sarcoma final
TRANSCRIPT
Ateneo de Davao UniversityCollege of Nursing
In Partial Fulfillment of the Requirements in Related Learning Experience
A Case Study On
RHABDOMYOSARCOMA
Submitted to:
Ms. Honeylet P. Villanueva, RN, MNClinical Instructor
Submitted by:
Jan Mikhail Louise Paolo FrascoJhon Bernand Hernandez
Angeline Nicole EspinoPatrick Antoni DerechoKlyde Louise JarabeloChristine Jay Domingo
Jenny Pearl EstuyaSheena Fe DanueLawrence CalvoPatrick Calanoy
August 2011
Table of Contents
I. Acknowledgement 01
II. Introduction 02
III. Objectives 04
IV. Patient’s Data 07
V. Genogram 09
VI. Family Background / Health History 10
VII. Developmental Data 14
VIII. Physical Assessment 22
IX. Definition of Complete Diagnosis 26
X. Anatomy and Physiology 31
XI. Etiology 39
XII. Symptomatology 41
XIII. Pathophysiology 43
XIV. Doctors Order 46
XV. Diagnostic Exam 54
XVI. Drug Study 77
XVII. Nursing Theories 101
XVIII. Nursing Care Plan 103
XIX. Prognosis 125
XX. Discharge Plan 128
XXI. Recommendation 131
XXII. Reference 133
ACKNOWLEDGEMENT
The researchers wish to express their deepest gratitude and warmest
appreciation to the following people, who, in any way have contributed and
inspired the researchers to the overall success of the undertaking:
To Mam. Li Derla for her guidance and support in the duration of the
study.
Mam Honeylet Villanueva for helping us and supporting us to find a
case during our duty. to the NOD at SPMC house of hope for the
accommodation and pure hospitality.
to our patient and his family, for their selfless cooperation and sharing
their precious time.
To our friends, who have been unselfishly extending their efforts and
understanding.
To our parents who have always been very understanding and
supportive both financially and emotionally.
And above all, to the Almighty God, who never cease in loving us and
for the continued guidance and protection.
The Researchers
INTRODUCTION
Rhabdomyosarcoma is a malignant tumor that starts in muscle, its
primarily a childhood tumor and occurs most often in children under 5 years of
age. Over 60% of cases show up before age 10. On rare occasions,
rhabdomyosarcoma affects adults.
Rhabdomyosarcoma can begin anywhere there is muscle including the
head and neck, arms and legs, genitourinary tract, and the trunk.
Treatment for rhabdomyosarcoma may involve surgery, radiotherapy or
chemotherapy. Usually two or three of these modalities of treatment are
employed. For example, a surgeon may first try to remove as much tumor as
possible. Then the patient may undergo several weeks of chemotherapy,
possibly followed by radiation therapy, and then more chemotherapy.
There are 2 main types of rhabdomyosarcomas. Embryonal
rhabdomyosarcoma (ERMS) is the most common type of rhabdomyosarcoma.
It usually affects infants and young children. The cells of ERMS look like the
developing muscle cells of a 6- to 8-week-old embryo. ERMS tends to occur
in the head and neck area, bladder, vagina, and in or around the prostate and
testicles. Alveolar rhabdomyosarcoma (ARMS) typically affects older children
or teenagers and occurs more often in large muscles of the trunk, arms, and
legs. ARMS cells look like the normal muscle cells seen in a 10-week-old
fetus. ARMS tends to grow faster than ERMS and usually requires more
intensive treatment.
About 3% of all childhood cancers are rhabdomyosarcomas. About 350
new cases of rhabdomyosarcoma occur each year in the United States. The
number of new cases has not changed much over the past few
decades.http://www.cancer.org/Cancer/Rhabdomyosarcoma/DetailedGuide/
rhabdomyosarcoma-key-statistics
We the researchers chose this case study because of the following
reasons. First, the researcher identified the case as a chance to study and
learn about the disease on why thus this illness increased globally. The
researchers aimed that the readers will have greater insights and more
understanding about this disease. And We also aim that this case study may
become a tool in improving care and in developing new medical technology in
relation to this disease. The researchers is aiming that this will help in
improving the quality of care given to patients suffering Rhabdomyosarcoma
With this study, it will also contribute and help the people involved
especially the nurse, by giving them enough knowledge to deal appropriately
with this disease. It will also help to let the client’s family understand the
disease condition and give them information or knowledge on how to care for
the client.
OBJECTIVES
A GENERAL:
Within our 3 days shift 3-11 shift span of duty we will be able to formulate a comprehensive case study about, which could essentially be a way of identifying and presenting all the accompanying characteristics and information contained in the patient’s condition including its prospective management. This would also able our group to:
B SPECIFIC
Cognitive:
—Discuss in details Acute Pyelonephritis in Sepsis for our case study so as to gain insight and knowledge.
—Gather necessary and pertinent data, concerning the client and family, as a baseline information about the ask data;
—Determine the degree of development in order to point out certain problems or foreseeable crisis that would affect the maintenance of health of my patient;
—Present the definition of complete diagnosis that would explain the illness of my client;
—Discuss the Anatomy and Physiology of the affected system (Urinary, Immune, Lymphatic and Hematologic Systems) of the disease;
—Present the Etiology and Symptomatology and trace the Pathophysiology of the disease with diagram;
—Present the diagnostic examinations undergone by the patient and know it's clinical significance;
—Present drug studies for all the medications prescribed by the physician administered to the patient such as; Cefuroxime, Domperidone, Paracetamol, Captopril, Ceftriaxone Sodium, Cefotaxime Sodium, Omeprazole, Eperisone, Tramadol and Diazepam.
—List all the actual medical management for the patient and interpret;
—Identify and Prioritize the need for our patient;
—Evaluate prognosis for my client with proper justification.
AFFECTIVE:
—Have a purposeful interaction with the client as well as her significant other.
—Establish rapport with our client and her family in order to gain cooperation and come up with a reliable information needed in this case study;
—Be able to relate the patient’s disease with the different nursing theories specifically those of Florence Nightingale (Environmental Theory), Jean Watson (Human Caring Theory), Lydia Hall(Care Core Cure theory) and Dorothea Orem’s (Self- care theory).
—Formulate a specific, measurable, attainable, realistic and time-bounded nursing care plan for the client
—Provide health teachings to the client and the family
—Outline recommendations based on the case study’s findings
PSYCHOMOTOR:
—Enhance the ability to identify and apply nursing interventions to provide a better care for the client with the said disease.
—Conduct a cephalocaudal assessment to our patient in order to note any alterations or deviations from the normal physical structures;
—Formulate an appropriate and realistic health teachings as part of the optimal and holistic care to achieve recovery;
—Provide the patient and family with proper discharge planning (M.E.T.H.O.D.)
Patient’s Data
Patient’s Name : Patient J
Gender : Male
Birthdate : August 5, 1996
Birthplace : Tagbilaran City, Bohol
Age : 14 years old
Number of Siblings : 7
Ordinal Rank : 5th Child
Address : Quarry 1, Villaverde Tagbina Surigao del sur
Nationality : Filipino
Civil Status : Single
Occupation : None
Religion : Catholic
Denomination : Roman Catholic
Educational Attainment : Grade 5
Admitting Data
Date of Admission : July 9, 2011
Time of Admission : 07:01 am
Hospital : Southern Philippines Medical Center
Ward : Orthopedic Male ward [Bed 25]
Vital Signs upon Admission
Blood Pressure 90/60 mmHg
Pulse Rate 100 beats per minute
Respiratory Rate 17 cycles per minute
Temperature 36.5 degree Celsius
Weight : 64 lbs
Height : 54cm
Body Mass Index : 1.1851852
Chief Complaint : Mass Right Deltoid
Admitting Physician : Dr. Chris George C. Pales
Admitting Diagnosis : Right Arm Mass Probably Sarcoma
Complete Diagnosis : Rhabdomyosarcoma, Right Shoulder
Source of Information : Patient and Patient’s chart and Patient’s Watcher
GENOGRAM
Paternal Side
Maternal Side
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ƱRhabdomyosarcoma, @ Right Shoulder
Health History
Family Background
Patient J is the son of Mom QQ and Father RR. He was born on
August 5, 1996 in Tagbilaran City, Bohol. He is a 14 year old male and the
5th child among the seven siblings. According to Patient J, their
grandparents in the paternal side died due to old age and not of any kind of
disease. In the maternal side his grandparents are still alive and they were
not diagnosed of any sort of disease. His father who was 54 years old died
by committing suicide due to financial problem. His 47 year old mother is still
alive and not diagnosed of any sort of disease. Patient J studied at Villaverde
Elementary School. He loves to play with his friends and classmates and
watch television. He sometimes goes to the nearest river and play once a
week and every weekend he sometimes goes to terraces where his mother
works there as a peasant and helps her throughout the day.
In terms of familial relationship, Patient J is playful, funny and
sometimes hardheaded just like the other kids. He usually gets along with his
friends and classmates. He does not have any experience of having conflicts
with anyone of them. He usually wakes up at 6:00 am to prepare for his
morning class. With regards to their health condition Ms. QQ takes part in
making decision.
In terms of economic status, they belong to the lower class. His
Mother is a housewife. Aside from being a housewife she also works part-
time as a peasant at Surigao Del sur. His brother A is also contributing in
giving extra money to their mother. According to his brother, this helps in
their daily expenses. Their estimated monthly income is 2000 pesos. Their
monthly electricity bill is 400 pesos and their water bill is free because they
use safety tank where the rain drops are filtered. According to his brother
they have not gotten any disease from that tank. The school expenses are
1000 pesos annually for each child in a public school.
Patient J and most of his siblings are not engage in any kind of vices
except the 2nd brother who is Mr. B. Mr. B is a smoker. He smokes Philip
Morris and Hope and consumes more or less 3 sticks per day. Mr. A usually
gives his brother B advice regarding smoking. He wants him to stop because
it is dangerous to one’s health.
Client’s Lifestyle, Diet, and Activities of daily Living (ADL)
Patient J’s typical day starts with preparing himself and go to school.
During his free time, he watches television like cartoons and anime; he
always plays with his friends and classmates a “tumba lata”, “takyan” and
going to the river etc.
His diet is mainly fish such as “galong-gong”, “tulingan”, “bangus” and
“sari-sari”, vegetables that can be bought in the wet market and those that
they planted at their backyard themselves. He was able to have at least three
meals a day. During breakfast, lunch and dinner he eats fish and vegetables
and sometimes with a glass of milk. Patient J said that he doesn’t have any
usual routines for exercise but he considered his playtime as exercise. He
always wakes up early in the morning even during the weekends. He sleeps
at around 9:00 pm and wakes up at around 6:00 am. Every Sunday his family
goes to church to attend mass.
History of Past Illness
Patient J was born via Normal Spontaneous Vaginal Delivery at
Tagbilaran City, Bohol. According to his mother there were no complications
or abnormalities noted upon delivery. He said that he had a chicken pox at
the age of 3 and according to his mother she had him immunized and
completed it. He also experienced headache, fever and cough but able to
manage these through taking over-the-counter drugs such as Biogesic,
Neozep, and Tuseran.
According to Patient J, in January 2011, he noticed a painful tiny mass
on his right arm. Then, he and his mother decided to go to the Barangay
Health Center and a nurse adviced him to take antibiotic and analgesic which
is amoxicillin and mefenamic acid. After 1 month the tiny mass was gone.
History of Present Illness
However, on April 2011 the painful mass on his right arm came back.
Patient J just decided to take the antibiotic and analgesic again rather than
consulting a doctor because they don’t have enough money to pay for the
consultation fee. However, it came to the point that the tiny mass gone bigger
and painful. This time he was very eager to consult a doctor. When he finally
met the doctor he was recommended to undergo an operation to remove the
mass on his deltoid. On August 5, 2011 he had his amputation at Southern
Philippines Medical Center and was then admitted in Orthopedic Ward in the
same hospital and on September 1, 2011 where he had his Skin graft. Upon
admission, his vital signs were as follows: Blood Pressure = 90/60 mmHg,
Temperature =36.5 degree Celsius, Respiratory rate = 17 cycles per minute
and Pulse rate = 100 beats per minute.
Effects/ Expectations of Illness to Self/ Family
Patient J and his family are very religious and active to attend mass.
His current condition does have a great impact within their family. His
Mother, siblings and other relatives are there to support here emotionally and
financially. Even though they are tight on the budget, they still submit the
patient for better treatment and never lose hope for Patient J to be in good
health.
Medication Reconciliation
Medication Indication as
known by the
patient
Dosage Prescribing
health care
provider
Biogesic For fever and for
headache
250mg t.i.d
Neozep For colds 250mg t.i.d
Tuseran For cough 250mg t.i.d
Amoxicillin To treat and
prevent infections
500mg t.i.d Nurse
Mefenamic Acid Pain Reliever 500mg prn Nurse
Review of Systems
Prior to admission the patient complains pain at his right arm with a pain
scale of 7 out of 10. According to patient J it was painful and uncomfortable.
His vital signs upon admission are as follows. : Blood Pressure = 90/60
mmHg, Temperature =36.5 degree Celsius, Respiratory rate = 17 cycles per
minute and Pulse rate = 100 beats per minute.
DEVELOPMENTAL DATA
Developmental data contains records and analysis of an increase or
stagnancy in the complexity of function and skill progression. It manifests the
person’s capability and skills in adapting to a dynamic environment. It begins
in infancy stage and ends in the old age stage while attaining intelligence,
developing problem-solving ability and coping and adapting to the
environment in all aspects. Development is the behavioral aspect of growth
such as person’s ability to walk, talk, run and even feelings of sensation and
emotion. It proceeds from simple to complex such as from single acts to
integrated ones. In attempt to analyze a person’s developmental data a
developmental delay is monitored. A developmental delay is any significant
lag in a child's physical, cognitive, behavioral, emotional, or social
development, in comparison with norms.
Erikson’s Stages of Psychosocial Development
Erik Erikson, Erikson’s stages of psychosocial development describe eight
stages through which a healthy developing human should surpass from
infancy to late adulthood. In each stage, a person faces and hopefully
masters new challenges. These challenges may come back as problems in
the future if these are not successfully completed from each stage.
Stage Description Result Justificationfidelity - Identity vs.
Role ConfusionTeens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of
unachieved Patient J has not successfully achieved this
stage because he is in constant confusion on
what will be his role in the
society. He is still dependent on his older siblings and
self. mother emotionally.
Havighurst’s Developmental Task
Havighurst (1972) defines a developmental tasks as one that arises at
a certain period in our lives, the successful achievement of which leads to
happiness and success with later tasks; while leads to unhappiness, social
disapproval, and difficulty with later tasks He identifies three sources of
developmental tasks (Havighurst, 1972).
o Tasks that arise from physical maturation
o Tasks that arise from personal values
o Tasks that have their source in the pressures of society
Havighurst also identified Six Major Stages in human life covering birth to old
age which are the following:
Infancy & early childhood (Birth till 6 years old)
Middle childhood (6-12 years old)
Adolescence (13-18 years old)
Early Adulthood (19-30 years old)
Middle Age (30-60years old)
Later maturity (60 years old and over)
Our client belongs to the 3rd stage which is the adolescence, Tasks
that arise from personal values: Choosing an occupation, socializing with
same age group, figuring out ones philosophical outlook.
