final case
TRANSCRIPT
Capitol University
College of Nursing
Papillary Carcinoma of the Thyroid
(A case study of RLE7,ThFS, group 12)
In partial fulfillment of the requirements
Of RLE 7-2nd semester, SY 2009-2010
Presented by:
Gaid, Paulo
Jangaw, Wilbur
Japos, Leizel
Jose, Yumi
Kiamco, Paula Christy
Labininay, Marigold
Lagamon, Robina Joyce
Langam, Ronald
Layam, Gerome
Leones, Japhet
Lequigan, katrene
Presented to:
Ryan Ruiz, R.N.
February 2009
Table of Contents
Introduction……………………………………………………………………………..
Client’s Profile………………………………………………………………………….
Socio-demographic data……………………………………………………..
Vital Signs……………………………………………………………………..
Physical Assessment………………………………………………………...
Anatomy and Physiology…………………………………………………………….
Pathophysiology………………………………………………………………………
Laboratory Tests and Results……………………………………………………...
Nursing Care Plans………………………………………………………………….
Drug Studies…………………………………………………………………………
Discharge Planning…………………………………………………………………
Learning Experiences………………………………………………………………
References…………………………………………………………………………..
Introduction
Having heard such a very rare case wherein even up to the present times
experts have not yet discovered an all cure for the disease condition really
challenges the group to pursue a case study of such.
Cancer, specifically papillary carcinoma of the thyroid, is one of which
effective medical treatment is not really established, perhaps, that which would really
save the life of the patient even when diagnosed at the very late stage.
Papillary carcinoma, by definition, is a relatively common well-differentiated
thyroid cancer. It must be considered a variant of papillary thyroid carcinoma (mixed
form). It typically arises as an irregular, solid or cystic mass that arises from
otherwise normal thyroid tissue (http://www.google.com).
Thyroid cancer is a cancer that starts in the thyroid gland. Papillary
carcinomas typically grow very slowly. Usually they develop in only one lobe of
thyroid gland, but sometimes they occur in both lobes. Even though they grow
slowly, papillary carcinoma often spread to the lymph nodes in the neck. Both most
of the time, this can be successfully treated and is rarely fatal. Despite its well-
differentiated characteristics, papillary carcinoma may be overtly or minimally
invasive. In fact, these tumors may spread easily to other organs. Papillary tumors
have a propensity to invade lymphatic but are less likely to invade blood vessels.
Tumors that invade or extend beyond the thyroid capsule have a worse prognosis
because of an high local recurrence rate (http://www.yahoo.com).
This is closely related to the activation of trk and rets proto-oncogenes, both
acting by amplifying and rearranging mechanisms. The trk proto-oncogene codes for
tyrosine kinase receptors; the ret shows a paracentric inversion of chromosome 10
and 11 in 30% of the cases. However, the ret proto-oncogene is over expressed
some molecules that physiologically regulate the growth of the thyrocytes, such as
interleukin-1 and interleukin-8, or other cytokines(ie, insulin like growth factor-1
transforming growth factor -beta, epidermal growth factor) could play a role in the
pathogene's of this cancer.(htt://www.wikipedia.com)
Thyroid cancers are more often found in patients with a history of low-or-high-
dose external irradiation. Papillary tumors of the thyroid are the most common form
of thyroid cancer to result from exposure to radiation. Accounts for 85% of thyroid
cancers due to radiation exposure.
It occurs more frequently in women and presents in the 30-40 year age group
and it may also occur in children. 5%-10% of these are malignant and men have a
higher risk, even it is not common to them, of a nodule being malignant.
This case study has come to realization with the primordial aim of
understanding the disease condition in order to formulate plans of effective nursing
interventions that would help bring back the patient to the normal health status in a
gradual stage. Nursing care has been rendered to patient for one-duty shift. Hence,
evaluation of the effectivity and efficiency of such nursing interventions was not well
established.
Client’s Profile
Socio-demographic Data
Patient X is a 75-year-old, female, a Filipino citizen, from Layawan, Oroqueta City. She is religiously affiliated to Mormons religious group. She is a widow left with 9 children. Her primary language is Cebuano and is a high school graduate. She is a chronic smoker and started to smoke during her early 20’s for about 1/2 pack of cigarettes per day. She also has inherited diabetes mellitus from both sides of her parents who had a history of the disease.
