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I. INTRODUCTION A.

Overview of the study Spinal cord injury: Spinal cord injury is damage to the spinal cord as a result of a direct trauma to the spinal cord itself or as a result of indirect damage to the bones and soft tissues and vessels surrounding the spinal cord. SCI results in a decreased or absence of movement, sensation, and body organ function below the level of the injury. The most common sites of injury are the cervical and thoracic areas. SCI is a common cause of permanent disability and death in children and adults. The spine consists of 33 vertebrae, including the following:

7 cervical (neck) 12 thoracic (upper back) 5 lumbar (lower back) 5 sacral (sacrum located within the pelvis) 4 coccygeal (coccyx located within the pelvis)

Injury to the vertebrae does not always mean the spinal cord has been damaged. Likewise, damage to the spinal cord itself can occur without fractures or dislocations of the vertebrae. National Spinal Cord Injury Statistical Center (2009) Current estimates are 250,000 - 400,000 individuals living with Spinal Cord Injury or Spinal Dysfunction.

82% male, 18% female Highest occurs between ages 16-30 Average age at injury - 33 Median age at injury - 26 Mode (most frequent) age at injury 19

As a requirement of NCM501104, we the students were required to conduct a Case study. In relation to this, I have chosen the Patient WS for my case study. B. Objectives and Purpose of the Study As a student nurse, it is indeed my vocation to adjoined hands with the health care team for the promotion of wellness of our clients. My main goals for this study are the following: To establish rapport To identify chief complaints of clients to give its specific interventions To determine the family and personal history of the client that many affect clients present condition To identify the cause and effect the main problem through the correct analysis of the pathophysiology of the case To determine the medical management given through identifying doctors order and its rationale To make nursing care plans for the different health problems encountered by the client To evaluate the effectiveness of the actual nursing care plan that was established C. Scope and Limitation of the Study Specifically this study is more concerned with the care of one patient in NMMC Ortho Ward. I performed physical assessment to the patient to properly identify the nursing problems, which requires necessary and direct interventions and medical regimen. I had 1 day duty or 8 hours care for the patient and some limited informants.. Thus this care study focuses on the particular case of the patient. The study of the medications and doctors order are limited to my chosen patient, a case of Spinal Cord Injury.

II. HEALTH HISTORY A. Patients Profile Name of Patient: WS Sex: Male Age: 33 years old Birthday: September 21, 1978 Birthplace: Misamis Oriental Religion: Roman Catholic Civil Status: Single Educational Attainment: High School Level Occupation: ElectricianC Number of Siblings: 5 Nationality: Filipino Date Admitted: September 24, 2011 Time Admitted: 8:30 pm Informant: Father Blood Pressure: 110/60 mmHg Temperature: 37.7O C Pulse Rate: 82 bpm Respiration: 21 cpm Allergy: No known allergy Attending Physician: Dr. C Admitting Diagnosis: Acute Spinal Cord Injury Cervical Spine C5 (incomplete) (Central Cord Syndrome)

B. Past Health History and Family history According to pt. WS, he had experienced some common childhood illnesses such as measles, chicken pox and mumps when he was in elementary. He had also experienced sore throat, cough, colds, and fever. He managed it through bed rest and sometimes he takes herbal medicine such

as oregano for cough and guava leaves if he has wounds. He also took OTC drugs such as paracetamol for fever, biogesic for headache and neozep for colds.. He has no allergy to foods, drugs & animals. And He had never undergone any major/minor operation and he had no history of fracture. According to patient WS , they had a history of asthma on maternal side & hypertension on both sides. They dont have any history of Diabetes Mellitus, Cancer & any other diseases which are hereditary. C. Chief Complains and History of Present Illness Pt. WS is a 33, y.o male born on September 21, 1978, Currently living in Magsaysay, admitted for the 1st time at NMMC. His chief complaint is limitation of movement at extremities. 5 days prior to admission, pt. was apparently well when he was repairing electrical wiring on the ceiling and accidentally fell. Pt hit face first on the floor causing loss of level of consciousness and then he vomits, after that he already experience minimal movement of extremeties. Pt. tolerated the condition with no consultation done and no medication taken persistence of the condition.

