I.

Introduction

Brief Description of the Disease Condition

The body is made up of many types of cells. Normally, cells grow, divide and die. Sometimes,
cells mutate (change) and begin to grow and divide more quickly than normal cells. Rather than
dying, these abnormal cells clump together to form tumors. If these tumors are malignant
(cancerous), they can invade and kill your body's healthy tissues. From these tumors, cancer
cells can metastasize (spread) and form new tumors in other parts of the body. By contrast,
benign (noncancerous) tumors do not spread to other parts of the body. Nasopharyngeal (say:
"nay-zo-fair-in-gee-al") cancer is a malignant tumor that develops in the nasopharynx (say:
"nay-zo-fair-inks"). The nasopharynx is the area where the back part of your nose opens into
your upper throat. This is also where tubes from your ears open into your throat.

Nasopharyngeal cancer is rare. It most often affects people who are between 30 and 50 years of
age. Men are more likely to have nasopharyngeal cancer than women. You are most likely to get
this cancer if you or your ancestors came from southern China, particularly Canton (now called
Guangzhou) or Hong Kong. You are also more likely to get this cancer if you are from a country
in Southeast Asia, like Laos, Vietnam, Cambodia or Thailand. No one knows for sure what
causes nasopharyngeal cancer. Eating salt-preserved foods (like fish, eggs, leafy vegetables and
roots) during early childhood may increase the risk of getting this form of cancer. The Epstein-
Barr virus may also make a person more likely to get nasopharyngeal cancer. This is the same
virus that causes infectious mononucleosis (also called "mono"). You may also inherit a
tendency to get nasopharyngeal cancer.

Reason for Choosing the Case

Nasopharyngeal Cancer is one of the unusual terms for a lay person and a rare case that a nurse
would encounter. Acquisition of cognitive knowledge regarding the topic would enable the
researchers in providing optimum care for clients suffering such and in delivering appropriate
interventions that would promote health and wellness for the client.

Statistics (Global and Local)

Cancer of the nasopharynx is a rare neoplasm in most countries. However, it occurs at high
frequencies in China and Southeast Asia. The highest incidence rates in the SEER regions occur
among the Chinese. Rates are also high in Vietnamese and Filipino men, two groups that

1
include persons of Chinese heritage. Incidence rates of nasopharyngeal cancer are also available
for black, Hispanic and white men and for white women in the SEER areas. There were too few
nasopharyngeal cancers diagnosed between 1988 and 1992 in the other racial/ethnic groups to
provide meaningful incidence rates.

The average annual age-adjusted incidence rate of nasopharyngeal cancer in Chinese men, 10.8
per 100,000, is 1.4 times greater than that of Vietnamese men and nearly 2.8 times greater than
that of Filipino men. In fact, the rate among Filipino men, although relatively high, is the same
as that for Chinese women. Rates of one per 100,000 and lower occur in black men, Hispanic
and non-Hispanic white men and non-Hispanic white women.

The United States mortality rates for cancer of the nasopharynx reflect patterns similar to those
for SEER incidence rates. Mortality is highest in Chinese, lower in Filipinos and lowest among
blacks, Hispanics and non-Hispanic whites. No mortality rates are currently available for
Vietnamese. Incidence-to-mortality rate ratios vary, with Chinese and Filipinos having higher
incidence relative to mortality (2.3 for men in both groups and 3.2 for Chinese women) than
other groups (ranging from about 1.7 for white Hispanic men to two for non-Hispanic white
men). Incidence and mortality rates for nasopharyngeal cancer increase through the oldest age
group, although the small number of cases precluded the calculation of reliable rates for many
populations.

The major modifiable risk factor identified for cancer of the nasopharynx is the consumption of
Cantonese salted fish, which is a common food item eaten from early infancy onward by groups
with high risk of this disease. Other possible risk factors include extensive exposures to dusts
and smoke and regular consumption of other fermented foods. The role of Epstein-Barr virus in
the development of nasopharyngeal cancer continues to be explored.

Nurse-centered Objectives:
The group aims:
to have a better understanding about the causes of nasopharyngeal cancer.
to determine the medical and surgical treatment that has given to the disease entity.

