Ateneo de Davao University College of Nursing In Partial Fulfillment of the Requirements in Related Learning Experience A Case Study On RHABDOMYOSARCOMA

Submitted to: Ms. Honeylet P. Villanueva, RN, MN Clinical Instructor

Submitted by: Jan Mikhail Louise Paolo Frasco Jhon Bernand Hernandez Angeline Nicole Espino Patrick Antoni Derecho Klyde Louise Jarabelo Christine Jay Domingo Jenny Pearl Estuya Sheena Fe Danue Lawrence Calvo Patrick Calanoy

August 2011

Table of Contents I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. Acknowledgement Introduction Objectives Patients Data Genogram Family Background / Health History Developmental Data Physical Assessment Definition of Complete Diagnosis Anatomy and Physiology Etiology Symptomatology Pathophysiology Doctors Order Diagnostic Exam Drug Study 01 02 04 07 09 10 14 22 26 31 39 41 43 46 54 77 101 103 125 128 131 133

XVII. Nursing Theories XVIII. Nursing Care Plan XIX. XX. XXI. Prognosis Discharge Plan Recommendation

XXII. Reference

ACKNOWLEDGEMENT

The researchers wish to express their deepest gratitude and warmest appreciation to the following people, who, in any way have contributed and inspired the researchers to the overall success of the undertaking: To Mam. Li Derla for her guidance and support in the duration of the study. Mam Honeylet Villanueva for helping us and supporting us to find a case during our duty. to the NOD at SPMC house of hope for the

accommodation and pure hospitality. to our patient and his family, for their selfless cooperation and sharing their precious time. To our friends, who have been unselfishly extending their efforts and understanding. To our parents who have always been very understanding and supportive both financially and emotionally. And above all, to the Almighty God, who never cease in loving us and for the continued guidance and protection.

The Researchers

INTRODUCTION

Rhabdomyosarcoma is a malignant tumor that starts in muscle, its primarily a childhood tumor and occurs most often in children under 5 years of age. Over 60% of cases show up before age 10. On rare occasions, rhabdomyosarcoma affects adults. Rhabdomyosarcoma can begin anywhere there is muscle including the head and neck, arms and legs, genitourinary tract, and the trunk.

Treatment for rhabdomyosarcoma may involve surgery, radiotherapy or chemotherapy. Usually two or three of these modalities of treatment are employed. For example, a surgeon may first try to remove as much tumor as possible. Then the patient may undergo several weeks of chemotherapy, possibly followed by radiation therapy, and then more chemotherapy.

There are 2 main types of rhabdomyosarcomas. Embryonal rhabdomyosarcoma (ERMS) is the most common type of rhabdomyosarcoma. It usually affects infants and young children. The cells of ERMS look like the developing muscle cells of a 6- to 8-week-old embryo. ERMS tends to occur in the head and neck area, bladder, vagina, and in or around the prostate and testicles. Alveolar rhabdomyosarcoma (ARMS) typically affects older children or teenagers and occurs more often in large muscles of the trunk, arms, and legs. ARMS cells look like the normal muscle cells seen in a 10-week-old fetus. ARMS tends to grow faster than ERMS and usually requires more intensive treatment.

About 3% of all childhood cancers are rhabdomyosarcomas. About 350 new cases of rhabdomyosarcoma occur each year in the United States. The number of new cases has not changed much over the past few decades.http://www.cancer.org/Cancer/Rhabdomyosarcoma/DetailedGuide/rh abdomyosarcoma-key-statistics

We the researchers chose this case study because of the following reasons. First, the researcher identified the case as a chance to study and learn about the disease on why thus this illness increased globally. The researchers aimed that the readers will have greater insights and more understanding about this disease. And We also aim that this case study may become a tool in improving care and in developing new medical technology in relation to this disease. The researchers is aiming that this will help in improving the quality of care given to patients suffering Rhabdomyosarcoma

With this study, it will also contribute and help the people involved especially the nurse, by giving them enough knowledge to deal appropriately with this disease. It will also help to let the clients family understand the disease condition and give them information or knowledge on how to care for the client.

OBJECTIVES

A GENERAL: Within our 3 days shift 3-11 shift span of duty we will be able to formulate a comprehensive case study about, which could essentially be a way of identifying and presenting all the accompanying characteristics and information contained in the patients condition including its prospective management. This would also able our group to: B SPECIFIC Cognitive: Discuss in details Acute Pyelonephritis in Sepsis for our case study so as to gain insight and knowledge.

Gather necessary and pertinent data, concerning the client and family, as a baseline information about the ask data;

Determine the degree of development in order to point out certain problems or foreseeable crisis that would affect the maintenance of health of my patient;

Present the definition of complete diagnosis that would explain the illness of my client;

Discuss the Anatomy and Physiology of the affected system (Urinary, Immune, Lymphatic and Hematologic Systems) of the disease;

Present the Etiology and Symptomatology and trace the Pathophysiology of the disease with diagram;

Present the diagnostic examinations undergone by the patient and know it's clinical significance;

Present drug studies for all the medications prescribed by the physician administered to the patient such as; Cefuroxime, Domperidone, Paracetamol, Captopril, Ceftriaxone Sodium, Cefotaxime Sodium, Omeprazole, Eperisone, Tramadol and Diazepam.

List all the actual medical management for the patient and interpret;

Identify and Prioritize the need for our patient;

Evaluate prognosis for my client with proper justification.

AFFECTIVE: Have a purposeful interaction with the client as well as her significant other.

Establish rapport with our client and her family in order to gain cooperation and come up with a reliable information needed in this case study;

Be able to relate the patients disease with the different nursing theories specifically those of Florence Nightingale (Environmental Theory), Jean Watson (Human Caring Theory), Lydia Hall(Care Core Cure theory) and Dorothea Orems (Self- care theory).

Formulate a specific, measurable, attainable, realistic and time-bounded nursing care plan for the client

Provide health teachings to the client and the family

Outline recommendations based on the case studys findings

PSYCHOMOTOR:

Enhance the ability to identify and apply nursing interventions to provide a better care for the client with the said disease.

Conduct a cephalocaudal assessment to our patient in order to note any alterations or deviations from the normal physical structures;

Formulate an appropriate and realistic health teachings as part of the optimal and holistic care to achieve recovery;

Provide the patient and family with proper discharge planning (M.E.T.H.O.D.)

Patients Data Patients Name

: Patient J

Gender

: Male

Birthdate

: August 5, 1996

Birthplace

: Tagbilaran City, Bohol

Age

: 14 years old

Number of Siblings

:7

Ordinal Rank

: 5th Child

Address

: Quarry 1, Villaverde Tagbina Surigao del sur

Nationality

: Filipino

Civil Status

: Single

Occupation

: None

Religion

: Catholic

Denomination

: Roman Catholic

Educational Attainment

: Grade 5

Admitting Data

Date of Admission

: July 9, 2011

Time of Admission

: 07:01 am

Hospital

: Southern Philippines Medical Center

Ward

: Orthopedic Male ward [Bed 25]

Vital Signs upon Admission

Blood Pressure

90/60 mmHg

Pulse Rate

100 beats per minute

Respiratory Rate

17 cycles per minute

Temperature

36.5 degree Celsius

Weight

: 64 lbs

Height

: 54cm

Body Mass Index

: 1.1851852

Chief Complaint

: Mass Right Deltoid

Admitting Physician

: Dr. Chris George C. Pales

Admitting Diagnosis

: Right Arm Mass Probably Sarcoma

Complete Diagnosis

: Rhabdomyosarcoma, Right Shoulder : Patient and Patients chart and Patients Watcher

Source of Information

GENOGRAM

Paternal Side Maternal Side

PP OO

TT

SS

hjg Aa Bb Cc Dd Ee RR Ff Gg Hh Ii Jj QQ

Kk

Ll

Mm

PATIENT

Deceased

Rhabdomyosarcoma, @ Right Shoulder

Health History

Family Background

Patient J is the son of Mom QQ and Father RR. He was born on August 5, 1996 in Tagbilaran City, Bohol. He is a 14 year old male and the 5th child among the seven siblings. According to Patient J, their grandparents in the paternal side died due to old age and not of any kind of disease. In the maternal side his grandparents are still alive and they were not diagnosed of any sort of disease. His father who was 54 years old died by committing suicide due to financial problem. His 47 year old mother is still alive and not diagnosed of any sort of disease. Patient J studied at Villaverde Elementary School. He loves to play with his friends and classmates and watch television. He sometimes goes to the nearest river and play once a week and every weekend he sometimes goes to terraces where his mother works there as a peasant and helps her throughout the day. In terms of familial relationship, Patient J is playful, funny and sometimes hardheaded just like the other kids. He usually gets along with his friends and classmates. He does not have any experience of having conflicts with anyone of them. He usually wakes up at 6:00 am to prepare for his morning class. With regards to their health condition Ms. QQ takes part in making decision. In terms of economic status, they belong to the lower class. His Mother is a housewife. Aside from being a housewife she also works parttime as a peasant at Surigao Del sur. His brother A is also contributing in giving extra money to their mother. According to his brother, this helps in their daily expenses. Their estimated monthly income is 2000 pesos. Their monthly electricity bill is 400 pesos and their water bill is free because they use safety tank where the rain drops are filtered. According to his brother they have not gotten any disease from that tank. The school expenses are 1000 pesos annually for each child in a public school. Patient J and most of his siblings are not engage in any kind of vices except the 2nd brother who is Mr. B. Mr. B is a smoker. He smokes Philip

Morris and Hope and consumes more or less 3 sticks per day. Mr. A usually gives his brother B advice regarding smoking. He wants him to stop because it is dangerous to ones health.

Clients Lifestyle, Diet, and Activities of daily Living (ADL) Patient Js typical day starts with preparing himself and go to school. During his free time, he watches television like cartoons and anime; he always plays with his friends and classmates a tumba lata, takyan and going to the river etc. His diet is mainly fish such as galong-gong, tulingan, bangus and sari-sari, vegetables that can be bought in the wet market and those that they planted at their backyard themselves. He was able to have at least three meals a day. During breakfast, lunch and dinner he eats fish and vegetables and sometimes with a glass of milk. Patient J said that he doesnt have any usual routines for exercise but he considered his playtime as exercise. He always wakes up early in the morning even during the weekends. He sleeps at around 9:00 pm and wakes up at around 6:00 am. Every Sunday his family goes to church to attend mass.

History of Past Illness

Patient J was born via Normal Spontaneous Vaginal Delivery at Tagbilaran City, Bohol. According to his mother there were no complications or abnormalities noted upon delivery. He said that he had a chicken pox at the age of 3 and according to his mother she had him immunized and completed it. He also experienced headache, fever and cough but able to manage these through taking over-the-counter drugs such as Biogesic, Neozep, and Tuseran. According to Patient J, in January 2011, he noticed a painful tiny mass on his right arm. Then, he and his mother decided to go to the Barangay

Health Center and a nurse adviced him to take antibiotic and analgesic which is amoxicillin and mefenamic acid. After 1 month the tiny mass was gone.

History of Present Illness

However, on April 2011 the painful mass on his right arm came back. Patient J just decided to take the antibiotic and analgesic again rather than consulting a doctor because they dont have enough money to pay for the consultation fee. However, it came to the point that the tiny mass gone bigger and painful. This time he was very eager to consult a doctor. When he finally met the doctor he was recommended to undergo an operation to remove the mass on his deltoid. On August 5, 2011 he had his amputation at Southern Philippines Medical Center and was then admitted in Orthopedic Ward in the same hospital and on September 1, 2011 where he had his Skin graft. Upon admission, his vital signs were as follows: Blood Pressure = 90/60 mmHg, Temperature =36.5 degree Celsius, Respiratory rate = 17 cycles per minute and Pulse rate = 100 beats per minute.

Effects/ Expectations of Illness to Self/ Family

Patient J and his family are very religious and active to attend mass. His current condition does have a great impact within their family. His Mother, siblings and other relatives are there to support here emotionally and financially. Even though they are tight on the budget, they still submit the patient for better treatment and never lose hope for Patient J to be in good health.

Medication

Indication as known by the patient

Dosage

Prescribing health care provider

Biogesic

For fever and for headache

250mg t.i.d

Neozep Tuseran Amoxicillin

For colds For cough To treat and prevent infections

250mg t.i.d 250mg t.i.d 500mg t.i.d Nurse

Mefenamic Acid

Pain Reliever

500mg prn

Nurse

Medication Reconciliation

Review of Systems

Prior to admission the patient complains pain at his right arm with a pain scale of 7 out of 10. According to patient J it was painful and uncomfortable. His vital signs upon admission are as follows. : Blood Pressure = 90/60 mmHg, Temperature =36.5 degree Celsius, Respiratory rate = 17 cycles per minute and Pulse rate = 100 beats per minute.

DEVELOPMENTAL DATA Developmental data contains records and analysis of an increase or stagnancy in the complexity of function and skill progression. It manifests the persons capability and skills in adapting to a dynamic environment. It begins in infancy stage and ends in the old age stage while attaining intelligence, developing problem-solving ability and coping and adapting to the environment in all aspects. Development is the behavioral aspect of growth such as persons ability to walk, talk, run and even feelings of sensation and emotion. It proceeds from simple to complex such as from single acts to integrated ones. In attempt to analyze a persons developmental data a developmental delay is monitored. A developmental delay is any significant lag in a child's physical, cognitive, behavioral, emotional, or social development, in comparison with norms.

Eriksons Stages of Psychosocial Development Erik Erikson, Eriksons stages of psychosocial development describe eight stages through which a healthy developing human should surpass from infancy to late adulthood. In each stage, a person faces and hopefully masters new challenges. These challenges may come back as problems in the future if these are not successfully completed from each stage. Stage fidelity - Identity vs. Role Confusion Description Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role Result unachieved Justification Patient J has not successfully achieved this stage because he is in constant confusion on what will be his role in the society. He is still

confusion and a weak sense of self.

dependent on his older siblings and mother emotionally.

Havighursts Developmental Task Havighurst (1972) defines a developmental tasks as one that arises at a certain period in our lives, the successful achievement of which leads to happiness and success with later tasks; while leads to unhappiness, social disapproval, and difficulty with later tasks He identifies three sources of developmental tasks (Havighurst, 1972). o Tasks that arise from physical maturation o Tasks that arise from personal values o Tasks that have their source in the pressures of society

Havighurst also identified Six Major Stages in human life covering birth to old age which are the following:

Infancy & early childhood (Birth till 6 years old) Middle childhood (6-12 years old) Adolescence (13-18 years old) Early Adulthood (19-30 years old) Middle Age (30-60years old) Later maturity (60 years old and over) Our client belongs to the 3rd stage which is the adolescence, Tasks

that arise from personal values: Choosing an occupation, socializing with same age group, figuring out ones philosophical outlook. The following are the developmental task that a adolescence adult must fulfill or achieve:

DEVELOPMENTAL

ACHIEVED OR NOT

JUSTIFICATION

TASK Achieving new and more mature age sexes. relations of with both

ACHIEVED Achieved Patient J was able to

achieve this. He was active with interacting with his

mates

classmates at school.

Achieving a masculine or feminine social role.

Achieved

He was able to achieve it since he is willing to help his mother on the farm. He

accepts the responsibility of being a male in his family by helping his younger siblings and Accepting ones helps with the

maintenance of the house. Achieved Patient J achieved this since he has already accepted that his arm is amputated. He was able to adapt with his present condition by

physique and using the body effectively

doing alternative measures in his ADLs. Achieving independence emotional from Achieved Patient J achieved this since he has emotional stability in his present condition and does not depend on his mother. Achieving assurance of economic independence and selecting and Unachieved Patient J has not achieved this since he only finished 5th grade and with his present condition he will have a hard time landing a job.

parents and other adults.

preparing for occupation

Preparing for marriage

Unachieved

Patient J has not achieved

and family life.

this since he is still not financially capable of

supporting a family. He says he is not thinking of

marriage as of the moment. Developing skills and intellectual concepts for civic Unachieved Patient J has not achieved it since he only finished 5th grade. With his present requires

necessary competence;

condition

which

admittance in the hospital and financial situation, he

was not able to develop the skills necessary for civic competence. Desiring and achieving socially behavior. responsible Achieved Patient J was able to

achieve this since he has the desire to be responsible and help in little ways in the family prior to his sickness like helping in farm and babysitting siblings. his younger

Acquiring a set of values and an ethical system as a guide to behavior

Achieved

Patient

was

able

to

achieve this since he was taught by his mother and older siblings good conduct. He says he follows the rules set by his mother in the house.

Kohlberg's Stages of Moral Development This theory specifically addresses moral development in children and adults. The morality of an individuals decision was not Kohlbergs concern; rather, he focused on the reasons an individual makes a decision. Stage Conventional Stage (Law and Order Orientation) Description Result Justification In this stage of Kohlberg's Moral Development theory, it is a must for the client to pursue the laws in order to continue a good functioning in the society as a good citizen. Patient J also expressed that as a member of this society, one must follow rules or else your gonna be punished. Because of his young age, he was not able to expound his ideas regarding the

The conventional level of ACHIEVED moral reasoning is typical of adolescents and adults.

