kAVILk UNIVLkSI1 A1LNLC DL CAGAAN

CCLLLGL CI NUkSING
NCM 1031 kLL


A Case Study of a S0 year o|d Iema|e pat|ent d|agnosed w|th
Cvar|an Cancer Mass|ve nemothorax (k)


ln arLlal lulflllmenL of Lhe 8equlremenLs
ln nurslng Care ManagemenL 1031 8elaLed Learnlng Lxperlences


resented to
Ma'am Ma !esseca MonsanLo 8n Mn


repared by
ulao Ldsel Marc L !acoL !emlma 8
!abay Mark aulo C klng Lavelle Lauren 8
kee !ames 8yan L LlbeLarlo ChrlsLlne Anne 8
uano Ma Angellca v Lumbre klmble M
uel Carmen SamanLha Claze C Macaraeg SLacey Lyn u
Lmplales vlna !ane k Morales 8lcardo Alvaro u
Perana aLrlcla Lunlse l

AugusL 26 2011
8Sn3 / nC



ACKNOWLEDGMENT

We would like to acknowledge the following for their presence and gracious help
leading to the success of our case presentation:
First and foremost, the group would like to dedicate a heartfelt gratitude to God
Almighty who has constantly been the group's greatest source of inspiration and
guidance for this clinical experience and has been with us throughout the entirety of
completing this case presentation and for giving us different opportunities to grow, learn,
and serve;
To the patient and the family for being cooperative and participative during the
course of the nursing care. Without their participation and cooperation this case study
would not be possible;
To the German Doctors Hospital staff, for the opportunity of letting us widen our
scope and experience, knowledge, skills and attitude; and for their accommodation
during our duty and letting us have access to documentations and information of our
case patient;
To our clinical instructor, Ma'am Ma. Jesseca P. Monsanto, RN, MN for her
guidance, assistance and effort in empowering us student nurses to our greatest
potentials in providing optimum quality care to our patient;
To the Dean of the College of Nursing, Ma'am Heidi C. Palad, RN,MAN,MaEd for
the unconditional support to us through the College of Nursing, Xavier University;
To Xavier University, especially the College of Nursing, where we are provided
with the best quality of education and various opportunities to improve our skills,
knowledge, and attitude in order for us to become competent nurses;
To our parents and family, for giving us the privilege of quality education and for
inspiring us all the way to become humble servants in the society.
And lastly, to our team members, for their efforts of in carrying out their
responsibilities from assessment, implementation and evaluation of the patient, and the
research needed for this case study.



TABLE OF CONTENTS

I. Introduction
A. Brief ntroduction of Case---------------------------------------------------------------------
B. General Objectives------------------------------------------------------------------------------
C. Specific Objectives------------------------------------------------------------------------------
D. Scope and Limitations--------------------------------------------------------------------------

II. Assessment
A. Case History ------------------------------------------------------------------------------------
B. Assessment Tool----------------------------------------------------------------------------
C. Laboratory Tests & Diagnostic Exams-----------------------------------------------
D. Body Map ----------------------------------------------------------------------------------------

III. Anatomy and PhysioIogy-------------------------------------------------------------------------

IV. PathophysioIogy------------------------------------------------------------------------------------

V. MedicaI Management
A. deal Management--------------------------------------------------------------------------
B. Actual Management----------------------------------------------------------------------------

VI. Drug Study -------------------------------------------------------------------------------------------

VII. Nursing Care PIans (NCP) --------------------------------------------------------------------------

VIII. Discharge PIan ----------------------------------------------------------------------------------------

IX. Prognosis ---------------------------------------------------------------------------------------------

X. ConcIusion-------------------------------------------------------------------------------------------------

XI. Recommendations--------------------------------------------------------------------------------------

XII. Appendices
A. VitaI Signs ----------------------------------------------------------------------------------------------
B. Intake & Output Sheet ------------------------------------------------------------------------------
C. Doctor's Order-----------------------------------------------------------------------------------------
D. Nurse's Notes------------------------------------------------------------------------------------------
E. Admission & Discharge Record -----------------------------------------------------------------
F. Operation Period Sheet -----------------------------------------------------------------------------
G. IV / BIood Sheet & Medication Sheet ----------------------------------------------------------
H. HematoIogy Report-----------------------------------------------------------------------------------
I. UrinaIysis ------------------------------------------------------------------------------------------------
J. BIood Chemistry --------------------------------------------------------------------------------------
K. PIeuraI FIuid (BacterioIogy) -----------------------------------------------------------------------
L. FecaIysis ------------------------------------------------------------------------------------------------
M. Crossmatching ----------------------------------------------------------------------------------------
N. X-Ray ----------------------------------------------------------------------------------------------------
O. Weight Monitoring Sheet --------------------------------------------------------------------------

XIII. BibIiography--------------------------------------------------------------------------------------------

I. INTRODUCTION



A. Brief Introduction of Case

This case study is about patient TC, a fifty (50) years old patient diagnosed with
"Ovarian Cancer with Massive Hemothorax (R). By the recommendation of his
physician Dr. Gabatan, Patient AG was admitted to German Doctors Hospital on August
1, 2011 @ 10:00 am. The chief complaints were generalized weakness, dyspnea,
enlarged abdomen, pain @ abdomen & activity intolerance.



B. GeneraI Objectives


A fter one hour of presentation, we will be able to present & discuss the case of
patient TC to the clinical instructor/s and guests. We will be able to broaden our clinical
minds & attain aptitude in nursing interventions to embody the role of the ideal nurse.
Furthermore, as BSN-3 students, we will know the appropriate health teachings which a
nurse should share to the patient and the significant others concerning both the case of
the patient and how they should continue their utmost care en route for her health
rehabilitation and health promotion.















C. Specific Objectives


At the end of 1 hour of Case Presentation, the presenters will be able to:

a.) Set up the venue in a presentable & appealing atmosphere during the case
presentation.

b.) Start on the time scheduled to maximize the allotted time for the group.

c.) Provide clear and understandable visual aids that will suffice the group presentation.

d.) Present and discuss the assessment of the patient briefly.

e.) Present the abnormal laboratory values and findings.

f.) Name the major health problems of the client.

g.) Present the signs and symptoms manifested by the patient which are relevant to the
case.

h.)Define the technical terms used in the course of duty to facilitate better understanding

i.) Present the anatomy and physiology of the system/s involved in the case.

j.) Discuss the Pathophysiology of the client's disease condition

k.) Evaluate the efficiency of the nursing care provided according to the nursing care
plan.

l.) Defend presentation by answering questions raised by fellow student nurses and
clinical instructors.

m.) Accept inaccuracies and positive criticisms from the audience, especially from
the clinical instructor(s).

n.) Have a brief recap of the case presentation, with corrections noted, for the benefit of
the group /fellow student nurses, and as well as the clinical instructors.

o.) Do after care of the venue and the equipments.







D. Scope and Limitations


SCOPE
In terms of actual contact with patient AC, the practical scope of this case study spans
the equivalent of some 23 hours: two hours on assessment day on Tuesday (08/16), 16 hours
(two morning shifts) on Wednesday and Thursday (08/17 and 08/18), and some five hours total
spanning Friday (08/19), Saturday (08/20), and Monday-Thursday of this next week (08/21-
08/25) for additional assessment, interventions, and follow-up on the patient's chart. However,
the theoretical scope of this study includes data since the incidence of patient AC's reported
first presentation of signs and symptoms (___), following her admission at Xavier University
Community Health Care Center (XUCHCC) on (___), up until the final day of student nurse-
patient contact, upon which time she was still for surgery. Significant data are collated from her
chart, interview with the patient herself and her son, and from actual physical examination by
student nurses. The following output will present concepts pertinent to patient AG's most
salient clinical manifestations. They give context to her care management, including nursing
care plans, which will follow.

LIMITATION
As mentioned, student nurse-patient contact is limited only to approximately 23 hours.
That student nurses were not with patient AC since her admission is already a limitation. A
further limitation, perhaps most significant, is the lack of a definitive diagnosis explaining the
patient's true underlying condition. Doctors suspect beyond a reasonable doubt that patient AC
has an ovarian neoplasm, but the final determination of its nature as either benign or malignant
has not been established, as diagnostic blood tests for cancer tumor marker CA-125 has not
yet been carried out, and the patient's persistent hypotension has precluded timely diagnostic
pelvic laparotomy. Therefore, the following case study presumes the simplest and more likely
explanation of her most striking clinical manifestations, and this explanation is of an ovarian
malignancy that has undergone remote metastases to produce local affectations in the
abdominopelvic region (i.e. ascites), and more remote affectations in the chest cavity (i.e.
hemothorax). The pathophysiology proposing the mechanism of such a clinical presentation is
presented accordingly. However, we acknowledge the limitation in this assumption, because
we cannot definitively rule out the possibility of patient AC presenting seemingly disparate
manifestations indeed due to independent etiologies, or if she is perhaps a case of a rare and
relatively unknown condition called Meig's syndrome, which involves a benign ovarian tumor
that somehow results in comorbid presentations of ascites and pleural effusion. But in this case
study, as just mentioned, the simpler and perhaps more elegant explanation of a malignancy
having metastasized has been presumed.

