bile *light colored stool *pruritus

bilirubin not conjugated & excreted Inc. urobilinogen *dark urine

Distention of collateral veins, radiates to abdomen *caput medusa

Backflow of blood *edema on lower extremities, grade 2

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Hepatorenal syndrome *inc. uric acid *inc. creatinine Releases *BUN metalloproteinase enzyme

Protooncogenes mutate into oncogenes Severe genomic instability (cancer cell) Rapid growth of primary tumor Formation of blood vessels w/in the tumor itself (tumor angiogenesis) Some segments of tumor detach from primary tumor Releases metalloproteinase enzyme HEPATOCELLULAR CARCINOMA

Basement membrane of blood vessels are destroyed

Metastatic tumor cell penetrates into the blood vessel, enters the blood circulation Blood from liver goes to right atrium of the heart, to pulmonary artery to lungs for oxygenation Metastatic tumor cells arrest in the capillary beds Adhere to capillary basement membrane Gain entrance into the lung parenchyma Immunologic surveillance of macrophages: -phagocytosis -processing of target cells -release of cytokines

Pathologic changes

Nonspecific inflammatory changes w/ hypersecretion of mucus

Disruption of thoracic duct Lymphatic fluid leak into pleural space HYDROTHORAX

Reactive hyperplasia of basal cells

Metaplasia of epithelium to stratified squamous cells

HYPERTROPHY Immunologic escape mechanisms of cancer cells: -suppression of factors -weak surface antigens -immune systems tolerance to tumor antigens -suppression of immune response -blocking antibodies Tumor cell proliferation & angiogenesis LUNG METASTASIS

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Medical Management 1. Intravenous fluid therapy > Giving of substances directly into a vein; the administration of a balanced electrolyte solution into the venous circulation; the administration / introduction of fluids directly into the vein. Aside from iv hydrates the patient, IV also maintain & replace body stores of water, electrolytes, vitamins, proteins, fats & calories of the patient. It also restores the volume of blood components as well as providing avenue for the administration of medication. For the patient: > D5NM @ KVO >Hypertonic solution draws fluid from the ICF causing cells to shrink and ECF to expand. It initially increases osmolarity causing the fluid to be pulled from the interstitial & intracellular compartments into the blood vessel (intravascular space). It is indicated to regulate urine output, stabilize blood pressure and reduce risk of edema. It is also given to patients with fluid loss, hyponatremia and anemia. Nursing considerations: Check for signs of IV infiltration. Regulate and monitor the flow rate. It should be in the right amount. In giving IV medications, it should be slowly administrated to lessen the pain in administering especially those antibiotics. IV fluids should be slowly administrated to prevent overload. Check the sodium levels of the patient.

2. Antibiotic therapy > A drug used to treat infections caused by bacteria and other microorganisms. An antibiotic was a substance produced by one microorganism that selectively inhibits the growth of another. Antibiotics are also known as antibacterials. Bacteria are tiny organisms that can sometimes cause illness to humans. There are many types of antibiotic, these includes macrolydes, cephalosporin, fluoroquinolone, penicillin, tetracycline, and macrolyde. Nursing considerations: Check for hypersensitivity of the drug. Check for allergies. Consider the 5 rights of medication before administering it.

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Monitor the patient for adverse reactions. Instruct the patient to report any unusual symptoms immediately.

3. Oxygen therapy > The administration of oxygen as a therapeutic modality. It is prescribed by the physician, who specifies the concentration, method of delivery, and liter flow per minute. It alleviates tiredness and decreases shortness of breath of the patient. >the 02 that the patient had is via nasal cannula/ nasal prongs regulated at 2-4L/min. >It is the most inexpensive device used to administer oxygen. It doesnt interfere with the clients ability to talk. Nursing Considerations: Place cautionary signs reading No Smoking: Oxygen in use on the clients door, at the foot or head of the bed, and on the oxygen equipment. Check the nasal catheter if its working properly with your hand. Assess skin, breathing pattern, chest movement, and Lung sounds to check the effectivity of the therapy. Regulate the flow rate as prescribed. Monitor V/S to note any signs of distress.