2
 to perform well our role as student nurses in the treatment and achieving the optimum
level of health of the patient.
to enhance our nursing skills most importantly focusing on promotive and preventive
nursing measures.

3
II. Nursing Assessment

Personal Data
Mr. Split, 74 years old, married and a father of 7 children. Offspring of Mr. and Mrs. Choco
Split, he was born on December 31, 1934 in Angeles Pampanga, and at this point in time, he
resides in Timog Park, Angeles. He is a Filipino-born citizen. He was admitted last September
18, 2008 in Angeles Medical Center (AMC).

Mr. Split is a jeepney operator and he is the sole provider for their means of living. His children,
mostly married, some are presently unemployed and contribute to the burden on financial matters
to the family of orientation.

Mr. Split has a lifestyle of eating food that should or not allowed to him such as foods that are
high amounts in sugar and low density cholesterol. Besides that Mr. Split is also attached to
cigarette smoking. He also worked as a painter of houses for living for the past 20 years.

History of Past Illness

Mr. Splits last check-up was done 3 years ago and was diagnosed to have nasopharyngeal
cancer. Prior to this, he has also been diagnosed to have Diabetes Mellitus Type 1 and Pulmonary
Tuberculosis. According to his daughter, his first admission in the hospital was September 18,
2008.

History of Present Illness

One (1) month PTA, Mr. Split experienced difficulty of breathing, and anorexia lasting for 1
week. A week PTA, he still experienced difficulty of breathing, and anorexia associated plus
muscle weakness with easy fatigability but still he did not seek medical attention. A day PTA, he
still experienced the same signs but this time he decided to seek medical attention.

4
Family Health Illness History

Mr. Split

Legend:

= Male = Diabetes Mellitus = Tuberculosis

= Female = Cancer = Deceased

5
III. Physical Examination

Angeles Medical Center (AMC) (September 18, 2008)

Upon admission:
(+) body weakness accompanied by difficulty of breathing and anorexia.

Physical Examination:
Drowsy, coherent, afebrile, in respiratory distress, pale palpable conjunctiva, (+) irregular
mass on nasal area, (+) rales, no murmur, normal abdominal bowel sounds, pale nail bed,
weak pulses.

1st Assessment (September 20, 2008)

General Appearance:
Received pt in a fowlers position with contraptions. Pt is with body odor and with minimal foul
breath odor. Pts speech is slightly incomprehensive.

Vital Signs:
T: 36.4 C RR: 29 cpm
PR: 87 bpm BP: 120/80 mmHg

Physical Assessment:
Integument
Noted dryness
Presence of tattoo in the right arm
Poor skin turgor
Capillary refill test: delayed return in pink color (3 seconds)
Presence of scars on the lower extremities
Head
Hair generally white
Presence of patches of hair loss

6
 Noted thinning of eyebrows
Eyes
Pale palpebral conjuctiva
Anicteric sclera
Unable to read newsprint within reading distance
Reactive to light accomodation
Ears
Symmetrical
Presence of cerumen
Nose and Sinuses
Presence of neoplasm
Mouth and Throat
Gums grayish in color
Presence of halitosis
2 sets of teeth left on frontal portion of the mandible
Brown discoloration of the enamel of the teeth
Noted difficulty in uttering words
Presence of cough
Breast and Axillae
Absence of discharge
Absence of signs of edema
Respiratory/Chest
Chest is symmetric
Presence of tachypnea
Presence of chest pain
Gastrointestinal/Abdomen
Flat contour of the abdomen
Liver is non-palpable