II. ASSESSMENT
A. Case History
































xAvlL8 unlvL8Sl1?
A1LnLC uL CACA?An
CCLLLCL Cl nu8SlnC
GLNLkAL ASSLSSMLN1 1CCL
07 26 11
I GLNLkAL INICkMA1ICN
name 1C Age 30 years old
8lrLhday May 26 1961 Clvll SLaLus SeparaLed
Sex lemale 8ellglon 8oman CaLhollc CccupaLlon none sLlll a sLudenL
Address 2720 upper nazareLh Cagayan de Cro ClLy Mlsamls CrlenLal
lnformanL paLlenL herself
Admlsslon daLe AugusL 1 2011 1lme 1000 pm
Chlef ComplalnL generallzed weakness dyspnea enlarged abdomen paln [ abdomen
acLlvlLy lnLolerance
ALLendlng hyslclan ur CabaLan
ulagnosls/lmpresslon Ovotloo coocet wltb Mosslve nemotbotox (k)
PlsLory of resenL lllness
6 monLhs 1A paLlenL experlenced paln [ abdomen reporLed pressure on abdomen (baod2x")
8M dlarrhea consLlpaLlon (alLernaLlng lnLermlLLenL) wlLh loss of appeLlLe 3 monLhs 1A paLlenL
observed Lhe progresslve enlargemenL of Lhe abdomen + Lhe abovemenLloned slgns sympLoms 2
monLhs 1A bllaLeral leg edema wlLh furLher enlargemenL up unLll 2 weeks 1A dyspnea
consLlpaLlon loss of appeLlLe sLlll presenL 1 monLh 1A general malalse / weakness severe dyspnea
wlLh progresslve enlargemenL of abdomen 2 weeks 1A up Lo presenL decreased urlne ouLpuL [
same frequency (8/16/11 lncreased frequency ouLpuL) paln raLed [ 3 ouL of 3 (08/16/11 2 ouL of
3) dyspnea consLlpaLlon sLlll presenL murag naay mugawas sa ako klnaLawo sa kasaklL" no
malnLenance medlcaLlons

V|ta| S|gns P8 90bpm 88 22 cpm 28 durlng acLlvlLles 1emp 363 HC
8 90/60 (resL)130/60mmPg (acLlve)
C
2
SaL 97 WelghL 333 kg


II AC1IVI1 ] kLS1
5ubjective
usual acLlvlLles / hobbles planL harvesL [ mlnl garden near Lhe house
Lelsure 1lme acLlvlLles waLch Lelevlslon / read newspaper
LlmlLaLlons lmposed by condlLlon dlfflculLy ln walklng paln [ abdomen noL able Lo move much
# of hrs of sleep 13 hours only naps none Alds none
ulfflculLy ln sleeplng paLlenL experlences back paln aL abdomlnal area leadlng hlm Lo have
resLrlcLed movemenLs warm envlronmenL dlscomforL
leellng on awakenlng nonlrrlLable


CLhers / CommenLs
aLlenL verballzed small amounL of sleep slnce she ls busy wlLh housework
planLlng

bjective
ObsetveJ tespoose to octlvlty (wolkloq otoooJ tbe wotJ)
Cardlovascular lncreases (P8 8) palplLaLlons
8esplraLory lncreases (88) SC8 dyspnea (lf acLlvlLy ls prolonged)
MenLal SLaLus orlenLed Lo Llme place person coherenL / responslve ____________
osLure Semlfowlers
8CM passlve even when ambulaLlng 1remors no Lremors noLed_
CLhers / CommenLs
aLlenL experlences paln ofLen whlch causes Lhe oLher body sysLems Lo________
compensaLe lncreased 88 P8 8 needs asslsLance ln ambulaLlng

III CIkCULA1ICN
5ubjective
PlsLory of PyperLenslon none PearL Lrouble none
Ankle/ Leg Ldema none Slow heallng none
ClaudlcaLlon none
Cough / PemopLysls nonproducLlve cough
LxLremlLles numbness none 1lngllng none
Change ln frequency/amounL of urlne more frequenL wlLh more urlne ouLpuL (see
llmlootloo) 100 cc / hr
CLhers / CommenLs
aLlenL ls currenLly Laklng lurosemlde 40 mg 8lu C resulLlng Lo lncreased urlnary
ouLpuL ___ ______ _____

bjective
8 k Lylng 90/60 100/70 mmPg SlLLlng 110/60 SLandlng 110/70
L lylng noL Laken 81 ongolng SlLLlng 100/70 SLandlng 110/60
ulse pressure 30 mmPg Ml 3Lh lCS
PearL raLe / Sounds 90 bpm S1 S2 8hyLhm regular
ulse CaroLld 90bpm 8adlal 89 bpm opllLeal 88 bpm
1emporal 86 bpm lemoral 83 bpm uorsalls edls _83 bpm
vascular 8rulL none 8reaLh sounds no advenLlLlous sounds normal (bronchlal)
!ugular veln dlsLenLlon none
LxLremlLles 1emp 363HC
Color brown buL sllghLly pallor on flngerLlps
Caplllary reflll 2 secs ____________ Poman's slgn negaLlve


IV LGC IN1LGkI1
5ubjective
8eporLs of sLress facLors hosplLallzaLlon noL belng able Lo walk around paln flnances
Ways of handllng sLress relaxaLlon sleeplng or Lalklng wlLh chlldren crylng
llnanclal concerns ?es only her eldesL daughLer (flnanclal supporL)
8elaLlonshlp sLaLus separaLed sad regardlng separaLlon from husband
able Lo lnLeracL wlLh oLhers
LlfesLyle acLlve before admlsslon (baskeLball eLc) healLhy (mlxed) dleL
buL now passlve even when ambulaLlng dleL ls resLrlcLed Lo low na low laL dleL
8ecenL changes passlve llfesLyle due Lo presenL condlLlon enlarged abdomen
wlLh paln general weakness / malalse whlch decreased her selfesLeem
leellng of Pelplessness none
leellng of Popelessness none
leellng of owerlessness none
CLhers / CommenLs
aLlenL has a poslLlve ouLlook regardlng condlLlon recovery ________

bjective
LmoLlonal SLaLus calm
Cbserved physlologlc response able Lo verballze concerns / dlscomforL
CLhers / CommenLs
aLlenL was calm buL became very emoLlonal abouL Lhelr separaLlon (husband)
husband lefL her upon knowlng her condlLlon


V LLIMINA1ICN
5ubjective
usual 8owel paLLern 12 Llmes a day (everyday aL Llmes every oLher day) now 2x a day
CharacLer of sLool before formed sofL and brown ln color now hard black sLool
LasL 8M 2 days ago LaxaLlve use none
PlsLory of bleedlng none Pemorrholds ?es 3 years
ConsLlpaLlon ?es even before ularrhea none
usual voldlng aLLern 4 3 Llmes a day depends lnconLlnence none
urgency none 8eLenLlon none lrequency up Lo 7x a day (now)_
aln/burnlng/dlfflculLy ln voldlng none
PlsLory of kldney/bladder dlsease none
CLhers / CommenLs
aLlenL ls Laklng leSC4 + lA lurosemlde as ordered by Lhe physlclan resulLlng Lo
black sLool (hard) lncrease ln frequency amounL (urlnaLlon)

bjective
Abdomen 1ender presenL nonrebound SofL/llrm llrm
alpable mass noL palpable 8ladder sounds none
8ladder palpable no ulsLended no
CLhers / CommenLs
aln ls presenL worsens when abdomen ls palpaLed (lncreases from 2 Lo 4 ouL of 3)


VI ICCD ] ILUID
5ubjective
usual dleL (Lype) mlxed hlgh CPC rlce vegeLables soup meaL seldom
number of meals dally 3x a day + snacks (eg bolled sweeL poLaLo banana eLc)
LasL meal/lnLake 10 am (Loday)
Loss of appeLlLe ?es presenL
nausea/vomlLlng none uenLures none
Allergy/lood lnLolerance none PearLburn/lndlgesLlon someLlmes 4x a week (12x a day)
MasLlcaLlon/swallowlng problems none
usual welghL 409 kg Changes ln welghL decrease Lo 333 kg ( 36 kg)
ulureLlc use lurosemlde (see utoq 5toJy)
CLhers / CommenLs
aLlenL losL 36 kg slnce admlsslon ls Laklng a dlureLlc (lurosemlde) slnce 08/13/11


bjective
CurrenL welghL 333 kg PelghL 13494 cm (3'4'') 8ody 8ulld ecLomorph
Skln Lurgor good
Mucous membranes molsL/dry dry________
Pernla/masses enlarged abdomen wlLh lobulaLed solld mass 19x11x12 cm [ 8
uependenL edema / AsclLes moderaLe asclLes (see c\k utz tesolts)
1hyrold enlarged none
PallLosls presenL unpleasanL due Lo poor oral hyglene denLal carles (boLh upper lower)
CondlLlon of LeeLh/gums some LeeLh are absenL (ex fronLal) w/ denLal carles
Appearance of Longue plnk sllghLly dry no cranker sores noLed
CLhers / CommenLs
8Ml 333kg / (13494 m)
2
1470 kg/m
2
paLlenL ls underwelghL hallLosls was noLed
whenever Lhe paLlenL opens hls mouLh and Lalks due Lo poor hyglene presence of denLal
carles

