College of Nursin

Calayan Educational Foundation Inc.

CASE STUDY

Submitted b Group 3 BSN III y :

Kirk Ivan Hogo Mhary Ann Gwen Llagas Margarette Yancey Lastimado Amandy Shiela Marie Mara Jane Manalo Austria Patrick Catausan Jan Patrick Villamin Abegail Daluz

Almira u Garcia t e d S bmit

to: Mr. Bernie Lechug

al Are a: Medici n Instit e Ward ution: Magsay say Di strict Clinni Hospit cal Ca a se: Cervi
cal Ca rcinom a

Clinic

Part I

CASE INTRODUCTION

Summary / Synopsis of the Case / Disease

Patient X is a 58 year old man. He lives at Brgy. Mapulot TagkawayanQuezon. He had a chief complaint of abdominal pain PTA. He was admitted to Quezon Medical Center by Dra Rosali Tayao, and had undergone the procedure of explore laparotomy last February 1, 2011 at around 3:50 am.

Summary / Synopsis of the Case / Disease

Explore Laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside of the abdominal cavity.

Summary / Synopsis of the Case / Disease

Summary / Synopsis of the Case / Disease

An urinary tract infection (UTI) is an inflammation of the bladder due to infection with a microorganism. UTIs are more common in women because their urethras are short, making it easier for organisms to get from outside into the bladder.

Part II

CASE PROFILE

A . General Data
Name: Avendao, Mary Grace Alde Age: 31 y/o Sex: Female Birthdate: August 15, 1979 Address: Brgy. Sta. Maria Calauag, Quezon Chief Complain: Vaginal Bleeding Date of Admission: Feb. 18, 2011 Time of Admission: 6:15 pm Admitting Physician: Dr. Perez Diagnosis: Cervical Cancer

B . HISTORY

Medical

History of Present Illness: LMP: - Dec. 2003 on contraceptive with occasional spotting -Dec. 2010- profuse vaginal bleeding -Jan. 8-15- Admitted @ memorial, cervical biopsy done(result [?] )

Medical

B . HISTORY

Patient Physical Exam on Admission: -IE CX converted to 5-6 cm friable, hard mass -Corpuscle enlargedGAMT -P-nodular, almost fixed to PSW

B . HISTORY

NURSING

Coarse in the Ward: On admission pt. was handed to D5LR 1 Liter x 30 gtts/min, lap work-ups requested and done. Patient has referred and seen by gyne oncologist. Patient was sent home on 3rd HD with homemeds.

B . HISTORY

NURSING

During our shift, the patient suffered from abdominal pain due to enlargement of the liver as revealed by the radiologic report. She cant move freely because of pain felt at her abdomen. She had generalized edema.

SSMENT L ASSE YSICA PH

nt ) m Assessme ( Syste

Date: Vital Signs BP- 100/70 mmHg RR: 21 cpm PR: 88 bpm Temperature: 36.8 C

SSMENT L ASSE YSICA PH

nt ) m Assessme ( Syste

A. General Appearance: Weak and pale in appearance with generalized edema With facial grimace

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B. Neurological: Level of Orientation: 3/5 Weak

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C. Cardiovascular: Heart rate: 84 bpm Pulse rate (Radial): 84 bpm c capillary refill of 3-4 sec.

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D.Respiratory: No complaints of difficulty of breathing with normal chest expansion upon breathing Respiratory rate : 22 cpm Bronchovesicular sound heard upon auscultation

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F. Genitourinay: Voids freely

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G. Musculoskeletal:

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H.Integumentary: Slightly warm c Poor skin turgor c Generalized edema

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nt ) m Assessme ( Syste

H. Integumentary: Slightly warm c Poor skin turgor c Generalized edema

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nt ) m Assessme ( Syste

I. Psycho/Social: 5y/o, female child, Filipino conscious Family at bedside Cant participate to ADL

Part III

REVIEW OF SYSTEM

A . Normal Anatomy and Physiology

A little more than an inch long, the cervix is the narrow end of the uterus that opens into the upper part of the vagina. In pregnancy, the cervix helps hold the uterus closed. Several weeks prior to labor and childbirth, the cervix thins and begins to expand, or dilate. At delivery, the cervix opens completely to allow the movement of the baby through the birth canal.

The bulk of the cervix, or stroma, is formed by connective tissue. This is covered by a surface layer called the epithelium. The epithelium is made up of two different types of cells. The epithelium of the endocervical canal (the inner surface of the cervix) is comprised of tall glandular cells that produce cervical mucus.

The epithelium on the outer aspect of the cervix that can be seen at the top of the vaginal canal (the ectocervix) is formed by layers of flat, disc-like cells called squamous cells. The area where the squamous cells meet the glandular cells is called the transformation zone. The transformation zone is the area that is most susceptible to the changes that can lead to cancer. Cancer that resembles the squamous cells is called squamous cell

That that resembles the glandular cells is called adenocarcinoma. Of all invasive (invading neighboring tissue) cervical cancers that are diagnosed, roughly 80-90 percent are squamous cell carcinomas and most of the remaining are adenocarcinomas.

Several types of adenocarcinomas exist. Around 60% are endocervical adenocarcinomas, about 20% are adenosquamous (contain squamous-like elements), about 10% are endometrioid (resemble the cells that line the uterus), and about 10% are clear cell.

