UNIVERSITY OF ILOILO Phinma Education Network Rizal St.

, Iloilo City COLLEGE OF NURSING

WESTERN VISAYAS MEDICAL CENTER Mandurriao, Iloilo City

(FM1 WARD)

CERVICAL CANCER SECONDARY TO ANEMIA SECONDARY TO ASCITES

Case Study

Presented to Mr. Roger John C. Baguio, R.N. Clinical Instructor

Presented by BSN IV-C Draug, CherryMae Fernandez, Grace S. Gonzaga, Honeylee G. Hilisan, Harlyn Iwag, Erick Laine Mariano, Arlene Olmos, Pearl Joy August 29, 2011

NURSING ASSESSMENT
I. BIOGRAPHIC DATA
NAME: Ms. N. S. ADDRESS: San Pedro, Jaro Iloilo City AGE: 70 Years Old BIRHT DATE: April 21, 1940 GENDER: Female RELIGION: Roman Catholic RACE: Filipino STATUS: Single OCCUPATION: Health Worker SOURCE OF HEALTH FINANCING: Herself DATE AND TIME OF ADMISSION: August 12, 2010 (7:50 PM)

CHIEF COMPLAINT: Gasige-sige sakit tiyan ko, mga 2 na ka bulan as verbalized by the patient.
ADMITTING DIAGNOSIS: Choledocholithiasis Beginning Cholangitis FINAL DIAGNOSIS: Acute Calculus Cholecystitis II. CLINICAL ASSESSMENT

A. NURSING HISTORY 1. HISTORY OF PRESENT ILLNES

According to her since she got an illness, there is a great change in her lifestyle. She couldnt do all her usual tasks. She experienced the symptoms 2 months ago in the middle of July. It was sudden and often since then. She pointed out that the exact location of the pain was in the epigastric area radiating to her lower back. Over fatigue was her primary reason of how the problem occurred. She experienced the symptoms such as nausea, vomiting, and body malaise. The problem aggravates during her eating time and alleviates when she takes a nap. She denies any family members having related disease as hers.

2. PAST HISTORY OF ILLNESS

According to her, she wasnt able to complete the different immunizations offered at her time. She already had Chicken pox; she had allergies to dust, and drugs such as afloxacin. She had Diabetes Mellitus when she was 59 and been prescribed with Dimetron and soon discontinued. She only managed it by having a proper diet. Whenever she perspires, she often experience flushed skin and diminishes when wiping it. She had suffered from minor trauma brought by a vehicular accident when she was a child but immediately coped up. 3. FAMILY HISTORY OF ILLNESS Her father has hypertension as well as her 2 siblings: her Mother died with unknown cause; the uncle in her mother side also has Diabetes Mellitus. And there is no family history of Osteoarthritis, Malignant Neoplasia and Cholecystisis. GENOGRAM

89

87

/A

89

88

86

84

82

79

85

72 70 ,DM Calculous Cholecystitis 67

37

85

63

Legend:

--Male

--Deceased

--Hypertension -- Unknown

--Female

--Deceased

--Alive and well

--Old Age

4. PATIENTS EXPECTATIONS She expects to get well during her stay at the hospital; she wanted also to be educated regarding the Dos and Donts of her disease as well as the right foods and proper management. She said that the nursing care nowadays is better than before and her needs are always attended. 5. PATTERNS OF FUNCTIONING a. Breathing Pattern: Respiratory Problems: Shortness of breath caused by her operation alleviated when put in semi- Fowlers position. b. Circulation: Her usual blood pressure before was 110/70 mmHg but now it increased to 140/90 mmHg. She experienced palpitations whenever she was surprised and she suffers mild hypertension. c. Sleeping Pattern: Usual Bedtime: 10:00 PM- 4:00 AM No. of Pillows: Only one under head Bedtime Rituals: Doing rosary or watching television at times Problems regarding sleep: None
d. Drinking Pattern Type of Fluid 1. Water 2. Juice 3. Coffee 4. Soft drinks No. of Bottles/Glasses per Day 8 glasses 2 glasses 2 cup 1 Bottle Pattern of drinking Everyday Weekends Morning, afternoon Weekends

e. Eating Pattern Meal Breakfast Morning Snacks Lunch Type and Amount of Food Oatmeal (1 bowl) Skyflakes(2 pieces) Rice (1/2 cup) Vegetable (1 serve preparation) Fish (1 serve preparation) Afternoon Snacks Skyflakes (2 pieces) 3-4 pm 11-12nn Time 6-7 am 9-10am