VII nGILNL
5ubjective
Act|v|t|es of Da||y L|v|ng
MoblllLy DependenL Pyglene DependenL 1olleLlng DependenL
leedlng DependenL uresslng DependenL
LqulpmenL/presence of devlces requlred none
AsslsLance provlded by sons / sLudenL nurse
CLhers / CommenLs
aLlenL ls hlghly dependenL as of now

bjective
Ceneral appearance weak dyspnelc mlnlmal sweaLlng orlenLed
Manner of dress approprlaLe for age
PablLs none 8ody odor sour / unpleasanL
CondlLlon of scalp dry flaky resence of vermln none
CLhers / CommenLs
PealLh Leachlngs glven regardlng proper oral body hyglene

VIII NLUkCSLNSCk
5ubjective
lalnLlng spells/ dlzzlness dlzzlness ls presenL especlally when movlng
Peadache none LocaLlon n/A lrequency n/A
1lngllng/numbness/weakness (locaLlon) general weakness malalse
Selzures none Aura n/A Pow conLrolled n/A
Lyes ]V|s|on |oss
Claucoma none CaLaracL none
LasL examlnaLlon aLlenL never had an eye exam Lhere changes ln vlslon was noL
measured reporLed vlslon ls blurry (as she ages)
Sense of smell good able Lo ldenLlfy alcohol when placed under Lhe nose eLc
LplsLaxls none
CLhers / CommenLs
aLlenL has noL Laken any eye examlnaLlons ever

bjective
Menta| status
CrlenLed/ulsorlenLed 1lme orlenLed lace orlenLed erson orlenLed
AffecL llaL ueluslons none PalluclnaLlons none
Memory 8ecenL sLlll able Lo recall 8emoLe sLlll able Lo recall
Speech paLLern nonslurred Congruence always congruenL
Classes none ConLacLs none Pearlng alds none
upll slze/reacLlon 8 reducLlon Lo 3mm upon lllumlnaLlon
L reducLlon Lo 3mm upon lllumlnaLlon
upll Lqually 8ound 8eacLlve Lo LlghL AccommodaLlon (L88LA)
laclal drooplng none Swallowlng dlfflculLy when paln ls presenL
Pandgrlp/release 8 weak L weak
osLurlng ln semlfowler's poslLlon u18 acLlve no abnormallLles
aralysls none
CLhers / CommenLs
aLlenL ls sLlll orlenLed abouL Llme place person and can sLlll recall recenL and remoLe
evenLs responds well Lo quesLlons





Ik AIN ] CCMICk1
5ubjective


CnseL upon palpaLlon / movemenL uuraLlon 3 mlnuLes
LocaLlon abdomlnal area chesL area as well
lnLenslLy (13) 2 hurLs LlLLle more lrequency upon movlng
CuallLy sharp
uescrlpLlon of aln lnLermlLLenL paln when aL tesL 2 ouL of 3 upon octlvlty ouL of 3
reclplLaLlng facLors movemenL progresslve enlargemenL of abdomen palpaLlon of abdomen
AggravaLlng facLors prolonged palpaLlon conLlnuous movemenL coughlng
Pow relleved resL relaxaLlon / belng sLlll bendlng knees
AssoclaLed slgns/ sympLoms lncreased resplraLory raLe SC8 / dyspnea grlmaclng guardlng
aL Llmes wlLh palplLaLlons
CLhers / CommenLs
aln lncreases from 2 Lo 4 ouL of 3 upon acLlvlLy and manlfesLaLlons lncreases

bjective
O Crlmaclng
O Slghlng
O Movlng very slow
O Avoldlng physlcal acLlvlLy
O Lylng down all day
O 8equesLlng help / hlghly dependenL
O Walklng wlLh abnormal galL sLopplng frequenLly
O Movlng ln a guarded or proLecLlve manner
O Poldlng or supporLlng Lhe palnful bodys area

CLhers/ commenLs
aLlenL experlences dlfflculLy ln movlng and hlndrance ln dolng acLlvlLles due Lo paln felL
aL abdomlnal area or upon movlng


k kLSIkA1ICN
5ubjective
uyspnea relaLed Lo (someLlmes occur) due Lo paln aggravaLed by coughlng movemenL
also relaLed Lo masslve hemoLhorax (accumulaLlon)
Cough/spuLum nonproducLlve cough (lnLermlLLenL)
PlsLory of AsLhma exposure Lo noxlous fumes (eg smoke eLc)
Smoker no acks/day n/A # of years n/A
use of resplraLory alds resenL (C2 lnhalaLlon) Cxygen [ 2L /mln vla nasal cannula
bjective
88 22 cpm uepLh 1 ln shallow SymmeLry bllaLeral / symmeLrlcal
use of accessory muscles none
nasal flarlng presenL
lremlLus no abnormallLles
8reaLh Sounds no advenLlLlous breaLh sounds noLed buL breaLh sounds seem sllghLly dlmlnlshed on 8 slde
Cyanosls none Clubblng of llngers none
SpuLum characLerlsLlcs none 8esLlessness none


kI SAIL1
5ubjective
Allergles/senslLlvlLy none
8eacLlon none
PlsLory of S1u (daLe/Lype) none
8lood 1ransfuslon/number 8 bags When Slnce 8/12/11 up Lo presenL
PlsLory of accldenLal ln[urles [ 14 yo fell from cablneL hurL shoulder
lracLures/dlslocaLlons ulslocaLlon [ 8 shoulder (consulLed LreaLed by local physlclan)
ArLhrlLls/unsLable [olnLs none
8ack problems ?es palnful aL Llmes (noL palnful aL Lhe momenL)
Changes ln moles none Lnlarged nodes none
rosLhesls none AmbulaLory devlces none
Lxpresslon of ldeaLlon of vlolence (self/oLhers) none
CLhers / CommenLs
aLlenL has ongolng 81 (L) lW8 430 cc (level 300 cc) 1ype C" 8h+

bjective
1emperaLure 36 3HC ulaphoresls presenL moderaLe
Skln lnLegrlLy noL lmpalred Scars presenL aL dlfferenL slLes ln Lhe body (old)
8ashes none LaceraLlon none
ulceraLlons none Lcchymosls none 8llsLers none
8urns (degree/ ) none
uralnage (noLe locaLlon) [ 8 apex wlLh 700 ml dralnage (C11)
Ceneral sLrengLh weak Muscle Lone poor
CalL Llmplng aresLhesla/paralysls none
CLhers / CommenLs
aLlenL has ChesL LhoracosLomy Lube [ 8 slde wlLh dralnage


kII SLkUALI1
Sexually acLlve no Sexual concerns/dlfflculLles none
8ecenL change ln frequency/lnLeresL no lnLeresL (no parLner) affecLed by condlLlon


ILMALL
5ubjective
Age of menarche 16 years old LengLh of cycle 2 days only
Menopause ?es vaglnal dlscharge whlLe Lhlck dlscharge (someLlmes)
8leedlng beLween perlods none
regnancy Px C _8 1 _7_ _0 A _1_ L _7_ M _C_
LplsloLomy ?es durlng 1
sL
4 dellverles
CompllcaLlon/s of pregnancy _none_
Surgerles _none_
Pormonal Lherapy / calclum use none durlng pregnancy now glven wlLh calclum
gluconaLe because of 81 ____
racLlce S8L _?es_ ulscharges no abnormallLy
LasL ap smear _never_ MeLhod of blrLh conLrol _none_


CLhers / CommenLs
aLlenL never used any famlly plannlng meLhod never had a ap smear / exam


bjective
LxamlnaLlon 8reasL no abnormallLles enls noL assessed pL sLrongly refused
1esLlcles noL assessed pL sLrongly refused


kIII SCCIAL IN1LkAC1ICNS
5ubjective
MarlLal sLaLus SeparaLed ?ears ln relaLlonshlp 27 years
Llvlng wlLh 4 chlldren + 3 sLepsons
Concerns /sLresses flnances ambulaLlon hosplLallzaLlon recovery
LxLended famlly chlldren wlLh sLepsons
CLher supporL person none
8ole wlLhln famlly sLrucLure moLher also provldes of food
8eporL of problems relaLed Lo lllness/condlLlon dlfflculLy ln walklng abdomlnal back paln
dyspnea general weakness malalse


kIV 1LACnING ] LLAkNING
5ubjective
uomlnanL language (speclfy) vlsayan
LlLeraLe ?es able Lo read wrlLe
LducaLlonal level Crade 6
PealLh bellefs/pracLlces/supersLlLlons Leas herbal healLh cenLer selfmedlcaLlons (eg
durlng fever)


