Adeno Carcinoma 28-43

LICEO DE CAGAYAN UNIVERSITY

COLLEGE OF NURSING
PASEO DEL RIO, MACASNDIG
CAGAYAN DE ORO CITY
SY 2019-2020
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN N104

RELATED LEARNING EXPERIENCE
A CASE STUDY ON
RECTAL ADENOCARCINOMA
SUBMITTED BY: 
Mercado, Frances Dianne G.
 
BSN-3
SUBMITTED TO:
JOSEPH F. ABANG, RN, MN
CLINICAL INSTRUCTOR
DATE SUBMITTED:
DECEMBER 19 2019
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TABLE OF CONTENTS
I. Patient’s Profile…………………………………………………………..3
II. Introduction………………………………………………………………4
III. Database and History…………………………………………………….7
IV. Nursing Assessment……………………………………………..……….8
V. Nursing System Review Chart
VI. Laboratory Results…………………………………………………….24
VII.Doctor’s Order
VIII. Drug Study…………………………………………………………….28
IX. Nursing Care Plan……………………………………………………..43
X. Health Teaching…………………………………………………….…59
XI. Anatomy and Physiology
XII.Pathophysiology……………………………………………………….60
XIII.Observations and Implications………………………………….……64
XIV. Summary………………………………………………………..……67
XV. Referral……………………………………………………….……….69
XVI. Bibliography……………………………………………..…………..70
XVII. Documentation………………………………………..…………….72
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I. Patient’s Profile
Name of Patient: Pacita, Aniñon
Age: 71yrs old
Birthday: June 6 1948
Address: Gomez St, Cagayan De Oro City
Religion: Roman Catholic
Civil Status: Married
Educational College Graduate
Attainment:
Occupation: Retired Election Officer (FEBECO)
Contact number: 09364514330
Husbands name: Julio Pacita

Age: 69 years old
Birthday: July 8 1950
Religion: Roman Catholic
Educational Vocational
Attainment:
Occupation: Retired Government Worker
Number of Children: 2
Obstetric History:
Name of Child: Jurgen Rananon
Age: 38 years old
Type of delivery: NSVD
Name of Child: Bryan Pacita

Age: 17 years old
Type of delivery: NSVD
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II. Introduction
A.Brief Description of Disease

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral
cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach
and intestines to the rectum and anus, where food is expelled. There are various accessory
organs that assist the tract by secreting enzymes to help break down food into its
component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have
important functions in the digestive system. Food is propelled along the length of the GIT by
peristaltic movements of the muscular walls.
 
The primary purpose of the gastrointestinal tract is to break food down into nutrients, which
can be absorbed into the body to provide energy. First food must be ingested into the mouth
to be mechanically processed and moistened. Secondly, digestion occurs mainly in the
stomach and small intestine where proteins, fats and carbohydrates are chemically broken
down into their basic building blocks. Smaller molecules are then absorbed across the
epithelium of the small intestine and subsequently enter the circulation. The large intestine
plays a key role in reabsorbing excess water. Finally, undigested material and secreted
waste products are excreted from the body via defecation (passing of faeces).
 
In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal
t r a c t a r e n o t a c h i e v e d s u c c e s s f u l l y. P a t i e n t s m a y d e v e l o p s y m p t o m s
of nausea, vomiting, diarrhoea, malabsorption, constipation or obstruction. Gastrointestinal
problems are very common and most people will have experienced some of the above
symptoms several times throughout their lives.
The rectum is a chamber that begins at the end of the large intestine, immediately following
the sigmoid colon, and ends at the anus (see also Overview of the Anus and Rectum).
Ordinarily, the rectum is empty because stool is stored higher in the descending colon.
Eventually, the descending colon becomes full, and stool passes into the rectum, causing an
urge to move the bowels (defecate). Adults and older children can withstand this urge until
they reach a bathroom. Infants and young children lack the muscle control necessary to
delay bowel movement.
Rectal cancer is the growth of abnormal cancerous cells in the lower part of the colon that
connects the anus to the large bowel. Rectal cancer develops usually over years; its actual
cause is not known, but risk factors include increasing age (over 50), smoking, family
history, high-fat diet, or a history of polyps or colorectal cancer or inflammatory bowel
disease.
The major symptom of rectal cancer is bleeding from the rectum; other symptoms
include anemia, fatigue, shortness of breath, dizziness and/or a fast heartbeat, bowel
obstruction, small diameter stools, and weight loss. For diagnosis, exams and tests may
include fecal occult blood testing, endoscopy, digital rectal examination, sigmoidoscopy, CT/
MRI imaging studies, along with routine blood tests and detection of carcinoembryonic
antigen (CEA). Medical treatment depends on the stage of rectal cancer (stages I-IV), with
IV being the most severe stage; multiple chemotherapy medications are available and are
chosen by the specialist (oncologist) to fit the individual's stage of rectal cancer; other
specialists may need to be consulted. Surgery is used to both treat and reduce symptoms
and, in some individuals, may result in a remission of the cancer. Radiation therapy is also
used to kill or shrink rectal cancers. Follow-up is important to make sure that rectal cancer
does not recur. Prevention involves detection and removal of precancerous growths. xThe
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outlook or prognosis for individuals with rectal cancer is usually related to the stage of
cancer, with stages III and IV having the poorest outcomes.
B. Reasons for choosing case