Dinner

Rice (1/2 cup) Grilled fish (1 piece)

4-5pm

Midnight Snacks

Skyflakes (1 whole pack)

10-11pm

Food Likes: Ice Cream, cake, chocolates Food Dislikes: None

f.

Elimination Pattern 1. Bowel Movement

Frequency: Once a day Problems or Difficulties: None Usual Remedy: N/A 2. Urination Frequency: 5-7x/ day Problems or Difficulties: None Usual Remedy: N/A g. Exercise-walking, jogging and aerobics h. Personal Hygiene 1. BATH Type: Full Bath Frequency: 2x a day Time of Day: 8-9am and 8-9pm 2. ORAL CARE Frequency: 3x a day Care of Dentures: Tooth Brushing 3. SHAVING: N/A 4. USE OF COSMETICS: Make-up occasionally, Pedicure

i. j.

Recreation- Seldom attends to party. Usually present on health seminars in their barangay health clinic. Health Supervision- Seek consultation whenever there is a change in physiologic function.

B. PSYCHOSOCIAL ASSESSMENT
NAME: N. S. CENTER THEORY AGE: 70 YEARS OLD DATE: 08-19-10 ERICK ERICKSON theory of psychosocial development HOSPITAL: WEST VISAYAS STATE MEDICAL SIGMUND FREUD theory of psychosexual development theory GENITAL STAGE JEAN PIAGET theory of cognitive development LAWRENCE KOHLBERG theory of moral development

OLD AGE / LATE ADULT STAGE

PSYCHOLOGICAL CRISIS: INTEGRITY VS. DESPAIR,DISGUST

FORMAL OPERATIONS

POST CONVENTION

DEFINITION As the aging process creates physical and social looses the adult also suffered loss status and function such as through retirement or illness this external struggles met also with internal struggles, such as search for meaning in life. Meeting this challenge creates the potential for growth and wisdom. Many elders review their lives with the sense of satisfaction even with the inevitable mistakes. Others see them selves as failures with marked contempt and disgust.

True maturity requires the timing of aggressive and sexual urges, allowing them to release.

The person at this stage can think abstractive.

AL An individual reaches this stage acts out universal principals based upon equality and worth of all.

C. CLINICAL INSPECTION
Date and Time Taken: Aug. 20, 2010 (6:00 am) Vital Signs T- 36.8C PR- 82 bpm 1. Height: 411 2. Weight: 50 kg 3. Physical Assessment A. Integumentary System Brown complexion, uniformly warm to touch, and moist with skin turgor of approximately 1second. No lesions noted. B. Neurologic System Alert, conscious and coherent. Oriented to person, place and able to recall previously done activities. CN I (Olfactory): intact as able to identify aroma of coffee. CN II (Optic): intact as evidenced by ability to see and recognize nurses and folks and able to read magazine. CN III (Oculomotor); IV (Trochlear), VI ( Abducens): intact as evidenced by the ability of eyes to move in a smooth, coordinated motion of six ocular movements, P E R R L A. CN V (Trigeminal): intact as evidenced by ability to differentiate sharp and blunt points of pencil, ability to clench teeth. Eyelids blink bilaterally. CN VII (Facial): intact as evidenced by ability to smile, frown, wrinkles forehead, raise eyebrows, close eyes, purses lip and puff cheeks symmetrically in symmetrical manner. RR: 17 cpm BP: 140/90 mm Hg