Three years ago, patient X has started consultation from a doctor for complaints of swollen mass palpated in the neck and choking sensation everytime she eats. However, the mass has increased in size for the past few months and on January 20, 2010 she was diagnosed with papillary carcinoma on both lobes of the thyroid. Then on January 22, 2010 she underwent thyroidectomy and tracheostomy.
Patient X’s age is 75 years old. Her mobility status is limited due to her age. She requires special nutritional needs appropriate for her age – low fat especially low saturated fats, low in sodium and sugar. She also needs to eat vegetables and fruits.
Vital Signs
Temperature: 36.1 degrees Celcius Respiratory Rate: 11 cpm
Pulse Rate: 59 bpm Blood Pressure: 100/70 mmHg
Physical Assessment
This portion of the case study will present the deviation from the abnormal findings
of the physical assessment presented in a cephalo-caudal approach. These data are
then considered in the making of the nursing care plan.
Head
Aspect of Consideration Findings
Hair Dry Hair
Nose
Aspect of Consideration Findings
Mucosa Pale
Others With Nasogastric Tube in placed
Mouth
Aspect of Consideration Findings
Lips Pallor
Mucosa Pallor
Teeth Missing teeth with dentures
Gums Pallor
Neck
Aspect of Consideration Findings
Neck With tracheostomy Decreased range of motion
Skin
Aspect of Consideration Findings
General color Pallor
Texture Rough
Moisture Dry
Others Lesions and cracks between
toes
With edema in lower extremities
Respiratory
Aspect of Consideration Findings
Breathing Pattern > Bradypnea and use of accessory
muscles
> Wheezes and ronchi upon
auscultation
Cough Productive cough with light
green sputum
Abdomen
Aspect of Consideration Findings
General With striae
Bowel sounds Hypoactive
Elimination Pattern
Aspect of Consideration Findings
Usual bowel Pattern 3 -4 times a week, with light-
yellow colored stool
Bowel sounds Hypoactive
Others: LBM February 1, 2010
Activities of Daily Living /Mobility Status
0- Total independence 3- Assist with device and person
1- Assist with device 4- Total dependence
2- Assist with person
Feeding: 3 Meal Preparation: 4 Bed Mobility: 2
Bathing: 4 Cleaning: 4 Chair /toilet transfer: 4
Dressing; 4 Laundry: 4 Ambulation: 3
Grooming: 2 Toileting: 4 ROM: 3
Cognitive – Perceptual Pattern
Aspect of Consideration Findings
Appropriate behavior/ communication Unable to communicate verbally
due to tracheostomy tube
Emotional state Worried,anxious, restless,
irritable
Anatomy and Physiology
The thyroid gland is a
butterfly-shape organ and is
composed of two cone-like lobes or
wings, lobus dexter (right lobe) and
lobus sinister (left lobe), and is also
connected with the isthmus. The
organ is situated on the anterior side
of the neck, lying against and around
the larynx and trachea, reaching
posteriorly the oesophagus and
carotid sheath. It starts cranially at
the oblique line on the thyroid
cartilage (just below the laryngeal
prominence or Adam's apple) and extends inferiorly to the fifth or sixth tracheal ring.
It is difficult to demarcate the gland's upper and lower border with vertebral levels
because it moves position in relation to these during swallowing.
The thyroid gland is covered by a fibrous sheath, the capsula glandulae
thyroidea, composed of an internal and external layer. The external layer is
anteriorly continuous with the lamina pretrachealis fasciae cervicalis and
posteriorolaterally continuous with the carotid sheath. The gland is covered
anteriorly with infrahyoid muscles and laterally with the sternocleidomastoid muscle.
On the posterior side, the gland is fixed to the cricoid and tracheal cartilage and
cricopharyngeus muscle by a thickening of the fascia to form the posterior
suspensory ligament of Berry. In variable extent, Lalouette's Pyramid, a pyramidal
extension of the thyroid lobe, is present at the most anterior side of the lobe. In this
region, the recurrent laryngeal nerve and the inferior thyroid artery pass next to or in
the ligament and tubercle. Between the two layers of the capsule and on the
posterior side of the lobes there are on each side two parathyroid glands.