Iam|||a| 8lsk facLors dlabeLes (daughLer only) hearL dlsease (uncle) Lpllepsy
MenLal lllness (nephew) cancer (faLher)
use of Alcohol (amounL/frequency) none

CLhers / CommenLs
aLlenL ls aware LhaL her faLher had cancer and ls aware of Lhe posslblllLy of acqulrlng lL


rescr|bed drugs ] med|cat|ons


0rug Name


0osage, T|m|ng and
Route (actua|}

6|ass|f|cat|on
Cenera| 6|ass & Fam||y

|nd|cat|on|s
6efurox|me
(Z|racel)
Z50 rg lvTT q8 AN3T

> Arl|o|ol|c
>Cepra|ospor|r
> Per|operal|ve propry|ax|s
Furosem|de
(Las|x)
10 rg lvTT 00
(8-1-11)

10 rg lvTT q12 (8-10-11)

10 rg 1lao P0
(1-1-0)
(8-13-11)

> Loop d|urel|c > lreals l|u|d relerl|or (edera)
6a|c|um g|uconate
1 arp s|oW lvTT roW

(8-15-11)
> Arlac|d
> E|eclro|yle
> Preverl|or ol rypoca|cer|a dur|rg
excrarge lrarslus|ors

> Treal regal|ve ca|c|ur oa|arce
Naproxen
(Araprox)
250rg 8l0 P0 x 3 days

(8-5-11)

> Ara|ges|c (rorop|o|d)
>N3Al0
>V||d lo roderale pa|r, lerporar||y re||el ol
r|ror acres ard pa|rs assoc|aled W|lr
readacre, ruscu|ar acres, oac|acre ard
r|ror pa|r ol arlrr|l|s ard reducl|or ol lever.
Paracetamo|
500rg 1lao P0 q1 PRN lor
T <38C

(8-1-11)

> ara|ges|c
> arl|pyrel|c

> Fever, Re||el ol r||d lo roderale pa|r |||e
readacres, ruscu|ar acres ard pa|r,
loolracre, co|ds, earacre, lever due lo
lors|||eclory, |rocu|al|ors, ard vacc|ral|ors.

Fe804 + Fo||c Ac|d

1 lao 8l0 P.0

(8-1-11)

> lror preparal|or > preverl / lreal lror del|c|ercy arer|a
> ard as d|elary supp|ererl lor lror
0|c|ofenac
(Calal|ar)
50rg lvTT q8 x 3 doses
corl|rue q8AV

(8-13-11)
>Ara|ges|c (rorop|o|d)
> Arl|-|rl|arralory
>Arl|pyrel|c
>N3Al0
>Acule or |org-lerr lrealrerl ol r||d lo
roderale pa|r.
0meprazo|e
(Losec)
10rg 8l0 P0

(8-1-11)
>Arl|secrelory drug
>Prolor purp |rr|o|lor
>srorl-lerr lrealrerl lor acl|ve duodera|
u|cer
6o-amox|c|av
(Nalravox)
25rg 8l0 P.0

(8-1-11)
>8road-speclrur per|c||||r >KroWr or suspecled arox|c||||r-res|slarl
|rlecl|ors |rc|ud|rg resp|ralory lracl, s||r ard
soll l|ssue, ger|lour|rary, ard ear, rose ard
lrroal |rlecl|ors.
C Laboratory ] D|agnost|c kesu|ts

O kkay kesu|ts
72711
AsclLes
robable overlylng pelvlc abdomlnal mass mass llkely
8eproducLlve ln orlgln
aralyLlc lleus
lor ulLrasound correlaLlon


1S11

lollow up sLudy as compared wlLh prevlous fllm daLe 81411 shows moderaLe clearlng
of Lhe pleural effuslon ln Lhe rlghL afLer chesL Lube lnserLlon 8esL of Lhe flndlngs ls unchanged
lollow up ls sLlll suggesLed


O Cross match|ng
8/23/11
kh+ 8|ood type C reparat|on 8CC
Non react|ve Lo vu8L Plv Negat|ve Lo P8sAg AnLl PCv 8SM




O 1ransvag|na| Utz

8/8/11
Jltb 19x11x12 cm of sollJ loboloteJ moss lo tbe k obJomeo exteoJloq to
tbe obJomloopelvlce oteo soqqestlve of oo ovotloo mollqooocy MoJetote
oscltes AotevetteJ otetos wltblo eoJomettlom

O nemato|ogy keport


C8C
]12]2011

]1S]2011 ]17]2011
kLILkLNCL UNI1

otetptetotloo aLlenL ls 1ype C" 8h+ a unlversal donor buL can ooly recelve Lype
C blood ls poslLlve for 8h facLor (lnherlLed from our parenLs)

Interpretat|on
kLSUL1 kLSUL1 kLSUL1

Pemoglobln 76 7 12 1216 g/dl nemoqloblo
nemotoctlt ote
botb JecteoseJ
PemaLocrlL 23 21 36 3747
ifferentio/ count
Loslnophlls 13
8LLLDING
1IML
1 mln 40
sec

CLC11ING
1IML
3 mln 40
sec



O Ur|na|ys|s
8/12/2011
Co|or uark ?ellow us Ce|| 02 k8C 02 1ransparency SllghLly 1urbld
pn 80 Spec|f|c Grav|ty 1003 (normal 1010 Lo 1020)
Lp|the||a| ce|| (Squamous) lew 8acter|a lew Mucus 1hread lew


O 8|ood Chem|stry
VALUL kLILkLNCL
Albumln
31 3833 mg/dl
SCC1
68 0042 lu
SC1
438 038 lu



O |eura| I|u|d (8acter|o|ogy)
VALUL kLILkLNCL
WhlLe blood CounL 1430 300010000 cumm
SegmenLers 28 3373


otetptetotloo 1here ls lnfecLlon slnce Lhere are few bacLerla presenL Lhe urlne ls Lurbld
otetptetotloo lndlcaLes llver damage or dlsease lL can also reflecL dlseases ln whlch Lhe kldneys
cannoL prevenL albumln from leaklng from Lhe blood lnLo Lhe urlne and belng losL
otetptetotloo aLlenL ls lmmunocompromlsed aL Lhe momenL uefense ls low
lncreased rlsk for acqulrlng more lnfecLlon posslble exacerbaLlon


O Ieca|ys|s
Co|or 8rown 8acter|a AbundanL Cons|stency SofL
us Ce||s none k8C none


O Ckk
08/13/11
9leotol effosloo ln Lhe lower 1/3 of Lhe lung fleld
1horacosLomy Lube wlLh Llp ln Lhe 8 apex


UDA1LS














otetptetotloo 1here ls an lnfecLlon
Lnlarged abdomen paln
[ 2 ouL of 3 (sharp)
guardlng
lncreased urlnaLlon
up Lo 7x wlLh more
urlne ouLpuL



Body Map:




































nasal flarlng
?ellowlsh con[uncLlva
PallLosls denLal carles
uyspnea chesL paln
88 22cpm
lncreases Lo 28 cpm
durlng acLlvlLy
8ack paln
(lnLermlLLenL)
ln Semllowler's
poslLlon
09 naCl (nSS)
#3 kvC 1L [
800 cc
81 lW8 S# 21611
82611086068 [ 430 cc
(level 300 cc) 1ype C"
8h+
8lack (hard)
sLool because
of leSC4 + lA
consLlpaLed
C11 wlLh 700 cc
dralnage [ 8 apex
u3L8 1L [ 20 gLLs/mln
[ 730 cc
laclal grlmaclng (ln paln)






III. ANATOMY & PHYSIOLOGY












































IV. CONCEPT MAP & PATHOPHYSIOLOGY












































V. MedicaI Management


A. IdeaI Management:










































B. ActuaI Management:



Diagnostic Tests / Treatment:


Other Management:
O FBC Fr 16 attached to Urobag
O V Fluids / Blood Transfusion:








O Medications:
















VI DkUG S1UD

Drug Name


Dosage,
Timing
and
Route
(actuaI)