CN VIII (Auditory): intact as evidenced by the ability to hear the ticks of a wrist watch 5 inches away from the ears. CN IX (Glossopharyngeal): intact as evidenced by the ability to move tongue from side by side, uvula and soft palate rise bilaterally and symmetrically on phonation. CN X (Vagus): intact as evidenced by ability to swallow foods and fluids. Gag reflex intact. CN XI (Spinal Accessory): intact as evidenced by ability to move head from side by side. CN XII (Hypoglossal Nerve): intact as evidenced by ability to protrude tongue at the midline and move from side by side in apparent strength. C. Respiratory System Nose at midline, both nares are patent as evidenced by ability to identify the aroma of coffee. RR- 17cpm, regular in rate and rhythm, shallow inhalation, deep expiration. Clear lung sounds upon auscultation of all lung fields. D. Cardiovascular/ Circulatory System PR- 82bpm, BP- 140/90 mmHg, capillary refill of approximately 2 seconds in upper and lower extremities. E. Gastrointestinal System Lips dark red, moist; pink moist tongue; grade 1 tonsils; gag reflex present, able to swallow foods and fluids, abdomen not tender upon palpation. F. Hepatobiliary System Liver not palpable. G. Genitourinary System With Foley catheter attached to urobag, drained at approximately 50cc/hr of light yellow urine. Bladder not distended. H. Reproductive System Symmetrical breast. No lumps upon palpation and unnecessary discharge noted. I. Musculoskeletal System Full ROM in upper and lower extremities, muscle strength of 5/5 in both extremities. J. Lymphatic System Lymph nodes are not palpable. K. Hematopoetic System Hematology result as of 8/18/10 Hgb= 117g/L Hct= RBC=

D. LABORATORY FINDINGS A. Clinical Chemistry

NAME OF EXAMINATION

DEFINITION

PURPOSE

DATE

RESULTS

NORMAL VALUES

SIGNIFCANCE OF ABNORMAL RESULTS

SODIUM

This is the predominant cation in the extracellular fluid, including plasma. This is the predominant cation in the cellular fluid.

To assess for level of sodium in relation to loss of water. To determine changes in serum concentration of potassium that could produce profound effects on the nerve excitation, muscle contraction, and myocardial potential

8/12/10

142.3 mmol/L

135-148 mmol/L Normal

POTASSIUM

8/12/10

4.06 mmol/L

3.5- 5.3 mmol/L Normal

CREATININE

8/12/10

96.3 mmol/L 5.86 mmol/L 4.3 mmol/L 1.27 mmol/L 1.02 mmol/L 7.32 mmol.L

53.0115.0 umol/L 1.3- 5.2 mmol/L 0.0- 3.9 mol/L 0.17-1.7 mmol/L 0.9- 1.55 mmol/L 3.9- 6.1 mml/L

Normal

CHOLESTEROL LDLCHOLESTEROL REV. TRIGLYCRIDE HDLCHOLESTEROL GLUCOSE This is the principal sugar of the body; permits all body water. To assess level of glucose in the blood resulting from either failure to synthesize or ingestion of superfluous quantities.

8/13/10 8/13/10 8/13/10 8/13/10 8/13/10

Normal Normal

B. Hematology

Definition: It is a basic screening test and one of the most frequently ordered blood test. It includes hemoglobin and hematocrit measurements, RBC count, WBC count, RBC indices, and a differential white cell count. Purpose: To serve as baseline data. To detect any abnormalities or disease process in the body.
RESULTS 8/12/10 HEMOGLOBIN ERYTHROCYTE ERYTHROCYTE NO. CONCENTRATION 131g/L 0.34L/L 3.811012L 8/17/10 87g/L 0.26L/L 2.711012L 8/18/10 117g/L 0.34L/L 3.631012L 120160g/dL 0.370.47L/L 4.25.41012L Decreased in RBC may indicate anemia and it may result from decreased production of RBC in spleen and kidney because of inflammatory response. Increase in no. concentration of leukocytes indicates inflammation. Increased in response to breakdown of RBCs marginated polymorphonuclear neutrophils mobilize and the sphlenic reserve of PMNs is exhausted. Normal 0.24 0.12 0.22 0.20-0.40 Normal 0.01 0.02 0.01-0.04 NORMAL VALUES Significance

NAME OF EXAMINATION

LEUKOCYTE NO. CONCENTRATION

8.51012L

10.71012L

12.61012L

4.511.010L

NEUTROPHIL No. Fraction (SEGMENTER)

0.76

0.86

0.76

0.50-0.70

LYMPHOCYTE NUMBER FRACTION EOSINOPHIL NUMBER FRACTION

C. Radiological Exams
RESULTS: Follow up study done as compared with previous study taken 5/7/10 shows normal- sized liver with hyperechogenic parenchyma. No focal masses seen. The intrahepatic ducts are not dilated. The common bile duct measures 0.5 cm in its widest visualized diameter.

