38514463 case presentation final(2)

8/8/2019 38514463 Case Presentation Final(2)

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SAINT LOUIS UNIVERSITYCOLLEGE OF NURSING

CASE PRESENTATION: NON-HODGKINS LYMPHOMA,METABOLIC ACIDOSIS, ANEMIA, HYPOCALCEMIA,

ANEMIA

Submitted To:MAAM DYMONDE F. CATILING

Clinical Instructor

Submitted By:BSN 3-B2

BAGUILAT, Mark AmielBAUTISTA, Irish DanicaCLERIGO, Kezia Lianne

EGALLA, NicanorEMPERADOR, Julienne Jill

ISURITA, Rizza DonnaMAPPALA, Charisse

ORIBELLO, JenniferORTIZ, Jan Phillip

SADURAL, AngelicaTELIAKEN, Jovie AnnYAGYAGEN, Justin


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PATIENTS DATA

Name: Lopez, Eduardo Oneill

Age: 81 years old

Date of Birth: December 28, 1928

Place of Birth: Manila City

Sex: Male

Address: 29 PNB Village, Bakakeng Central, Marcos Highway, Baguio City

Occupation: Unemployed

Next of Kin: Maria Teresa Lopez Tabuena

Relationship to the Patient: Daughter

Occupation: Employee

Employer: Rustans

Latest Hospitalization Date: February 16, 2010

Admitting Physician: Dr. Oliver

Attending Physician: Dr. Candelario, Dr. Demyttenaere, Dr. Revilla

Date of Admission: February 19, 2010

Time of Admission: 3:00 pm

Impression or Diagnosis: Upper gastrointestinal bleeding, small intestinal tumor

probably malignant

Final Diagnosis: Non-Hodgkins Lymphoma at the small intestines upper GI bleeding

severe anemia, metabolic acidosis, hypocalcemia


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PAST MEDICAL HISTORY

On 2001, patient had been diagnosed as having a cardiovascular disease at the LMCA

territory. He also has Hypertension and is maintained on Amlodipine 5mg 1 tab once a

day. He also has Diabetes Mellitus and is maintained on Diamicron. On May 2009,

patient underwent endoscopy and was found out that there are multiple polyps and

hemorrhoids on the gastrointestinal tract. He was also diagnosed as having gastritis.

On February 2010, he was then diagnosed with small intestinal cancer. There were no

known allergies to food or medications.

FAMILY HISTORY

Patient has heredofamilial disease of hypertension and diabetes mellitus. No family

history of cancer, pulmonary tuberculosis and asthma.

SOCIAL AND ENVIRONMENTAL HISTORY

Patient is an occasional alcoholic beverage drinker and a non-smoker

HISTORY OF PRESENT ILLNESS

The present condition started about one day prior to admission when the patient

manifested body malaise after being discharged in this institution. There was dizziness

and headache noted. The condition persisted until about 12 hours prior to admission,

patient had melena about 2 episodes that day. The patient ignored it thinking it was

just a side effect of the suppository given to him. About 4 hours prior to admission, the

patient had 4 episodes of melena. There was still associated body malaise, headache

and dizziness. About 2 hours prior to admission, condition persisted now associated

with 1 episode of vomiting. Vomitus was however non-blood streaked amounting to


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cup. He was then brought back in this institution for consult hence the subsequent

admission.

PHYSICAL ASSESSMENT

I. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

The patient perceives that his current health situation now is already incurable since it

had already progressed. But despite of this condition, he does his best to stick to the

treatment regimen offered to him like taking his medications even if he does not like the

taste of it. Generally, he is weak as manifested by needing assistance from his family

friend in changing his position.