CIassification
GeneraI
CIass &
FamiIy

Indication/s

Mechanism of
Action
IIIustration

Side Effects

Nursing Considerations
Cefurox|me
(Zlnacef)
730 mg
lv11 q8
AnS1


> Arl|o|ol|c
>Cepra|ospor|r




> LoWer resp|ralory
|rlecl|ors caused oy 3.
Preuror|ae, E. Co||

> 0erralo|og|c |rlecl|or
caused oy
Erlerooaclers, K.
Preuror|ae

> Per|operal|ve
propry|ax|s

8acler|c|da|: lrr|o|ls
syrlres|s ol oacler|a|
ce|| Wa||, caus|rg
dealr

> leadacre
> 0|zz|ress
> Nausea & vor|l|rg
> 0|arrrea
> Fal|gue
> 308
> F|alu|erce
>lypoprolrroro|rer|a

> Cu|lure |rlecl|or, ard arrarge lor
sers|l|v|ly lesls oelore ard dur|rg lrerapy |l
expecled resporse |s rol seer

> lave v|lar|r K ava||ao|e |r case
rypoprolrroro|rer|a occurs

> 0|scorl|rue |l rypersers|l|v|ly reacl|or
occurs

> Reporl severe d|arrrea, d|ll|cu|ly
orealr|rg, urusua| l|redress or lal|gue, pa|r
al |rjecl|or s|le

Iurosem|de
(Laslx)
40 mg
lv11 Cu
(8111)

40 mg
lv11 q12
(81011)

40 mg
1Lab C
(110)
> Loop d|urel|c

> lreals l|u|d relerl|or
(edera) |r peop|e
W|lr corgesl|ve rearl
la||ure, ||ver d|sease, or
a ||drey d|sorder sucr
as reprrol|c syrdrore.
Tr|s red|cal|or |s a|so
used lo lreal r|gr o|ood
pressure (ryperlers|or).

lrr|o|ls reaosopl|or
ol Na ard C| lror
lre prox|ra| ard
d|sla| luou|es ard
ascerd|rg ||ro ol
lre |oop ol ler|e,
|ead|rg lo a Na-r|cr
d|ures|s

> 0|zz|ress
> verl|go
> Pareslres|as
> Xarlrops|a
> wea|ress
> lypolers|or

> Prolourd d|eres|s W|lr Waler ard
e|eclro|yle dep|el|or car occur, carelu|
red|ca| superv|s|or |s requ|red.

> Reduce dosage |l g|ver W|lr olrer
arl|ryperlers|ves: readjusl dosage as 8P
respord

> 0|ve ear|y |r lre day so lral |rc ur|ral|or
W||| rol d|sluro s|eep
(81311)


> Avo|d lv use |l ora| use |s al a|| poss|o|e

> 0o rol expose lo ||grl, Wr|cr ray d|sco|or
lao|els or so|'r; do rol use d|sco|ored drug
or so|'r

> 0|scard d||uled so|'r aller 21 rours

> Veasure ard record We|grl lo ror|lor l|u|d
crarges

> Arrarge lo ror|lor serur e|eclro|yles,
rydral|or, ||ver ard rera| lurcl|or

> Arrarge lor K-r|cr d|el or supp|ererl K as
reeded
Ca|c|um
g|uconate
1 amp
slow lv11
now

(81311)
> Arlac|d
> E|eclro|yle

> Preverl|or ol
rypoca|cer|a dur|rg
excrarge lrarslus|ors

> Treal regal|ve
ca|c|ur oa|arce
ll re|ps lac|||lale
rerve ard rusc|e
perlorrarce as We||
as rorra| card|ac
lurcl|or.

Aosorpl|or: 3o|uo|e
ca|c|ur |s
predor|rarl|y
aosoroed lror lre
sra|| |rlesl|re oy
acl|ve lrarsporl ard
pass|ve d|llus|or.
3ra|| |rlesl|res oy
acl|ve lrarsporl ard
pass|ve d|llus|or.
Trere |s |rcreased

> 0l |rr|lal|or

> soll-l|ssue
ca|c|l|cal|or

>s||r s|ougr|rg or
recros|s aller lV/3C
|rjecl|ors

>lyperca|cer|a
craracler|zed oy:
arorex|a
Nausea
vor|l|rg
Corsl|pal|or
aodor|ra| pa|r
rusc|e Wea|ress
rerla| d|sluroarces
> Assessment & 0rug Effects
Assess lor culareous ourr|rg sersal|ors
ard per|prera| vasod||al|or, W|lr roderale
la|| |r 8P, dur|rg d|recl lv |rjecl|or.
Vor|lor EC0 dur|rg lv adr|r|slral|or lo
delecl ev|derce ol ryperca|cer|a:
decreased 0T |rlerva| assoc|aled W|lr
|rverled T Wave.
0oserve lv s|le c|ose|y. Exlravasal|or
ray resu|l |r l|ssue |rr|lal|or ard recros|s.
Vor|lor lor rypoca|cer|a ard
ryperca|cer|a (see 3|grs & 3yrplors,
Apperd|x F).
Lao lesls: 0elerr|re |eve|s ol ca|c|ur ard
prosprorus (lerd lo vary |rverse|y) ard
aosorpl|or |r ca|c|ur
del|c|ercy ard dur|rg
cr||drood, pregrarcy
ard |aclal|or.

0|slr|oul|or: Crosses
lre p|acerla ard
erlers oreasl r|||.

Excrel|or: Excreled
ra|r|y |r lre ||dreys
(as excess ca|c|ur),
laeces (as
uraosoroed ca|c|ur)
W|lr lraces lourd |r
sWeal, s||r, ra|r ard
ra||s.
po|yd|ps|a
po|yur|a
reprroca|c|ros|s rera|
ca|cu||

> cra||y lasle

> rol l|usres

> Per|prera|
vasod||al|or

Polerl|a||y Fala|:
Card|ac arrrylrr|as &
cora.
ragres|ur lrequerl|y, dur|rg susla|red
lrerapy. 0el|c|erc|es |r olrer |ors,
parl|cu|ar|y ragres|ur, lrequerl|y coex|sl
W|lr ca|c|ur |or dep|el|or.

> Pat|ent & Fam||y Educat|on
Reporl 3&3 ol ryperca|cer|a (see
Apperd|x F) prorpl|y lo your care
prov|der.
V||| ard r||| producls are lre oesl
sources ol ca|c|ur (ard prosprorus).
0lrer good sources |rc|ude dar| greer
vegelao|es, soy oears, lolu, ard carred
l|sr W|lr oores.
Ca|c|ur aosorpl|or car oe |rr|o|led oy
z|rc-r|cr loods: ruls, seeds, sprouls,
|egures, soy producls (lolu).
Crec| W|lr prys|c|ar oelore se|l-
red|cal|rg W|lr a ca|c|ur supp|ererl.
0o rol oreasl leed Wr||e la||rg lr|s drug
W|lroul corsu|l|rg prys|c|ar.

Naproxen
(Anaprox)
230mg
8lu C x
3 days

(8311)

> Ara|ges|c
(rorop|o|d)
>N3Al0
>V||d lo roderale pa|r,
lerporar||y re||el ol
r|ror acres ard pa|rs
assoc|aled W|lr
readacre, ruscu|ar
acres, oac|acre ard
r|ror pa|r ol arlrr|l|s
ard reducl|or ol lever.
>Ara|ges|c, arl|-
|rl|arralory, ard
arl|pyrel|c acl|v|l|es
|arge|y re|aled lo
|rr|o|l|or ol
proslag|ard|r
syrlres|s.
>leadacre
>d|zz|ress
>sorro|erce
>|rsorr|a
>rasr
>prur|lus
>sWeal|rg
>Nausea
>0l pa|r
>0ysur|a

>Ta|e drug W|lr lood or rea|s |l 0l upsel
occurs; la|e or|y prescr|oe dosage.

>0|zz|ress, droWs|ress car occur (avo|d
perlorr|rg razardous las|)

>Reporl sore lrroal; lever; rasr; |lcr|rg;
We|grl ga|r; sWe|||rg |r ar||es or l|rgers;
crarges |r v|s|or; o|ac|, larry sloo|s.


>rera| |rpa|rrerl
>o|eed|rg
>parcyloper|a
>dysprea
>reroplys|s
aracetamo|
300mg
1Lab C
q4 8n
for 1
38C

(8111)

> ara|ges|c
> arl|pyrel|c

> Fever, Re||el ol r||d
lo roderale pa|r |||e
readacres, ruscu|ar
acres ard pa|r,
loolracre, co|ds,
earacre, lever due lo
lors|||eclory,
|rocu|al|ors, ard
vacc|ral|ors.


lrr|o|ls
proslag|ard|r
syrlres|s |r lre CN3
ard o|oc|s lre pa|r
|rpu|se lrrougr a
per|prera| acl|or. ll
acls or lre
rypolra|ar|c real-
regu|al|rg cerler,
produc|rg per|prera|
vasod||al|or. ll
resu|ls |r arl|pyres|s
ard produces
ara|ges|c ellecl.