Pharmacologic Management Generic Name: Allopurinol Brand Name: Zyloprim Therapeutic Classification: Antigout drug Indication: Management of patients with malignancies that result in elevations of serum and urinary uric acid Dosage: 100 mg 1 tablet OD Drug Action: Inhibits the enzyme responsible for the conversion of purines to uric acid with a decrease in serum and sometimes in urinary uric acid levels, relieving the signs and symptoms of gout Side Effects and Adverse Reactions: Headache, drowsiness, nausea, vomiting, diarrhea Nursing Responsibilities: Administer drug following meals Arrange for regular medical follow-up and blood tests

Generic Name: Ciprofloxacin Brand Name: Ciloxan

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Therapeutic Classification: Antibacterial, Fluoroquinolone Indication: For the treatment of lower respiratory tract infection Dosage: 200mg IVTT every 8 hours Drug Action: Bactericidal; interferes with DNA replication in susceptible bacteria preventing cell reproduction Side Effects and Adverse Reactions: Headache, dizziness, nausea, vomiting, diarrhea Nursing Responsibilities: Arrange for culture and sensitivity tests before beginning therapy Continue therapy for 2 days after signs and symptoms of infection are gone Ensure that patient is well hydrated Encourage patient to complete full course of therapy

Generic Name: Furosemide Brand Name: Lasix Therapeutic Classification: Loop Diuretic Indication: Edema associated with hepatocellular carcinoma Dosage: 20 mg IVTT every 12 hours Drug Action: Inhibits reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodium-rich diuresis Side Effects and Adverse Reactions: Dizziness, vertigo, paresthesias, xanthopsia, weakness, orthostatic hypotension, thrombophlebitis, photosensitivity, rash, pruritus, urticaria, nausea, anorexia, vomiting, oral and gastric irritation, leukopenia, anemia, constipation, diarrhea, urinary bladder spasm, thrombocytopenia, muscle cramps and muscle spasms Nursing Responsibilities: Administer with food or milk to prevent GI upset Give early in the day so that increased urination will not disturb sleep Measure and record weight to monitor fluid changes Arrange to monitor serum electrolytes, hydration, liver and renal function
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Arrange for potassium-rich diet of supplemental potassium as needed

Generic Name: Omeprazole Brand Name: Zegerid Therapeutic Classification: Antisecretory Drug, Proton Pump Inhibitor Indication: Reduction of risk of upper GI bleeding in critically ill patients Dosage: 40 mg IVTT OD secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production Side Effects and Adverse Reactions: Headache, dizziness, diarrhea, abdominal pain, nausea and vomiting, URI symptoms Nursing Responsibilities: Administer before meals Administer antacids with, if needed Instruct patient to report severe headache, worsening of symptoms, fevers, chills Drug Action: Gastric acid-pump inhibitor: Suppresses gastric acid

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35

NURSING CARE MANAGEMENT

SUBJECTIVE
Patient whispered Tabangi ko ninyo, lisud na kaayo iginhawa.

NURSING CARE PLAN (PRIORITY NO. 1)

NURSING DIAGNOSIS
Impaired gas exchange related to ventilation perfusion imbalance secondary to massive right sided hydrothorax Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolicapillary membrane Source: Nurses Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.