The thyroid isthmus is variable in presence and size, and can encompass a
cranially extending pyramid lobe (lobus pyramidalis or processus pyramidalis),
remnant of the thyroglossal duct. The thyroid is one of the larger endocrine glands,
weighing 2-3 grams in neonates and 18-60 grams in adults, and is increased in
pregnancy.
The thyroid is supplied with arterial blood from the superior thyroid artery, a
branch of the external carotid artery, and the inferior thyroid artery, a branch of the
thyrocervical trunk, and sometimes by the thyroid ima artery, branching directly from
the brachiocephalic trunk. The venous blood is drained via superior thyroid veins,
draining in the internal jugular vein, and via inferior thyroid veins, draining via the
plexus thyroideus impar in the left brachiocephalic vein.
Lymphatic drainage passes frequently the lateral deep cervical lymph nodes and
the pre- and parathracheal lymph nodes. The gland is supplied by sympathetic nerve
input from the superior cervical ganglion and the cervicothoracic ganglion of the
sympathetic trunk, and by parasympathetic nerve input from the superior laryngeal
nerve and the recurrent laryngeal nerve.
Physiology
The primary function of the thyroid is production of the hormones thyroxine
(T4), triiodothyronine (T3), and calcitonin. Up to 80% of the T4 is converted to T3 by
peripheral organs such as the liver, kidney and spleen. T3 is about ten times more
active than T4.
T3 and T4 production and action
The system of the thyroid hormones T3 and
T4.
Thyroxine (T4) is synthesised by the
follicular cells from free tyrosine and on the
tyrosine residues of the protein called
thyroglobulin (Tg). Iodine is captured with
the "iodine trap" by the hydrogen peroxide
generated by the enzyme thyroid
peroxidase (TPO) and linked to the 3' and
5' sites of the benzene ring of the tyrosine residues on Tg, and on free tyrosine.
Upon stimulation by the thyroid-stimulating hormone (TSH), the follicular cells
reabsorb Tg and proteolytically cleave the iodinated tyrosines from Tg, forming T4
and T3 (in T3, one iodine atom is absent compared to T4), and releasing them into
the blood. Deiodinase enzymes convert T4 to T3. Thyroid hormone that is secreted
from the gland is about 90% T4 and about 10% T3.
Cells of the brain are a major target for the thyroid hormones T3 and T4.
Thyroid hormones play a particularly crucial role in brain maturation during fetal
development. A transport protein that seems to be important for T4 transport across
the blood-brain barrier (OATP1C1) has been identified. A second transport protein
(MCT8) is important for T3 transport across brain cell membranes.
Non-genomic actions of T4 are those that are not initiated by liganding of the
hormone to intranuclear thyroid receptor. These may begin at the plasma membrane
or within cytoplasm. Plasma membrane-initiated actions begin at a receptor on the
integrin alphaV beta3 that activates ERK1/2. This binding culminates in local
membrane actions on ion transport systems such as the Na(+)/H(+) exchanger or
complex cellular events including cell proliferation. These integrins are concentrated
on cells of the vasculature and on some types of tumor cells, which in part explains
the proangiogenic effects of iodothyronines and proliferative actions of thyroid
hormone on some cancers including gliomas. T4 also acts on the mitochondrial
genome via imported isoforms of nuclear thyroid receptors to affect several
mitochondrial transcription factors. Regulation of actin polymerization by T4 is critical
to cell migration in neurons and glial cells and is important to brain development.
T3 can activate phosphatidylinositol 3-kinase by a mechanism that may be
cytoplasmic in origin or may begin at integrin alpha V beta3.
In the blood, T4 and T3 are partially bound to thyroxine-binding globulin,
transthyretin, and albumin. Only a very small fraction of the circulating hormone is
free (unbound) - T4 0.03% and T3 0.3%. Only the free fraction has hormonal activity.
As with the steroid hormones and retinoic acid, thyroid hormones cross the cell
membrane and bind to intracellular receptors (α1, α2, β1 and β2), which act alone, in
pairs or together with the retinoid X-receptor as transcription factors to modulate
DNA transcription [1] .
T3 and T4 regulation
The production of thyroxine and triiodothyronine is regulated by thyroid-
stimulating hormone (TSH), released by the anterior pituitary. The thyroid and
thyrotropes form a negative feedback loop: TSH production is suppressed when the
T4 levels are high, and vice versa. The TSH production itself is modulated by
thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus and
secreted at an increased rate in situations such as cold (in which an accelerated
metabolism would generate more heat). TSH production is blunted by somatostatin
(SRIH), rising levels of glucocorticoids and sex hormones (estrogen and
testosterone), and excessively high blood iodide concentration.