> Crarp|rg
> rearlourr
> aodor|ra| d|slerl|or
> rypersers|l|v|ly
reacl|ors

Ear|y s|gns of
tox|c|ty:
> Arorex|a
> Nausea
> 0|aprores|s
> 0erera||zed
Wea|ress (12-21 rrs)

Late s|gns of tox|c|ty:
> vor|l|rg
> r|grl upper quadrarl
> lerderress
> e|evaled ||ver
lurcl|or lesls W|lr|r 18-Z2
rours aller |rgesl|or

> ll lo oe g|ver as ara|ges|a, assess orsel,
lype, |ocal|or, dural|or ol pa|r.

> Car oe g|ver W|lroul regards lo rea|s.

> ll crarged lror lvT lo P0, lao|els car oe
crusred.

> Assess lerperalure d|recl|y oelore ard 1
rour aller g|v|rg red|cal|or.

> ll resp|ral|ors are <12/r|r (<20/r|r |r
cr||drer), W|lrro|d lre red|cal|or ard
corlacl lre prys|c|ar

> Eva|uale lor lrerapeul|c resporse: re||el ol
pa|r, sl|llress, sWe|||rg; |rcreas|rg |r jo|rl
roo|||ly; reduced jo|rl lerderress; |rprove
gr|p slrerglr.

O Trerapeul|c o|ood serur
|eve|: 10-30 rcg/rL;
lox|c serur |eve|: >200
rcg/rL.
IeSC

+ Io||c
Ac|d

1 Lab 8lu
C

(8111)



D|c|ofenac
(CaLaflam)
30mg
lv11 q8 x
3 doses
conLlnue
q8AM

(81311)
>Ara|ges|c
(rorop|o|d)
> Arl|-
|rl|arralory
>Arl|pyrel|c
>N3Al0
>Acule or |org-lerr
lrealrerl ol r||d lo
roderale pa|r.
>lrr|o|ls
proslag|ard|r
syrlrelase lo casue
arl|pyrel|c ard arl|-
|rl|arralory ellecls.
>leadacre
>d|zz|ress
>sorro|erce
>l|redress
>|rsorr|a
>rasr
>sWeal|rg
>rausea
>dyspeps|a
>l|alu|erce
>vor|l|rg
>dysur|a
>o|eed|rg


>Adr|r|sler drug W|lr lood or rea|s |l 0l
upsel occurs.

>la|e or|y prescr|oed dosage.

>You ray exper|erce lrese s|de ellecls:
d|zz|ress or droWs|ress (avo|d do|rg
razardous las| Wr||e us|rg lr|s drug)

>Reporl sore lrroal; lever; rasr; |lcr|rg;
We|grl ga|r; sWe|||rg |r ar||es or l|rgers;
crarges |r v|s|or; o|ac|, larry sloo|s.


Cmeprazo|e
(Losec)

40mg
8lu C

(81611)
>Arl|secrelory
drug
>Prolor purp
|rr|o|lor
>srorl-lerr lrealrerl
lor acl|ve duodera|
u|cer
>0aslr|c ac|d-purp
|rr|o|lor: 3uppresses
gaslr|c ac|d secrel|or
oy spec|l|c |rr|o|l|or
ol lre rydroger-
polass|ur ATPase
erzyre sysler al
lre secrelory surlace
ol lre gaslr|c par|ela|
ce||s; o|oc|s lre l|ra|
slep ol ac|d
producl|or.
>leadacre
>d|zz|ress
>aslrer|a
>verl|go
>|rsorr|a
>apalry
>rasr
>prur|lus
>a|opec|a
>dry s||r
>cougr
>ep|slax|s

>Adr|r|sler oelore rea|s. Caul|or pal|erl lo
sWa||oW capsu|es Wro|e-- do rol oper, creW
or crusr lrer.

>lave regu|ar red|ca| lo||oW-up v|s|ls.

>You ray exper|erce lrese s|de ellecls:
0|zz|ress (avo|d perlorr|rg razardous
las|); readacre (requesl red|cal|ors);
rausea, vor|l|rg, d|arrrea (ra|rla|r proper
rulr|l|or); syrplors ol cougr (do rol se|l-
red|cale.

>Reporl severe readacre, Worser|rg ol
syrplors, lever, cr|||s.
Co
amox|c|av
623mg
8lu C

>8road-speclrur
per|c||||r
>KroWr or suspecled
arox|c||||r-res|slarl
|rlecl|ors |rc|ud|rg
>Ar arl|o|ol|c lral
coro|res arox|c||||r
ard c|avu|ar|c ac|d.
>d|zz|ress
>readacre
>corvu|s|ors

>Co-arox|c|av |s corlra|rd|caled |r pal|erls
W|lr a r|slory ol a||erg|c reacl|ors lo ary
(naLravox)
(81611) resp|ralory lracl, s||r
ard soll l|ssue,
ger|lour|rary, ard ear,
rose ard lrroal
|rlecl|ors.
ll deslroys oacler|a
oy d|srupl|rg lre|r
ao|||ly lo lorr ce||
Wa||s.
>C|avu|ar|c ac|d
o|oc|s lre crer|ca|
delerce, |roWr as
oela-|aclarase, lral
sore oacler|a rave
aga|rsl per|c||||rs.
Co-arox|c|av |s
acl|ve aga|rsl
oacler|a| |rlecl|ors
lral rave oecore
res|slarl lo
arox|c||||r.

>0|arrrea
>|rd|gesl|or
>rausea
>vor|l|rg
>rucoculareous
card|d|as|s
>url|car|a| ard
erylreralous s||r
rasres
>lrroroocyloper|a
>o|eed|rg
>vag|ra| |lcr|rg
per|c||||r.

>ll |s a|so corlra|rd|caled |r pal|erls W|lr a
prev|ous r|slory ol arox|c||||r-polass|ur
c|avu|arale-assoc|aled cro|eslal|c jaurd|ce/
repal|c dyslurcl|or.

>lr pal|erls W|lr rera| |rpa|rrerl, dosage
srou|d oe adjusled accord|rg lo lre degree
ol |rpa|rrerl.

>ll gaslro|rlesl|ra| s|de ellecls occur W|lr
ora| lrerapy lrey ray oe reduced oy la||rg
Co-arox|c|av al lre slarl ol rea|s.















'||. Nurs|ng 6are P|an (N6P} NUR8|NC PR|0R|TY # 1

A88E88HENT

0|ACN08|8

PLANN|NC

|HPLEHENTAT|0N

E'ALUAT|0N
|NTER'ENT|0N RAT|0NALE

8ubject|ve cues:

Cresl pa|r (p|eur|l|c-
|||e): 'd||| |aayo ra|a
g|raWa ug |a|or |ay
sa||l as veroa||zed
oy pal|erl.

308: '|u|arg arg
rarg|r as veroa||zed
oy pal|erl


0bject|ve cues:

gerera| pa||or
e|evaled RR: 28 cpr
sra||oW resp|ralory
deplr
rasa| l|ar|rg
decreased 02 sal:
89
d|r|r|sred orealr
sourds
ursyrrelr|ca| cresl:

|neffect|ve
reath|ng Pattern
r/l l|u|d ard a|r
accuru|al|or |r
per|lorea| ard
p|eura| cav|l|es
secordary lo
gursrol lraura














|neffect|ve breath|ng
pattern:

'lrsp|ral|or ard/or
exp|ral|or lral does rol

8h0RT TERH:

Aller 20 r|rules ol rurs|rg
|rlerverl|ors, lre c||erl W||| :

O relurr derorslrale ard
veroa||ze |rporlarce ol
deep orealr|rg ard
cougr|rg exerc|ses

O agree lo perlorr deep
orealr|rg ard cougr|rg
exerc|ses al rore aller
d|scrarge


Aller 8 rours ol rurs|rg
|rlerverl|ors, lre c||erl W||| :

O rave acr|eved ard
susla|red |rproved
resp|ralory pararelers,
|rc|ud|rg rorra|
resp|ralory rale ard
deplr, ard 02 salural|or
ol al |easl 90

O exr|o|l decreased pa||or

|N0EPEN0ENT:

1. Va|rla|r palercy ol
Cresl luoe lroracoslory
oy |eep|rg luo|rg lree ol
||r|s & ersur|rg proper
l|da||rg |r Waler sea|
corparlrerl



2. Ersure sler||e sa||re,
sler||e gauze, ard p|asler
are al oeds|de.













3. Pos|l|or c||erl
corlorlao|y |r ser|-
FoW|er's or r|gr-FoW|er's



- Cresl luoe dra|rage sysler
rusl rera|r |rlacl lo rerove
aororra| gases ard l|u|ds
lror c||erl's cresl lo
ra|rla|r proper regal|ve
|rlrap|eura| pressure ard
lac|||lale adequale
verl||al|or.

