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CHAPTER I
CASE OVERVIEW
Introduction
Hepatoma is the one of the most common cancer in the world with 1
Million new cases diagnosed every year. Roughly 20,000 new cases are
diagnosed every year in United States. It is more frequent in men and
Oriental-Americans. The average age at the time of diagnosis is 60
years. Cancer of the liver can grow for a long time without causing
any problems. Most patients are diagnosed in advanced stages. If left
untreated, or if it fails to respond to treatment, liver cancer can
spread to the rest of normal liver, causing liver failure, and also
to lymph glands in the abdomen and lungs.
This is the case of Ms. L. C., 88 years old, from Manjuyod,
Negros Oriental, who was admitted last April 12, 2011 at Negros
Oriental Provincial Hospital due to edema on lower extremities,
weakness and epigastric pain. She was diagnosed with Hepatoma Right
Lobe Metastasis Lungs Right-side Hypertrophy by Dr. V. J. T. She was
attended to, and medicated, and has underwent several laboratory exams
yet her condition worsened due to poor prognosis.
Though the case was personally given by the clinical instructor,
the presenters find reasons to continue with the case. First, it is a
unique and interesting case, knowing that it is about cancer which is
a rare case a student nurse can encounter and handle. Secondly, health
history of the patient is quite enough to support the diagnosis,
especially the manifestations and laboratory results. And lastly, they
take this as a challenge since they have not yet had any discussion on
oncology in their year level that would hopefully help in the
understanding and analysis of Hepatoma.
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Objectives
In this clinical paper, the presenters have the following goals:
1. Describe the structure of a cell and the process of cell
proliferation and differentiation, discuss the normal anatomy and
physiology of the related systems which are the respiratory,
cardiovascular and systems and how their functions are altered in
the presence of Hepatoma, Right Lobe Metastasis Lungs, and Right-
sided Hypertrophy.
2. Show the current health status of the patient through thorough
physical assessment, laboratory examinations, as well as
diagnostic procedures of which the patient underwent.
3. Relate theories from books and other sources with the actual data
gathered from the patient during interaction and assessment.
4. Create a comprehensive pathophysiology to trace the pathogenesis
of the disease processes starting from the precipitating and
predisposing etiologic factors down to the complications,
including the clinical manifestations and their corresponding
interventions.
5. Formulate SMART nursing care plans that are effective and
efficient in enhancing the well-being of the patient and
alleviating the progression of the disease, and prioritize them
accordingly.
6. Justify all medical and nursing actions applied to the patient.
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Scope
The gathering of data and patient interaction was done for 4hours
during the clinical exposure and on the final visit later in the
afternoon of same day. Within this clinical paper is the discussion of
the information related to the care and condition of the patient
during her present hospitalization; the contents include the physical
assessment, laboratory results with their corresponding
interpretations, background of the normal anatomy and physiology of
the affected systems, theoretical background of the admitting
impression in connection to the patient’s status and manifestations,
the pathophysiology designed to trace the progression of the disease
process and the measures provided to solve each existing problems and
manifestations, the effectiveness of these interventions reflected on
the progress notes, and proposed discharge planning for the promotion
of the patient’s well-being.
Limitations
In the process of making this clinical paper, the group
encountered some limitations which are the following:
1. No data about the patient’s grandparents were gathered
because those people died before she was born and was not
told by her parents about their causes of death.
2. Health history and other pertinent data were only limited
to the patient’s responsiveness and SO’s knowledge.
3. Discussion on the pathology of the disease, particularly
Hepatoma, is limited only to the presentors’ own
understanding through researching since the topic cancer
was not yet included in their classroom discussions.
4. Some laboratory exams were taken only once, so tracking
of the disease progression is also limited.
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CHAPTER II
CASE DATA AND INFORMATION
BIOGRAPHICAL DATA
Name: L. C.
Address: Manjuyod, Negros Oriental
Age: 88 years old
Gender: Female
Birthplace: Manjuyod, Neg. Or., via home delivery
Birth Date: August 10, 1922
Civil Status: Single
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: Elementary Undergraduate
Health care financing: none
Date of Admission: April 12, 2011 at 10:26 PM
Final Diagnosis: Hepatoma Right Lobe, Metastasis Lungs Right-sided
Hypertrophy
Physician: Dr. V. J. T.
Source of information: Patient: 20%
SO: 30%
Patient’s chart: 50%__
100%
CHIEF COMPLAINT
“Abtik paman ni siya atong Enero-Pebrero, makalakaw-lakaw pa gud
ni siya; nikalit lang man siya ug kaluya, dayon mao lagi ning iyahang
dire (referring to the abdomen) nidako man, nisamot pud ang hubag sa
iyang batiis,” as verbalized by the patient’s sister.
PRESENT HEALTH HISTORY
One month prior to admission, patient started to experience
swelling on lower extremities, epigastric pain and body weakness. She
consulted a local physician and was medicated. By end week of March,
her condition worsened. She became bed-ridden and her abdomen became
bigger and harder. The edema on her lower extremities also worsened,
and was associated with pitting. April 12, 2011, at around 9:00 in the
evening, patient was brought to Bais District Hospital due to the
worsening condition. She was received at the Emergency Department and
was hooked with IVF of D5NS at 15gtts/min. She was then referred
immediately to Negros Oriental Provincial Hospital via ambulance. She
was then admitted at 10:26 PM in the said hospital.
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PAST HEALTH HISTORY
Childhood illness: fever, common cough and colds
Childhood immunization: no knowledge about patient’s immunizations
Hospitalizations: present is the first hospitalization
Surgeries: has not undergone any surgery, both minor and major
Allergies: no known allergy to foods
Accidents and Injuries: no history of accidents and injuries
Serious Illnesses: no known serious illnesses by history
Medications: uses herbal medicines like mayana, decoction of guava
leaves, heated atis leaves and pound malunggay cloves
Recent Travel: no other travel outside Negros Oriental than
transportation from Manjuyod to Dumaguete for hospitalization
FAMILY HEALTH HISTORY
Legend:
- female
- male
- patient
AW - alive and well
LP - Liver Problem
+ - deceased
OA - Old Age
Hem - Hematemesis
HTN - hypertension
OD - occasional dyspnea
JP - joint pain
93,+ 105,+
LP OA
82,+ 80,AW 78,JP, 78,OD
Hem HTN
Interpretation:
Patient’s mother died at the age of 93 due to liver problem. Her
father died at 105 years old due to old age. She has 4 siblings. Her
sister next to her died at the age of 82. They do not know the exact
problem, yet they claimed that she vomited blood. The only male among
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her siblings has been experiencing joint pain and hypertension. The
youngest has been having difficulty in breathing occasionally. Data
about the patient’s grandparents were not taken due to her limited
ability to speak and SO has no knowledge about such.
PSYCHOSOCIAL PROFILE
Health Practices and Belief: Patient believes in the effectiveness
of herbal medicine and that prayers can heal sickness/illnesses.
Usually use herbal medicines to cure illnesses like cough,
bruises, and wounds. She also believes in quack doctors and
“hilots”.
Typical Day: Patient usually wakes up at around 5:00 in the morning
and drinks coffee with bread for breakfast. Then she walks around
the house, and does her gardening activity. After which, she goes
to market with a “nigo” filled with dried tobacco leaves for
business. She takes “pot-pot” as her transportation to get
there. She goes home for lunch at around 12:00 and takes her
rest after eating for about 30 minutes to an hour. She goes to
market again to continue selling. She arrives home at around 5:00
in the afternoon. She eats her dinner with her niece, who lives
with her as her adopted, at around 6:00-7:00 in the evening.
She watches TV at night and retires to bed sometimes at
9:00PM, but usually by 8:00PM. By March, she started to become
weak and eventually went into being bed-ridden.
Nutritional Patterns: Patient usually eats vegetables in a menu of
“law-oy” and fish, most often, dried salty fish and “ginamos”.
She eats corn, not rice. She has a regular eating pattern and
complete 3 meals a day, no snacks in between. She uses spoon for
eating. She can consume a maximum of 2 glasses of water after
meal. She started to loss her appetite when she became ill. She
can barely consume her food served on a plate. She also started
to lose weight.
Activity and Exercise: She goes up and down from their room by a 5-
step stair and walks around the house every morning and does
her gardening. She does not walk anywhere else, she just ride
“pot- pot” for transportation. By the time she became weak, she
seldom go downstairs, until she became bedridden.
Elimination Pattern: She urinates 2-3 times a day with dark colored
urine, about a glass in quantity, and defecates usually once a
day and sometimes never at all. When she became bedridden, she
wears diaper. She seldom defecates, usually every other day. She
uses 2-3 diapers a day, and gets changed by the help of her
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adopted daughter.
Sleep/rest: She usually gets 9hours of sleep at night time and
30minutes to an hour at noon. She has no sleep disturbance; she
only wakes when she urinates. During the occurrence of the
problem, her sleeping pattern changed. She cannot sleep well at
night. She complains of abdominal pain associated with difficulty
in breathing.
Personal Habits: She is neither a smoker nor an alcoholic, yet she
experienced drinking once when she was adolescent.
Occupational and Socioeconomic Health Pattern: Her income in selling
tobacco is their major source of money for their daily
consumptions. Her nieces and nephews sometimes give her money or
goods. Her siblings also share some food to her when they have
enough. When she became weak, she stopped selling; her other
family members supports her in the needs and expenses.
