CHAPTER I CASE OVERVIEW Introduction Hepatoma is the one of the most common cancer in the world with 1 Million new cases diagnosed every year. Roughly 20,000 new cases are diagnosed every year in United States. It is more frequent in men and Oriental-Americans. The average age at the time of diagnosis is 60 years. Cancer of the liver can grow for a long time without causing any problems. Most patients are diagnosed in advanced stages. If left untreated, or if it fails to respond to treatment, liver cancer can spread to the rest of normal liver, causing liver failure, and also to lymph glands in the abdomen and lungs. This is the case of Ms. L. C., 88 years old, from Manjuyod, Negros Oriental, who was admitted last April 12, 2011 at Negros Oriental Provincial Hospital due to edema on lower extremities, weakness and epigastric pain. She was diagnosed with Hepatoma Right Lobe Metastasis Lungs Right-side Hypertrophy by Dr. V. J. T. She was attended to, and medicated, and has underwent several laboratory exams yet her condition worsened due to poor prognosis. Though the case was personally given by the clinical instructor, the presenters find reasons to continue with the case. First, it is a unique and interesting case, knowing that it is about cancer which is a rare case a student nurse can encounter and handle. Secondly, health history of the patient is quite enough to support the diagnosis, especially the manifestations and laboratory results. And lastly, they take this as a challenge since they have not yet had any discussion on oncology in their year level that would hopefully help in the understanding and analysis of Hepatoma. 1
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CHAPTER I
CASE OVERVIEW
Introduction
Hepatoma is the one of the most common cancer in the world with 1
Million new cases diagnosed every year. Roughly 20,000 new cases are
diagnosed every year in United States. It is more frequent in men and
Oriental-Americans. The average age at the time of diagnosis is 60
years. Cancer of the liver can grow for a long time without causing
any problems. Most patients are diagnosed in advanced stages. If left
untreated, or if it fails to respond to treatment, liver cancer can
spread to the rest of normal liver, causing liver failure, and also
to lymph glands in the abdomen and lungs.
This is the case of Ms. L. C., 88 years old, from Manjuyod,
Negros Oriental, who was admitted last April 12, 2011 at Negros
Oriental Provincial Hospital due to edema on lower extremities,
weakness and epigastric pain. She was diagnosed with Hepatoma Right
Lobe Metastasis Lungs Right-side Hypertrophy by Dr. V. J. T. She was
attended to, and medicated, and has underwent several laboratory exams
yet her condition worsened due to poor prognosis.
Though the case was personally given by the clinical instructor,
the presenters find reasons to continue with the case. First, it is a
unique and interesting case, knowing that it is about cancer which is
a rare case a student nurse can encounter and handle. Secondly, health
history of the patient is quite enough to support the diagnosis,
especially the manifestations and laboratory results. And lastly, they
take this as a challenge since they have not yet had any discussion on
oncology in their year level that would hopefully help in the
understanding and analysis of Hepatoma.
1
Objectives
In this clinical paper, the presenters have the following goals:
1. Describe the structure of a cell and the process of cell
proliferation and differentiation, discuss the normal anatomy and
physiology of the related systems which are the respiratory,
cardiovascular and systems and how their functions are altered in
the presence of Hepatoma, Right Lobe Metastasis Lungs, and Right-
sided Hypertrophy.
2. Show the current health status of the patient through thorough
physical assessment, laboratory examinations, as well as
diagnostic procedures of which the patient underwent.
3. Relate theories from books and other sources with the actual data
gathered from the patient during interaction and assessment.
4. Create a comprehensive pathophysiology to trace the pathogenesis
of the disease processes starting from the precipitating and
predisposing etiologic factors down to the complications,
including the clinical manifestations and their corresponding
interventions.
5. Formulate SMART nursing care plans that are effective and
efficient in enhancing the well-being of the patient and
alleviating the progression of the disease, and prioritize them
accordingly.
6. Justify all medical and nursing actions applied to the patient.
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Scope
The gathering of data and patient interaction was done for 4hours
during the clinical exposure and on the final visit later in the
afternoon of same day. Within this clinical paper is the discussion of
the information related to the care and condition of the patient
during her present hospitalization; the contents include the physical
assessment, laboratory results with their corresponding
interpretations, background of the normal anatomy and physiology of
the affected systems, theoretical background of the admitting
impression in connection to the patient’s status and manifestations,
the pathophysiology designed to trace the progression of the disease
process and the measures provided to solve each existing problems and
manifestations, the effectiveness of these interventions reflected on
the progress notes, and proposed discharge planning for the promotion
of the patient’s well-being.
Limitations
In the process of making this clinical paper, the group
encountered some limitations which are the following:
1. No data about the patient’s grandparents were gathered
because those people died before she was born and was not
told by her parents about their causes of death.