OBJECTIVE
-RR= 28 cpm, deep and labored -Jaw jutting and nasal flaring noted -Poor capillary refill of 4 seconds -Pallor noted on conjunctivae and fingernails -Labored breathing with use of accessory muscles (intercostal and abdominal muscles) noted -Diminished peripheral sounds noted on right lung field when auscultated -Decreased sensorium observed - Chest x-ray result showed a massive right sided hydrothorax -GCS of 11/15, moderate brain injury

SCIENTIFIC ANALYSIS
According to Lewis, Heitkemper, Dirksen, OBrien,and Butcher, hydrothorax/pleural effusion is a collection of fluid in the pleural space, secondary to altered hydrostatic or oncotic pressure. With this increased volume of fluid in the pleural space, one can conclude that there will be a decreased movement of the chest wall, thus causing dyspnea and impaired gas exchange. Moreover, it has been mentioned that hydrothorax is not a disease in itself, but rather, a manifestation of a serious disease, which, in the case of our patient, is hepatoma, or hepatocellular carcinoma. A large effusion (hepatic hydrothorax) occasionally appears during the course of the

PLANNING
Immediate GoalThat after 1530 minutes: -Patient/SO will be able to verbalize understanding of causative factors and appropriate interventions related to gas exchange Short-term goals- That after two hours, the patient will demonstrate improved ventilation and oxygenation as manifested by: -respiratory rate returning to normal or near normal range (12-20 cpm) -decreased use of accessory muscles -improved capillary refill (1-3 seconds) - reduced jaw jutting and nasal flaring -pinkish mucous

INTERVENTIONS
Independent: -Take vital signs of the patient especially respiratory rate and heart rate. - Assess level of consciousness and mentation changes with use of Glascow coma scale.

RATIONALE
- To provide a baseline data for comparison of patients health status. - Poor brain oxygenation can reduce patients sensory ability. A decline to below 50% oxygen in brain is considered to be indicative of cerebral ischemia. - By gravity, the diaphragm is freed from the enlarged liver and provides enough space for the lungs to expand and receive oxygen. - Promotes optimal chest expansion and drainage of secretions. - Helps limit oxygen needs and consumption.

EVALUATION
That after 2 hours, the patient had a remarkable decrease in perfusion as manifested by: -respiratory rate 29 cpm, deep and labored -constant use of accessory muscles -poor capillary refill of 4 seconds -jaw jutting and nasal flaring noted -pale mucous membranes and fingernails noted -diminished breath sounds noted - reduced Glasgow coma scale to 3/15, severe brain injury -patient is unresponsive to speech and painful stimuli

-Elevate head of bed to semifowler or high fowlers position.

- Encourage frequent position changes. - Encourage adequate rest and limit activities to within client tolerance. -Evaluate pulse oximetry to determine

- The body ideally should receive at least 95% of oxygen.

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disease. The fluid in the pleural space is believed to be derived from ascitic fluid that may accompany hepatic cirrhosis. Although the exact mechanism is somewhat controversial, it appears that the ascitic fluid is transported directly into the pleural space. A therapeutic thoracentesis, usually accompanied by a paracentesis, these interventions may not be successful. Management of hepatic hydrothorax remains a clinical challenge. Source: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., & Bucher, L.

membranes and fingernails -clearer breath sounds when auscultated Long-Term GoalThat after 1 week: -Patient will maintain optimal gas exchange.

oxygenation.

Below it would pose problem on brains vital functions. - Intubation ensures that oxygen is delivered straight to lung alveoli, improving perfusion. Suctioning helps remove secretions that may block lung ventilation - Inhaled and systemic glucocorticosteroids, bronchodilators. To treat underlying conditions. -Thoracentesis is a procedure to remove fluid from the space between the lungs and chest wall.

- Ensure availability of proper emergency equipment including ET/trach set and suction machines. Dependent: - Administer medications as indicated.

Collaborative: -Assist with thoracentesis.

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NURSING CARE PLAN (PRIORITY NO. 2)

SUBJECTIVE
Tabangi ko ninyo, lisud na kaayo iginhawa, as verbalized by the patient

OBJECTIVE
-RR= 22 cpm, deep and labored -nasal flaring noted -Poor capillary refill of 4 seconds -Pallor noted on conjunctivae and fingernails -Labored breathing with use of accessory muscles (intercostal and abdominal muscles) noted -muscle strength of 0 on both lower extremities, no palpable muscular contraction (paralysis) -GCS of 11/15, moderate brain injury -asterixis noted on both arms and hands Functional Level Classification: Level IV-dyspnea and fatigue at rest

NURSING DIAGNOSIS
Activity intolerance related to generalized weakness secondary to hepatic encephalopathy Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities Source: Nurses Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.