Environmental Health Patterns: She lives in a separate house just
beside her sister’s. With her is her adopted daughter, her niece,
who helps around. The house is a small 2-storey hut, with a
“sinibit” roof. The stair leading to their bed room has 5 steps
made of bamboo. She sleeps on a wooden bed, covered with a
“banig”, beside her adopted daughter. The surrounding is a non-
cemented land with few trees and plants. Their source of water is
“flowing” where they connected a hose directly towards their
household. They use pour flush as their toilet facility. The
house location is just near the street, with other neighboring
houses. The market is about 15meters away.
Cultural influences and religious/spiritual influences: She believes
in quack doctors and “hilots”, but she believes most in God.
Their family has a tradition of not taking a bath on Wednesdays
and Fridays because for them this may cause illnesses and death
of a family member. She goes to Church on Sundays with her
adopted and sometimes with her sister.
Sexual pattern: Patient never got married, but experienced having
suitors and boyfriends during her adolescence. (Detailed
information about this was not taken due to limited ability to
speak, and her sister has no knowledge about it).
Social Support: She is well-loved by her siblings, nieces and
nephews. She receives all types of support from her family, may
it be physiological, emotional, or spiritual. They share with one
another what they have and solve problems immediately.
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REVIEW OF SYSTEMS
Assessment (April 16, 2011 at 8AM) Assessment (April 16, 2011 at 4AM)
General Survey
Pt. is 88 years old, female,
oriented to place and person only,
appears emaciated, awake and
responsive to verbal communication,
with slurred speech in a low tone
voice, but unable to maintain eye
contact; scratching on elbows
noted; wearing adult diaper; with
ongoing IVF of D5NM 1L running at
KVO rate, infusing well at left
metacarpal vein, with a level of
800mL; O2 therapy of 2-4L/min via
nasal cannula, and NGT passing into
the right nostril.
Vital signs of: 36. 2 °C, afebrile;
87 bpm, regular but weak; 22 cpm,
deep, with use of accessory
muscles; 110/70 mmHg
INTEGUMENTARY SYSTEM
Skin
-Inspection: jaundice noted on
palms and soles, sagging skin on
upper extremities, shiny skin
surfaces on edematous lower
extremities noted; visible
muscle wasting
-Palpation: rough skin texture
on upper extremities, smooth on
lower extremities; warm to
touch; pitting noted on lower
extremities edema of grade 2
Hair
-Inspection: body hair noted all
over, but with less hair growth
on lower extremities
Nails
-Inspection: pale, intact, firm,
adhere well to nail bed, and
absence of clubbing; cuticles
are pale as well as nail beds;
-Palpation: poor capillary
refill of 3 seconds on upper
extremities, (lower extremities
General Survey
Condition worsened associated with
rigidity on upper lip, inability to
open eyes, blood stains noted in
oral area, inability to speak,
unresponsive to verbal command;
still with ongoing IVF of D5NM 1L
running at KVO rate, infusing well
at left metacarpal vein, with a
level of 300mL; O2 therapy of 2-
4L/min via nasal cannula, and NGT
passing into the right nostril.
Level of orientation not assessed
due to inability to speak
Vital signs of: 38.9 °C, febrile;
96 bpm, regular but weak; 28 cpm,
deep, use of accessory muscles;
90/60 mmHg
---SAME---
---SAME--
---SAME---
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not assessed due to presence of
nail polish)
HEENT
Head and face
-Inspection: head size
appropriate to age, white hair
evenly distributed on scalp;
less facial movements upon
communication,
-Palpation: scalp slightly
mobile, no lessions
Eyes
-Inspection:pallor conjunctivae
noted
(visual acuity, accommodation
and extraoccular movement not
assessed due to patient’s
inability to maintain eye
opening)
Nose
-Inspection: nose located
midline with symmetrical nares,
nasal flaring noted, no
drainage, with O2 cannula
connected, and NGT inserted into
right nares
Neck and Throat
-Inspection: lips midline,
symmetrical, appears dry with
cracks noted; has 6 teeth,
yellow discoloration noted; neck
erect and midline; (gag reflex
not assessed due to inability to
open mouth widely, and tolerance
to procedures)
-Palpation: no lumps or masses
on neck
RESPIRATORY SYSTEM
-Inspection: trachea located
midline, no deviation; bulging
of chest on right side noted,
use of accessory muscles noted
upon breathing, nasal flaring
noted, with O2 therapy of
2-4L/min via nasal cannula; with
---SAME---
Additional: jaw jutting noted
---SAME---
---SAME---
---SAME---
Additional: rigidity on upper lip
noted, with blood stains in the oral
area
---SAME---
Additional: breathing through mouth
noted; with RR of 28 cpm, deep, use of
accessory muscles
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RR of 22 cpm, deep, with use of
accessory muscles
Auscultation:Diminished
peripheral sounds on right lung
field
CARDIOVASCULAR SYSTEM
-Inspection: visible carotid
pulsation, observable neck vein
distention, positive pulsation
at epigastric area noted,
visible blood vessels on
extremities
-Palpation: bounding heart beat
on apex, weak peripheral pulses,
pulse on lower extremities
nonpalpable; with a pulse rate
of 87 bpm, regular but weak
-Auscultation: loud heart beat,
no extra heart sound heard; with
a BP reading of 110/70 mmHg
ABDOMEN
-Inspection: Caput medusa noted
extending from the umbilicus;
umbilicus midline and inverted
with no discharges;positive
pulsation noted, rounded abdomen
with assymetrical contour
-Auscultation: hypoactive bowel
sounds on all quadrants: 1 on
LLQ, 2 on RLQ, 1 on RUQ, and 1
on LUQ
-Palpation: hard and rigid
MUSCULOSKELETAL SYSTEM
-Inspection: measurement of
extremities are the following:
Right arm length of 69 cm with a
circumference of 17.5 cm; Left
arm length of 69 cm with a
circumference of 18 cm; Right
leg is 80cm in length and 42.5cm
in circumference; Left leg is
81cm in length and 41cm in
circumference; asterixis noted
on both arms and hands
-Palpation: pitting noted on
lower extremities edema of grade
---SAME---
-with a PR of 96 bpm, regular but
weak; with a BP of 90/60 mmHg
---SAME---
---SAME---
Additional: 0 muscle strength on both
upper and lower extremities, no active
range of motion & no palpable muscle
contraction (paralysis)
10
2; muscle strength on lower
extremities is 0, no active
range of motion & no palpable
muscle contraction (paralysis);
2 on upper extremities, reduced
active range of motion & no
muscle resistance
(posture, gait, balance and
coordination not assessed due to
patient’s inability to stand and
walk)
NEUROLOGIC SYSTEM
Cerebral Functions
-awake, responsive to verbal
communication, with slurred
speech in a low tone voice
-GCS score of 11/15 (Moderate
brain injury):
Eye = 4, eye opens
spontaneously
Verbal = 2, incomprehensible
Motor= 5, localizes to pain
Cranial Nerves
(not assessed due to patient’s
limited response and tolerance)
REPRODUCTIVE SYSTEM
(not assessed due to wearing of
diaper)
---SAME---
Additional: unconscious, unresponsive
to any command
-GCS score of 3/15 (severe brain
injury):
Eye = 1, no eye opening
Verbal= 1, no verbal response
Motor= 1, no motor response
--SAME—
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Diagnostic Imaging Studies
Taken on April 13, 2011
CHEST X-RAY (PA)
This is to visualize the physical structure of the lungs to rule out
abnormalities, specifically consolidation on the lung parenchyma.
Result:
Massive right sided hydrothorax noted. Hidden pulmonary mass cannot be
ruled out
Interpretation:
This result shows that there is the passage of ascites from the
peritoneal to the pleural cavity through small diaphragmatic defects.
Patients with advanced cirrhosis and portal hypertension have abnormal
extracellular fluid volume regulation that in most cases results in
accumulation of fluid, typically in the abdominal cavity (ascites) or
lower extremities (edema). The negative intrathoracic pressure
generated during inspiration favors the passage of fluid from the
intra-abdominal to the pleural space.
April 13, 2011
ULTRASOUND – WHOLE ABDOMEN
- The liver is enlarged with multiple echogenic masses seen in
the right lobe. Minimal free fluid noted in the hepatic
recess.
- The pancreas, spleen, and kidneys are sonographically normal
- The gallbladder and urinary bladder with normal wall thickness
and echofree
- The uterus and ovaries are technically difficult to imague due
to bowel gas
Remarks:
1. Solid hepatic masses. Consider primary new growths
2. Non-visualization of uterus and ovaries due to bowel gas.
-Suggest: Transvaginal or transrectal ultrasound for better
visualization
3. The other visualized organs are sonographically
unremarkable
Interpretation:
Cancer starts with damage to DNA (a nucleic acid that contains the
genetic instructions used in the development and functioning of all
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known living organisms ). This damage causes changes in these
instructions. Liver cancer also occurs as metastatic cancer, which
happens when tumors from other parts of the body spread (metastasize)
to the liver. In the liver cancer, some cells begin to grow
abnormally. One result is that cells may begin to grow out of control
and eventually form a tumor/mass of malignant cells.
Laboratory Examinations
April 12, 2011
Hepatitis B surface antigen (HBsAG) - Protein that is present on the
surface of the virus; will be present in the blood with acute and
chronic HBV infections
Often used to screen for and detect HBV infections; earliest indicator
of acute hepatitis B and frequently identifies infected people before
symptoms appear; undetectable in the blood during the recovery period;
it is the primary way of identifying those with chronic infections.