7
Urinary
Pt in foley catheter
Urine light yellow in color

8
IV.Diagnostic and Laboratory Procedures

Procedures done to the Client

Diagnostic/ Date Ordered/ Normal Values

Indication(s)/
Laboratory Date Result(s) Result(s) (units used in the Analysis and interpretation of results
Purposes(s)
Procedures Released hospital)
Blood Chemistry 09/18/08 To assess a wide Hct > 32.7 @m: 40.0 54.0 Hematocrit level as shown are below the
range of conditions standard values.
and the function of Platelet Count > 759 @m: 140 - 440 Platelet count is above the average level.
organs. Often, blood Hemoglobin level is lower than the
tests check Hgb (Hemoglobin)>9.5 @m: 14 18 g/dl established normal values.
electrolytes, the
minerals that help White blood cells are higher than the
keep the body's fluid WBC (White Blood @m: 4.3 10.0 x 1/l usual amount.
levels in balance, and Cells)>27.9
are necessary to help Lymphocytes are below the average
the muscles, heart, Lymhocytes > 10 @m: 28.0 48.0 levels.
and other organs Granulocytes are beyond the normal
work properly. To Granulocytes > 90% @m: 44.2 80.2(x 10/1) values.
assess kidney
function and blood
sugar, blood tests
measure other Glucose (FBS) > 138.6 @76 - 111 mg/dl Glucose levels in the patients body are
09/19/08 substances. within normal values.
BUN > 13.72 @7 - 21 mg/dl Results show that BUN is at average
levels.
Creatinine > 0.78 @0.5 - 1.69 mg/dl Result shows that creatinine are at
normal values.
Potassium > 3.6 @3.5 - 5.0 Potassium is at the normal values.

Sodium > 143 @136 - 145 mmo/L Result shows that sodium levels are
within regular values.

Nursing responsibilities:
inform patient on the procedure to be done. Explain the details on what and how the procedure is going to be administered.

9
 let client sign a waiver or a consent before starting the procedure.
provide the best possible nursing care for the patient who is to undergo a procedure.
inform patient that the test would be done for the better of the patients condition.
inform the patient with the results of the procedure done, explain the implications of each result, client has the right to know.

Diagnostic/ Laboratory Normal Values

Indication(s)/ Purposes(s) Analysis and interpretation of results
Procedures (units used in the hospital)

Chest X-ray Commonly used to detect Minimal Pulmonary Tuberculosis on left lateral
abnormalities in the lungs, but portion of the lungs
can also detect abnormalities in
the heart, aorta, and the bones of
the thoracic area. Metallic
objects, such as jewelry are
removed from the chest and neck
areas for a chest x-ray to avoid
interference with x-ray
penetration and improve
accuracy of the interpretation.

Nursing Responsibilities:
Inform the patient about the procedure
Ask the patient to remove any radiopaque objects (jewelry, belts, or metal buttons).
Assist patient to wear a gown.
Assist patient when positioning.
Note pertinent findingssuch as the presence of a pacemaker or an artificial joint.

10
11
V. The Patient and His Illness

Anatomy and Physiology of the Human Respiratory System

The respiratory system consists of all the organs
involved in breathing. These include the nose, pharynx,
larynx, trachea, bronchi and lungs. The respiratory
system does two very important things: it brings
oxygen into our bodies, which we need for our cells to
live and function properly; and it helps us get rid of
carbon dioxide, which is a waste product of cellular
function. The nose, pharynx, larynx, trachea and
bronchi all work like a system of pipes through which
the air is funneled down into our lungs. There, in very
small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is
pushed from the blood out into the air. When something goes wrong with part of the respiratory
system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need
and to get rid of the waste product carbon dioxide. Common respiratory symptoms include
breathlessness, cough, and chest pain.

The Upper Airway and Trachea

When you breathe in, air enters your body through
your nose or mouth. From there, it travels down
your throat through the larynx (or voicebox) and
into the trachea (or windpipe) before entering your
lungs. All these structures act to funnel fresh air
down from the outside world into your body. The
upper airway is important because it must always
stay open for you to be able to breathe. It also helps
to moisten and warm the air before it reaches your
lungs.

12
The Lungs
The lungs are paired, cone-shaped organs which take up most of the space in our chests, along
with the heart. Their role is to take oxygen into the body, which we need for our cells to live and
function properly, and to help us get rid of carbon dioxide, which is a waste product. We each
have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of
tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only
two, because the heart takes up some of the space in the left side of our chest. The lungs can also
be divided up into even smaller portions, called 'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other by membranes.
There are about 10 of them in each lung. Each segment receives its own blood supply and air
supply.

Air enters your lungs through a system of pipes called the bronchi. These pipes start from the
bottom of the trachea as the left and right bronchi and branch many times throughout the lungs,
until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli
are where the important work of gas exchange takes place between the air and your blood.
Covering each alveolus is a whole network of little blood vessel called capillaries, which are
very small branches of the pulmonary arteries. It is important that the air in the alveoli and the
blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or
diffuse) between them. So, when you breathe in, air comes down the trachea and through the
bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will
travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is
carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is
then breathed out. In this way, you bring in to your body the oxygen that you need to live, and
get rid of the waste product carbon dioxide.