The following are the developmental task that a adolescence adult must fulfill
or achieve:
DEVELOPMENTAL
TASK
ACHIEVED OR NOT
ACHIEVED
JUSTIFICATION
Achieving new and more Achieved Patient J was able to
mature relations with
age mates of both
sexes.
achieve this. He was active
with interacting with his
classmates at school.
Achieving a masculine
or feminine social role.
Achieved He was able to achieve it
since he is willing to help his
mother on the farm. He
accepts the responsibility of
being a male in his family by
helping his younger siblings
and helps with the
maintenance of the house.
Accepting one’s
physique and using the
body effectively
Achieved Patient J achieved this since
he has already accepted
that his arm is amputated.
He was able to adapt with
his present condition by
doing alternative measures
in his ADL’s.
Achieving emotional
independence from
parents and other adults.
Achieved Patient J achieved this since
he has emotional stability in
his present condition and
does not depend on his
mother.
Achieving assurance of
economic independence
and selecting and
preparing for occupation
Unachieved Patient J has not achieved
this since he only finished 5th
grade and with his present
condition he will have a hard
time landing a job.
Preparing for marriage
and family life.
Unachieved Patient J has not achieved
this since he is still not
financially capable of
supporting a family. He says
he is not thinking of
marriage as of the moment.
Developing intellectual
skills and concepts
necessary for civic
competence;
Unachieved Patient J has not achieved it
since he only finished 5th
grade. With his present
condition which requires
admittance in the hospital
and financial situation, he
was not able to develop the
skills necessary for civic
competence.
Desiring and achieving
socially responsible
behavior.
Achieved Patient J was able to
achieve this since he has
the desire to be responsible
and help in little ways in the
family prior to his sickness
like helping in farm and
babysitting his younger
siblings.
Acquiring a set of values
and an ethical system as
a guide to behavior
Achieved Patient J was able to
achieve this since he was
taught by his mother and
older sibling’s good conduct.
He says he follows the rules
set by his mother in the
house.
Kohlberg's Stages of Moral Development
This theory specifically addresses moral development in children and
adults. The morality of an individual’s decision was not Kohlberg’s concern;
rather, he focused on the reasons an individual makes a decision.
Stage Description Result Justification
Conventional
Stage (Law
and Order
Orientation)
The conventional level of
moral reasoning is typical of
adolescents and adults.
In this stage, it is important
to obey laws, dictums and
social conventions because
of their importance in
maintaining a functioning
society. Right is being good,
with the values and norms of
family and society at large.
The self enters society by
filling social roles; therefore
society must learn to
transcend individual needs.
A central ideal or ideals often
prescribe what is right and
wrong, such as in the case
of fundamentalism. If one
person violates a law,
perhaps everyone would—
thus there is an obligation
and a duty to uphold laws
and rules. When someone
does violate a law, it is
morally wrong;
responsibility is thus a
significant factor in this stage
as it separates the bad
domains from the good
ones. Most active members
of society remain at stage
ACHIEVED In this stage of Kohlberg's Moral
Development theory, it is a must
for the client to pursue the laws
in order to continue a good
functioning in the society as a
good citizen. Patient J also
expressed that as a member of
this society, one must follow
rules or else your gonna be
punished. Because of his young
age, he was not able to expound
his ideas regarding the
questions. Patient J was raised
by his mother with the proper
values that is acceptable in our
society. He believes that there is
order if one follows the rules as
he gives anologies in their
household.
four, where morality is still
predominantly dictated by an
outside force
DEFINITION OF COMPLETE DIAGNOSIS
(Rhabdomyosarcoma, Right Shoulder)
Rhabdomyosarcoma (rab’do-mi-o-sark-ko’mah)
A malignant neoplasm derived from skeletal (striated) muscle; characterized
in adults by poorly differentiated oblong, as well as rounded and bizarre, cells
with large hyperchromatic nuclei; the cytoplasm is usually granular and
structures that resemble cross striations may be observed.
Illustrated stedman’s medical dictionary 24th edition,1982. P. 1230.
USA: Williams and wilkins.
a sarcoma containing striated muscle fibers
DORLAND'S ILLUSTRATED MEDICAL DICTIONARY. 23RD
EDITION.: L., Et al. (eds.) Brainerd
Rhabdomyosarcoma is a fast-growing, highly malignant tumor which
accounts for over half of the soft tissue sarcomas in children. Less frequently,
other soft tissue sarcomas are found in children: fibrosarcoma,
mesenchymoma, synovial sarcoma, and liposarcoma.z`
Blakistons new gould medical dictionary 8th edition page 1024 USA
RIGHT
Toward or on the right.
Daniels, R., Nosek, L., Nicoll, L. Contemporary Medical Surgical
Nursing. 2007. p. 1780. USA: Thomas Delmar Learning.
the condition of having the right side distinct or different from the left.
Tamparo, Carol. Diseases of The Human Body. (2005) Davis
Company. ISBN: 0-8036-1245-1.
location near or direction toward the right side
Late, P. (2009). Seeley’s Principle of Anatomy and Physiology. (p.
616) McGraw Hill; New York, NY 10020
Shoulder
The lateral portion of the scapular region, where the scapula joins with the
clavicle and humerus and is covered by the rounded mass of the deltoid
muscle.
Illustrated stedman’s medical dictionary 24th edition,1982. P. 1282.
USA: Williams and wilkins.
The part of the body between the neck and the upper arm
Dorlands illustrated medical dictionary 23rd edition p. 1184 press of
W.B. sanders company USA
The region where the arm joins the trunk formed by the meeting of the
clavicle and scapula and the overlying soft parts.
Blakistons new gould medical dictionary 8th edition page 929 USA
Rhabdomyosarcoma, Right Shoulder
A rhabdomyosarcoma is a type of cancer, specifically a sarcoma (cancer of connective tissues), in which the cancer cells are thought to arise from
skeletal muscle progenitors. It can also be found attached to muscle tissue, wrapped around intestines, or in any anatomic location. Most occur in areas
naturally lacking in skeletal muscle, such as the head, neck, and genitourinary tract. Rhabdomyosarcoma is a relatively rare form of cancer.
PHYSICAL ASSESSMENT
Date of Assessment: 15 Sept. 2010
Time of Assessment: 7:00 pm during Physical Assessment
General Sur-vey
Received lying on bed, at supine position, awake, conscious, coherent, alert, & oriented. He has wounds at right thigh (3) & right shoulder (1). Appears thin, height of 48”, weight of 64 lbs., relaxed, bent posture, unsteady gait; coordinated movement, dominantly uses left foot in standing, able to sits up straight, and walks at moderate speed, clean, unkempt appearance, presence of purulent wound odor, withdrawn, able to follow instructions, affect is appropriate to situation, speech is understandable, moderate pace; clear tone & inflection; exhibits thought association, relevance & organization of thought has relevant s sequence; makes sense; has sense of reality. BMI=14.3
Integument
Nails
Convex curvature; angle of nail plate about 160 degrees, smooth texture, highly vascular & pink, intact epidermis, prompt return of pink or usual color.
Hair
Evenly distributed, thin, silk, resilient, no infection or infestation, variable amount.
Skin
Color is light brown, generally uniform except in areas exposed to the sun, no edema, wound size at right shoulder is 12” x 6” 4 mm deep at most, wounds sizes at thigh are 1 x 1”; 4 x 2”; 4 x 4”; itchy, 2 mm deep at most, uniform temperature; within normal range, when pinched then skin springs back to previous state.
Head
Skull & Face
Vital Signs Results
Blood Pressure 80/50 mmHg
Pulse rate 84 BpM
Respiratory rate 32 CpM
Temperature 37.7 degrees Celsius
Rounded (normocephalic and symmetric with frontal, parietal, and occipital prominences); smooth skull contour, smooth uniform consistency; absence of nodules or masses, almost symmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds, symmetric facial movements.
Eye structures & visual acuity
Visual acuity
Able to read newsprint
Extraocular Muscle Tests
Light falls symmetrically on both pupils, uncovered eye does not move on cover test
Visual Fields
When looking straight ahead, client can see objects in the periphery, both eyes coordinated, move in unison, with parallel alignment
External Eye Structures
Eyebrows hair evenly distributed; skin intact, eyebrows symmetrically aligned; equal movement, equally distributed eyelashes; curled slightly outward, eyelid skin is intact; no discharge; no discoloration, lids close symmetrically, approximately 15 to 20 involuntary blinks per minute; bilateral blinking, when lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered, Transparent bulbar conjunctiva; capillaries sometimes evident; sclera appears white, shiny, smooth, and pink palpebral conjunctiva, no edema or tenderness over 3 mm in diameter; round, smooth border, iris flat & round lacrimal gland, no edema or tearing on the lacrimal sacs & nasolacrimal ducts, transparent, shiny, & smooth cornea; details of the iris are visible, client blinks when the cornea is touched, transparent anterior chamber, no shadows of light on iris, depth of about 3 mm, pupils are black in color; equal size, 3 mm in diameter; round, smooth border, iris flat & round, illuminated pupil constricts (direct response), nonilluminated pupil constricts (consensual response), Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose.
Ears & Hearing
Gross Hearing Acuity Tests
Normal voice tones audible, able to hear ticking in both ears.
External Ear Canal and Tympanic Membrane
Distal third contains glands, dry cerumen, and tan color, tympanic membrane has pearly gray color, semitransparent.
Auricles
Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye; about 10 degrees from vertical, mobile, firm, & not tender; pinna recoils after it is folded.
Nose & Sinuses
Nose
Symmetric & straight, no discharge, uniform color, not tender; no lesions, air move freely as the client breathes through the nares, mucosa pink, clear, watery discharge, no lesions, nasal septum intact & in midline.
Facial Sinuses
Not tender
Mouth & Oropharynx
Lips & Buccal Mucosa
Outer lips has a uniform pink color, soft, moist, smooth texture, symmetry of contour, able to purse lips, inner lips & buccal mucosa has uniform pink color, moist, smooth, glistening, & elastic texture
Teeth & Gums
30 teeth, white, stained tooth enamel, pink gums, no retraction of gums.
Tongue/Floor of the Mouth
Tongue is at the center, pink color, smooth lateral margins; no lesions, raised papillae, moves freely; no tenderness, tongue base has prominent veins
Salivary Glands
Same as color of buccal mucosa & floor of mouth
Palates & Uvula
Soft palate is light pink, lighter pink hard palate, more irregular texture, uvula is positioned in midline of soft palate
Oropharynx & Tonsils
Pink & smooth posterior wall, pink & smooth tonsils, no discharge, of normal size: Grade 1 (normal), present gag reflex.
Neck
Neck Muscles
Muscle equal in size; head centered, head movement is coordinated, smooth movements with no discomfort, head flexes 45 degrees, hyperextends 60 degrees, laterally flexes 40 degrees, laterally rotates 70 degrees, muscle strength is equal when turning head, equal when shrugging shoulders
Lypmh Nodes
Not palpable
Trachea
Centrally placed in the midline of neck; space are equal on both sides
Thyroid Gland
Not visible on inspection, gland ascends during swallowing but is not visible, lobes cannot be palpated, absence of bruit.
Chest, Lungs and Axilla
Thorax & Lungs
Anterior Thorax
Quiet, rhythmic, & effortless respirations, costal angle is less than 90 degrees & the ribs insert into the spine at approximately 45 degrees angle, vocal fremitus is the same as posterior thorax; vocal fremitus decreased over heart & breast tissue, percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas bone, dull on areas over the heart & the liver, & tympanic over the underlying stomach, bronchial and tubular breath sounds are heard on the trachea, bronchovesicular & vesicular breath sounds are heard on the bronchi between over the sternum and the clavicles
Cardiovascular & Peripheral Vascular Systems
Heart & Central Vessels
No pulsations in the aortic & pulmonic areas, no pulsations; lift in the tricuspid area, no lift or heave in the apical area, aortic pulsations at the epigastric area, S1: heard at all sites, S2: heard at all sites, systole: silent interval; slightly shorter duration than diastole, diastole: silent interval; slightly longer duration than systole
Carotid Arteries
Symmetric pulse volume, full pulsations, thrusting quality, quality remains the same when client breathes, turns head, & changes from sitting to supine position, elastic arterial wall, no sound heard on auscultation
Jugular Veins
Veins not visible
Peripheral Vascular System
Symmetric pulse volumes, full pulsations,
Peripheral Veins
Symmetric pulse volumes, full pulsations
Peripheral Veins
Limbs not tender, symmetric in size
Peripheral Perfusion
Skin color pink, skin temperature not excessively warm or cold, no edema.
Buerger’s Test
Original color returns in 10 sec.; veins in feet or hands fill in about 15 sec.
Capillary Refill Test
Immediate return of color=< 2 sec.
Breast & Axillae
Flat, muscles not yet developed, skin uniform in color, smooth & intact, areola are oval & bilaterally the same, dark brown, nipples are round, everted, equal in size; similar in color; both point in the same direction, no discharge, axillary, subclavicular, supraclavicular lymph nodes are not tender, no masses, breast has no masses, tenderness, nodules, discharge
Abdomen
Inspection
Unblemished skin, uniform color, flat, no evidence of enlargement of liver or spleen, symmetric contour, symmetric movements caused by respiration, no visible vascular pattern
Auscultation
Absence of friction rub, Audible bowel sounds, Absence of arterial bruits
Percussion
Tympany over the stomach; dullness especially over the liver & spleen
Percussion of the Liver
2.5” in the mid-clavicular line; 1.5” at the midsternal line
Palpation
No tenderness; relaxed abdomen with smooth, consistent tension
Palpation of the Liver
Not palpable
Palpation of the bladder
Not palpable
Genito-Urinary
Pubic Hair
Pt. denies assessment & does not answer directly.
Penis
Pt. denies assessment but states that there is no problem & he is circumcised.
Scrotum
Pt. denies assessment but states that there is no problem.
Inguinal Area
Pt. denies assessment but states that there is no problem.
Rectum & Anus
Pt. denies assessment but states that there is no problem.
Back
Posterior Thorax
Anteroposterior to transverse diameter in ratio of 1:2, chest symmetric, spine vertically aligned, spinal column is straight, right & left shoulders & hips are at same height, skin intact, uniform temperature, chest wall intact, Full and symmetric chest expansion, bilateral symmetry of vocal fremitus, fremitus is heard most clearly at the apex of the lungs, Percussion notes resonates; except over left scapula, Lowest point of resonance is at the diaphragm, percussion on a rib elicits dullness, vesicular & bronchovesicular breath sounds present.
Upper extremities
Muscles
No contractures, no tremors, normally firm, smooth coordinated movements, equal strength on each body side, no right arm muscles.
Bones
No right scapula, no tenderness, no radius, no ulna, no humerus.
Joints
No swelling, no tenderness, no crepitating sounds, no nodules, joints move smoothly, normal range of motion
Lower Extremities
Muscles
No contractures, no tremors, normally firm, smooth coordinated movements, equal strength on each body side.
Bones
No tenderness, no deformities.
Joints
No swelling, no tenderness, no crepitating sounds, no nodules, joints move smoothly, normal range of motion.
Anatomy & Physiology
I. Upper limb
Front of right upper extremity.
Back of right upper extremity.
Latin: Membrum Superius
Gray's: subject #289 1325
System: Musculoskeletal
MeSH: Extremity Upper Extremity
A. The upper limb or upper extremity is the region extending from the deltoid region to the hand, including the arm, axilla and shoulder.