Result:
Reactive
Interpretation:
This result shows that patient is positive for hepatitis B. Hepatitis
B virus has three antigens for which there are commonly-used tests -
the surface antigen (HBsAg), the core antigen (HBcAg) and the e
antigen (HBeAg). Markers found in the blood can confirm hepatitis B
infection and differentiate acute from chronic infection. These
markers are substances produced by the hepatitis B virus (antigens)
and antibodies produced by the immune system to fight the virus.
TUBE METHOD: FORWARD AND REVERSE TYPING RH TYPING
Anti-A Anti-B Anti-D Known A Known B
0 4+ 4+ 2+ 0
Type B+
April 12, 2011, 12:50 am
RANDOM BLOOD SUGAR TEST
Random blood sugar (RBS) measures blood glucose regardless of when the
person last ate. Several random measurements may be taken throughout
the day. Random testing is useful because glucose levels in healthy
13
people do not vary widely throughout the day. Blood glucose levels
that vary widely may mean a problem. This test is also called a casual
blood glucose test.
Result Normal Range
RBS 76 mg/dl 45-130 mg/dl
April 12, 2011, 2:08 am
Complete Blood Count
The CBC is used as a broad screening test to check for such disorders
as anemia, infection, and many other diseases. It is actually a panel
of tests that examines different parts of the blood
Results Normal Range Remark
Hemoglobin 12.4 g% 12-14 g% Normal
Hematocrit 40.4 vol% 37-44 vol% Normal
WBC Count 6.600 T/cumm 5-10 T/cumm Normal
Differential Count:
Neutrophil Seg 78% 55-60% Increased
Lymphocytes 17% 20-35% Decreased
Monocytes 4% 1-6% Normal
Eosinophils 1% 1-4% Normal
Basophils - 0-0.5% Normal
Platelet Count 188,000 150-400 T/cumm Normal
Interpretation:
A high neutrophil count can be caused by cancer spreading in the body.
Cancer is a group of diseases in which symptoms are due to an abnormal
and excessive growth of cells in one of the body organs or tissues. A
cell is the smallest, most basic unit of life, that is capable of
existing by itself. Abnormal values of the differential count suggest
infection or may be altered process of cellular differentiation.
April 13, 2011, 2:02 am
ELECTROLYTES
The electrolyte panel is frequently ordered as part of a routine
physical, either by itself or as components of a basic metabolic
panel or comprehensive metabolic panel. It is used to screen for an
electrolyte or acid-base imbalance and to monitor the effect of
treatment on a known imbalance that is affecting bodily organ
function. Since electrolyte and acid-base imbalances can be present
14
with a wide variety of acute and chronic illnesses, the electrolyte
panel is frequently ordered for hospitalized patients and those who
come to the emergency room.
Sodium 140.6 mmol/L 135-148 mmol/L
Potassium 3.44 mmol/L 3.5-5.3 mmol/L
April, 14, 2011 - 9:51:45 am
BLOOD CHEMISTRY - SERUM
Assays Results Normal Range Details
BUN 61 mg/dl 11-36 mg/dl High
Creatinine 1.08 mg/dl 0.57-0.9 mg/dl High
Uric Acid 7,2 mg/dl 2.5-6.8 mg/dl High
Cholesterol 202 mg/dl 0-200 mg/dl High
Triglycerides 61 mg/dl 0-250 mg/dl Normal
Chol-HDL 9 mg/dl 45-65 mg/dl Low
Chol-LDL 181 mg/dl 0-150 mg/dl High
SGPT 96 U/L 0-36 U/L High
Interpretation: most results are high which indicate dysfunctional
liver, probably liver failure. Liver fails to do its normal functions
properly.
15
CHAPTER III
LITERATURE REVIEW
Normal Anatomy and Physiology
Cells make up the smallest level of a living organism such as
yourself and other living things. The cellular level of an organism is
where the metabolic processes occur that keep the organism alive. That
is why the cell is called the fundamental unit of life. Cells are sacs
of fluid surrounded by membranes. Inside the fluid float chemicals and
organelles. An organism contains parts that are smaller than a cell,
but the cell is the smallest part of the organism that retains
characteristics of the entire organism. For example, a cell can take
in fuel, convert it to energy, and eliminate wastes, just like the
organism as a whole can. But, the structures inside the cell cannot
perform these functions on their own, so the cell is considered the
lowest level. Therefore, cells not only make up living things; they
are living things. The most important characteristic of a cell is that
it can reproduce by dividing. If cells did not reproduce, you or any
other living thing would not continue to live. Cell division is the
process by which cells duplicate and replace themselves.
The cell-division cycle is a vital process by which a single-
celled egg develops into a mature organism, as well as the process by
which hair, skin, blood cells, and some internal organs are renewed.
Cell Division:
Interphase Time between
divisions
Protein synthesis
carried out
Chromatin present
Nucleolus present
DNA replicated
towards division
time
Prophase Chromatin thickens
into chromosomes
Nuclear membrane
disintegrates
Centriole pairs
move to opposite
ends of the cell
Spindle fibers
begin to form
Metaphase Guided by the
16
spindle fibers, the
chromosome pairs
line up along the
center of the
spindle structure
Anaphase The chromosome
pairs (sisters)
begin to pull apart
Once separated,
they are called
daughter
chromosomes
Due to pull, many
chromosomes bend
Groove in plasma
membrane present
Telophase Chromosomes return
to chromatin
Spindle
disintegrates
Nuclear membrane
takes shape again
Centrioles
replicate
Membrane continues
to pinch inward
(in plant cells a
new cell wall is
laid)
When the process is complete, each cell will have the same genetic
material that the original cell had before replication. Each of the
daughter cells is also identical to each other. Note that once
telophase is complete, the cell returns to interphase.
In either case it is the completion of the cell cycle that produces
new organisms, a process that can go on throughout life by forming a
group of cells to form a tissue that composed an organ, which
comprises a system just like the respiratory system, Gastrointestinal
system, that are responsible in maintaining homeostasis.
Cell Differentiation
17
Within the bone marrow there is a pluripotent stem cell. This stem
cell is the “Mother Cell” or the originator of all blood cells. It has
the ability to self-renew and create progenitor stem cell lines. They
are naturally limited in number.
By reviewing the diagram, you can see that all cells come from the
stem cell. An attack on the stem cell can theoretically affect all of
them similarly.
THE RESPIRATORY SYSTEM
The respiratory system is a group of organs and tissues that help you
18
breathe. The main parts of this system are the airways, the lungs and
linked blood vessels, and the muscles that enable breathing.
Respiratory system is divided into two tracts: upper respiratory tract
(nose, pharynx, larynx, and trachea), and lower respiratory tract
(bronchus, bronchioles, and alveoli).
The Pathway
Air enters the nostrils
passes through the nasopharynx,
the oral pharynx
through the glottis
into the trachea
into the right and left bronchi, which branches and rebranches
into
bronchioles, each of which terminates in a cluster of
alveoli
LUNGS
The lungs are the body's major organs of respiration. The two
vital parts that make up the lungs are located on each side of the
chest within the rib cage. They are separated by the heart and other
contents of the mediastinum. The top, or apex, of each lung extends
into the lowest part of the neck, just above the level of the first
rib. The bottom, or base, of each lung extends down to the diaphragm,
which is the major breathing-associated muscle that separates the
chest from the abdominal cavity.
Each lung is divided into upper and lower lobes. The right lung is
larger and heavier than the left lung, which is somewhat smaller in
size because of the position of the heart. The root connects the lungs
to the heart and the trachea (windpipe). Each root is made up of a
main stem bronchus (large air passage connecting the windpipe to the
right or left lungs), pulmonary artery (major artery that brings
oxygen-poor blood back to the right or left lungs), pulmonary vein
(major vein receiving oxygen-rich blood from the lobes of the right or
left lungs), the bronchial arteries and veins, as well as nerves and
lymphatic vessels. A clear, thin, shiny covering known as pleura,
which covers the lungs. The inner, visceral layer of the pleura is
attached to the lungs and the outer, parietal layer is attached to the
chest wall. The trachea splits into right and left main stem bronchi.
These are the major air passages from the trachea to the lungs and are
similar to the trachea in tissue composition. The tracheobronchial
tree conducts, humidifies, and heats air that is breathed in, or
inspired. At its endpoints, the tracheobronchial tree connects with
19
the blood vessels. The lining of the tracheobronchial tree is composed
of columnar epithelium (column-shaped surface cells) and glands that
produce mucus and serous (clear plasma) fluid. The cilia (hair-like
projections on columnar epithelium) move in a constant, beating motion
to cleanse the airways of foreign bodies and infectious organisms. A
watery "mucous blanket" - a gel-like liquid - covers and is moved by
the cilia and aids the lungs' self-cleaning. Coughing triggers a high-
speed flow of air that mobilizes the mucous blanket. The sputum
produced by such mobilization contains mucus, nasal secretions, and
saliva. The essential tissue of the lung—lung parenchyma—is made up of
clusters of spongy air sacs called lobules. Each lobule contains about
2,200 alveoli (air sacs and ducts) and have connective tissue
coverings are called segmental bronchi. The smallest subdivisions, and
do not have connective tissue coverings, are called bronchioles. The
final branches of the bronchioles are called terminal bronchioles. The
bronchioles end in irregular, swollen projections known as alveolar
ducts (terminal branches composed of special gas-exchanging tissue)
and alveolar sacs (blind passages of alveolar ducts).