Blood Supply
The lungs are very vascular organs, meaning they receive a very large blood supply. This is
because the pulmonary arteries, which supply the lungs, come directly from the right side of your
heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so

13
that the carbon dioxide can be blown off, and more oxygen can be absorbed into the
bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins
into the left side of your heart. From there, it is pumped all around your body to supply oxygen
to cells and organs.

The Pleurae
The lungs are covered by smooth membranes that
we call pleurae. The pleurae have two layers, a
'visceral' layer which sticks closely to the outside
surface of your lungs, and a 'parietal' layer which
lines the inside of your chest wall (ribcage). The
pleurae are important because they help you
breathe in and out smoothly, without any friction.
They also make sure that when your ribcage
expands on breathing in, your lungs expand as
well to fill the extra space.

The Diaphragm and Intercostal Muscles

When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The
diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does
much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe
in, the diaphragm contracts and flattens out, expanding the space in your chest and drawing air
into your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles)
also help by moving your ribcage in and out. Breathing out (expiration) does not normally
require your muscles to work. This is because your lungs are very elastic, and when your
muscles relax at the end of inspiration your lungs simply recoil back into their resting position,
pushing the air out as they go.

The Respiratory System and Ageing

The normal process of ageing is associated with a number of changes in both the structure and
function of the respiratory system. These include:

14
 Enlargement of the alveoli. The air spaces get bigger and lose their elasticity, meaning
that there is less area for gases to be exchanged across. This change is sometimes referred
to as 'senile emphysema'.
The compliance (or springiness) of the chest wall decreases, so that it takes more effort to
breathe in and out.
The strength of the respiratory muscles (the diaphragm and intercostal muscles)
decreases. This change is closely connected to the general health of the person.

All of these changes mean that an older person might have more difficulty coping with increased
stress on their respiratory system, such as with an infection like pneumonia, than a younger
person would.

15
Pathophysiology (Book-based and Client-centered)

Definition of the Disease

Nasopharyngeal cancer is a disease in which malignant (cancer) cells form in the tissues of the
nasopharynx.

Predisposing Factors
People who are between 30 and 50 years of age
Men are more likely to have nasopharyngeal cancer than women
Chinese or Asian ancestry
Hereditary

Precipitating Factors
Eating salt-preserved foods (like fish, eggs, leafy vegetables and roots) during early
childhood
Cigarette smoking
Alcohol abuse
Poor Oral Hygiene
Long Term Sun Exposure
Occupational Exposure (chemicals esp. asbestos)

Signs and Symptoms with Rationale

Anorexia is a decreased sensation of appetite caused by the complications of compression
of the esophagus.
Atelectasis is a collapse of lung tissue affecting part or all of one lung because of presence
of fluid in the lungs.
Chest pain pain caused by the obstruction of the vena cava.
Chest wall pain pain caused by the invasion of the pleural cavity irritating nerve fibers.
Chronic Cough caused by sputum production brought by the irritation of the bronchioles.
Difficulty in swallowing condition caused by the compression of the esophagus.

16
 Distended neck veins caused by the obstruction of the vena cava.
Dyspnea caused by the invasion of the pleural space.
Facial, arm, and trunk swelling caused by the obstruction of the vena cava.
Hemoptysis is the expectoration of blood caused by lesions in the blood vessels.
Hoarseness of voice caused by the irritation of the laryngeal nerve.
Hyperglycemia a manifestation caused by Cushings syndrome.
Hyperkalemia a manifestation caused by Cushings syndrome.
Hypertension a manifestation caused by Cushings syndrome.
Hypervolemia a manifestation caused by Cushings syndrome.
Immunosupression a manifestation caused by Cushings syndrome.
Osteoporosis caused by high levels of cortisol.
Pneumonia condition caused by the invasion of the pleural space and it is characterized
by inflammation and abnormal alveolar filling with fluid.
Shortness of breath caused by the irritation and obstruction of airway.
Venous stasis caused by the obstruction of the vena cava.
Weight loss caused by dysphagia and the metastases in the liver.