B. Anatomy
1. The muscles of the upper limb can be classified by origin, topography, function, or innervation. While a grouping by innervation reveals embryological and phylogenetic origins, the functional-topographical classification below reflects the similarity in action between muscles (with the exception of the shoulder girdle, where muscles with similar action can vary considerably in their location and orientation.
2. Musculoskeletal system
a) Shoulder girdle
(1) Bones of the shoulder girdle
(i) The shoulder girdle or
pectoral girdle, composed of
the clavicle and the scapula,
connects the upper limb to the axial
skeleton through
the sternoclavicular joint (the only
joint in the upper limb that directly
articulates with the trunk), a ball and
socket joint supported by
the subclavius muscle which acts as
a dynamic ligament. While this
muscle prevents dislocation in the
joint, strong forces tend to break the
clavicle instead.
The acromioclavicular joint, the joint
between the acromion process on
the scapula and the clavicle, is
similarly strengthened by strong
ligaments, especially the
coracoclavicular ligament which
prevents excessive lateral and
medial movements. Between them
these two joints allow a wide range
of movements for the shoulder
girdle, much because of the lack of
a bone-to-bone contact between the
scapula and the thoracic cage.
The pelvic girdle is, in contrast,
firmly fixed to the axial skeleton,
which increases stability and load-
bearing capabilities.
(ii) The mobility of the shoulder
girdle is supported by a large
number of muscles. The most
important of these are muscular
sheets rather than fusiform or strap-
shaped muscles and they thus
never act in isolation but with some
fibres acting in coordination with
fibres in other muscles.
(2) Muscles of shoulder girdle excluding the glenohumeral joint
(a) Migrated from head
(i) Trapezius, sternocleidomastoideus, omohyoideus
(b) Posterior(i) Rhomboideus major, rhomboideus minor, levator scapulae
(c) Anterior(i) Subclavius, pectoralis minor, serratus anterior
b) Shoulder joint
(1) Shoulder joint with ligaments
(2) The glenohumeral joint (colloquially called
the shoulder joint) is the highly mobile ball and
socket joint between the glenoid cavity of the
scapula and the head of the humerus. Lacking the
passive stabilisation offered by ligaments in other
joints, the glenohumeral joint is actively stabilised
by the rotator cuff, a group of short muscles
stretching from the scapula to the humerus. Little
inferior support is available to the joint and
dislocation of the shoulder almost exclusively
occurs in this direction.
(3) The large muscles acting at this joint
perform multiple actions and seemingly simple
movements are often the result of composite
antagonist and protagonist actions from several
muscles. For example, pectoralis major is the
most important arm flexor and latissimus dorsi the
most important extensor at the glenohumeral
joint, but, acting together, these two muscles
cancel each other's action leaving only their
combined medial rotation component. On the
other hand, to achieve pure flexion at the joint
the deltoid and supraspinatus must cancel the
adduction component and the teres minor
and infraspinatus the medial rotation component
of pectoralis major. Similarly, abduction (moving
the arm away from the body) is performed by
different muscles at different stages. The first 10°
is performed entirely by the supraspinatus, but
beyond that fibres of the much stronger pectoralis
major are in position to take over the work.
Furthermore, to achieve the full 180° range of
abduction the arm must be rotated medially and
the scapula must be rotate about itself to direct
the glenoid cavity upward. c) Muscles of shoulder joint proper
(1) Posterior(a) Supraspinatus, infraspinatus, teres minor, subscapularis, deltoideus, latissimus dorsi, teres major
(2) Anterior(a) Pectoralis major, coracobrachialis
d) Arm
(1)
(a) Superficial muscles of the arm
(2) The arm proper (brachium), the region between the shoulder and the elbow, is composed of the humerus with the elbow joint at its distal end.
(3) The elbow joint is a complex of three joints
(a) The humeroradial, humeroulnar, and superior radioulnar joints
(i) The former two allowing flexion and extension whilst the latter, together with its inferior namesake, allows supination and pronation at the wrist. Triceps is the major extensor and brachialis and biceps the major flexors. Biceps is, however, the major pronator and while performing this action it ceases to be an effective flexor at the elbow.
(4) Muscles of the arm
(a) Posterior
(i) Triceps brachii, anconeus
(b) Anterior
(i) Brachialis, biceps brachii
e) Forearm
(1) Ventral superficial muscles of the forearm
(a) The forearm
(antebrachium) composed of
the radius and ulna; the latter is the main
distal part of the elbow joint, while the
former composes the main proximal part of
the wrist joint.
(2) Most of the large number of muscles in the
forearm are divided into the wrist, hand, and
finger extensors on the dorsal side (back of hand)
and the ditto flexors in the superficial layers on
the ventral side (side of palm).
(a) These muscles are attached to
either the lateral or medial epicondyle of
the humerus. They thus act on the elbow,
but, because their origins are located close
to the centre of rotation of the elbow, they
mainly act distally at the wrist and hand.
Exceptions to this simple division are
(i) brachioradialis
(a) a strong elbow flexor
(ii) palmaris longus
(a) A weak wrist flexor
which mainly acts to tense
the palmar aponeurosis. The
deeper flexor muscles are
extrinsic hand muscles;
strong flexors at the finger
joints used to produce the
important power grip of the
hand, whilst forced extension
is less useful and the
corresponding extensor thus
are much weaker.
(b) Biceps is the major supinator (drive
a screw in with the right arm) and
(c) pronator teres and pronator
quadratus the major pronators
(unscrewing)
(i) The latter two role the radius
around the ulna (hence the name of
the first bone) and the former
reverses this action assisted
by supinator. Because biceps is
much stronger than its opponents,
supination is a stronger action than
pronation (hence the direction of
screws). (3) Muscles of the forearm
(a) Posterior
(i) (Superficial) extensor
digitorum, extensor digiti
minimi, extensor carpi ulnaris,
(deep) supinator, abductor pollicis
longus, extensor pollicis
brevis, extensor pollicis
longus, extensor indicis
(b) Anterior
(i) (Superficial) pronator
teres, flexor digitorum
superficialis, flexor carpi
radialis, flexor carpi ulnaris, palmaris
longus, (deep) flexor digitorum
profundus, flexor pollicis
longus, pronator quadratus
(c) Radial
(i) Brachioradialis, extensor
carpi radialis longus, extensor carpi
radialis brevis
f) Wrist
(1) The wrist (carpus), composed of the carpal
bones, articulates at the wrist joint (or radiocarpal
joint) proximally and the carpometacarpal
joint distally. The wrist can be divided into two
components separated by the midcarpal joints.
The small movements of the eight carpal bones
during composite movements at the wrist are
complex to describe, but flexion mainly occurs in
the midcarpal joint whilst extension mainly occurs
in the radiocarpal joint; the latter joint also
providing most of adduction and abduction at the
wrist.
(2) How muscles act on the wrist is complex to
describe. The five muscles acting on the wrist
directly
(a) flexor carpi radialis, flexor carpi
ulnaris, extensor carpi radialis, extensor
carpi ulnaris, and palmaris longus
(b) Are accompanied by the tendons of
the extrinsic hand muscles (i.e. the
muscles acting on the fingers). Thus, every
movement at the wrist is the work of a
group of muscles; because the four
primary wrist muscles (FCR, FCU, ECR,
and ECU) are attached to the four corners
of the wrist, they also produce a secondary
movement (i.e. ulnar or radial deviation).
To produce pure flexion or extension at the
wrist, these muscles therefore must act in
pairs to cancel out each other’s secondary
action. On the other hand, finger
movements without the corresponding
wrist movements require the wrist muscles
to cancel out the contribution from the
extrinsic hand muscles at the wrist. g) Hand
h)
(1) Bones of the hand
(a) The hand
(manus), the metacarpals (in the hand
proper) and the phalanges of the fingers,
form the metacarpophalangeal
joints (MCP, including the knuckles)
and interphalangeal joints (IP).
(b) Of the joints between the carpus
and metacarpus, the carpometacarpal
joints, only the saddle-shaped joint of the
thumb offers a high degree of mobility
while the opposite is true for the
metacarpophalangeal joints. The joints of
the fingers are simple hinge joints.
(c) The primary role of the hand itself is
grasping and manipulation; tasks for which
the hand has been adapted to two main
grips — power grip and precision grip. In a
power grip an object is held against the
palm and in a precision grip an object is
held with the fingers, both grips are
performed by intrinsic and extrinsic hand
muscles together. Most importantly, the
relatively strong thenar muscles of the
thumb and the thumb's flexible first joint
allow the special opposition movement that
brings the distal thumb pad in direct
contact with the distal pads of the other
four digits. Opposition is a complex
combination of thumb flexion and
abduction that also requires the thumb to
be rotated 90° about its own axis. Without
this complex movement, humans would not
be able to perform a precision grip.
(d) In addition, the central groups of
intrinsic hand muscles give important
contributions to human dexterity. The
palmar and dorsal interossei abduct and
adduct at the MCP joints and are important
in pinching. The lumbricals, attached to the
tendons of the flexor digitorum
profundus (FDP) and extensor digitorum
communis (FDC), flex the MCP joints while
extending the IP joints and allow a smooth
transfer of forces between these two
muscles while extending and flexing the
fingers. (e) Muscles of the hand
(i) Metacarpal
(a) Lumbricals, dorsal
interossei, palmar introssei
(ii) Thenar
(a) Abductor pollicis
brevis, adductor
pollicis, flexor pollicis
brevis, opponens pollicis
(iii) Hypothenar
(a) Abductor digiti
minimi, flexor digiti
minimi, opponens digiti
minimi, palmaris brevis
3. Neurovascular system
a) Innervation
(1) Branches of brachial plexus
(2) The motor and sensory supply of the upper
limb is provided by the brachial plexus which is
formed by the ventral rami of spinal nerves C5-
T1. In the posterior triangle of the neck these rami
form three trunks from which fibers enter the axilla
region (armpit) to innervate the muscles of the
anterior and posterior compartments of the limb.
In the axilla, cords are formed to split into
branches, including the five terminal branches
listed below. The muscles of the upper limb are
innervated segmentally proximal to distal so that
the proximal muscles are innervated by higher
segments (C5–C6) and the distal muscles are
innervated by lower segments (C8–T1).
(3) Motor innervation of upper limb by the five
terminal nerves of the brachial plexus:
(a) The musculocutaneous
nerve innervates all the muscles of
the anterior compartment of the arm.
(b) The median nerve innervates all the
muscles of the anterior compartment of the
forearm except flexor carpi ulnaris and the
ulnar part of the flexor digitorum profundus.
It also innervates the three thenar muscles
and the first and second lumbricals.
(c) The ulnar nerve innervates the
muscles of the forearm and hand not
innervated by the median nerve.
(d) The axillary nerve innervates
the deltoid and teres minor.
(e) The radial nerve innervates the
posterior muscles of the arm and forearm
(4) Collateral branches of the brachial plexus:
(a) The dorsal scapular
nerve innervates rhomboid
major and minor.
(b) The long thoracic
nerve innervates serratus anterior.
(c) The suprascapular
nerve innervates supraspinatus and infrasp
inatus
(d) The lateral pectoral
nerve innervates pectoralis major
(e) The medial pectoral
nerve innervates pectoralis
major and minor
(f) The upper subscapular
nerve innervates subscapularis
(g) The thoracodorsal
nerve innervates latissimus dorsi
(h) The lower subscapular
nerve innervates subscapularis and teres
major
(i) The medial brachial cutaneous
nerve innervates the skin of medial arm
(j) The medial antebrachial cutaneous
nerve innervates the skin of medial forearm
II. Prokaryotic cells
A. Diagram of a typical prokaryotic cell
B. Nuclear material of prokaryotic cell consists of a single
chromosome that is in direct contact with cytoplasm. Here, the
undefined nuclear region in the cytoplasm is called nucleoid.
A prokaryotic cell has three architectural regions:
1. On the outside
a) flagella
(1) A tail-like projection that protrudes from the
cell body and functions in locomotion.
b) and pili
(1) Pili connect a bacterium to another of its
species, or to another bacterium of a different
species, and build a bridge between the interior of
the cells. This enables the transfer
of plasmids between the bacteria.
c) Project from the cell's surface. These are
structures (not present in all prokaryotes) made of
proteins that facilitate movement and communication
between cells;
2. Enclosing the cell is the cell envelope
a) covering a plasma membrane
(1) The protective envelope that separates the
inside of the cell from its surroundings. It contains
specialized receptors that detect chemical
messages, as well as pumps and pores that
regulate the flow of substances into and out of the
cell. The membrane also anchors the cells to the
surrounding tissues and links adjacent cells at
specialized junctions, to form tissues
b) The envelope gives rigidity to the cell and
separates the interior of the cell from its environment,
serving as a protective filter.
3. Inside the cell is the cytoplasmic region
a) A transparent, gel-like region outside the nucleus,
in which the organelles are suspended
b) that contains
(1) The cell genome (DNA) and ribosomes
and various sorts of inclusions...
(2) Though not forming a nucleus, the DNA is
condensed in a nucleoid.
(3) Prokaryotes can carry extrachromosomal
DNA elements called plasmids, which are usually
circular.
(a) Plasmids enable additional
functions, such as antibiotic resistance.
(4) Microfilaments
(a) Fine thread-like fibers made from a
protein called actin. These form part of the
cell’s internal skeleton, allowing the cell to
change shape and move by ‘rolling’ or
‘crawling’ along a surface
(5) Centrioles
(a) Are small cylinders, at right angles
to one another, made up of nine sets of
microtubules. They are involved in the
formation and elongation of the cell’s
microtubules,
(6) Lysosomes
(a) Small vesicles containing that
powerful acids and enzymes that
breakdown worn-out organelles, and digest
bacteria and foreign substances taken up
by the cell.
(7) Golgi Apparatus
(a) The cell’s processing & transport
area. It stores, sorts and modifies products
made within the cell, and transports them
to other organelles or to the cell surface in
vesicles. Most cells need only one Golgi
apparatus, but some have more
(8) Peroxisome
(a) Small vesicles that detoxify alcohol,
hydrogen peroxide and other toxins that
may be present within a cell.
(9) Rough Endoplasmic Reticulum
(a) An internal network of flattened
sacs, studded with ribosomes, which is
involved in packaging proteins
(10) Mitochondria
(a) Batteries of a cell. They use oxygen,
glucose and fatty acids to release energy
plus waste carbon dioxide gas. It contains
its own genetic material, and is believed to
have evolved from symbiotic bacteria that
combine with single-celled organisms at
the dawn of life on earth.
(11) Ribosomes
(a) Small units that assemble the amino
acid chains that form proteins. Some
ribosomes move freely within the
cytoplasm, while others are attached to the
rough endoplasmic reticulum, which
funnels newly formed proteins to the Golgi
apparatus.
(12) Smooth Endoplasmic Reticulum
(a) An internal network of branching
tubes involved in the production of fatty
acids, steroids and the storage and release
of Ca.
(13) Microtubules
(a) Hollow tubes, made from a protein
called tubulin, which form part of the cell’s
internal skeleton, maintaining its shape and
assisting with cell division, movement of
organelles within the cell and transport of
vesicles
(14) The nucleus is separated from the rest of
the cell by the nuclear envelope.
(i) The membrane that
separates the nucleus from the rest
of the cell. Chemicals can move to
and from the nucleus to the
cytoplasm via holes in the envelope
known as nuclear pores
(b) Nucleus
(i) The largest organelle. It is the
cell’s control centre and contains the
chromosomes.