II. NUTRITIONAL-METABOLIC PATTERN

Prior to admission, the patient usually eats foods with meat and meat products. He also

verbalized that he is an occasional drinker and a non-smoker. He eats 3 times a day,

sometimes with break or merienda meals at between. Two hours prior to admission, he

experienced nausea and vomiting and passed out vomitus which is non-blood streaked

and approximately cup in volume. He has difficulty in digesting fish products. Upon

assessment, the patient has a bloated abdomen. The patient manifested a good skin

turgor, about 1-2 seconds. His mucosal membranes are moist and no unusual lesions

were identified. No edema, jugular vein distention, and enlargement of thyroid gland

are present. The lung fields of the patient are clear upon auscultation and the patient

exhibits symmetrical chest wall expansion. The latest oxygen saturation of the patient

is at 89-90%, and he is on oxygen at 1 liter per minute/ nasal cannula. There were no

associated pain, soreness, ulcer, bleeding, and difficulty in swallowing when it comes

to the patients mouth. The teeth of the patient are yellowish in color, and his tongue is


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pale pink in color, both with no unusual lesions observed. The patient exhibits

hyperactive bowel sounds upon auscultation. There is also the presence of 3 incisions:

one at the umbilicus area, approximately 5 inches long, vertical and 2 at the left and

right lower quadrant, each measuring about 1 inch, diagonal. There were no signs of

infection manifested on these 3 incisions.

III.ELIMINATION PATTERN

Prior to admission, patient urinates for 3-4 times a day. Urine is characterized as

yellowish in color, with no unusual odor. When it comes to defecation, the patient

usually defecates at 1-2 times a day. Stool is characterized as soft, brownish in color,

and with no unusual discoloration and odor. During our shift, the patient defecated 2

times, the stool is reddish in color, soft in consistency, with no unusual odor. The

patient had melena or defecated a black, tarry stool indicative of upper gastrointestinal

bleeding 12 hours prior to admission. Upon performing endoscopy on the patient,

hemorrhoids and small intestinal tumors were identified. The abdomen is flappy, soft

and firm upon palpation, with tympanitic palpable mass at the hypogastric areameasuring about 4x5cm , firm, movable, and non-tender.

IV.ACTIVITY-EXERCISE PATTERN

The patient is currently unemployed. His usual activities are limited in the house since

he is already feeling weak. This includes watching television, reading magazines, and

the like. For him, he considers walking as a form of exercise. Upon assessment of his

respiratory status, the patient has productive cough and passed out sputum with

characteristics of purulent or yellowish in color, and with no unusual odor. Whenever

the patient coughs, he experiences pain. The patient has clear lung fields, and he has

a symmetrical chest wall expansion. The latest oxygen saturation obtained from him is


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89-90%, and he is on medical oxygen regulated at 1 liter per minute/ nasal cannula.

His muscle strength on all extremities are 5/5, and his reflexes are normal. Upon

auscultation of the heart, the point of maximal impulse can be heard at the 5th

intercostals space, left midclavicular line. There were no murmurs heard, and the rate

and rhythm of the heart beats are normal.

V. SLEEP REST-PATTERN

The patient can sleep for 8 hours but with interruptions in between. He sleeps for an

hour, then wakes up, then goes back to sleep again. Lately, he cannot get a good

sleep since the wound on his abdomen is painful but tolerable. Before he goes to rest

he prays. His level of consciousness is awake and oriented to time and place. There

were no tremors observed.

VI. COGNITIVE-PERCEPTUAL PATTERN

The patient is awake, conscious, coherent, aware of his surroundings and relatives,

and oriented to time and place. He does not experience dizziness, headache

numbness, and tremors. He experiences pain on the abdominal area due to the woundmade by the incisions of the procedure he underwent which is emergency explore

laparotomy. He has an anicteric sclera, and is palpebral conjunctiva is pink in color.