SCIENTIFIC ANALYSIS
Hepatic encephalopathy is a neuropsychiatric manifestation of liver damage. It is considered a terminal complication in liver disease. It can occur in any condition in which liver damage causes ammonia to enter the systemic circulation without liver detoxification (Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., & Bucher, L., 2008). This disease is basically a disorder of protein metabolism and excretion. The main pathogenic agents appear to be nitrogenous ammonia and aromatic amino acids. The ammonia normally goes to the liver via portal

PLANNING
Immediate goalThat after 15-30 minutes: -Patient/SO will identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible Short-term goalthat after 1 hour: -Patient will use identified techniques to help enhance patients activity tolerance Long-term goalsthat after 1 week: -Patient will participate willingly in necessary/ desired activities -Patient will report measurable increase in activity tolerance

INTERVENTIONS
Independent: -Note presence of factors contributing to fatigue (e.g., cancer)

RATIONALE
-Fatigue affects both the clients actual and perceived ability to participate in activities -to prevent overexertion -to conserve energy

EVALUATION
After 8 hours, patient has been able to: -increase RR from 22 cpm to 28 cpm -demonstrate deep and labored breathing still -reduce GCS from 11/15 (moderate brain injury) to 3/15 (severe brain injury) -demonstrate a muscle strength of O in both upper and lower extremities

-Adjust intensity level of activities -increase exercise/ activity levels gradually -Plan care to carefully balance rest periods with activities -Provide positive atmosphere, while acknowledging difficulty of the situation for the client -promote comfort measures and provide for relief of pain -Instruct client/SO in

-to reduce fatigue

-to help minimize frustration and rechannel energy

-to enhance ability to participate in activities -there may be a need to alter

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circulation and is converted to urea, which is then excreted by the kidneys. When the liver is unable to convert ammonia to urea, large quantities of ammonia remain in the systemic circulation. The ammonia crosses the blood-brain barrier and produces neurologic toxic manifestations. Clinical manifestations of encephalopathy include changes in neurologic & mental responsiveness (ranging from sleep disturbance, to lethargy, to deep coma), slow and deep respirations, slow and slurred speech, hyperactive reflexes, and asterixix (flapping tremors). Source: Medical-Surgical Nursing:

-patient will be able to demonstrate a decrease in physiological signs of intolerance

monitoring response to activity -Plan for progressive increase of activity level

activity level

-both activity tolerance and health status may improve with progressive training -to enhance sense of wellbeing

-Encourage client to maintain positive attitude (e.g., suggest use of relaxation techniques) Dependent: -Provide O2 therapy

-to help patient relieve from dyspnea and fatigue

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Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., & Bucher, L.

40

SUBJECTIVE
Init na siya kayo. Murag nagpatol na gani siya kay nikalit ug puti ang mata unya nanggahi napaakan ang dila, as verbalized by the significant other.

OBJECTIVE
-T= 38. 9 C -RR= 28 cpm, tachypneic -patient is hot to touch -diaphoresis noted -seizure/ convulsion occurence

NURSING DIAGNOSIS
Hyperthermia related to infectious process Definition: Body temperature elevated above normal range Source: Nurses Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.