(a) A circular molecule
(ii) Most cells have only one
nucleus, a few specialized skeletal
muscle cells have several nuclei and
mature red blood cells and the clear
cells found in the crystalline lens of
the eye have none.
III. DNA
A.
B. Contains a human’s full genetic blueprint stored as
1. Chromosomes
a) There are 23 pairs. One of each pair was
inherited from an individual’s mother, the other from the
father. 44 of these chromosomes contain genes
(1)
(2) That provides the code for proteins
involved in the structure & function of every cell.
(3) The stretch of DNA that provides all the
coding needed to make a single protein.
Scientists from around the world have
collaborated in the human Genome Project to
decode the sequence of genes that make up a
human being. They have determined that each
own about 40,000 genes-a figure originally
thought to be considerably higher.
(4) The genes within every cell in a person are
identical, but, depending on the type of cell,
different genes are switched on and off, so the
cell can make the particular proteins it requires.
That is why liver cells, muscle cells, skin cells &
fat cells are all so different from 1 another.
(5) Each gene exists in many different forms
within the population, according to the exact order
of it’s A and T or C and G sub-units. A man
inherits 23 chromosomes from each parent.
Although everyone inherits the same number and
types of genes, the subtle difference within them
make each person unique from the other 6.5
billion on this planet. Some of the genes that a
man inherits determine his visible features, such
as his skin, hair & eye colour, while others
determine how his metabolism functions and
whether or not he is at risk of developing medical
problems such as high blood pressure, diabetes
or cancer.
b) The remaining pair of sex chromosomes contains
information that determines an individual’s male (Y) &
female (X) characteristics.
c) The DNA molecules are loosely wound around
special proteins (histones), which form a spaghetti-like
complex called chromatin. Before a cell divides, each
molecule of DNA is copied & condenses to form a
duplicated chromosome. Each duplicated molecule
chromosome contains 2 identical strands of DNA,
referred to as sister chromatids. The chromatids remain
attached at a point called telomeres, which never copy.
After duplication, the DNA molecules condense again to
form copies of the X-shaped structures known as
duplicated chromosomes.
d) 46 highly coiled molecules, made up of 2 chains
of units called
(1) Nucleotides, which roll around each other
to form a long, spiral shaped, double helix.
(a)
(b) Each nucleotide consists of a
phosphate group, the sugar deoxyribose
and one of 4 chemicals called bases:
adenine (A), thymine (T), cytosine (C) or
guanine (G). These bases face inwards
and pair up to form the rungs of the
double-helix ladder. Importantly, A always
pairs with T, and C always pairs with G.
(c) The DNA provides the code needed
for cells to make proteins, which are
formed from a chain of amino acids. The
code depends on the order in which the
bases occur along 1 strand-known as the
sense strand-of the DNA helix. Each run of
3 bases-called a triplet-provides the code
for a particular amino acid. This code tells
each cell the order in which place amino
acids in a protein chain.
Date/Time Doctor’s Order Rationale Remarks7/9/117AM
Please admit under GS 2 S. West
Admission is required to assess and observe the patient further. This is also to monitor patient's condition and provide necessary care and interventions related to diagnosis.
Done
Secure consent to care
Patient has the right to be consented in all procedures to be done.
Done
DAT Diet as tolerated to maintain nutritional status of patient.
Done
Monitor VS q4 To monitor vital signs so that any unusualities will be referred as follows.
Done
IVF: D5LR @ 100cc/hr
For fluid replacement. Done
Labs: CBC PC CBC with PC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.
Done
Serum calcium electrolyte
Serum calcium indicates whether there is a calcium deficit or an abnormal increase of calcium level in the blood stream.
Done
X-ray ® arm To see whether a bone has been fractured or a joint dislocated. It is also used to check for an injury or damage from conditions such as an infection, arthritis, bone growths (tumors), or other bone diseases.
Done
Blood transfusion Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.
Done
Chest X-ray Ordered for symptoms of shortness of breath, cough,
Done
or chest pain.
Meds: Mefenamic acid 250mg, q6, take with meals
For relief of pain including muscular, traumatic, fever, and headache.
Done
For referral to consultant
This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
4PM STAT Ketorolac 30mg q8
Effective in the management of moderately severe acute pain.
Done
7/10/11 Continue meds Compliance with meds will avert any complications.
Done
For transfer service to GS 1
For specialized care and management.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/11/11 For referral to consultant
This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/12/118AM
Continue meds Compliance with meds will avert any complications.
Done
For referral to consultant
This may create a collaborative treatment among the client and health providers; thus it
Done
also makes a good coordination in the treatment of the client.
11AM To secure 1 unit of PRBC & transfer once with cross
matching
RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.Cross matching is done to determine if the donor's blood is compatible with the blood of an intended recipient.
Not done
Start cefuroxime 750mg IVTT q8
ANST
For the treatment of many different types of bacterial infections.
Done
For CT scan of chest include shoulder with
contrast
CT scans allow doctors to inspect the inside of the body without having to operate or perform unpleasant examinations including the affected part which is the shoulder.
Not done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/15/1112PM
Still to secure blood RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.
Not done
For compliance of medicine
Compliance with meds will avert any complications.
Done
Defer CT scan Not done
For MRI of ® arm to include shoulder
MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor.
Not done.
Refer to Anesthesia For pain management. DoneRefer This may create a
collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
4:10PM May start Tramadol- Ketorolac drip,
Tramadol 250mg + Ketorolac 90mg in
500cc D5W @ 20cc/hr x 1 cycle
Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.
Done
Give Ketorolac 30mg IVTT
For pain reliever. Done
Give Tramadol 40mg IVTT prior to
drip then q6 PRN for severe pain
For severe pain. Done
Metoclopromide 10mg IVTT PRN for
vomiting
It is commonly used to treat nausea and vomiting, to facilitate gastric emptying.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/16/116AM
Continue Tramadol-Ketorolac drip
Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.
Done
Still for MRI MRI can find changes in the structure of organs or other
Not done
tissues. It also can find tissue damage or disease, such as infection or a tumor.
Still to secure blood RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.
Not done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/17/116PM
Still for MRI MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor.
Not done
Continue Tramadol-Ketorolac drip
Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.
Done
Still to secure blood RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.
Not done
7/18/11 For repeat CBC today
CBC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells.
Not done
To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.
To secure 1 unit of PRBC & transfer
after cross matching
RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.Cross matching is done to determine if the donor's blood is compatible with the blood of an intended recipient.
Not done
To secure another 4 unit of PRBC for OR
use
For blood loss replacement during the operation.
Done
Continue Meds Compliance with meds will avert any complications.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/20/1112:30AM
Give Paracetamol 500mg tab now then
after q4 PRN for fever
It is commonly used for the relief of fever, headaches, and other minor aches and pains. Given every hours for 24 hours. And as needed if temperature is greater than 38° C.
Done
9AM Still for MRI MRI can find changes in the structure of organs or other tissues. It also can find tissue damage or disease, such as infection or a tumor.
Not done
Still for repeat CBC CBC determines the quantity of each quantity of blood cell in a given
Not done
specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.
Continue Meds Compliance with meds will avert any complications.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/21/118:45AM
Still for repeat CBC CBC with determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.
Done
Continue Meds Compliance with meds will avert any complications.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the
Done
treatment of the client.
Refer to Ortho and possible transfer
service
For evaluation. Not done
7/23/1111:10PM
Follow up: Serum Calcium
Serum calcium indicates whether there is a calcium deficit or an abnormal increase of calcium level in the blood stream.
Done
Alkaline Phosphatase
Used to help detect liver disease or bone disorders.
Done
ESR To help detect conditions associated with acute and chronic inflammation, including infections, cancers, and autoimmune diseases.
Done
Continue blood transfer
Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.
Done
7/24/1110AM
For re-cross matching prior to
transfusion
To determine if the donor's blood is compatible with the blood of an intended recipient.
Not done
Continue meds Compliance with meds will avert any complications.
Done
Continue Tramadol-Ketorolac drip
Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/25/116AM
S/F re-cross matching
To determine if the donor's blood is compatible with the blood of an intended recipient.
Done
Continue Tramadol-Ketorolac drip
Tramadol with Ketorolac drip for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain.
Done
S/F transfer to Ortho service
For evaluation. Done
ReferThis may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/26/113:24PM
May transfer to Ortho once cleared
by GS
Transfer to Orthopedic ward for further evaluation.
Done
Transfuse 2 units available blood of
patient’s blood type properly secure 2nd cross
matched.
Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.
Done
Give Diphenhydramine
50mg IVTT once BT starts
To limit allergic reactions to blood products.
Done
7/27/111PM
Cleared from GS Patient is ready to be transferred to Ortho Ward.
Done
Transfer to Ortho ward
Orthopedic ward caters patients with skeletal or bone problems such as fracture and dislocation.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
7/29/11 To secure 4 units of For correction of anemia. Done
blood of patient’s blood type.Pressure sore
precaution on shoulder mass ®
To avoid infection. Done
7/31/119:16Am
Please transfuse available blood of
patient’s blood type and after proper
cross matching as previously ordered
RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.Cross matching is done to determine if the donor's blood is compatible with the blood of an intended recipient.
Done
Decrease IVF to KVO rate while BT
To prevent circulatory overload.
Done
For referral on pedia onco tomorrow
Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
8/1/1111AM
Repeat CBC post 2 units of transfusion
To check for hemoglobin level.
Done
2PM Verbal order: To give paracetamol 300mg IVTT now
It is commonly used for the relief of fever, headaches, and other minor aches and pains. Given every hours for 24 hours. And as needed if temperature is greater than 38° C
Done
8/3/119:30AM
S/F correction of anemia
RBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical
Done
problems, and are one of the most important blood components used in transfusion medicine.
Follow up referral to pedia onco for evaluation and
clearance
Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.
Done
Continue meds Compliance with meds will avert any complications.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
2:50PM Please transfuse 2 units available blood
of patient’s blood type after properly
cross matched
Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.
Done
Decrease IVF rate to KVO once in BT
To prevent circulatory overload
Done
Give Diphenhydramine 50mg IVTT once transfuse starts
To limit allergic reactions to blood products.
Done
Watch out for fever, dyspnea, pruritus
and others
These are signs and symptoms of transfusion reaction.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
8/4/118AM
Please schedule patient for STAT OR 3rd table other room tomorrow
8/5/11
In preparation for the planned operation.
Done
Plan Fore Quarter Amputation
A major surgical procedure in which the upper extremity and a variable portion of the supporting shoulder girdle is amputated, to treat either advanced malignancy.
Done
NPO @ 3AM To avoid aspiration during operation.
Done
Cefazolin 2g IVTT 1 hour prior to OR, 1g
q8 there after
Cefazolin is given 1 hour prior to OR to reduce the incidence of certain postoperative infections in patients undergoing surgical procedures which are classified as contaminated or potentially contaminated.
Done
Inform OR/AR OD For reservation of table in the Operating room and endorsement of patient.
Done
Secure pedia onco clearance for
surgery
Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.
Done
3PM Ranitidine 30 mg IVTT 1 hour prior
Ranitidine reduces preoperative gastric fluid acidity and volume.
Done
To secure 4 units PRBC
PRBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia due to trauma or other medical problems, and are one of the most important blood components used in transfusion medicine.
Done
To secure 2 unit Fresh Frozen
Plasma, Patient’s blood type properly
retype
Used for patients with a coagulopathy who are bleeding or at risk of bleeding. FFP should be blood type-matched to ensure compatibility.
Done
Refer accordingly This may create a Done
collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Follow up repeat RBC port Blood
Transfusion
Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.
Done
4PM NPO post midnight To avoid aspiration during operation.
Done
To secure pedia ICU reservation
For possible post-op use. Done
Adequate hydration To keep the stomach and intestines clear, limit strain to the digestive system, but keep the body hydrated prior to or recover from a medical procedure.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
8/5/117PM
S/P Fore Quarter Amputation under
GETA
Operation done to the patient.
Done
To PACU until stable then to Ortho
ward
Post-op patients are transferred to PACU for close monitoring and to watch out for any unusualities and complications after undergoing a surgery.
Done
May have soft diet until fully awake with
aspiration precaution
The digestive system tolerates softer foods better after surgery so cramps and abdominal pain can be avoided.
Done
Monitor VS q15 until stable then hourly
To monitor vital signs so that any unusualities will be referred as follows.
Done
Q15 since patient is post-op and there is a higher risk for complications to occur after surgery.
Continue venoclysis with PLR @ KVO
rate
For fluid resuscitation. Done
Continue blood transfusion @
80cc/hr – Left arm
Transfusions are used to treat blood loss or to supply blood components that the body cannot make for itself.
Done
Terminate IV line @ R arm
Right arm was amputated. Done
Meds: Morphine drip: D5W 500ml +
10mg Morphine with 20mgtts/min, may
give 1.5mg PRN for severe pain
To reduce pain. Done
Meds: Ketorolac 15mg q6 IVTT x 8 doses then shift to
Mefenamic acid 500mg cap 1 cap q6
PO after meals
Switching from intravenous (IV) to oral (PO) therapy as soon as patients are clinically stable can reduce the length of hospitalization and lower associated costs.
Done
Meds: Ranitidine 35mg q8 IVTT x
2days
Treatment and prevention of heartburn, acid indigestion, and sour stomach.
Done
Meds: Metoclopromide
10mg tablet, 1tab q6 PO, PRN for pain
It is commonly used to treat nausea and vomiting, to facilitate gastric emptying.
Done
Meds: Furosemide 20mg IVTT post-BT
Furosemide is a "water pill" (diuretic) that causes you to make more urine.
Done
MHBR Allows greater lung expansion and prevent compression on the diaphragm from prolong
Done
bed rest.Thermo regulate
patientTo check for fever. Done
O2 inhalation @ 6L/min face mask
To alleviate dyspnea. Done
Monitor I&O qhour and record
To monitor the elimination status of the patient and the kidney function as well as for any complications and unusualitiesQhour since patient is post-op.
Done
For CBC post BT @ ward
To check for RBC, WBC, and Platelet count of the patient.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
11:05PM IV rates: PLR @60cc/hr, PNSS @ 10cc/hr, Morphine
drip 20cc/hr =90cc/hr
To replace fluid loss. Done
8/6/119PM
Continue Antibiotics Compliance with meds will avert any complications.
Done
8/7/111AM
Phone order: O2 inoculation via nasal
cannula @ 2Lpm
To relieve dyspnea and other problems in breathing.
Done
9:05AM May remove Foley catheter
To void freely. Done
Monitor I&O q shift To monitor the elimination status of the patient and the kidney function as well as for any complications and unusualities
Done
Cont. VS monitor qhour
To monitor vital signs so that any unusualities
Done
will be referred as follows. Q1hour since patient is post-op and complications usually occur hours after a surgery.
Tramadol 35mg q6 IVTT PRN
To give as needed for severe pain.
Done
9:55AM Maintain 1 IV line, D/C other IV lines
To correct electrolyte imbalances, to deliver medications, for blood transfusion or as fluid replacement to correct, for example, dehydration.
Done
Wound dressing To avoid wound infection. DoneContinue antibiotics Compliance with meds will
avert any complications. Done
DAT Diet as tolerated to maintain nutritional status of patient.
Done
Refer to pedia onco for post-op co-management
Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.
Done
8/8/1112PM
Follow up referral to pedia onco
Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.