- 3rou|d lre dra|rage luoe oe
acc|derla||y delacred lror
co||ecl|or craroer, erd ol
luoe car |rred|ale|y oe
suorerged |r sler||e sa||re lo
ra|rla|r Waler sea| ard
preverl exaceroal|or ol
preurolrorax; 3rou|d lre
dra|rage luoe oe acc|derla||y
reroved lror cresl,
lroracoslory |rc|s|or s|le car
oe |rred|ale|y covered W|lr
sler||e gauze laped W|lr
p|asler lo reduce r|s| ol
|rlecl|or ard exaceroal|or ol
preurolrorax. Trese salely
reasures ersure |rlegr|ly ol
pal|erl's pr|rary posloperal|ve
red|ca| raragererl.

- E|evaled read pos|l|or
lac|||lales d|aprragral|c

8h0RT TERH:

Aller 20 r|rules ol
rurs|rg |rlerverl|ors, lre
goa|s Were rel.




Aller 8 rours ol rurs|rg
|rlerverl|ors, lre goa|s
Were rel




L0NC TERH:

Aller 1 rours ol rurs|rg
|rlerverl|ors up url||
d|scrarge, lre goa|s Were
rel.

r|grl s|de W|lr grealer
arleroposler|or
d|areler
l08 = g/d|
lCT = .8


prov|de adequale
verl||al|or.

(0oerges, 151)






L0NC TERH:

Aller 1 rours ol rurs|rg
|rlerverl|ors up url||
d|scrarge, lre c||erl W||| :

O rave ra|rla|red rorra|
resp|ralory rale ard
deplr, ard 02 salural|or
ol al |easl 95

O exr|o|l l|usr s||r

O rave oeer ooserved
perlorr|rg deep
orealr|rg ard cougr|rg
exerc|ses or oWr vo||l|or

pos|l|or.

1. lrslrucl c||erl lo perlorr
deep orealr|rg ard
cougr|rg exerc|ses every
rour:
a.) |rra|e deep|y lrrougr
rose
o.) ro|d orealr lor 3-5
secords
c.) exra|e W|lr pursed
||ps
d.) repeal al |easl 5-10
l|res
e.) cougr deep|y

5. lrslrucl c||erl roW lo
prys|ca||y reduce pa|r oy
l|ex|rg |rees ard sp||rl|rg
aodorer area W|lr p|||oW
Wrer cougr|rg ard
crarg|rg pos|l|ors.


0EPEN0ENT:

1. Adr|r|sler oxygeral|or
oy rasa| carru|a as
prescr|oed al 1 L/r|r

2. Adr|r|sler Ce|ecox|o
200rg P0 8l0 as
prescr|oed

60LLA0RAT|'E:

Reler pal|erl lo resp|ralory
lrerap|sl, |l ava||ao|e.
excurs|or ard opl|ra| |urg
expars|or.

- Expards |urgs ard proroles
ellecl|ve gas excrarge,
o|ood oxygeral|or, ard C02
e||r|ral|or






- 3p||rl|rg car reduce pa|r oy
supporl|rg Wourds ard
app|y|rg d|lluse pressure
over surrourd|rg areas lo
c|ose 'gale corlro|. F|ex|rg
|rees car reduce pa|r oy
decreas|rg aodor|ra|
lers|or. Reduced pa|r oeller
ercourages pal|erl lo
perlorr deep orealr|rg ard
cougr|rg exerc|ses lo
|rprove verl||al|or.

- lrproves oxyger o|ood
salural|or.

- 0ecreases pa|r lo prorole
corlorl ard decrease
oxygeral|or derards.
-
- Resp|ralory lrerap|sls rave lre
experl|se lo prov|de a rore
|rd|v|dua||zed exerc|se reg|rer
largel|rg rusc|es ol resp|ral|or.
NUR8|NC PR|0R|TY #

A88E88HENT

0|ACN08|8

PLANN|NC

|HPLEHENTAT|0N

E'ALUAT|0N
|NTER'ENT|0N RAT|0NALE

8ubject|ve cues:

Pl veroa||zes d|lluse
pa|r over surg|ca|
|rc|s|or s|les ol 1 oul
ol 5 (5 as rosl
pa|rlu|) upor resl, 3
oul ol 5 upor acl|v|ly


Prelererce lor s|ll|rg
pos|l|or veroa||zed oy
pal|erl.


0bject|ve cues:

lroracoslory surg|ca|
|rc|s|or, 1|r |ell 5
lr

lC3

Exp|oralory
|aparalory surg|ca|
|rc|s|or, 11|r r|d||re
arourd uro|||cus

guard|rg ol |rc|s|ora|

Acute pa|n r/l slao
Wourd ard
lroracoslory ard
exp|oralory
|aparolory surg|ca|
|rc|s|ors






Acute Pa|n:

'urp|easarl sersory
ard erol|ora|
exper|erce ar|s|rg
lror aclua| or polerl|a|
l|ssue darage or
descr|oed |r lerrs ol
sucr darage
(lrlerral|ora|
Assoc|al|or lor lre
3ludy ol Pa|r); sudder
or s|oW orsel ol ary
|rlers|ly lror r||d lo
severe W|lr ar
arl|c|paled or
pred|clao|e erd ard a
dural|or ol |ess lrar
rorlrs.

8h0RT TERH:

Aller 20 r|rules ol rurs|rg
|rlerverl|ors, lre c||erl W|||:

O relurr derorslrale ard
veroa||ze |rporlarce ol
deep orealr|rg exerc|ses


Aller 30 r|rules ol rurs|rg
|rlerverl|ors, lre c||erl W||| :

O reporl a decrease |r pa|r
|eve| lror 3 lo 1 (acl|v|ly)

O exr|o|l decreased
guard|rg over surg|ca|
Wourds

L0NC TERH:

Aller Z2 rours ol rurs|rg
|rlerverl|ors up url||
d|scrarge, lre c||erl W||| :

O reporl corp|ele aoserce
ol pa|r

|N0EPEN0ENT:

1. Ass|sl W|lr Wourd care
ard dress|rg.


2. Ass|sl W|lr proper
p|acererl ol aodor|ra|
o|rder.


3. App|y co|d pac|s lo rear
|rc|s|ors lor 20-r|rule
|rlerva|s.


1. lrslrucl c||erl lo l|ex
|rees.



5. Prov|de corlorl
reasures (e.g. luc| |r oed
||rers, prorole a qu|el
erv|rorrerl, W|pe c||erl
per|od|ca||y lo |eep r|r dry,
lar c||erl lo |eep r|r coo|)


. Prov|de d|vers|ora|
acl|v|l|es (e.g. corversal|or,
lrerapeul|c loucr ard
rassage)



- Proper Wourd ryg|ere
preverls |rlecl|or lral Wou|d
exaceroale pa|r.

- 3upporls surg|ca| |rc|s|or,
lrereoy reduc|rg pa|r.



- Co|d ras ara|ges|c ellecls.




- 8erl |rees reduce
aodor|ra| lers|or, lrereoy
reduc|rg pa|r |r lre area.


- Ar urcorlorlao|e
erv|rorrerl Wou|d olrerW|se
exaceroale pa|r.





- Trese d|slracl pal|erl's
allerl|or lror pa|r.



8h0RT TERH:

Aller 20 r|rules ol
rurs|rg |rlerverl|ors, lre
goa|s Were rel.

Aller 30 r|rules ol
rurs|rg |rlerverl|ors, lre
goa|s Were rel.





L0NC TERH:

Aller Z2 rours ol rurs|rg
|rlerverl|ors up url||
d|scrarge, lre goa|s Were
rel.

s|le rear |oWer
aodorer

gr|rac|rg

e|evaled RR: 28 cpr

gerera| Wea|ress

||rped ga|l


(0oerges, 58)

O oe ao|e lo Wa|| ard
crarge pos|l|ors rore
eas||y, W|lroul pa|r

O ul|||ze var|ous
|rdeperderl pa|r
raragererl reasures
(e.g. deep orealr|rg ard
|ragery or oWr accord)


Z. Fac|||lale rarge ol rol|or
exerc|ses sucr as l|ex|or
ard exlers|or ol
exlrer|l|es, ard/or ass|sl
W|lr arou|al|or as rucr as
pal|erl car lo|erale.


0EPEN0ENT:

1. Adr|r|sler P0 pa|r
reds Ce|ecox|o 200rg 8l0
P0

2. Adr|r|sler P0
arl|o|ol|cs Celurox|re
(Z|racel) 500rg 8l0, P0




60LLA0RAT|'E:

Reler pal|erl lo prys|ca|
lrerap|sl, |l ava||ao|e.









- Exerc|se proroles o|ood
c|rcu|al|or, lrereoy
exped|l|rg rea||rg ol Wourds
ard corsequerl reducl|or ol
pa|r.




- Ara|ges|cs re||eve
pa|r.


