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DATA BASE AND HISTORY

Patient Z, 81 years old, widowed, Filipino, a Roman Catholic from Ibabao, Agus, Lapu-Lapu City was admitted for the first time in VSMMC last January 31, 2011 at around 12:30 pm due to an inflamed wound at Right maxillary area of her face. Three months PTA, the patient had a small wart on her Right cheek as reported by patients S.O. but was not taken care of. The wart increased in size due to skin irritation such as scratching resulted to further infection.Two months PTA, the S.O. encouraged the patient to have a check-up on the nearest health center because of the increase of the size of the wart forming a mass but was then advised to go to the district hospital but the patient refused to do so. A month PTA, the S.O noticed a moist drainage from the mass. Two weeks PTA, the drainage became more purulent without reporting it to her S.O. The patient continues to rub the mass because of pruritic sensation. Two days PTA, the S.O. noticed a bloody discharge from the mass prompted them to seek medical attention at Lapu-Lapu City District Hospital later was referred to VSMMC for further medical management. The patient was then diagnosed with Squamous Cell carcinoma with the following Vital Signs upon admission of TEMP:37.1 C; PULSE:81bpm RESPIRATORY: 25cpm; BP: 140/90 mmHg. The patient has not received any blood transfusion before and has no known allergies to food and drugs. The patient was accompanied by her daughter-in-law. Her mother and father died by age, 12th rank in the family out of 18 siblings. She has 6 children and owns a Sari-Sari store. She lived in a concrete house which she owns with 3 rooms with her grandchildren and daughter-in-law. She usually awakens at night at around 11-12 oclock in the midnight to urinate and six times all in all in one day. And preferred to be in side-lying position when sleeping. Usually defecates every other day, as reported by the patient at around 8 oclock in the morning with a semi-formed stool, mode of human waste is water-sealed. The patient usually takes her breakfast at around 7 oclock in the morning with coffee and bread and lunch usually around 12 oclock in the afternoon and dinner around 6 in the evening. Likes to eat fish and utan. Takes a nap at 1-4 oclock in the afternoon and usually have snacks in between meals. Takes a bath once a day, shampoo her hair once a week and do handwashing as necessary and gargles with salt. There water source is artesian well for daily use and Distilled water for drinking and stores it in a dispenser and pitcher. Usually likes to watch t.v. and sleeps. The patient has no heredofamilial disease of Asthma, Diabetes Mellitus and Cancer but has Hypertension. Menarche of patient when she

was 14 years old, onset every second week of the month duration of 3-7 days, 30-day cycle with scanty bleeding and dysmenorrhea rarely occurs. She does not experience any difficulty encountered during her pregnancy with an obstetrical record of G-6,P-6, A-O. And the patient menopause at the age of 54 years old. The patient has no previous illness or surgery. And the patients present illness is Squamous Cell Carcinoma at Right maxillary area, a malignant proliferation arising from the epidermis.

SUBJECTIVE COMMUNICATION Comments Dili kayo siya makadungog day pero wala man siya maggamit ug eyeglass as verbalized by the pt. S.O. OXYGENATION Comments Naa na siyay ubo day magduha na ka semana as verbalized by the S.O. of the patient.

OBJECTIVE

The pupil size is 3mm on both Right and Left eyes. REACTION is Pupil Equally Round Reactive to Light Accommodation. Needs repetition of words before she could comprehend it. The respiratory rate of the patient is 16cpm with symmetrical chest expansion, nonproductive cough noted, wheezes heard upon auscultation, use of accessory muscle upon inhalation and expiration CIRCULATION The pulse of the patient is Comments Kung mulingkod 80bpm upon assessment. ko kay akong ipapatong ang Numbness of lower extremities akong tiil as verbalized by the reported by the patient. No pt. ankle edema noted. NUTRITION Comments Ginagmay ra jud na siya mukaon day pero mukaon man jud siya as verbalized by the S.O. ELIMINATION Date of Last Bowel Movement was on February 2, 2012 (date of assessment is February 4, 2012. Urinary frequency of 6-7 times MGT. OF HEALTH & ILLNESS LMP Pt. has menopause at age 55 years old. No history of alcohol intake reported. Patient has no difficulty in swallowing and recent change in appetite reported. The patient has no dentures but has partial teeth in both upper and lower palate. 10 borborygmous sounds heard upon auscultation per minute. Abdominal distention noted. Urine is light yellow in color with aromatic smell. Due to patients age, she cannot follow the treatment regimen but the S.O. of the patient is compliant to any treatment advised.

SUBJECTIVE

OBJECTIVE

SKIN INTEGRITY Comments Uga na jud ang pamanit sa tigulang day pero katol kaayo kaning dapit sa akong samad as verbalized by the patient. ACTIVITY/SAFETY Comments Manggunit siya kung mulakaw siya day niya usahay kay amo nalang siya palingkuron sa wheelchair para dili siya matumba as verbalized by S.O. of the patient. COMFORT/SLEEP/AWAKE Comments Maglisud ko ug katulog diri sa ospital day mong matulog nalang ko ug buntag, udto as verbalized by the S.O. of the patient. COPING The patient owns a sari-sari store near her house but depends on the financial support of her children. Her grandson is the most supportive member of her household

The skin is dry, warm to touch. A small erythema noted located at the right thigh of the patient. Patient is seen touching the mass and reported pruritic sensation on the area. The mass is covered with clean OS and changed every day. Limited motion of joint and when ambulating and changing position. Patient needs assistance in changing clothes but can feed herself. Patient is conscious, awake and responds some of the questions asked. There is pain on the maxillary area, pt. verbalized having sleeping difficulties. Patient seen taking naps in the afternoon. Siderails are raised to prevent fall and any other forms of injury. Patient does answer some of the questions asked but most of the time the S.O. do the answering but they are very cooperative and open to any questions asked.