NURSING CARE PLAN (PRIORITY NO. 3) SCIENTIFIC PLANNING INTERVENTIONS ANALYSIS

Infection is a primary cause of death in the patient with cancer.The usual sites of infection include the lungs, the GU system, mouth, rectum, peritoneal cavity, and blood. Infection occurs as a result of the ulceration and necrosis of a tumor, compression of vital organs by the tumor, and neutropenia caused by the disease process or the treatment of cancer. Patients who have a temperature of 38C or higher should be reported immediately. Assessment most often includes signs and symptoms of fever, determination of possible Immediate GoalThat after 15-30 minutes, patient/SO will be able to: -identify underlying cause/ contributive factors, and importance of treatment Short-Term Goals-That after 8 hours, patient will demonstrate the ff: -T= 36.5-37.5 C -Skin cool to touch -No reccurence of seizure/ convulsion -SO demonstrates behavior to monitor and promote normothermia. Long-Term GoalsThat after 1 week, patient will be able to: -maintain core temperature within normal range -be free of seizure activity Independent: -Monitor core temperature. -Assess neurological response, noting level of consciousness and orientation. -Apply tepid sponge bath - apply local ice packs especially in the groin and axillae -maintain bedrest

RATIONALE
- To evaluate effects/degree of hypothermia. - High fever can cause seizures predisposing patients to further seizure related injuries. -promote heat loss by evaporation. - this promote heat loss in areas of high blood flow -to reduce metabolic demands/oxygen consumption -to offset increased oxygen demands and consumption -to treat infection

EXPECTED OUTCOME
That after 8 hours, the patient is afebrile as evidenced by: -T= 37.1C -Diaphoresis noted -Skin is slightly cool to touch -No recurrence of fever -SO verbalized, Di gyud to magsalig lang sa tambal. Kinahanglan na mag spongebath para dali manaog ang hilanat.

Independent: -provide supplemental oxygen -administer antibiotics as ordered Collaborative: -provide highcalorie diet,

-to meet increased

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etiology, and CBC. Source: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., & Bucher, L.

-demonstrate behaviors to monitor and promote normothermia -be free of complications such as is irreversible brain damage and acute renal failure

tube feedings, and parenteral nutrition -administer replacement fluids and electrolytes

metabolic needs

-to support circulating volume and tissue perfusion

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SUBJECTIVE
Nigamay gyud pag-ayo si mama sa la pa siya nagreklamo unya karon nahospital siya, maluoy na mi maglantaw sa iyahang lawas, as verbalized by SO Di naman gyud siya mukaon, mao to gipatubuhan nalang sa doctor para didto nalang iagi tanan iyahang pagkaon, as verbalized by SO

OBJECTIVE
-patient appears very weak to chew and swallow -emaciated -pale and dry mucous membrane observed -noted weakness of the muscles required for mastication

NURSING DIAGNOSIS
Imbalanced nutrition: less than body requirements related to loss of appetite and inability to absorb nutrients secondary to Hepatoma Definition: Intake of nutrients insufficient to meet metabolic needs Source: Nurses Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.

NURSING CARE PLAN (PRIORITY NO. 4) SCIENTIFIC PLANNING ANALYSIS

A persons appetite to ingest food is a significant factor in how much food is eaten. An appetite center is located in the hypothalamus. It is directly/indirectly stimulated by hypoglycaemia, an empty stomach, decrease in body temperature, and input from higher brain centers. (Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., & Bucher, L., 2008) The hormone ghrelin released from the stomach mucosa plays a role in appetite stimulation. Leptin, another hormone, is involved in appetite suppression. Thus, appetite may be inhibited by stomach distention, illness (especially accompanied by fever), hyperglycemia, and n/v. (Lewis, S., Heitkemper, M., Immediate GoalThat after 15-30 minutes, patient/SO will: -verbalize understanding of some factors causing malnutrition Short-Term Goals- That after 8 hours, patient will demonstrate the ff: -Pinkish and moist mucous membrane -Reduce respiratory rate -Regain strength and muscle tone to perform basic ADLs Long-Term GoalsThat after 4 weeks, patient will be able to: -Demonstrate behaviors/ lifestyle changes to maintain appropriate weight -Display normalization of laboratory values and be free of signs of

