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SAINT LOUIS UNIVERSITY

COLLEGE OF NURSING

CASE PRESENTATION: NON-HODGKIN’S LYMPHOMA,


METABOLIC ACIDOSIS, ANEMIA, HYPOCALCEMIA,
ANEMIA

Submitted To:
MAAM DYMONDE F. CATILING
Clinical Instructor

Submitted By:
BSN 3-B2
BAGUILAT, Mark Amiel
BAUTISTA, Irish Danica
CLERIGO, Kezia Lianne
EGALLA, Nicanor
EMPERADOR, Julienne Jill
ISURITA, Rizza Donna
MAPPALA, Charisse
ORIBELLO, Jennifer
ORTIZ, Jan Phillip
SADURAL, Angelica
TELIAKEN, Jovie Ann
YAGYAGEN, Justin
PATIENT’S DATA

Name: Lopez, Eduardo O’neill


Age: 81 years old
Date of Birth: December 28, 1928
Place of Birth: Manila City
Sex: Male
Address: 29 PNB Village, Bakakeng Central, Marcos Highway, Baguio City
Occupation: Unemployed
Next of Kin: Maria Teresa Lopez Tabuena
Relationship to the Patient: Daughter
Occupation: Employee
Employer: Rustan’s
Latest Hospitalization Date: February 16, 2010
Admitting Physician: Dr. Oliver
Attending Physician: Dr. Candelario, Dr. Demyttenaere, Dr. Revilla
Date of Admission: February 19, 2010
Time of Admission: 3:00 pm
Impression or Diagnosis: Upper gastrointestinal bleeding, small intestinal tumor
probably malignant
Final Diagnosis: Non-Hodgkin’s Lymphoma at the small intestines upper GI bleeding,
severe anemia, metabolic acidosis, hypocalcemia
PAST MEDICAL HISTORY
On 2001, patient had been diagnosed as having a cardiovascular disease at the LMCA
territory. He also has Hypertension and is maintained on Amlodipine 5mg 1 tab once a
day. He also has Diabetes Mellitus and is maintained on Diamicron. On May 2009,
patient underwent endoscopy and was found out that there are multiple polyps and
hemorrhoids on the gastrointestinal tract. He was also diagnosed as having gastritis.
On February 2010, he was then diagnosed with small intestinal cancer. There were no
known allergies to food or medications.
FAMILY HISTORY
Patient has heredofamilial disease of hypertension and diabetes mellitus. No family
history of cancer, pulmonary tuberculosis and asthma.
SOCIAL AND ENVIRONMENTAL HISTORY
Patient is an occasional alcoholic beverage drinker and a non-smoker
HISTORY OF PRESENT ILLNESS
The present condition started about one day prior to admission when the patient
manifested body malaise after being discharged in this institution. There was dizziness
and headache noted. The condition persisted until about 12 hours prior to admission,
patient had melena about 2 episodes that day. The patient ignored it thinking it was
just a side effect of the suppository given to him. About 4 hours prior to admission, the
patient had 4 episodes of melena. There was still associated body malaise, headache
and dizziness. About 2 hours prior to admission, condition persisted now associated
with 1 episode of vomiting. Vomitus was however non-blood streaked amounting to ¼
cup. He was then brought back in this institution for consult hence the subsequent
admission.