III. DEVELOPMENT DATA A. Erik Eriksons Stages of Psychosocial Development Theory Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Each of Erikson's stages of psychosocial development are marked by a conflict, for which successful resolution will result in a favourable outcome and by an important event that this conflict resolves itself around. B. Sigmund Freuds Psychosexual Development Theory

According to Freud, people enter the world as unbridled pleasure seekers. Specifically, people seek pleasure through from a series of erogenous zones. These erogenous zones are only part of the story, as the social relations learned when focused on each of the zones are also important. Freud's theory of development has 2 primary ideas: One, everything you become is determined by your first few years - indeed, the adult is exclusively determined by the child's experiences, because whatever actions occur in adulthood are based on a blueprint laid down in the earliest years of life (childhood solutions to problems are perpetuated) Two, the story of development is the story of how to handle anti-social impulses in socially acceptable ways. My patient belongs to the genital stage which begins at puberty involves the development of the genitals, and libido begins to be used in its sexual role. However, those feelings for the opposite sex are a source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted from all that. C.Robert J. Havighursts Developmental Task Theory Havighurst categorized the tasks, in first category are the tasks, which has to be completed in certain period, and the second are the tasks that continue for a long, sometimes for a lifetime.So what happens if the task is not completed in that stage or completed in a later date? Havighurst reply to that it is critical that the tasks should be completed during the appropriate stage, otherwise result will be the failure to achieve success in future tasks. D. Jean Piagets Theory of Development According to Piaget, development is driven by the process of equilibration. Equilibration encompasses assimilation (i.e., people transform incoming information so that it fits within their existing schemes or thought patterns) and accommodation (i.e., people adapt their schemes to include incoming information). My patient belongs to the formal operational stage. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations. The

abstract quality of the adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving ability. The logical quality of the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as a scientist thinks, devising plans to solve problems and systematically testing solutions. They use hypothetical-deductive reasoning, which means that they develop hypotheses or best guesses, and systematically deduce, or conclude, which is the best path to follow in solving the problem.

IV. MEDICAL MANAGEMENT A. DOCTORS ORDER DATE September 24, 2011 8:30 pm ORDER PLEASE ADMIT TO Ortho Ward under the service of Dr. C Secure consent for admission & manageme nt DAT with aspiration precaution Dx: CBC; To evaluate for possible abnormalitie s indicating infection or in platelet count or if there is any deviation. Informed the patient & his SO about the laboratory exams needs to be done. RATIONALE To intervene & give the needed health service As a form for legal purposes. NURSING RESPONSIBILITY Admitted the patient at the ward as ordered. Witnessed the signing of consent & checked if the consent was signed Inform the Patient and his SO about his diet and its important.

For nutritional supplement

Blood

Typing;

To know the ABO blood type prior to blood transfusion. To visualize the cervical spine & determine if there is any part affected by the accident. Observed the 10 Rs before administerin g the drug

CT Mylogram of the cervical spine

Meds: Tramadol 50 mg IVTT q8 Start venolysis with D5LR @ 20 gtts/ min

Treatment for acute pain

Bedsore Precaution Refer accordingly September 27, 2011

To inform the physician about the condition of the patient

Referred to the physician if there is untoward signs and symptoms

September 28, 2011 September

Follo w up CT mylogram of the cervical spine Log roll every 2o Still

29, 2011 October 1, 2011

for CT mylogram No new orders Still for CT mylogram Still for CT mylogram of the cervical spine Conti nue Log roll every 2o Still for CT mylogram

October 3, 2011

B. LABORATORY TEST
Result Hemoglobin Hematocrit RBC count Platelet count WBC count 135 g/dL 0.42 l/l 4.36 x 10/L 3.21 x 10/L 16.0 x 10/L Normal Values 135-180 g/dL 0.42-0.52 l/l 4.7-6.1 x 10/L 150-400 x 10/L 5-10 x 10/L Rationale Normal Normal Decrease due to bleeding Normal Increase due to inflammatory process Normal