2. Health history and other pertinent data were only limited
to the patient’s responsiveness and SO’s knowledge.
3. Discussion on the pathology of the disease, particularly
Hepatoma, is limited only to the presentors’ own
understanding through researching since the topic cancer
was not yet included in their classroom discussions.
4. Some laboratory exams were taken only once, so tracking
of the disease progression is also limited.
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CHAPTER II
CASE DATA AND INFORMATION
BIOGRAPHICAL DATA
Name: L. C.
Address: Manjuyod, Negros Oriental
Age: 88 years old
Gender: Female
Birthplace: Manjuyod, Neg. Or., via home delivery
Birth Date: August 10, 1922
Civil Status: Single
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: Elementary Undergraduate
Health care financing: none
Date of Admission: April 12, 2011 at 10:26 PM
Final Diagnosis: Hepatoma Right Lobe, Metastasis Lungs Right-sided
Hypertrophy
Physician: Dr. V. J. T.
Source of information: Patient: 20%
SO: 30%
Patient’s chart: 50%__
100%
CHIEF COMPLAINT
“Abtik paman ni siya atong Enero-Pebrero, makalakaw-lakaw pa gud
ni siya; nikalit lang man siya ug kaluya, dayon mao lagi ning iyahang
dire (referring to the abdomen) nidako man, nisamot pud ang hubag sa
iyang batiis,” as verbalized by the patient’s sister.
PRESENT HEALTH HISTORY
One month prior to admission, patient started to experience
swelling on lower extremities, epigastric pain and body weakness. She
consulted a local physician and was medicated. By end week of March,
her condition worsened. She became bed-ridden and her abdomen became
bigger and harder. The edema on her lower extremities also worsened,
and was associated with pitting. April 12, 2011, at around 9:00 in the
evening, patient was brought to Bais District Hospital due to the
worsening condition. She was received at the Emergency Department and
was hooked with IVF of D5NS at 15gtts/min. She was then referred
immediately to Negros Oriental Provincial Hospital via ambulance. She
was then admitted at 10:26 PM in the said hospital.
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PAST HEALTH HISTORY
Childhood illness: fever, common cough and colds
Childhood immunization: no knowledge about patient’s immunizations
Hospitalizations: present is the first hospitalization
Surgeries: has not undergone any surgery, both minor and major
Allergies: no known allergy to foods
Accidents and Injuries: no history of accidents and injuries
Serious Illnesses: no known serious illnesses by history
Medications: uses herbal medicines like mayana, decoction of guava
leaves, heated atis leaves and pound malunggay cloves
Recent Travel: no other travel outside Negros Oriental than
transportation from Manjuyod to Dumaguete for hospitalization
FAMILY HEALTH HISTORY
Legend:
- female
- male
- patient
AW - alive and well
LP - Liver Problem
+ - deceased
OA - Old Age
Hem - Hematemesis
HTN - hypertension
OD - occasional dyspnea
JP - joint pain
93,+ 105,+
LP OA
82,+ 80,AW 78,JP, 78,OD
Hem HTN
Interpretation:
Patient’s mother died at the age of 93 due to liver problem. Her
father died at 105 years old due to old age. She has 4 siblings. Her
sister next to her died at the age of 82. They do not know the exact
problem, yet they claimed that she vomited blood. The only male among
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her siblings has been experiencing joint pain and hypertension. The
youngest has been having difficulty in breathing occasionally. Data
about the patient’s grandparents were not taken due to her limited
ability to speak and SO has no knowledge about such.
PSYCHOSOCIAL PROFILE
Health Practices and Belief: Patient believes in the effectiveness
of herbal medicine and that prayers can heal sickness/illnesses.
Usually use herbal medicines to cure illnesses like cough,
bruises, and wounds. She also believes in quack doctors and
“hilots”.
Typical Day: Patient usually wakes up at around 5:00 in the morning
and drinks coffee with bread for breakfast. Then she walks around
the house, and does her gardening activity. After which, she goes
to market with a “nigo” filled with dried tobacco leaves for
business. She takes “pot-pot” as her transportation to get
there. She goes home for lunch at around 12:00 and takes her
rest after eating for about 30 minutes to an hour. She goes to
market again to continue selling. She arrives home at around 5:00
in the afternoon. She eats her dinner with her niece, who lives
with her as her adopted, at around 6:00-7:00 in the evening.
She watches TV at night and retires to bed sometimes at
9:00PM, but usually by 8:00PM. By March, she started to become
weak and eventually went into being bed-ridden.
Nutritional Patterns: Patient usually eats vegetables in a menu of
“law-oy” and fish, most often, dried salty fish and “ginamos”.
She eats corn, not rice. She has a regular eating pattern and
complete 3 meals a day, no snacks in between. She uses spoon for
eating. She can consume a maximum of 2 glasses of water after
meal. She started to loss her appetite when she became ill. She
can barely consume her food served on a plate. She also started
to lose weight.