PHYSICAL ASSESSMENT
I. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
The patient perceives that his current health situation now is already incurable since it
had already progressed. But despite of this condition, he does his best to stick to the
treatment regimen offered to him like taking his medications even if he does not like the
taste of it. Generally, he is weak as manifested by needing assistance from his family
friend in changing his position.
II. NUTRITIONAL-METABOLIC PATTERN
Prior to admission, the patient usually eats foods with meat and meat products. He also
verbalized that he is an occasional drinker and a non-smoker. He eats 3 times a day,
sometimes with break or merienda meals at between. Two hours prior to admission, he
experienced nausea and vomiting and passed out vomitus which is non-blood streaked
and approximately ¼ cup in volume. He has difficulty in digesting fish products. Upon
assessment, the patient has a bloated abdomen. The patient manifested a good skin
turgor, about 1-2 seconds. His mucosal membranes are moist and no unusual lesions
were identified. No edema, jugular vein distention, and enlargement of thyroid gland
are present. The lung fields of the patient are clear upon auscultation and the patient
exhibits symmetrical chest wall expansion. The latest oxygen saturation of the patient
is at 89-90%, and he is on oxygen at 1 liter per minute/ nasal cannula. There were no
associated pain, soreness, ulcer, bleeding, and difficulty in swallowing when it comes
to the patient’s mouth. The teeth of the patient are yellowish in color, and his tongue is
pale pink in color, both with no unusual lesions observed. The patient exhibits
hyperactive bowel sounds upon auscultation. There is also the presence of 3 incisions:
one at the umbilicus area, approximately 5 inches long, vertical and 2 at the left and
right lower quadrant, each measuring about 1 inch, diagonal. There were no signs of
infection manifested on these 3 incisions.
III. ELIMINATION PATTERN
Prior to admission, patient urinates for 3-4 times a day. Urine is characterized as
yellowish in color, with no unusual odor. When it comes to defecation, the patient
usually defecates at 1-2 times a day. Stool is characterized as soft, brownish in color,
and with no unusual discoloration and odor. During our shift, the patient defecated 2
times, the stool is reddish in color, soft in consistency, with no unusual odor. The
patient had melena or defecated a black, tarry stool indicative of upper gastrointestinal
bleeding 12 hours prior to admission. Upon performing endoscopy on the patient,
hemorrhoids and small intestinal tumors were identified. The abdomen is flappy, soft
and firm upon palpation, with tympanitic palpable mass at the hypogastric area
measuring about 4x5cm , firm, movable, and non-tender.
IV.ACTIVITY-EXERCISE PATTERN
The patient is currently unemployed. His usual activities are limited in the house since
he is already feeling weak. This includes watching television, reading magazines, and
the like. For him, he considers walking as a form of exercise. Upon assessment of his
respiratory status, the patient has productive cough and passed out sputum with
characteristics of purulent or yellowish in color, and with no unusual odor. Whenever
the patient coughs, he experiences pain. The patient has clear lung fields, and he has
a symmetrical chest wall expansion. The latest oxygen saturation obtained from him is
89-90%, and he is on medical oxygen regulated at 1 liter per minute/ nasal cannula.
His muscle strength on all extremities are 5/5, and his reflexes are normal. Upon
auscultation of the heart, the point of maximal impulse can be heard at the 5th
intercostals space, left midclavicular line. There were no murmurs heard, and the rate
and rhythm of the heart beats are normal.
V. SLEEP REST-PATTERN
The patient can sleep for 8 hours but with interruptions in between. He sleeps for an
hour, then wakes up, then goes back to sleep again. Lately, he cannot get a good
sleep since the wound on his abdomen is painful but tolerable. Before he goes to rest,
he prays. His level of consciousness is awake and oriented to time and place. There
were no tremors observed.
VI. COGNITIVE-PERCEPTUAL PATTERN
The patient is awake, conscious, coherent, aware of his surroundings and relatives,
and oriented to time and place. He does not experience dizziness, headache,
numbness, and tremors. He experiences pain on the abdominal area due to the wound
made by the incisions of the procedure he underwent which is emergency explore
laparotomy. He has an anicteric sclera, and is palpebral conjunctiva is pink in color.
The pupils were symmetrical, equally round and reactive to light and accommodation,
and is about 2-3 mm. The extra-ocular movement and the sense of sight are also
intact. There were no pain, redness or blurring of vision noted. For the ears, there were
no unusual discharges, pain, and decrease in hearing noted. For the nose, the
olfactory nerve (cranial nerve 1) is intact as manifested by patient being able to
distinguish different types of scents. The patient is not manifesting any colds,
obstruction, pain and congestion in his nose. The nostrils are also patent. The patient
is positive for having a gag reflex, is able to shrug shoulders, and able to protrude
tongue. There were no diminished senses, and his reflexes are normal, with no
Babinski and ankle clonus reflexes.
VII. SELF-PERCEPTION / SELF-CONCEPT PATTERN
The patient perceives that since he is already diagnosed with stage IV non-Hodgkin’s
lymphoma, his time is almost up. But still he is calm and verbalized that he accepts
whatever may happen to him. He also verbalized that he had done his responsibilities
as an employee, a friend, a parent, and the like. He did not have any regrets in the
past, and is very grateful to his family friend for taking good care of him. Although his
daughter is in Manila and the other daughter is in America, he verbalized that he
understood the situation since they have their own family to look after, and that life is
very hard nowadays. He feels lonely at times because he is living alone in their
household, without any relatives to take care of him.
VIII. ROLE-RELATIONSHIP PATTERN
The patient’s wife died a long time ago, while his second wife left him and did not
return anymore. As a husband, he told us that he is not that satisfied since he felt that
he did not fulfill his duties as a husband. As a parent, he verbalized that he is satisfied
since he saw his daughters grew up and become successful in their lives.
IX. COPING-STRESS TOLERANCE PATTERN
Whenever the patient is faced with a distress, like for example, misunderstandings with
his relatives, he lets them cool off by not talking to them for a day and when both of
them are ready, they talk about the problems in a nice way. He also prays to the Lord
for guidance and wisdom.
X. VALUE-BELIEF PATTERN
The patient is a Roman Catholic. Being a Roman Catholic, he has no restrictions when
it comes to the food they eat, only at times like the Holy week when they do not eat
meat. He recognizes this as having a little bearing with regards to his current health.
He usually goes to church every Sunday when he has time and when his body is able
to move.