Lymphocyte

0.23

.20-.40

Blood type A

V. PATHOPHYSIOLOGY & ANATOMY AND PHYSIOLOGY A. PATHOPHYSIOLOGY of SPINAL CORD INJURY BOOK BASED AND PATIENT CENTERED Predisposing Factor Age (16-35 y/o) Gender (male) Etiology > accidents > falls, sport activities > Disease (bone cancer, osteoporosis, arthritis) Can result to any of the following: Hyperextension Hyperflexion Rotational movement Compression Lateral flexion Fracture and dislocation of vertebral disc Excessive force is exerted on spinal cord Precipitating Factor

> work (ELECTRICIAN)

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C5 controls extremities Muscle weakness Absence of withdrawal reflex Absence of Biceps reflex Muscle Paralysis In gray matter Increase in size rapidly Necrosis Scaring Shrinkage of axonal and Myelin sheath

can lead to: > Ischemia > Hemorrhage

in white matter lead to massive edema frequently spreads to involve surrounding segment

Rapid loss of axonal conduction Result to production of free radicals - normally found in the body but quickly controlled by antioxidant enzyme tissue When antioxidant is overwhelmed

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Free radicals damage tissue

Dilation of arterioles in injured area Result capillary bed close Increase blood flow of injured tissue at injured site

inflammatory process (lumbar area) Increase capillary permeability lead to loss of protein rich fluid in extravascular tissue

Bleeding

pain

hematoma Decrease extravascular osmotic pressure Fluid shift Edema fever (compensatory mechanism) Increase intravascular osmotic pressure

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B. ANATOMY AND PHYSIOLOGY

Spinal cord is a bundle of nerves that carries messages between the brain and the rest of the body. The spinal cord functions in the transmission of ascending impulses to the brain and of descending impulses from the brain to the cord. Spinal Column Common name applied to the structure of bone or cartilage surrounding and protecting the spinal cord.

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Humans are born with 33 separate vertebrae. By adulthood, most have only 24, due to the fusion of the vertebrae in certain parts of the spine during normal development.

The spine consists of 33 vertebrae, including the following:


7 cervical (neck) 12 thoracic (upper back) 5 lumbar (lower back) 5 sacral* (sacrum located within the pelvis) 4 coccygeal* (coccyx located within the pelvis)

By adulthood, the five sacral vertebrae fuse to form one bone, and the four coccygeal vertebrae fuse to form one bone.) L4 supplies many muscles, either directly or through nerves originating from L4. They are not innervated with L4 as single origin, but partly by L4 and partly by other spinal nerves. The muscles are: Quadratus lumborum Is a common source of lower back pain. Because the QL connects the pelvis to the spine and is therefore capable of extending the lower back when contracting bilaterally, the two QLs pick up the slack, as it were, when the lower fibers of the erector spinae are weak or inhibited (as they often are in the case of habitual seated computer use and/or the use of a lower back support in a chair). Gluteus medius One of the three gluteal muscles, is a broad, thick, radiating muscle, situated on the outer surface of the pelvis.

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With the leg in neutral (straightened), the gluteus medius and gluteus minimus function together to pull the thigh away from midline, or "abduct" the thigh Gluteus minimus The gluteus medius and gluteus minimus abduct the thigh, when the limb is extended, and are principally called into action in supporting the body on one limb, in conjunction with the Tensor fasci lat Tensor fasciae latae

is a muscle of the thigh

is a tensor of the fascia lata; continuing its action, the oblique direction of its fibers enables it to abduct the thigh and assists with internal rotation and flexion of the hip inward (medial rotation). Obturator externus muscle Obturator externus muscle is a flat, triangular muscle, which covers the outer surface of the anterior wall of the pelvis. Inferior gemellus muscle Inferior gemellus muscle is a muscle of the human body. The Gemelli are two small muscular fasciculi, accessories to the tendon of the Obturator internus which is received into a groove between them. The Gemellus inferior arises from the upper part of the tuberosity of the ischium, immediately below the groove for the Obturator internus tendon. It blends with the lower part of the tendon of the Obturator internus, and is inserted with it into the medial surface of the greater trochanter. Rarely absent.