In this stage, it is important to obey laws, dictums and social conventions because of their importance a in

maintaining

functioning

society. Right is being good, with the values and norms of family and society at large. The self enters society by filling social roles; therefore society must learn to

questions. Patient J was raised by his mother with the proper values that is acceptable in our society. He believes that there is order if one follows the rules as he gives anologies in their

transcend individual needs. A central ideal or ideals often prescribe what is right and wrong, such as in the case of fundamentalism. If one person violates a law,

household.

perhaps everyone would thus there is an obligation and a duty to uphold laws and rules. When someone does violate a law, it is morally responsibility is wrong; thus a

significant factor in this stage as it separates the bad domains from the good

ones. Most active members of society remain at stage four, where morality is still predominantly dictated by an outside force

DEFINITION OF COMPLETE DIAGNOSIS (Rhabdomyosarcoma, Right Shoulder)

Rhabdomyosarcoma (rabdo-mi-o-sark-komah) A malignant neoplasm derived from skeletal (striated) muscle; characterized in adults by poorly differentiated oblong, as well as rounded and bizarre, cells with large hyperchromatic nuclei; the cytoplasm is usually granular and structures that resemble cross striations may be observed. Illustrated stedmans medical dictionary 24th edition,1982. P. 1230. USA: Williams and wilkins. a sarcoma containing striated muscle fibers

DORLAND'S ILLUSTRATED MEDICAL DICTIONARY. 23RD EDITION.: L., Et al. (eds.) Brainerd

Rhabdomyosarcoma is a fast-growing, highly malignant tumor which accounts for over half of the soft tissue sarcomas in children. Less frequently, other soft tissue sarcomas are found in children: fibrosarcoma, mesenchymoma, synovial sarcoma, and liposarcoma.z` Blakistons new gould medical dictionary 8th edition page 1024 USA RIGHT Toward or on the right. Daniels, R., Nosek, L., Nicoll, L. Contemporary Medical Surgical Nursing. 2007. p. 1780. USA: Thomas Delmar Learning.

the condition of having the right side distinct or different from the left. Tamparo, Carol. Diseases of The Human Body. (2005) Davis Company. ISBN: 0-8036-1245-1. location near or direction toward the right side Late, P. (2009). Seeleys Principle of Anatomy and Physiology. (p. 616) McGraw Hill; New York, NY 10020

Shoulder

The lateral portion of the scapular region, where the scapula joins with the clavicle and humerus and is covered by the rounded mass of the deltoid muscle.

Illustrated stedmans medical dictionary 24th edition,1982. P. 1282. USA: Williams and wilkins.

The part of the body between the neck and the upper arm Dorlands illustrated medical dictionary 23rd edition p. 1184 press of W.B. sanders company USA

The region where the arm joins the trunk formed by the meeting of the clavicle and scapula and the overlying soft parts. Blakistons new gould medical dictionary 8th edition page 929 USA

Rhabdomyosarcoma, Right Shoulder

A rhabdomyosarcoma is a type of cancer, specifically a sarcoma (cancer of connective tissues), in which the cancer cells are thought to arise from skeletal muscle progenitors. It can also be found attached to muscle tissue, wrapped around intestines, or in any anatomic location. Most occur in areas naturally lacking in skeletal muscle, such as the head, neck, and genitourinary tract. Rhabdomyosarcoma is a relatively rare form of cancer.

PHYSICAL ASSESSMENT Date of Assessment: 15 Sept. 2010 Time of Assessment: 7:00 pm during Physical Assessment

Vital Signs Blood Pressure Pulse rate Respiratory rate Temperature

Results 80/50 mmHg 84 BpM 32 CpM 37.7 degrees Celsius

General Survey Received lying on bed, at supine position, awake, conscious, coherent, alert, & oriented. He has wounds at right thigh (3) & right shoulder (1). Appears thin, height of 48, weight of 64 lbs., relaxed, bent posture, unsteady gait; coordinated movement, dominantly uses left foot in standing, able to sits up straight, and walks at moderate speed, clean, unkempt appearance, presence of purulent wound odor, withdrawn, able to follow instructions, affect is appropriate to situation, speech is understandable, moderate pace; clear tone & inflection; exhibits thought association, relevance & organization of thought has relevant s sequence; makes sense; has sense of reality. BMI=14.3 Integument Nails Convex curvature; angle of nail plate about 160 degrees, smooth texture, highly vascular & pink, intact epidermis, prompt return of pink or usual color. Hair Evenly distributed, thin, silk, resilient, no infection or infestation, variable amount. Skin Color is light brown, generally uniform except in areas exposed to the sun, no edema, wound size at right shoulder is 12 x 6 4 mm deep at most, wounds sizes at thigh are 1 x 1; 4 x 2; 4 x 4; itchy, 2 mm deep at most, uniform temperature; within normal range, when pinched then skin springs back to previous state. Head Skull & Face Rounded (normocephalic and symmetric with frontal, parietal, and occipital prominences); smooth skull contour, smooth uniform consistency; absence of nodules or masses, almost symmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds, symmetric facial movements. Eye structures & visual acuity Visual acuity

Able to read newsprint Extraocular Muscle Tests Light falls symmetrically on both pupils, uncovered eye does not move on cover test Visual Fields When looking straight ahead, client can see objects in the periphery, both eyes coordinated, move in unison, with parallel alignment External Eye Structures Eyebrows hair evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement, equally distributed eyelashes; curled slightly outward, eyelid skin is intact; no discharge; no discoloration, lids close symmetrically, approximately 15 to 20 involuntary blinks per minute; bilateral blinking, when lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered, Transparent bulbar conjunctiva; capillaries sometimes evident; sclera appears white, shiny, smooth, and pink palpebral conjunctiva, no edema or tenderness over 3 mm in diameter; round, smooth border, iris flat & round lacrimal gland, no edema or tearing on the lacrimal sacs & nasolacrimal ducts, transparent, shiny, & smooth cornea; details of the iris are visible, client blinks when the cornea is touched, transparent anterior chamber, no shadows of light on iris, depth of about 3 mm, pupils are black in color; equal size, 3 mm in diameter; round, smooth border, iris flat & round, illuminated pupil constricts (direct response), nonilluminated pupil constricts (consensual response), Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose. Ears & Hearing Gross Hearing Acuity Tests Normal voice tones audible, able to hear ticking in both ears. External Ear Canal and Tympanic Membrane Distal third contains glands, dry cerumen, and tan color, tympanic membrane has pearly gray color, semitransparent. Auricles Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye; about 10 degrees from vertical, mobile, firm, & not tender; pinna recoils after it is folded.

Nose & Sinuses Nose Symmetric & straight, no discharge, uniform color, not tender; no lesions, air move freely as the client breathes through the nares, mucosa pink, clear, watery discharge, no lesions, nasal septum intact & in midline. Facial Sinuses Not tender Mouth & Oropharynx Lips & Buccal Mucosa Outer lips has a uniform pink color, soft, moist, smooth texture, symmetry of contour, able to purse lips, inner lips & buccal mucosa has uniform pink color, moist, smooth, glistening, & elastic texture Teeth & Gums 30 teeth, white, stained tooth enamel, pink gums, no retraction of gums. Tongue/Floor of the Mouth Tongue is at the center, pink color, smooth lateral margins; no lesions, raised papillae, moves freely; no tenderness, tongue base has prominent veins Salivary Glands Same as color of buccal mucosa & floor of mouth Palates & Uvula Soft palate is light pink, lighter pink hard palate, more irregular texture, uvula is positioned in midline of soft palate Oropharynx & Tonsils Pink & smooth posterior wall, pink & smooth tonsils, no discharge, of normal size: Grade 1 (normal), present gag reflex. Neck Neck Muscles

Muscle equal in size; head centered, head movement is coordinated, smooth movements with no discomfort, head flexes 45 degrees, hyperextends 60 degrees, laterally flexes 40 degrees, laterally rotates 70 degrees, muscle strength is equal when turning head, equal when shrugging shoulders Lypmh Nodes Not palpable Trachea Centrally placed in the midline of neck; space are equal on both sides Thyroid Gland Not visible on inspection, gland ascends during swallowing but is not visible, lobes cannot be palpated, absence of bruit. Chest, Lungs and Axilla Thorax & Lungs Anterior Thorax Quiet, rhythmic, & effortless respirations, costal angle is less than 90 degrees & the ribs insert into the spine at approximately 45 degrees angle, vocal fremitus is the same as posterior thorax; vocal fremitus decreased over heart & breast tissue, percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas bone, dull on areas over the heart & the liver, & tympanic over the underlying stomach, bronchial and tubular breath sounds are heard on the trachea, bronchovesicular & vesicular breath sounds are heard on the bronchi between over the sternum and the clavicles Cardiovascular & Peripheral Vascular Systems Heart & Central Vessels No pulsations in the aortic & pulmonic areas, no pulsations; lift in the tricuspid area, no lift or heave in the apical area, aortic pulsations at the epigastric area, S1: heard at all sites, S2: heard at all sites, systole: silent interval; slightly shorter duration than diastole, diastole: silent interval; slightly longer duration than systole Carotid Arteries

Symmetric pulse volume, full pulsations, thrusting quality, quality remains the same when client breathes, turns head, & changes from sitting to supine position, elastic arterial wall, no sound heard on auscultation Jugular Veins Veins not visible Peripheral Vascular System Symmetric pulse volumes, full pulsations, Peripheral Veins Symmetric pulse volumes, full pulsations Peripheral Veins Limbs not tender, symmetric in size Peripheral Perfusion Skin color pink, skin temperature not excessively warm or cold, no edema. Buergers Test Original color returns in 10 sec.; veins in feet or hands fill in about 15 sec. Capillary Refill Test Immediate return of color=< 2 sec. Breast & Axillae Flat, muscles not yet developed, skin uniform in color, smooth & intact, areola are oval & bilaterally the same, dark brown, nipples are round, everted, equal in size; similar in color; both point in the same direction, no discharge, axillary, subclavicular, supraclavicular lymph nodes are not tender, no masses, breast has no masses, tenderness, nodules, discharge Abdomen Inspection Unblemished skin, uniform color, flat, no evidence of enlargement of liver or spleen, symmetric contour, symmetric movements caused by respiration, no visible vascular pattern Auscultation

Absence of friction rub, Audible bowel sounds, Absence of arterial bruits Percussion Tympany over the stomach; dullness especially over the liver & spleen Percussion of the Liver 2.5 in the mid-clavicular line; 1.5 at the midsternal line Palpation No tenderness; relaxed abdomen with smooth, consistent tension Palpation of the Liver Not palpable Palpation of the bladder Not palpable Genito-Urinary Pubic Hair Pt. denies assessment & does not answer directly. Penis Pt. denies assessment but states that there is no problem & he is circumcised. Scrotum Pt. denies assessment but states that there is no problem. Inguinal Area Pt. denies assessment but states that there is no problem. Rectum & Anus Pt. denies assessment but states that there is no problem. Back Posterior Thorax

Anteroposterior to transverse diameter in ratio of 1:2, chest symmetric, spine vertically aligned, spinal column is straight, right & left shoulders & hips are at same height, skin intact, uniform temperature, chest wall intact, Full and symmetric chest expansion, bilateral symmetry of vocal fremitus, fremitus is heard most clearly at the apex of the lungs, Percussion notes resonates; except over left scapula, Lowest point of resonance is at the diaphragm, percussion on a rib elicits dullness, vesicular & bronchovesicular breath sounds present. Upper extremities Muscles No contractures, no tremors, normally firm, smooth coordinated movements, equal strength on each body side, no right arm muscles. Bones No right scapula, no tenderness, no radius, no ulna, no humerus. Joints No swelling, no tenderness, no crepitating sounds, no nodules, joints move smoothly, normal range of motion Lower Extremities Muscles No contractures, no tremors, normally firm, smooth coordinated movements, equal strength on each body side. Bones No tenderness, no deformities. Joints No swelling, no tenderness, no crepitating sounds, no nodules, joints move smoothly, normal range of motion.

Anatomy & Physiology

I.

Upper limb

Front of right upper extremity.

Back of right upper extremity.

Latin:

Membrum Superius

Gray's: System: MeSH:

subject #289 1325 Musculoskeletal Extremity Upper Extremity

A. The upper limb or upper extremity is the region extending from the deltoid region to the hand, including the arm, axilla and shoulder. B. Anatomy 1. The muscles of the upper limb can be classified by origin, topography, function, or innervation. While a grouping by innervation reveals embryological and phylogenetic origins, the functional-topographical classification below reflects the similarity in action between muscles (with the exception of the shoulder girdle, where muscles with similar action can vary considerably in their location and orientation. 2. Musculoskeletal system a) Shoulder girdle

(1)

Bones of the shoulder girdle (i) The shoulder girdle or pectoral girdle, composed of the clavicle and the scapula, connects the upper limb to the axial skeleton through

the sternoclavicular joint (the only joint in the upper limb that directly articulates with the trunk), a ball and socket joint supported by the subclavius muscle which acts as a dynamic ligament. While this muscle prevents dislocation in the joint, strong forces tend to break the clavicle instead. The acromioclavicular joint, the joint between the acromion process on the scapula and the clavicle, is similarly strengthened by strong ligaments, especially the coracoclavicular ligament which prevents excessive lateral and medial movements. Between them these two joints allow a wide range of movements for the shoulder girdle, much because of the lack of a bone-to-bone contact between the scapula and the thoracic cage. The pelvic girdle is, in contrast, firmly fixed to the axial skeleton, which increases stability and loadbearing capabilities. (ii) The mobility of the shoulder girdle is supported by a large number of muscles. The most important of these are muscular sheets rather than fusiform or strapshaped muscles and they thus never act in isolation but with some fibres acting in coordination with fibres in other muscles.

(2) Muscles of shoulder girdle excluding the glenohumeral joint (a) Migrated from head (i) Trapezius, sternocleidomasto ideus, omohyoideus (b) Posterior (i) Rhomboideus major, rhomboideus minor, levator scapulae

b)

Anterior (i) Subclavius, pectoralis minor, serratus anterior Shoulder joint

(c)

(1)

Shoulder joint with ligaments

(2) The glenohumeral joint (colloquially called the shoulder joint) is the highly mobile ball and socket joint between the glenoid cavity of the scapula and the head of the humerus. Lacking the passive stabilisation offered by ligaments in other joints, the glenohumeral joint is actively stabilised by the rotator cuff, a group of short muscles

stretching from the scapula to the humerus. Little inferior support is available to the joint and dislocation of the shoulder almost exclusively occurs in this direction. (3) The large muscles acting at this joint perform multiple actions and seemingly simple movements are often the result of composite antagonist and protagonist actions from several muscles. For example, pectoralis major is the most important arm flexor and latissimus dorsi the most important extensor at the glenohumeral joint, but, acting together, these two muscles cancel each other's action leaving only their combined medial rotation component. On the other hand, to achieve pure flexion at the joint the deltoid and supraspinatus must cancel the adduction component and the teres minor and infraspinatus the medial rotation component of pectoralis major. Similarly, abduction (moving the arm away from the body) is performed by different muscles at different stages. The first 10 is performed entirely by the supraspinatus, but beyond that fibres of the much stronger pectoralis major are in position to take over the work. Furthermore, to achieve the full 180 range of abduction the arm must be rotated medially and the scapula must be rotate about itself to direct the glenoid cavity upward. c) Muscles of shoulder joint proper (1) Posterior (a) Supraspinatus, infraspinatus, teres minor, subscapularis, deltoideus, latissimu s dorsi, teres major (2) Anterior (a) Pectoralis major, coracobrachialis

d)

Arm

(1) (a) Superficial muscles of the arm

(2) The arm proper (brachium), the region between the shoulder and the elbow, is composed of the humerus with the elbow joint at its distal end. (3) The elbow joint is a complex of three joints (a) The humeroradial, humeroulnar, and superior radioulnar joints (i) The former two allowing flexion and extension whilst the latter, together with its inferior namesake, allows supination and pronation at the wrist. Triceps is the major extensor and brachialis and biceps the major flexors. Biceps is, however, the major pronator and while performing this action it ceases to be an effective flexor at the elbow. Muscles of the arm

(4)

(a) (b) e) Forearm

Posterior (i) Triceps brachii, anconeus Anterior (i) Brachialis, biceps brachii

(1)

Ventral superficial muscles of the forearm (a) The forearm (antebrachium) composed of the radius and ulna; the latter is the main distal part of the elbow joint, while the former composes the main proximal part of the wrist joint.

(2) Most of the large number of muscles in the forearm are divided into the wrist, hand, and finger extensors on the dorsal side (back of hand) and the ditto flexors in the superficial layers on the ventral side (side of palm). (a) These muscles are attached to either the lateral or medial epicondyle of the humerus. They thus act on the elbow,

but, because their origins are located close to the centre of rotation of the elbow, they mainly act distally at the wrist and hand. Exceptions to this simple division are (i) brachioradialis (a) (ii) a strong elbow flexor

palmaris longus (a) A weak wrist flexor which mainly acts to tense the palmar aponeurosis. The deeper flexor muscles are extrinsic hand muscles; strong flexors at the finger joints used to produce the important power grip of the hand, whilst forced extension is less useful and the corresponding extensor thus are much weaker.

(b) Biceps is the major supinator (drive a screw in with the right arm) and (c) pronator teres and pronator quadratus the major pronators (unscrewing) (i) The latter two role the radius around the ulna (hence the name of the first bone) and the former reverses this action assisted by supinator. Because biceps is much stronger than its opponents, supination is a stronger action than pronation (hence the direction of screws). (3) Muscles of the forearm

(a)

Posterior (i) (Superficial) extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, (deep) supinator, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis Anterior (i) (Superficial) pronator teres, flexor digitorum superficialis, flexor carpi radialis, flexor carpi ulnaris, palmaris longus, (deep) flexor digitorum profundus, flexor pollicis longus, pronator quadratus Radial (i) Brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis

(b)

(c)

f)

Wrist (1) The wrist (carpus), composed of the carpal bones, articulates at the wrist joint (or radiocarpal joint) proximally and the carpometacarpal joint distally. The wrist can be divided into two components separated by the midcarpal joints. The small movements of the eight carpal bones during composite movements at the wrist are complex to describe, but flexion mainly occurs in the midcarpal joint whilst extension mainly occurs in the radiocarpal joint; the latter joint also providing most of adduction and abduction at the wrist. (2) How muscles act on the wrist is complex to describe. The five muscles acting on the wrist directly

(a)

flexor carpi radialis, flexor carpi

ulnaris, extensor carpi radialis, extensor carpi ulnaris, and palmaris longus (b) Are accompanied by the tendons of the extrinsic hand muscles (i.e. the muscles acting on the fingers). Thus, every movement at the wrist is the work of a group of muscles; because the four primary wrist muscles (FCR, FCU, ECR, and ECU) are attached to the four corners of the wrist, they also produce a secondary movement (i.e. ulnar or radial deviation). To produce pure flexion or extension at the wrist, these muscles therefore must act in pairs to cancel out each others secondary action. On the other hand, finger movements without the corresponding wrist movements require the wrist muscles to cancel out the contribution from the extrinsic hand muscles at the wrist. g) Hand

h)

(1)

Bones of the hand (a) The hand (manus), the metacarpals (in the hand proper) and the phalanges of the fingers, form the metacarpophalangeal joints (MCP, including the knuckles) and interphalangeal joints (IP). (b) Of the joints between the carpus and metacarpus, the carpometacarpal joints, only the saddle-shaped joint of the thumb offers a high degree of mobility while the opposite is true for the metacarpophalangeal joints. The joints of the fingers are simple hinge joints. (c) The primary role of the hand itself is grasping and manipulation; tasks for which the hand has been adapted to two main grips power grip and precision grip. In a power grip an object is held against the palm and in a precision grip an object is held with the fingers, both grips are performed by intrinsic and extrinsic hand muscles together. Most importantly, the relatively strong thenar muscles of the thumb and the thumb's flexible first joint allow the special opposition movement that brings the distal thumb pad in direct contact with the distal pads of the other four digits. Opposition is a complex combination of thumb flexion and abduction that also requires the thumb to be rotated 90 about its own axis. Without this complex movement, humans would not be able to perform a precision grip.