The researcher had an extensive thorough assessment among the cases in Station 2.
Cagayan de Oro Medical Center. After careful deliberation, it was decided that the case of
Mrs. Aniñon was the most pertinent for the following basis.
Mrs. Aniñon’s condition relates to the N104 concept under Cancer with her diagnosis of
Rectal Adenocarcinoma as evidenced by her biopsy diagnostic test. Additionally, her other
laboratory works was readily available since she had prior checkups before the admission.
The client was able to verbally report her clinical manifestations thoroughly which assisted
the interpretation of the assessment. Furthermore, the client already had her intervention to
ruling out her diagnosis which supported the available medical management for treatment.
C. Statistics
Global Statisitics:
Colorectal cancer is the third most commonly occurring cancer in men and the second most
commonly occurring cancer in women. There were over 1.8 million new cases in 2018. The
top 25 countries with the highest rates of colorectal cancer in 2018 are given in the tables
below.
-World Cancer Research Fund, 2018
Nationwide Statistics
PSG's recent data shows that there are over 3,000 new cases of CRC among Filipinos
annually. Of these more than 3,000, over 2,000 die, said Dy, and these are only based on
reported cases.
Just last year, a global research even found out that the Philippines has the highest increase
in mortality among the 37 countries surveyed, Dy noted. This means, he said, that CRC
patients in the Philippines die faster than those in other countries.
-Philippine Society of Gastroenterology, 2018
Local Statistics
No available statistic incidence
D. Scope and Limitation

The scope of this study consists of one post surgical patient of Room 311, Station 2,
Cagayan de Oro Medical Center, Cagayan de Oro city, A case of Aniñon, Pacita diagnosed
with Rectal Adenocarcinoma, post operative after ex laparatomy, lower anterior resection,
with end to end anastomosis. Patient was under the care of institution since November 27
2019 and still in. The client was able to narrate the clincal manifestation and progession of
the dieases. The students nurse was able to render care and interventions on days
December 1, 2 and 3 which consist of 1 day assessment and 2 days regular duty which on
those days this study will be focused. The said dates were maximized to gather information
including patients’ profile, data base, history of present illness, chart data, laboratory results
and other documents for the development of an extensive and accurate case study.
The limitations include: (1) This study is restricted to 3 days, maximized to gather
information including patients’ profile, data base, history of present illness, chart data,
laboratory results and other documents for the development of an extensive and accurate
case study. (2) After the duty period, there is no means for update regarding the progress of
Aniñon’s condition. (3) (4) This study cannot be generalized with other Rectal
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Adenocarcinoma. However this case study aims to provide significance to one of the
surgical cases particularly in Cagayan de Oro City.
E. Objectives
At the end of this case study, the researcher will able to:
Interpret the objective and subjective data in a thorough manner
Appreciate the anatomy and physiology of the Gastrointestinal System
Discuss the pathophysiology of Rectal Adenocarcinoma
Distinguish predisposing/precipatating factors
Formulate an effective nursing care plan
Assess the parameters of this study
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III. Database and History
Name of Patient: Aniñon, Pacita Sex: F Age: 71Y Religion: Roman Catholic
Civil Status: Married Income: 8000/month pension Nationality: Filipino
Date Admitted: 11/27/2019 Time: 8:29 AM Informant: Jurgen Rananon
Temperature: 36.0°C Pulse Rate: 77 bpm Respiratory Rate: 20cpm BP: 130/80mmHg
Height: 5’1ft Weight: 41kgs
Chief Complaint and History of Present Illness

A case of Aniño, Pacita 71yrs old married female from Gomez St. CDOC with a chief
compliant of hematochezia.
1 month prior to admission patient noted onset of hematochezia with occasional
black tarry stools, no abdominal pain persistence prompted consult, colonoscopy done
showing rectal growth, hence advised for ex laparotomy, possible LAR (lower anterior
resection) upon admission hence admitted in Cagayan de Oro Medical Center
Types of Previous Illness/Pregnancy/Delivery Date

Familial History
(-) Hypertension, (-) DM, (-) Cancer, (-) Tumor
Obstretic History G2P2 (2002)
No previous hospitalization
No previous surgery
Has received blood in the past: _____Yes / No If yes, list dates ______
Reaction ____Yes ____No
Allergies: No known allergies to food and drugs
Medication Name Dose/Frequency Last Time of Dose

Herbal Medication from 1 Concoction October 2019
Sabadista
B Complex 1 tab OD 11/26/2019 9am
Admitting Diagnosis: Rectal Adenocarnima

Admitting Physician: Abujuela, Nhicoo Francis R. MD
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IV. Nursing Assessment
A. NURSING ASSESSMENT
Name of patient: Aniñon, Pacita Ward/Room: Station 2 Room
311
NURSING SYSTEM REVIEW CHART

Temp: 36.5 C PR: 79bpm RR: 20cpm BP: 130/80mmhg Height: 5’1ft Weight: 41kg Date: 12/1/19
EENT
[]impaired vision []blind []pain Melasma on face
[]reddened []drainage []gums
[]hard hearing []deaf []burning Hypoactive bowel sounds
[]edema []lesion []teeth
Assess eyes, ears, nose, throat for any abnormalities Tolerable pain on surgical
[x]no problem
Site upon movement
RESPIRATORY
[]asymmetric []tachypnea []apnea
[]rales []cough []barrel chest postoperative wound dry
[]bradypnea []shallow []rhonchi And intact
[]sputum []diminished []dyspnea
[]orthopnea []labored []wheezing
[]pain []cyanotic
Assess respiration, rate, rhythm, depth, pattern,

breath sounds, comfort [x]no problem
CARDIOVASCULAR
[]arrhythmia []tachypnea []numbness
[]diminished pulses []edema []fatigue
[]irregular []bradycardia []murmur
[]tingling []absent pulses []pain
Assess heart sound, rate, rhythm, pulse, blood

pressure, circulation, fluid retention, comfort
[x]no problem
GASTROINTESTINAL TRACT
[]obese []distention []mass
[]dysphagia []rigidity [x]pain
Assess abdomen, bowel habits, swallowing, bowel

sound, comfort []no problem
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GENITO-URINARY & GYNE
[]pain []urine color [ ] v a g i n a l

bleeding
[]hematuria []discharges []nocturia
Assess urine frequency, control, color, odor, comfort,

gyne bleeding, discharges []no problem
NEURO
[]paralysis []stuporous []unsteady
[]seizures []lethargic []comatose
[]vertigo []tremors []confused
[]vision []grip diet: sips of water
Assess motor function, sensation, Loc, strength, grip,

gait, coordination, orientation, speech [x]no problem
MUSCULOSKELETAL & SKIN D5LR @30gtts/min
[]appliance []stiffness []itching
[]petechiae []hot []drainage
[]prosthesis []swelling []lesion Hematochezia
[]poor turgor []cool []deformity Turbid dark yellow urine
[]wound []rash []skin color
[]flushed []atrophy []pain (back)
[]ecchymosis []diaphoretic []moist
Assess mobility, motion, gait, alignment, joint,

function, skin color, texture, turgor, integrity []no
problem
Instructions on the use of this tool:

-Put an X in the box before the given assessment finding.
-Put an X also on the part/parts of the figure which is/are affected.
-Specify in the blanks assessment findings related to the item which you put an X.
-You may also place in the blanks assessment findings which are not found in the
given list.
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NURSING ASSESSMENT II
SUBJECTIVE DATA OBJECTIVE DATA
COMMUNICATIO Comments: “wala [x]Glasses []Languages
N koy kabag’ohan
saakng paglantaw
[]Hearing Loss ug pagdungog” as []Contact Lens []Hearing Aide
[]Visual Changes verbalized by client P u p i l L R []Speech difficulties
s i z e
3mm
[x]Denied Reaction Pupils equally round and reactive to

light and accommodation
OXYGENATION Comments: “Wala Respiration [x]Regular []Irregular
mn ko nag ubo ug
[]Dyspnea pag lisod sa pag Describe: RR within normal range of 20cpm,
ginhawa.” As clear breath sounds, not in distress
[]Smoking History
verbalized by client
[]Cough
[]Sputum R: Equal rise and fall with left lung
[x]Denied L : Equal rise and fall with right lung
CIRCULATION Comments: “Wala Heart Rhythm [x]Regular []Irregular
ko kabatis ug sakit
[]Chest Pain sa dughan.” As Ankle Edema: No ankle edema
Pulse Car Rad AP Fem*
[]Numbness of R
extremities
L
[x]Denied Comments
NUTRITION Comments: “Wala [x]Dentures []None
pa man ko gipa
Diet: Sips of water kaon ni doc maam.” Complete Incomplete
[]Recent change in As verbalized by Upper [] [x]
weight a n d client
appetite Lower [] [x]
[]Swallowing
Difficulty
[x]Denied
ELIMINATION Urinary frequency Comments: “Wala pko Bowel Sounds:
ka kalibang sukad na Hypoactive
Usual b o w e l 4-8xday operahan ko. Ga cge
pattern gyapn ko ug ihi
1-2x an day []Urgency maam.” Verbalized Abdominal Distention
client
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LICEO DE CAGAYAN
client UNIVERSITY
C o n s t i p a t i o n []Dysuria [x]Yes []No
Remedy
Water []Hematuria Urine color,

consistency, odor
Date of last BM []Incontinence Turbid, dark yellow,
11/28/2019 []Polyuria strong odor
Diarrhea Character []Foley in place

No diarrhe []Denied
MANAGEMENT OF HEALTH AND Briefly describe patient’s ability to follow
ILLNESS treatments (diets, medications, etc.)
[]Alcohol [x]Denied Patient has no medication for any chronic
health problems, complies to B Complex
vitamins
[]SBE Last Pap Smear:
never had papsmear
LMP: Menopause, cannot recall
SUBJECTIVE DATA OBJECTIVE DATA

SKIN INTEGRITY Comments: “Medyo []Dry []Cold Pale
sakit akng samad
[]Dry kung malihok sha []Flushed [x]Warm
[]Itching gamay.” As []Moist []Cyanotic
[]Denied Rashes, ulcers, decubitus (describe size,
location, drainage, color, odor) no rash,
ulcer, decubits
ACTIVITY & SLEEP Comments: “Maka LOC & Orientation: awake, conscious &
lihok man ko maam coherent, aware of self. time, place, and
[]Convulsion pero patabang lang event, participative with assessment
gyd ko sa pagbakod
[]Dizziness ug higda kay dili Gait: []Walker []Cane
[]Limited Motion of kaau ko maka [x]Steady []Unsteady
Joints pangusog.” As
verbalized by client Sensory & motor losses in face and
[x]Limitation in ability extremities: No loss of sensory & motor
to ambulate losses in face or extremities
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[]Bathe self ROM Limitations: No range of motion
limitation
[]Denied
COMFORT/SLEEP/AWAKE []Facial Grimace
[x]Pain (location, Comments: “Akong [x]Guarding
frequency & remedy samad sa opera ky
s a k i t g a m a y. ” A s []Other signs of pain
[]Nocturia Side rails release: Side rails raised for

safety
[]Sleep Difficulty
[]Denied
COPING Observed non-verbal behavior: Patient was
responsive and participative, able to
Occupation: Retired election committee maintain eye contact
Members of household: Husband Person and phone number that can be
reached at any time: 09173068648
Most supportive person: Husband
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VI. Laboratory Results
Complete Blood Count 11/27/2019
Component Results Normal Range Interpretation
WBC 4300 5000-10000 Low WBC: Side eﬀect of treatment
Rbc 3.71 4.35-5.90 Low Red Blood components: blood loss