Quadratus femoris

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Quadratus femoris is, as its name implies, a flat, quadrilateral skeletal muscle. Located on the posterior side of the hip joint, it is a strong lateral rotator and adductor of the thigh, but also acts to stabilize the femoral head in the Acetabulum. VI. NURSING REVIEW CHART IV. PHYSICAL ASSESSMENT NURSING SYSTEM REVIEW CHART Name: WS Date:October 2, 2011 Vital Signs: Pulse: 82 bpm BP: 110/60

Temp:

37.7

Respi: 20 cpm

EENT [] impaired vision [] blind [] pain reddened [] drainage [] gums [] hard of hearing [] deaf [] burning [] edema [] lesion teeth [] asses eyes, ears, nose [] throat for abnormality [X] no problem RESPIRATION [] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing [] pain [] cyanotic [] assess resp rate, rhythm, depth, pattern [] breath sounds, comfort [X]no problem GASTRO INTESTINAL TRACT [] obese [] distention [] mass [] dysphagia [] rigidly [] pain [] asses abdomen, bowel habits, swallowing [] bowel sounds, comfort [X]no problem GENITO-URINARY and GYNE [] pain [] urine color [] vaginal bleeding [] hematuria [] discharge [] nocturia [] assess urine freq., control, color, odor, comfort [] grip, gait, coordination, speech, [X]no problem NEURO [] paralysis [] stuporous [] unsteady [] seizure [] lethargic [] comatose [] vertigo [] tremors [] confused [] vision [X] grip [] assess motor function, sensation, LOC, strength [] grip, gait, coordination, speech, []no problem

FEVER

No biceps reflex

Generalized weakness

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2 MUSCULOSKELETAL and SKIN [] appliance [] stiffness [] itching [] petechiae [X] hot [] drainage [] prosthesis [] swelling [] lesion [X] poor turgor [] cool [] deformity [] atrophy [] pain [] ecchymosis [] diaphoretic [] assess mobility, motion, gait, alignment, joint function [X] skin color, texture, turgor, integrity [] no problem

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VII. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT PATIENT: WS


Assessment SUBJECTIVE: dili kaayo ko ka lihok lihok as verbalized by the patient. OBJECTIVE: Decreased muscle control/strength Limited ROM Inability to purposefully more within the physical environment. Diagnosis Impaired physical mobility related to neuromascular impairment. Objective Intervention Rationale Evaluates status of individual situation (motor-sensory impairment may be mixed and/ or not clear) for a specific level of injury, affecting type and choice of intervention. Enables patient to have sense of control, and reduces fear of being left alone. Enhances circulation, restores or maintains muscle tone and joint mobility, and prevent disuse contractures and muscle atrophy. Evaluation Goal not met the pt. was not cooperative.

Within the duration Continually asses of duty, the motor function by patient will requesting patient maintain position to perform certain of function and actions. skin integrity as evidenced by absence of foot drops, contractures and decubitus ulcer Provide means to summon help.

Assist in range of motion exercises on all extremities and joints, using slow, smooth movements.

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Plan activities to provide Prevents fatigue, uninterrupted rest allowing periods. opportunity for Encourage maximal efforts or involvement within participations by individual patient. tolerance or ability. Reduces pressure Reposition areas, promotes periodically even peripheral when sitting in circulation. chair. Teach patient how to use Open expression weight-shifting allows client to deal techniques. with feelings and Encourage begin problem verbalization of solving. feelings. Altered circulation, Inspect the skin loss of sensation, daily. Observe for and paralysis pressure areas, potentiate pressure and provide sore formation. meticulous skin care. Helpful in planning and implementing Consult with individualized physical or exercise program occupational and identifying or therapist. developing assistive devices to maintain function

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enhance mobility and independence.

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Assessment Subjective: Dali rako kapoyon maong matulog nlang ko Objective: Needs assistance in repositioning Inability to do his ADLs

Diagnosis Activity intolerance r/t neuromuscular impairment

Planning Within the duration of duty, the patient will demonstrate a decrease in physiologic sign of intolerance

Intervention

Rationale

Evaluation Goal not met. The patient didnt cooperate.