Note: Items marked in RED were experienced by the client.

17
 Schematic Diagram (Book-based)

Predisposing Factors: Precipitating Factors:

People who are between 30 and 50 years of age Eating salt-preserved foods (like fish, eggs, leafy
Men are more likely to have nasopharyngeal cancer vegetables and roots) during early childhood
than women Cigarette smoking
Chinese or Asian ancestry Alcohol abuse
Hereditary Poor Oral Hygiene
Long Term Sun Exposure
Occupational Exposure (chemicals esp. asbestos)

Formation of benign bronchial

epithelium tissue

Transformation benign
tissue to neoplastic tissue

Nasopharyngeal Cancer/
Lung Cancer

Squamous Cell Carcinoma Small Cell Carcinoma Adenocarcinoma Large Cell Carcinoma

Chronic cough Sputum Irritation and obstruction of airway Lesions erode to Hemoptysis
production the blood vessels

Shortness of Wheezing Invasion of the Triggering of pain Chest wall pain

breath pleural cavity receptors
Atelectasis
Pleural Effusion

Invasion of the Synthesis of Dyspnea

mediastinum bioactive products
Pneumonitis
Vena cava Cushings
syndrome Syndrome
Irritation of the Compression of Pneumonia
laryngeal nerve the esophagus Shortness of Hyperglycemia
breath
Hypertension
Hoarseness Difficulty in Facial, arm, and
of voice swallowing trunk swelling
Hypervolemia

Chest pain
Metastases to Anorexia Hyperkalemia
the liver
Distended
neck veins Osteoporosis
Weight Loss

Venous stasis Immunosupression

18
Schematic Diagram (Client-centered)

Predisposing Factors: Precipitating Factors:

People who are between 30 and 50 years of age Eating salt-preserved foods (like fish, eggs, leafy
Men are more likely to have nasopharyngeal cancer vegetables and roots) during early childhood
than women Cigarette smoking
Chinese or Asian ancestry Alcohol abuse
Hereditary Poor Oral Hygiene
Long Term Sun Exposure
Occupational Exposure (chemicals esp. asbestos)

Formation of benign bronchial

epithelium tissue

Transformation benign
tissue to neoplastic tissue

Nasopharyngeal Cancer/
Lung Cancer

Chronic cough
(September 20, Sputum Irritation and obstruction of airway Invasion of the Triggering of
2008) production pleural cavity pain receptors

Shortness of Wheezing Invasion of the

breath mediastinum Chest wall pain
(September 20, 2008)

Irritation of the Compression of

laryngeal nerve the esophagus

Hoarseness of voice Difficulty in

(September 20, 2008) swallowing

Anorexia
(August 2008)

Weight Loss

19
VI. The Patient and His Care

Medical Management
a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy, etc.
Date Ordered, Date
Medical Management Indication(s) or Clients Response to
Performed, Date General Description
Treatment Purpose(s) the treatment
Changed/ D/C
D5LRS Date ordered: Lactated Ringer's solution is a solution Severe dehydration, Responded positively
09/18/08 that is isotonic with blood and intended hypovolemia, replace ECF
Date started: for intravenous administration. It is a loss, shock, diabetic
09/18/08 nonpyrogenic solution for fluid and ketoacidosis
electrolyte replenishment and caloric
supply in a single dose container for
intravenous administration.
D5NSS Date ordered: Isotonic sodium chloride with a 5% Replaced extracellular fluid Responded positively
09/18/08 dextrose. It is typically the first fluid volume, hyponatremia,
Date started: used when dehydration is severe diabetic ketoacidosis,
09/18/08 enough to threaten the adequacy of diluent for
blood circulation and is the safest fluid
to give quickly in large volumes.
mediacations, flush, maintain patency
of intravenous access device
D5NM Date ordered: Have a greater concentration of solutes To supply fluid and Complies positively
08-19-08 than plasma. electrolyte balance for the
Date performed: It is the solution that draw fluid out of patients need.
08-19-08 the intracellular and interstitial
compartments into the vascular It is also used as a passage
compartment, expanding vascular way in giving medication
volume to the patient.
Oxygen therapy Date ordered: Oxygen therapy is Helps to prevent tissue Complies positively
09-18-08 being prescribed for clients with mild or hypoxia and lessens the
Date performed: severe anemia because of their blood workload of the heart as it
09-18-08 has a reduced capacity for oxygen struggles to compensate for
Changed: the lower hb level
09-19-08
09-20-08