occured due to hematochezia
Hemoglobin 12.0 13.7-16.7
Hematocrit 36.5 40.5-49.7
Platelet 160 000 144000-372000
MCV 98 79.7-97.0
High MCV: may be related to B12 or folic
acid deficiency
MCH 33.2 26.1-33.33
MCHC 33.7 32.2-35
Rdw-w p3.9 11.5-14.5
Neutrophil 62.9 43.4-76.2
Lymphocyte 30.8 17.4-46.2
Monocytes 4.7 4.5-10.5
Eosinophils 1.6 2.0-3.0
Basophils 0.0 0.0-0.5
White cell count- a blood test to measure the number of white blood cells it is also called
leukocytes. They help fight infections. In this case, our patients initial CBC Result prior to
admission was higher than normal and indicates that the patient has infection or
inflammation.
Red cell Count: Is known as an erythrocyte count. The test is important because RBCs
contains hemoglobin, the number of RBCs you have can affect how much oxygen your
tissues receive. Your tissues need oxygen to function. In this case our patient has low RBC
than the usual values, the patient might experience fatigue, dizziness, weakness and
shortness of breath. This might lead to some diseases such as external and internal
bleedings, bone marrow failure, and anemia.
Hemoglobin or haemoglobin, abbreviated Hb or Hgb, is the iron-containing oxygen-

transport metalloprotein in the red blood cells of almost all vertebrates as well as the tissues
of some invertebrates. Hemoglobin in blood carries oxygen from the lungs or gills to the rest
of the body.
Hematocrit: is the volume of red blood cells in your body. A hematocrit test measures the
ratio of RBCs in your blood. Another term for low hematocrit is anemia. The causes of low
hematocrit, or anemia, include: Bleeding (ulcers, trauma, colon cancer, internal bleeding),
22
Destruction of red blood cells (sickle cell anemia, enlarged spleen), Decreased production of
red blood cells (bone marrow suppression, cancer, drugs), Nutritional problems (low iron,
B12, folate and malnutrition), Overhydration (polydypsia, intravenous overhydration)
MCV(mean corpuscular volume): when red blood cells are too small. This condition is
called microcytic anemia. The MCV will be lower than normal when red blood cells are too
small. This condition is called microcytic anemia. Microcytic anemia may be caused by: iron
deficiency, which can be caused by poor dietary intake of iron, menstrual bleeding, or
gastrointestinal bleeding; thalassemia; lead poisoning; chronic diseases.
MCH (mean cell haemoglobin): this refers to the average amount of hemoglobin found in
the red blood cells in the body. Different types of anemia can cause low MCH levels. For
example, microcytic anemia occurs when the blood cells are too small and cannot take in as
much hemoglobin as they should. This can be due to malnutrition or nutritional deficiencies.
Some medical conditions can also cause anemia, even if the person eats a balanced and
healthful diet. Low amounts of iron in the blood can also cause low MCH levels. The body
uses iron to make hemoglobin. If the body runs out of iron, iron deficiency anemia can cause
low MCH levels. This type of anemia may be more common in vegetarians or people with
poor nutritional intake.
MCHC (mean corpuscular hemoglobin concentration): are the average weight of that
hemoglobin based on the volume of red blood cells. The most common cause of low MCHC
is anemia. Hypochromic microcytic anemia commonly results in low MCHC. This condition
means your red blood cells are smaller than usual and have a decreased level of
hemoglobin.
Differential Count
An increase in neutrophils in your blood may be caused by:
• infection
• thyroiditis
• trauma
A decrease in neutrophils in your blood may be caused by:
• bacterial infection
• influenza or other viral illnesses
• radiation exposure
An increase in lymphocytes in your blood may be caused by:
• chronic infection
• viral infection, such as the mumps or measles
A decrease in lymphocytes may be caused by:
• chemotherapy
• HIV infection
• leukemia
• radiation exposure, either accidental or from radiation therapy
An increase in monocytes may be caused by:
• chronic inflammatory disease
• viral infection, such as measles, mononucleosis, and mumps
A decrease in monocytes may be caused by:
• bloodstream infection
• chemotherapy
• bone marrow disorder
• skin infections
An increase in eosinophils may be caused by:
• an allergic reaction
A decrease in basophils may be caused by acute allergic reaction.
23
Prothrombin 11/27/2019
Ww01 12.3
Patent 12.3
% activity 100.00
INR 1:00
A prothrombin time (PT) test measures the amount of time it takes for your blood plasma to
clot. Prothrombin, also known as factor II, is just one of many plasma proteins involved in
the clotting process.
ABO 11/27/2019
O+
Other Blood Diagnostic 11/27/2019

FBS 94
Creatine 0.71
Albumin 4.4
Fasting blood sugar levels give vital clues about how a person's body is managing blood
sugar
High fasting blood sugar levels point to insulin resistance or diabetes, while abnormally low
fasting blood sugar could be due to diabetes medications.
Tests for albumin and creatinine are done on a urine sample collected randomly (not timed)
and an albumin-to-creatinine ratio (ACR) is calculated. This is done to provide a more
accurate indication of the how much albumin is being released into the urine. Creatinine, a
byproduct of muscle metabolism, is normally released into the urine at a constant rate and
its level in the urine is an indication of the urine concentration. This property of creatinine
allows its measurement to be used to correct for urine concentration when measuring
albumin in a random urine sample.
The presence of a small amount of albumin in the urine may be an early indicator of kidney
disease. A small amount of albumin in the urine is sometimes referred to as urine
microalbumin or microalbuminuria. "Microalbuminuria" is slowly being replaced with the term
"albuminuria," which refers to any elevation of albumin in the urine.
Radiology 11/27/2019
Linear densities are seen in the left upper lobe heart not enlarged
aorta is turtuous & calcified diaphragm low typing
Impression
-pulmonary fibrosis, left upper lobe
-pulmonary hyper aeration
- tortuous & atherossclerotic aorta
Radiology is done to support or rule out a diagnosis
Biopsy 10/11/2019
Well differentiated adenocarcinoma
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A biopsy is a sample of tissue taken from the body in order to examine it more closely. A
doctor should recommend a biopsy when an initial test suggests an area of tissue in the
body isn't normal. Doctors may call an area of abnormal tissue a lesion, a tumor, or a mass.
Colonoscopy report 10/11/2019