(d)

In addition, the central groups of

intrinsic hand muscles give important contributions to human dexterity. The palmar and dorsal interossei abduct and adduct at the MCP joints and are important in pinching. The lumbricals, attached to the tendons of the flexor digitorum profundus (FDP) and extensor digitorum communis (FDC), flex the MCP joints while extending the IP joints and allow a smooth transfer of forces between these two muscles while extending and flexing the fingers. (e) Muscles of the hand (i) Metacarpal (a) Lumbricals, dorsal interossei, palmar introssei Thenar (a) Abductor pollicis brevis, adductor pollicis, flexor pollicis brevis, opponens pollicis Hypothenar (a) Abductor digiti minimi, flexor digiti minimi, opponens digiti minimi, palmaris brevis

(ii)

(iii)

3. a)

Neurovascular system Innervation

(1)

Branches of brachial plexus

(2) The motor and sensory supply of the upper limb is provided by the brachial plexus which is formed by the ventral rami of spinal nerves C5T1. In the posterior triangle of the neck these rami form three trunks from which fibers enter the axilla region (armpit) to innervate the muscles of the anterior and posterior compartments of the limb. In the axilla, cords are formed to split into branches, including the five terminal branches listed below. The muscles of the upper limb are innervated segmentally proximal to distal so that the proximal muscles are innervated by higher segments (C5C6) and the distal muscles are innervated by lower segments (C8T1). (3) Motor innervation of upper limb by the five terminal nerves of the brachial plexus: (a) The musculocutaneous nerve innervates all the muscles of the anterior compartment of the arm.

(b)

The median nerve innervates all the

muscles of the anterior compartment of the forearm except flexor carpi ulnaris and the ulnar part of the flexor digitorum profundus. It also innervates the three thenar muscles and the first and second lumbricals. (c) The ulnar nerve innervates the muscles of the forearm and hand not innervated by the median nerve. (d) The axillary nerve innervates the deltoid and teres minor. (e) The radial nerve innervates the posterior muscles of the arm and forearm (4) Collateral branches of the brachial plexus: (a) The dorsal scapular nerve innervates rhomboid major and minor. (b) The long thoracic nerve innervates serratus anterior. (c) The suprascapular nerve innervates supraspinatus and infrasp inatus (d) The lateral pectoral nerve innervates pectoralis major (e) The medial pectoral nerve innervates pectoralis major and minor (f) The upper subscapular nerve innervates subscapularis (g) The thoracodorsal nerve innervates latissimus dorsi (h) The lower subscapular nerve innervates subscapularis and teres major (i) The medial brachial cutaneous nerve innervates the skin of medial arm

(j) The medial antebrachial cutaneous nerve innervates the skin of medial forearm II. Prokaryotic cells

A.

Diagram of a typical prokaryotic cell

B. Nuclear material of prokaryotic cell consists of a single chromosome that is in direct contact with cytoplasm. Here, the undefined nuclear region in the cytoplasm is called nucleoid. A prokaryotic cell has three architectural regions: 1. On the outside a) flagella (1) A tail-like projection that protrudes from the cell body and functions in locomotion. b) and pili (1) Pili connect a bacterium to another of its species, or to another bacterium of a different species, and build a bridge between the interior of

the cells. This enables the transfer of plasmids between the bacteria. c) Project from the cell's surface. These are structures (not present in all prokaryotes) made of proteins that facilitate movement and communication between cells; 2. Enclosing the cell is the cell envelope

a)

covering a plasma membrane (1) The protective envelope that separates the inside of the cell from its surroundings. It contains specialized receptors that detect chemical messages, as well as pumps and pores that regulate the flow of substances into and out of the cell. The membrane also anchors the cells to the surrounding tissues and links adjacent cells at specialized junctions, to form tissues

b) The envelope gives rigidity to the cell and separates the interior of the cell from its environment, serving as a protective filter. 3. Inside the cell is the cytoplasmic region a) A transparent, gel-like region outside the nucleus, in which the organelles are suspended b) that contains (1) The cell genome (DNA) and ribosomes and various sorts of inclusions... (2) Though not forming a nucleus, the DNA is condensed in a nucleoid. (3) Prokaryotes can carry extrachromosomal DNA elements called plasmids, which are usually circular. (a) Plasmids enable additional functions, such as antibiotic resistance. (4) Microfilaments (a) Fine thread-like fibers made from a protein called actin. These form part of the cells internal skeleton, allowing the cell to change shape and move by rolling or crawling along a surface Centrioles (a) Are small cylinders, at right angles to one another, made up of nine sets of microtubules. They are involved in the formation and elongation of the cells microtubules, Lysosomes

(5)

(6)

(a)

Small vesicles containing that

(7)

powerful acids and enzymes that breakdown worn-out organelles, and digest bacteria and foreign substances taken up by the cell. Golgi Apparatus (a) The cells processing & transport area. It stores, sorts and modifies products made within the cell, and transports them to other organelles or to the cell surface in vesicles. Most cells need only one Golgi apparatus, but some have more Peroxisome (a) Small vesicles that detoxify alcohol, hydrogen peroxide and other toxins that may be present within a cell.

(8)

(9)

Rough Endoplasmic Reticulum (a) An internal network of flattened sacs, studded with ribosomes, which is involved in packaging proteins

(10)

Mitochondria (a) Batteries of a cell. They use oxygen, glucose and fatty acids to release energy plus waste carbon dioxide gas. It contains its own genetic material, and is believed to have evolved from symbiotic bacteria that combine with single-celled organisms at the dawn of life on earth.

(11)

Ribosomes (a) Small units that assemble the amino acid chains that form proteins. Some ribosomes move freely within the cytoplasm, while others are attached to the rough endoplasmic reticulum, which

funnels newly formed proteins to the Golgi apparatus. (12) Smooth Endoplasmic Reticulum (a) An internal network of branching tubes involved in the production of fatty acids, steroids and the storage and release of Ca. (13) Microtubules (a) Hollow tubes, made from a protein

called tubulin, which form part of the cells internal skeleton, maintaining its shape and assisting with cell division, movement of organelles within the cell and transport of vesicles (14) The nucleus is separated from the rest of the cell by the nuclear envelope. (i) The membrane that separates the nucleus from the rest of the cell. Chemicals can move to and from the nucleus to the cytoplasm via holes in the envelope known as nuclear pores (b) Nucleus (i) The largest organelle. It is the cells control centre and contains the chromosomes. (a) A circular molecule

(ii) Most cells have only one nucleus, a few specialized skeletal muscle cells have several nuclei and mature red blood cells and the clear cells found in the crystalline lens of the eye have none.

III.

DNA

A. B. Contains a humans full genetic blueprint stored as 1. Chromosomes a) There are 23 pairs. One of each pair was inherited from an individuals mother, the other from the father. 44 of these chromosomes contain genes

(1) (2) That provides the code for proteins involved in the structure & function of every cell. (3) The stretch of DNA that provides all the coding needed to make a single protein. Scientists from around the world have collaborated in the human Genome Project to decode the sequence of genes that make up a human being. They have determined that each own about 40,000 genes-a figure originally thought to be considerably higher. (4) The genes within every cell in a person are identical, but, depending on the type of cell, different genes are switched on and off, so the cell can make the particular proteins it requires. That is why liver cells, muscle cells, skin cells & fat cells are all so different from 1 another. (5) Each gene exists in many different forms within the population, according to the exact order of its A and T or C and G sub-units. A man inherits 23 chromosomes from each parent. Although everyone inherits the same number and types of genes, the subtle difference within them make each person unique from the other 6.5 billion on this planet. Some of the genes that a

man inherits determine his visible features, such as his skin, hair & eye colour, while others determine how his metabolism functions and whether or not he is at risk of developing medical problems such as high blood pressure, diabetes or cancer. b) The remaining pair of sex chromosomes contains information that determines an individuals male (Y) & female (X) characteristics. c) The DNA molecules are loosely wound around

special proteins (histones), which form a spaghetti-like complex called chromatin. Before a cell divides, each molecule of DNA is copied & condenses to form a duplicated chromosome. Each duplicated molecule chromosome contains 2 identical strands of DNA, referred to as sister chromatids. The chromatids remain attached at a point called telomeres, which never copy. After duplication, the DNA molecules condense again to form copies of the X-shaped structures known as duplicated chromosomes. d) 46 highly coiled molecules, made up of 2 chains of units called (1) Nucleotides, which roll around each other to form a long, spiral shaped, double helix.

(a) (b) Each nucleotide consists of a phosphate group, the sugar deoxyribose and one of 4 chemicals called bases: adenine (A), thymine (T), cytosine (C) or guanine (G). These bases face inwards and pair up to form the rungs of the double-helix ladder. Importantly, A always pairs with T, and C always pairs with G. (c) The DNA provides the code needed for cells to make proteins, which are formed from a chain of amino acids. The code depends on the order in which the bases occur along 1 strand-known as the sense strand-of the DNA helix. Each run of 3 bases-called a triplet-provides the code for a particular amino acid. This code tells each cell the order in which place amino acids in a protein chain.

Date/Time 7/9/11 7AM

Doctors Order Please admit under GS 2 S. West

Secure consent to care

Rationale Admission is required to assess and observe the patient further. This is also to monitor patient's condition and provide necessary care and interventions related to diagnosis. Patient has the right to be consented in all procedures to be done. Diet as tolerated to maintain nutritional status of patient. To monitor vital signs so that any unusualities will be referred as follows. For fluid replacement. CBC with PC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets. Serum calcium indicates whether there is a calcium deficit or an abnormal increase of calcium level in the blood stream. To see whether a bone has been fractured or a

Remarks Done

Done

DAT

Done

Monitor VS q4

Done

IVF: D5LR @ 100cc/hr Labs: CBC PC

Done Done

Serum calcium electrolyte

Done

X-ray arm

Done

Blood transfusion

Chest X-ray

Meds: Mefenamic acid 250mg, q6, take with meals For referral to consultant

joint dislocated. It is also used to check for an injury or damage from conditions such as an infection, arthritis, bone growths (tumors), or other bone diseases. Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself. Ordered for symptoms of shortness of breath, cough, or chest pain. For relief of pain including muscular, traumatic, fever, and headache. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Effective in the management of moderately severe acute pain. Compliance with meds will avert any complications. For specialized care and management. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the

Done

Done

Done

Done

4PM

STAT Ketorolac 30mg q8

Done

7/10/11

Continue meds

Done

For transfer service to GS 1 Refer

Done Done

7/11/11

For referral to consultant

treatment of the client. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Compliance with meds will avert any complications. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine. Cross matching is done to determine if the donor's blood is compatible with the blood of an intended recipient. For the treatment of many different types of bacterial infections. CT scans allow doctors to inspect the inside of the body without having to operate or perform

Done

7/12/11 8AM

Continue meds

Done

For referral to consultant

Done

11AM

To secure 1 unit of PRBC & transfer once with cross matching

Not done

Start cefuroxime 750mg IVTT q8 ANST For CT scan of chest include shoulder with contrast

Done

Not done

Refer

7/15/11 12PM

Still to secure blood

For compliance of medicine Defer CT scan For MRI of arm to include shoulder

unpleasant examinations including the affected part which is the shoulder. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine. Compliance with meds will avert any complications. MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor. For pain management. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-

Done

Not done

Done Not done Not done.

Refer to Anesthesia Refer

Done

4:10PM

May start TramadolKetorolac drip, Tramadol 250mg + Ketorolac 90mg in 500cc D5W @ 20cc/hr x 1 cycle

Done

Give Ketorolac 30mg IVTT Give Tramadol 40mg IVTT prior to drip then q6 PRN for severe pain Metoclopromide 10mg IVTT PRN for vomiting Refer

severe pain. For pain reliever. For severe pain.

Done Done

7/16/11 6AM

Continue TramadolKetorolac drip

Still for MRI

Still to secure blood

Refer

It is commonly used to treat nausea and vomiting, to facilitate gastric emptying. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-tosevere pain. MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor. RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine. This may create a collaborative treatment

Done

Done

Done

Not done

Not done

Done

7/17/11 6PM

Still for MRI

Continue TramadolKetorolac drip

Still to secure blood

7/18/11

For repeat CBC today

To secure 1 unit of PRBC & transfer

among the client and health providers; thus it also makes a good coordination in the treatment of the client. MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor. Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-tosevere pain. RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine. CBC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets. RBCs are used to restore oxygen carrying capacity

Not done

Done

Not done

Not done

Not done

7/20/11 12:30AM

9AM

to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine. Cross matching is done to determine if the donor's blood is compatible with the blood of an intended recipient. To secure another 4 For blood loss unit of PRBC for OR replacement during the use operation. Continue Meds Compliance with meds will avert any complications. Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Give Paracetamol It is commonly used for 500mg tab now then the relief of fever, after q4 PRN for headaches, and other fever minor aches and pains. Given every hours for 24 hours. And as needed if temperature is greater than 38 C. Still for MRI MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor. Still for repeat CBC CBC determines the quantity of each quantity of blood cell in a given specimen of blood, often

after cross matching

Done

Done Done

Done

Not done

Not done

including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets. Continue Meds Refer Compliance with meds will avert any complications. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. CBC with determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets. Compliance with meds will avert any complications. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Done Done

7/21/11 8:45AM

Still for repeat CBC

Done

Continue Meds Refer

Done Done

7/23/11 11:10PM

Refer to Ortho and possible transfer service Follow up: Serum Calcium

For evaluation.

Not done

Alkaline Phosphatase ESR

Continue blood transfer

7/24/11 10AM

For re-cross matching prior to transfusion Continue meds Continue TramadolKetorolac drip

Refer

Serum calcium indicates whether there is a calcium deficit or an abnormal increase of calcium level in the blood stream. Used to help detect liver disease or bone disorders. To help detect conditions associated with acute and chronic inflammation, including infections, cancers, and autoimmune diseases. Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself. To determine if the donor's blood is compatible with the blood of an intended recipient. Compliance with meds will avert any complications. Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-tosevere pain. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

Done Done

Done

Not done

Done Done

Done

7/25/11 6AM

To determine if the donor's blood is compatible with the blood of an intended recipient. Continue Tramadol- Tramadol with Ketorolac Ketorolac drip drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-tosevere pain. S/F transfer to Ortho For evaluation. service This may create a Refer collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. May transfer to Ortho once cleared by GS Transfuse 2 units available blood of patients blood type properly secure 2nd cross matched. Give Diphenhydramine 50mg IVTT once BT starts Cleared from GS Transfer to Ortho ward Transfer to Orthopedic ward for further evaluation. Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself. To limit allergic reactions to blood products.

S/F re-cross matching

Done

Done

Done Done

7/26/11 3:24PM

Done

Done

Done

7/27/11 1PM

Refer

Patient is ready to be transferred to Ortho Ward. Orthopedic ward caters patients with skeletal or bone problems such as fracture and dislocation. This may create a collaborative treatment among the client and health providers; thus it

Done Done

Done

also makes a good coordination in the treatment of the client. 7/29/11 To secure 4 units of blood of patients blood type. Pressure sore precaution on shoulder mass Please transfuse available blood of patients blood type and after proper cross matching as previously ordered For correction of anemia. Done

To avoid infection.

Done

7/31/11 9:16Am

RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine. Cross matching is done to determine if the donor's blood is compatible with the blood of an intended recipient. Decrease IVF to To prevent circulatory KVO rate while BT overload. For referral on pedia Pediatric oncology is a onco tomorrow specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer. Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Repeat CBC post 2 units of transfusion To check for hemoglobin level.

Done

Done Done

Done

8/1/11 11AM

Done

2PM

Verbal order: To give paracetamol 300mg IVTT now

8/3/11 9:30AM

S/F correction of anemia

It is commonly used for the relief of fever, headaches, and other minor aches and pains. Given every hours for 24 hours. And as needed if temperature is greater than 38 C RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine. Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer. Compliance with meds will avert any complications. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself. To prevent circulatory overload To limit allergic reactions

Done

Done

Follow up referral to pedia onco for evaluation and clearance

Done

Continue meds Refer

Done Done

2:50PM

Please transfuse 2 units available blood of patients blood type after properly cross matched Decrease IVF rate to KVO once in BT Give

Done

Done Done

8/4/11 8AM

These are signs and symptoms of transfusion reaction. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Please schedule In preparation for the patient for STAT OR planned operation. 3rd table other room tomorrow 8/5/11 Plan Fore Quarter A major surgical Amputation procedure in which the upper extremity and a variable portion of the supporting shoulder girdle is amputated, to treat either advanced malignancy. NPO @ 3AM To avoid aspiration during operation. Cefazolin 2g IVTT 1 Cefazolin is given 1 hour hour prior to OR, 1g prior to OR to reduce the q8 there after incidence of certain postoperative infections in patients undergoing surgical procedures which are classified as contaminated or potentially contaminated. Inform OR/AR OD For reservation of table in the Operating room and endorsement of patient. Secure pedia onco Pediatric oncology is a clearance for specialty discipline in surgery medicine concerned with diagnosing and treating

Diphenhydramine 50mg IVTT once transfuse starts Watch out for fever, dyspnea, pruritus and others Refer

to blood products.