Other, more rare cancers of the cervix include cervical sarcoma, neuroendocrine tumors, cervical melanoma, adenoid carcinomas, and glassy cell carcinoma

B . Case Pathophysiology

PREDISPOSING FACTORS: Age Sex

PRECIPITATING FACTORS: Dietary Lifestyle Environment Hygiene

Invasion of bacteria in the urinary tract (bladder and urethra)

Delayed emptying of the bladder

Voiding washes organisms out of lower urinary

minished the defense mechanism of the urinary system

Infection will no occur

ly and the sterility of the urine will quickly reestablish

Infection will occur fever

anuria

dysuria

nflammation and damage of urinary tract

Clinical Manifestation

UTI

oliguria

hesitancy

Part IV

Management

A . MEDICA L

Cross- Matching Result Form

Pa ti n t s N a m e : M a ry G ra ce A ve n d a o e B l o d Typ e : O o R H : p o si ve ti A g e : 3 1 ye a rs o l d W a rd : H ya ci th S ex : Fe m a l n e D a te : Fe b . 1 8 , 2 0 1 1 B e d # : 6 D o n o r s N a m e / S e ri lN o . : Q M C H a 6 1 8 9 -1 1

Transfusion Return

B . NURSING

At first glance I saw my patient crying with the SO at her bedside and in severe shallow breathing . According to the S.O. they brought the pt. to the hospital last July 11, 2010 because the patient

PartIV

Reference and Bibliographies

Plan of Care

PRIORITY NANDA NO. DIANOSTIC STATEMENET 1 NDx:

GOAL

NURSING RATIONALE INTERVENTION

EVALUATION

Provide At the end of Allowed the shift, the verbalization baseline data Acute pain related patient will of feelings and receive emotion to infection or proper and inflammation along good care Assessed level the urinary tract. Provide that will of pain lessen baseline data Subjective data: patients for evaluation discomfort of pain relief Lagi syang strategies napapaiyak kapag and pain. umiihi as verbalized Encouraged to Promotes dilute by the SO. have fluid urine and intake flushing of LUT Objective data: w/ facial grimace To participate upon urination as Provided and feel verbalized by the SO. therapeutic comfortable cant void freely touch restlessness Seems irritable

Goal partially met as evidenced by verbalization of medyo hindi na daw masakit ang kanyang pagihi by the SO .

PRIORITY NANDA NO. DIANOSTIC STATEMENET 1

GOAL

Nsg Intervention

Rationale

Evaluation

Instructed SO to provide proper care to the patient

To lessen the pain with the help of her family

Provided instructions about recommended voiding pattern and hygienic practices

Delayed emptying of the bladder and poor hygiene may contribute to pain

PRIORITY NANDA NO. DIANOSTIC STATEMENET 2 NDx: Imbalance nutrition less than body requirements related to inability to utilize nutrients to meet metabolic needs. Subjective data: Nawawalan sya ng ganang kumain as verbalized by the SO. Objective data: loss of appetite slightly weak in appearance Temp: 36.4C

GOAL

NURSING INTERVENTION

RATIONALE

EVALUATION

At the end of nursing intervention, the client will display behaviors, lifestyle changes to regain and maintain an adequate nutritional intake.

Provide Allowed verbalization of baseline data feelings

Auscultated bowel sound

To evaluate degree of deficit

Goal partially met as evidenced by : Seen eating and taking food fairly

Promoted pleasant and relaxing environment

To enhance intake

Temp: 36.5C

no further complaints

It may affect Instructed SO, to the appetite give proper and be nutrition and comfortable proper hygiene

PRIORITY NANDA NO. DIANOSTIC STATEMENET 3 NDx:

GOAL

NURSING INTERVENTION

RATIONALE

EVALUATION

At the end of Allowed nursing verbalization of Knowledge deficit intervention, feelings the patient related to with the SO unfamiliarity w/ Provided quiet will information verbalized atmospheric and resources regarding understanding therapeutic to the condition and about the environment w/o condition and interruption treatment related treatment Subjective data: Bakit ba nagkaroon ng ganitong sakit ang Provided access anak ko as information for verbalized by the SO. contact person

Provide Goal baseline data partially met as evidenced This allows by : patient with Participate the SO to concentrate in a certain more complete procedures

Objective data: seen pt. confused regarding to the certain procedure seen uncomfortable

Discussed client perception of needs

Verbalization To answer of knowing questions the pt. about the together w/ information the SO about the disease So that client condition feels Seen respected comfortable and relaxed

PRIORITY NANDA NO. DIANOSTIC STATEMENET 4 NDx:

GOAL

NURSING INTERVENTION

RATIONALE

EVALUATION

At the end of Allowed the nursing verbalization of Boredom related intervention, feelings and the patient emotions to prolonged together with hospitalization Assessed pt. the SO will demonstrate degree of boredom Subjective data: ways on how to Instructed to do Nangungulit sya na minimized diversional gusto ng umuwi as feelings of activities such verbalized by the SO. boredom as talking to SO Objective data: Anxious Encouraged SO not Seems worried to leave he restlessness patient Slightly irritable w/ difficult in concentrating

Provide baseline data

To evaluate anxiety

Goal partially met as evidenced by :

Seen smiling

To divert mind Actively from being talking to SO anxious Seen and relaxed and It enhance calm therapeutic No further relationship and be complaints comfortable

PRIORITY NANDA NO. DIANOSTIC STATEMENET 4

GOAL

Nsg Intervention

Rationale

Evaluation

It enhance Provided comfort measures such as quiet therapeutic and calm environment relationship and be comfortable

Thank You!!!