Evaluated clients To provide actual and perceive comparative limitations/ degree of baseline and provide deficit in light of usual information about status needed education/ intervention regarding quality of life Noted clients report Symptoms may of weakness, fatigue, results of/or pain and difficulty contribute to accomplishing his intolerance of task. activity Ascertained ability to move about and To determined degree of assistance current status and necessary use of needs associated equipment with participation in needed desired activities. Encouraged expression of feelings To assist the client contributing to his to deal with condition contributing factors and manage activities within individual limits Assist with activities and provide/ monitor To protect from clients use of assistive injury devices

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Promote comfort measures and provide relief of pain To enhanced the ability to participate in activities Repositioning every 2 hours To prevent bedsore and to maintain body alignment all the time. Made repositioning schedule and post at To prevent bedsore bedside and educated and to promote the patients S.O in circulation. proper turning the patient

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CUES Subjective Data: Pt. verbalized... gitugnaw ko Objective Data - Temp: 37.7 oC - skin warm to touch - body malaise - poor appetite - chills noted

NURSING DX Hyperthermia related to disease process as evidenced by chills noted

OBJECTIVES That within my 8o span of care, the patients body temperature will lower from 37.7 oC to 37oC and will demonstrate absence of chills

INTERVENTIONS - Perform tepid sponge bath - Apply cold wet compress if necessary - Remove some blankets and clothes which are not necessary - If patients skin feels cold to touch, apply friction - Advise to wear loose and comfortable clothes

RATIONALE Vaporization of water relieves heat from the surface of the skin To help normalize body temperature To provide air movement, to augment heat loss. To stimulate circulation To be more Comfortable

EVALUATION GOAL MET: At the end of my 8o span of care: - the patients temperature will lowers to 37.5oC - The patient will manifest negative chilling - The patient will verbalize comfort

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B. ACTUAL NURSING MANAGEMENT PATIENT: RF


S

gitugnaw ko
as verbalized by the patient

- Temp: 37.7 oC - skin warm to touch - body malaise - poor appetite - chills noted
A

Hyperthermia related to disease process as evidenced by chills noted That within my 8o span of care, the patients body temperature will lower from 37.7 oC to 37oC and will Demonstrate absence of chills - Perform tepid sponge bath - Apply cold wet compress if necessary - Remove somem blankets and clothes which are not necessary - If patients skin feels cold to touch, apply friction - Advise to wear loose and comfortable clothes

GOAL MET: At the end of my 8o span of care: - the patients temperature lowers to 37oC

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C. DRUG STUDY
DRUG/MEDICATION Tramadol Dose: 150mg Frequency: q 8 route: P.O. CLASSIFICATION ACTION INDICATION SIDE EFFECTS toCNS: Dizziness, CV: Vasodilation EENT: Visual disturbances GI TRACT: Nausea, vomiting,dyspepsia, mouth, and diarrhea. SKIN: Pruritus, and rash. headache, and anxiety. NSG. IMPLICATION Analgesics- relieve painUnknown. A centrally actingModerate without loss ofsynthetic analgesicsevere pain consciousness Anti-depressantssymptoms depressions compound not chemically related to opiates. Drug ofreceptors and serotonin. and inhibit
-use consciously in pt. risk for

vertigo,seizures or respiratory depression;


increased intracranial pressure or head injury, or and acute in abdominal, heptic physical condition impairment; renalor

prevent or relieve thethrough to mind to opiola reuptate of norepinephrine

dependence on opiodes. -monitor bowel and bladder fxn. Anticipate need for laxative.

constipation,- for better analgesic effect give drug drybefore onset of intense pain.
-monitor pt. at risk for seizure. Drug may reduce threshold. -monitor pt. for drug dependence. Drug similar can to produce that of dependence codeine or

dextropropoxyphene and thus has potential for abuse.