Done

Done

Done

Done

Done Done

Done

Done

3PM

Ranitidine 30 mg IVTT 1 hour prior To secure 4 units PRBC

children, usually up to the age of 18, with cancer. Ranitidine reduces preoperative gastric fluid acidity and volume. PRBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine. Used for patients with a coagulopathy who are bleeding or at risk of bleeding. FFP should be blood type-matched to ensure compatibility. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

Done

To secure 2 unit Fresh Frozen Plasma, Patients blood type properly retype Refer accordingly

Done

Done

4PM

Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself. NPO post midnight To avoid aspiration during operation. To secure pedia ICU For possible post-op use. reservation Adequate hydration To keep the stomach and intestines clear, limit strain to the digestive system, but keep the body

Follow up repeat RBC port Blood Transfusion

Done

Done Done Done

Refer

8/5/11 7PM

Post-op patients are transferred to PACU for close monitoring and to watch out for any unusualities and complications after undergoing a surgery. May have soft diet The digestive system until fully awake with tolerates softer foods aspiration better after surgery so precaution cramps and abdominal pain can be avoided. Monitor VS q15 until stable then hourly To monitor vital signs so that any unusualities will be referred as follows. Q15 since patient is postop and there is a higher risk for complications to occur after surgery. For fluid resuscitation.

S/P Fore Quarter Amputation under GETA To PACU until stable then to Ortho ward

hydrated prior to or recover from a medical procedure. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Operation done to the patient.

Done

Done

Done

Done

Done

Continue venoclysis with PLR @ KVO rate Continue blood transfusion @ 80cc/hr Left arm

Done

Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.

Done

Switching from intravenous (IV) to oral (PO) therapy as soon as patients are clinically stable can reduce the length of hospitalization and lower associated costs. Meds: Ranitidine Treatment and prevention 35mg q8 IVTT x of heartburn, acid 2days indigestion, and sour stomach. Meds: It is commonly used to Metoclopromide treat nausea and vomiting, 10mg tablet, 1tab q6 to facilitate gastric PO, PRN for pain emptying. Meds: Furosemide Furosemide is a "water 20mg IVTT post-BT pill" (diuretic) that causes you to make more urine. MHBR Allows greater lung expansion and prevent compression on the diaphragm from prolong bed rest. Thermo regulate To check for fever. patient O2 inhalation @ To alleviate dyspnea. 6L/min face mask Monitor I&O qhour To monitor the elimination and record status of the patient and the kidney function as well as for any complications and unusualities Qhour since patient is post-op.

Terminate IV line @ R arm Meds: Morphine drip: D5W 500ml + 10mg Morphine with 20mgtts/min, may give 1.5mg PRN for severe pain Meds: Ketorolac 15mg q6 IVTT x 8 doses then shift to Mefenamic acid 500mg cap 1 cap q6 PO after meals

Right arm was amputated. To reduce pain.

Done Done

Done

Done

Done

Done

Done

Done Done Done

For CBC post BT @ ward Refer

11:05PM

8/6/11 9PM 8/7/11 1AM 9:05AM

IV rates: PLR @60cc/hr, PNSS @ 10cc/hr, Morphine drip 20cc/hr =90cc/hr Continue Antibiotics

To check for RBC, WBC, and Platelet count of the patient. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. To replace fluid loss.

Done

Done

Done

Compliance with meds will avert any complications. To relieve dyspnea and other problems in breathing. To void freely. To monitor the elimination status of the patient and the kidney function as well as for any complications and unusualities To monitor vital signs so that any unusualities will be referred as follows. Q1hour since patient is post-op and complications usually occur hours after a surgery. To give as needed for severe pain. To correct electrolyte imbalances, to deliver medications, for blood transfusion or as fluid replacement to correct, for

Done

Phone order: O2 inoculation via nasal cannula @ 2Lpm May remove Foley catheter Monitor I&O q shift

Done

Done Done

Cont. VS monitor qhour

Done

9:55AM

Tramadol 35mg q6 IVTT PRN Maintain 1 IV line, D/C other IV lines

Done Done

Wound dressing Continue antibiotics

example, dehydration. To avoid wound infection. Compliance with meds will avert any complications. Diet as tolerated to maintain nutritional status of patient. Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer. Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer. To avoid wound infection. Compliance with meds will avert any complications. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. To avoid wound infection. Antibiotics will be given PO. Cefuroxime is used for treatment of serious infections of the lower respiratorytracts. To avoid wound infection. Cefuroxime is used for

Done Done

DAT

Done

Refer to pedia onco for post-op comanagement

Done

8/8/11 12PM

Follow up referral to pedia onco

Done

8/9/11

For dressing of wound Cont. meds Refer

Done Done Done

8/10/11 9:45AM

For wound dressing Discontinue antibiotics IVTT Start Cefuroxime 500mg/cap; 1tab BID PO

Done Done Done

8/12/11

For wound dressing today Cont. meds:

Done Done

Cefuroxime:PO Amikacin: IV-D/C

Refer to dietary Pls. include 3 egg whites per meal

Follow up official biopsy result 8/13/11 9:30AM Dressing wound Cont. antibiotics

treatment of serious infections of the lower respiratorytracts.. For nutritional build-up. Egg Whites provide an excellent source of amino acids for developing muscles. A means of acquiring a tissue in order to make a definitive diagnosis. To avoid wound infection. Compliance with meds will avert any complications. To avoid wound infection. Compliance with meds will avert any complications. For appropriate diet. Egg Whites provide an excellent source of amino acids for developing muscles. Compliance with meds will avert any complications. To avoid wound infection. High albumin diet is a combination of high calorie and high protein diet. It is important in regulating blood volume by maintaining the osmotic pressure of the blood compartment. This may create a collaborative treatment among the client and health providers; thus it also makes a good

Done Done

Done

Done Done

8/14/11 3:50PM

Wound dressing For strict compliance of antibiotics. Follow up referral to dietary For compliance with 3 egg whites per meal daily

Done Done Done Done

8/15/11 11:50AM

For compliance with meds Wound dressing For compliance with high albumin diet

Done Done Done

Refer

Done

5:50PM

Start Cloxacillin 500mg/cap q6

Wound care High protein calorie diet

8/16/11 9AM

Follow up biopsy result Wound dressing Strict compliance of oral antibiotics High protein calorie diet

8/17/11 7:10AM

Maintain high protein calorie diet

Strict compliance with antibiotic Change dressing Follow up office of biopsy result

coordination in the treatment of the client. This is used to treat many different types of infections caused by staphylococcus bacteria. 500 mg orally every 6 hours for up to 21 days, depending on the nature and severity of the infection. To avoid wound infection. A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness. To make a definitive diagnosis. To avoid wound infection. Compliance with meds will avert any complications. A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness. A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness. Compliance with meds will avert any complications. For hygienic purposes and to prevent infection. To make a definitive diagnosis.

Done

Done Done

Done Done Done Done

Done

Done Done Done

8/18/11

For compliance with meds High protein calorie diet

8/19/11 5:10PM

Follow up biopsy result Strict compliance with meds Dressing done Refer for repeat CBC today Continue meds Wound dressing For debridement of wound

8/20/11 8:52AM

8/21/11 8:35AM

For wound care Please follow up debridement of wound Continue meds

Compliance with meds will avert any complications. A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness. To make a definitive diagnosis. Compliance with meds will avert any complications. For hygienic purposes and to prevent infection. To check for hemoglobin, WBC, platelet count. Compliance with meds will avert any complications. To prevent infection. To remove patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. To prevent infection. To carry out the planned procedure. Compliance with meds will avert any complications. To prevent infection. Compliance with meds will avert any complications. To make a definitive diagnosis. Compliance with meds will avert any complications. For further management.

Done Done

Done Done Done Done Done Done Done

Done Done

Done Done Done Done Done Done

8/22/11 11:20AM

For wound care Continue meds

8/23/11 8:40AM

Follow up biopsy result Continue meds Refer back to Pedia onco

8/25/11 7:10AM

8/27/11 9:10AM

Official biopsy: A type of cancer, Rhabdomyosarcoma specifically a sarcoma , in which the cancer cells are thought to arise from skeletal muscle progenitors. Please inform pedia Pediatric oncology is a onco specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer. For wound dressing To prevent infection. For repeat CBC PC CBC with PC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets. Compliance with meds will avert any complications. To avoid infection. In preparation for a surgery. To remove patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Compliance with meds will avert any complications.

Done

Done

Done Done

Continue meds 8/28/11 8:51Am For wound dressing For OR schedule Plan debridement: Split Thickness Skin Graft (STSG)

Done Done Done Done

D/C: Loxacillin Continue other meds

Done Done

8/29/11

For wound dressing Secure blood and OR material For STAT CX today

To avoid infection. In preparation for planned surgery.

the

Done Done Done

To help diagnose symptoms such as shortness of breath, a bad or persistent cough, and chest pain or injury.

8/30/11 7:30AM 8/31/11 9:50AM

In preparation for a surgery. Pls. schedule patient In preparation for the for OR tomorrow 2nd planned operation. table. Plan STSG To remove patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Inform ROD For reservation of table in the Operating room and endorsement of patient. Secure consent Patient has the right to be consented in all procedures to be done. To avoid aspiration during operation. IVF D5LR 1L @ For fluid replacement and 100cc/hr for administering IVTT meds. To Ortho Ward once Orthopedic ward caters stable @ PACU patients with skeletal or bone problems such as fracture and dislocation. Cont. Cefazolin 1gm Treatment of bone and IVTT q8 joint infection. Maintain dressing in To keep wound close and hemi-thorax intact. Refer This may create a collaborative treatment among the client and NPO post midnight

For OR schedule

Done Done

Done

Done

Done

Done Done

3:50PM

Done

Done Done Done

health providers; thus it also makes a good coordination in the treatment of the client. 9/1/11 11:29AM Maintain dressing in hemi-thorax Cont. Cefazole 1gm IVTT q8 Meds: Ascorbic acid 500mg, 1 tsp OD To avoid infection. Treatment of bone and joint infection. Ascorbic acid helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels. For relief of pain including muscular, traumatic, fever, and headache. Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-tosevere pain. This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. STSG surgical procedure is done. For close monitoring. Patient should be closely supervised when eating. Done Done Done

Meds: Mefenamic acid 500mg cap, 1cap q6 PO Cont. Tramadol + Ketorolac as previously ordered

Done

Done

Refer

Done

3:50PM

S/P STSG, Right shoulder under GETA To PACU until stable then to ward May have DAT when fully awake with aspiration

Done

Done Done

precaution Monitor VS Meds: Tramadol 30mg Removal of Foley catheter Cont. IV antibiotics DAT

To monitor unusualities. For pain reliever. To void freely.

any

Done Done Done Done Done

9/2/11 12PM 9/3/11 10:20AM

For treatment of infections. Diet as tolerated to maintain nutritional status of patient For treatment of infections. Administered to patients with low albumin level. Protein is essential for tissue growth and regeneration. Egg Whites provide an excellent source of amino acids for developing muscles. To avoid wound infection.

9/4/11 9AM

Cont. IV antibiotics To secure 25% Albumin and transfuse in 4 hours Maintain high protein diet Advice 3 egg whites per meal daily

Done Done

Done

Done

9/5/11 11:08AM

Protein is essential for tissue growth and regeneration. For strict compliance Compliance with meds will of oral antibiotics avert any complications. Add 3 egg whites Egg Whites provide an per meal daily excellent source of amino acids for developing muscles. Shift Cefazolin to Cefuroxime is used for Cefuroxime 500mg treatment tab; 1tab BID PO of serious infections of the lower respiratorytracts. Refer This may create a collaborative treatment

For change of dressing of recipient site Maintain high protein diet

Done

Done

Done Done

Done

Done

among the client and health providers; thus it also makes a good coordination in the treatment of the client. 9/7/11 9:40AM For wound dressing today Cont. PO antibiotics High protein/ caloric diet Ascorbic acid 500mg tab BID To avoid wound infection. Compliance with meds will avert any complications. Protein is essential for tissue growth and regeneration. Ascorbic acid helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels. Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer. Ascorbic acid helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels. To avoid wound infection. For specialized care and management. For specialized care and management. Done Done Done

9/9/11 8:29AM

Done

9/10/11

MGH- Ortho Refer to pedia onco for transfer of service

Done Done

Med: Ascorbic acid 500mg tab BID

Done

9/11/11 10:31AM

Wound dressing as instructed Follow up referral to Pedia onco for transfer of service Transfer to pedia onco unit if obey to

Done Done

Done

9/12/11

9/13/11 9:06AM

mask secure for pedia onco to start chemotherapy Notify transfer to pedia onco unit for chemotherapy For chemotherapy

For specialized care and management. Used to stop cancer cells from dividingso they stop growing or die. For specialized care and management. House of hope provides the psychosocial needs of children with cancer. Ascorbic acid helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels. Used to stop cancer cells from dividingso they stop growing or die. To provide data to the House of Hope once patient is transferred.

Done

Done

Refer to pedia for transfer of service MGH to House of Hope Cont. Ascorbic Acid

Done Not done

Done

For chemotherapy once with available bed at the pedia onco ward Photocopy all operative technique and biopsy

Not done

Not done

 Introduce July 28, 2011 Blood Chemistry your name to the patient and establish rapport.

Identify

the right client.

Discuss the importance and purpose of the procedure.

Explain the procedure to the patient.

Assess the patient for any factor that will probably affect the results of the test.

Creatinine 53 115 umol/L

30.40U mol/L (normal )

Used to evaluate renal dysfunction. Increased creatinine levels in the

blood suggest diseases or conditions that affect kidney function.

measure of the Blood Urea Nitrogen 1.1 3.20 2.40 amount of urea in the blood. Urea forms in the liver as the end product of protein metabolism, circulates in the blood, and is excreted through the

kidney in urine. The BUN, determined by a blood test, is directly related to the metabolic function of the liver and the excretory function of the kidney. Normal findings (in mg/dL) are 10 to 20 for adults, 5 to 18 for children and infants, 3 to 12 for newborns, and 21 to 40 for cord blood. In the elderly, the BUN may be slightly higher than the normal adult range. A critical value of 100 mg/dL indicates serious impairment of renal function. Also

called urea nitrogen, serum urea nitrogen. July 29, 2011 IPD hematology Erythrocyte Sedimentatio n Rate 0.0010.0mm/hr July 09, 2011 Blood type (ABO test) A Blood typing in the ABO system, and others, involves the identification of specific proteins that are contained in the blood. Red Blood Cells have either antigen (protein) A, B, or AB or none, on the surface of the cells. These antigens, (proteins) make 60 H the rate at which red blood cellssediment in a period of 1 hour. It is a common hemat ology test that is a nonspecific measure of inflammation

the blood of each person unique and separate from one another. Blood typing then, categorizes blood in individuals according to these proteins (ABO) test for the Rh Blood type B + RH positiv e factor protein on the RBC, Red Blood Cell. Increase of LD activity in serum may occur in any injury that causes loss of cell cytoplasm. More specific information can be obtained by LD isoenzyme studies. Also, elevation of serum LD is observed due to in vivo effects of anesthetic agents, clofibrate, dicumarol, ethanol, fluorides, imipramine,

Aug ust 04, 2011

LDH 266 500.00 u/L

1580.0 H

methotrexate, mithramycin, narcotic analgesics, nitrofurantoin, propoxyphene, quinidine, and sulfonamides. Decrease of serum LD is probably not clinically significant. There are two main analytical methods for measuring LD: pyruvate>lactate and lactate>pyruvate. Assay conditions (particularly temperature) vary among labs. The reference range for the assaying laboratory must be carefully studied when interpreting any individual result. Many European labs assay alphahydroxybutyrat e dehydrogenase (HBD or HBDH), which roughly equates to LD isoenzymes 1 and 2 (the fractions found in heart, red

blood cells, and kidney).

Aug ust 27, 2011 Sodium 136-155 mmoL/L 136.10 mmol/L (normal ) Measures the amount of sodium in the blood. It plays a major role in regulating the amount of water in the body. Sodium is a mineral that is vital to normal body processes, which include nerve and muscle functioning. Too much sodium can increase the chances of high blood pressure

Potassium 3.7 to 5.5

3.94 (normal

This test measures the

mmol/L.

amount of potassium in the blood.

Potassium (K+) helps nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells. Calcium 1.75 2.39 Mmol/L 2.40 L a blood or urine test used to evaluate parathyroid function and calcium metabolism by directly measuring the total amount of calcium in the blood. It is used to monitor patients with renal failure, renal transplantation, hyperparathyroi dism, and various malignancies, as well as to monitor calcium levels during and after large-

volume blood transfusions. Sept embe r 02, A/G Ratio 2011 1.0 2.50

0.8 L

Globulin is increased di sproportionatel y to albumin (decreasing the albumin/globuli n ratio) in states characterized by chronic inflammation and in Blymphocyte neoplasms, like myeloma and Waldenstrm's macroglobuline mia. More relevant information concerning increased globulin may be obtained by serum protein electrophoresis . Decreased glo bulin may be seen in congenital or acquired hypogammaglo bulinemic states. Serum and urine protein electrophoresis may help to better define the clinical problem.

Total protein 64.00 83.00 g/L

57.40 g/L L

The total protein test is a rough measure of all theproteins fou nd in the fluid portion of your blood. Specifically it looks at the total amount of two classes of proteins: album in and globulin.

Globulin 23.0 30.0 g/L

32.60g/ L H

any of a class of proteins insoluble in water, but soluble in saline solutions (euglobulins), or watersoluble proteins (pseudoglobuli ns); their other physical properties resemble true globulins Albumin is a

Albumin 35.00 50.00

24.80 (low)

protein made by the liver. A

g/L

serum albumin test measures the amount of this protein in the clear liquid portion of the blood.