Done
8/9/11 For dressing of wound
To avoid wound infection. Done
Cont. meds Compliance with meds will avert any complications.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
8/10/119:45AM
For wound dressing To avoid wound infection. Done
Discontinue antibiotics IVTT
Antibiotics will be given PO.
Done
Start Cefuroxime Cefuroxime is used for Done
500mg/cap; 1tab BID PO
treatment of serious infections of the lower respiratorytracts.
8/12/11 For wound dressing today
To avoid wound infection. Done
Cont. meds: Cefuroxime:PO
Amikacin: IV-D/C
Cefuroxime is used for treatment of serious infections of the lower respiratorytracts..
Done
Refer to dietary For nutritional build-up. DonePls. include 3 egg whites per meal
Egg Whites provide an excellent source of amino acids for developing muscles.
Done
Follow up official biopsy result
A means of acquiring a tissue in order to make a definitive diagnosis.
Done
8/13/119:30AM
Dressing wound To avoid wound infection. Done
Cont. antibiotics Compliance with meds will avert any complications.
Done
8/14/113:50PM
Wound dressing To avoid wound infection. Done
For strict compliance of
antibiotics.
Compliance with meds will avert any complications.
Done
Follow up referral to dietary
For appropriate diet. Done
For compliance with 3 egg whites per
meal daily
Egg Whites provide an excellent source of amino acids for developing muscles.
Done
8/15/1111:50AM
For compliance with meds
Compliance with meds will avert any complications.
Done
Wound dressing To avoid wound infection. DoneFor compliance with
high albumin diet
High albumin diet is a combination of high calorie and high protein diet. It is important in regulating blood volume by maintaining the osmotic pressure of the blood compartment.
Done
Refer This may create a collaborative treatment among the client and
Done
health providers; thus it also makes a good coordination in the treatment of the client.
5:50PM Start Cloxacillin 500mg/cap q6
This is used to treat many different types of infections caused by staphylococcus bacteria. 500 mg orally every 6 hours for up to 21 days, depending on the nature and severity of the infection.
Done
Wound care To avoid wound infection. DoneHigh protein calorie
dietA high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness.
Done
8/16/119AM
Follow up biopsy result
To make a definitive diagnosis.
Done
Wound dressing To avoid wound infection. DoneStrict compliance of
oral antibioticsCompliance with meds will avert any complications.
Done
High protein calorie diet
A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness.
Done
8/17/117:10AM
Maintain high protein calorie diet
A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness.
Done
Strict compliance with antibiotic
Compliance with meds will avert any complications.
Done
Change dressing For hygienic purposes and to prevent infection.
Done
Follow up office of biopsy result
To make a definitive diagnosis.
Done
8/18/11 For compliance with meds
Compliance with meds will avert any complications.
Done
High protein calorie diet
A high protein and high calorie diet is made up of foods that are high in both protein and calories. It helps gain weight and get stronger after a surgery or illness.
Done
Follow up biopsy result
To make a definitive diagnosis.
Done
8/19/115:10PM
Strict compliance with meds
Compliance with meds will avert any complications.
Done
Dressing done For hygienic purposes and to prevent infection.
Done
Refer for repeat CBC today
To check for hemoglobin, WBC, platelet count.
Done
8/20/118:52AM
Continue meds Compliance with meds will avert any complications.
Done
Wound dressing To prevent infection. DoneFor debridement of
wound
To remove patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
Done
8/21/118:35AM
For wound care To prevent infection. Done
Please follow up debridement of
wound
To carry out the planned procedure.
Done
Continue meds Compliance with meds will avert any complications.
Done
8/22/1111:20AM
For wound care To prevent infection. Done
Continue meds Compliance with meds will avert any complications.
Done
8/23/118:40AM
Follow up biopsy result
To make a definitive diagnosis.
Done
Continue meds Compliance with meds will avert any complications.
Done
8/25/117:10AM
Refer back to Pedia onco
For further management. Done
Official biopsy: A type of cancer, specifically Done
Rhabdomyosarcoma
a sarcoma , in which the cancer cells are thought to arise from skeletal muscle progenitors.
Please inform pedia onco
Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.
Done
8/27/119:10AM
For wound dressing To prevent infection. Done
For repeat CBC PC CBC with PC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood The platelet count measures the quantity of the platelets.
Done
Continue meds Compliance with meds will avert any complications.
Done
8/28/118:51Am
For wound dressing To avoid infection. Done
For OR schedule In preparation for a surgery.
Done
Plan debridement: Split Thickness Skin
Graft (STSG)
To remove patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
Done
D/C: Loxacillin DoneContinue other
medsCompliance with meds will avert any complications.
Done
8/29/11 For wound dressing To avoid infection. DoneSecure blood and
OR materialIn preparation for the planned surgery.
Done
For STAT CX today To help diagnose symptoms such as shortness of breath, a bad or persistent cough, and chest pain or injury.
Done
8/30/117:30AM
For OR schedule In preparation for a surgery.
Done
8/31/119:50AM
Pls. schedule patient for OR tomorrow 2nd table.
In preparation for the planned operation.
Done
Plan STSG To remove patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
Done
Inform ROD For reservation of table in the Operating room and endorsement of patient.
Done
Secure consent Patient has the right to be consented in all procedures to be done.
Done
NPO post midnight To avoid aspiration during operation.
Done
IVF D5LR 1L @ 100cc/hr
For fluid replacement and for administering IVTT meds.
Done
3:50PM To Ortho Ward once stable @ PACU
Orthopedic ward caters patients with skeletal or bone problems such as fracture and dislocation.
Done
Cont. Cefazolin 1gm IVTT q8
Treatment of bone and joint infection.
Done
Maintain dressing in ® hemi-thorax
To keep wound close and intact.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
9/1/1111:29AM
Maintain dressing in ® hemi-thorax
To avoid infection. Done
Cont. Cefazole 1gm IVTT q8
Treatment of bone and joint infection.
Done
Meds: Ascorbic acid 500mg, 1 tsp OD
Ascorbic acid helps produce collagen, a protein needed to develop
Done
and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels.
Meds: Mefenamic acid 500mg cap,
1cap q6 PO
For relief of pain including muscular, traumatic, fever, and headache.
Done
Cont. Tramadol + Ketorolac as
previously ordered
Tramadol with Ketorolac drip for clinical use has been shown to be an
effective balanced analgesic regimen in
alleviating moderate-to-severe pain.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
3:50PM S/P STSG, Right shoulder under
GETA
STSG surgical procedure is done.
Done
To PACU until stable then to ward
For close monitoring. Done
May have DAT when fully awake
with aspiration precaution
Patient should be closely supervised when eating.
Done
Monitor VS To monitor any unusualities.
Done
Meds: Tramadol 30mg
For pain reliever. Done
9/2/1112PM
Removal of Foley catheter
To void freely. Done
9/3/1110:20AM
Cont. IV antibiotics For treatment of infections. Done
DAT Diet as tolerated to maintain nutritional status of patient
Done
9/4/119AM
Cont. IV antibiotics For treatment of infections. Done
To secure 25% Albumin and
transfuse in 4 hours
Administered to patients with low albumin level.
Done
Maintain high protein diet
Protein is essential for tissue growth and regeneration.
Done
Advice 3 egg whites per meal daily
Egg Whites provide an excellent source of amino acids for developing muscles.
Done
9/5/1111:08AM
For change of dressing of recipient
site
To avoid wound infection. Done
Maintain high protein diet
Protein is essential for tissue growth and regeneration.
Done
For strict compliance of oral
antibiotics
Compliance with meds will avert any complications.
Done
Add 3 egg whites per meal daily
Egg Whites provide an excellent source of amino acids for developing muscles.
Done
Shift Cefazolin to Cefuroxime 500mg tab; 1tab BID PO
Cefuroxime is used for treatment of serious infections of the lower respiratorytracts.
Done
Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.
Done
9/7/119:40AM
For wound dressing today
To avoid wound infection. Done
Cont. PO antibiotics Compliance with meds will avert any complications.
Done
9/9/118:29AM
High protein/ caloric diet
Protein is essential for tissue growth and regeneration.
Done
Ascorbic acid 500mg tab BID
Ascorbic acid helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels.
Done
9/10/11 MGH- Ortho DoneRefer to pedia onco
for transfer of service
Pediatric oncology is a specialty discipline in medicine concerned with diagnosing and treating children, usually up to the age of 18, with cancer.
Done
Med: Ascorbic acid 500mg tab BID
Ascorbic acid helps produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels.
Done
Wound dressing as instructed
To avoid wound infection. Done
9/11/1110:31AM
Follow up referral to Pedia onco for
transfer of service
For specialized care and management.
Done
Transfer to pedia onco unit if obey to
mask secure for pedia onco to start
chemotherapy
For specialized care and management.
Done
9/12/11 Notify transfer to pedia onco unit for
chemotherapy
For specialized care and management.
Done
9/13/119:06AM
For chemotherapy Used to stop cancer cells from dividingso they stop growing or die.
Done
Refer to pedia for transfer of service
For specialized care and management.
Done
MGH to House of Hope
House of hope provides the psychosocial needs of children with cancer.
Not done
Cont. Ascorbic Acid Ascorbic acid helps Done
produce collagen, a protein needed to develop and maintain healthy teeth, bones, gums, cartilage, vertebrae discs, joint linings, skin and blood vessels.
For chemotherapy once with available
bed at the pedia onco ward
Used to stop cancer cells from dividingso they stop growing or die.
Not done
Photocopy all operative technique
and biopsy
To provide data to the House of Hope once patient is transferred.
Not done
July
28,
2011
Blood
Chemistry
Introduce
your name to
the patient
and establish
rapport.
Identify the
right client.
Discuss the
importance
and
purpose of
the
procedure.
Explain the
procedure
to the
patient.
Assess the
patient for
any factor
that will
probably
affect the
results of
the test.
Creatinine
53 – 115
umol/L
30.4
0Umol/L
(normal
)
Used to
evaluate renal
dysfunction.
Increased
creatinine
levels in the
blood suggest
diseases or
conditions that
affect kidney
function.
Blood Urea
Nitrogen
1.1 – 3.20
2.40
measure of the
amount of urea
in the blood.
Urea forms in
the liver as the
end product of
protein
metabolism,
circulates in the
blood, and is
excreted
through the
kidney in urine.
The BUN,
determined by
a blood test, is
directly related
to the
metabolic
function of the
liver and the
excretory
function of the
kidney. Normal
findings (in
mg/dL) are 10
to 20 for adults,
5 to 18 for
children and
infants, 3 to 12
for newborns,
and 21 to 40 for
cord blood. In
the elderly, the
BUN may be
slightly higher
than the normal
adult range. A
critical value of
100 mg/dL
indicates
serious
impairment of
renal function.
Also
called urea
nitrogen, serum
urea nitrogen.
July
29,
2011
IPD hematology
ErythrocyteSedimentationRate
0.00-10.0mm/hr
60H
the rate at which red blood cellssediment in a period of 1 hour. It is a common hematology test that is a non-specific measure of inflammation
July
09,
2011
Blood type
(ABO test)
A Blood typing in
the ABO
system, and
others, involves
the
identification of
specific
proteins that
are contained
in the blood.
Red Blood
Cells have
either antigen
(protein) A, B,
or AB or none,
on the surface
of the cells.
These
antigens,
(proteins) make
the blood of
each person
unique and
separate from
one another.
Blood typing
then,
categorizes
blood in
individuals
according to
these proteins
(ABO)
Blood type
B + RH
positiv
e
test for the Rh
factor protein
on the RBC,
Red Blood Cell.
Aug
ust
04,
2011
LDH
266 – 500.00
u/L
1580.0
H
Increase of LD activity in serum may occur in any injury that causes loss of cell cytoplasm. More specific information can be obtained by LD isoenzyme studies. Also, elevation of serum LD is observed due to in vivo effects of anesthetic agents, clofibrate, dicumarol, ethanol, fluorides, imipramine, methotrexate, mithramycin, narcotic analgesics, nitrofurantoin,
propoxyphene, quinidine, and sulfonamides.Decrease of serum LD is probably not clinically significant.There are two main analytical methods for measuring LD: pyruvate->lactate and lactate->pyruvate. Assay conditions (particularly temperature) vary among labs. The reference range for the assaying laboratory must be carefully studied when interpreting any individual result.Many European labs assay alpha-hydroxybutyrate dehydrogenase (HBD or HBDH), which roughly equates to LD isoenzymes 1 and 2 (the fractions found in heart, red blood cells, and kidney).
Aug
ust
27,
2011
Sodium
136-155
mmoL/L
136.10
mmol/L
(normal
)
Measures the
amount of
sodium in the
blood. It plays
a major role in
regulating the
amount of
water in the
body.
Sodium is a
mineral that is
vital to normal
body
processes,
which include
nerve and
muscle
functioning.
Too much
sodium can
increase the
chances of
high blood
pressure
Potassium
3.7 to 5.5
mmol/L.
3.94
(normal
)
This test
measures the
amount of
potassium in
the blood.
Potassium (K+)
helps nerves
and muscles
communicate.
It also helps
move nutrients
into cells and
waste products
out of cells.
Calcium
1.75 – 2.39Mmol/L
2.40L
a blood or urine test used to evaluate parathyroid function and calcium metabolism by directly measuring the total amount of calcium in the blood. It is used to monitor patients with renal failure, renal transplantation, hyperparathyroidism, and various malignancies, as well as to monitor calcium levels during and after large-volume blood transfusions.
September 02,2011
A/G Ratio
1.0 – 2.50
0.8
L
Globulin is increased disproportionately to albumin (decreasing the albumin/globulin ratio) in states characterized by chronic inflammation and in B-lymphocyte neoplasms, like myeloma and Waldenström's macroglobulinemia. More relevant information concerning increased globulin may be obtained by serum protein electrophoresis.Decreased globulin may be seen in congenital or acquired hypogammaglobulinemic states. Serum and urine protein electrophoresis may help to better define the clinical problem.
Total protein The total
64.00 – 83.00
g/L
57.40
g/L
L
protein test is a rough measure of all theproteins found in the fluid portion of your blood. Specifically it looks at the total amount of two classes of proteins: albumin and globulin.
Globulin
23.0 – 30.0
g/L
32.60g/
L
H
any of a class
of proteins
insoluble in
water, but
soluble in
saline solutions
(euglobulins),
or water-
soluble
proteins
(pseudoglobuli
ns); their other
physical
properties
resemble true
globulins
Albumin
35.00 – 50.00
g/L
24.80
(low)
Albumin is a
protein made
by the liver. A
serum albumin
test measures
the amount of
this protein in
the clear liquid
portion of the
blood.
SURGERY: Debridement, Split Thickness Skin Graft
DATE: September 5, 2011
HOSPITAL: SPMC – OR
SURGEON: Dr. Gabutan
ANESTHESIOLOGIST: Dr. Ranola
TYPE of ANESTHESIA: General Anesthesia TIME BEGAN: 2:15 PM – 4:15 PM
OPERATION DIAGNOSIS: Rhabdomyosarcoma right , status post forequarter amputation
OPERATION STARTED: 3:00 PM
OPERATION ENDED: 3:50 PM
Definition
Debridement is a medical procedure performed to remove damaged tissue from a patient to promote the development of healing in the underlying tissue. Surgical debridementis recommended when the tissue damage is so extensive that working on a conscious patient would be painful, as well as risky, as in the case of very deep or large wounds. This procedure can be done by a general surgeon or a specialist, depending on the location and nature of the damage.