The pupils were symmetrical, equally round and reactive to light and accommodation,

and is about 2-3 mm. The extra-ocular movement and the sense of sight are also

intact. There were no pain, redness or blurring of vision noted. For the ears, there were

no unusual discharges, pain, and decrease in hearing noted. For the nose, the

olfactory nerve (cranial nerve 1) is intact as manifested by patient being able to

distinguish different types of scents. The patient is not manifesting any colds

obstruction, pain and congestion in his nose. The nostrils are also patent. The patient


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is positive for having a gag reflex, is able to shrug shoulders, and able to protrude

tongue. There were no diminished senses, and his reflexes are normal, with no

Babinski and ankle clonus reflexes.

VII. SELF-PERCEPTION / SELF-CONCEPT PATTERN

The patient perceives that since he is already diagnosed with stage IV non-Hodgkins

lymphoma, his time is almost up. But still he is calm and verbalized that he accepts

whatever may happen to him. He also verbalized that he had done his responsibilities

as an employee, a friend, a parent, and the like. He did not have any regrets in the

past, and is very grateful to his family friend for taking good care of him. Although his

daughter is in Manila and the other daughter is in America, he verbalized that he

understood the situation since they have their own family to look after, and that life is

very hard nowadays. He feels lonely at times because he is living alone in their

household, without any relatives to take care of him

VIII. ROLE-RELATIONSHIP PATTERN

The patients wife died a long time ago, while his second wife left him and did notreturn anymore. As a husband, he told us that he is not that satisfied since he felt that

he did not fulfill his duties as a husband. As a parent, he verbalized that he is satisfied

since he saw his daughters grew up and become successful in their lives.

IX. COPING-STRESS TOLERANCE PATTERN

Whenever the patient is faced with a distress, like for example, misunderstandings with

his relatives, he lets them cool off by not talking to them for a day and when both of

them are ready, they talk about the problems in a nice way. He also prays to the Lord

for guidance and wisdom.


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X. VALUE-BELIEF PATTERN

The patient is a Roman Catholic. Being a Roman Catholic, he has no restrictions when

it comes to the food they eat, only at times like the Holy week when they do not eat

meat. He recognizes this as having a little bearing with regards to his current health.

He usually goes to church every Sunday when he has time and when his body is able

to move.

DRUG STUDY

1. METRONIDAZOLE

Classification: Trichomonacide and amebicide

Mechanism of Action: Direct-acting trichomonaside and amebicide that works inside

and outside the intestines. Its thought to enter the cells of microorganisms that contain

nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis,

causing cell death.

Indication: To prevent postoperative infection in contaminated or potentially

contaminated colorectal surgery.

Adverse Effects: Headache, fever, dizziness, weakness, nausea, vomiting, abdomina

cramping or pain

Nursing Responsibilities:

Monitor liver function test results carefully in elderly patients.

Give oral form with meals. Ensure safety by raising siderails.

Monitor vital signs especially temperature.


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Tell patient to avoid alcohol and alcohol-conatining drugs during and for at least 3

days after treatment course.

2. CEFUROXIME SODIUM (ZINACEF)

Classification: Second generation cephalosporin

Mechanism of Action: Inhibits cell-wall synthesis, promoting osmotic instability

usually bactericidal

Indication: Perioperative prevention

Adverse Effects: Phlebitis, thrombophlebitis, nausea, vomiting, diarrhea


Monitor intake and output

Assess characteristics of stool

Absorption of oral drug is enhanced by food

Tell patient to notify prescriber about loose stools or diarrhea

Monitor site of IV insertion for signs of thrombophlebitis.

3. CELECOXIB (CELEBREX)

Classification: Nonsteroidal anti-inflammatory drug

Mechanism of Action: Thought to inhibit prostaglandin synthesis, impeding

cyclooxygenase-2 (COX-2) to produce anti-inflammatory, analgesic, and antipyretic

effects.

Indication: Acute pain

Adverse Effects: Dizziness, headache, insomnia, abdominal pain, diarrhea


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Provide rest periods by clustering nursing care.