Rectal newgrowth malignant looking from the anus partially obstructing main tension
A colonoscopy can be used to look for colon polyps or bowel cancer and to help diagnose
symptoms such as unexplained diarrhoea, abdominal pain or blood in the stool.
25
VII. Doctor’s Order
Date Doctor’s Order Rationale
11/27/19 -Please admit patient to room of choice

Soft diet: serves as a transition in
-Secure content
preparation for the surgery, helpful to
-Soft Diet
patients who are undergoing
-Attach Endoscopy and biopsy results
treatments to the abdominal areas,
-Labs
which may cause digestive problems.
1. CBC w/ platelet

2. BT
Labs: Clinical laboratory test purposes
3. FBS
Define risk or disease, eg detect
4. PTPA, serum albumin
hyperglycemia, hypercholesterolemia
5. Chest xray, PA
Stratify a person into a disease or
6. ECG
nondisease state, in which the
7. 2D Echo
population is bimodal with overlapping
-Schedule for ex-laporotomy, possible LAR parameters, which include above
on 11/29/2019 7am
normal without disease and low
-Secure consent for procedure
normal with disease
-Start IVF w/ D5LR@ 20gtts/min

Monitor a condition
-Piperacillin+ Tazobactam 45mg IV q8
Consent: for legal purpose
IVF: To ensure electrolyte balance
11/28/19 -NPO at midnight

NPO: preparation for Intraoperative to
-IV to 30gtts/min
decrease risk of aspiration
-For OR tomorrow
26
11/29/19 Post Op
v/s monitoring: ensure that there is no
-To recovery room now
post operative complications
-s/p ex lap low anterior anastomasis under O2: ensure oxygenation levels during
GA int TCI
recovery period
-Please monitor q15min until stable then

q1hourx4hours then q2hoursx6hours then medications: please check drug study
q4hour
-O2 mask by at 5-6LBPMx2hours
-NPO
-IVF D5LR 1L x 8hours
PlainLR 1L x 8hours
D5LR 1L x 8hours
Meds
continue
1. Piperacillin + Tazobactam (Vigocid) 45gm

IV q8h
continue
2. Metronidazole (Dazomet) 500mg IV

infusion q8h
3. Parexcoxib (Dynastat) 40mg IVq12h x 2

Doses ANST
4. Tramadol 50mg slow IV q6-8 x 4doses

then PRN for pain
-Ambulate
-NPO
11/30/201 -Discontinue CBG monitor

9
12/1/2019 -Sips of water

Sips of water: As a rule you will be
-Continue all mes
able to drink as soon as the nurses
-D5LR 1L @30gtts/min and physicians hear your bowel
sounds and you will be able to eat
safely as soon as you pass gas or
have a bowel movement.
12/2/2019 -Prepare ointment for dressing

ointment: topical antibacterial for
-Afebrile wound dressing
12/3/2019 -Soft diet tomorrow

Soft diet: Transistion to liquid diet to
-Continue all meds full diet after surgery
27
X. Health Teachings 
MEDICATIONS Instructed patient and significant other to comply with the

medications on an appropriate time and dosage as prescribed by
the physician after the discharge order
1. Amoxiclav 625mg 1 tab twice a day for 7days
2. Celecoxib 200mg 1 cap twice a day for 5 days
EXERCISE Encouraged the patient to ensure rest and refrain from strenuous
activity.
Advised the patient to get adequate amounts of sleep, preferably

at 8-10 hours a day.
Encouraged deep breathing exercise.
TREATMENT Instructed patient to wash hands always.

Encouraged for proper hygiene.
Instruct the appropriate way on how to clean the surgical
site inorder prevent infection such as wound care.
OUTPATIENT Instructed patient to come back for follow up check up on

December 12 2019 with Dr. Gudito at Cagayan de Oro Medical
(CHECK-UP) Center
Instructed to be back immediately if there is any pain on
the surgical site or any unusualities
DIET Advised the patient and family to drink plenty of fluids to

prevent dehydration and to replenish hydration in the body.
Encouraged the patient to eat healthy foods such as pechay,
kalamunggay and refrain from dark colored foods.
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XI. Anatomy and Physiology
gastrointestinal tract
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral
cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach
and intestines to the rectum and anus, where food is expelled. There are various accessory
organs that assist the tract by secreting enzymes to help break down food into its
component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have
important functions in the digestive system. Food is propelled along the length of the GIT
by peristaltic movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break food down into nutrients, which
can be absorbed into the body to provide energy. First food must be ingested into the mouth
to be mechanically processed and moistened. Secondly, digestion occurs mainly in the
stomach and small intestine where proteins, fats and carbohydrates are chemically broken
down into their basic building blocks. Smaller molecules are then absorbed across the
epithelium of the small intestine and subsequently enter the circulation. The large intestine
plays a key role in reabsorbing excess water. Finally, undigested material and secreted
waste products are excreted from the body via defecation (passing of faeces). 
In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal
tract are not achieved successfully. Patients may develop symptoms
of nausea, vomiting, diarrhoea, malabsorption, constipation or obstruction. Gastrointestinal
problems are very common and most people will have experienced some of the above
symptoms several times throughout their lives.
 