Split Thickness Skin Graft is a skin graft including the epidermis and part of the dermis. Its thickness depends on the donor site and the needs of the patient. It can be processed through a skin mesher which makes apentures onto the graft, allowing it to expand up to nine times its size. Split-thickness grafts are frequently used as they can cover large areas and the rate of autorejection is low. You can take from the same site again after 6 weeks. The donor site heals by re-epitheliasation from the dermis and surrounding skin and requires dressings.
Procedure
The most important part of any skin graft procedure is proper preparation of
the wound. Skin grafts will not survive on tissue with a limited blood supply
(cartilage or tendons) or tissue that has been damaged by radiation
treatment. The patient's wound must be free of any dead tissue, foreign
matter, or bacterial contamination. After the patient has been anesthetized,
the surgeon prepares the wound by rinsing it with saline solution or a diluted
antiseptic (Betadine) and removes any dead tissue by débridement. In
addition, the surgeon stops the flow of blood into the wound by applying
pressure, tying off blood vessels, or administering a medication (epinephrine)
that causes the blood vessels to constrict.
Following preparation of the wound, the surgeon then harvests the tissue for
grafting. A split-thickness skin graft involves the epidermis and a little of the
underlying dermis; the donor site usually heals within several days. The
surgeon first marks the outline of the wound on the skin of the donor site,
enlarging it by 3–5% to allow for tissue shrinkage. The surgeon uses a
dermatome (a special instrument for cutting thin slices of tissue) to remove a
split-thickness graft from the donor site. The wound must not be too deep if a
split-thickness graft is going to be successful, since the blood vessels that
will nourish the grafted tissue must come from the dermis of the wound itself.
The graft is usually taken from an area that is ordinarily hidden by clothes,
such as the buttock or inner thigh, and spread on the bare area to be
covered. Gentle pressure from a well-padded dressing is then applied, or a
few small sutures used to hold the graft in place. A sterile nonadherent
dressing is then applied to the raw donor area for approximately three to five
days to protect it from infection.Indication
1. Debridement is indicated to our patient in preparation for split thickness skin graft.
2. An STSG is indicated in most wounds that cannot be closed primarily and when closure by secondary intention is contraindicated. It is also indicated for a relatively large wound (> 5–6 cm in diameter) that would take many weeks to heal secondarily. A skin graft provides more stable coverage for large wounds than the scar that results from secondary closure. A large wound also heals more quickly with a skin graft than with dressing changes alone. The wound must be clean. All necrotic tissue must be removed before skin grafting, and there should be no signs of infection in the surrounding tissues.
Anesthesia
General anesthesia puts the entire body to sleep by giving medicine. It is
often used during emergency surgery. It is also commonly used if a
procedure would make you uncomfortable if you were awaken
Position
When doing debridement the position of the patient should be side lying
position on the unaffected part.So that the surgical site is clearly expose and
for the convenience of the surgeon and the rest of the surgical team. Also in
doing the split thickness skin grafting, the position of the client is in supine
position.
InstrumentationKidney basin A bean-shaped basin used
for collection of bodily discharges or cleaning and irrigation.
Asepto syringe Used for intraoperative irrigation
Yankauer suction blood and fluids
Scalpel Used to cut
Abdominal Pack General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges
Operating sponge
General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges
Prosta Pack General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges
Mayo tray Sterile field which holds all surgical instruments used
Kelly clamps Used to clamp larger vessels and tissue
Needle Holder Facilitate use of suture
Army navy Used for tissue and bone retraction
Tissue forceps Grasps soft tissues and facilitates suturing of the site
Thumb forceps Used for grasping hard tissues
Mayo scissors Used to cut heavy tissue (fascia and muscle)
Metzenbaum scissors
Used to cut delicate tissue
Towel clips Holds towels in place around the surgical site
Water Saline solution
Irrigating surgical site and cleaning
Richardson Used for retraction
Straight mayo General purpose and suture cutting scissors
Allis forceps For grasping soft tissue
Bobcock for grasping soft tissue
Humby knife A knife with a roller and a calibration device to cut skin grafts of different thickness
Graft-meshing machine
a device used to make fine cuts in skin grafts
Padgett dermatome
was the first rotary drum manual dermatome to be devised
Bone curette A surgical instrument shaped like a scoop or spoon, used to remove tissue or growths from a body cavity.
Cotton tip applicator
For wound care
I. Nursing Responsibilities
Preoperative Phase
a. Assessment and Data Collection
The patient should be in best possible physical condition before
surgery. In emergencies, of course, this cannot be controlled, but
planned surgery might be postponed until the patient is physically
able to withstand the stress of anesthesia and the surgery.
First, the perioperative nurse gathers data specific to the surgical
procedure and postoperative course:
- health history and psychosocial assessment (what is the
reason for this surgery?)
- cultural assessment (what are your cultural customs regarding
privacy and blood transfusions?)
- spiritual assessment (do you have spiritual or religious
beliefs?)
- physical assessment (such as weight and vital signs)
- laboratory and diagnostic test data (note any abnormal
findings)
Any significant deviations from normal range should be brought to
the attention of the surgeon.
Second, the nurse assesses surgical risk factors. Carefully assess
the patient before surgery for risks of complications such as
advanced age with inactivity, obesity and cardiovascular problems,
excessive fear, substance abuse, respiratory disease, diabetes
mellitus and other chronic diseases.
b. General preoperative teaching
General information that almost all surgical patients should receive
includes information related to:
- Preoperative procedures: skin preparation, care of belongings,
restriction of food and fluid intake, time to come to hospital
- Technical information: anticipated surgical procedure, location
of incisions
- Day of surgery: time surgery is scheduled, time to arrive at
hospital, probable length of procedure, where family will wait
In addition, teaching the patient correct breathing, coughing,
turning and leg exercises is a high priority during the preoperative
period. Explain the importance of doing the exercises and show
the patient how to do each one and ask for a return demonstration.
c. The nurse checks that a consent form has been signed before
giving the preoperative medication. Before the surgeon can
perform an operation, written permission signed by either the
patient, her guardian, or whoever holds power of attorney must be
obtained.
Intraoperative Phase
Scrub nurse
The scrub nurse works directly with the surgeon within the sterile field,
passing instruments, sponges, and other items needed during the
procedure. Surgical team members who work within the sterile field have
scrubbed their hands and arms with special disinfecting soap and
generally wear surgical gowns, caps, eyewear, and gloves.
Major functions include:
- Gathers all equipment for the procedure
- Prepares all sterile supplies using sterile technique
- Gowns and gloves surgeons upon entry into operating room
- Assists with sterile draping of the patient
- Maintains sterility within the sterile field during surgery
- Maintains a neat instrument table
- Label and handles surgical specimens correctly
- Maintains an accurate count of sponges, sharps, and
instruments on the sterile field; verifies counts with circulating
nurse before and after surgery
- Monitors for breaks in sterile technique and points them out
- Cleans up after the surgery is over
Circulating nurse
The circulating nurse serves as the patient advocate while the patient is
least able to care for him or herself.
Functions include:
- Responsible for managing the nursing care of the patient within
the OR and coordinating the needs of the surgical team with
other care providers
- Observes the surgery and the surgical team from a broad
perspective
- Assists the team to create and maintain a safe and comfortable
environment for the patient
- Assesses the patient's condition before, during, and after the
operation to ensure an optimal outcome for the patient
Postoperative phase
The nurse checks the patient’s identity, settles the patient in bed, and
performs an initial postoperative assessment. Airway, breathing and
circulation are always the top priorities.
Monitoring for signs of the various complications that may occur as a
result of surgery is a major nursing responsibility.
Other responsibilities of the nurse towards the patient include:
- Maintaining ventilation: maintaining a patent airway is a priority
measure
- Maintain circulation and tissue perfusion
- Prevent injury and infection: use aseptic technique when caring
for postoperative patient. Good hand washing is the primary
means of preventing infection
- Maintain fluid balance
- Promote comfort: pain and discomfort interfere with rest and
inhibit the processes of healing and repair. Although analgesic
drugs are almost always prescribed for the postoperative
patient, comfort measures should also be used.
- Promote rest and activity
- Promote wound healing: adequate rest, sufficient blood supply,
and proper nutrition all promote wound healing
- Prevent postoperative complications such as wound infection
- Promote psychological adjustment: the patient may be
concerned about the ability to perform self-care post-
operatively
- The nurse assesses the graft area for signs of adequate blood
supply. She inspects the color of the graft area, which should be
the same color as the other skin on the patients body to see if
it has enough blood supply. The nurse also checks to make
sure the graft area is warm as this indicates sufficient blood
supply to the area.
- The nurse checks the patency of drains placed in the graft
area. She makes sure they are not blocked, so drainage can flow
out of the graft site instead of accumulating in it and potentially
causing an infection.
- The nurse ensures blood circulation to the graft area by
positioning the patient off the graft. Taking pressure off the
graft and skin surrounding it reduces the risk of decreased
blood supply to the area.
- The nurse may place the patient on a low pressure bed when
lying down or low pressure cushion for sitting down. The less
pressure exerted on the graft area, the more likely that it will
be adequately perfused. Low pressure beds and cushions
exert low pressure on the skin.
- Another nursing intervention for skin graft patients is to provide
an over the bed trapeze. The nurse makes sure that the patient is
aware of how to use it for moving around in bed. This
reduces the amount of shearing and friction that could occur
during movement and possibly displace the graft.
sources:
http://www.surgeryencyclopedia.com/Pa-St/Skin-Grafting.html
Dipietro, Luisa A., and Aime L. Burns, eds. Wound Healing: Methods and
Protocols. Totowa, NJ: Humana Press, 2003.
Herndon, David, ed. Total Burn Care , 2nd ed. London, UK: W. B. Saunders
Co., 2001.
Tura, A., ed. Vascular Grafts: Experiment and Modelling , 1st ed. Billerica,
MA: WIT Press/Computational Mechanics, 2003.
SURGERY: Forequarter Amputation
DATE: August 5, 2011
HOSPITAL: SPMC – OR
SURGEON: Dr. Penaranda/ Dr. Sabal/ Dr. Gabutan
ANESTHESIOLOGIST: Dr.Bermulo
TYPE of ANESTHESIA: General Anesthesia (GETA)TIME BEGAN: 3:20 PM – 6:45 PM
OPERATION DIAGNOSIS: to consider sarcoma right arm
OPERATION STARTED: 4:20 PM
OPERATION ENDED: 6:30 PM
Definition
Forequarter amputation (interscapulothoracic amputation) entails the surgical removal of the entire upperextremity and shoulder girdle, including the scapula and a portion of the clavicle.Traditionally forequarteramputations were most commonly performed for highgrade bone sarcomas of the proximal humerus andscapula . The proximal humerus is thethird most common site for osteosarcomas, and thesetumors are the most common primary malignancy of the proximal humerus. Chondrosarcomas and Ewing’s sarcoma tend to occur in the scapula.
Procedure
1. Posterior incision from medial end of clavicle, along clavicle over acromion and down lateral border of scapula, ending ~ 5 cm from midline at back. Anterior incision from mid clavicle, curving down just lateral and parallel with the deltopectoral groove, down over anterior axillary fold inferiorly and posteriorly to meet the posterior incision at the lower 1/3 of the axillary border of the scapula
2. Develop the posterior flap to expose the vertebral border of the scapula and divide trapezius, rhomboids, levator scapulae and latisimus dorsi from the scapula
3. Reflect scapula to divide attachment of serratus anterior and omo-hyoid
4. Allow arm to drop forward to bring plexus under tension and divide cords of the brachial plexus near the spine
5. Double ligation of subclavian artery and vein6. From the anterior incision divide clavicle near medial end7. Divide pectoralis muscles and insertion of latisimus dorsi to complete
the resection8. Perform a myoplastic closure and close skin over drains
Indication
The Forequarter amputation is indicated
1.Unresectable high-grade osteosarcoma (or any otherhigh-grade tumor) of the proximal humerus or the scapula (most commonly, chondrosarcoma).
2. Axillary soft-tissue sarcomas involving the brachial plexus.
3. Recurrent bone or soft-tissue sarcomas following a failed limb-sparing procedure.
4. Some radiation-induced sarcomas of the shoulder girdle.
5. Palliative amputation (primarily due to tumor fungation, infection, or bleeding).
6. Recurrent breast carcinoma involving the brachial plexus.
7. Pathological fracture through a high-grade sarcoma, especially if there is a poor response to induction chemotherapy.
Anesthesia
General anesthesia is a treatment that renders you unconscious during medical procedures, so you don't feel or remember anything that happens. General anesthesia is commonly produced by a combination of intravenous drugs and inhaled gasses (anesthetics).
The "sleep" you experience under general anesthesia is different from regular sleep. The anesthetized brain doesn't respond to pain signals or surgical manipulations.
The practice of general anesthesia also includes controlling your breathing and monitoring your body's vital functions during your procedure. General anesthesia is administered by a specially trained physician, called an anesthesiologist, often in conjunction with a certified registered nurse anesthetist.
Position
Intravenous lines are secured, and a Foley catheter is placed in the bladder. The patient is placed in a full lateral position and secured at the hips with tape. Alternatively, a VAC pack can be used to secure the torso. An axillary roll is placed under the axilla to allow full excursion of the chest, and a sponge-rubber pad is placed under the hip to prevent ischemic damage to the skin in this area. The skin is prepared, and the tumor-bearing extremity is draped free.
Instrumentation
Cautery cord and pencil
Uses electricity to cut or cauterize blood vessels.
Kidney basin A bean-shaped basin used for collection of bodily discharges or cleaning and irrigation.
Asepto syringe Used for intraoperative irrgation
Yankauer suction blood and fluids
Scalpel Used to cut
Abdominal Pack
General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges
Operating sponge
General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges
Prosta Pack General purpose such as cleaning, wiping fluids and as absorbent to bodily discharges
Mayo tray Sterile field which holds all surgical instruments used
Kelly clamps Used to clamp larger vessels and tissue
Needle Holder Facilitate use of suture
Army navy Used for tissue and bone retractiob
Tissue forceps Grasps soft tissues and facilitates suturing of the site
Thumb forceps Used for grasping hard tissues
Mayo scissors Used to cut heavy tissue (fascia and muscle)
Metzenbaum scissors
Used to cut delicate tissue
Towel clips Holds towels in place around the surgical site
Water Saline solution
Irrigating surgical site and cleaning
Richardson Used for retraction
Straight mayo General purpose and suture cutting scissors
Allis forceps For grasping soft tissue
Bobcock for grasping soft tissue
Gigli saw a flexible wire saw used by surgeons for bone cutting. A gigli saw is used mainly for amputation surgeries, where the bones have to be smoothly cut at the level of amputation.
II. Nursing Responsibilities
Preoperative Phase
d. Assessment and Data Collection
The patient should be in best possible physical condition before
surgery. In emergencies, of course, this cannot be controlled, but
planned surgery might be postponed until the patient is physically
able to withstand the stress of anesthesia and the surgery.
First, the perioperative nurse gathers data specific to the surgical
procedure and postoperative course:
- health history and psychosocial assessment (what is the
reason for this surgery?)
- cultural assessment (what are your cultural customs regarding
privacy and blood transfusions?)
- spiritual assessment (do you have spiritual or religious
beliefs?)