An additional hormone produced by the thyroid contributes to the regulation of
blood calcium levels. Parafollicular cells produce calcitonin in response to
hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition
to the effects of parathyroid hormone (PTH). However, calcitonin seems far less
essential than PTH, as calcium metabolism remains clinically normal after removal
of the thyroid (thyroidectomy), but not the parathyroids.
Significance of iodine
In areas of the world where iodine is lacking in the diet, the thyroid gland can
be considerably enlarged, resulting in the enlarged thyroid glands of endemic goitre.
In this situation, women with severe iodine deficiency can give birth to infants with
thyroid hormone deficiency, who will have physical growth and development
problems. Brain development can be severely impaired. This is a condition called
endemic cretinism, and it is one cause of congenital hypothyroidism. Newborn
children in many developed countries are now routinely tested for congenital
hypothyroidism as part of newborn screening. Children with congenital
hypothyroidism are treated by supplementation with levothyroxine, which enables
them to grow and develop normally.
Thyroxine is critical to the regulation of metabolism and growth throughout the
animal kingdom. Among amphibians, for example, administering a thyroid-blocking
agent such as propylthiouracil (PTU) can prevent tadpoles from metamorphosing
into frogs; in contrast, administering thyroxine will trigger metamorphosis.
Because the thyroid concentrates this element, it also concentrates various
radioactive isotopes of iodine produced by nuclear fission. In the event of large
accidental releases of such material into the environment, the uptake of radioactive
iodine isotopes by the thyroid can, in theory, be blocked by saturating the uptake
mechanism with a large surplus of non-radioactive iodine, taken in the form of
potassium iodide tablets. While biological researchers making compounds labelled
with iodine isotopes do this,November 2009 in the wider world such preventive
measures are usually not stockpiled before an accident, nor are they distributed
adequately afterward. One consequence of the Chernobyl disaster was an increase
in thyroid cancers in children in the years following the accident.
The use of iodised salt is an efficient way to add iodine to the diet. It has
eliminated endemic cretinism in most developed countries, and some governments
have made the iodination of flour, cooking oil or salt mandatory. Potassium iodide
and sodium iodide are typically used forms of supplemental iodine.
As with most substances, either too much or too little can cause problems.
Recent studies on some populations are showing that excess iodine intake could
cause an inceased prevelence of autoimmune thyroid disease resulting in
permanent hypothyroidism. Some governments are reviewing the quantity of iodine
added to salt using local salt consumption data.
Predisposing Factors: (Please refer to Fig A)
Precipitating Factors: (Please refer to Fig B)
Papillary carcinoma develops in the thyroid
Tumors grows slowly
Tumor cells becomes invasive
Goes to invading into the lymphatic
Though Uncommon Distant spread of cancer cells may occur
Compromise other organs major function
May invade other organs
Cancer may become Systemic
Surgery:
Removal of the thyroid
If treated:
SurgeryChemotherapyRadiotherapy
Destruction of cancer cells:
ChemotherapyRadiotherapy
Abnormal Growth of mass in the right
breast
If not treated
May spread to other organs and thyroids greatly impede swallowing.
Pathologic Report: Positive for Cancer Cells
DEATH
Cancer Cells Destroyed
Etiologic Factors Actual Rationale
Age: Thyroid carcinoma is common in person at all ages with mean age of 49 years old.
Patient X is an elderly, most likely she is more prone on having thyroid cancer age75 years old.
Elderly person tend to be more at risk on developing thyroid cancer
Gender: Recent studies found out that the female-to-male ratio is almost 3:1 related in patients’ age which older than 45 years.
Patient X’s gender is female
Women are three times more prone to develop cancer than men.
Lifestyle: cigarette smoking mostly increase the risk of developing thyroid disorders/cancer
Patient X has been smoking for more than 30 years
Foreign studies found out that smoking greatly increase the risk of developing thyroid disorders. One component of tobacco smoke is cyanide, which is converted to thiocyanate, which acts as an anti-thyroid agent, directly inhibiting iodide uptake and hormone synthesis.
Predisposing Factors (figure A.)
Precipitating Factors (figure B.)