Activity and Exercise: She goes up and down from their room by a 5-
step stair and walks around the house every morning and does
her gardening. She does not walk anywhere else, she just ride
“pot- pot” for transportation. By the time she became weak, she
seldom go downstairs, until she became bedridden.
Elimination Pattern: She urinates 2-3 times a day with dark colored
urine, about a glass in quantity, and defecates usually once a
day and sometimes never at all. When she became bedridden, she
wears diaper. She seldom defecates, usually every other day. She
uses 2-3 diapers a day, and gets changed by the help of her
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adopted daughter.
Sleep/rest: She usually gets 9hours of sleep at night time and
30minutes to an hour at noon. She has no sleep disturbance; she
only wakes when she urinates. During the occurrence of the
problem, her sleeping pattern changed. She cannot sleep well at
night. She complains of abdominal pain associated with difficulty
in breathing.
Personal Habits: She is neither a smoker nor an alcoholic, yet she
experienced drinking once when she was adolescent.
Occupational and Socioeconomic Health Pattern: Her income in selling
tobacco is their major source of money for their daily
consumptions. Her nieces and nephews sometimes give her money or
goods. Her siblings also share some food to her when they have
enough. When she became weak, she stopped selling; her other
family members supports her in the needs and expenses.
Environmental Health Patterns: She lives in a separate house just
beside her sister’s. With her is her adopted daughter, her niece,
who helps around. The house is a small 2-storey hut, with a
“sinibit” roof. The stair leading to their bed room has 5 steps
made of bamboo. She sleeps on a wooden bed, covered with a
“banig”, beside her adopted daughter. The surrounding is a non-
cemented land with few trees and plants. Their source of water is
“flowing” where they connected a hose directly towards their
household. They use pour flush as their toilet facility. The
house location is just near the street, with other neighboring
houses. The market is about 15meters away.
Cultural influences and religious/spiritual influences: She believes
in quack doctors and “hilots”, but she believes most in God.
Their family has a tradition of not taking a bath on Wednesdays
and Fridays because for them this may cause illnesses and death
of a family member. She goes to Church on Sundays with her
adopted and sometimes with her sister.
Sexual pattern: Patient never got married, but experienced having
suitors and boyfriends during her adolescence. (Detailed
information about this was not taken due to limited ability to
speak, and her sister has no knowledge about it).
Social Support: She is well-loved by her siblings, nieces and
nephews. She receives all types of support from her family, may
it be physiological, emotional, or spiritual. They share with one
another what they have and solve problems immediately.
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REVIEW OF SYSTEMS
Assessment (April 16, 2011 at 8AM) Assessment (April 16, 2011 at 4AM)
General Survey
Pt. is 88 years old, female,
oriented to place and person only,
appears emaciated, awake and
responsive to verbal communication,
with slurred speech in a low tone
voice, but unable to maintain eye
contact; scratching on elbows
noted; wearing adult diaper; with
ongoing IVF of D5NM 1L running at
KVO rate, infusing well at left
metacarpal vein, with a level of
800mL; O2 therapy of 2-4L/min via
nasal cannula, and NGT passing into
the right nostril.
Vital signs of: 36. 2 °C, afebrile;
87 bpm, regular but weak; 22 cpm,
deep, with use of accessory
muscles; 110/70 mmHg
INTEGUMENTARY SYSTEM
Skin
-Inspection: jaundice noted on
palms and soles, sagging skin on
upper extremities, shiny skin
surfaces on edematous lower
extremities noted; visible
muscle wasting
-Palpation: rough skin texture
on upper extremities, smooth on
lower extremities; warm to
touch; pitting noted on lower
extremities edema of grade 2
Hair
-Inspection: body hair noted all
over, but with less hair growth
on lower extremities
Nails
-Inspection: pale, intact, firm,
adhere well to nail bed, and
absence of clubbing; cuticles
are pale as well as nail beds;
-Palpation: poor capillary
refill of 3 seconds on upper
extremities, (lower extremities
General Survey
Condition worsened associated with
rigidity on upper lip, inability to
open eyes, blood stains noted in
oral area, inability to speak,
unresponsive to verbal command;
still with ongoing IVF of D5NM 1L
running at KVO rate, infusing well
at left metacarpal vein, with a
level of 300mL; O2 therapy of 2-
4L/min via nasal cannula, and NGT
passing into the right nostril.