20
IVF
Nursing Responsibilities:
Select venipuncture site.
Clean site using circular motion from inner to outer with alcohol.
Apply tourniquet.
Anchor vein by stretching skin; insert bevel up to 20 30 degree angle.
Watch for blood return in flashback chamber of the catheter.
Advance needle another inch; then advance catheter into the vein until hub is at the venipuncture site.
Stabilize the catheter and release tourniquet.
Remove needle stylet and attach tubing or saline lock to catheter hub. Flush with saline to verify patency.
Secure catheter and apply sterile dressing (gauze or transparent) to site.

Oxygen Therapy
Nursing Responsibilities:
Explain the procedure to the patient.
Check the doctors order.
Monitor the clients vital signs.
Check equipment patency.
Instruct the client and visitors about the hazard

21
b. Pharmacotherapy
Name of drugs Date Ordered, Date taken/Given, Dosage, Frequency General Action, Mechanism Clients Response to the
Generic Name/ Brand Name Date Changed/ D/ C and Route of Action Medication
Cefuroxime Date ordered: 750 mg IV q8 Haematopoietic Agents The client responded well to
(Zegen) 09/18/08 the medication
Date started: Second generation
09/18/08 cephalosporins that inhibits
cell-wall synthesis, promoting
osmotic instability; usually
bactericidal.

Nursing Responsibilities:
Observe 10 Rs of drug administration.
Before administration, ask patient if he is allergic to penicillins.

Name of drugs Date Ordered, Date taken/Given, Dosage, Frequency General Action, Mechanism Clients Response to the
Generic Name/ Brand Name Date Changed/ D/ C and Route of Action Medication
Piperacillin Na, Tazobactam Na Date ordered: 2.25 g IV infusion q8 Penicillin The client responded well to
(Piptaz) 09/18/08 the medication
Date started: Inhibits cell-wall synthesis
09/18/08 during bacterial multiplication.

Nursing Responsibilities:
Observe 10 Rs of drug administration.

Name of drugs Date Ordered, Date taken/Given, Dosage, Frequency General Action, Mechanism Clients Response to the
Generic Name/ Brand Name Date Changed/ D/ C and Route of Action Medication
Human Insulin Date ordered: 10 units SQ stat Antidiabetics The client responded well to
(Humulin R) 09/18/08 the medication

22
 Date started: Increases glucose transport
09/18/08 across muscle and fat cell
membranes and reduce glucose
level. Helps convert glucose to
glycogen; triggers amino acid
uptake and conversion to
protein in muscle cells;
stimulates triglyceride
formation and inhibits release
of free fatty acids from adipose
tissue; and stimulates
lipoprotein lipase activity,
which converts circulating
lipoproteins to fatty acids.

Nursing Responsibilities:
Ask the patient if she/he ever had any allergic reaction with Tranexamic Acid.

Name of drugs Date Ordered, Date taken/Given, Dosage, Frequency General Action, Mechanism Clients Response to the
Generic Name/ Brand Name Date Changed/ D/ C and Route of Action Medication
Epoetin Date ordered: 4, 000 units SQ today Haematopoietic Agent The client responded well to
(Renogen) 09/19/08 the medication
Date started: Mimics effect of erythropoietin.
09/19/08 Functions as a growth factor
and as a differentiating factor,
enhancing RBC production.

Nursing Responsibilities:
Ask patient if he/she ever had allergy to Mefenamic acid
Ask patient if he/she has a history of heart attack, stroke or blood clot.

Name of drugs Date Ordered, Date taken/Given, Dosage, Frequency General Action, Mechanism Clients Response to the

23
 Generic Name/ Brand Name Date Changed/ D/ C and Route of Action Medication
Methyldopa hydrochloride Date ordered: 1 vial IV Anti-Hypertensive The client responded well to
(D50-50) 09/18/08 the medication AEB a
Date started: Unknown. Thought to inhibit decrease in blood pressure
09/18/08 the central vasomotor centers, from 140/90 to 120/80.
thereby decreasing sympathetic
outflow to the heart, kidneys,
and peripheral vasculature.