SURGERY: DATE: HOSPITAL: SURGEON: ANESTHESIOLOGIST: TYPE of ANESTHESIA: PM 4:15 PM OPERATION DIAGNOSIS: forequarter amputation OPERATION STARTED: OPERATION ENDED:

Debridement, Split Thickness Skin Graft September 5, 2011 SPMC OR Dr. Gabutan Dr. Ranola General Anesthesia TIME BEGAN: 2:15

Rhabdomyosarcoma right , status post

3:00 PM 3:50 PM

Definition Debridement is a medical procedure performed to remove damaged tissue from a patient to promote the development of healing in the underlying tissue. Surgical debridementis recommended when the tissue damage is so extensive that working on a conscious patient would be painful, as well as risky, as in the case of very deep or large wounds. This procedure can be done by a general surgeon or a specialist, depending on the location and nature of the damage. Split Thickness Skin Graft is a skin graft including the epidermis and part of the dermis. Its thickness depends on the donor site and the needs of the patient. It can be processed through a skin mesher which makes apentures onto the graft, allowing it to expand up to nine times its size. Split-thickness grafts are frequently used as they can cover large areas and the rate of autorejection is low. You can take from the same site again after 6 weeks. The donor site heals by re-epitheliasation from the dermis and surrounding skin and requires dressings. Procedure The most important part of any skin graft procedure is proper preparation of the wound. Skin grafts will not survive on tissue with a limited blood supply (cartilage or tendons) or tissue that has been damaged by radiation treatment. The patient's wound must be free of any dead tissue, foreign matter, or bacterial contamination. After the patient has been anesthetized,

the surgeon prepares the wound by rinsing it with saline solution or a diluted antiseptic (Betadine) and removes any dead tissue by dbridement. In addition, the surgeon stops the flow of blood into the wound by applying pressure, tying off blood vessels, or administering a medication (epinephrine) that causes the blood vessels to constrict. Following preparation of the wound, the surgeon then harvests the tissue for grafting. A split-thickness skin graft involves the epidermis and a little of the underlying dermis; the donor site usually heals within several days. The surgeon first marks the outline of the wound on the skin of the donor site, enlarging it by 35% to allow for tissue shrinkage. The surgeon uses a dermatome (a special instrument for cutting thin slices of tissue) to remove a split-thickness graft from the donor site. The wound must not be too deep if a split-thickness graft is going to be successful, since the blood vessels that will nourish the grafted tissue must come from the dermis of the wound itself. The graft is usually taken from an area that is ordinarily hidden by clothes, such as the buttock or inner thigh, and spread on the bare area to be covered. Gentle pressure from a well-padded dressing is then applied, or a few small sutures used to hold the graft in place. A sterile nonadherent dressing is then applied to the raw donor area for approximately three to five days to protect it from infection. Indication 1. Debridement is indicated to our patient in preparation for split thickness skin graft. 2. An STSG is indicated in most wounds that cannot be closed primarily and when closure by secondary intention is contraindicated. It is also indicated for a relatively large wound (> 56 cm in diameter) that would take many weeks to heal secondarily. A skin graft provides more stable coverage for large wounds than the scar that results from secondary closure. A large wound also heals more quickly with a skin graft than with dressing changes alone. The wound must be clean. All necrotic tissue must be removed before skin grafting, and there should be no signs of infection in the surrounding tissues. Anesthesia General anesthesia puts the entire body to sleep by giving medicine. It is often used during emergency surgery. It is also commonly used if a procedure would make you uncomfortable if you were awaken

Position When doing debridement the position of the patient should be side lying position on the unaffected part.So that the surgical site is clearly expose and for the convenience of the surgeon and the rest of the surgical team. Also in doing the split thickness skin grafting, the position of the client is in supine position. Kidney basin A bean-shaped basin used for collection of bodily discharges or cleaning and irrigation.

Asepto syringe

Used for irrigation

intraoperative

Yankauer

suction blood and fluids

Scalpel

Used to cut

Abdominal Pack

General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Instrumentation

Operating sponge

General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Prosta Pack

Mayo tray

General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges Sterile field which holds all surgical instruments used

Kelly clamps

Used to clamp vessels and tissue

larger

Needle Holder

Facilitate use of suture

Army navy Tissue forceps

Used for tissue and bone retraction Grasps soft tissues and facilitates suturing of the site Used for grasping hard tissues

Thumb forceps

Mayo scissors

Used to cut heavy tissue (fascia and muscle)

Metzenbaum scissors

Used to cut delicate tissue

Towel clips

Holds towels in place around the surgical site

Water Saline solution Richardson

Irrigating surgical site and cleaning Used for retraction

Straight mayo

General purpose and suture cutting scissors For grasping soft tissue

Allis forceps

Bobcock

for grasping soft tissue

Humby knife

Graft-meshing machine

A knife with a roller and a calibration device to cut skin grafts of different thickness a device used to make fine cuts in skin grafts

Padgett dermatome

was the first rotary drum manual dermatome to be devised

Bone curette

A surgical instrument shaped like a scoop or spoon, used to remove tissue or growths from a body cavity.

Cotton applicator

tip

For wound care

I.

Nursing Responsibilities

Preoperative Phase

a. Assessment and Data Collection

The patient should be in best possible physical condition before surgery. In emergencies, of course, this cannot be controlled, but planned surgery might be postponed until the patient is physically able to withstand the stress of anesthesia and the surgery.

First, the perioperative nurse gathers data specific to the surgical procedure and postoperative course:

health history and psychosocial assessment (what is the reason for this surgery?)

cultural assessment (what are your cultural customs regarding privacy and blood transfusions?)

spiritual assessment (do you have spiritual or religious beliefs?)

physical assessment (such as weight and vital signs)

laboratory and diagnostic test data (note any abnormal findings)

Any significant deviations from normal range should be brought to the attention of the surgeon.

Second, the nurse assesses surgical risk factors. Carefully assess the patient before surgery for risks of complications such as advanced age with inactivity, obesity and cardiovascular problems, excessive fear, substance abuse, respiratory disease, diabetes mellitus and other chronic diseases.

b. General preoperative teaching

General information that almost all surgical patients should receive includes information related to:

Preoperative procedures: skin preparation, care of belongings, restriction of food and fluid intake, time to come to hospital

Technical information: anticipated surgical procedure, location of incisions

Day of surgery: time surgery is scheduled, time to arrive at hospital, probable length of procedure, where family will wait

In addition, teaching the patient correct breathing, coughing, turning and leg exercises is a high priority during the preoperative period. Explain the importance of doing the exercises and show

the patient how to do each one and ask for a return demonstration.

c. The nurse checks that a consent form has been signed before giving the preoperative medication. Before the surgeon can perform an operation, written permission signed by either the patient, her guardian, or whoever holds power of attorney must be obtained.

Intraoperative Phase

Scrub nurse

The scrub nurse works directly with the surgeon within the sterile field, passing instruments, sponges, and other items needed during the procedure. Surgical team members who work within the sterile field have scrubbed their hands and arms with special disinfecting soap and generally wear surgical gowns, caps, eyewear, and gloves.

Major functions include:

Gathers all equipment for the procedure

Prepares all sterile supplies using sterile technique

Gowns and gloves surgeons upon entry into operating room

Assists with sterile draping of the patient

Maintains sterility within the sterile field during surgery

Maintains a neat instrument table

Label and handles surgical specimens correctly

Maintains an accurate count of sponges, sharps, and instruments on the sterile field; verifies counts with circulating nurse before and after surgery

Monitors for breaks in sterile technique and points them out

Cleans up after the surgery is over

Circulating nurse

The circulating nurse serves as the patient advocate while the patient is least able to care for him or herself.

Functions include:

Responsible for managing the nursing care of the patient within the OR and coordinating the needs of the surgical team with other care providers

Observes the surgery and the surgical team from a broad perspective

Assists the team to create and maintain a safe and comfortable environment for the patient

Assesses the patient's condition before, during, and after the operation to ensure an optimal outcome for the patient

Postoperative phase

The nurse checks the patients identity, settles the patient in bed, and performs an initial postoperative assessment. Airway, breathing and circulation are always the top priorities.

Monitoring for signs of the various complications that may occur as a result of surgery is a major nursing responsibility.

Other responsibilities of the nurse towards the patient include:

Maintaining ventilation: maintaining a patent airway is a priority measure

Maintain circulation and tissue perfusion

Prevent injury and infection: use aseptic technique when caring for postoperative patient. Good hand washing is the primary means of preventing infection

Maintain fluid balance

Promote comfort: pain and discomfort interfere with rest and inhibit the processes of healing and repair. Although analgesic drugs are almost always prescribed for the postoperative patient, comfort measures should also be used.

Promote rest and activity

Promote wound healing: adequate rest, sufficient blood supply, and proper nutrition all promote wound healing

Prevent postoperative complications such as wound infection

Promote psychological adjustment: the patient may be concerned about the ability to perform self-care postoperatively

The nurse assesses the graft area for signs of adequate blood supply. She inspects the color of the graft area, which should be patients body to see if the same color as the other skin on the

it has enough blood supply. The nurse also checks to make sure the graft area is warm as this indicates sufficient blood supply to the area. The nurse checks the patency of drains placed in the graft area. She makes sure they are not blocked, so drainage can flow out of the graft site instead of accumulating in it and potentially causing an infection. The nurse ensures blood circulation to the graft area by positioning the patient off blood supply to the area. The nurse may place the patient on a low pressure bed when lying down or low pressure cushion for sitting down. The less more likely that it will pressure exerted on the graft area, the exert low pressure on the skin. Another nursing intervention for skin graft patients is to provide an over the bed trapeze. The nurse makes sure that the patient is aware of how to use it for moving around in bed. This occur reduces the amount of shearing and friction that could during movement and possibly displace the graft. the graft. Taking pressure off the decreased graft and skin surrounding it reduces the risk of

be adequately perfused. Low pressure beds and cushions

sources: http://www.surgeryencyclopedia.com/Pa-St/Skin-Grafting.html Dipietro, Luisa A., and Aime L. Burns, eds. Wound Healing: Methods and Protocols. Totowa, NJ: Humana Press, 2003. Herndon, David, ed. Total Burn Care , 2nd ed. London, UK: W. B. Saunders Co., 2001. Tura, A., ed. Vascular Grafts: Experiment and Modelling , 1st ed. Billerica, MA: WIT Press/Computational Mechanics, 2003.

SURGERY: DATE: HOSPITAL: SURGEON: ANESTHESIOLOGIST: TYPE of ANESTHESIA: PM 6:45 PM

Forequarter Amputation August 5, 2011 SPMC OR Dr. Penaranda/ Dr. Sabal/ Dr. Gabutan Dr.Bermulo General Anesthesia (GETA)TIME BEGAN: 3:20

OPERATION DIAGNOSIS: OPERATION STARTED: OPERATION ENDED:

to consider sarcoma right arm 4:20 PM 6:30 PM

Definition Forequarter amputation (interscapulothoracic amputation) entails the surgical removal of the entire upperextremity and shoulder girdle, including the scapula and a portion of the clavicle.Traditionally forequarteramputations were most commonly performed for highgrade bone sarcomas of the proximal humerus andscapula . The proximal humerus is thethird most common site for osteosarcomas, and thesetumors are the most common primary malignancy of the proximal humerus. Chondrosarcomas and Ewings sarcoma tend to occur in the scapula. Procedure 1. Posterior incision from medial end of clavicle, along clavicle over acromion and down lateral border of scapula, ending ~ 5 cm from midline at back. Anterior incision from mid clavicle, curving down just lateral and parallel with the deltopectoral groove, down over anterior axillary fold inferiorly and posteriorly to meet the posterior incision at the lower 1/3 of the axillary border of the scapula

2. Develop the posterior flap to expose the vertebral border of the scapula and divide trapezius, rhomboids, levator scapulae and latisimus dorsi from the scapula 3. Reflect scapula to divide attachment of serratus anterior and omohyoid 4. Allow arm to drop forward to bring plexus under tension and divide cords of the brachial plexus near the spine 5. Double ligation of subclavian artery and vein 6. From the anterior incision divide clavicle near medial end 7. Divide pectoralis muscles and insertion of latisimus dorsi to complete the resection 8. Perform a myoplastic closure and close skin over drains

Indication The Forequarter amputation is indicated 1.Unresectable high-grade osteosarcoma (or any otherhigh-grade tumor) of the proximal humerus or the scapula (most commonly, chondrosarcoma). 2. Axillary soft-tissue sarcomas involving the brachial plexus. 3. Recurrent bone or soft-tissue sarcomas following a failed limbsparing procedure. 4. Some radiation-induced sarcomas of the shoulder girdle. 5. Palliative amputation (primarily due to tumor fungation, infection, or bleeding). 6. Recurrent breast carcinoma involving the brachial plexus. 7. Pathological fracture through a high-grade sarcoma, especially if there is a poor response to induction chemotherapy. Anesthesia General anesthesia is a treatment that renders you unconscious during medical procedures, so you don't feel or remember anything that happens. General anesthesia is commonly produced by a combination of intravenous drugs and inhaled gasses (anesthetics). The "sleep" you experience under general anesthesia is different from regular sleep. The anesthetized brain doesn't respond to pain signals or surgical manipulations.

The practice of general anesthesia also includes controlling your breathing and monitoring your body's vital functions during your procedure. General anesthesia is administered by a specially trained physician, called an anesthesiologist, often in conjunction with a certified registered nurse anesthetist.

Position Intravenous lines are secured, and a Foley catheter is placed in the bladder. The patient is placed in a full lateral position and secured at the hips with tape. Alternatively, a VAC pack can be used to secure the torso. An axillary roll is placed under the axilla to allow full excursion of the chest, and a sponge-rubber pad is placed under the hip to prevent ischemic damage to the skin in this area. The skin is prepared, and the tumor-bearing extremity is draped free.

Instrumentation

Cautery cord and pencil

Uses electricity to cut cauterize blood vessels.

or

Kidney basin

A bean-shaped basin used for collection of bodily discharges or cleaning and irrigation.

Asepto syringe

Used for intraoperative irrgation

Yankauer

suction blood and fluids

Scalpel

Used to cut

Abdominal Pack

General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Operating sponge

General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges

Prosta Pack

Mayo tray

General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges Sterile field which holds all surgical instruments used

Kelly clamps

Used to clamp larger vessels and tissue

Needle Holder

Facilitate use of suture

Army navy Tissue forceps

Used for retractiob

tissue

and

bone

Grasps soft tissues and facilitates suturing of the site Used for grasping hard tissues

Thumb forceps

Mayo scissors

Used to cut heavy tissue (fascia and muscle)

Metzenbaum scissors

Used to cut delicate tissue

Towel clips

Holds towels in place around the surgical site

Water Saline solution Richardson

Irrigating surgical cleaning Used for retraction

site

and

Straight mayo

General purpose and suture cutting scissors For grasping soft tissue

Allis forceps

Bobcock

for grasping soft tissue

Gigli saw

a flexible wire saw used by surgeons for bone cutting. A gigli saw is used mainly for amputation surgeries, where the bones have to be smoothly cut at the level of amputation.

II.

Nursing Responsibilities

Preoperative Phase

d. Assessment and Data Collection

The patient should be in best possible physical condition before surgery. In emergencies, of course, this cannot be controlled, but planned surgery might be postponed until the patient is physically able to withstand the stress of anesthesia and the surgery.

First, the perioperative nurse gathers data specific to the surgical procedure and postoperative course:

health history and psychosocial assessment (what is the reason for this surgery?)

cultural assessment (what are your cultural customs regarding privacy and blood transfusions?)

spiritual assessment (do you have spiritual or religious

beliefs?)

physical assessment (such as weight and vital signs)

laboratory and diagnostic test data (note any abnormal findings)

Any significant deviations from normal range should be brought to the attention of the surgeon.

Second, the nurse assesses surgical risk factors. Carefully assess the patient before surgery for risks of complications such as advanced age with inactivity, obesity and cardiovascular problems, excessive fear, substance abuse, respiratory disease, diabetes mellitus and other chronic diseases.

e. General preoperative teaching

General information that almost all surgical patients should receive includes information related to:

Preoperative procedures: skin preparation, care of belongings, restriction of food and fluid intake, time to come to hospital

Technical information: anticipated surgical procedure, location of incisions

Day of surgery: time surgery is scheduled, time to arrive at hospital, probable length of procedure, where family will wait

In addition, teaching the patient correct breathing, coughing, turning and leg exercises is a high priority during the preoperative period. Explain the importance of doing the exercises and show the patient how to do each one and ask for a return demonstration.

f. The nurse checks that a consent form has been signed before giving the preoperative medication. Before the surgeon can perform an operation, written permission signed by either the patient, her guardian, or whoever holds power of attorney must be obtained.

Intraoperative Phase

Scrub nurse

The scrub nurse works directly with the surgeon within the sterile field, passing instruments, sponges, and other items needed during the procedure. Surgical team members who work within the sterile field have scrubbed their hands and arms with special disinfecting soap and generally wear surgical gowns, caps, eyewear, and gloves.

Major functions include:

Gathers all equipment for the procedure

Prepares all sterile supplies using sterile technique

Gowns and gloves surgeons upon entry into operating room

Assists with sterile draping of the patient

Maintains sterility within the sterile field during surgery

Maintains a neat instrument table

Label and handles surgical specimens correctly

Maintains an accurate count of sponges, sharps, and instruments on the sterile field; verifies counts with circulating nurse before and after surgery

Monitors for breaks in sterile technique and points them out

Cleans up after the surgery is over

Circulating nurse

The circulating nurse serves as the patient advocate while the patient is least able to care for him or herself.

Functions include:

Responsible for managing the nursing care of the patient within the OR and coordinating the needs of the surgical team with other care providers

Observes the surgery and the surgical team from a broad perspective

Assists the team to create and maintain a safe and comfortable environment for the patient

Assesses the patient's condition before, during, and after the operation to ensure an optimal outcome for the patient

Postoperative phase The nurse checks the patients identity, settles the patient in bed, and performs an initial postoperative assessment. Airway, breathing and circulation are always the top priorities.

Monitoring for signs of the various complications that may occur as a result of surgery is a major nursing responsibility.

Other responsibilities of the nurse towards the patient include:

Maintaining ventilation: maintaining a patent airway is a priority measure

Maintain circulation and tissue perfusion

Prevent injury and infection: use aseptic technique when caring for postoperative patient. Good hand washing is the primary means of preventing infection

Maintain fluid balance

Promote comfort: pain and discomfort interfere with rest and inhibit the processes of healing and repair. Although analgesic drugs are almost always prescribed for the postoperative patient, comfort measures should also be used.