Level of orientation not assessed
due to inability to speak
Vital signs of: 38.9 °C, febrile;
96 bpm, regular but weak; 28 cpm,
deep, use of accessory muscles;
90/60 mmHg
---SAME---
---SAME--
---SAME---
8
not assessed due to presence of
nail polish)
HEENT
Head and face
-Inspection: head size
appropriate to age, white hair
evenly distributed on scalp;
less facial movements upon
communication,
-Palpation: scalp slightly
mobile, no lessions
Eyes
-Inspection:pallor conjunctivae
noted
(visual acuity, accommodation
and extraoccular movement not
assessed due to patient’s
inability to maintain eye
opening)
Nose
-Inspection: nose located
midline with symmetrical nares,
nasal flaring noted, no
drainage, with O2 cannula
connected, and NGT inserted into
right nares
Neck and Throat
-Inspection: lips midline,
symmetrical, appears dry with
cracks noted; has 6 teeth,
yellow discoloration noted; neck
erect and midline; (gag reflex
not assessed due to inability to
open mouth widely, and tolerance
to procedures)
-Palpation: no lumps or masses
on neck
RESPIRATORY SYSTEM
-Inspection: trachea located
midline, no deviation; bulging
of chest on right side noted,
use of accessory muscles noted
upon breathing, nasal flaring
noted, with O2 therapy of
2-4L/min via nasal cannula; with
---SAME---
Additional: jaw jutting noted
---SAME---
---SAME---
---SAME---
Additional: rigidity on upper lip
noted, with blood stains in the oral
area
---SAME---
Additional: breathing through mouth
noted; with RR of 28 cpm, deep, use of
accessory muscles
9
RR of 22 cpm, deep, with use of
accessory muscles
Auscultation:Diminished
peripheral sounds on right lung
field
CARDIOVASCULAR SYSTEM
-Inspection: visible carotid
pulsation, observable neck vein
distention, positive pulsation
at epigastric area noted,
visible blood vessels on
extremities
-Palpation: bounding heart beat
on apex, weak peripheral pulses,
pulse on lower extremities
nonpalpable; with a pulse rate
of 87 bpm, regular but weak
-Auscultation: loud heart beat,
no extra heart sound heard; with
a BP reading of 110/70 mmHg
ABDOMEN
-Inspection: Caput medusa noted
extending from the umbilicus;
umbilicus midline and inverted
with no discharges;positive
pulsation noted, rounded abdomen
with assymetrical contour
-Auscultation: hypoactive bowel
sounds on all quadrants: 1 on
LLQ, 2 on RLQ, 1 on RUQ, and 1
on LUQ
-Palpation: hard and rigid
MUSCULOSKELETAL SYSTEM
-Inspection: measurement of
extremities are the following:
Right arm length of 69 cm with a
circumference of 17.5 cm; Left
arm length of 69 cm with a
circumference of 18 cm; Right
leg is 80cm in length and 42.5cm
in circumference; Left leg is
81cm in length and 41cm in
circumference; asterixis noted
on both arms and hands
-Palpation: pitting noted on
lower extremities edema of grade
---SAME---
-with a PR of 96 bpm, regular but
weak; with a BP of 90/60 mmHg
---SAME---
---SAME---
Additional: 0 muscle strength on both
upper and lower extremities, no active
range of motion & no palpable muscle
contraction (paralysis)
10
2; muscle strength on lower
extremities is 0, no active
range of motion & no palpable
muscle contraction (paralysis);
2 on upper extremities, reduced
active range of motion & no
muscle resistance
(posture, gait, balance and
coordination not assessed due to
patient’s inability to stand and
walk)
NEUROLOGIC SYSTEM
Cerebral Functions
-awake, responsive to verbal
communication, with slurred
speech in a low tone voice
-GCS score of 11/15 (Moderate
brain injury):
Eye = 4, eye opens
spontaneously
Verbal = 2, incomprehensible
Motor= 5, localizes to pain
Cranial Nerves
(not assessed due to patient’s
limited response and tolerance)
REPRODUCTIVE SYSTEM
(not assessed due to wearing of
diaper)
---SAME---
Additional: unconscious, unresponsive
to any command
-GCS score of 3/15 (severe brain
injury):
Eye = 1, no eye opening
Verbal= 1, no verbal response
Motor= 1, no motor response
--SAME—
11
Diagnostic Imaging Studies
Taken on April 13, 2011
CHEST X-RAY (PA)
This is to visualize the physical structure of the lungs to rule out
abnormalities, specifically consolidation on the lung parenchyma.
Result:
Massive right sided hydrothorax noted. Hidden pulmonary mass cannot be
ruled out
Interpretation:
This result shows that there is the passage of ascites from the
peritoneal to the pleural cavity through small diaphragmatic defects.
Patients with advanced cirrhosis and portal hypertension have abnormal
extracellular fluid volume regulation that in most cases results in
accumulation of fluid, typically in the abdominal cavity (ascites) or
lower extremities (edema). The negative intrathoracic pressure
generated during inspiration favors the passage of fluid from the
intra-abdominal to the pleural space.