Etiologic Factors Actual Rationale
Developing abnormal buildup of mass in the front upper neck.
Patient X experience an enlargement of her neck and difficulty in swallowing
3 months prior to admission patient X experience chocking when swallowing food even in small amount and notices build up of mass in the neck.
Laboratory and Tests Results
Microbiology Gram Stain Report
February 5, 2010
Result: No microorganism seen
Polymorphonuclear cells: Moderate
Epithelial cells: Few
Interpretation:
Neutrophils or polymorphonuclear cells (Polys) fight bacterial infections. They normally account for 55% to 70% of WBCs. If you have a very low count, you could get a bacterial infection. This condition is called neutropenia. Advanced HIV disease can cause neutropenia. So can some medications including ganciclovir, a drug used to treat cytomegalovirus and the anti-HIV drug.
Clinical Chemistry
February 4, 2010
Ionized Calcium
Result: 0.91 mmol/L
Reference range: 1.12 – 1.32 mmol/L
Interpretation:
Ionized calcium is vitally important in blood coagulation, nerve conduction, neuromuscular transmission and in muscle contraction. Decreased ionized calcium (hypocalcemia) often results in cramps (tetany), reduced cardiac stroke work and depressed left ventricular function. Prolonged hypocalcemia may result in bone demineralization (osteoporosis) which can lead to spontaneous fractures.
January 25, 2010
Final Pathological Report:
Papillary Carcinoma, both lobes
Fibro-collagenous Tissue, Specimen B
Gross and Microscopic Description:
Received two specimens:
a. A specimen consists of the thyroid gland the left and right lobes measure 10.2 x 7.5 x 4 and 6.8 x 7 x 3 cm. The isthmus measure 3 x 0.2 cm. Cut sections of the left and right lobe show ill defined fan mass, 8 x 4.7 and 3.2 x 1.8 cm, surrounded by meats and fan parenchyma.
b. Specimen consists of an irregular strip of grayish white rubbery tissue fragment measuring 0.3 cm. Black all.
Microscopic Description:
Microsections of both lobes show thyroid tissues. There are solid sheets tumor cells, round to avoid with nuclear clearing. Fibrous tissues separate sheets of tumor cells.
Microsection of specimen b show fibro-collagenous tissues. There is no evidence of malignancy.
Interpretation:
Papillary carcinoma: About 8 of 10 thyroid cancers are papillary carcinomas (also called papillary cancers or papillary adenocarcinomas). Papillary carcinomas typically grow very slowly. Usually they develop in only one lobe of the thyroid gland, but sometimes they occur in both lobes. Even though they grow slowly, papillary carcinomas often spread to the lymph nodes in the neck. But most of the time, this can be successfully treated and is rarely fatal.
Several different variants (subtypes) of papillary carcinoma can be recognized under the microscope. Of these, the follicular variant (also calledmixed papillary-follicular variant) occurs most often. The usual form of papillary carcinoma and the follicular variant have the same outlook for survival (prognosis), and treatment is the same for both. Other variants of papillary carcinoma (columnar, tall cell, diffuse sclerosis) are not as common and tend to grow and spread more quickly
HEMOGLUCOTEST
Normal Values: Before Meals: 90-130 mg/dl
After Meals: less than 180 mg/dl
Results
January 27, 2010 227 mg/dl
January 31, 2010 243 mg/dl
February 2, 2010 104 mg /dl----------7:50 pm
February 4, 2010 183 mg /dl ----------7:30 pm
February 4, 2010 107 mg/dl ----------11:30 am
February 5, 2010 231 mg/dl
Interpretation:
Healthy blood sugar level ranges
Blood sugar levels over 200 mg/dL (mg/dL = milligrams of glucose per deciliter of blood) or under 60 mg/dL are considered unhealthy. High blood sugar levels (above 200 mg/dL) may be a sign of inadequate levels of insulin, caused by diabetes medication, overeating, lack of exercise, or other factors. Low blood sugar levels (below 60 mg/dL) may be a caused by taking too much insulin, skipping or postponing a meal, over-exercising, excessive alcohol consumption, or other factors.
The following are the most common symptoms of hyperglycemia (high blood sugar). However, each individual may experience symptoms differently. Symptoms may include rapid weight loss, feeling sick, thirst, vomiting, fatigue, blurred vision and fainting. The following are the most common symptoms of hypoglycemia (low blood sugar). However, each individual may experience symptoms differently. Symptoms may include: hunger, fatigue and shakiness.