The alveolar sacs are tiny, thin-walled, cup-shaped structures are
lined with a detergent-like substance known as surfactant, which
reduces surface tension and prevents them from collapsing during
breathing.
Functions of the Respiratory System
Providing large area for gas exchange between air and circulating
blood.
Moving air to and from the gas-exchange surfaces of the lungs.
Protecting the respiratory surfaces from dehydration and
temperature changes and defending against invading pathogens.
Producing sounds permitting speech, singing, and non-verbal
auditory communication.
Providing olfactory sensations to the central nervous system for
the sense of smell.
How the Lungs Work
The lungs expand upon inhalation, or inspiration, and fill with air.
They then return to their resting volume and push air out upon
exhalation, or expiration. These two movements make up the process of
breathing, or respiration.
The respiratory system contains several structures. When you breathe,
the lungs facilitate this process:
1. Air comes in through the mouth and/or nose, and travels down
through the trachea, or "windpipe." This air travels down the
trachea into two bronchi, one leading to each lung. The bronchi
20
then subdivide into smaller tubes called bronchioles. The air
finally fills the alveoli, which are the small air sacs at the
ends of the bronchioles.
2. In the alveoli, the lungs facilitate the exchange of oxygen and
carbon dioxide to and from the blood. Adult lungs have hundreds
of alveoli, which increase the lungs' surface area and speed this
process. Oxygen travels across the membranes of the alveoli and
into the blood in the tiny capillaries surrounding them.
3. Oxygen molecules bind to hemoglobin in the blood and are carried
throughout the body. This oxygenated blood can then be pumped to
the body by the heart.
4. The blood also carries the waste product carbon dioxide back to
the lungs, where it is transferred into the alveoli in the lungs
to be expelled through exhalation.
The Lungs' Protections
Several lung parts and functions act as protective mechanisms to
keep out irritants and foreign particles. The hairs and mucus in the
nose prevent foreign particles from entering the respiratory system.
The breathing tubes in the lungs secrete mucus, which also helps
protect the lungs from foreign particles. This mucus is naturally
pushed up toward the epiglottis, where is passed into the esophagus
and swallowed.
Mechanisms of breathing
To take a breath in, the external intercostal muscles contract,
moving the ribcage up and out. The diaphragm moves down at the same
time, creating negative pressure within the thorax. The lungs are held
to the thoracic wall by the pleural membranes, and so expand outwards
as well. This creates negative pressure within the lungs, and so air
rushes in through the upper and lower airways.
Expiration is mainly due to the natural elasticity of the lungs, which
tend to collapse if they are not held against the thoracic wall. This
is the mechanism behind lung collapse if there is air in the pleural
space (pneumothorax).
Gas Exchange
Each branch of the bronchial tree eventually sub-divides to form
very narrow terminal bronchioles, which terminate in the alveoli.
There are many millions of alveoli in each lung, and these are the
areas responsible for gaseous exchange, presenting a massive surface
area for exchange to occur over.
Each alveolus is very closely associated with a network of capillaries
containing deoxygenated blood from the pulmonary artery. The capillary
and alveolar walls are very thin, allowing rapid exchange of gases by
21
passive diffusion along concentration gradients.
CO2 moves into the alveolus as the concentration is much lower in the
alveolus than in the blood, and O2 moves out of the alveolus as the
continuous flow of blood through the capillaries prevents saturation
of the blood with O2 and allows maximal transfer across the membrane.
THE LIVER
The liver fills the right and center of the upper abdominal
cavity just below the diaphragm. It has a larger right lobe and a
smaller left lobe.
The blood supply of the liver differs from that of other organs.
The liver receives oxygenated blood by way of the hepatic artery. By
way of the portal vein, blood from the abdominal digestive organs and
the spleen is brought to the liver before being returned to the heart.
This special pathway is called hepatic portal circulation and permits
the liver to regulate blood levels of nutrients or to remove
potentially toxic substances such as alcohol from the blood before
the blood circulates to the rest of the body.
The only digestive function of the liver is the production of
bile by the hepatocytes (liver cells). Bile flows through small bile
ducts, converges into larger ones, and leaves the liver by way of the
common hepatic duct. The common hepatic duct joins the cystic duct of
the gallbladder to form the common bile duct, which carries bile
to the duodenum.
Bile is mostly water and bile salts. Its excretory function is to
carry bilirubin and excess cholesterol to the intestines for
elimination in feces. The digestive function of bile is accomplished
via bile salts, which emulsify fats in the small intestine.
Emulsification is a type of mechanical digestion in which large fat
globules are broken into smaller globules but are not chemically
changed. Production of bile is stimulated by the hormone secretin,
which is produced by the duodenum when acidic chyme enters the small
intestine.
22
Functions of the Liver
The liver is involved in a great variety of metabolic functions,
most of which involve the synthesis of specific enzymes. For the sake
of simplicity, these functions may be grouped into categories.
CARBOHYDRATE METABOLISM. The liver regulates the blood glucose level
by storing excess glucose as glycogen and changing glycogen back to
glucose when the blood glucose level is low. The liver also changes
other monosaccharides such as fructose and galactose to glucose, which
is more readily used by cells for energy production.
AMINO ACID METABOLISM. The liver regulates the blood levels of amino
acids based on tissue needs for protein synthesis. Of the 20 amino
acids needed for the production of human proteins, the liver is able
to synthesize 12, called the nonessential amino acids, by the process
of transamination. The other eight amino acids, which the liver cannot
synthesize, are called the essential amino acids. Essential amino
acids are required in the diet.
Excess amino acids (those not needed for protein synthesis)
undergo the process of deamination in the liver; the amino group is
removed and the remaining carbon chain is converted to a simple
carbohydrate that is used for energy production or converted to fat
for energy storage. The amino groups are converted to urea, a
nitrogenous waste product that is removed from the blood by the
kidneys and excreted
in urine.
LIPID METABOLISM. The liver forms lipoproteins for the transport of
lipids in the blood to other tissues. The liver also synthesizes
cholesterol and excretes excess cholesterol into bile to be eliminated
23
in feces.
The liver is also the main site of the process called beta
oxidation, in which fatty acid molecules are split into twocarbon
acetyl groups. These acetyl groups may be used by the liver to produce
energy, or they may be combined to form ketones to be transported to
other cells for energy production.
SYNTHESIS OF PLASMA PROTEINS. The liver synthesizes albumin, clotting
factors, and globulins. Albumin, the most abundant plasma protein,
helps maintain blood volume by pulling tissue fluid into capillaries.
Clotting factors produced by the liver include prothrombin and
fibrinogen, which circulate in the blood until needed for chemical
clotting. The globulins synthesized by the liver become part
of lipoproteins or act as carriers for other molecules in the
blood.
PHAGOCYTOSIS BY KUPFFER CELLS. The fixed macrophages of the liver are
called Kupffer cells (or stellate reticuloendothelial cells). They
phagocytize worn blood cells and pathogens that circulate through the
liver. Many of the bacteria that enter the liver come from the colon,
after being absorbed along with water. Portal circulation brings this
blood to the liver before entering circulation throughout the
remainder of the body. These bacteria are normal flora of the colon
but would be harmful elsewhere.
FORMATION OF BILIRUBIN. The fixed macrophages of the liver phagocytize
worn red blood cells (RBCs) and form bilirubin from the heme portion
of their hemoglobin. The liver also removes from the blood the
bilirubin formed in the spleen and red bone marrow and excretes it
into bile to be eliminated in feces.
STORAGE. The liver stores the minerals iron and copper; the fat-
soluble vitamins A, D, E, and K; and the water soluble vitamin B12.
DETOXIFICATION. The liver synthesizes enzymes that alter harmful
substances to less harmful ones. Alcohol and medications are examples
of potentially toxic chemicals. The liver also converts ammonia from
the colon bacteria to urea, a less toxic substance.
ACTIVATION OF VITAMIN D. The skin, kidneys, and liver each perform a
different role in providing the body with activated vitamin D.
24
Theoretical Background
Primary Liver Cancer
Primary liver cancer develops from the benign tumors. It is the most
common type of cancer. Most of the growths in the liver such as
hemangiomas, focal nodular hyperplasia, hepatic adenomas are usually
benign, that is, non-cancerous. Chronic kidney disease, hepatitis B or
C, some toxins, viral infections of the liver can cause primary liver
cancer. It is further divided into three types.
Hepatocellular Carcinoma or Hepatoma
Cholangiocarcinomas or Bile Duct Cancer
Angiosarcomas and Hemangiosarcoma
Hepatocellular carcinoma is the most common primary liver cancer. it
is an uncontrolled growth of hepatocyte cells in the liver results in
hepatocellular carcinoma. About 80% of people with primary liver
cancer have cirrhosis of the liver. Hepatitis C infection is
responsible for about 50% to 60% of all liver cancers, and hepatitis B
is responsible for approximately 20%.
Metastatic carcinoma or the liver is more common than primary
carcinoma. The liver is a common site of metastatic growth because of
its high rate of blood flow and extensive capillary network. Cancer
cells in other parts of the body are commonly carried to the liver via
the portal circulation.