Ensure safety by raising siderails


Instruct patient to promptly report signs of gastrointestinal bleeding such as blood

in vomit, urine, stool; or black, tarry stools.

4. TRAMADOL HYDROCHLORIDE

Classification: Centrally acting non-opioid analgesic

Mechanism of Action: A centrally acting synthetic analgesic not chemically related to

opioids. Thought to bind to opiate receptors and inhibit reuptake of norepinephrine and

serotonin.

Indication: Moderate to moderately severe pain

Adverse Effects: Dizziness, headache, malaise, nausea, vomiting


Reassess patients level of pain at least 30 minutes after administration.


Raise side rails of the bed

Warn patient not to stop the drug abruptly

5. ACETYLCYSTEINE (FLUIMUCIL)

Classification: Mucolytic

Mechanism of Action: Mucolytic that reduces the viscosity of pulmonary secretions by

splitting disulfide linkages between mucoprotein molecular complexes. Also, restores

liver stores of glutathione to treat acetaminophen toxicity


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Indication: Abnormal viscid or thickened mucous secretions

Adverse Effects: Nausea, vomiting, fever, rashes


Monitor cough type and frequency

Monitor vital signs especially temperature

Encourage patient to cough out secretions

Warn patient that drug may have a foul taste that may be distressing

6. METOCLOPRAMIDE (PLASIL)

Classification: Antiemetic

Mechanism of Action: Stimulates motility of the upper gastrointestinal tract, increases

lower esophageal sphincter tone, and blocks dopamine receptors at the chemoreceptor

trigger zone.

Indication: To prevent and reduce postoperative nausea and vomiting

Adverse Effects: Restlessness, drowsiness, fatigue, diarrhea


Monitor bowel sounds

Tell patient to avoid activities that require alertness for 2 hours after doses

7. ESOMEPRAZOLE MAGNESIUM (NEXIUM)

Classification: Proton pump inhibitor

Mechanism of Action: Reduces gastric acid secretion and decreases gastric acidity

Indication: To reduce the risk of gastric ulcers in patients receiving continuous NSAID

therapy

Adverse Effects: Headache, dry mouth, diarrhea, abdominal pain, nausea, vomiting


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Give drug at least 1 hour before meals

Monitor patient for rash or signs and symptoms of hypersensitivity

Monitor bowel sounds

Warn patient not to chew or crush drug because this inactivates the drug

8. FUROSEMIDE (LASIX)

Classification: Loop diuretic

Mechanism of Action: Inhibits sodium and chloride reabsorption at the proximal and

distal tubules and the ascending loop of Henle

Adverse Effects: Headache, dizziness, fever, weakness, restlessness


Monitor vital signs especially temperature

Ensure safety by raising side rails

Assist patient in changing position

Monitor weight early in the morning

Advise patient to take drug with food to prevent gastrointestinal upset

9. CALCIUM CARBONATE (CALTRATE PLUS)

Classification: Calcium replacement

Mechanism of Action: Replaces calcium and maintains calcium level

Indication: Hypocalcemia

Adverse Effects: Bradycardia, nausea, vomiting, abdominal pain


Monitor calcium levels frequently


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Monitor vital signs especially heart rate

Tell patient to take oral calcium with a full glass of water

10. VITAMIN K

Classification: Vitamins and minerals

Mechanism of Action: An antihemorrhagic factor that promotes hepatic formation of

active coagulation factors

Indication: Hypoprothrombinemia caused by vitamin K malabsorption, drug therapy

Adverse Effects: Dizziness, diaphoresis


Give fresh frozen plasma once severe bleeding occurs

Tell patient to avoid hazardous activities if dizziness occurs

11. PARECOXIB SODIUM (DYNASTAT)

Classification: Nonsteroidal anti-inflammatory drug

Mechanism of Action: Thought to inhibit prostaglandin synthesis, impeding

cyclooxygenase-2 (COX-2) to produce anti-inflammatory, analgesic, and antipyretic

effects.