April 13, 2011
ULTRASOUND – WHOLE ABDOMEN
- The liver is enlarged with multiple echogenic masses seen in
the right lobe. Minimal free fluid noted in the hepatic
recess.
- The pancreas, spleen, and kidneys are sonographically normal
- The gallbladder and urinary bladder with normal wall thickness
and echofree
- The uterus and ovaries are technically difficult to imague due
to bowel gas
Remarks:
1. Solid hepatic masses. Consider primary new growths
2. Non-visualization of uterus and ovaries due to bowel gas.
-Suggest: Transvaginal or transrectal ultrasound for better
visualization
3. The other visualized organs are sonographically
unremarkable
Interpretation:
Cancer starts with damage to DNA (a nucleic acid that contains the
genetic instructions used in the development and functioning of all
Indication: Reduction of risk of upper GI bleeding in critically ill
patients
Dosage: 40 mg IVTT OD
Drug Action: Gastric acid-pump inhibitor: Suppresses gastric acid
secretion by specific inhibition of the hydrogen-
potassium ATPase enzyme system at the secretory surface
of the gastric parietal cells; blocks the final step of
acid production
Side Effects and Adverse Reactions: Headache, dizziness, diarrhea,
abdominal pain, nausea and
vomiting, URI symptoms
Nursing Responsibilities:
Administer before meals
Administer antacids with, if needed
Instruct patient to report severe headache, worsening of
symptoms, fevers, chills
33
34
NURSING CARE MANAGEMENTNURSING CARE PLAN (PRIORITY NO. 1)
SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS
SCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
Patient whispered “Tabangi ko ninyo, lisud na kaayo iginhawa.”
-RR= 28 cpm, deep and labored-Jaw jutting and nasal flaring noted-Poor capillary refill of 4 seconds-Pallor noted on conjunctivae and fingernails -Labored breathing with use of accessory muscles (intercostal and abdominal muscles) noted-Diminished peripheral sounds noted on right lung field when auscultated-Decreased sensorium observed- Chest x-ray result showed a massive right sided hydrothorax -GCS of 11/15, moderate brain injury
Impaired gas exchange related to ventilation perfusion imbalance secondary to massive right sided hydrothorax
Definition:Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveoli-capillary membrane
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
According to Lewis, Heitkemper, Dirksen, O’Brien,and Butcher, hydrothorax/pleural effusion is a collection of fluid in the pleural space, secondary to altered hydrostatic or oncotic pressure. With this increased volume of fluid in the pleural space, one can conclude that there will be a decreased movement of the chest wall, thus causing dyspnea and impaired gas exchange. Moreover, it has been mentioned that hydrothorax is not a disease in itself, but rather, a manifestation of a serious disease, which, in the case of our patient, is hepatoma, or hepatocellular carcinoma. A large effusion (hepatic hydrothorax) occasionally appears during the course of the
Immediate Goal- That after 15-30 minutes:-Patient/SO will be able to verbalize understanding of causative factors and appropriate interventions related to gas exchange
Short-term goals- That after two hours, the patient will demonstrate improved ventilation and oxygenation as manifested by:-respiratory rate returning to normal or near normal range (12-20 cpm)-decreased use of accessory muscles-improved capillary refill (1-3 seconds)- reduced jaw jutting and nasal flaring-pinkish mucous
Independent:-Take vital signs of the patient especially respiratory rate and heart rate.
- Assess level of consciousness and mentation changes with use of Glascow coma scale.
-Elevate head of bed to semi-fowler or high fowler’s position.
- Encourage frequent position changes.
- Encourage adequate rest and limit activities to within client tolerance.
-Evaluate pulse oximetry to determine
- To provide a baseline data for comparison of patient’s health status.
- Poor brain oxygenation can reduce patient’s sensory ability. A decline to below 50% oxygen in brain is considered to be indicative of cerebral ischemia.
- By gravity, the diaphragm is freed from the enlarged liver and provides enough space for the lungs to expand and receive oxygen.
- Promotes optimal chest expansion and drainage of secretions.
- Helps limit oxygen needs and consumption.
- The body ideally should receive at least 95% of oxygen.
That after 2 hours, the patient had a remarkable decrease in perfusion as manifested by:-respiratory rate 29 cpm, deep and labored-constant use of accessory muscles-poor capillary refill of 4 seconds-jaw jutting and nasal flaring noted-pale mucous membranes and fingernails noted-diminished breath sounds noted- reduced Glasgow coma scale to 3/15, severe brain injury-patient is unresponsive to speech and painful stimuli
35
disease. The fluid in the pleural space is believed to be derived from ascitic fluid that may accompany hepatic cirrhosis. Although the exact mechanism is somewhat controversial, it appears that the ascitic fluid is transported directly into the pleural space. A therapeutic thoracentesis, usually accompanied by a paracentesis, these interventions may not be successful. Management of hepatic hydrothorax remains a clinical challenge.