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DRUGS/MEDICATION Paracetamol (biogesic) Route: P.O Dose: 500mg

CLASSIFICATION Antipyretic

ACTION Antipyretic:

INDICATION reduces>common colds viral

SIDE EFFECTS ,CNS: headache, andCV: GI: chest hepatic

NSG. IMPLICATION >observed the rights of pain,giving needs >do not exceed the

fever by acting directlyother

Frequency: P.R.N forAnalgesic fever

on the hypothalamicbacterial infection withdyspnea heat-regulating centerpain and fever. to cause vasodilation and sweating w/c helps discipate heat.

toxicityrecommended dosage. drug if hypersensitivity reaction occurs. >assess allergy >advice patient that paracetamol is only for short-term use.

and failure, jaundice. >d/c

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DRUG/MEDICATION Tramal Dose:30 mg Route: IVTT Frequency: q 8

CLASSICATION

ACTION

INDICATION Short-term management o moderately severe, acute pain singledose treatment.

SIDE EFFECTS CNS: drowsiness, sedation, dizziness, headache. CV: edema, hypertension, palpitations. GI: nausea, dyspepsia, GI pain, diarrhea, peptic ulceration, vomiting, constipation, flatulence, stomatitis. HEMATOLOGIC: prolonged bleeding time SKIN: rash, diaphoresis.

NSG.IMPLICATION >use cautiously in patients with hepatic or renal impairment >carefUlly observed patients with coagulopathies and those taking coagulant. >dont give drug epidurally or intrathecally because of alcohol content. >correct hypovolemia before giving.

Non-steroidal anti- Unknwon. Though inflammatory drugs to inhibit =prevent prostaglandin inflammation, pain synthesis and fever support Route: IV the blood clotting Onset: immediate function of platelets, Peak: 1 to 3min. and protect the Duration: 6 to 8 hrs. lining of the stomach from the damaging effects of acid

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VIII. REFERRAL AND FOLLOW UP HEALTH TEACHINGS => Encourage the patients family to wash hands with an antibacterial soap and maintain good hygiene. => Instruct the family to inform the health care providers if symptoms persist beyond 3 days discharged from the hospital. ANTICIPATORY S/S sites. => After recommending the patient with his diet/nutrition he will be able to gain weight and recover from undesired weight loss/cachexia SPIRITUALITY strengthen faith to GOD. MEDICATION the patient feels better. => Instruct also the patients family member to take home the medication and follow the frequency ordered by the doctor. INCISION CARE => Instruct the family members to clean and dressed => Instruct the Family members to use sterile materials in assessing/cleaning the incision sites of the patient. NUTRITION ENVIRONMENT => Recommend patient to increase fluid intake and eat => Encourage the patient and his family members to foods thats more on fiber. maintain clean surroundings (especially patients room). IX. EVALUATION AND IMPLICATION At the end of our hospital duty, I was able to render care to our patient to help him resolve his health condition. Through observing the patients status, I was able to identify priority problems related to his health. The patient was willing 29 with bandage the incision site of the patient. => Instruct the patients father to continue medication as what his doctor has ordered for the patient and not to discontinue even If => Encourage the patients family members to pray for the patients fast recovery and encourage also the patient to have a => Upon instructing the patient to take his medicines ordered by his doctor, the patient will be able to lessen the pain at his incision

to pursue the medical therapy just to promote health and wellness for the betterment of his condition. I have also made the patients father realize the importance of completing the course of therapy by taking the medicines prescribed or ordered for him by his physician. In addition, eating healthy or nutritious foods that were prescribed to him by the health providers was further been explained to the benefits he will gain in eating those foods. Moreover, this several intervention to him as given to the patient made his body conditioning normal and I can say that our patient has somehow recovered from his illness. X. BIBLIOGRAPHY BOOKS Suzzanne C. Smeltzer, EdD, RN,FAAN,et.al Medical Surgical Nursing 11th Edition, Lippincott Williams and Wilkins Manual of Nursing Practice 7th Edition c 2001 by Lippincott Williams and Wilkins WEBSITES www.nursingcrib.com www.scribd.com www.wikipedia.com/coloncancer

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