Cancer cells cause the liver to be enlarged and misshapen. Hemorrhage
and necrosis in the liver are common. Lesions may be singular or
numerous and nodular or diffusely spread over the entire liver. Some
tumors infiltrate into other organs such as the gallbladder or into
the peritoneum or diaphragm. Primary liver tumors commonly metastasize
to the lung.
Secondary Liver Cancer
Secondary cancer is caused by the spread of cancerous cells, which are
located outside the liver. It can spread from gastrointestinal organs
like stomach, pancreas and colon, as the blood flows from these organs
to the liver or it can also spread through the lymphatic
system. Secondary liver cancer is also called as metastatic cancer. In
most of the cases, it is a result of primary liver cancer. It can be a
result of advanced breast cancer, colorectal cancer, lung cancer,
kidney cancer or some other types of cancers.
25
Risk Factors for Liver Cancer
The exact cause of primary liver cancer is still unknown. In adults,
however, certain factors are known to place some individuals at higher
risk of developing liver cancer. These factors include:
Gender. The male/female ratio for hepatoma is 4:1.
Age over 60 years.
Environmental exposure to carcinogens (cancer causing
substances). Examples of environmental carcinogens are aflatoxin,
substance produced by a mold that grows on rice and peanuts;
thorium dioxide, used at one time as a contrast dye for x rays of
the liver; and vinyl chloride, used in manufacturing plastics.
Use of oral estrogens for contraception (birth control).
Hereditary hemochromatosis. Hemochromatosis is a disorder
characterized by abnormally high levels of iron storage in the
body. It often progresses to cirrhosis.
Cirrhosis. Hepatomas appear to be a frequent complication of
cirrhosis of the liver. Between 30-70% of hepatoma patients also
have cirrhosis. It is estimated that a patient with cirrhosis has
40 times the chance of developing a hepatoma than a person with a
healthy liver. Cirrhosis usually results from alcohol abuse or
chronic viral hepatitis.
Exposure to hepatitis B (HBV) or hepatitis C (HBC) viruses. In
Africa and most of Asia, exposure to hepatitis B is an important
factor; in Japan and some Western countries, exposure to
hepatitis C is associated with a higher risk of developing liver
cancer. In the United States, nearly 25% of patients with liver
cancer have evidence of HBV infection. Hepatitis B and C are
commonly found among intravenous drug abusers.
Clinical Manifestations
It is difficult to diagnose and differentiate liver cancer from
cirrhosis in its early stages because of their similar clinical
manifestations (e.g., hepatomegaly, splenomegaly, jaundice, weight
loss, peripheral edema, ascites, portal hypertension). Other common
manifestations of liver cancer include dull abdominal pain in the
epigastric or right upper quadrant region, anorexia, nausea and
vomiting, increased abdominal girth. Patients frequently have
pulmonary emboli.
Underlined words signify the clinical manifestations exhibited by
the patient
26
Medical Management
Administer oxygen inhalation at 2-4 LPM via nasal cannula
Chemotherapy
o Chemotherapy is used for patients with hepatocellular cancer
who are not likely to benefit from other procedures (e.g.,
surgery, transplantation, ablation). A variety of
chemotherapeutic agents (e.g., 5-fluoracil [5-FU] and
leucovorin) administered either systemically or regionally
have been used to treat liver cancer. Sorafenib (Nexavar), a
targeted therapy, is used to treat metastatic liver cancer.
It inhibits tyrosine kinases, some of which are involved in
promoting new blood vessel growth to tumors.
Surgical Management
Radiofrequency Ablation Treatment
o A thin needle is inserted through the skin and into the core
of the tumor. Then electrical energy is used to create heat
in a specific location for a limited amount of time. The end
result is destruction of tumor cells. This procedure can be
done percutaneously, laparoscopically, or through an open
incision. This therapy, although not ideal for all patients,
can be used both for tumors (<5cm in size) that are
considered resectable and for palliative purposes.
Complications are not common but can include infection,
bleeding, dysrhythmias, and skin burn.
Chemoembolization
o A catheter is placed in the arteries to the tumor and an
embolic agent is administered, often mixed with a
chemotherapeutic agent(s). the embolic agent reduces the
blood supply, thus allowing greater exposure of liver cells
to the chemotherapy drugs.
Nursing Management
Give analgesics as ordered and encourage the patient to identify
care measures that promote comfort.
Provide patient with a sodium, fluid, and protein restricted diet
and that prohibits alcohol.
Elevate the patient’s legs to increase venous return and decrease
edema.
27
Monitor and treat fever.
Provide meticulous skin care.
Turn the patient to sides frequently and keep bed linens from
wrinkles to prevent pressure ulcers.
Provide comprehensive care and emotional assistance towards the
patient and to the significant others as well.
Monitor the patient for fluid retention and ascites.
Monitor respiratory function.
Explain the treatments to the patient and his family, including
adverse reactions the patient may experience.
CHAPTER IV
CASE ANALYSIS AND INTERVENTIONS
28
Pathophysiology:
(prolongation)
29
EtiologyPrecipitating: Predisposing:-nutrition -age -familial hx of liver problem -HBV
Injury to liver
Inflammation (hepatitis) Healing, scarring
Constant necrosis & proliferation cycle
Chronic liver disease
Proliferation arrest, stellate cell
activation
Extensive scarring
Liver cirrhosisDisorganized
nodular regeneration
Obstructs biliary, vascular channels
Increased pressure in mesenteric tributaries of portal vein
Increased hydrostatic
pressure
Fluid shifts out of vessels
Decreases intravascular vol
Less bld supply to renal system
Hepatorenal syndrome
*inc. uric acid*inc. creatinine*BUN
Obstructive jaundice
Obx of bile
canali-culi
bilirubin not
conju-gated & excreted
Inc. urobili-nogen
*dark urine
Bile duct obx
Conju-gated
bilirubin enters
bld stream,
reabsorption of bile
*light colored
stool*pruritus
Blood bypasses liver
+ ammonia in bld reaches
brain
HEPATIC ENCEPHALO-
PATHY*coma
*asterixis
Portal hypertension
Disten-tion of
collateral veins,
radiates to
abdomen*caput medusa
Backflow of blood*edema on lower
extre-mities, grade 2
Moderate genomic instability, acted by HBV DNA
Protooncogenes mutate into oncogenes
Severe genomic instability
(cancer cell)HEPATOCELLULAR
CARCINOMARapid growth of primary tumor
Formation of blood vessels w/in the tumor
itself(tumor angiogenesis)
Some segments of tumor detach from
primary tumor
Releases metalloproteinase
enzyme
Releases metalloproteinase
enzyme
Basement membrane of blood vessels are
destroyed
Metastatic tumor cell penetrates into the
blood vessel, enters the blood circulation
Blood from liver goes to right atrium of the heart, to pulmonary
arteryto lungs for oxygenation
Metastatic tumor cells arrest in the capillary
bedsAdhere to capillary
basement membraneGain entrance into the
lung parenchyma
Immunologic surveillance of macrophages:-phagocytosis
-processing of target cells
-release of cytokines
Immunologic escape mechanisms of cancer
cells:-suppression of factors-weak surface antigens
-immune system’s tolerance to tumor
antigens-suppression of
immune response-blocking antibodies
Tumor cell proliferation & angiogenesis LUNG METASTASIS Pathologic changes
Nonspecific inflammatory changes w/ hypersecretion of
mucusDisruption of thoracic
ductLymphatic fluid leak
into pleural spaceHYDROTHORAX
Reactive hyper-
plasia of basal cells
Metaplasia of
epithelium to stratified squamous
cellsHYPERTROPHY
Legend:Italics - manifestationsArrows – Disease ProcessALL CAPS - Complications
Medical Management
1. Intravenous fluid therapy
> Giving of substances directly into a vein; the administration of a
balanced electrolyte solution into the venous circulation; the
administration / introduction of fluids directly into the vein. Aside
from iv hydrates the patient, IV also maintain & replace body stores
of water, electrolytes, vitamins, proteins, fats & calories of the
patient. It also restores the volume of blood components as well
as providing avenue for the administration of medication.
For the patient:
> D5NM @ KVO
>Hypertonic solution draws fluid from the ICF causing cells to shrink
and ECF to expand. It initially increases osmolarity causing the fluid
to be pulled from the interstitial & intracellular compartments into
the blood vessel (intravascular space). It is indicated to regulate
urine output, stabilize blood pressure and reduce risk of edema. It is
also given to patients with fluid loss, hyponatremia and anemia.
Nursing considerations:
· Check for signs of IV infiltration.
· Regulate and monitor the flow rate. It should be in the right
amount.
· In giving IV medications, it should be slowly administrated to
lessen the pain in administering especially those antibiotics.
· IV fluids should be slowly administrated to prevent overload.
· Check the sodium levels of the patient.
2. Antibiotic therapy
> A drug used to treat infections caused by bacteria and other
microorganisms. An antibiotic was a substance produced by one
microorganism that selectively inhibits the growth of another.
Antibiotics are also known as antibacterials. Bacteria are tiny
organisms that can sometimes cause illness to humans. There are many
types of antibiotic, these includes macrolydes, cephalosporin,
fluoroquinolone, penicillin, tetracycline, and macrolyde.
Nursing considerations:
· Check for hypersensitivity of the drug.
· Check for allergies.
· Consider the 5 rights of medication before administering it.
30
· Monitor the patient for adverse reactions.
· Instruct the patient to report any unusual symptoms immediately.