Promote rest and activity

Promote wound healing: adequate rest, sufficient blood supply, and proper nutrition all promote wound healing

Prevent postoperative complications such as wound infection

Promote psychological adjustment: the patient may be concerned about the ability to perform self-care postoperatively

Minimizing altered sensory perceptions Promoting wound healing Enhancing body image Promoting independent self-care Helping the patient to achieve physical mobility

Source: http://www.sarcoma.org/publications/mcs/ch17.pdf Dipietro, Luisa A., and Aime L. Burns, eds. Wound Healing: Methods and Protocols. Totowa, NJ: Humana Press, 2003

DRUG STUDY

Generic Name

Ketorolac

Brand Name

Toradol

Classification

Nonsteroidal anti-inflammatory agents, nonopioid analagesics

Ordered Dosage

Route: IVTT Dosage : 15 mg

Dosage Frequency

Q6 x 3 doses

Mechanism of

It

inhibits

prostaglandin

synthesis,

producing

peripherally

mediated analgesia. Also have antipyretic and anti-inflammatory properties. Action Therapeutic effect: Decreased pain

Indications

For short term management of pain (not to exceed 5 days total for all routes combined).

Contraindications

Contraindicated in patients with hypersensitivity cross-sensitivity with other NSAIDS may exist, labor, delivery or lactation, pre- or perioperative use and known alcohol intolerance (injection only).

Side effects and Adverse Reactions

CNS: 1) drowsiness 2) abnormal thinking 3) dizziness 4) euphoria 5) headacheRESP: 1) asthma 2) dyspnea CV:

1) edema 2) pallor 3) vasodilation GI: 1) GI Bleeding 2) abnormal taste 3) diarrhea 4) dry mouth 5) dyspepsia 6) GI pain 7) nausea GU: 1) oliguria 2) renal toxicity 3) urinary frequency DERM: 1) pruritis 2) purpura 3) sweating 4) urticaria HEMAT: 1) prolonged bleeding time LOCAL: 1) injection site pain NEURO: 1) paresthesia MISC: 1) allergic reaction, anaphylaxis

1. Ensure right patient, ask the patient his name and check Nursing the ID band. 2. Check the drug label before preparing the drug. 3. Check the latest doctor prescribed dosage and asks somebody for clarifications about the dosage. 4. Check Responsibilities latest doctor prescribed dosage frequency.

Administer on time. 5. Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing

hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria. 6. Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. 7. Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy. 8. Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. 9. Advise patient to consult if rash, itching, visual

disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes

(chills,fever,muscles aches, pain) occur. 10. Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.

Generic Name Tramadol

Brand Name Ultram

Classification Analgesics

Ordered Dosage

Route: IVTT Dosage: 30 mg

Dosage Frequency

Q6

Mechanism of Action Physiologic Mechanism Decreased pain.

Pharmacologic Mechanism Binds to mu-opioid receptors. Inhibits reuptake of serotonin and norepinephrine in the CNS.

Indications Moderate to moderately severe pain

Contraindications

Hypersensitivity totramadol, opioids, orany component of theformulation; intoxicationwith opioid-dependent alcohol,hypnotics, patients;acute centrally-acting

analgesics,opioids, orpsychotropic drugs

Side effects Side effects and Adverse Reactions Dizziness or vertigo Nausea and Vomiting Constipation Headache Dry mouth

Adverse Reactions Respiratory depression Seizures

 Prolonged duration of action and cumulative effect may occur in patients with impaired hepatic or renal function.

Nursing Responsibilities

1. Verify the identity of the patient 2. Inform the patient about the administration of drugs and its purpose 3. Assess onset, type, location, and duration of pain. 4. Effect of medication is reduced if full pain recurs before next dose. 5. Assess drug history especially carbamazepine, CNS depressant medication, MAOIs. 6. Review past medical history, especially epilepsy or seizures. 7. Assess renal or hepatic function laboratory values. 8. Give without regards to meals 9. Monitor pulse and blood pressure. 10. Assist with ambulation if dizziness or vertigo occurs. 11. Dry crackers or cola may relieve nausea. 12. Palpate bladder for urinary retention. 13. Monitor pattern of daily bowel activity and stool consistency. 14. Sips of tepid water may relieve dry mouth. 15. Assess for clinical improvement and record onset of relief from pain.

Generic Name

Mefenamic acid Oral

Brand Name Mefalth, Mefalth T, Ponstel, Ponstan, Ponstal, Parkemed, Mafepain, Mefamed, Mephadolor, Meftal, Dyfenamic, Potarlon, Dolfenal, Meyerdonal, Alfoxan, Fenagesic, Spiralgin.

Classification

Non-steroidal anti-inflammatory drug.

Ordered Dosage

Route: PO Dosage:500 mg

Dosage Frequency

Q6

Mechanism of Action

Mefenamic acid binds the prostaglandin synthetase receptors COX-1 and COX-2, inhibiting the action of prostaglandin synthetase. As these receptors have a role as a major mediator of inflammation and/or a role for prostanoid signaling in activity-dependent plasticity, the symptoms of pain are temporarily reduced.

Indications Pain and inflammation.

Contraindications

Inflammatory bowel disease; peptic ulcer; neonates; pregnancy (3rd trimester), lactation. Coronary artery bypass graft surgery, severe renal impairment, and severe heart failure.

Side effects and Adverse Reactions

Dependent on the dose and the duration of treatment, mefenamic acid frequently causes diarrhea. Long-term treatment can lead to enteritis or colitis (sometimes with steatorrhea). The drug can also cause nausea, vomiting and upper abdominal pain. Like other anti-inflammatory agents, it occasionally is the cause of peptic ulcers or even of bleeding or perforations. Mefenamic acid seems to cause hematologic problems (especially autoimmune hemolytic anemias) more often than other anti-inflammatory drugs. Several cases of renal failure (partially without oliguria) have been observed. Vertigo, headaches and skin reactions can occur under mefenamic acid.

Nursing Responsibilities

1. Ensure right patient, ask the patient his name and check

the ID band. 2. Check the drug label before preparing the drug. 3. Check the latest doctor prescribed dosage and ask somebody for clarifications about the dosage. 4. Check latest doctor prescribed dosage frequency. Administer on time. 5. If patient have had a stomach ulcer or bleeding, tell healthcare provider. 6. Instruct patient to avoid alcohol (includes wine, beer, and liquor) when taking this medicine since it can cause increases in stomach irritation. 7. Use caution if the patient has a weakened heart. It may cause increased shortness of breath or weight gain. Then recommend to talk with healthcare provider or its own physician. 8. Avoid aspirin, aspirin-containing products, other pain medicines, other blood thinners (warfarin, ticlopidine, clopidogrel), garlic, ginseng, ginkgo, and vitamin E while taking. Talk with healthcare provider. 9. If patient is allergic to any medicine, especially aspirin, or have asthma. Make sure to tell about the allergy and how it affected the patient by consulting its attending physician.

Generic Name Cefuroxime

Brand Name

Aeruginox, Altacef, Ambixime, Bactipoz, Cefogen, Ceftin, Cefucil, Cefuzime, Zefur, Zinacef, and Zinnat.

Classification Second-generation Cephalosporin and antibiotic.

Ordered Dosage

Route: PO Dosage: 500mg BIP

Dosage Frequency

Mechanism of Action Cefuroxime binds to bacterial membranes. It inhibits synthesis of bacterial cell wall

Indications

For the treatment of many different types of bacterial infections such as bronchitis, sinusitis, tonsillitis, ear infections, skin infections, gonorrhea, and urinary tract infections

Contraindications

Cefuroxime is contraindicated in patients with known allergy to the cephalosporin group of antibiotics. Solutions containing dextrose may be contraindicated in patients with hypersensitivity to corn products.

Oral candidiasis (mouth and/or tongue sores) Side effects and Adverse Reactions Mild diarrhea Mild abdominal cramping Vaginal candidiasis Nausea Serum sickness reaction (joint pain, fever) Allergic reactions Thrombophlebitis Nursing Responsibilities 1. Check the drug label before preparing the drug. 2. Check the latest doctor prescribed dosage and ask somebody for clarifications about the dosage. 3. Check latest doctor prescribed dosage frequency. Administer on time. 4. Question for history of allergies, particularly cephalosporins and penicillins. 5. Give without regards to meals. If GI upset occurs give with food or milk. 6. Avoid crushing tablets due to bitter taste. 7. Suspension must be given with food. 8. Intramuscular injections must be administered deep IM to minimize discomfort. 9. Assess mouth for white patches on mucous membranes and tongue. Ensure right patient, ask the patient his name and check the ID band.

10. Monitor bowel activity and stool consistency carefully. 11. Mild GI effects may be tolerable but increasing severity may indicate onset of antibiotic-associated colitis. 12. Monitor input and output and renal function reports for nephrotoxicity. 13. Be alert for superinfection: severe genital or anal pruritus, abdominal pain, and severe mouth soreness, moderate to severe diarrhea. 14. Assess for hypersensitivity and other contraindications and current fluid intake and output record if present. 15. Check fluid intake and output and presence of side effects and adverse reactions. 16. Document drug administration and reactions if present. Record the administration in the medication sheet. 17. Assess and confirm if patient is having problems with regards to the medication and for reasons of refusing drug administration. Confirm from the patient and significant others on their view of the drug administration. 18. Instruct patient on proper drug compliance and report for signs of side and adverse effects. Orient the patient and significant other about the drugs action and effects.

Generic Name

Paracetamol Brand Name Common Brand names are Aeknil, Biogesic, Calpol, Neokiddielets, Tempra.

Classification Analgesic (pain reliever) and Antipyretic (fever reducer)

Ordered Dosage

Route: IVTT Dosage: 300mg PTOR

Dosage Frequency

Mechanism of Action

Thought to produce analgesic by pain impulses, probably by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to mechanical or chemical stimulation. Its thought to relieve fever by central action in the hypothalamic heat-regulating center.

Indications Fever, Relief of mild to moderate pain like headaches, muscular aches and pain, toothache, colds, earache, fever due to tonsillectomy, inoculations, and vaccinations.

Contraindications

Contraindicated in patients hypersensitive to drug Use cautiously in patients with long-term alcohol use because therapeutic doses cause hepatotoxicity in the patients.

Side effects and Adverse Reactions

Side effects -Cramping - Heartburn - Abdominal distention can be experienced - Hypersensitivity reactions. Adverse Reactions Anorexia, nausea, diaphoresis (excessive sweating), generalized weakness within the first 12-24 hours. Liver damage, jaundice, hypoglycemia, rash, vomiting 1. Ensure right patient, ask the patient his name and check the ID band. 2. Check the drug label before preparing the drug, before administering intravenously, and after administration. 3. Check the latest doctor prescribed dosage and ask somebody for clarifications about the dosage. 4. Check latest doctor prescribed dosage frequency. Administer on time. 5. Inform patient about the drug and the purpose of administration 6. If to be given as analgesia, assess onset, type, location, duration of pain.

Nursing Responsibilities

7. Can be given without regards to meals. 8. Tablets can be crushed. 9. Assess temperature directly before and 1 hour after giving medication. 10. If respirations are <12/min (<20/min in children), withhold the medication and contact the physician. 11. Evaluate for therapeutic response: relief of pain, stiffness, swelling; increasing in joint mobility; reduced joint tenderness; improve grip strength. 12. Therapeutic blood serum level: 10-30 mcg/mL; toxic serum level: >200 mcg/mL. 13. Assess for hypersensitivity and other contraindications and current fluid intake and output record if present. 14. Check fluid intake and output and presence of side effects and adverse reactions. 15. Document drug administration and reactions if present. Record the administration in the medication sheet. 16. Assess and confirm if patient is having problems with regards to the medication and for reasons of refusing drug administration. Confirm from the patient and significant others on their view of the drug administration. 17. Instruct patient on proper drug compliance and report for signs of side and adverse effects. Orient the patient and significant other about the drugs action and effects. Patient Teaching Consult physician for use in children less than 2 years old; oral use more than 5 days for children, more than 10 days for adults, or fever more than 3 days. Do not crush or chew sustained-release or enteric-coated form. Report ringing in ears and persistent GI pain. Severe, recurrent pain or high continuous fever may indicate serious illness.

Generic Name

Diphenhydramine

Brand Name

BENADRYL

Classification Antihistamine

Ordered Dosage

Route: IVTT Dosage: 500 mg

Dosage Frequency

Once blood transfusion started

Mechanism of Action

Diphenhydramine competes with histamine at histamine receptor sites. It inhibits central acetylcholine. It results in anticholinergic, antipruritic, antitussive, and antiemetic effect. Diphenhydramine produces antidyskinetic and sedative effect.

Indications

Diphenhydramine

is used

to

treat

allergic reactions and

parkinsonism. It is also used in the prevention and treatment of nausea, vomiting, and vertigo due to motion sickness.

Diphenhydramine is also an antitussive and can be used as a short term treatment of insomnia. A topical form of

Diphenhydramine can be used to relieve pruritus, insect bites, and skin irritations.

Contraindications

Diphenhydramine

is

contraindicated

in

patients

who

are

hypersensitive to it or other antihistamines in its class. Because of their anticholinergic activity, antihistamines should be used with caution in patients with angle closure glaucoma, prostatic hypertrophy, pyloroduodenal or bladder neck obstruction, and COPD if mucosal secretions are a problem

Side effects and Adverse Reactions

Side Effects : Drowsiness Dizziness Muscular weakness Hypotension Dry mouth, nose, throat, or lips Urinary retention thicknening of bronchial secretions Sedation Epigastric distress Flushing Visual or hearing disturbances Paresthesia Diaphoresis

Chills Adverse Reactions: Dominant paradoxical reactions (restlessness, insomnia, euphoria, nervousness, and tremors)

o o o o

Hallucinations Seizures Hypersensitivity reactions (eczema, pruritus, rash, cardiac disturbances, and photosensitivity) CNS depression (sedation, apnea, hypotension, cardiovascular collapse, and death)

Nursing Responsibilities

1. Verify the identity of the patient 2. Inform the patient about the administration of drugs and its purpose 3. Assess onset, type, location, and duration of pain. 4. Give without regards to meals. 5. Scored tablets may be crushed. 6. Do not crush capsules or film-coated tablets. 7. If patient is having acute allergic reactions, obtain history of recently ingested food, drugs, environmental exposure, and recent emotional stress. 8. Monitor rate, depth, rhythm, and type of respiration. 9. Monitor rate, depth, rhythm, and quality or rate of pulse. 10. Assess lung sounds for rhonchi, wheezing, rales. 11. Monitor blood pressure especially in elderly. 12. Monitor children closely for paradoxical reaction. Patient Teachings
o o o o

Tolerance to antihistamine effect generally does not occur; tolerance to sedative effect may occur. Avoid tasks that require alertness and motor skills until response to drug is established. Dry mouth, drowsiness, and dizziness may be an expected response of drug. Avoid alcoholic beverages.

Generic Name

Cefazolin

Brand Name

Ancef

Classification

Therapeutic: Anti-infectives Pharmacologic: First generation cephalosphorins

Ordered Dosage

Route: IVTT Dosage: 1 g

Dosage Frequency

Q8

Mechanism of

Bind to bacterial cell wall membrane, causing cell death.

Action

Active against many gram-positive cocci including: Streptococcus pneumoniae, Group A beta-hemolytic streptococci; Penicillinas-producing staphylococci.

Indications

Treatment of: Skin & skin structure infections; pneumonia; urinary tract infections; bone & joint infections

Contraindications

Hypersensitivity to cephalosporin. Serious hypersensitivity to penicillin.

Side effects and Adverse Reactions

CNS: Seizures (high doses) GI: Pseudomembranous colitis, diarrhea, nausea, vomiting, cramps GU: Interstitial nephritis DERM: Rashes, urticaria HEMAT: Blood dyscrasias, hemolytic anemia LOCAL: Pain at IM site, phlebitis at IV site MISC: Allergic reactions including Anaphylaxis and Serum sickness, super infection

Nursing Responsibilities

1. Verify the identity of the patient 2. Inform the patient about the administration of drugs and its purpose 3. Assess patient for infection (vital signs; appearance of surgical site, urine; WBC) at beginning and during therapy. 4. Before initiating therapy, obtain a history to determine previous use of and reactions to penicillins or

cephalosphorins. Persons with a negative history of penicillin sensitivity may still have an allergic response. 5. Obtain specimens for culture and sensitivity before initiating therapy. 6. Observe patient for signs and symptoms of anaphylaxis (rash, pruritis, laryngeal edema, wheezing). Discontinue drug and notify physician or other health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of anaphylactic reaction. 7. Monitor site for thrombophlebitis (pain, redness, swelling). Change sites every 48-72 hr to prevent phlebitis. 8. Instruct patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy. 9. Instruct patient to notify health care professional if fever and diarrhea develop, especially if diarrhea contains blood, mucus, or pus. Advise not to treat diarrhea without consulting healthcare professional.

Generic Name

Amikacin

Brand Name

Amikin, Amikin Pediatric

Classification

Amino glycoside

Ordered Dosage

Route: IVTT Dosage: 240 mg

Dosage Frequency

Q12

Mechanism of Action

Amikacin binds to 30S ribosomal subunits of susceptible bacteria, thus inhibiting its protein synthesis. Distribution: Detected in body tissues and fluids after inj; crosses the placenta but does not readily penetrate the CSF. Significant amounts penetrate the blood-brain barrier in children with meningitis.

Excretion: Via the urine by glomerular filtration (within 24 hr); 2-3 hr (elimination half-life).

Indications

Amikacin is indicated for the treatment of infections of: central nervous system, urogenital system, biliary and intestinal tracts, skin and subcutaneous tissues, intraabdominal infections, pneumonia, caused by Gram-negative microorganisms, secondary infections after combustion, bacterial septicemia, infections of the bones and joints (caused by sensitive to Amikacin microorganisms).