Indication: Acute pain

Adverse Effects: Dizziness, headache, insomnia, abdominal pain, diarrhea


Provide rest periods by clustering nursing care.

Ensure safety by raising siderails



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Instruct patient to promptly report signs of gastrointestinal bleeding such as blood

in vomit, urine, stool; or black, tarry stools.

LABORATORY RESULTS

Biopsy (February 25,2010)

GROSS DESCRIPTION: Specimen consists of a segment of small intestine measuring

36cm long, previously sectioned at the site of the mass. The resection margins

(proximal and distal), measure 4.5 cm in circumference and are both grossly

unremarkable. There is circumferential, gray-white, firm mass measuring 9.8x4x2cm

completely obstructing the intestinal lumen. Cut sections of the mass show a gray-

white firm mass involving the entire thickness of the intestinal wall (approximately

measuring 1.4-2.8cm). This lesion is seen 13-14cm away. The adjacent, uninvolved

intestinal mucosa is flattened and hemorrhagic. There are tumor nodules formed in the

adjacent, serosal fat measuring from 1.5cmx1cm to 5x3cm. Representative sections

submitted for study labeled: A- resection margins (1- proximal, 2- distal), B- mass,

C- random sections of the ileum and D and E- tumor nodules

MICROSCOPIC DEFINITION: Sections reveal a diffuse proliferation of lymphocytes

predominantly of the large cell type, having pleomorphic, vesicular nuclei with

prominent nucleoli and scanty amount of cytoplasm. These atypical cells are mainly

seen in the submucosa and are almost completely effacing the mucosa. The tumor is

extending up to the serosal layer with formation of tumor nodules. There are nogerminal centers seen. Scattered areas of tumor necrosis are noted. Occasional mitotic

figures are seen.


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DIAGNOSIS: Segment of small intestine (distal ileum) Non-Hodgkins lymphoma

large cell type diffusely infiltrating the entire intestinal wall thickness with formation of

tumor nodules. Resection margins (proximal and distal), negative for tumor. Random

sections of the uninvolved colon, mucosal flattening, negative for tumor. Nine lymph

nodes: non-hodgkins lymphoma, large cell type.

Interpretation: This test diagnosed the specific disease of the patient which is Non-

Hodgkins lymphoma. Some of the characteristics of Non-Hodgkins lymphoma are as

follows: multiple peripheral nodes are involved, noncontiguous spread, rarely localized

extent of disease, extranodal involvement are commonly involved.

X-Ray (February 21, 2010)

RESULTS: Clear and normovascular lung fields, cardiac shadow is unenlarged

atherosclerotic aortic knob, prominent ascending and descending aorta, intac

diaphragm, clear costophrenic angles

Interpretation: The x-ray results showed that there is the fatty deposition in the aortic

knob, which may predispose the patient in having increased blood pressure in that

area, which may further predispose the patient to have hypertension.


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Complete Blood Count (February 27, 2010)

RESULTS NORMAL RANGE

WBC: 10.5x10e9/L* 5-10

81.5%N* 45-70

4.29%L* 20-40

10.8%M 0-12

2.05%E 0-8

1.29%B 0-2

RBC: 4.01x10e12/L* 4.5-6

Hgb: 115g/L* 120-170

Hct: 0.332L/L* 0.40-0.54

MCV: 82.8fL 76-96

MCH: 28.7pg 27-32

MCHC: 347g/L 320-360

Platelet: AdequateComments: Normocytic, normochromic

Interpretation: The patient undergone complete blood count in order to confirm the

presence of an infection. White blood cells are increased whenever there is an

infectious process going on to the patient. This is also accompanied by an increase in

the neutrophils and the decrease of lymphocytes (lymphopenia). The red blood cells of

the patient are decreased, confirming his diagnosis of anemia. It also follows that the

patient has low hemoglobin or the oxygen-carrying capacity of the red blood cells. This


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can be manifested as general body weakness since there is impairment in the tissue

perfusion in the body.