- physical assessment (such as weight and vital signs)
- laboratory and diagnostic test data (note any abnormal
findings)
Any significant deviations from normal range should be brought to
the attention of the surgeon.
Second, the nurse assesses surgical risk factors. Carefully assess
the patient before surgery for risks of complications such as
advanced age with inactivity, obesity and cardiovascular problems,
excessive fear, substance abuse, respiratory disease, diabetes
mellitus and other chronic diseases.
e. General preoperative teaching
General information that almost all surgical patients should receive
includes information related to:
- Preoperative procedures: skin preparation, care of belongings,
restriction of food and fluid intake, time to come to hospital
- Technical information: anticipated surgical procedure, location
of incisions
- Day of surgery: time surgery is scheduled, time to arrive at
hospital, probable length of procedure, where family will wait
In addition, teaching the patient correct breathing, coughing,
turning and leg exercises is a high priority during the preoperative
period. Explain the importance of doing the exercises and show
the patient how to do each one and ask for a return demonstration.
f. The nurse checks that a consent form has been signed before
giving the preoperative medication. Before the surgeon can
perform an operation, written permission signed by either the
patient, her guardian, or whoever holds power of attorney must be
obtained.
Intraoperative Phase
Scrub nurse
The scrub nurse works directly with the surgeon within the sterile field,
passing instruments, sponges, and other items needed during the
procedure. Surgical team members who work within the sterile field have
scrubbed their hands and arms with special disinfecting soap and
generally wear surgical gowns, caps, eyewear, and gloves.
Major functions include:
- Gathers all equipment for the procedure
- Prepares all sterile supplies using sterile technique
- Gowns and gloves surgeons upon entry into operating room
- Assists with sterile draping of the patient
- Maintains sterility within the sterile field during surgery
- Maintains a neat instrument table
- Label and handles surgical specimens correctly
- Maintains an accurate count of sponges, sharps, and
instruments on the sterile field; verifies counts with circulating
nurse before and after surgery
- Monitors for breaks in sterile technique and points them out
- Cleans up after the surgery is over
Circulating nurse
The circulating nurse serves as the patient advocate while the patient is
least able to care for him or herself.
Functions include:
- Responsible for managing the nursing care of the patient within
the OR and coordinating the needs of the surgical team with
other care providers
- Observes the surgery and the surgical team from a broad
perspective
- Assists the team to create and maintain a safe and comfortable
environment for the patient
- Assesses the patient's condition before, during, and after the
operation to ensure an optimal outcome for the patient
Postoperative phase
The nurse checks the patient’s identity, settles the patient in bed, and
performs an initial postoperative assessment. Airway, breathing and
circulation are always the top priorities.
Monitoring for signs of the various complications that may occur as a
result of surgery is a major nursing responsibility.
Other responsibilities of the nurse towards the patient include:
- Maintaining ventilation: maintaining a patent airway is a priority
measure
- Maintain circulation and tissue perfusion
- Prevent injury and infection: use aseptic technique when caring
for postoperative patient. Good hand washing is the primary
means of preventing infection
- Maintain fluid balance
- Promote comfort: pain and discomfort interfere with rest and
inhibit the processes of healing and repair. Although analgesic
drugs are almost always prescribed for the postoperative
patient, comfort measures should also be used.
- Promote rest and activity
- Promote wound healing: adequate rest, sufficient blood supply,
and proper nutrition all promote wound healing
- Prevent postoperative complications such as wound infection
- Promote psychological adjustment: the patient may be
concerned about the ability to perform self-care post-
operatively
- Minimizing altered sensory perceptions- Promoting wound healing- Enhancing body image- Promoting independent self-care- Helping the patient to achieve physical mobility
Source:
http://www.sarcoma.org/publications/mcs/ch17.pdf
Dipietro, Luisa A., and Aime L. Burns, eds. Wound Healing: Methods and Protocols. Totowa, NJ: Humana Press, 2003
DRUG STUDY
Generic NameKetorolac
Brand NameToradol
Classification Nonsteroidal anti-inflammatory agents, nonopioid analagesics
Ordered DosageRoute: IVTT
Dosage : 15 mg
Dosage Frequency Q6 x 3 doses
Mechanism of
Action
It inhibits prostaglandin synthesis, producing peripherally
mediated analgesia. Also have antipyretic and anti-inflammatory
properties.
Therapeutic effect: Decreased pain
Indications For short term management of pain (not to exceed 5 days total for
all routes combined).
ContraindicationsContraindicated in patients with hypersensitivity cross-sensitivity
with other NSAIDS may exist, labor, delivery or lactation, pre- or
perioperative use and known alcohol intolerance (injection only).
Side effects and
Adverse Reactions
CNS:
1) drowsiness
2) abnormal thinking
3) dizziness
4) euphoria
5) headache-
RESP:
1) asthma
2) dyspnea
CV:
1) edema
2) pallor
3) vasodilation
GI:
1) GI Bleeding
2) abnormal taste
3) diarrhea
4) dry mouth
5) dyspepsia
6) GI pain
7) nausea
GU:
1) oliguria
2) renal toxicity
3) urinary frequency
DERM:
1) pruritis
2) purpura
3) sweating
4) urticaria
HEMAT:
1) prolonged bleeding time
LOCAL:
1) injection site pain
NEURO:
1) paresthesia
MISC:
1) allergic reaction, anaphylaxis
Nursing
Responsibilities
1. Ensure right patient, ask the patient his name and check
the ID band.
2. Check the drug label before preparing the drug.
3. Check the latest doctor prescribed dosage and asks
somebody for clarifications about the dosage.
4. Check latest doctor prescribed dosage frequency.
Administer on time.
5. Patients who have asthma, aspirin-induced allergy, and
nasal polyps are at increased risk for developing
hypersensitivity reactions. Assess for rhinitis, asthma, and
urticaria.
6. Assess pain (note type, location, and intensity) prior to and
1-2 hr following administration.
7. Ketorolac therapy should always be given initially by the IM
or IV route. Oral therapy should be used only as a
continuation of parenteral therapy.
8. Caution patient to avoid concurrent use of alcohol, aspirin,
NSAIDs, acetaminophen, or other OTC medications without
consulting health care professional.
9. Advise patient to consult if rash, itching, visual
disturbances, tinnitus, weight gain, edema, black stools,
persistent headche, or influenza-like syndromes
(chills,fever,muscles aches, pain) occur.
10.Effectiveness of therapy can be demonstrated by decrease
in severity of pain. Patients who do not respond to one
NSAIDs may respond to another.
Generic Name
Tramadol
Brand Name
Ultram
Classification
Analgesics
Ordered DosageRoute: IVTT
Dosage: 30 mg
Dosage Frequency Q6
Mechanism of Action
Physiologic Mechanism
• Decreased pain.
Pharmacologic Mechanism
• Binds to mu-opioid receptors.
• Inhibits reuptake of serotonin and norepinephrine in the
CNS.
Indications
Moderate to moderately severe pain
ContraindicationsHypersensitivity totramadol, opioids, orany component of
theformulation; opioid-dependent patients;acute
intoxicationwith alcohol,hypnotics, centrally-acting
analgesics,opioids, orpsychotropic drugs
Side effects and
Adverse Reactions
Side effects
Dizziness or vertigo
Nausea and Vomiting
Constipation
Headache
Dry mouth
Adverse Reactions
Respiratory depression
Seizures
Prolonged duration of action and cumulative effect may
occur in patients with impaired hepatic or renal function.
Nursing Responsibilities 1. Verify the identity of the patient
2. Inform the patient about the administration of drugs
and its purpose
3. Assess onset, type, location, and duration of pain.
4. Effect of medication is reduced if full pain recurs
before next dose.
5. Assess drug history especially carbamazepine, CNS
depressant medication, MAOIs.
6. Review past medical history, especially epilepsy or
seizures.
7. Assess renal or hepatic function laboratory values.
8. Give without regards to meals
9. Monitor pulse and blood pressure.
10.Assist with ambulation if dizziness or vertigo occurs.
11.Dry crackers or cola may relieve nausea.
12.Palpate bladder for urinary retention.
13.Monitor pattern of daily bowel activity and stool
consistency.
14.Sips of tepid water may relieve dry mouth.
15.Assess for clinical improvement and record onset of
relief from pain.
Generic Name
Mefenamic acid – Oral
Brand Name
Mefalth, Mefalth T, Ponstel, Ponstan, Ponstal, Parkemed,
Mafepain, Mefamed, Mephadolor, Meftal, Dyfenamic, Potarlon,
Dolfenal, Meyerdonal, Alfoxan, Fenagesic, Spiralgin.
ClassificationNon-steroidal anti-inflammatory drug.
Ordered DosageRoute: PO
Dosage:500 mg
Dosage Frequency Q6
Mechanism of Action Mefenamic acid binds the prostaglandin synthetase receptors
COX-1 and COX-2, inhibiting the action of prostaglandin
synthetase. As these receptors have a role as a major
mediator of inflammation and/or a role for prostanoid signaling
in activity-dependent plasticity, the symptoms of pain are
temporarily reduced.
Indications
Pain and inflammation.
ContraindicationsInflammatory bowel disease; peptic ulcer; neonates; pregnancy
(3rd trimester), lactation. Coronary artery bypass graft surgery,
severe renal impairment, and severe heart failure.
Side effects and
Adverse Reactions
Dependent on the dose and the duration of treatment, mefenamic acid frequently causes diarrhea. Long-term treatment can lead to enteritis or colitis (sometimes with steatorrhea). The drug can also cause nausea, vomiting and upper abdominal pain. Like other anti-inflammatory agents, it occasionally is the cause of peptic ulcers or even of bleeding or perforations.Mefenamic acid seems to cause hematologic problems (especially autoimmune hemolytic anemias) more often than other anti-inflammatory drugs. Several cases
of renal failure (partially without oliguria) have been observed. Vertigo, headaches and skin reactions can occur under mefenamic acid.
Nursing Responsibilities 1. Ensure right patient, ask the patient his name and check the ID band.
2. Check the drug label before preparing the drug.3. Check the latest doctor prescribed dosage and ask
somebody for clarifications about the dosage. 4. Check latest doctor prescribed dosage frequency.
Administer on time.5. If patient have had a stomach ulcer or bleeding, tell
healthcare provider.6. Instruct patient to avoid alcohol (includes wine, beer,
and liquor) when taking this medicine since it can cause increases in stomach irritation.
7. Use caution if the patient has a weakened heart. It may cause increased shortness of breath or weight gain. Then recommend to talk with healthcare provider or its own physician.
8. Avoid aspirin, aspirin-containing products, other pain medicines, other blood thinners (warfarin, ticlopidine, clopidogrel), garlic, ginseng, ginkgo, and vitamin E while taking. Talk with healthcare provider.
9. If patient is allergic to any medicine, especially aspirin, or have asthma. Make sure to tell about the allergy and how it affected the patient by consulting its attending physician.
Generic Name
Cefuroxime
Brand NameAeruginox, Altacef, Ambixime, Bactipoz, Cefogen, Ceftin, Cefucil, Cefuzime, Zefur, Zinacef, and Zinnat.
Classification
Second-generation Cephalosporin and antibiotic.
Ordered DosageRoute: PO
Dosage: 500mg
Dosage FrequencyBIP
Mechanism of
Action Cefuroxime binds to bacterial membranes. It inhibits synthesis of bacterial cell wall
IndicationsFor the treatment of many different types of bacterial infections such as bronchitis, sinusitis, tonsillitis, ear infections, skin infections, gonorrhea, and urinary tract infections
ContraindicationsCefuroxime is contraindicated in patients with known allergy to the cephalosporin group of antibiotics. Solutions containing dextrose may be contraindicated in patients with hypersensitivity to corn products.
Side effects and
Adverse Reactions
Oral candidiasis (mouth and/or tongue sores)
Mild diarrhea
Mild abdominal cramping
Vaginal candidiasis
Nausea
Serum sickness reaction (joint pain, fever)
Allergic reactions
Thrombophlebitis
Nursing
Responsibilities
Ensure right patient, ask the patient his name and check the ID band.
1. Check the drug label before preparing the drug.2. Check the latest doctor prescribed dosage and ask
somebody for clarifications about the dosage. 3. Check latest doctor prescribed dosage frequency.
Administer on time.4. Question for history of allergies, particularly cephalosporins
and penicillins.5. Give without regards to meals. If GI upset occurs give with
food or milk.
6. Avoid crushing tablets due to bitter taste.7. Suspension must be given with food.8. Intramuscular injections must be administered deep IM to
minimize discomfort.9. Assess mouth for white patches on mucous membranes
and tongue.10.Monitor bowel activity and stool consistency carefully.11.Mild GI effects may be tolerable but increasing severity may
indicate onset of antibiotic-associated colitis.12.Monitor input and output and renal function reports for
nephrotoxicity.13.Be alert for superinfection: severe genital or anal pruritus,
abdominal pain, and severe mouth soreness, moderate to severe diarrhea.
14.Assess for hypersensitivity and other contraindications and current fluid intake and output record if present.
15.Check fluid intake and output and presence of side effects and adverse reactions.
16.Document drug administration and reactions if present. Record the administration in the medication sheet.
17.Assess and confirm if patient is having problems with regards to the medication and for reasons of refusing drug administration. Confirm from the patient and significant others on their view of the drug administration.
18. Instruct patient on proper drug compliance and report for signs of side and adverse effects. Orient the patient and significant other about the drugs action and effects.
Generic Name
Paracetamol
Brand Name
Common Brand names are Aeknil, Biogesic, Calpol, Neo-kiddielets, Tempra.
Classification
Analgesic (pain reliever) and Antipyretic (fever reducer)
Ordered Dosage Route: IVTT
Dosage: 300mg
Dosage FrequencyPTOR
Mechanism of
ActionThought to produce analgesic by pain impulses, probably by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to mechanical or chemical stimulation. It’s thought to relieve fever by central action in the hypothalamic heat-regulating center.
Indications
Fever, Relief of mild to moderate pain like headaches, muscular aches and pain, toothache, colds, earache, fever due to tonsillectomy, inoculations, and vaccinations.
Contraindications Contraindicated in patients hypersensitive to drug Use cautiously in patients with long-term alcohol use
because therapeutic doses cause hepatotoxicity in the patients.
Side effects and
Adverse Reactions
Side effects-Cramping-Heartburn-Abdominal distention can be experienced-Hypersensitivity reactions.
Adverse ReactionsAnorexia, nausea, diaphoresis (excessive sweating), generalized weakness within the first 12-24 hours. Liver damage, jaundice, hypoglycemia, rash, vomiting
Nursing
Responsibilities
1. Ensure right patient, ask the patient his name and check the ID band.
2. Check the drug label before preparing the drug, before administering intravenously, and after administration.
3. Check the latest doctor prescribed dosage and ask somebody for clarifications about the dosage.
4. Check latest doctor prescribed dosage frequency. Administer on time.
5. Inform patient about the drug and the purpose of administration
6. If to be given as analgesia, assess onset, type, location, duration of pain.
7. Can be given without regards to meals.8. Tablets can be crushed.9. Assess temperature directly before and 1 hour after giving
medication.10. If respirations are <12/min (<20/min in children), withhold
the medication and contact the physician.11.Evaluate for therapeutic response: relief of pain, stiffness,
swelling; increasing in joint mobility; reduced joint
tenderness; improve grip strength.12.Therapeutic blood serum level: 10-30 mcg/mL; toxic serum
level: >200 mcg/mL.13.Assess for hypersensitivity and other contraindications and
current fluid intake and output record if present.14.Check fluid intake and output and presence of side effects
and adverse reactions.15.Document drug administration and reactions if present.