Basic structure
The gastrointestinal tract is a muscular tube lined by a special layer of cells, called
epithelium. The contents of the tube are considered external to the body and are in
continuity with the outside world at the mouth and the anus. Although each section of the
29
tract has specialised functions, the entire tract has a similar basic structure with regional
variations.
The wall is divided into four layers as follows:
Mucosa
The innermost layer of the digestive tract has specialised epithelial cells supported by an
underlying connective tissue layer called the lamina propria. The lamina propria contains
blood vessels, nerves, lymphoid tissue and glands that support the mucosa. Depending on
its function, the epithelium may be simple (a single layer) or stratified (multiple layers). 
Areas such as the mouth and oesophagus are covered by a stratified squamous (flat)
epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or
glandular epithelium lines the stomach and intestines to aid secretion and absorption. The
inner lining is constantly shed and replaced, making it one of the most rapidly dividing areas
of the body! Beneath the lamina propria is the muscularis mucosa. This comprises layers of
smooth muscle which can contract to change the shape of the lumen.
Submucosa
The submucosa surrounds the muscularis mucosa and consists of fat, fibrous connective
tissue and larger vessels and nerves. At its outer margin there is a specialized nerve plexus
30
called the submucosal plexus or Meissner plexus. This supplies the mucosa and
submucosa.
Muscularis externa
This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibres
separated by the myenteric plexus or Auerbach plexus. Neural innervations control the
contraction of these muscles and hence the mechanical breakdown and peristalsis of the
food within the lumen.
Serosa/mesentery
The outer layer of the GIT is formed by fat and another layer of epithelial cells called
mesothelium.
 
Individual components of the gastrointestinal system
Oral cavity
The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified
squamous oral mucosa with keratin covering those areas subject to significant abrasion,
such as the tongue, hard palate and roof of the mouth. Mastication refers to the mechanical
breakdown of food by chewing and chopping actions of the teeth. The tongue, a strong
muscular organ, manipulates the food bolus to come in contact with the teeth. It is also the
sensing organ of the mouth for touch, temperature and taste using its specialised sensors
known as papillae. 
Insalivation refers to the mixing of the oral cavity contents with salivary gland secretions.
The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity also plays a limited
role in the digestion of carbohydrates. The enzyme serum amylase, a component of saliva,
starts the process of digestion of complex carbohydrates. The final function of the oral cavity
is absorption of small molecules such as glucose and water, across the mucosa. From the
mouth, food passes through the pharynx and oesophagus via the action of swallowing.
Salivary glands
Three pairs of salivary glands communicate with the oral cavity. Each is a complex gland
with numerous acini lined by secretory epithelium. The acini secrete their contents into
specialised ducts. Each gland is divided into smaller segments called lobes. Salivation
occurs in response to the taste, smell or even appearance of food. This occurs due to nerve
signals that tell the salivary glands to secrete saliva to prepare and moisten the mouth. Each
pair of salivary glands secretes saliva with slightly different compositions.
31
Parotids
The parotid glands are large, irregular shaped glands located under the skin on the side of
the face. They secrete 25% of saliva. They are situated below the zygomatic arch
(cheekbone) and cover part of the mandible (lower jaw bone). An enlarged parotid gland can
be easier felt when one clenches their teeth. The parotids produce a watery secretion which
is also rich in proteins. Immunoglobins are secreted help to fight microorganisms and a-
amylase proteins start to break down complex carbohydrates.
Submandibular
The submandibular glands secrete 70% of the saliva in the mouth. They are found in the
floor of the mouth, in a groove along the inner surface of the mandible. These glands
produce a more viscid (thick) secretion, rich in mucin and with a smaller amount of protein.
Mucin is a glycoprotein that acts as a lubricant.
Sublingual
The sublinguals are the smallest salivary glands, covered by a thin layer of tissue at the floor
of the mouth. They produce approximately 5% of the saliva and their secretions are very
sticky due to the large concentration of mucin. The main functions are to provide buffers and
lubrication.
Oesophagus
The oesophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. It
extends from the pharynx to the stomach after passing through an opening in the
diaphragm. The wall of the oesophagus is made up of inner circular and outer longitudinal
layers of muscle that are supplied by the oesophageal nerve plexus. This nerve plexus
surrounds the lower portion of the oesophagus. The oesophagus functions primarily as a
transport medium between compartments.
32
Stomach
The stomach is a J shaped expanded bag, located just left of the midline between the
oesophagus and small intestine. It is divided into four main regions and has two borders
called the greater and lesser curvatures. The first section is the cardia which surrounds the
cardial orifice where the oesophagus enters the stomach. The fundus is the superior, dilated
portion of the stomach that has contact with the left dome of the diaphragm. The body is the
largest section between the fundus and the curved portion of the J. 
This is where most gastric glands are located and where most mixing of the food occurs.
Finally the pylorus is the curved base of the stomach. Gastric contents are expelled into the
proximal duodenum via the pyloric sphincter. The inner surface of the stomach is contracted
into numerous longitudinal folds called rugae. These allow the stomach to stretch and
expand when food enters. The stomach can hold up to 1.5 litres of material. The functions of
the stomach include:
1. The short-term storage of ingested food.