Serum Calcium Level (February 27, 2010)

RESULTS:

Calcium (ionized)* - 1.07 mmol/L

Normal Range: 1.13-1.32

Interpretation: This test confirms the diagnosis of the patient which is hypocalcemia.

This may manifest in the patient as having tetany, in which there is an increase in the

neural excitability of the patient.


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PATHOPHYSIOLOGY

Neoplastic growth of lymphoid

tissue in the intestines

Cell immortalization andincrease in malignant cells

Intestinal obstruction

Sequestration of gas and fluid

roximal to obstruction

Pressure on diaphragm Colicky abdominal pain Acute pain

Distention

Nausea and vomiting due todecreased food intakeDecreased nutrient absorptionDecreased carbohydratereserves

Decreased respiratory volume

Loss of water and electrolytes

HypocalcemiaMetabolic Acidosis

Deficient fluid volume

Imbalanced nutrition:

less than body

requirements

Age of greater than 65,

alcohol intake, obesit


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Ineffective

airway clearance

Body weakness

Difficulty of breathing

Activity IntoleranceImpaired physical mobility

Ineffective tissue perfusion Anemia

Decreased plasma volume

Decreased central venous

pressureDecreased extracellular fluid

volume

Impaired skin integrity Dehydration


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PRIORITIZATION AND JUSTIFICATION

Prioritization Justification1. Ineffective airway clearance

related to retained secretions

at the tracheobronchial tree

According to ABCD prioritization, A

goes first which is Airway

establishment. This is the first

prioritized problem since adequate

perfusion to other parts of the body

is necessary to maintain normal

bodily functions.

2. Imbalanced nutrition: less than

body requirements related to

inability to absorb nutrients

secondary to intestinal tumors

In Hendersons 14 Fundamental

Needs of Man, this is the first listed

need of man which is to eat and

drink adequately. This is prioritized

as second because although the

patient eats adequately, the

nutrients are not absorbed properly

because of the ongoing disease

process and the intestines are thesites where absorption of nutrients

take place.

3. Deficient fluid volume related

to inability to reabsorb water

secondary to intestinal tumors

This is also the first listed need of

man in Hendersons 14 fundamental

needs. This is prioritized as third

because without correcting the

nutrition of the patient, correcting the

fluid volume would not be essential.

4. Ineffective tissue perfusion

related to decreased number

This is the fourth prioritized problem

since we can increase the perfusion


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of circulating red blood cells in

the body

of oxygen in the body by offering

iron-rich foods for the patient, which

is addressed in the secondprioritized problem. This is also C in

ABCD which is circulation.

5. Acute pain related to lack of

blood supply to the abdomen

secondary to gastritis

According to ABCD prioritization,

this is D which is disability. This is

also the chief complaint of the

patient. This is the fifth prioritized

problem because it does not

significantly affect the patients

activities of daily living such as

eating and sleeping.

6. Activity intolerance related to

lack of circulating oxygen to

the body

This is the fourth listed need of man

in Hendersons theory. This is the

sixth prioritized problem since the

patient is unable to change his

position without assistance. This is

also in relation to lack of oxygen

adequately perfusing the body due

to his severe anemia.

7. Impaired physical mobility

related to distention of

abdomen secondary to

gastritis

This is also in relation to the sixth

prioritized problem. It is also listed

as number 4 in Hendersons 14

Fundamental Needs of Man. This is

prioritized as seventh because if thedisease entitiy is suppressed or

resolved, this would follow as being

solved.


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8. Impaired skin integrity related

to continuous fluid loss

This is the seventh listed need of

man that needs to be addressed

according to Virginia Henderson.This is the last prioritized problem

because with adequate nutrition and

adequate hydration, the patient

would not manifest problems in his

integumentary system.

38514463 case presentation final(2)

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