INTERVENTIONS
Independent: -Determine clients ability to chew, swallow and taste food. - Assess drug interactions and use of laxatives and diuretics. - Assess weight and muscle mass, and laboratory test such as amino acid profile, BUN, liver function and electrolytes. - Note age, body build, strength, activity/rest level. -provide NGT feeding properly

RATIONALE
-This can affect ingestion and digestion of food nutrients. -This may affect appetite, food intake and absorption. - This provides baseline parameters

EXPECTED OUTCOME
At the end of our care, the patient will be able to: -decrease creatinine, BUN, and uric acid levels to within normal range -increase HDL levels to within normal range - develop pinkish and moist mucous membranes -increase in muscle tone

- Helps determine nutritional needs. -to aid in the proper digestion and absorption of nutrients in the body -to prevent dehydration

-provide adequate fluid intake Dependent: - Assist in inserting nasogastric tubes to deliver

- NGT can ensure that nutrients reach to gastric organs and more

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Dirksen, S., OBrien, P., & Bucher, L., 2008) Source: MedicalSurgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., & Bucher, L.

malnutrition

osteorized feeding. - Assist in administering parenteral D5NM. Watch for overinfusion.

ready for absorption. - Multiple and balanced intravenous solutions helps correct electrolyte deficiency. -to aid in decreasing BUN, creatinine, and uric acid levels and to provide the patient with adequate energy needed for the bodys good functioning

Collaborative: -provide a soft diet composed of less than 1,600 calories and low protein, as ordered

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SUBJECTIVE
Ayaw ko ninyo pasagdai. Tabangi ko ninyo pag-ampo. Dili na nako kaya. Iampo ko day, as verbalized by patient Muanhi man to si Father unya para ampuan siya kay nagrequest man siya kanako, as verbalized by SO

OBJECTIVE -patient
is sulken -weak -crying observed

NURSING DIAGNOSIS
Death anxiety related to uncertainty about the existence of higher power and life after death. Definition: Vague, uneasy feeling of discomofort or dread generated by perceptions of a real or imagined threat to ones existence. Source: Nurses Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.

NURSING CARE PLAN (PRIORITY NO. 5) SCIENTIFIC PLANNING INTERVENTIONS ANALYSIS

Death is defined by Lewis, Heitkemper, Dirksen, OBrien,& Bucher, as the irreversible cessation of circulatory and respiratory function or the irreversible cessation of all functions of the entire brain, including the brainstem. Today, as a result of the increasing number of persons with chronic diseases, terminal illness and dying have received greater attention. Most individuals will have a long period of serious illness before dying, with the onset of months/years before death. For example, approximately half of all patients Immediate GoalThat after 15 to 30 minutes, patient will: -verbalize feelings of sadness, guilt and fear Short-Term GoalThat after 2 hours hours, patient will: -formulate a plan dealing with individual concerns and eventualities of dying as appropriate Long-Term GoalsThat after 3 days, patient and SO will: -look toward/plan for the future one day at a time -be able to readily say goodbye to each other Independent: -Ascertain current knowledge of situation to identify misconceptions, lack of information and other pertinent issues. -Provide open and trusting relationship

RATIONALE
-The concept of higher power in the afterlife provides comfort and strength to the dying person.

EVALUATION
At the end of our care, the S/O verbalized, Dinhi na si Father. Giampuan na siya. Nagpasalamat ra pud mi na nahumana ang pag-ampo para makapreparar siya sa kamatayon.

-Genuine rapport can help the patient express her feelings to the nurse about the unknown. -This promotes relaxation and ability to deal with the situation. -This reduces feelings of guilt allowing the person to move forward toward resolution. -To help with the grief work.

-Provide calm, peaceful setting and privacy as appropriate -Assist the client in engaging spiritual activities and experience prayer and meditation -Refer to therapists and spiritual advisers.