2. Mechanical breakdown of food by churning and mixing motions.
3. Chemical digestion of proteins by acids and enzymes.
4. Stomach acid kills bugs and germs.
5. Some absorption of substances such as alcohol.
Most of these functions are achieved by the secretion of stomach juices by gastric glands in
the body and fundus. Some cells are responsible for secreting acid and others secrete
enzymes to break down proteins.
Small intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It averages
approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-
caecal valve separating the ileum from the caecum. The small intestine is compressed into
numerous folds and occupies a large proportion of the abdominal cavity. 
The duodenum is the proximal C-shaped section that curves around the head of the
pancreas. The duodenum serves a mixing function as it combines digestive secretions from
the pancreas and liver with the contents expelled from the stomach. The start of the jejunum
is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the
majority of digestion and absorption occurs. The final portion, the ileum, is the longest
segment and empties into the caecum at the ileocaecal junction.
33
The small intestine performs the majority of digestion and absorption of nutrients. Partly
digested food from the stomach is further broken down by enzymes from the pancreas and
bile salts from the liver and gallbladder. These secretions enter the duodenum at the
Ampulla of Vater. After further digestion, food constituents such as proteins, fats, and
carbohydrates are broken down to small building blocks and absorbed into the body’s blood
stream. 
The lining of the small intestine is made up of numerous permanent folds called plicae
circulares. Each plica has numerous villi (folds of mucosa) and each villus is covered by
epithelium with projecting microvilli (brush border). This increases the surface area for
absorption by a factor of several hundred. The mucosa of the small intestine contains
several specialised cells. Some are responsible for absorption, whilst others secrete
digestive enzymes and mucous to protect the intestinal lining from digestive actions.
Large intestine
The large intestine is horse-shoe shaped and extends around the small intestine like a
frame. It consists of the appendix, caecum, ascending, transverse, descending and sigmoid
colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. 
The caecum is the expanded pouch that receives material from the ileum and starts to
compress food products into faecal material. Food then travels along the colon. The wall of
the colon is made up of several pouches (haustra) that are held under tension by three thick
bands of muscle (taenia coli). 
The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before it
passes through the anorectal canal to the anus. Thick bands of muscle, known as
sphincters, control the passage of faeces.
34
The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal surface
is flat with several deep intestinal glands. Numerous goblet cells line the glands that secrete
mucous to lubricate faecal matter as it solidifies. The functions of the large intestine can be
summarised as:
1. The accumulation of unabsorbed material to form faeces.

2. Some digestion by bacteria. The bacteria are responsible for the formation of intestinal
gas.
3. Reabsorption of water, salts, sugar and vitamins.
Liver
The liver is a large, reddish-brown organ situated in the right upper quadrant of the
abdomen. It is surrounded by a strong capsule and divided into four lobes namely the right,
left, caudate and quadrate lobes. The liver has several important functions. It acts as a
mechanical filter by filtering blood that travels from the intestinal system. It detoxifies several
metabolites including the breakdown of bilirubin and oestrogen. In addition, the liver has
synthetic functions, producing albumin and blood clotting factors. However, its main roles in
digestion are in the production of bile and metabolism of nutrients. All nutrients absorbed by
the intestines pass through the liver and are processed before traveling to the rest of the
body. The bile produced by cells of the liver, enters the intestines at the duodenum. Here,
bile salts break down lipids into smaller particles so there is a greater surface area for
digestive enzymes to act.
Gall bladder
The gallbladder is a hollow, pear shaped organ that sits in a depression on the posterior
surface of the liver’s right lobe. It consists of a fundus, body and neck. It empties via the
cystic duct into the biliary duct system. The main functions of the gall bladder are storage
and concentration of bile. Bile is a thick fluid that contains enzymes to help dissolve fat in
the intestines. Bile is produced by the liver but stored in the gallbladder until it is needed.
Bile is released from the gall bladder by contraction of its muscular walls in response to
hormone signals from the duodenum in the presence of food.
Pancreas
Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its head
communicates with the duodenum and its tail extends to the spleen. The organ is
approximately 15cm in length with a long, slender body connecting the head and tail
segments. The pancreas has both exocrine and endocrine functions. Endocrine refers to
production of hormones which occurs in the Islets of Langerhans. The Islets produce insulin,
35
glucagon and other substances and these are the areas damaged in diabetes mellitus. The
exocrine (secretrory) portion makes up 80-85% of the pancreas and is the area relevant to
the gastrointestinal tract. 
It is made up of numerous acini (small glands) that secrete contents into ducts which
eventually lead to the duodenum. The pancreas secretes fluid rich in carbohydrates and
inactive enzymes. Secretion is triggered by the hormones released by the duodenum in the
presence of food. Pancreatic enzymes include carbohydrases, lipases, nucleases and
proteolytic enzymes that can break down different components of food. These are secreted
in an inactive form to prevent digestion of the pancreas itself. The enzymes become active
once they reach the duodenum.
36
XII. Pathophysiology
37
38
XIII. Observations and Implications
The clinical manifestation of the Mrs. Aniñon began on early October 2019 when
she was able to detect the presence of clumpy blood with her stool with no pain, she
immediately seek checkup in Cagayan de Oro Medical Center with Dr. Gudito. After a
biopsy test, it was identified that she has acquired Rectal Adenocarcinoma.The physician
suggested ex laparotomy with lower anterior resectioning.
Patient verbalized that it took time for her to undergo the procedure due to financial
constraint, her main mode of income is her pension which is not enough to compensate for
the whole hospital duration even after insurance allocation. After almost 2 months, her
daughter volunteered to cover the hospital expense for admission.
The client was then admitted on November 27 2019 on which the preoperative
phase began. Further diagnostic test was done to ensure a successful operation.
Prophylaxis medication was given to minimize the risk of infection. It was also ensured that
all her vital signs were within normal range.
2 days after admission, the client had her operation. The operation done was ex
laparotomy, low anterior resection with end to end anastomosis. After she was stabilized,
she was transferred to her private room from the PACU to continue her recovery.
2 days after the operation, the student nurse from Liceo de Cagayan University was
assigned to the patient. On the first day assessment, client was surprisingly active and
responsive even after the operation, she is able to stand and walk with little assistance, she
reported a moderate tolerable pain at the surgical site. Upon inspection, the site was dry
and intact. She had no signs for possible infections with vital signs within normal range.
On the first day duty proper, the patient was very active in bed as she was already
combing her hair during the morning assessment. The student nurse oﬀered morning care
ensuring safety by raising her siderails to prevent falls. The doctor ordered for her to only
have sips of water on which this was emphasized. All her medications were given in time
and the student nurse ended the shift making certain that the client’s condition was
alleviated through nursing interventions
On the second day duty proper, client reported that she already had bowel
movement and was instructed by the Physician for her to be able soft foods the next day.
The student nurse maintained a cool environment to prevent perspiration to keep the
surgical site dry and intact. The client seemed to have a good family support system, her
husband assisted in most activities together with the son in law. Her daughter was also
present in the morning to check on her mother before work. During the shift, the student
nurse emphasized health teachings especially on medication instructions as ordered,
maintaining good hygiene with proper hand washing. Additionally, client was instructed to
follow up check up on December 12 2019 as noted on her discharge plan.
The student nurse ended the rotation that the client will have a smooth recovery and
will be discharged soon.
39
XIV. SUMMARY
After the completion of the study for case presentation the students was able to become
knowledgeable about the gastrointestinal system, rectum, adenocarcinoma, their
mechanism of the origin of the condition of the Patient. We also met the specific goal to
determine patient health profile with the used of nursing system guide, discussed the
anatomy and physiology and relates to the concept on the actual situation of the patient, the
diagnostic findings, provided with a nursing care plan and determined the prognosis of the
patient.
Throughout the course of our 2week patient’s assessment, we ceaselessly provided the
care and reassurance to the patient and his significant other. In addition we aimed to
carefully closed monitored patient's health condition and rest assured the group had left the
patient and her significant other in a good respectful manners and optimistic wellness.
XV. REFERRAL
Mrs. Aniñon is under the care of Dr. Gudito at Cagayan de Oro Medical Center. Patient is
still in for observation for any possible unusual signs and symptoms after the procedure.
After discharge, patient is instructed for followup check on December 12 2019 with Dr.
Gudito. Patient was also advised to seek immediate medical attention if any unusualities
arise anytime.
40
XVI. BIBLIOGRAPHY
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(National guidelines for diagnostic, treatment and follow-up care of colon and rectum
cancer, Norwegian Directorate of Health)
References on the surgical partA. Nesbakken