Nursing Responsibilities:
Ask patient if he/she is allergic to FeSO4
Ask the patient if he/she is taking any other drugs
Ask the patient if he/she had multiple blood transfusions

c. Diet
Date Ordered/ Date Started/ Indication(s) or Clients Response & or reaction
Type of Diet General Description
Date Changed Pupose(s) to the Activity
Diet as Tolerated DO: 08-18-08 Maintaining dietary Is ordered when the patients Complies positively
nutrition needed for appetite/ ability to eat and
the patient. tolerated for certain foods may
change.

Nursing Responsibilities:
Provide oral hygiene before and after meal.
Advise client to take nutritious foods especially foods rich in iron

24
VII. Nursing Care Plans

Ineffective Airway Clearance

Scientific Nursing
Assessment Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions

Subjective cues: Ineffective airway Ineffective airway After 3 hours of NI, Establish rapport To get the trust of
"Magkasakit ya clearance r/t tissue clearance is the pt will be able to the pt.
knyan mangisnawa necrosis located in inability to clear verbalize Position head to To open or
nang, lalu na pag nasal area AEB secretions or understanding of facilitate airway maintain open
sasabi ya" as dyspnea, obstruction from the cause and airway in at-rest or
verbalized by the restlessness, use of respiratory tract to therapeutic com promised
SO accessory muscle, maintain a clear management individual
cough, and nasal airway in which regimen and Elevate head of To take advantage
Objective cues: flaring. partial or complete demonstrate bed of gravity
Dyspnea blockage of the behaviors to decreasing
Restlessness breathing tubes to improve or maintain pressure on the
Use of accessory the lungs. clear airway. diaphragm and
muscle Obstruction of the enhancing
airway can be due to
Cough drainage
different causes
Nasal flaring Encourage deep- To maximize
including foreign
Prolonged breathing and effort in
bodies, allergic
expiratory phase coughing exercise expectorating
reactions, infections,
secretions
anatomical
abnormalities and Increase fluid Hydration can
trauma. The onset of intake help liquefy
respiratory distress viscous secretions
may be sudden with and improve
cough. There is secretion
often agitation in the clearance
early stage of Support To improve lung
airway obstruction. reduction/cessatio function
n of smoking

25
Impaired Physical Mobility
Scientific Nursing
Assessment Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions

Subjective cues: Impaired physical Impaired physical After 3 hours of establish rapport to gain
Magkasakit kung mobility related to mobility is nursing intervention, cooperation
gagalo, as decreased muscle limitation in the pt. will be able monitor and for baseline data
verbalized by the strength a independent, to participate in record VS
patient. manifested by the purposeful physical ADLs and desired advise pt. to have to regain strength
patients limited movement of the activities as adequate rest
Objective cues: movements, limited body or of one or evidenced by an
encourage pt to eat to increase energy
with limited ability to perform more extremities. increase in the pt.s
foods rich in level
movements gross/fine motor Mobility is also movements, ability
carbohydrates
limited ability to skills, difficulty related to body to perform
turning, and slowed changes from aging. gross/fine motor advise pt. to do to promote energy
perform gross/fine deep breathing
motor skills movements. Reduction in muscle skills, can turn
strength and easily, and an advise pt. to take to prevent
with difficulty
function, stiffer and increase in motor adequate fluid dehydration
turning intake
less mobile joints agility.
with slowed encourage pt. to to promote energy
affecting balance
movements rest between and regain
can significantly
compromise the activities strength
mobility of elderly encourage pt. to to reduce fatigue
patients. engage in ROM
Restricted exercise
movement affects
the performance of
most activities of
daily living (ADLs.)