Source:Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
membranes and fingernails-clearer breath sounds when auscultated
Long-Term Goal-That after 1 week:-Patient will maintain optimal gas exchange.
oxygenation.
- Ensure availability of proper emergency equipment including ET/trach set and suction machines.
Dependent:- Administer medications as indicated.
Collaborative:-Assist with thoracentesis.
Below it would pose problem on brain’s vital functions.
- Intubation ensures that oxygen is delivered straight to lung alveoli, improving perfusion. Suctioning helps remove secretions that may block lung ventilation
- Inhaled and systemic glucocorticosteroids, bronchodilators. To treat underlying conditions.
-Thoracentesis is a procedure to remove fluid from the space between the lungs and chest wall.
36
NURSING CARE PLAN (PRIORITY NO. 2)
SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS
SCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
“Tabangi ko ninyo, lisud na kaayo iginhawa,” as verbalized by the patient
-RR= 22 cpm, deep and labored-nasal flaring noted-Poor capillary refill of 4 seconds-Pallor noted on conjunctivae and fingernails -Labored breathing with use of accessory muscles (intercostal and abdominal muscles) noted-muscle strength of 0 on both lower extremities, no palpable muscular contraction (paralysis)-GCS of 11/15, moderate brain injury-asterixis noted on both arms and hands
Functional Level Classification:Level IV-dyspnea and fatigue at rest
Activity intolerance related to generalized weakness secondary to hepatic encephalopathy
Definition:Insufficient physiological or psychological energy to endure or complete required or desired daily activities
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
“Hepatic encephalopathy is a neuropsychiatric manifestation of liver damage. It is considered a terminal complication in liver disease. It can occur in any condition in which liver damage causes ammonia to enter the systemic circulation without liver detoxification” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2008). This disease is basically a disorder of protein metabolism and excretion. The main pathogenic agents appear to be nitrogenous ammonia and aromatic amino acids. The ammonia normally goes to the
Immediate goal-That after 15-30 minutes:-Patient/SO will identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible
Short-term goal- that after 1 hour:-Patient will use identified techniques to help enhance patient’s activity tolerance
Long-term goals-that after 1 week:-Patient will participate willingly in necessary/ desired activities-Patient will report measurable increase in activity
Independent:-Note presence of factors contributing to fatigue (e.g., cancer)
-Adjust intensity level of activities
-increase exercise/ activity levels gradually
-Plan care to carefully balance rest periods with activities
-Provide positive atmosphere, while acknowledging difficulty of the situation for the client
-promote comfort measures and provide for relief of pain
-Instruct
-Fatigue affects both the client’s actual and perceived ability to participate in activities
-to prevent overexertion
-to conserve energy
-to reduce fatigue
-to help minimize frustration and rechannel energy
-to enhance ability to participate in activities
-there may be a
After 8 hours, patient has been able to:-increase RR from 22 cpm to 28 cpm-demonstrate deep and labored breathing still-reduce GCS from 11/15 (moderate brain injury) to 3/15 (severe brain injury)-demonstrate a muscle strength of O in both upper and lower extremities
37
liver via portal circulation and is converted to urea, which is then excreted by the kidneys. When the liver is unable to convert ammonia to urea, large quantities of ammonia remain in the systemic circulation. The ammonia crosses the blood-brain barrier and produces neurologic toxic manifestations. Clinical manifestations of encephalopathy include changes in neurologic & mental responsiveness (ranging from sleep disturbance, to lethargy, to deep coma), slow and deep respirations, slow and slurred speech, hyperactive reflexes, and asterixix (flapping tremors).
Source:Medical-Surgical
tolerance-patient will be able to demonstrate a decrease in physiological signs of intolerance
client/SO in monitoring response to activity
-Plan for progressive increase of activity level
-Encourage client to maintain positive attitude (e.g., suggest use of relaxation techniques)
Dependent:-Provide O2
therapy
need to alter activity level
-both activity tolerance and health status may improve with progressive training
-to enhance sense of well-being
-to help patient relieve from dyspnea and fatigue
38
Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
39
NURSING CARE PLAN (PRIORITY NO. 3)SUBJECTIVE OBJECTIVE NURSING
DIAGNOSISSCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
“Init na siya kayo. Murag nagpatol na gani siya kay nikalit ug puti ang mata unya nanggahi napaakan ang dila,” as verbalized by the significant other.