DRUG STUDY
1. METRONIDAZOLE
Classification: Trichomonacide and amebicide
Mechanism of Action: Direct-acting trichomonaside and amebicide that works inside
and outside the intestines. It’s thought to enter the cells of microorganisms that contain
nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis,
causing cell death.
Indication: To prevent postoperative infection in contaminated or potentially
contaminated colorectal surgery.
Adverse Effects: Headache, fever, dizziness, weakness, nausea, vomiting, abdominal
cramping or pain
Nursing Responsibilities:
• Monitor liver function test results carefully in elderly patients.
• Give oral form with meals.
• Ensure safety by raising siderails.
• Monitor vital signs especially temperature.
• Tell patient to avoid alcohol and alcohol-conatining drugs during and for at least 3
days after treatment course.

2. CEFUROXIME SODIUM (ZINACEF)


Classification: Second generation cephalosporin
Mechanism of Action: Inhibits cell-wall synthesis, promoting osmotic instability;
usually bactericidal
Indication: Perioperative prevention
Adverse Effects: Phlebitis, thrombophlebitis, nausea, vomiting, diarrhea
Nursing Responsibilities:
• Monitor intake and output
• Assess characteristics of stool
• Absorption of oral drug is enhanced by food
• Tell patient to notify prescriber about loose stools or diarrhea
• Monitor site of IV insertion for signs of thrombophlebitis.