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diagnosed with cancer will die from their disease within a few years. However, the time from diagnosis of a terminal illness to death varies considerably depending on the patients diagnosis and extent of disease. Most patients and families struggle with a terminal diagnosis and the realization that there is no cure. The patient and the family feel overwhelmed, powerless, fatigued, and fearful. With this, both the patient and the significant others may experience death anxiety. For the Catholics, however, they believe in eternal life after death. Yes, we are fully confident,

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and we would rather be away from these earthly bodies, for then we will be at home with the Lord. (2 Corinthians 5:8 ) This biblical quote may offer much comfort for those Catholics who have the faith as that of a mustard seed (Matthew 17:20) Source: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., & Bucher, L. The New American Bible: The New Catholic Translation (1987), by Heenan, J.C.

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PROGRESS NOTES
DATE April 12, 2011 April 13, 2011 PROBLEM -dyspnea MEDICAL/SURGICAL INTERVENTION -O2 inhalation ordered at 2-4 LPM -CBC taken -continued O2 inhalation at 2-4 LPM -Chest X-ray done -Prescribed diet: CHON, soft diet -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered -electrolyte levels assessed (Na and K) -NGT inserted; prescribed diet: 1600 cal, Osteorized Feeding -blood chemistry done -continued O2 inhalation at 2-4 LPM -Prescribed diet: CHON -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered -prescribed diet: 1600 cal, Osteorized Feeding NURSING INTERVENTION -place a no smoking sign in the room -place a no smoking sign in the room -Elevate the patients legs to increase venous return and decrease edema -keep bed linens from wrinkles -give health teachings and demonstrate to patient/SO about importance of ROM exercises -place a no smoking sign in the room OUTCOME -dyspnea was relieved -dyspnea was relieved -edema not relieved, patient complained of decreased sensorium on lower extremities

-dyspnea

-grade 2 bipedal pitting edema on both lower extremities

-body weakness

April 14, 2011

-dyspnea

-patient tried to remove NGT and complained of discomfort upon feeding -dyspnea was relieved

-grade 2 bipedal pitting edema on both lower extremities Noted -body weakness

-keep bed linens from wrinkles -turn patient to sides

-edema not relieved, reports of pain on lower extremities

-give health teachings and demonstrate to patient/SO about importance of ROM exercises -place a no smoking sign in the room -Elevate the patients legs to increase venous return and decrease edema -encourage SO to help patient turn to sides regularly

April 15, 2011

-dyspnea

-continued O2 inhalation at 2-4 LPM -Prescribed diet: CHON, soft diet -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered -electrolyte levels assessed (Na and K)

-patient tried to remove NGT and complained of discomfort upon feeding -dyspnea was treated -edema not relieved, patient complained of decreased sensorium and pain on lower extremities

-grade 2 bipedal pitting edema on both lower extremities

-body 49

-patient

weakness

-prescribed diet: 1600 cal, Osteorized Feeding

April 16, 2011

-dyspnea

-continued O2 inhalation at 2-4 LPM -Prescribed diet: CHON -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered

-give health teachings and demonstrate to patient/SO about importance of ROM exercises -place a no smoking sign in the room -encouraged to turn to sides -provide health teachings to SO regarding meticulous skin care -health teachings given regarding proper application of TBS

tried to remove NGT and complained of discomfort upon feeding

-dyspnea was treated -edema not relieved, reports of pain on lower extremities

-grade 2 bipedal pitting edema on both lower extremities noted

-Fever of 38.9C

-fever was treated

-body weakness, 0 muscle strength

-prescribed diet: 1600 cal, Osteorized Feeding

-instruct SO to provide passive proper ROM exercises regularly

-muscle strength still O

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DISCHARGE PLAN MEDICATIONS:

Generic Name: Allopurinol Therapeutic Classification: Antigout drug Indication: Management of patients with malignancies that result in elevations of serum and urinary uric acid Dosage: 100 mg 1 tablet OD Drug Action: Inhibits the enzyme responsible for the conversion of purines to uric acid with a decrease in serum and sometimes in urinary uric acid levels, relieving the signs and symptoms of gout Side Effects and Adverse Reactions: Headache, drowsiness, nausea, vomiting, diarrhea Client Teaching: Administer following meals