3. Oxygen therapy
> The administration of oxygen as a therapeutic modality. It is
prescribed by the physician, who specifies the concentration, method
of delivery, and liter flow per minute. It alleviates tiredness and
decreases shortness of breath of the patient.
>the 02 that the patient had is via nasal cannula/ nasal prongs
regulated at 2-4L/min.
>It is the most inexpensive device used to administer oxygen. It
doesn’t interfere with the client’s ability to talk.
Nursing Considerations:
· Place cautionary signs reading “No Smoking: Oxygen in use” on the
clients door, at the foot or head of the bed, and on the oxygen
equipment.
· Check the nasal catheter if it’s working properly with your hand.
· Assess skin, breathing pattern, chest movement, and Lung sounds
to check the effectivity of the therapy.
· Regulate the flow rate as prescribed.
· Monitor V/S to note any signs of distress.
Pharmacologic Management
Generic Name: Allopurinol
Brand Name: Zyloprim
Therapeutic Classification: Antigout drug
Indication: Management of patients with malignancies that result in
elevations of serum and urinary uric acid
Dosage: 100 mg 1 tablet OD
Drug Action: Inhibits the enzyme responsible for the conversion of
purines to uric acid with a decrease in serum and
sometimes in urinary uric acid levels, relieving the
signs and symptoms of gout
Side Effects and Adverse Reactions: Headache, drowsiness,
nausea, vomiting, diarrhea
Nursing Responsibilities:
Administer drug following meals
Arrange for regular medical follow-up and blood tests
Generic Name: Ciprofloxacin
Brand Name: Ciloxan
31
Therapeutic Classification: Antibacterial, Fluoroquinolone
Indication: For the treatment of lower respiratory tract infection
Dosage: 200mg IVTT every 8 hours
Drug Action: Bactericidal; interferes with DNA replication in
susceptible bacteria preventing cell reproduction
Side Effects and Adverse Reactions: Headache, dizziness, nausea,
vomiting, diarrhea
Nursing Responsibilities:
Arrange for culture and sensitivity tests before beginning
therapy
Continue therapy for 2 days after signs and symptoms of infection
are gone
Ensure that patient is well hydrated
Encourage patient to complete full course of therapy
Generic Name: Furosemide
Brand Name: Lasix
Therapeutic Classification: Loop Diuretic
Indication: Edema associated with hepatocellular carcinoma
Dosage: 20 mg IVTT every 12 hours
Drug Action: Inhibits reabsorption of sodium and chloride from the
proximal and distal tubules and ascending limb of the
loop of Henle, leading to a sodium-rich diuresis
Side Effects and Adverse Reactions: Dizziness, vertigo, paresthesias,
xanthopsia, weakness, orthostatic
hypotension, thrombophlebitis,
photosensitivity, rash, pruritus,
urticaria, nausea, anorexia,
vomiting, oral and gastric
irritation, leukopenia, anemia,
constipation, diarrhea, urinary
bladder spasm, thrombocytopenia,
muscle cramps and muscle spasms
Nursing Responsibilities:
Administer with food or milk to prevent GI upset
Give early in the day so that increased urination will not
disturb sleep
Measure and record weight to monitor fluid changes
Arrange to monitor serum electrolytes, hydration, liver and renal
function
32
Arrange for potassium-rich diet of supplemental potassium as
needed
Generic Name: Omeprazole
Brand Name: Zegerid
Therapeutic Classification: Antisecretory Drug, Proton Pump Inhibitor
Indication: Reduction of risk of upper GI bleeding in critically ill
patients
Dosage: 40 mg IVTT OD
Drug Action: Gastric acid-pump inhibitor: Suppresses gastric acid
secretion by specific inhibition of the hydrogen-
potassium ATPase enzyme system at the secretory surface
of the gastric parietal cells; blocks the final step of
acid production
Side Effects and Adverse Reactions: Headache, dizziness, diarrhea,
abdominal pain, nausea and
vomiting, URI symptoms
Nursing Responsibilities:
Administer before meals
Administer antacids with, if needed
Instruct patient to report severe headache, worsening of
symptoms, fevers, chills
33
34
NURSING CARE MANAGEMENTNURSING CARE PLAN (PRIORITY NO. 1)
SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS
SCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
Patient whispered “Tabangi ko ninyo, lisud na kaayo iginhawa.”
-RR= 28 cpm, deep and labored-Jaw jutting and nasal flaring noted-Poor capillary refill of 4 seconds-Pallor noted on conjunctivae and fingernails -Labored breathing with use of accessory muscles (intercostal and abdominal muscles) noted-Diminished peripheral sounds noted on right lung field when auscultated-Decreased sensorium observed- Chest x-ray result showed a massive right sided hydrothorax -GCS of 11/15, moderate brain injury
Impaired gas exchange related to ventilation perfusion imbalance secondary to massive right sided hydrothorax
Definition:Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveoli-capillary membrane
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
According to Lewis, Heitkemper, Dirksen, O’Brien,and Butcher, hydrothorax/pleural effusion is a collection of fluid in the pleural space, secondary to altered hydrostatic or oncotic pressure. With this increased volume of fluid in the pleural space, one can conclude that there will be a decreased movement of the chest wall, thus causing dyspnea and impaired gas exchange. Moreover, it has been mentioned that hydrothorax is not a disease in itself, but rather, a manifestation of a serious disease, which, in the case of our patient, is hepatoma, or hepatocellular carcinoma. A large effusion (hepatic hydrothorax) occasionally appears during the course of the
Immediate Goal- That after 15-30 minutes:-Patient/SO will be able to verbalize understanding of causative factors and appropriate interventions related to gas exchange
Short-term goals- That after two hours, the patient will demonstrate improved ventilation and oxygenation as manifested by:-respiratory rate returning to normal or near normal range (12-20 cpm)-decreased use of accessory muscles-improved capillary refill (1-3 seconds)- reduced jaw jutting and nasal flaring-pinkish mucous
Independent:-Take vital signs of the patient especially respiratory rate and heart rate.
- Assess level of consciousness and mentation changes with use of Glascow coma scale.
-Elevate head of bed to semi-fowler or high fowler’s position.
- Encourage frequent position changes.
- Encourage adequate rest and limit activities to within client tolerance.
-Evaluate pulse oximetry to determine
- To provide a baseline data for comparison of patient’s health status.
- Poor brain oxygenation can reduce patient’s sensory ability. A decline to below 50% oxygen in brain is considered to be indicative of cerebral ischemia.
- By gravity, the diaphragm is freed from the enlarged liver and provides enough space for the lungs to expand and receive oxygen.
- Promotes optimal chest expansion and drainage of secretions.
- Helps limit oxygen needs and consumption.
- The body ideally should receive at least 95% of oxygen.
That after 2 hours, the patient had a remarkable decrease in perfusion as manifested by:-respiratory rate 29 cpm, deep and labored-constant use of accessory muscles-poor capillary refill of 4 seconds-jaw jutting and nasal flaring noted-pale mucous membranes and fingernails noted-diminished breath sounds noted- reduced Glasgow coma scale to 3/15, severe brain injury-patient is unresponsive to speech and painful stimuli
35
disease. The fluid in the pleural space is believed to be derived from ascitic fluid that may accompany hepatic cirrhosis. Although the exact mechanism is somewhat controversial, it appears that the ascitic fluid is transported directly into the pleural space. A therapeutic thoracentesis, usually accompanied by a paracentesis, these interventions may not be successful. Management of hepatic hydrothorax remains a clinical challenge.
Source:Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
membranes and fingernails-clearer breath sounds when auscultated
Long-Term Goal-That after 1 week:-Patient will maintain optimal gas exchange.
oxygenation.
- Ensure availability of proper emergency equipment including ET/trach set and suction machines.
Dependent:- Administer medications as indicated.
Collaborative:-Assist with thoracentesis.
Below it would pose problem on brain’s vital functions.
- Intubation ensures that oxygen is delivered straight to lung alveoli, improving perfusion. Suctioning helps remove secretions that may block lung ventilation
- Inhaled and systemic glucocorticosteroids, bronchodilators. To treat underlying conditions.
-Thoracentesis is a procedure to remove fluid from the space between the lungs and chest wall.