3. CELECOXIB (CELEBREX)
Classification: Nonsteroidal anti-inflammatory drug
Mechanism of Action: Thought to inhibit prostaglandin synthesis, impeding
cyclooxygenase-2 (COX-2) to produce anti-inflammatory, analgesic, and antipyretic
effects.
Indication: Acute pain
Adverse Effects: Dizziness, headache, insomnia, abdominal pain, diarrhea
Nursing Responsibilities:
• Provide rest periods by clustering nursing care.
• Ensure safety by raising siderails
• Monitor intake and output
• Instruct patient to promptly report signs of gastrointestinal bleeding such as blood
in vomit, urine, stool; or black, tarry stools.
4. TRAMADOL HYDROCHLORIDE
Classification: Centrally acting non-opioid analgesic
Mechanism of Action: A centrally acting synthetic analgesic not chemically related to
opioids. Thought to bind to opiate receptors and inhibit reuptake of norepinephrine and
serotonin.
Indication: Moderate to moderately severe pain
Adverse Effects: Dizziness, headache, malaise, nausea, vomiting
Nursing Responsibilities:
• Reassess patient’s level of pain at least 30 minutes after administration.
• Monitor intake and output
• Raise side rails of the bed
• Warn patient not to stop the drug abruptly
5. ACETYLCYSTEINE (FLUIMUCIL)
Classification: Mucolytic
Mechanism of Action: Mucolytic that reduces the viscosity of pulmonary secretions by
splitting disulfide linkages between mucoprotein molecular complexes. Also, restores
liver stores of glutathione to treat acetaminophen toxicity
Indication: Abnormal viscid or thickened mucous secretions
Adverse Effects: Nausea, vomiting, fever, rashes
Nursing Responsibilities:
• Monitor cough type and frequency
• Monitor vital signs especially temperature
• Encourage patient to cough out secretions
• Warn patient that drug may have a foul taste that may be distressing
6. METOCLOPRAMIDE (PLASIL)
Classification: Antiemetic
Mechanism of Action: Stimulates motility of the upper gastrointestinal tract, increases
lower esophageal sphincter tone, and blocks dopamine receptors at the chemoreceptor
trigger zone.
Indication: To prevent and reduce postoperative nausea and vomiting
Adverse Effects: Restlessness, drowsiness, fatigue, diarrhea
Nursing Responsibilities:
• Monitor bowel sounds
• Tell patient to avoid activities that require alertness for 2 hours after doses
7. ESOMEPRAZOLE MAGNESIUM (NEXIUM)
Classification: Proton pump inhibitor
Mechanism of Action: Reduces gastric acid secretion and decreases gastric acidity
Indication: To reduce the risk of gastric ulcers in patients receiving continuous NSAID
therapy
Adverse Effects: Headache, dry mouth, diarrhea, abdominal pain, nausea, vomiting
Nursing Responsibilities:
• Give drug at least 1 hour before meals
• Monitor patient for rash or signs and symptoms of hypersensitivity
• Monitor bowel sounds
• Warn patient not to chew or crush drug because this inactivates the drug
8. FUROSEMIDE (LASIX)
Classification: Loop diuretic
Mechanism of Action: Inhibits sodium and chloride reabsorption at the proximal and
distal tubules and the ascending loop of Henle
Adverse Effects: Headache, dizziness, fever, weakness, restlessness
Nursing Responsibilities:
• Monitor vital signs especially temperature
• Ensure safety by raising side rails
• Assist patient in changing position
• Monitor weight early in the morning
• Advise patient to take drug with food to prevent gastrointestinal upset
9. CALCIUM CARBONATE (CALTRATE PLUS)
Classification: Calcium replacement
Mechanism of Action: Replaces calcium and maintains calcium level
Indication: Hypocalcemia
Adverse Effects: Bradycardia, nausea, vomiting, abdominal pain
Nursing Responsibilities:
• Monitor calcium levels frequently
• Monitor vital signs especially heart rate
• Tell patient to take oral calcium with a full glass of water
10. VITAMIN K
Classification: Vitamins and minerals
Mechanism of Action: An antihemorrhagic factor that promotes hepatic formation of
active coagulation factors
Indication: Hypoprothrombinemia caused by vitamin K malabsorption, drug therapy
Adverse Effects: Dizziness, diaphoresis
Nursing Responsibilities:
• Give fresh frozen plasma once severe bleeding occurs
• Tell patient to avoid hazardous activities if dizziness occurs
11. PARECOXIB SODIUM (DYNASTAT)
Classification: Nonsteroidal anti-inflammatory drug
Mechanism of Action: Thought to inhibit prostaglandin synthesis, impeding
cyclooxygenase-2 (COX-2) to produce anti-inflammatory, analgesic, and antipyretic
effects.
Indication: Acute pain
Adverse Effects: Dizziness, headache, insomnia, abdominal pain, diarrhea
Nursing Responsibilities:
• Provide rest periods by clustering nursing care.
• Ensure safety by raising siderails
• Monitor intake and output
• Instruct patient to promptly report signs of gastrointestinal bleeding such as blood
in vomit, urine, stool; or black, tarry stools.