The gallbladder measures 7.4 x 3.8 x 3.7 cm (L x W x AP) with thickened wall measuring 0.9 cm. Multiple high intensity echoes with posterior sonic shadowing are still seen intraluminally, the largest measuring 1.3 cm. The pancreatic head is normal in size and parenchymal echopattern. The pancreatic body and tail are obscured. The pancreatic duct is not dilated. The spleen is normal in size and parenchymal echoppattern. No focal masses seen. There is no disparity in the size of the kidneys. The right kidney measures 9.7 x 4.8 x 4.2 cm (L x W x AP) with cortical thickness of 0.9 cm, while the left kidney measures 10.2 x 4.1 x 3.9 cm (L x W x AP) with cortical thickness of 1.0 cm. The central echo complexes are intact. The cortico- medullary demarcations are well defined. No lithiasis seen. The urinary bladder is well distended. Its wall is not thickened. Intraluminal echoes noted. The uterus is atrophic measuring 3.4 x 2.9 x 2.6 cm (L x W x AP) with an endometrial stripe thickness of 0.4 cm (previously 4.0 x 2.4 x 1.0 cm). No focal masses noted. No adnexal masses ascites demonstrated. Impression: FATTY LIVER CALCULOUS CHOLECYSTITIS ATROPHIC UTERUS NORMAL PANCREATIC HEAD, SPLEEN, KIDNEYS AND URINARY BLADDER ULTRASONOGRAPHICALLY

D. Other Special Exams a. Chest X-ray

RESULT: Poor inspiratory film shows crowding of the pulmonary vascular markings. The trache is deviated to the right due to positional obliquity The heart appears enlarged with CT-ratio of 0.56. The aorta is atherosclerotic. The costophrenic sulci are intact The hemidiaphragms are elevated The rest of the findings are unremarkable IMPRESSION: CARDIOMEGALY. ATHEROSCLEROTIC AORTA. FOLLOW-UP WITH BETTER INSPIRATORY EFFORT SUGGESTED FOR FURTHER EVALUATION.

b. Urinalysis
PHYSICAL PROPERTIES: Color: Straw Transparency: hazy Reaction: Acidic (6.5) Specific Gravity: 1.010 MICROSCOPIC FINDINGS: Pus Cells: 2-4/hpf Red blood cells: 14-16/hpf Cast: Hyaline: Fine granular: Coarse granula:/lpf Crystals Amorphous: Many urates Squamous Epithelial Cells: few Round Epithelial Cells: few Mucus Threads:

CHEMICALS TESTS Sugar: Albumin: Ketone: Others: Negative

c. ECG Interpretation: Sinus Bradycardia

VII. DISCHARGE PLAN Discharging N. S.,70y/o, female, RC; with working diagnosis of Acute Calculous Cholecystitis; under the service of Dr. T; with the following discharge criteria: 1. Within normal range. 2. Intravenous solution discontinued and pulled out. 3. Pulled out Epidural Catheter. 4. Signs and symptoms of Acute Calculous Cholecystitis, not manifested. 5. With 100% appetite. 6. Patients significant others will be able to understand discharge instruction well. EXERCISE OR ABILITIES: Gradual increase in activities to bring back energy level.

HEALTH TEACHINGS: Two major steps on preventing the illness: 1. Foods rich in saturated fats. These foods might initiate the reformation of stone for those who suffered already from this illness. 2. Patient is encouraged to seek for medical advice if she experiences again the signs and symptoms of the illness. Early detection of the recurrent illness would be beneficial to her. New or old complications might be prevented if its detected earlier.

Sources: Brunner and Suddarths. Medical and Surgical Nursing 12th ed. Lippincott Williams and Wilkins. New York.2008