Creatinine
Normal range: 0.6 - 1.2 mg/dL
Sodium
Normal range: 135 - 145 mEq/L
BUN
Normal range: 5 – 35
Potassium
Normal range: 3.5 - 5.0 mEq/L
Decrease in serum potassium is seen usually in states characterized by excess K+ loss, such as in vomiting, diarrhea, villous adenoma of the colorectum, certain renal tubular defects, hypercorticoidism, etc. Redistribution hypokalemia is seen in glucose/insulin therapy, alkalosis (where serum K+ is lost into cells and into urine), and familial periodic paralysis. Drugs causing hypokalemia include amphotericin, carbenicillin, carbenoxolone, corticosteroids, diuretics, licorice, salicylates, and ticarcillin.
Drug Study
Generic Name: atorvastatin calcium
Brand Name: Lipitor
Classification: Antilipemics
Dosage: 40 mg
Route: PO
Frequency: OD @ HS
Indications and dosages:
- Adjunct to diet to reduce LDL and total cholesterol, apolipoprotein B and triglyceride levels in patients with primary hypercholesterolemia and mixed dyslipidemia; primary dysbetelipoproteinemia that doesn’t respond adequately to diet; adjunct to diet for elevated triglyceride levels.
- Alone or as adjunct to lipid-lowering treatments such as LDL apheresis in patients with homozygous familial hypercholesterolemia.
Mechanism action:
- Inhibits 3-hydroxy-3-methyglutaryl coenzyme A (HMG-CoA) reductase, which is an early (and rate-limiting) step in cholesterol biosynthesis.
Adverse reactions:
CNS: headache, asthenia, insomia.
EENT: rhinitis, pharyngitis, sinusitis.
GI: abdominal pain, dyspepsia, flatulence, nausea, constipation, diarrhea.
GU: urinary tract infection.
Musculoskeletal: arthritis, myalgia.
Respiratory: bronchitis.
Other: infection, peripheral edema.
Contraindications:
- Contraindicated in patients hypersensitive to drug and in those with active liver disease or unexplained persistent elevations of transaminase levels. Also contraindicated in pregnant and breast-feeding women and in women of childbearing potential.
Nursing Responsibilities:
- Remember 10 rights of drug administration
- Drug should be withheld or discontinued in patients at risk for renal failure, in serious, acute conditions that suggest myopathy, and severe acute infection, hypotension and uncontrolled seizures.
- Start drug therapy only after diet and other nonpharmacologic treatments prove ineffective. Patient should follow a standard low-cholesterol diet before and during therapy.
- Drug maybe given as a single dose at any time of the day, with or without food.
- Warn patient to avoid alcohol.
- Advise patient that drug can be taken at any time of the day, without regard to meals.
Generic name: budesonide
Brand name: Pulmicort turbuhaler
Classification: Respiratory tract drugs
Dosage: ½ neb
Route: via tracheostomy
Frequency: tid
Indications and Dosages:
-Prophylactic therapy in maintenance treatment of asthma.
Action:
- Anti-inflammatory corticosteroid that exhibits potent glucocorticoid activity and weak mineralocorticoid activity. Have a wide range of inhibitory activity against such cell types as mast cells and macrophages and mediator involved in allergic and non-allergic inflammation.
Adverse Reactions:
CNS: headache, asthenia, insomia.
EENT: rhinitis, pharyngitis, sinusitis.
GI: oral candidiasis, dyspepsia, nausea, dry mouth, taste perversion, vomiting and abdominal pain.
Metabolic: weight gain
Respiratory: increased cough, bronchospasm.
Musculoskeletal: back pain, fractures, myalgia.
Other: flu-like symptoms, fever, hypersensitivity reactions.
Contraindications:
- Contraindicated in patients hypersensitive to drug and in those with status asthmaticus or other acute asthma episodes.
Nursing Responsibilities:
- Remember 10 rights of drug administration.
- If bronchospasm occurs after using budesonide, stop therapy and treat with bronchodilator
- Improve lung function has been observed within 24 hours of starting budesonide treatment, although maximum benefit may not achieved for 1 – 2 weeks or longer.
- In rare cases, inhaled corticosteroids have been linked to increased intraocular pressure and cataract development. If local irritation occurs, drug may be discontinued.