- Arl|o|ol|cs preverl
|rlecl|or lral Wou|d
olrerW|se aggravale
pa|r




- Prys|ca| lrerap|sl ras
experl|se lo prov|de
pal|erl W|lr a rore
|rd|v|dua||zed reg|rer
ol prys|ca| acl|v|ly.
Tr|s |rcreases lee||rgs
ol We|| oe|rg ard
proroles rea||rg ard
ray decrease pa|r
d|recl|y oy prorol|rg
re|ease ol erdogerous
op|o|ds.

NUR8|NC PR|0R|TY # 3

A88E88HENT

0|ACN08|8

PLANN|NC

|HPLEHENTAT|0N

E'ALUAT|0N
|NTER'ENT|0N RAT|0NALE

8ubject|ve cues:

'luya rar |ayo
a|o par|raW sa
l|ouo| ra |aWas u|,
d||| jud |o |a||ro|
||ro| |ay rusa||l
|ag| arg a|org
rga l|rar|ar,
ragpalaoarg pa
ga|| |o sa a|o
rara as
veroa||zed oy lre
pal|erl

'0o, 2a||soo na
oayon ko u
|nnaua |urg
rag|a|aW2x o
||ro|2x a|o rao
ra rga ua koy
ana rarg||ro|
as veroa||zed oy
lre pal|erl

308


0bject|ve cues:
RR 28cpr

Act|v|ty |nto|erance
re|aled lo
gerera||zed
Wea|ress lror
recerl surgery &
pa|r le|l or lre
|rc|s|or s|les upor
acl|v|l|es








Act|v|ty |nto|erance

'lrsull|c|erl
prys|o|og|ca| or
psycro|og|ca| erergy
lo erdure or
corp|ele requ|red or
des|red da||y
acl|v|l|es

(0oerges, 9)

8h0RT TERH:

Aller 30 r|rules ol rurs|rg
|rlerverl|ors, lre c||erl W|||:

O lderl|ly regal|ve
laclors allecl|rg acl|v|ly
|rlo|erarce ard
e||r|rale or reduce
lre|r ellecls Wrer
poss|o|e

O use |derl|l|ed
lecrr|ques (e.g. deep
orealr|rg, pauses,
d|slracl|or elc.) lo
errarce acl|v|ly
lo|erarce


L0NC TERH:

Aller 2 rours ol rurs|rg
|rlerverl|ors, lre c||erl W|||:

O Parl|c|pale
W||||rg|y |r
recessary/
des|red acl|v|l|es


|N0EPEN0ENT:

1.) Prov|de pos|l|ve
alrosprere, Wr||e
ac|roW|edg|rg d|ll|cu|ly ol
lre s|lual|or lor lre c||erl &
ercourage lo arou|ale
progress|ve|y

2.) Prov|de rea|lr leacr|rg |r
lre c||erl regard|rg lre:

O orgar|zal|or ard l|re
raragererl lecrr|que
Wr||e or acl|v|ly
O regal|ve laclors
allecl|rg acl|v|ly
|rlo|erarce
O lecrr|ques sucr as
deep orealr|rg (pa|r),
pauses & d|slracl|or


3.) Prov|de erougr a|r lror
lre e|eclr|c lar or lror lre
W|rdoW

1.) 0eve|op & adjusl s|rp|e
acl|v|ly |||e orusr|rg r|s
leelr, Wa|||rg loWards lre
corlorl roor (prov|de
ass|slarce |l recessary)






- re|ps lo r|r|r|ze
lruslral|or ard re-crarre|
acl|v|ly




- lo prov|de adequale
|roW|edge lo c||erl / errarce











- lo errarce c||erl's ao|||ly lo
parl|c|pale |r lre acl|v|ly
(lo|erao|e)

- lo |rcrease pal|erl's
lo|erarce lo acl|v|l|es, ||ll|e oy
||ll|e; prorole |rdeperderce |r se|l-
care acl|v|l|es as lo|eraled ; preverl
overexerl|or



8h0RT TERH:

Aller 30 r|rules ol rurs|rg
|rlerverl|ors, lre goa|s Were
rel.



L0NC TERH:

Aller 2 rours ol rurs|rg
|rlerverl|ors lre goa|s Were
rel.


lrcrease |r 8P
lror 110/80 lo
130/Z0 rrlg

Pa||or (|l pro|orged
acl|v|l|es)

3|oW, guarded
rovererls



O Reporl
reasurao|e
|rcrease |r acl|v|ly
lo|erarce

O 8a|arces acl|v|ly
ard resl

O 0erorslrale a
decrease |r
prys|o|og|ca|
s|grs ol
|rlo|erarce (e.g.
lR & 8P W|lr|r
rorra| ||r|ls,
pa||or, dysprea.)

5.) Prov|de corlorl & salely
reasures or lre acl|v|ly &
a|lerrale acl|v|ly & resl

.) Adequale l|u|d |rla|e


0EPEN0ENT:

1.) Prov|de supp|ererla|
0xyger, red|cal|ors &
lrealrerl reg|rers as
|rd|caled oy lre
prys|c|ar.

2.) Prov|de ara|ges|cs
(Ce|ecox|o 200rg P0
8l0) as prescr|oed oy
lre prys|c|ar


60LLA0RAT|0N:

Relerra| lo olrer
d|sc|p||res sucr as
lrerapy , recreal|or /
|e|sure spec|a||sls as
|rd|caled







- lo prolecl c||erl lror |rjury;
r|r|r|ze exrausl|or & re|ps
oa|arce 02 supp|u & derard

- lo ra|rla|r rydral|or





- lo a|d |r slao|||z|rg v|la|
s|grs & preverl resp|ralory
d|slress



- lo re||eve pa|r, lrus pal|erl
W||| oe ao|e lo rove W|lroul
lre lear ol pa|r






- lo deve|op |rd|v|dua||y
appropr|ale lrerapeul|c
reg|rers

VIII. Discharge PIan DATA (-ENCODE PA)
RationaIe
Medication
O



Exercise
O Avoid strenuous activity
O Early ambulation:
Walking early in the morning or in
the late afternoon



- prevent bleeding & promote healing
- promote healing
Treatment
O Adhere to medication regimen as
prescribed by the physician




- to gain therapeutic effects
Diet
O Fiber-rich foods such as pineapple,
corn, oatmeal, green and leafy
vegetables, etc.
O Protein-rich foods such as meat,
beans, soya, etc.
O ncrease fluid intake



- prevent complications, constipation


- promote healing

- to maintain / promote hydration
FoIIow-up
O follow-up check up one week after
discharge (_________)



- to check for therapeutic effects of
treatment and prevent complication
SpirituaIity
O Encourage patient to engage in
spiritual activities such as praying,
meeting, etc.



- to lessen anxiety and promote presence
of mind and to strengthen his spiritual life




IX. Prognosis
A. #esponse of the patient regarding the presence of the pain after its management -

B. Physiologic response of the body to disease process -

C. #elief of symptoms associated with the disease condition

D. Performance of activities of daily living during confinement

E. Compliance of the patient to the medication and/ or therapy

F. Adequacy of rest periods and sleep

G. Patient's consumption of nutrition - GOOD

H. Patient's significant others' behavior regarding the health teaching given by the health
caregiver and the physician - GOOD

. Attitude - GOOD

J. Duration of Illness and recovery - GOOD

K. Family Support - GOOD

L. Level of Consciousness - GOOD



Tabulation:
Good:
Fair:
Poor:




44

. 6onc|us|on











|. Recommendat|ons
A. To the Pat|ent:
1. Ercourage lo ra|rla|r oa|arced rulr|l|or & adequale l|u|d |rla|e
2. Fo||oW lre prescr|oed rore red|cal|ors re||g|ous|y & lre d|scrarge p|ar lo prorole lasler
recovery
3. Ercourage lo relurr lo NVVC, 1 Wee| aller d|scrarge
1. Adopl a l|rarc|a| slralegy lo save rorey & address corcerrs regard|rg rea|lr cord|l|or
5. Prorole a rea|lry ||lesly|e W|lr|r lre lar||y


. To the 8tudent Nurses:
1. Pracl|ce learWor| & ur|ly so lral lre group W||| rave a oeller oulpul
2. Fo||oW a scredu|e lor lr|s W||| prorole orgar|zal|or
3. Varage l|re W|se|y lo accorp||sr requ|rererls & duly respors|o|||l|es ellecl|ve|y
1. Va|rla|r ar ellecl|ve & lrerapeul|c use ol se|l lo lac|||lale |r prov|d|rg rurs|rg care |rlerverl|ors
5. Ta|e l|re lo assess pal|erls lrorougr|y; ||sler acl|ve|y & prooe |rlo sa||erl l|rd|rgs lurlrer
. 8e pal|erl W|lr ard sers|l|ve lo d|ll|cu|l pal|erls & / Walcrers; lrey are prooao|y urder slress
Z. Treal your pal|erls as you Wou|d your |oved ores
8. Pray every day & as| 0od lor gu|darce |r rerder|rg your rurs|rg care
9. Rereroer lo ac|roW|edge 0od's preserce W|lr|r eacr & everyore



44