-T= 38. 9 °C-RR= 28 cpm, tachypneic-patient is hot to touch-diaphoresis noted-seizure/convulsion occurence
Hyperthermia related to infectious process
Definition:Body temperature elevated above normal range
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
“Infection is a primary cause of death in the patient with cancer.The usual sites of infection include the lungs, the GU system, mouth, rectum, peritoneal cavity, and blood. Infection occurs as a result of the ulceration and necrosis of a tumor, compression of vital organs by the tumor, and neutropenia caused by the disease process or the treatment of cancer. Patients who have a temperature of 38°C or higher should be reported immediately. Assessment most often includes signs and symptoms of fever, determination of
Immediate Goal-That after 15-30 minutes, patient/SO will be able to:-identify underlying cause/ contributive factors, and importance of treatment
Short-Term Goals-That after 8 hours, patient will demonstrate the ff:-T= 36.5-37.5° C-Skin cool to touch-No reccurence of seizure/ convulsion
-SO demonstrates behavior to monitor and promote normothermia.
Long-Term Goals-That after 1 week, patient will be able to:-maintain core temperature within normal range-be free of
Independent:-Monitor core temperature.
-Assess neurological response, noting level of consciousness and orientation.
-Apply tepid sponge bath
- apply local ice packs especially in the groin and axillae
-maintain bedrest
Independent:-provide supplemental oxygen
-administer antibiotics as ordered
Collaborative:-provide high-
- To evaluate effects/degree of hypothermia.
- High fever can cause seizures predisposing patients to further seizure related injuries.
-promote heat loss by evaporation.
- this promote heat loss in areas of high blood flow
-to reduce metabolic demands/oxygen consumption
-to offset increased oxygen demands and consumption
-to treat infection
-to meet
That after 8 hours, the patient is afebrile as evidenced by:-T= 37.1°C-Diaphoresis noted-Skin is slightly cool to touch-No recurrence of fever-SO verbalized, “Di gyud to magsalig lang sa tambal. Kinahanglan na mag spongebath para dali manaog ang hilanat.”
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possible etiology, and CBC.”
Source:Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
seizure activity-demonstrate behaviors to monitor and promote normothermia-be free of complications such as is irreversible brain damage and acute renal failure
calorie diet, tube feedings, and parenteral nutrition
-administer replacement fluids and electrolytes
increased metabolic needs
-to support circulating volume and tissue perfusion
NURSING CARE PLAN (PRIORITY NO. 4)SUBJECTIVE OBJECTIVE NURSING
DIAGNOSISSCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
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“Nigamay gyud pag-ayo si mama sa la pa siya nagreklamo unya karon nahospital siya, maluoy na mi maglantaw sa iyahang lawas,” as verbalized by SO
“Di naman gyud siya mukaon, mao to gipatubuhan nalang sa doctor para didto nalang iagi tanan iyahang pagkaon,” as verbalized by SO
-patient appears very weak to chew and swallow-emaciated-pale and dry mucous membrane observed-noted weakness of the muscles required for mastication
Imbalanced nutrition: less than body requirements related to loss of appetite and inability to absorb nutrients secondary to Hepatoma
Definition:Intake of nutrients insufficient to meet metabolic needs
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
“A person’s appetite to ingest food is a significant factor in how much food is eaten. An appetite center is located in the hypothalamus. It is directly/indirectly stimulated by hypoglycaemia, an empty stomach, decrease in body temperature, and input from higher brain centers.” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2008) The hormone ghrelin released from the stomach mucosa plays a role in appetite stimulation. Leptin, another hormone, is involved in appetite suppression. Thus, “appetite may be inhibited by stomach distention, illness (especially accompanied by fever), hyperglycemia, and n/v.” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2008)
Immediate Goal- That after 15-30 minutes, patient/SO will:-verbalize understanding of some factors causing malnutrition
Short-Term Goals- That after 8 hours, patient will demonstrate the ff:-Pinkish and moist mucous membrane-Reduce respiratory rate-Regain strength and muscle tone to perform basic ADLs
Long-Term Goals- That after 4 weeks, patient will be able to:-Demonstrate behaviors/ lifestyle changes to maintain appropriate weight-Display normalization of laboratory values and be free of signs of malnutrition
Independent:-Determine client’s ability to chew, swallow and taste food.
- Assess drug interactions and use of laxatives and diuretics.
- Assess weight and muscle mass, and laboratory test such as amino acid profile, BUN, liver function and electrolytes.
- Note age, body build, strength, activity/rest level.
-provide NGT feeding properly
-provide adequate fluid intake
Dependent: - Assist in inserting nasogastric tubes to deliver osteorized feeding.
-This can affect ingestion and digestion of food nutrients.
-This may affect appetite, food intake and absorption.
- This provides baseline parameters
- Helps determine nutritional needs.
-to aid in the proper digestion and absorption of nutrients in the body
-to prevent dehydration
- NGT can ensure that nutrients reach to gastric organs and more ready for absorption.
At the end of our care, the patient will be able to:-decrease creatinine, BUN, and uric acid levels to within normal range-increase HDL levels to within normal range- develop pinkish and moist mucous membranes-increase in muscle tone
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Source: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
- Assist in administering parenteral D5NM. Watch for overinfusion.