Generic name: calcitriol
Brand name: Rocaltrol
Classification: Parathyroid like drugs
Dosage: .25 mg
Route: PO
Frequency: bid
Mechanism of action:
- Vitamin D analogue that stimulates calcium absorption from the GI tract and promotes movement of calcium from bone to blood.
Indications:
- hypocalcemia in patients undergoing long term dialysis.
- hypoparathyroidism, pseudohypoparathyroidism
- management of secondary hyperparathyroidism and resulting metabolic bone disease in predialysis patient.
Adverse reactions:
- none reported
Contraindications:
- Contraindicated in patients with hypercalcemia or vit. D toxicity. Withhold all preparations containing vit. D.
Nursing responsibilities:
- Use cautiously in patients receiving cardiac glycosides and in those with hyperparathyroidism.
- Protect drug from direct light.
- Tell patient to immediately report symptoms of vit. D intoxication: weakness, nausea, vomiting, dry mouth, constipation, muscle or bone pain, or metallic taste.
- Instruct patient to adhere to diet and calcium supplementation and to avoid unapproved OTC drugs and magnesium containing antacids.
Generic name: albumin 25%
Brand name: Albutein 25%
Classification: Blood derivatives or hematologic drugs
Dosage: 100 ml
Route: IVTT
Frequency: od
Mechanism of action:
- Albumin 25% provides intravascular oncotic pressure in a 5:1 ratio, causing a fluid shift from interstitial spaces to the circulation and slightly increasing plasma protein level.
Indications:
- hypovolemic shock
- hypoproteinemia
- hyperbilirubinemia
Adverse reactions:
- CNS: headache
- CV: vascular overload after rapid infusion, hypotension, tachycardia
- GI: increase salivation, nausea, vomiting
- Musculoskeletal: back pain,
- Respiratory: dyspnea, pulmonary edema
- Skin: urticaria, rash
- Others: chills, fever
Contraindications:
- Contraindicated in patient hypersensitive to drug and in those with severe anemia or cardiac failure.
Nursing responsibilities:
- Remember 10 rights of drug administration.
- Use with extreme caution in patients with hypertension, and pulmonary edema.
- Monitor vital signs carefully.
- Monitor fluid intake and output.
- Follow storage instructions on bottle freezing may cause bottle to break.
- Tell patient to report adverse reactions promptly
Generic name: methyprednisolone sodium
Brand name: Solu-Medrol
Classification: Hormonal drugs
Dosage: 50mg
Route: IVTT
Frequency: TID
Mechanism of action:
- Not clearly defined. Decreases inflammation, mainly by stabilizing leukocyte lysosomal membrane; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism.
Indications:
- severe inflammation or immunosuppression- shock
Adverse reactions:
CNS: insomnia, seizure, headache
CV: hypertension, edema, thrombophlebitis, heart failure, cardiac arrest, circulatory collapse after rapid use of large IV doses
EENT: cataracts, glaucoma
GI: peptic ulceration, GI irritation, nausea, vomiting
Metabolic: hypocalcemia, hypokalimia, hyperglycemia
Musculoskeletal: muscle weakness, osteoporosis
Skin: delayed wound healing, various skin eruptions
After abrupt withdrawal: rebound inflammation, fatigue, weakness, dizziness, lethargy, depression, dyspnea, orthostatic hypotension, hypoglycemia.
After prolonged use, sudden withdrawal maybe fatal.
Contraindications:
- contraindicated in patient hypersensitive to drug or its ingredients and in those with systemic fungal infection; also contraindicated in premature infants
Nursing responsibilities:
- Remember 10 rights of drug administration.- Determine whether patient is sensitive to other corticosteroid.- For better results and less toxicity, give once or daily dose in the morning.- Give oral dose with food when possible.- Watch for depression or psychotic episodes especially in high dose therapy.- Unless contraindicated, give low-sodium diet that’s high in potassium and
protein.- Gradually reduce dosage after long term therapy.- Tell patient not to stop drug abruptly or without prescriber’s consent.
Generic name: meropenem trihydrate
Brand name: Meronem
Classification: Anti-bacterial
Dosage: 500mg
Route: IVTT
Frequency: QID
Mechanism of action:
- Exerts its bactericidal action by interfering with vital bacterial cell wall synthesis. The ease with which it penetrates bactericidal cells, its high level of stability to all serine B-lactamase and its marked affinity for the penicillin binding proteins explain the potent bactericidal activity against broad spectrum of aerobia and anaerobic bacteria.