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Fatigue

Scientific Nursing
Assessment Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions

Subjective cues: Fatigue related to An overwhelming After 3 hours of Establish rapport to gain
Medyu poor physical sustained sense of nursing intervention, cooperation
mangalambut ku, condition as exhaustion and the patient will Monitor and for baseline data
as verbalized by the manifested by the decreased capacity verbalize an record vital signs
patient. patient appears for physical and understanding Encourage pt. to to conserve energy
weak, a decreased mental work at regarding the health sit instead of
Objective cues: ability in usual level teachings on how to standing in
appears weak performing Fatigue is a conserve energy as performing
decreased ability activities, and subjective complaint evidenced by the activities
in performing compromised with both acute and patient appears
Advise pt. to have to regain strength
activities concentration. chronic illnesses. In strong, an increase
adequate rest
with compromised an acute illness in the ability to
fatigue may have a perform activities, Encourage pt. to to reduce fatigue
concentration perform ROM
protective function and has the ability to
that keeps the concentrate fully. exercises
person from Encourage pt. to to increase energy
sustaining injury eat carbohydrates- level
from overwork in a containing food
weakened condition. Encourage pt. to to promote energy
As a common do focus breathing
symptom, fatigue is
associated with a
variety of physical
and psychological
conditions.

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Chronic Pain
Scientific Nursing
Assessment Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions

Subjective cues: Chronic pain r/t Chronic pain is After 4 hours of NI, Establish rapport to gain
"Mahigit neng pilan Chronic physical unpleasant sensory the patient cooperation
banwa ing keng disability AEB and emotional verbalizes Evaluate pain to determine
arung na" as facial grimace, self- experience arising acceptable level of behaviors client's response to
verbalized by the focusing, guarding from actual or pain relief and chronic situation
SO behavior and potential tissue ability to engage in Encourage pt to to lessen pt's
restlessness damage or described desired activities. take medicine suffering from his
Objective cues: in terms of such religiously chronic pain
Facial mask damage, constant or
Note lifestyle to know the
Self-focusing recurring without an
effect of pain such contributing factor
Reduced anticipated or
as depression of his chronic pain
interaction with predictable end and
condition
people duration of greater
than 6 months. Assist client to to assist in muscle
Guarding behavior learn breathing and generalized
Chronic pain may
restlessness be classified as techniques relaxation
chronic malignant
pain or chronic
nonmalignant pain.
In the former, the
pain is associated
with a specific cause
such as
nasopharyngeal
cancer. A tumor that
presses on bones,
nerves, or organs
can cause pain.

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Disturbed Energy Field
Scientific Nursing
Assessment Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions

Subjective cues: Disturbed energy Disruption of the After 3 hours of establish rapport to gain
Balamu pane kung field related to flow of energy nursing intervention, cooperation
mapagal slowing of energy surrounding a the pt. will verbalize monitor and for baseline data
panamdaman, as flow as manifested persons being that a sense of relaxation record VS
verbalized by the by the pt. appears results in a as evidenced by the advise pt. to have to regain strength
patient. weak, with low tone disharmony of the pt. appears strong, adequate rest
speech, and with body, mind, and/or high toned speech
encourage pt. to to increase energy
Objective cues: compromised spirit. and the ability to
eat foods rich in level
appears weak concentration concentrate.
carbohydrates
low tone speech secondary to illness.
advise pt. to do to promote energy
compromised deep breathing
concentration advise pt. to take to prevent
adequate fluid dehydration
intake
encourage pt. to to promote energy
rest between and regain
activities strength
allow pt. to have to strengthen own
period of inner resources
independency

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VIII. Discharge Plan

Topic: How to achieve health and wellness.

Time allotment: 1 hour
Venue: At the Eastwing of AMC; room 207
Objective Content Time Allotment Teaching Strategy Evaluation
----------
After 1 hour of health Teaching Discussion
teachings, the patient patient:
will be able to verbalize the right 20 mins.
understanding regarding nutritious
topics that are given. food
especially
the
importance
of taking
iron with
regards to
her present
condition.

to have an 15 mins.
adequate
exercise
every day

to have a 15 mins.
proper
hygiene to
promote
wellness.

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IX. Learning Derived

Comparatively, our rotation in Angeles Medical Center is much different from the previous
rotations we had. Since it is a private hospital, all of us experienced the so called culture shock
because we just had our duties from government/district hospitals. The setting in AMC is much
ideal considering the more advanced facilities and equipments it has.

The hospital staff is able to balance consideration and appropriate interventions to each and
every patient.

We have learned that the clients status in life should not be the basis of our fullness in rendering
services to them. After all, everyone deserves a fair treatment whatever aspect it may be.

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