36
NURSING CARE PLAN (PRIORITY NO. 2)
SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS
SCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
“Tabangi ko ninyo, lisud na kaayo iginhawa,” as verbalized by the patient
-RR= 22 cpm, deep and labored-nasal flaring noted-Poor capillary refill of 4 seconds-Pallor noted on conjunctivae and fingernails -Labored breathing with use of accessory muscles (intercostal and abdominal muscles) noted-muscle strength of 0 on both lower extremities, no palpable muscular contraction (paralysis)-GCS of 11/15, moderate brain injury-asterixis noted on both arms and hands
Functional Level Classification:Level IV-dyspnea and fatigue at rest
Activity intolerance related to generalized weakness secondary to hepatic encephalopathy
Definition:Insufficient physiological or psychological energy to endure or complete required or desired daily activities
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
“Hepatic encephalopathy is a neuropsychiatric manifestation of liver damage. It is considered a terminal complication in liver disease. It can occur in any condition in which liver damage causes ammonia to enter the systemic circulation without liver detoxification” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2008). This disease is basically a disorder of protein metabolism and excretion. The main pathogenic agents appear to be nitrogenous ammonia and aromatic amino acids. The ammonia normally goes to the
Immediate goal-That after 15-30 minutes:-Patient/SO will identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible
Short-term goal- that after 1 hour:-Patient will use identified techniques to help enhance patient’s activity tolerance
Long-term goals-that after 1 week:-Patient will participate willingly in necessary/ desired activities-Patient will report measurable increase in activity
Independent:-Note presence of factors contributing to fatigue (e.g., cancer)
-Adjust intensity level of activities
-increase exercise/ activity levels gradually
-Plan care to carefully balance rest periods with activities
-Provide positive atmosphere, while acknowledging difficulty of the situation for the client
-promote comfort measures and provide for relief of pain
-Instruct
-Fatigue affects both the client’s actual and perceived ability to participate in activities
-to prevent overexertion
-to conserve energy
-to reduce fatigue
-to help minimize frustration and rechannel energy
-to enhance ability to participate in activities
-there may be a
After 8 hours, patient has been able to:-increase RR from 22 cpm to 28 cpm-demonstrate deep and labored breathing still-reduce GCS from 11/15 (moderate brain injury) to 3/15 (severe brain injury)-demonstrate a muscle strength of O in both upper and lower extremities
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liver via portal circulation and is converted to urea, which is then excreted by the kidneys. When the liver is unable to convert ammonia to urea, large quantities of ammonia remain in the systemic circulation. The ammonia crosses the blood-brain barrier and produces neurologic toxic manifestations. Clinical manifestations of encephalopathy include changes in neurologic & mental responsiveness (ranging from sleep disturbance, to lethargy, to deep coma), slow and deep respirations, slow and slurred speech, hyperactive reflexes, and asterixix (flapping tremors).
Source:Medical-Surgical
tolerance-patient will be able to demonstrate a decrease in physiological signs of intolerance
client/SO in monitoring response to activity
-Plan for progressive increase of activity level
-Encourage client to maintain positive attitude (e.g., suggest use of relaxation techniques)
Dependent:-Provide O2
therapy
need to alter activity level
-both activity tolerance and health status may improve with progressive training
-to enhance sense of well-being
-to help patient relieve from dyspnea and fatigue
38
Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
39
NURSING CARE PLAN (PRIORITY NO. 3)SUBJECTIVE OBJECTIVE NURSING
DIAGNOSISSCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
“Init na siya kayo. Murag nagpatol na gani siya kay nikalit ug puti ang mata unya nanggahi napaakan ang dila,” as verbalized by the significant other.
-T= 38. 9 °C-RR= 28 cpm, tachypneic-patient is hot to touch-diaphoresis noted-seizure/convulsion occurence
Hyperthermia related to infectious process
Definition:Body temperature elevated above normal range
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
“Infection is a primary cause of death in the patient with cancer.The usual sites of infection include the lungs, the GU system, mouth, rectum, peritoneal cavity, and blood. Infection occurs as a result of the ulceration and necrosis of a tumor, compression of vital organs by the tumor, and neutropenia caused by the disease process or the treatment of cancer. Patients who have a temperature of 38°C or higher should be reported immediately. Assessment most often includes signs and symptoms of fever, determination of
Immediate Goal-That after 15-30 minutes, patient/SO will be able to:-identify underlying cause/ contributive factors, and importance of treatment
Short-Term Goals-That after 8 hours, patient will demonstrate the ff:-T= 36.5-37.5° C-Skin cool to touch-No reccurence of seizure/ convulsion
-SO demonstrates behavior to monitor and promote normothermia.
Long-Term Goals-That after 1 week, patient will be able to:-maintain core temperature within normal range-be free of
Independent:-Monitor core temperature.
-Assess neurological response, noting level of consciousness and orientation.
-Apply tepid sponge bath
- apply local ice packs especially in the groin and axillae
-maintain bedrest
Independent:-provide supplemental oxygen
-administer antibiotics as ordered
Collaborative:-provide high-
- To evaluate effects/degree of hypothermia.
- High fever can cause seizures predisposing patients to further seizure related injuries.
-promote heat loss by evaporation.
- this promote heat loss in areas of high blood flow
-to reduce metabolic demands/oxygen consumption
-to offset increased oxygen demands and consumption
-to treat infection
-to meet
That after 8 hours, the patient is afebrile as evidenced by:-T= 37.1°C-Diaphoresis noted-Skin is slightly cool to touch-No recurrence of fever-SO verbalized, “Di gyud to magsalig lang sa tambal. Kinahanglan na mag spongebath para dali manaog ang hilanat.”
40
possible etiology, and CBC.”
Source:Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
seizure activity-demonstrate behaviors to monitor and promote normothermia-be free of complications such as is irreversible brain damage and acute renal failure
calorie diet, tube feedings, and parenteral nutrition
-administer replacement fluids and electrolytes
increased metabolic needs
-to support circulating volume and tissue perfusion
NURSING CARE PLAN (PRIORITY NO. 4)SUBJECTIVE OBJECTIVE NURSING
DIAGNOSISSCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
41
“Nigamay gyud pag-ayo si mama sa la pa siya nagreklamo unya karon nahospital siya, maluoy na mi maglantaw sa iyahang lawas,” as verbalized by SO
“Di naman gyud siya mukaon, mao to gipatubuhan nalang sa doctor para didto nalang iagi tanan iyahang pagkaon,” as verbalized by SO
-patient appears very weak to chew and swallow-emaciated-pale and dry mucous membrane observed-noted weakness of the muscles required for mastication
Imbalanced nutrition: less than body requirements related to loss of appetite and inability to absorb nutrients secondary to Hepatoma
Definition:Intake of nutrients insufficient to meet metabolic needs
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
“A person’s appetite to ingest food is a significant factor in how much food is eaten. An appetite center is located in the hypothalamus. It is directly/indirectly stimulated by hypoglycaemia, an empty stomach, decrease in body temperature, and input from higher brain centers.” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2008) The hormone ghrelin released from the stomach mucosa plays a role in appetite stimulation. Leptin, another hormone, is involved in appetite suppression. Thus, “appetite may be inhibited by stomach distention, illness (especially accompanied by fever), hyperglycemia, and n/v.” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2008)
Immediate Goal- That after 15-30 minutes, patient/SO will:-verbalize understanding of some factors causing malnutrition
Short-Term Goals- That after 8 hours, patient will demonstrate the ff:-Pinkish and moist mucous membrane-Reduce respiratory rate-Regain strength and muscle tone to perform basic ADLs
Long-Term Goals- That after 4 weeks, patient will be able to:-Demonstrate behaviors/ lifestyle changes to maintain appropriate weight-Display normalization of laboratory values and be free of signs of malnutrition
Independent:-Determine client’s ability to chew, swallow and taste food.
- Assess drug interactions and use of laxatives and diuretics.
- Assess weight and muscle mass, and laboratory test such as amino acid profile, BUN, liver function and electrolytes.
- Note age, body build, strength, activity/rest level.
-provide NGT feeding properly
-provide adequate fluid intake
Dependent: - Assist in inserting nasogastric tubes to deliver osteorized feeding.
-This can affect ingestion and digestion of food nutrients.
-This may affect appetite, food intake and absorption.
- This provides baseline parameters
- Helps determine nutritional needs.
-to aid in the proper digestion and absorption of nutrients in the body
-to prevent dehydration
- NGT can ensure that nutrients reach to gastric organs and more ready for absorption.
At the end of our care, the patient will be able to:-decrease creatinine, BUN, and uric acid levels to within normal range-increase HDL levels to within normal range- develop pinkish and moist mucous membranes-increase in muscle tone
42
Source: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
- Assist in administering parenteral D5NM. Watch for overinfusion.
Collaborative:-provide a soft diet composed of less than 1,600 calories and low protein, as ordered
- Multiple and balanced intravenous solutions helps correct electrolyte deficiency.
-to aid in decreasing BUN, creatinine, and uric acid levels and to provide the patient with adequate energy needed for the body’s good functioning
NURSING CARE PLAN (PRIORITY NO. 5)SUBJECTIVE OBJECTIVE NURSING
DIAGNOSISSCIENTIFIC ANALYSIS
PLANNING INTERVENTIONS RATIONALE EVALUATION
43
“Ayaw ko ninyo pasagdai. Tabangi ko ninyo pag-ampo. Dili na nako kaya. Iampo ko day,” as verbalized by patient
“Muanhi man to si Father unya para ampuan siya kay nagrequest man siya kanako,” as verbalized by SO
-patient is sulken-weak-crying observed
Death anxiety related to uncertainty about the existence of higher power and life after death.
Definition:Vague, uneasy feeling of discomofort or dread generated by perceptions of a real or imagined threat to one’s existence.
Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.
Death is defined by Lewis, Heitkemper, Dirksen, O’Brien,& Bucher, as “the irreversible cessation of circulatory and respiratory function or the irreversible cessation of all functions of the entire brain, including the brainstem.” Today, as a result of the increasing number of persons with chronic diseases, terminal illness and dying have received greater attention. Most individuals will have a long period of serious illness before dying, with the onset of months/years before death. For example, approximately half of all patients diagnosed with cancer will die from their disease within a
Immediate Goal- That after 15 to 30 minutes, patient will:-verbalize feelings of sadness, guilt and fear
Short-Term Goal- That after 2 hours hours, patient will:-formulate a plan dealing with individual concerns and eventualities of dying as appropriate
Long-Term Goals- That after 3 days, patient and SO will:-look toward/plan for the future one day at a time-be able to readily say goodbye to each other
Independent:-Ascertain current knowledge of situation to identify misconceptions, lack of information and other pertinent issues.