Contraindications

A history of hypersensitivity to amikacin is a contraindication for its use. A history of hypersensitivity or serious toxic reactions to aminoglycosides may contraindicate the use of any other aminoglycoside because of the known cross-sensitivities of patients to drugs in this class

Side effects and Adverse Reactions

an allergic reaction (shortness of breath; closing of the throat; hives; swelling of the lips, face, or tongue; rash; or fainting); little or no urine; decreased hearing or ringing in the ears; dizziness, clumsiness, or unsteadiness; numbness, skin tingling, muscle twitching, or seizures; or Severe watery diarrhea and abdominal cramps.

Nursing Responsibilities 1. Ensure right patient, ask the patient his name and check the ID band. 2. Check the drug label before preparing the drug. 3. Check the latest doctor prescribed dosage and asks somebody for clarifications about the dosage. 4. Check latest doctor prescribed dosage frequency. Administer on time. 5. Patients should be counselled that antibacterial drugs including Amikacin should only be used to treat bacterial infections. 6. Patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. 7. Skipping doses or not completing the full course of therapy may: Decrease the effectiveness of the immediate treatment and Increase the likelihood that bacteria will develop resistance and will not be treatable by Amikacin or other antibacterial drugs in the future.

Generic Name

Ranitidine Hydrochloride

Brand Name

Zantac

Classification

Therapeutic: Anti-ulcer agents Pharmacologic: Histamine H2 antagonists

Ordered Dosage

Route: IVTT Dosage: 30 mg

Dosage Frequency Q8

Mechanism of Action Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. In addition, ranitidine bismuth citrate has some antibacterial action against H. pylori.

Indications Treatment and prevention of heartburn, acid indigestion, and sour stomach.

Contraindications

Hypersensitivity, Cross-sensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in: Renal impair Geriatric patients (more susceptible to adverse CNS reactions) Pregnancy or Lactation

Side effects and Adverse Reactions

Altered taste Constipation nausea

Nursing Responsibilities

Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid. Inform patient that it may cause drowsiness or dizziness. Inform patient that increased fluid and fiber intake may minimize constipation. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly.

Inform patient that medication may temporarily cause stools and tongue to appear gray black.

Assess patients GI condition before starting therapy and regularly thereafter to monitor the drugs effectiveness. Assess patients and familys knowledge of drug therapy. Be alert for adverse reactions and drug interactions. Assess patients and familys knowledge of drug therapy.

Patient teaching

Remind patient taking drug once daily to take at bed time. Instruct patient to take drug with or without food. Urge patient not to smoke cigarettes; smoking may increase

gastric acid secretions and worsen disease.

Generic Name Metoclopramide

Brand Name

Reglan

Classification

Function classification: Cholinergic and Antiemetic Chemical classification: central dopamine receptor antagonist

Ordered Dosage

Route: PO Dosage: 10 mg 1 tab

Dosage Frequency

Q6

Mechanism of Action Blocks dopamine receptors by disrupting CNS chemoreceptor trigger zone, increasing peristalsis and promoting gastric emptying

Indications

Preventing nausea and vomiting induced by cisplatin and other chemotherapy

Contraindications

contraindicated in patients with hypersensitivity to the drug or to sulfonamides; pheochromocytoma, because it it may induce hypertensive crisis; and seizure disorders, renal failure, liver failure, parkinsons disease GI hemorrhage or intestinal obstruction or perforation, because the drug may exacerbate symptoms of these disorders . Do not use the drug for longer than 12 weeks. Restlessness Anxiety Drowsiness Fatigue Lassitude Insomnia Headache Dizziness

Side effects and Adverse Reactions

Nursing Responsibilities

Obtain a baseline assessment of blood pressure, mental status, GI status, and history of seizure disorder or pheochromocytoma before therapy.

Be alter for adverse reactions or drug interactions during therapy Evaluate the patients and familys knowledge about metoclopramide. Be aware that safety and effectiveness have not been established for therapy that continues longer than 12 weeks Monitor effectiveness by observing the patient for nausea and vomiting Monitor fluid balance. Monitor Vital Signs Observe for changes in mental status, moods, and behavior. Use safety precautions for patients who develop adverse CNS reactions If patient is alert, encourage adequate intake of fluids to prevent fluid volume deficit.

Patient teaching Warn patient to avoid activities requiring alertness for 2 hours after taking each dose. Advise patient that changes in mood and behavior may accompany therapy with metoclopramide.

Generic Name

Furosemide

Brand Name

Lasix

Classification

Diuretic

Ordered Dosage

Route: IVTT Dosage: 20 mg

Dosage Frequency

Post BT

Mechanism of Action

Enhances excretion of sodium, chloride, potassium by direct action at ascending limb of loop of Henle and produces a diuretic effect.

Indications

Treatment of edema associated with congestive heart failure, chronic renal failure, hepatic cirrhosis, and acute pulmonary edema. It is also used for treatment of hypertension, alone or in combination with other hypertensive. Can also be used for treatment of hypercalcemia.

Contraindications

Pronounced hyponatremia or hypovolemia and anuria.

Side effects and Adverse Reactions

Side Effects Increase in urinary frequency or volume Nausea Gastric upset with cramping Diarrhea or constipation Electrolyte disturbances Dizziness or light headedness Headache Blurred Vision Paresthesia Photosensitivity Rash Weakness Bladder spasm Restlessness Diaphoresis Flank or loin pain Adverse Reactions Excessive diuresis may lead to increased water loss and electrolyte depletion resulting to hypokalemia, hyponatremia, and dehydration. Sudden volume depletion may result in increased risk f thrombosis, circulatory collapse, or sudden death. Acute hypotensive episodes may occur, sometimes several days after beginning of therapy. Ototoxicity manifested as deafness, vertigo, and tinnitus

may occur especially in patients with severe renal impairment. It can exacerbate diabetes mellitus, systemic lupus erthematosus, gout, and pancreatitis. Blood dyscrasias have been reported.

Nursing Responsibilities

1. Ensure right patient, ask the patient his name and check the ID band. 2. Check the drug label before preparing the drug. 3. Check the latest doctor prescribed dosage and asks somebody for clarifications about the dosage. 4. Check latest doctor prescribed dosage frequency. Administer on time. 5. Give with food to avoid gastroinestinal upset, preferably with breakfast (to prevent nocturia). 6. If given IM, temporary pain at injection site may be noted. 7. Check vital signs especially blood pressure for hypotension prior to administration. 8. Assess baseline electrolyte, particularly check for low potassium. 9. Assess edema, skin turgor, and mucous membranes for hydration status. 10. Assess muscle strength and mental status. 11. Obtain baseline weight. 12. Initiate Input and Output monitoring. 13. Note extent of diuresis.

Generic Name

Cloxacillin

Brand Name

Cloxapen, Tegopen

Classification

antiinfective; antibiotic, natural penicillin; beta-lactam

Ordered Dosage

Route: PO Dosage: 500 mg per cup

Dosage Frequency

Q6

Mechanism of Action

Cloxacillin is resistant to degradation by penicillinases. It is particularly useful against penicillinase-producing staphylococci. Highly active against S aureus, S pyogenes, S viridans and S pneumoniae. Absorption: Incompletely absorbed from the GI tract with peak plasma concentrations after 1-2 hr (oral); may be reduced in the presence of food. Completely absorbed with peak plasma

concentrations after 30 min (IM). Distribution: Pleural and synovial fluids and bone (therapeutic concentrations), CSF (small amounts except when the meninges are inflamed; crosses the placenta and enters the breast milk. Protein-binding: 94% Metabolism: Minimal metabolism. Excretion: Via the urine by glomerular filtration and renal tubular secretion (35% of an oral dose); via the bile (Up to 10%). Not removed by dialysis; 0.5-1 hr (elimination half-life).

Indications

Cloxacillin is effective against Penicillinase producing Staphylococcus. It also acts against Strep Pyogenes,Strep Viridans, Strep Pneumonia.

Contraindications

Contraindicated in hepatic failure, Lactation, Hypersensitivity to penicillin and pregnancy.

Side effects and Adverse Reactions

Side effects

An allergic reaction Severe watery diarrhea Severe cramps Unusual bleeding Mild nausea White patches on the tongue Vaginal yeast infection Black, "hairy" tongue or sore mouth or tongue

Nursing Responsibilities

1. Ensure right patient, ask the patient his name and check the ID band. 2. Check the drug label before preparing the drug. 3. Check the latest doctor prescribed dosage and asks somebody for clarifications about the dosage. 4. Check latest doctor prescribed dosage frequency. Administer on time 5. Determine previous exposure and sensitivity to penicillins and cephalosporins and other allergic reactions of any kind before treatment is initiated. 6. Monitor for S&S of anaphylactoid reaction (see Appendix G) or other signs or symptoms of hypersensitivity reaction (see Appendix F) as with other penicillins. 7. Lab tests: Periodic assessments of renal, hepatic, and hematopoietic function are advised in patients on long-term therapy. 8. Be sure to let healthcare provider know if your child has any allergies or reactions to medicine, food preservatives, or dyes. Make sure to tell about the allergy and how it affected your child. This includes telling about rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other symptoms involved.

Patient & Family Education

Take medication around the clock, do not miss a dose, and continue taking the medication until it is finished. Report to physician the onset of hypersensitivity reaction (see Appendix F) and superinfections. Check with physician if GI adverse effects (nausea, vomiting, diarrhea) appear. Do not breast feed while taking this drug.

Generic Name

Ascorbic Acid

Brand Name

CELIN(Glaxo), CHEWCEE(Wyeth Lederie), CELL -C (Sarabhai), CECON DROPS (Abbott),

Classification

Vitamins

Ordered Dosage

Route: PO Dosage: 500mg

Dosage Frequency

BID

Mechanism of Action

Assists in collagen formation, tissue repair; involved in oxidation reduction reactions, other metabolic reactions. Vitamin C is involved in metabolism; carbohydrate utilization; synthesis of lipids, proteins, carnitine. It also preserves blood vessel integrity.

Indications

Vitamin C is a compound that is necessary for proper growth and health. They are needed in small amounts only and are usually available in the normal foods that are ingested. Ascorbic acid( vitamin C) is necessary for wound healing. Vit C plays a major role in many oxidative and other metabolic reactions essential for formation and stabilization of collagens,conversion of folic acid to folinic acid, synthesis of adrenal steroids and catacholamines.It is very important for maintanance of intracellular tissue.

Contraindications

Use of sodium ascorbate in patients on sodium restriction; use of calcium ascorbate in patients receiving digitalis. Ascorbic acid may be contraindicated in patients with hemolytic anemia.

Side effects and Adverse Reactions

Side Effects Abdominal cramps Nausea Vomiting Diarrhea Increased urination with doses exceeding 1 gram Flushing Headache Dizziness Sleepiness or insomnia Adverse Reactions Urine acidification that may lead to crystalluria

Nursing Responsibilities

Nursing Considerations May give without regard to food. Assess for clinical improvement (improved sense of wellbeing and sleep patterns). Observe for reversal of deficiency symptoms (gingivitis, bleeding gums, poor wound healing, digestive difficulties, joint pain).

Patient Teachings Abrupt vitamin C withdrawal may produce rebound deficiency.

Generic Name

25 % Albumin vial

Brand Name

Commonly used brand name(s): Albuminar-25; Albuminar-5; Albutein 25%; Albutein 5%; Buminate 25%; Buminate 5%; Plasbumin-25; Plasbumin-5.

Classification

Ordered Dosage

Route: IVTT Dosage: 25% albumin vial

Dosage Frequency

Transfuse in 4 hours

Mechanism of Action

Blood volume expanderAlbumin is an important regulator of the volume of circulating blood. It accounts for 70 to 80% of the colloid oncotic pressure of plasma. An infusion of albumin 5% is oncotically equivalent to an equal volume of human plasma and increases blood volume by an amount approximately equal to the

volume of albumin infused; albumin 25% is oncotically equivalent to approximately 5 times the volume of human plasma and draws into the circulation an amount of fluid approximately 3.5 times the volume of albumin in infused. blood Albumin volume, provides which a

temporary increase

reduces

hemoconcentration and blood viscosity.

Indications

Albumin (Human), Human Albumin Grifols 25% is indicated: a. For the prevention and treatment of hypovolemic shock b. in conjunction with exchange transfusion in the treatment of neo-natal hyperbilirubinemia c. Concentrated Albumin (Human) solutions (e.g., 25%) have also been used successfully to induce diuresis in some patients with acute nephrosis who were refractory to other forms of treatment. However, Albumin (Human) has no role in the management of chronic nephrosis. d. More dilute Albumin (Human) solutions (e.g., 5%) have been used as pump priming fluids during cardiopulmonary bypass. However, an adequate blood volume can also be maintained during bypass with crystalloid as the only priming fluid without a significant difference in the clinical outcome achieved.

Contraindications

Contraindicated in patients with severe anemia or cardiac failure in the presence of normal or increased intravascular volume. The use of Human Albumin Grifols 25% is contraindicated in patients with a history of allergic reactions to albumin.

Side effects and Adverse Reactions

Rare- Nausea, fever, chills, flushing, hives, skin rash, itching, headache, breathing difficulty, rapid heartbeat or allergic reactions may occasionally occur. Potentially Fatal : Anaphylactic shock.

Nursing Responsibilities

1. Ensure right patient, ask the patient his name and check the ID band. 2. Check the drug label before preparing the drug. 3. Check the latest doctor prescribed dosage and asks somebody for clarifications about the dosage. 4. Check latest doctor prescribed dosage frequency. Administer on time 5. This product is usually given in a hospital setting. 6. Inform patients being treated with Albumin (Human) 20% about the potential risks and benefits with its use 7. Discontinue immediately if allergic symptoms occur (e.g. skin rashes, hives, itching, breathing difficulties, coughing, nausea, vomiting, fall in blood pressure, increased heart rate). 8. Inform patients that Albumin (Human) 20% is a derivative of human plasma and may contain infectious agents that cause disease (e.g., viruses, and theoretically, CJD agent). 9. Inform patients that the risk that Albumin (Human) 20% may transmit an infectious agent has been reduced by screening plasma donors for prior exposure for certain viruses, by testing the donated plasma for certain virus infections and by inactivating and/or removing certain viruses during manufacturing .

Nursing Theory 1. Florence Nightingale (Environmental theory)

Definition She stated in her nursing notes

Rationale Nurses should assist the

that client during his/her recovery. If

nursing "is an act of ever they are not able to give him utilizing the environment the most ideal environment there of the patient to assist is, it is the nurses duty to give him in his recovery" him the comfort as part of our care. Such ways include the good that it sanitation where the client stays;

(Nightingale 1860/1969), involves initiative the to

nurse's it includes cleaning the area configure always, attending to her

environmental appropriate gradual

settings immediate needs, and keeping for the environment suitable for clients of recovery.

restoration

the patient's health, and that external factors the

associated patient's

with

surroundings

affect life or biologic and physiologic processes,

and his development.

2. Adaptation Model (Callista Roy)

The major concepts are The theory is applicable to the the person or group as patient since it is focused to the an adaptive system; the adaptation ability of the patient environment as internal that and health external can greatly affect the

stimuli; recovery of the patient. In the and patients condition, it is very and important that hell be able to

as being whole

becoming

integrated; and nursing have a fast recovery because as the art and science of recovering would mean that the promoting The adaptation. patient will be able to go back to and the things that he used to do

philosophic

scientific are basic

assumptions before his admission and be able underlying to continue on with his life. The model However, the patient has already

concepts.

aims to direct nursing accepted his condition and is practice, research and slowly trying to live a normal life education. The despite of his condition.

widespread us of the model in each of these areas is well for

documented,

example, in all areas of practice, all levels of education, quantitative qualitative research. Halls theory of The patient cannot fully do the nursing involves three things he usually does when he interlocking circles, each still has both arms and somehow representing one aspect needs the assistance of the and in and

3. Core, Care, Cure Theory (Lydia E. Hall)

of nursing. The care nurse. The support coming from aspect represents his family motivates him to

intimate bodily care of comply with the therapy. While the patient. The core we nurses did our part by

aspect deals with the providing him the care that he innermost feelings and needs including the therapeutic motivations of the communication, body language

patient. The cure aspect that he deserves. tells how the nurse

helps the patient and family through the

medical aspect of care. The main tool the nurse

uses to help the patient realize her or her

motivations and to grow in self-awareness is that of reflection.

DATE & TIME

CUES

NEED

NURSING DIAGNOSIS

OBJECTIVES OF CARE

NURSING INTERVENTIONS

EVALUATION

1. Medicate patient with the Septemb er 15, 2011 @ 4:00 PM SUBJECTIVE: sakitakoangsugat dirisatiil, as verbalized by the patient. C O G N I T I OBJECTIVE: patient complains of pain at the right thigh; post skin graft; grimace face noted; guarding P E R C E P V E Pain is a subjective state which varies on how the client perceives it as well as on the clients level of pain threshold. Pain is commonly observed in clients who undergone surgery since Pain related to post surgical procedure secondary to Skin Grafting That within our 2 hours span of care our patient will be relieve from pain as evidenced by: a. Pain scale will be reduce from moderate to mild or absence of pain; Pain scale: 0 Absent: 1 to 3 Mild; 4 to 7 Moderate 7 to 10 Severe b. Demonstrate techniques that prescribed analgesics as ordered such as Ketorolac and Tramadol; evaluate and document patients response through the pain scale. Drug administration of analgesics will aid in relieving the pain, thus decreasing the severity of the pain. 2. Perform comfort measures passive range of motion of the hands and the like. These measures reduce muscle spasm, redistribute pressure on body parts and help patient focus on non-pain related subjects. 3. Plan activities with the patient to provide distraction, such as reading, talking, and other After rendering different sets appropriate, comprehensive and systematic nursing interventions our client was able to relieve from pain as evidenced by: a. pain scale of 1 out of 3 which signifies reduction of pain intensity from moderate to mild; GOAL MET September 15, 2011 @ 6:00 pm

behavior at the site of pain; motion is done in a slow manner; Pain Characteristic s: Severity: 4 Pain Scale o o Mild: 1 to 3 Moder ate: 4 to 6 o Sever e: 7 to 10 Location: Right thigh

T U A L P A T T E R N

trauma is being induce to the client couple with breakage in the continuity of the different levels of bodys tissues. In due to this existence our bodys normal reaction to this situation is pain.

can help to alleviate pain such as deep breathing exercises.

distraction techniques. These heighten ones concentration upon non-painful stimuli to decrease ones awareness and experience of pain. 4. Eliminate additional stressors or sources of discomfort whenever necessary or possible. Patient may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if the environmental, intrapersonal and intra-psychic factors are further stressing them.

b. able to perform relaxation techniques such as deep breathing exercises which helps in alleviating pain.