Generic Name: Ciprofloxacin Therapeutic Classification: Antibacterial, Fluoroquinolone Indication: For the treatment of lower respiratory tract infection Dosage: 500 mg 1 tablet every 8 hours, via NGT Drug Action: Bactericidal; interferes with DNA replication in susceptible bacteria preventing cell reproduction Side Effects and Adverse Reactions: Headache, dizziness, nausea, vomiting, diarrhea Client Teachings: o o o Continue therapy for 2 days after signs and symptoms of infection are gone Ensure that patient is well hydrated Encourage patient to complete full course of therapy

Generic Name: Furosemide Therapeutic Classification: Loop Diuretic Indication: Edema associated with hepatocellular carcinoma Dosage: 20 mg tablet every 12 hours Drug Action: Inhibits reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodium-rich diuresis Side Effects and Adverse Reactions: Dizziness, vertigo, paresthesias, weakness, orthostatic hypotension
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Photosensitivity, pruritus, urticaria, nausea, vomiting, anorexia, constipation, diarrhea

Client Teachings: o o o Administer with food or milk to prevent GI upset Give early in the day so that increased urination will not disturb sleep Arrange for potassium-rich diet of supplemental potassium as needed Generic Name: Omeprazole Therapeutic Classification: Antisecretory Drug, Proton Pump Inhibitor Indication: Reduction of risk of upper GI bleeding in critically ill patients Dosage: 40 mg tablet OD secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production Side Effects and Adverse Reactions: Headache, dizziness, diarrhea, abdominal pain, nausea and vomiting Client Teachings: o o o EXERCISE:

Drug Action: Gastric acid-pump inhibitor: Suppresses gastric acid

Administer before meals Administer antacids with, if needed Instruct patient to report severe headache, worsening of symptoms, fevers, chills

Avoid strenuous exercises. Turn patient to sides regularly to prevent the development of pressure ulcers. Maintain bed rest. However, patient must be encouraged to do exercises which she can tolerate. Teach the significant others how to help patient perform passive ROM.

HEALTH TEACHINGS:

Instruct SO(s) to support patient in maintaining hygiene and good grooming. They must know how to properly support the patient upon dressing, toileting, and other basic activities. Meticulous skin care must be provided.

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Elevate both feet to promote venous return and to decrease edema. Keep bed linens free from wrinkles to avoid pressure ulcer development

Instruct SO to constantly monitor fever and teach SO how to properly apply tepid sponge bath Explain the disease process, causative factors, signs and symptom and treatment to the patient and significant others. Follow the prescribed dosage of the medication, how many times it should be taken, and the route of the medication. Return for follow up care and evaluation Encourage patient to take the prescribed medications every day. Teach client on avoiding stress or stress control and its importance. Teach patient to follow prescribed diet strictly. Teach SO how to feed the patient via NGT and how to prepare osteurized food. Encourage patient to have regular check up or when signs and symptoms re-occur. Encourage patient to communicate with the health care provider regarding his condition and therapy. Counseling or a support group can help in emotional condition Avoid strenuous activity, heavy lifting and vigorous exercise Teach patient to avoid alcoholic beverages Encourage family to help the patient cope with his recent condition. Teach non-pharmacological techniques ( massage, music therapy, guided imagery and relaxation )

OUT-PATIENT: Contact physician for the following problems:

Any unanswered questions and emotional support needs. Fever more than 40C or chills Allergic or other reactions to medication(s) Anxiety, depression, trouble sleeping Change in bowel or bladder habits. Indigestion or difficulty in swallowing. Eat a balanced, sodium-restricted diet of no more than 2,000 mg or 2 g of sodium a day. 1600 calories must be consumed per day Limit proteins and fluid intake.

DIET:

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SPIRITUAL CARE:

Encourage patient and significant others to pray together and to offer special prayers with the intention of asking enough

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