Collaborative:-provide a soft diet composed of less than 1,600 calories and low protein, as ordered
- Multiple and balanced intravenous solutions helps correct electrolyte deficiency.
-to aid in decreasing BUN, creatinine, and uric acid levels and to provide the patient with adequate energy needed for the body’s good functioning
NURSING CARE PLAN (PRIORITY NO. 5)SUBJECTIVE OBJECTIVE NURSING
DIAGNOSISSCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
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“Ayaw ko ninyo pasagdai. Tabangi ko ninyo pag-ampo. Dili na nako kaya. Iampo ko day,” as verbalized by patient
“Muanhi man to si Father unya para ampuan siya kay nagrequest man siya kanako,” as verbalized by SO
-patient is sulken-weak-crying observed
Death anxiety related to uncertainty about the existence of higher power and life after death.
Definition:Vague, uneasy feeling of discomofort or dread generated by perceptions of a real or imagined threat to one’s existence.
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
Death is defined by Lewis, Heitkemper, Dirksen, O’Brien,& Bucher, as “the irreversible cessation of circulatory and respiratory function or the irreversible cessation of all functions of the entire brain, including the brainstem.” Today, as a result of the increasing number of persons with chronic diseases, terminal illness and dying have received greater attention. Most individuals will have a long period of serious illness before dying, with the onset of months/years before death. For example, approximately half of all patients diagnosed with cancer will die from their disease within a
Immediate Goal- That after 15 to 30 minutes, patient will:-verbalize feelings of sadness, guilt and fear
Short-Term Goal- That after 2 hours hours, patient will:-formulate a plan dealing with individual concerns and eventualities of dying as appropriate
Long-Term Goals- That after 3 days, patient and SO will:-look toward/plan for the future one day at a time-be able to readily say goodbye to each other
Independent:-Ascertain current knowledge of situation to identify misconceptions, lack of information and other pertinent issues.
-Provide open and trusting relationship
-Provide calm, peaceful setting and privacy as appropriate
-Assist the client in engaging spiritual activities and experience prayer and meditation
-Refer to therapists and spiritual advisers.
-The concept of higher power in the afterlife provides comfort and strength to the dying person.
-Genuine rapport can help the patient express her feelings to the nurse about the unknown.
-This promotes relaxation and ability to deal with the situation.
-This reduces feelings of guilt allowing the person to move forward toward resolution.
-To help with the grief work.
At the end of our care, the S/O verbalized,“Dinhi na si Father. Gi-ampuan na siya. Nagpasalamat ra pud mi na nahumana ang pag-ampo para makapreparar siya sa kamatayon.”
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few years. However, the time from diagnosis of a terminal illness to death varies considerably depending on the patient’s diagnosis and extent of disease. Most patients and families struggle with a terminal diagnosis and the realization that there is no cure. The patient and the family feel overwhelmed, powerless, fatigued, and fearful. With this, both the patient and the significant others may experience death anxiety. For the Catholics, however, they believe in eternal life after death. “Yes, we are fully confident, and we would rather be away from these earthly bodies,
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for then we will be at home with the Lord.” (2 Corinthians 5:8 ) This biblical quote may offer much comfort for those Catholics “who have the faith as that of a mustard seed” (Matthew 17:20)
Source:Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
The New American Bible: The New Catholic Translation (1987), by Heenan, J.C.
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PROGRESS NOTES
DATE PROBLEM MEDICAL/SURGICAL INTERVENTION
NURSING INTERVENTION
OUTCOME
April 12, 2011
-dyspnea -O2 inhalation ordered at 2-4 LPM-CBC taken
-place a “no smoking” sign in the room
-dyspnea was relieved
April 13, 2011
-dyspnea
-grade 2 bipedal pitting edema on both lower extremities
-body weakness
-continued O2 inhalation at 2-4 LPM
-Chest X-ray done-Prescribed diet: CHON, soft diet -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered-electrolyte levels assessed (Na and K)
-keep bed linens from wrinkles-turn patient to sides
-give health teachings and demonstrate to patient/SO about importance of ROM exercises
-dyspnea was relieved
-edema not relieved, reports of pain on lower extremities
-patient tried to remove NGT and complained of discomfort upon feeding
April 15, 2011
-dyspnea
-grade 2 bipedal pitting edema on both lower extremities
-body
-continued O2 inhalation at 2-4 LPM
-Prescribed diet:
CHON, soft diet -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered-electrolyte levels assessed (Na and K)
-place a “no smoking” sign in the room
-Elevate the patient’s legs to increase venous return and decrease edema-encourage SO to help patient turn to sides regularly-give health teachings and
-dyspnea was treated
-edema not relieved, patient complained of decreased sensorium and pain on lower extremities