Bibliography: Smeltzer,S.,Bare,B, . et al Brunner and Suddarths Textbook of Medical Surgical Nursing

5. Teach the patient on relaxation exercises, breathing exercises or even music therapy. Techniques are used to bring about a state of physical and mental awareness and tranquility. The goal of these techniques is to

Duration: Continuous Quality: Burning with medication/s of: Ketorolac; and Tramadol for pain.

Bare,B.,RN,MSN, Cheever, K, K, PhD, RN, Hinkle, J., PhD, RN,

reduce tension, subsequently reducing pain. 6. Provide rest periods especially to the client after performing those activities which may aid in alleviating the pain. This facilitates comfort, sleep and relaxation. In a cyclic fashion, feeling of pain may lead towards the occurrence of fatigue and even exhaustion, thus resting period is very much essential. 7. Help the patient in a comfortable position, and use pillows to splint or support painful areas as appropriate. This aid in reducing spasm at the site of pain, preventing worsening of painful stimulation and experience. 8. Provide anticipatory instruction on

pain causes, appropriate prevention and relief measures. Knowledge about what to expect can help the patient develop effective coping strategies for pain management. 9. Instruct patient to report existence or feeling of pain. Relief measures to be instituted as early as possible. 10. Instruct the patient to evaluate and even report effectiveness of measures used. Pain relief strategies can be modified, to promote more satisfactory comfort levels.

DATE & TIME

CUES

NEED

NURSING DIAGNOSIS

OBJECTIVES OF CARE

NURSING INTERVENTIONS

EVALUATION

Septembe r 15, 2011 @ 3:00 PM

S/O: Hiding altered body part with the use of clothing. Refusal to talk about the altered body part. Changes in social behavior. When asked about his

S E L F

Body Image Disturbance related to Permanent Alterations in structure and

Within our 8 hours span of nursing care, our patient will be able to demonstrate enhanced body image as evidenced

1. Note sign of grieving/indicators of severe or prolonged depression. To evaluate need for counseling and/or medications. 2. Observe interaction of patient with significant others. Distortion in body image may be unconsciously reinforced by family members.

September 15, 2011 @ 11:00 pm

GOAL PARTIALLY MET

P E R C E P T I O

function.

After our 8 hours span of nursing care, our patient was able to demonstrate enhanced body image as evidenced by:

Amputation is a reconstructive procedure that alters the patient's body image. The nurse encourages the patient to look

by:

Ability to look at, touch and talk about the altered body part.

3. Listen to patients comments and responses to the situation. Different situations are upsetting to different people, depending on individual coping skills.

Able to look at,

touch and talk about

amputated arm, he avoids the topic. He would feel irritated when interviewed about his amputated arm compared to other topics.

at, feel and care for the altered body

Able to enhance self esteem.

4. Note withdrawn behavior and the use of denial. may be normal response to situation or may be indicative of mental illness. 5. Visit patient frequently and acknowledge the individual as someone who is worthwhile. Provides opportunities for listening to concerns and questions. 6. Assist in correcting underlying problems. To promote optimal healing/adaptation. 7. Encourage verbalization of and role play anticipated conflicts. To enhance handling of potential situations. 8. Set limits on maladaptive behavior and assist patient to identify

the altered body part. Able to enhanced self esteem. Patient was not able to verbalized understanding of body changes.

part. The loss of an extremity may come as a shock even if the patient was prepared

Verbalize understandin g of body changes.

S E L F

preoperatively. The patient's behavior and expressed feelings reveal how the patient is

C O N C E P T

coping with the loss and working through the grieving process. the patient who is accepted as a whole person is more readily able to

resume

A T T E R N

responsibility for self care, self concept improves and body image changes as accepted.

positive behaviors. To aid in recovery. 9. Help patient to select and use of clothing. To minimize body changes and enhance appearance. 10. Provide information at patients

Bibliography: Brunner &Suddarths Textbook of Medical Surgical Nursing 11th edition

level of acceptance. To allow for easier assimilation.

DATE & TIME

CUES

NEED

NURSING DIAGNOSIS

OBJECTIVES OF CARE

NURSING INTERVENTIONS

EVALUATION

September 17, 2011 @ 3:00 PM

SUBJECTIVE: Katolakoangsug at as verbalized by the patient.

N U T R I

Impaired Skin Integrity related to humidity and moisture secondary to STSG

Within our 5 hours span of care the patient will be able to improve skin integrity as evidenced by: a. Demonstrate behaviors to

1. Discuss Importance of adequate nutrition especially, Increase intake of fluids, proteins and vitamins. These provide patient information how nutrition could elevate his chances of a faster recovery and wound healing. 2. Instruct not to scratch the wound. This provides patient a guide towards a proper skin management technique minimizing more skin trauma. 3. Emphasize principles of asepsis especially hand washing. To avoid possible infection

September 17, 2011 @ 8:00 PM

GOAL PARTIALLY MET

OBJECTIVE: Open wound Not covered with dressing Redness, Swelling and purulent discharges noted.

T I O N A L

At the end of 5 hours span of care the patient was able to improve skin integrity as evidenced by: a. Demonstrated behavior to promote healing and prevent complications such not touching the wound. b. There were minimal discharges noted. c. Able to cope with ADL.

The integument acts as a protective barrier from environmental

promote healing and prevent complication. b. Absence of discharges in the wound. c. Cope with the activities of daily living.

M E T A B O L I C

insults including trauma, radiation, harsh environmental conditions and infection.

Bibliography: Brunner'sand Suddarth's

thus hindering the wound healing process 4. Demonstrate wound care

P A T T E R N

Textbook of Medical-Surgical Nursing(2008)

technique such as wound cleansing and dressing changing. To provide the patient on the correct procedures and

techniques of wound caring. 5. Reinforce initial dressing/ Change as indicated. Protects wound from mechanical injury and contamination. 6. Caution client not to touch incision. Prevents contamination of area. 7. Provide information about signs of wound infection and order to report complications. Elevate the chances of faster wound healing which is important towards avoiding

further complications or early detections. 8. Encourage verbalization of feelings perceptions and fears. To evaluate patients perceptions upon her condition.

DATE & TIME

CUES

NEED

NURSING DIAGNOSIS

OBJECTIVES OF CARE

NURSING INTERVENTIONS

EVALUATION

Septembe r 16, 2011 @ 3:00 PM

S/O: Open wound at right leg. WBC of 23.67 Redness, swelling and purulent discharge s at incision. Meds: Cefazolin

H E A L T H

Risk for infection related to surgical procedure secondary to Fore Quarter Amputation

Within our 5 hours span of nursing care, my patient will be free from infection as evidence by:

1. Administer antibiotics such as Cefazolin as ordered. To kill microorganisms that may predispose infection. 2. Wash hands before and after handling the client. To deter the spread of microorganism. 3. Wear gloves when handling patient. Using gloves does not just protect the health worker but also prevent contamination to the wound. 4. Monitor the wound for redness, swelling, pain, discharges and

September 16, 2011 @ 8:00 pm

GOAL MET

Surgery P E R C E P T I O Brunner Bibliography: traumatizes the body by disrupting protective mechanisms and homeostasis.

Verbalize interventions that may prevent infection.

After our 5 hours span of nursing care, our patient was free from infection as evidenced by: Verbaliz ed: walananko

Absences of redness, swelling and purulent discharges at

&Suddarths Textbook of Medical Surgical Nursing 11 edition

th

post-op site.

heat. This may signify that an active inflammatory response to local area is present 5. Clean and dry surrounding tissue of lesion. Adjacent areas that are unclean may potentiate skin breakdown. 6. Replace soiled linens in contact with lesions

ginagunitan akoangsug atugnagahu gasnapudk ougkamot. Absenc e of redness , swelling and dischar ges at post-op site.

H E A L T H

M A N A G E M E N T

Soiled linens are good medium for microbial growth 7. Instruct to avoid scratching the healing lesions Healing wound is usually itchy. 8. Avoid unnecessary contact with the lesion It decreases the potentiality of acquiring infection 9. Monitor vital signs

Increase in vital signs, P A T T E R N especially temperature may indicate inflammatory response. 10. Provide/encourage balanced diet, emphasizing proteins to feed the immune system. Immune function is affected by protein intake, the balance between omega-6 and omega-3 fatty acid intake, and adequate amounts of vitamins A, C, and E and the minerals zinc and iron. A deficiency of these nutrients puts the client at an increased risk of infection. 11. Review individual nutritional needs, appropriate exercise program, and need for rest. Enhance immune system function and healing.

DATE & TIME

CUES

NEED

NURSING DIAGNOSIS

OBJECTIVES OF CARE

NURSING INTERVENTIONS

EVALUATION

September 17, 2011 @ 4:00 PM

SUBJECTIVE: Ayawgunitianga koangsugatkayb asig As verbalized by patient.

S E L F P E

Fear related to physical threat secondary surgical procedure (Skin Grafting)

Within our 2 hours span of nursing care, patient will be able to manifest a reduction or absence of fear as evidence by:

1. Determine what the patient is fearful of by careful and thoughtful questioning. The external sources of fear can be identified and current responses can be assessed. 2. Determine the degree of fear and the measures the patient uses to cope with fear. This helps determine the effectiveness of coping strategies used by patient. 3. Reinforce the idea that fear is a normal and appropriate response to situations when pain, danger, or loss of control is anticipated or experienced. Knowledge serves to reduce unrealistic expectations. 4. Assist the patient in identifying

September 17, 2011 @ 6:00 pm

GOAL MET

Fear is a strong and unpleasant emotion caused by the awareness or anticipation of pain, or danger. The factors that precipitate fear are fear of pain; bodily injury and surgical

demonstrate understanding through use of effective coping behaviors and resources and;

OBJECTIVE:

R C

Within our 2 hours span of nursing care, patient was able to manifest a reduction of fear as evidenced by: a. Demonstrated understanding through the use of effective coping behavior (relaxation

presence of wound at right thigh

E P T I O N

appears worried guarding behavior

Appear relax.

S E L F C

complication are common to most people.

Bibliography:

strategies used in the past to deal with fearful situations. These

O N C E P T

Lewis,S.et (2007)MedicalSurgical

al

measures may be helpful or comforting. This helps the patient to focus on fear as a real and natural part of life

exercises) b. appeared relax;

Nursing:

Assessmentand Management Clinical Problem of

that has been and can continue to be dealt with successfully. 5. Discuss resumption of activity.

P A T T E R N

Encourage light activities initially, with frequent rest periods, increasing activities and exercise as tolerated. Stress importance of individual response in recuperation. Client can expect to feel tired when he goes home and needs to plan a gradual resumption of activities, with return to school an individual matter. Prevents excessive fatigue; conserves energy for healing and tissue regeneration. 6. Instruct the patient to perform deep

breathing as self-calming measure that may reduce or make fear manageable. Controlled, rhythmic breathing can promote relaxation and feelings of being in control. 7. Instruct to perform exercises in relaxation, meditation, use of affirmations and calming self-talk. Exercise reduces physiological response to fear and it enhances patients sense of confidence and reassurance. 8. Stress importance of follow-up care. Provides opportunity to ask questions, clear up misunderstandings, and detect developing complications.

DISCHARGE PLAN

Medications Instruct patient to continue taking Ranitidine H2 inhibitor and Celecoxib an NSAIDs drug Inform client to take her medications on time, or as directed for the full course of therapy. Educate the patient about the side effects of Ranitidine such as; diarrhea, headache, nausea, dizziness and constipation, Celecoxib such as;headache and sore throat. Instruct patient and significant others not to stop taking the prescribed medications for the full course of therapy even if the patient already feels better or unless being approved by the patients attending physician. Instruct patient to check the labels of medicines before taking it.

Exercise Explain to client the value of exercise in our body like active ROM. Encourage the patient to have adequate rest and sleep. Instruct the patient that exercises performed should be within normal limits.

Treatment Instruct the client to continue drug therapy as ordered. Discuss to the client the complications of her sickness. Instruct the patient to report to the physician promptly any changes on health condition. Such as allergic reactions, high blood pressure or all of the unusualities that may happen to her.

Health Teachings Instruct the patient to do daily hygiene and grooming, which includes daily body bath and hand washing. Teach the patient and family how to promote healthy lifestyle like regular exercises and having adequate resting periods. Educate the family about the importance of maintaining the cleanliness of their surrounding environment. Inform the family of the patient about his condition and the necessary information for his treatment. Advice the patient to avoid strenuous activities until full recovery is achieved. Instruct patients significant others to provide emotional and social support to the patient. Teach patient how to do proper wound dressing. Follow up check-up after a week. Instruct patient the frequency of taking medications.

Outpatient Orders Instruct patient and significant others to have follow-up check-up. Encourage patient and significant other to notify the physician immediately if any unusalities in the health status have occurred. Encourage the patient to comply with all the regimen and instructions given to him. Continue medication as ordered.

Diet

Inform the patient and significant others the importance of following a healthy diet such as avoid drinking too much alcohol, low fatty foods, salty foods and increase iron intake such as ampalaya, raisins and liver.

Instruct patient to increase oral fluid intake.

Instruct patient to minimize intake of goitrogenic foods such radish, and other green leafy vegetables. Spirituality Encourage the patient to understand her situation whatever may happen . Advice the patient to keep on praying and never lose hope if any negative results will arise. Sexuality Advice the patient and significant other to refrain from doing sexual intercourse for the first few weeks of post surgery.

PROGNOSIS GOOD Onset of the illness FAIR POOR JUSTIFICATION The onset of the illness was gradual as the presence of mass on his right arm lasted for 3months. In terms of management, He was able to consult his doctor about it and respond to medications and surgery therefore had no delay on proper medical consultation Duration of illness For the past 3months the patient ignored his mass on the right arm and did respond to treatment. However, when he noticed that the mass is beginning to grow larger and he has difficulty in moving his arm because of it, he decided to consult a doctor and undergoes a surgery. Precipitating factors Lifestyle and diet, because the patient is lack of nutrients and the patient is in low class. And hes living in the farm which is far from the city proper.

Willingness to take medications and treatment

The patient is willing to take proper treatments accordingly since the surgery. They can afford the medicines and treatment needed for the improvement of her condition.

Age

Age do have a direct effect in the condition itself.However, the prevalence of

rhabdomyosarcomamost common in children ages one to five, and is also found in teens aged 15 to 19. According to statistics, by 3% of all childhood cancers are rhabdomyosarcomas.The patient is 14 years old. Environmental factors He is living in a farm where He defines well. That farm is far from the city proper. However theres a barangay health center near it, and far from

hospital but the patient chose to admit herself at SPMC in Davao. Family Support The patients family is very supportive throughout the treatment regimen of the patient.He is also frequently visited by his relatives to look out for his condition. Computation: Poor: (2*3)/7 = 0.86 Fair: (3*2)/7 = 6/7 = 0.86 = 0.86 2.58 Good: (3*2)/7 = 6/7 Total: Total 2 2 3 General Prognosis: 1-1.6 = POOR

1.7-2.3 = FAIR 2.4-3.0 = GOOD

General Prognosis: As shown by the calculated results with their respective points, the general prognosis of the client is GOOD. The patient has a good chance of recovering from his condition of having a rhabdomyosarcoma because of his age, presence of only two precipitating factors, compliance to some treatment regiment, and family support. Most rhabdomyosarcomaoccurs at the age 15 to 19. They are usually found by patients who feel a lump at their arms,legs, and jaws or after undergoing a physical examination. It is easily treated through surgery. As of now the patient has improved in terms of his health as evidenced by amputation

RECOMMENDATION

To the Patient She must be wary of abnormalities that are developing in her body like in the event when she observed that there was a mongo sized growth in her neck then she must have sought a medical advice. She should be wearing protective equipment when handling hazardous substances and be fearful of the consequences of not doing so for this is one of the suspected factors that made her sick. The patient must realize that her condition is uncommon. Hypocalcaemia must not be experienced by the client by taking calcium supplements as prescribed by the doctor. She can monitor apical pulse, blood pressure, & temperature at least every 4 hours. She must report palpitations, dyspnea, vertigo, or chest pain. She can keep her environment quiet & cool, change bed linens, & bath frequently.

She can elevate the head at night & use an eye lubricant. If photophobia is present, dark glasses or eye patches can be worn. If she cannot close the eyelids completely, she can tape the lids close with nonallergenic tape. If pressure behind the eye continues, she can undergo a doctor prescribed steroid therapy. She can take doctor prescribed diuretics to decrease edema around the eye. The client must report if there is an increase or recurrence of symptoms. She must have a regular follow-up. The client must inspect the incision area and report if there is redness, tenderness, drainage, and swelling to a member of a healthcare team. She can expect mood changes as a result of hyperthyroidism.

To the pt.s family Her family must encourage her to visit a physician & support her financially. They can try to hide their financial incapability to avoid discouraging her from undergoing a treatment and warn her of the larger cost of treating a severe disease. The family must be suspicious of recent weight loss & an increased appetite. The most important thing for them to watch out for is pt. diaphoresis even when the environmental temperature is comfortable for them.

To the Community The community must promote a positive atmosphere despite of the advanced stage of the disease. They must contain the backing out from the treatment thoughts of the patients mind. Her surrender in the treatment program must be related by them to her as an avenue for the worsening of her condition. They must let her realize that her condition is uncommon but controllable. They must give employment that is healthy in order for the people to have lesser chances of working in environment with toxic chemicals.

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Table of Contents I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. Acknowledgement Introduction Objectives Patients Data Genogram Family Background / Health History Developmental Data Physical Assessment Definition of Complete Diagnosis Anatomy and Physiology Etiology Symptomatology Pathophysiology Doctors Order Diagnostic Exam Drug Study 01 02 04 07 09 10 14 22 26 31 39 41 43 46 54 77 101 103 125 128 131 133

XVII. Nursing Theories XVIII. Nursing Care Plan XIX. XX. XXI. Prognosis Discharge Plan Recommendation

XXII. Reference