-Provide open and trusting relationship
-Provide calm, peaceful setting and privacy as appropriate
-Assist the client in engaging spiritual activities and experience prayer and meditation
-Refer to therapists and spiritual advisers.
-The concept of higher power in the afterlife provides comfort and strength to the dying person.
-Genuine rapport can help the patient express her feelings to the nurse about the unknown.
-This promotes relaxation and ability to deal with the situation.
-This reduces feelings of guilt allowing the person to move forward toward resolution.
-To help with the grief work.
At the end of our care, the S/O verbalized,“Dinhi na si Father. Gi-ampuan na siya. Nagpasalamat ra pud mi na nahumana ang pag-ampo para makapreparar siya sa kamatayon.”
44
few years. However, the time from diagnosis of a terminal illness to death varies considerably depending on the patient’s diagnosis and extent of disease. Most patients and families struggle with a terminal diagnosis and the realization that there is no cure. The patient and the family feel overwhelmed, powerless, fatigued, and fearful. With this, both the patient and the significant others may experience death anxiety. For the Catholics, however, they believe in eternal life after death. “Yes, we are fully confident, and we would rather be away from these earthly bodies,
45
for then we will be at home with the Lord.” (2 Corinthians 5:8 ) This biblical quote may offer much comfort for those Catholics “who have the faith as that of a mustard seed” (Matthew 17:20)
Source:Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
The New American Bible: The New Catholic Translation (1987), by Heenan, J.C.
46
PROGRESS NOTES
DATE PROBLEM MEDICAL/SURGICAL INTERVENTION
NURSING INTERVENTION
OUTCOME
April 12, 2011
-dyspnea -O2 inhalation ordered at 2-4 LPM-CBC taken
-place a “no smoking” sign in the room
-dyspnea was relieved
April 13, 2011
-dyspnea
-grade 2 bipedal pitting edema on both lower extremities
-body weakness
-continued O2 inhalation at 2-4 LPM
-Chest X-ray done-Prescribed diet: CHON, soft diet -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered-electrolyte levels assessed (Na and K)
-NGT inserted; prescribed diet: 1600 cal, Osteorized Feeding
-place a “no smoking” sign in the room -Elevate the patient’s legs to increase venous return and decrease edema-keep bed linens from wrinkles
-give health teachings and demonstrate to patient/SO about importance of ROM exercises
-dyspnea was relieved
-edema not relieved, patient complained of decreased sensorium on lower extremities
-patient tried to remove NGT and complained of discomfort upon feeding
April 14, 2011
-dyspnea
-grade 2 bipedal pitting edema on both lower extremitiesNoted
-body weakness
-blood chemistry done-continued O2 inhalation at 2-4 LPM
-Prescribed diet: CHON-Furosemide (Lasix) 20 mg IVTT every 12 hours ordered
-prescribed diet: 1600 cal, Osteorized Feeding
-place a “no smoking” sign in the room
-keep bed linens from wrinkles-turn patient to sides
-give health teachings and demonstrate to patient/SO about importance of ROM exercises
-dyspnea was relieved
-edema not relieved, reports of pain on lower extremities
-patient tried to remove NGT and complained of discomfort upon feeding
April 15, 2011
-dyspnea
-grade 2 bipedal pitting edema on both lower extremities
-body
-continued O2 inhalation at 2-4 LPM
-Prescribed diet:
CHON, soft diet -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered-electrolyte levels assessed (Na and K)
-place a “no smoking” sign in the room
-Elevate the patient’s legs to increase venous return and decrease edema-encourage SO to help patient turn to sides regularly-give health teachings and
-dyspnea was treated
-edema not relieved, patient complained of decreased sensorium and pain on lower extremities
-patient
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weakness -prescribed diet: 1600 cal, Osteorized Feeding
demonstrate to patient/SO about importance of ROM exercises
tried to remove NGT and complained of discomfort upon feeding
April 16, 2011
-dyspnea
-grade 2 bipedal pitting edema on both lower extremitiesnoted
-Fever of 38.9°C
-body weakness, 0 muscle strength
-continued O2 inhalation at 2-4 LPM
-Prescribed diet:
CHON-Furosemide (Lasix) 20 mg IVTT every 12 hours ordered
-prescribed diet: 1600 cal, Osteorized Feeding
-place a “no smoking” sign in the room-encouraged to turn to sides-provide health teachings to SO regarding meticulous skin care
-health teachings given regarding proper application of TBS
-instruct SO to provide passive proper ROM exercises regularly
-dyspnea was treated
-edema not relieved, reports of pain on lower extremities
-fever was treated
-muscle strength still O
DISCHARGE PLAN
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MEDICATIONS:
Generic Name: Allopurinol
Therapeutic Classification: Antigout drug
Indication: Management of patients with malignancies that result
in elevations of serum and urinary uric acid
Dosage: 100 mg 1 tablet OD
Drug Action: Inhibits the enzyme responsible for the conversion
of purines to uric acid with a decrease in serum and
sometimes in urinary uric acid levels, relieving the
signs and symptoms of gout
Side Effects and Adverse Reactions: Headache, drowsiness, nausea,
vomiting, diarrhea
Client Teaching: Administer following meals
Generic Name: Ciprofloxacin
Therapeutic Classification: Antibacterial, Fluoroquinolone
Indication: For the treatment of lower respiratory tract
infection
Dosage: 500 mg 1 tablet every 8 hours, via NGT
Drug Action: Bactericidal; interferes with DNA replication in
susceptible bacteria preventing cell reproduction
Side Effects and Adverse Reactions: Headache, dizziness, nausea,
vomiting, diarrhea
Client Teachings:
o Continue therapy for 2 days after signs and symptoms of
infection are gone
o Ensure that patient is well hydrated
o Encourage patient to complete full course of therapy
Generic Name: Furosemide
Therapeutic Classification: Loop Diuretic
Indication: Edema associated with hepatocellular carcinoma
Dosage: 20 mg tablet every 12 hours
Drug Action: Inhibits reabsorption of sodium and chloride from
the proximal and distal tubules and ascending limb
of the loop of Henle, leading to a sodium-rich
diuresis
Side Effects and Adverse Reactions: Dizziness, vertigo,
paresthesias, weakness, orthostatic hypotension
Photosensitivity, pruritus, urticaria, nausea,
vomiting, anorexia, constipation, diarrhea
49
Client Teachings:
o Administer with food or milk to prevent GI upset
o Give early in the day so that increased urination will not
disturb sleep
o Arrange for potassium-rich diet of supplemental potassium as
needed
Generic Name: Omeprazole
Therapeutic Classification: Antisecretory Drug, Proton Pump
Inhibitor
Indication: Reduction of risk of upper GI bleeding in critically
ill patients
Dosage: 40 mg tablet OD
Drug Action: Gastric acid-pump inhibitor: Suppresses gastric acid
secretion by specific inhibition of the hydrogen-
potassium ATPase enzyme system at the secretory surface
of the gastric parietal cells; blocks the final step of
acid production
Side Effects and Adverse Reactions: Headache, dizziness,
diarrhea, abdominal pain, nausea and vomiting
Client Teachings:
o Administer before meals
o Administer antacids with, if needed
o Instruct patient to report severe headache, worsening of
symptoms, fevers, chills
EXERCISE:
Avoid strenuous exercises.
Turn patient to sides regularly to prevent the development of
pressure ulcers.
Maintain bed rest. However, patient must be encouraged to do
exercises which she can tolerate. Teach the significant others
how to help patient perform passive ROM.
HEALTH TEACHINGS:
Instruct SO(s) to support patient in maintaining hygiene and good
grooming. They must know how to properly support the patient upon
dressing, toileting, and other basic activities. Meticulous skin
care must be provided.
Elevate both feet to promote venous return and to decrease edema.
Keep bed linens free from wrinkles to avoid pressure ulcer
development
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Instruct SO to constantly monitor fever and teach SO how to
properly apply tepid sponge bath
Explain the disease process, causative factors, signs and symptom
and treatment to the patient and significant others.
Follow the prescribed dosage of the medication, how many times it
should be taken, and the route of the medication.
Return for follow up care and evaluation
Encourage patient to take the prescribed medications every day.
Teach client on avoiding stress or stress control and its
importance.
Teach patient to follow prescribed diet strictly.
Teach SO how to feed the patient via NGT and how to prepare
osteurized food.
Encourage patient to have regular check up or when signs and
symptoms re-occur.
Encourage patient to communicate with the health care provider
regarding his condition and therapy.
Counseling or a support group can help in emotional condition
Avoid strenuous activity, heavy lifting and vigorous exercise
Teach patient to avoid alcoholic beverages
Encourage family to help the patient cope with his recent
condition.
Teach non-pharmacological techniques ( massage, music therapy,
guided imagery and relaxation )
OUT-PATIENT:
Contact physician for the following problems:
Any unanswered questions and emotional support needs.
Fever more than 40°C or chills
Allergic or other reactions to medication(s)
Anxiety, depression, trouble sleeping
Change in bowel or bladder habits.
Indigestion or difficulty in swallowing.
DIET:
Eat a balanced, sodium-restricted diet of no more than 2,000 mg
or 2 g of sodium a day.
1600 calories must be consumed per day
Limit proteins and fluid intake.
SPIRITUAL CARE:
Encourage patient and significant others to pray together and to
offer special prayers with the intention of asking enough
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