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London: National Institute for Clinical Excellence; 2004.
• Nationella riktlinjer för kolorektalcancersjukvård: medicinskt och hälsoekonomiskt
faktadokument. Stockholm: Socialstyrelsen; 2007. Tilgjengelig fra: http://
www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/
8944/2007-102-3_20071024.pdf
• NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)Fort Washington,
PA: National Comprehensive Cancer Network [oppdatert 2009; lest 2009]. Tilgjengelig
fra: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (krever
registrering)
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134
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for colonic cancer: complete mesocolic excision and central ligation--technical notes
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for optimization of colorectal cancer surgery and pathology. J Surg Oncol 2010;101(5):
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colon cancer surgical resection and its association with survival: a retrospective
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42
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mesocolic excision with central vascular ligation produces an oncologically superior
specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol
2010;28(2):272–8.
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Multivisceral resection for colon carcinoma. Dis Colon Rectum 2009;52(8):1381–6.
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endpoints of conventional versus laparoscopic-assisted surgery in patients with
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hospital case volume on short-term outcome after laparoscopic operation for colonic
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• Kuhry E, Schwenk WF, Gaupset R, Romild U, Bonjer HJ. Long-term results of
laparoscopic colorectal cancer resection. Cochrane Database Syst Rev 2008;
43
XVII. DOCUMENTATION
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LICEO DE CAGAYAN UNIVERSITY

LICEO DE CAGAYAN UNIVERSITY

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN N104

Mercado, Frances Dianne G.

Husbands name: Julio Pacita

Name of Child: Bryan Pacita

A.Brief Description of Disease

B. Reasons for choosing case

D. Scope and Limitation

Chief Complaint and History of Present Illness

Types of Previous Illness/Pregnancy/Delivery Date

Medication Name Dose/Frequency Last Time of Dose

Admitting Diagnosis: Rectal Adenocarnima

NURSING SYSTEM REVIEW CHART

[]impaired vision []blind []pain Melasma on face

[]reddened []drainage []gums

[]hard hearing []deaf []burning Hypoactive bowel sounds

[]edema []lesion []teeth

[]asymmetric []tachypnea []apnea

[]rales []cough []barrel chest postoperative wound dry

[]bradypnea []shallow []rhonchi And intact

[]sputum []diminished []dyspnea

[]orthopnea []labored []wheezing

Assess respiration, rate, rhythm, depth, pattern,

[]arrhythmia []tachypnea []numbness

[]diminished pulses []edema []fatigue

[]irregular []bradycardia []murmur

[]tingling []absent pulses []pain

Assess heart sound, rate, rhythm, pulse, blood

[]obese []distention []mass

[]dysphagia []rigidity [x]pain

Assess abdomen, bowel habits, swallowing, bowel

[]pain []urine color [ ] v a g i n a l

[]hematuria []discharges []nocturia

Assess urine frequency, control, color, odor, comfort,

[]paralysis []stuporous []unsteady

[]seizures []lethargic []comatose

[]vertigo []tremors []confused

[]vision []grip diet: sips of water

Assess motor function, sensation, Loc, strength, grip,

MUSCULOSKELETAL & SKIN D5LR @30gtts/min

[]appliance []stiffness []itching

[]petechiae []hot []drainage

[]prosthesis []swelling []lesion Hematochezia

[]poor turgor []cool []deformity Turbid dark yellow urine

[]wound []rash []skin color

[]flushed []atrophy []pain (back)

[]ecchymosis []diaphoretic []moist

Assess mobility, motion, gait, alignment, joint,

Instructions on the use of this tool:

[x]Denied Reaction Pupils equally round and reactive to

Water []Hematuria Urine color,

Diarrhea Character []Foley in place

SUBJECTIVE DATA OBJECTIVE DATA

[]Nocturia Side rails release: Side rails raised for

WBC 4300 5000-10000 Low WBC: Side eﬀect of treatment

Rbc 3.71 4.35-5.90 Low Red Blood components: blood loss

Hematocrit 36.5 40.5-49.7

Platelet 160 000 144000-372000

MCHC 33.7 32.2-35

Rdw-w p3.9 11.5-14.5

Neutrophil 62.9 43.4-76.2

Lymphocyte 30.8 17.4-46.2