IV. MEDICAL-SURGICAL MANAGEMENT


IDEAL LABORATORY EXAMINATIONS SCC Antigen released when SCCA is present PHARMACOLOGIC ERBITUX- epidermal growth factor receptor inhibitor -slow down/stop cell growth BLENOXANE- Bleomycin, antibiotic, antineoplasptic DIET High LYCOPENE High Vitamin E and C Low fiber TREATMENT EXCISION (SIMPLE)P- the doctor will cut out the cancerous tissue surrounding margin of healthy skin CURRETAGE and ELECTRODESICATIONscraping away cancer cells and using the electricity to kill any that any that remains JOHNS Surgery- removing the layer of skin and looking at it immediately under a microscopy then removing many layer of skin until there is no sign of cancer cells CHEMOTHERAPY-antineoplastic agents are used in attempt to destroy tumor cells by interfering cellular functions and reproduction SURGERY CRYOSURGERY-destroy tumor by deep freezing the tissue ELECTROSURGERYdestruction/ removal of tissue by electrical energy(heat) MOHs Micrographic Surgerytechnique that is most accurate and that best conserves the normal tissue. LASER THERAPY- intense beam of light vaporize the growth usually ACTUAL CBC U/A CxR ENALAPRIL MALEATE- antihypertensive Vitamin B-compexsupplement Ferrous Sulfate-Iron preparation Azithromycin- antibiotic CIPROFLOXACIN- anti-infective DAT Limit fluids to 1,200L/ day

INCISION BIOPSY- impending results BLOOD TRANSFUSION- to correct anemia - Last February 2&3, 2012 - O+

For schedule operation after anemia is corrected CP clearance-cleared

with little damage to surrounding tissue and with a reduced risk of bleeding, swelling and scarring.

Reference: Medical-Surgical Nursing Volume 2 10th edition

DISCHARGE SUMMARY
NAME of PATIENT: FAUSTINA AMORES_______________

MEDICATIONS

EXERCISE

TREATMENT

HEALTH-TEACHING

OUT-PATIENT

DIET

SPIRITUAL

Educated the patient and S.O. about the importance of drugs being prescribed, dosage and treatment regimen must be completed especially if the patient is prescribed with antibiotic to prevent microorganism-resistance. Sunscreens are also part of medication if there is any being prescribed by the doctor. Considering the age of the patient, exercise is limited to patient. Encouraging patient and S.O. to do active and passive ROM to avoid joint stiffness. Encouraged patient accompanied by her S.O. ambulatep as much as possible to increase gastric motility and avoiding sun exposure during 10AM-2PM. Encouraged S.O. of the patient for the continuation of Blood transfusion. The patient received to bags of PRBC lacking 2 and 1 bag standby for operation. Adviced the S.O. and the patient to comply all medications prescribed. Antibiotic creams are also applied to the site to prevent opportunistic infection. Instructed S.O. the importance of handwashing before and after handling the wound or whenever in contact with it. See to it that the dressing is intact, clean and if possible dry. Apply emollient cream, not powder, unto the surrounding area of the site to prevent dryness and further injury. Note that powder can be an irritant to the open wound. Instructed the S.O. and the patient to avoid unnecessary sun exposure (between 10am-2pm). Advise patient to wear protective clothing whenever going out. The wound is usually covered with a dressing to protect site from physical trauma and irritants, the patient is reminded with a note when will the patient be back for dressing change or if possible the S.O. is taught how to do wound dressing if in case it is on a daily basis. Discussed the importance of daily and proper wound dressing. Encouraged S.O. to watch signs of excessive bleeding and report to nearest hospital if possible. Advised the S.O. of the patient to prepare foods that are rich in lycopene like tomato,Vitamin E and C because they have antioxidant properties that help fight against cancer by slowing/ preventing the growth of cancerous cells. Also, advised patient to eat fruits and vegetables that promote wound healing and tissue repair( greenleafy). Increased fluid intake to flush out toxins in the body as tolerated by the patient and as remedy to constipation as well. Encouraged patient to continue have faith in God. Patient is a vocal, religious Roman Catholic. Encourage S.O. and patient to pray together.

DATE ORDER ED 2/3/201 2

DIAGNOSTIC/ LABORATORY EXAMINATIONS

NORMAL VALUES

UNIT

RESULT

INTERPRETATION

2/1/201 2

Urinalysis Color Transparen cy Specific Gravity pH Protein Glucose RBC WBC Hematology(C BC) WBC HgB HcT MCV MCH RBC MCHC RDW MPV Platelet Differential Neutrophil Lymphocyte Monocyte Eosinophil Basophil Hematology (CBC) HgB

Yellow Cloudy 1.015 7.5 (---) (---) 0-2 10-25

4.8-10.8 120-160 0.37-0.47 81-99 27-31 4.2-5.4 330-370 11-16 7-11.1 150-400 40-74 19-48 3-9 0-7 0-2

10^g/ L g/L L/L fl pg 10^1 2/L g/L fl fl 10^g/ L % % % % %

13.30 68 0.22 100.00 31.60 2.16 316 11.70 7.20 151.00 83.50 9.80 5.30 1.30 0.10

1/31/12