Indications:
- Lower respiratory tract infections- Urinary tract infections including complicated infections- Intraabdominal infections- Septicemia- Meningitis
Adverse reactions:
CNS: Seizures, headache
GI: Diarrhea, vomiting, constipation, glossitis
GU: Presence of RBC in urine
Respiratory: Apnea, dyspnea
Skin: Rash, pruritus
Contraindications:
- Contraindicated in patients who have demonstrated hypersensitivity to its product.
Nursing responsibilities:
- Remember 10 rights of drug administration.
- Use cautiously in elder patient and in those with history of seizure disorders or impaired renal functions.
- Stop drug and notify prescriber if an allergic reactions occurs.
- Monitor patient for signs and symptoms of infection.
- Monitor patient’s balance and weight carefully.
- Instruct patient to report adverse reactions.
Discharge Plan
Medication
> Strict compliance to the drug regimen should be emphasized
> Emphasis to take home medication consistently following the right drugs, dosage,
timing & frequency, and route.
Exercise
> It is best to start the exercise program slowly until you get stronger, also find a
suitable exercise program to suit your condition.
> Exercise is important this makes your heart stronger, lowers blood pressure, and
help keep your body healthy.
> Maintaining a regular exercise will help facilitate adequate blood flow for
nourishing different parts of the body.
Treatment
> Have a regular check-up with your physician regarding with your condition for any
continuing treatment and medications.
Health Teachings
> Emphasis on personal hygiene to promote comfort and prevent infection.
> Do regular exercises, eat right food, and take medications to enhance recovery
and healing as indicated by the physician.
Out Patient
> Regular check-up for monitoring of development and if there are presence of
complication.
Diet
> Consult a nutritionist for a proper diet program.
Tips:
> Eat nutritious and healthy food, to avoid constipation. Eat foods such as oatmeal,
whole-grain breads and cereals, fruits and vegetables.
> If certain food gives the client cramps or diarrhea do not include the food in the
diet, try the food again in few weeks by taking small portions then gradually increase
the portion size.
> Eat slowly and do not use straw when drinking.
> Drink at least 8-10 glasses of water a day; limit the amount of soda, tea and
coffee.
Spirituality
>Tell the patient/client to pray for God, for him nothing is impossible. Ask for inner
strength to carry his trials
Learning Experiences
In doing the case study, the essence of team effort and patience were always
their. Everything we have done entails patience, knowledge and skills in doing each
task correctly. We have learned a lot about proper nursing interventions, rendering
care to our patients, regarding the disease conditions, manifestations and a lot more.
One should also need to analyze all the significant data to know the relationship of
other data. We have also learned time-management in doing our individual task.
While in the other hand, our experience in CUMC – Station 2 was honestly
tiring but a promising experience indeed. It was fortunate to have a good relationship
with our group mates, hospital staffs and to our beloved clinical instructor as well.
What happened in this rotation was a lot of new ideas, new terms and topics that we
have not tackled from previous rotations. The hospital itself also imposes on what is
the ideal thing to do for the student nurse to follow; and as soon as we become
registered nurses, we will be able to follow the proper principle that a nurse must
follow. Although this rotation was a bit toxic, this will help each one of us to become
a lot better. We admit we have committed a couple of mistakes, but what is more
important is what you learned from your mistakes.
We would like to thank, our ever grateful, God Almighty, thank you so much
for giving the group strength to handle each situation confidently. To our dear CI,
Mr. Ryan C. Ruiz, R.N., thank you for being effective in the field. As a clinical
instructor, he emphasized the values of professionalism, respect and patience. To
our beloved parents who have shown support and understanding in all activities.
And to the Hospital Staffs who help and guide us for this rotation.
References
http://www.virtualcancercentre.com/diseases.asp?did=556&page=3
http://emedicine.medscape.com/article/281237-overview
http://www.dartmouth.edu/~humananatomy/part_6/chapter_36.html
http://www.fascrs.org/physicians/education/core_subjects/2003/
anatomy_colon_rectum_anus/
http://chestofbooks.com/health/anatomy/Human-Body-Construction/Blood-
Vessels.html