LABORATORY RESULTS
Biopsy (February 25,2010)
GROSS DESCRIPTION: Specimen consists of a segment of small intestine measuring
36cm long, previously sectioned at the site of the mass. The resection margins
(proximal and distal), measure 4.5 cm in circumference and are both grossly
unremarkable. There is circumferential, gray-white, firm mass measuring 9.8x4x2cm
completely obstructing the intestinal lumen. Cut sections of the mass show a gray-
white firm mass involving the entire thickness of the intestinal wall (approximately
measuring 1.4-2.8cm). This lesion is seen 13-14cm away. The adjacent, uninvolved
intestinal mucosa is flattened and hemorrhagic. There are tumor nodules formed in the
adjacent, serosal fat measuring from 1.5cmx1cm to 5x3cm. Representative sections
submitted for study labeled: “A”- resection margins (1- proximal, 2- distal), “B”- mass,
“C”- random sections of the ileum and “D” and “E”- tumor nodules
MICROSCOPIC DEFINITION: Sections reveal a diffuse proliferation of lymphocytes,
predominantly of the large cell type, having pleomorphic, vesicular nuclei with
prominent nucleoli and scanty amount of cytoplasm. These atypical cells are mainly
seen in the submucosa and are almost completely effacing the mucosa. The tumor is
extending up to the serosal layer with formation of tumor nodules. There are no
germinal centers seen. Scattered areas of tumor necrosis are noted. Occasional mitotic
figures are seen.
DIAGNOSIS: Segment of small intestine (distal ileum) – Non-Hodgkin’s lymphoma
large cell type diffusely infiltrating the entire intestinal wall thickness with formation of
tumor nodules. Resection margins (proximal and distal), negative for tumor. Random
sections of the uninvolved colon, mucosal flattening, negative for tumor. Nine lymph
nodes: non-hodgkin’s lymphoma, large cell type.

Interpretation: This test diagnosed the specific disease of the patient which is Non-
Hodgkin’s lymphoma. Some of the characteristics of Non-Hodgkin’s lymphoma are as
follows: multiple peripheral nodes are involved, noncontiguous spread, rarely localized
extent of disease, extranodal involvement are commonly involved.

X-Ray (February 21, 2010)


RESULTS: Clear and normovascular lung fields, cardiac shadow is unenlarged,
atherosclerotic aortic knob, prominent ascending and descending aorta, intact
diaphragm, clear costophrenic angles

Interpretation: The x-ray results showed that there is the fatty deposition in the aortic
knob, which may predispose the patient in having increased blood pressure in that
area, which may further predispose the patient to have hypertension.
Complete Blood Count (February 27, 2010)
RESULTS NORMAL RANGE
WBC: 10.5x10e9/L* 5-10
81.5%N* 45-70
4.29%L* 20-40
10.8%M 0-12
2.05%E 0-8
1.29%B 0-2
RBC: 4.01x10e12/L* 4.5-6
Hgb: 115g/L* 120-170
Hct: 0.332L/L* 0.40-0.54
MCV: 82.8fL 76-96
MCH: 28.7pg 27-32
MCHC: 347g/L 320-360
Platelet: Adequate
Comments: Normocytic, normochromic

Interpretation: The patient undergone complete blood count in order to confirm the
presence of an infection. White blood cells are increased whenever there is an
infectious process going on to the patient. This is also accompanied by an increase in
the neutrophils and the decrease of lymphocytes (lymphopenia). The red blood cells of
the patient are decreased, confirming his diagnosis of anemia. It also follows that the
patient has low hemoglobin or the oxygen-carrying capacity of the red blood cells. This
can be manifested as general body weakness since there is impairment in the tissue
perfusion in the body.

Serum Calcium Level (February 27, 2010)


RESULTS:
Calcium (ionized)* - 1.07 mmol/L
Normal Range: 1.13-1.32

Interpretation: This test confirms the diagnosis of the patient which is hypocalcemia.
This may manifest in the patient as having tetany, in which there is an increase in the
neural excitability of the patient.
PATHOPHYSIOLOGY
Age of greater than 65,
alcohol intake, obesity

Neoplastic growth of lymphoid


tissue in the intestines

Cell immortalization and


increase in malignant cells

Intestinal obstruction

Sequestration of gas and fluid


proximal to obstruction

Distention

Pressure on diaphragm Colicky abdominal pain Acute pain


Hypocalcemia
Metabolic Acidosis
Decreased respiratory volume Nausea and vomiting due to
decreased food intake
Decreased nutrient absorption Loss of water and electrolytes
Imbalanced nutrition: Decreased carbohydrate
less than body reserves
requirements Deficient fluid volume
Ineffective
Difficulty of breathing
airway clearance Impaired skin integrity Dehydration

Body weakness
Decreased plasma volume
Decreased central venous
Activity Intolerance pressure
Impaired physical mobility
Decreased extracellular fluid
volume

Ineffective tissue perfusion Anemia


PRIORITIZATION AND JUSTIFICATION
Prioritization Justification
1. Ineffective airway clearance According to ABCD prioritization, A
related to retained secretions goes first which is Airway
at the tracheobronchial tree establishment. This is the first
prioritized problem since adequate
perfusion to other parts of the body
is necessary to maintain normal
bodily functions.
2. Imbalanced nutrition: less than In Henderson’s 14 Fundamental
body requirements related to Needs of Man, this is the first listed
inability to absorb nutrients need of man which is to eat and
secondary to intestinal tumors drink adequately. This is prioritized
as second because although the
patient eats adequately, the
nutrients are not absorbed properly
because of the ongoing disease
process and the intestines are the
sites where absorption of nutrients
take place.
3. Deficient fluid volume related This is also the first listed need of
to inability to reabsorb water man in Henderson’s 14 fundamental
secondary to intestinal tumors needs. This is prioritized as third
because without correcting the
nutrition of the patient, correcting the
fluid volume would not be essential.
4. Ineffective tissue perfusion This is the fourth prioritized problem
related to decreased number since we can increase the perfusion
of circulating red blood cells in of oxygen in the body by offering
the body iron-rich foods for the patient, which
is addressed in the second
prioritized problem. This is also C in
ABCD which is circulation.
5. Acute pain related to lack of According to ABCD prioritization,
blood supply to the abdomen this is D which is disability. This is
secondary to gastritis also the chief complaint of the
patient. This is the fifth prioritized
problem because it does not
significantly affect the patient’s
activities of daily living such as
eating and sleeping.
6. Activity intolerance related to This is the fourth listed need of man
lack of circulating oxygen to in Henderson’s theory. This is the
the body sixth prioritized problem since the
patient is unable to change his
position without assistance. This is
also in relation to lack of oxygen
adequately perfusing the body due
to his severe anemia.
7. Impaired physical mobility This is also in relation to the sixth
related to distention of prioritized problem. It is also listed
abdomen secondary to as number 4 in Henderson’s 14
gastritis Fundamental Needs of Man. This is
prioritized as seventh because if the
disease entitiy is suppressed or
resolved, this would follow as being
solved.
8. Impaired skin integrity related This is the seventh listed need of
to continuous fluid loss man that needs to be addressed
according to Virginia Henderson.
This is the last prioritized problem
because with adequate nutrition and
adequate hydration, the patient
would not manifest problems in his
integumentary system.