Record the administration in the medication sheet.16.Assess and confirm if patient is having problems with
regards to the medication and for reasons of refusing drug administration. Confirm from the patient and significant others on their view of the drug administration.
17. Instruct patient on proper drug compliance and report for signs of side and adverse effects. Orient the patient and significant other about the drugs action and effects.
Patient Teaching - Consult physician for use in children less than 2 years old;
oral use more than 5 days for children, more than 10 days for adults, or fever more than 3 days.
- Do not crush or chew sustained-release or enteric-coated form.
- Report ringing in ears and persistent GI pain.- Severe, recurrent pain or high continuous fever may indicate
serious illness.
Generic Name
Diphenhydramine
Brand Name BENADRYL
Classification
Antihistamine
Ordered Dosage Route: IVTT
Dosage: 500 mg
Dosage Frequency Once blood transfusion started
Mechanism of
Action
Diphenhydramine competes with histamine at histamine receptor
sites. It inhibits central acetylcholine. It results in anticholinergic,
antipruritic, antitussive, and antiemetic effect. Diphenhydramine
produces antidyskinetic and sedative effect.
Indications Diphenhydramine is used to treat allergic reactions and
parkinsonism. It is also used in the prevention and treatment of
nausea, vomiting, and vertigo due to motion sickness.
Diphenhydramine is also an antitussive and can be used as a
short term treatment of insomnia. A topical form of
Diphenhydramine can be used to relieve pruritus, insect bites, and
skin irritations.
Contraindications Diphenhydramine is contraindicated in patients who are
hypersensitive to it or other antihistamines in its class. Because of
their anticholinergic activity, antihistamines should be used with
caution in patients with angle closure glaucoma, prostatic
hypertrophy, pyloroduodenal or bladder neck obstruction, and
COPD if mucosal secretions are a problem
Side effects and
Adverse ReactionsSide Effects :
Drowsiness Dizziness
Muscular weakness
Hypotension
Dry mouth, nose, throat, or lips
Urinary retention
thicknening of bronchial secretions
Sedation
Epigastric distress
Flushing
Visual or hearing disturbances
Paresthesia
Diaphoresis
Chills
Adverse Reactions:Dominant paradoxical reactions (restlessness, insomnia, euphoria, nervousness, and tremors)
Hallucinations
Seizures
Hypersensitivity reactions (eczema, pruritus, rash, cardiac disturbances, and photosensitivity)
CNS depression (sedation, apnea, hypotension, cardiovascular collapse, and death)
Nursing
Responsibilities
1. Verify the identity of the patient
2. Inform the patient about the administration of drugs and its
purpose
3. Assess onset, type, location, and duration of pain.
4. Give without regards to meals.
5. Scored tablets may be crushed.
6. Do not crush capsules or film-coated tablets.
7. If patient is having acute allergic reactions, obtain history of
recently ingested food, drugs, environmental exposure, and
recent emotional stress.
8. Monitor rate, depth, rhythm, and type of respiration.
9. Monitor rate, depth, rhythm, and quality or rate of pulse.
10.Assess lung sounds for rhonchi, wheezing, rales.
11.Monitor blood pressure especially in elderly.
12.Monitor children closely for paradoxical reaction.
Patient Teachings
Tolerance to antihistamine effect generally does not occur; tolerance to sedative effect may occur.
Avoid tasks that require alertness and motor skills until response to drug is established.
Dry mouth, drowsiness, and dizziness may be an expected response of drug.
Avoid alcoholic beverages.
Generic Name
Cefazolin
Brand Name Ancef
ClassificationTherapeutic: Anti-infectivesPharmacologic:First generation cephalosphorins
Ordered Dosage Route: IVTT
Dosage: 1 g
Dosage Frequency Q8
Mechanism of
Action• Bind to bacterial cell wall membrane, causing cell death.• Active against many gram-positive cocci including: Streptococcus pneumoniae, Group A beta-hemolytic streptococci; Penicillinas-producing staphylococci.
Indications •Treatment of:Skin & skin structure infections; pneumonia; urinary tract infections; bone & joint infections
Contraindications •Hypersensitivity to cephalosporin. Serious hypersensitivity to penicillin.
Side effects and
Adverse Reactions• CNS:Seizures (high doses)• GI:Pseudomembranous colitis, diarrhea, nausea, vomiting, cramps• GU:Interstitial nephritis• DERM:Rashes, urticaria• HEMAT:Blood dyscrasias, hemolytic anemia• LOCAL:Pain at IM site, phlebitis at IV site• MISC:Allergic reactions including Anaphylaxis and Serum sickness, super infection
Nursing 1. Verify the identity of the patient
2. Inform the patient about the administration of drugs and its
Responsibilities purpose
3. Assess patient for infection (vital signs; appearance of
surgical site, urine; WBC) at beginning and during therapy.
4. Before initiating therapy, obtain a history to determine
previous use of and reactions to penicillins or
cephalosphorins. Persons with a negative history of
penicillin sensitivity may still have an allergic response.
5. Obtain specimens for culture and sensitivity before
initiating therapy.
6. Observe patient for signs and symptoms of anaphylaxis
(rash, pruritis, laryngeal edema, wheezing). Discontinue
drug and notify physician or other health care professional
immediately if these problems occur. Keep epinephrine, an
antihistamine, and resuscitation equipment close by in case
of anaphylactic reaction.
7. Monitor site for thrombophlebitis (pain, redness, swelling).
Change sites every 48-72 hr to prevent phlebitis.
8. Instruct patient to report signs of superinfection (furry
overgrowth on the tongue, vaginal itching or discharge,
loose or foul-smelling stools) and allergy.
9. Instruct patient to notify health care professional if fever
and diarrhea develop, especially if diarrhea contains blood,
mucus, or pus. Advise not to treat diarrhea without
consulting healthcare professional.
Generic Name
Amikacin
Brand Name Amikin, Amikin Pediatric
Classification Amino glycoside
Ordered Dosage Route: IVTT
Dosage: 240 mg
Dosage Frequency Q12
Mechanism of
Action
Amikacin binds to 30S ribosomal subunits of susceptible bacteria,
thus inhibiting its protein synthesis.
Distribution: Detected in body tissues and fluids after inj; crosses
the placenta but does not readily penetrate the CSF. Significant
amounts penetrate the blood-brain barrier in children with
meningitis.
Excretion: Via the urine by glomerular filtration (within 24 hr); 2-3
hr (elimination half-life).
Indications Amikacin is indicated for the treatment of infections of: central
nervous system, urogenital system, biliary and intestinal tracts,
skin and subcutaneous tissues, intraabdominal infections,
pneumonia, caused by Gram-negative microorganisms, secondary
infections after combustion, bacterial septicemia, infections of the
bones and joints (caused by sensitive to Amikacin
microorganisms).
Contraindications A history of hypersensitivity to amikacin is a contraindication for its
use. A history of hypersensitivity or serious toxic reactions to
aminoglycosides may contraindicate the use of any other
aminoglycoside because of the known cross-sensitivities of
patients to drugs in this class
Side effects and
Adverse Reactions
an allergic reaction (shortness of breath; closing of the throat; hives; swelling of the lips, face, or tongue; rash; or fainting);
little or no urine; decreased hearing or ringing in the ears; dizziness, clumsiness, or unsteadiness; numbness, skin tingling, muscle twitching, or seizures; or Severe watery diarrhea and abdominal cramps.
Nursing
Responsibilities 1. Ensure right patient, ask the patient his name and check
the ID band.
2. Check the drug label before preparing the drug.
3. Check the latest doctor prescribed dosage and asks
somebody for clarifications about the dosage.
4. Check latest doctor prescribed dosage frequency.
Administer on time.
5. Patients should be counselled that antibacterial drugs
including Amikacin should only be used to treat bacterial
infections.
6. · Patients should be told that although it is common to feel
better early in the course of therapy, the medication should
be taken exactly as directed.
7. · Skipping doses or not completing the full course of
therapy may:
Decrease the effectiveness of the immediate treatment and
Increase the likelihood that bacteria will develop resistance and will not be treatable by Amikacin or other antibacterial drugs in the future.
Generic Name Ranitidine Hydrochloride
Brand Name Zantac
Classification
Therapeutic:
Anti-ulcer agents
Pharmacologic:
Histamine H2 antagonists
Ordered Dosage Route: IVTT
Dosage: 30 mg
Dosage Frequency Q8
Mechanism of
Action
• Inhibits the action of histamine at the H2 receptor site located
primarily in gastric parietal cells, resulting in inhibition of gastric
acid secretion.
• In addition, ranitidine bismuth citrate has some antibacterial
action against H. pylori.
Indications
•Treatment and prevention of heartburn, acid indigestion, and
sour stomach.
Contraindications •Hypersensitivity, Cross-sensitivity may occur; some oral liquids
contain alcohol and should be avoided in patients with known
intolerance.
Use Cautiously in:
• Renal impair
• Geriatric patients (more
susceptible to adverse CNS reactions)
• Pregnancy or Lactation
Side effects and
Adverse Reactions
Altered taste
Constipation
nausea
Nursing Responsibilities • Assess patient for epigastric or abdominal pain and frank or
occult blood in the stool, emesis, or gastric aspirate.
• Nurse should know that it may cause false-positive results for
urine protein; test with sulfosalicylic acid.
• Inform patient that it may cause drowsiness or dizziness.
• Inform patient that increased fluid and fiber intake may minimize
constipation.
• Advise patient to report onset of black, tarry stools; fever, sore
throat; diarrhea; dizziness; rash; confusion; or hallucinations to
health car professional promptly.
• Inform patient that medication may temporarily cause stools and
tongue to appear gray black.
Assess patient’s GI condition before starting therapy and
regularly thereafter to monitor the drug’s effectiveness.
Assess patient’s and family’s knowledge of drug therapy.
Be alert for adverse reactions and drug interactions.
Assess patient’s and family’s knowledge of drug therapy.
Patient teaching
Remind patient taking drug once daily to take at bed time.
Instruct patient to take drug with or without food.
Urge patient not to smoke cigarettes; smoking may increase
gastric acid secretions and worsen disease.
Generic Name
Metoclopramide
Brand Name Reglan
Classification
Function classification: Cholinergic and Antiemetic
Chemical classification: central dopamine receptor antagonist
Ordered Dosage Route: PO
Dosage: 10 mg 1 tab
Dosage Frequency Q6
Mechanism of
Action
Blocks dopamine receptors by disrupting CNS chemoreceptor
trigger zone, increasing peristalsis and promoting gastric
emptying
Indications Preventing nausea and vomiting induced by cisplatin and other
chemotherapy
Contraindications contraindicated in patients with hypersensitivity to the drug or to
sulfonamides; pheochromocytoma, because it it may induce
hypertensive crisis; and seizure disorders, renal failure, liver
failure, parkinson’s disease GI hemorrhage or intestinal
obstruction or perforation, because the drug may exacerbate
symptoms of these disorders . Do not use the drug for longer than
12 weeks.
Side effects and
Restlessness
Anxiety
Adverse Reactions Drowsiness
Fatigue
Lassitude
Insomnia
Headache
Dizziness
Nursing
Responsibilities
Obtain a baseline assessment of blood pressure, mental
status, GI status, and history of seizure disorder or
pheochromocytoma before therapy.
Be alter for adverse reactions or drug interactions during
therapy
Evaluate the patient’s and family’s knowledge about
metoclopramide.
Be aware that safety and effectiveness have not been
established for therapy that continues longer than 12 weeks
Monitor effectiveness by observing the patient for nausea
and vomiting
Monitor fluid balance.
Monitor Vital Signs
Observe for changes in mental status, moods, and
behavior.
Use safety precautions for patients who develop adverse
CNS reactions
If patient is alert, encourage adequate intake of fluids to
prevent fluid volume deficit.
Patient teaching
Warn patient to avoid activities requiring alertness for 2
hours after taking each dose.
Advise patient that changes in mood and behavior may
accompany therapy with metoclopramide.
Generic Name
Furosemide
Brand Name Lasix
Classification Diuretic
Ordered Dosage Route: IVTT
Dosage: 20 mg
Dosage Frequency Post BT
Mechanism of
Action
Enhances excretion of sodium, chloride, potassium by direct
action at ascending limb of loop of Henle and produces a diuretic
effect.
Indications Treatment of edema associated with congestive heart failure,
chronic renal failure, hepatic cirrhosis, and acute pulmonary
edema. It is also used for treatment of hypertension, alone or in
combination with other hypertensive. Can also be used for
treatment of hypercalcemia.
Contraindications Pronounced hyponatremia or hypovolemia and anuria.
Side effects and
Adverse ReactionsSide Effects Increase in urinary frequency or volume Nausea Gastric upset with cramping Diarrhea or constipation Electrolyte disturbances Dizziness or light headedness Headache Blurred Vision Paresthesia Photosensitivity Rash Weakness Bladder spasm Restlessness
Diaphoresis Flank or loin pain
Adverse Reactions Excessive diuresis may lead to increased water loss and
electrolyte depletion resulting to hypokalemia, hyponatremia, and dehydration.
Sudden volume depletion may result in increased risk f thrombosis, circulatory collapse, or sudden death.
Acute hypotensive episodes may occur, sometimes several days after beginning of therapy.
Ototoxicity manifested as deafness, vertigo, and tinnitus may occur especially in patients with severe renal impairment.
It can exacerbate diabetes mellitus, systemic lupus erthematosus, gout, and pancreatitis.
Blood dyscrasias have been reported.
Nursing
Responsibilities
1. Ensure right patient, ask the patient his name and check
the ID band.
2. Check the drug label before preparing the drug.
3. Check the latest doctor prescribed dosage and asks
somebody for clarifications about the dosage.
4. Check latest doctor prescribed dosage frequency.
Administer on time.
5. Give with food to avoid gastroinestinal upset, preferably
with breakfast (to prevent nocturia).
6. If given IM, temporary pain at injection site may be noted.
7. Check vital signs especially blood pressure for hypotension
prior to administration.
8. Assess baseline electrolyte, particularly check for low
potassium.
9. Assess edema, skin turgor, and mucous membranes for
hydration status.
10.Assess muscle strength and mental status.
11.Obtain baseline weight.
12. Initiate Input and Output monitoring.
13.Note extent of diuresis.
Generic Name
Cloxacillin
Brand Name Cloxapen, Tegopen
Classification antiinfective; antibiotic, natural penicillin; beta-lactam
Ordered Dosage Route: PO
Dosage: 500 mg per cup
Dosage Frequency Q6
Mechanism of
Action
Cloxacillin is resistant to degradation by penicillinases. It is
particularly useful against penicillinase-producing staphylococci.
Highly active against S aureus, S pyogenes, S viridans and S
pneumoniae.
Absorption: Incompletely absorbed from the GI tract with peak
plasma concentrations after 1-2 hr (oral); may be reduced in the
presence of food. Completely absorbed with peak plasma
concentrations after 30 min (IM).
Distribution: Pleural and synovial fluids and bone (therapeutic
concentrations), CSF (small amounts except when the meninges
are inflamed; crosses the placenta and enters the breast milk.
Protein-binding: 94%
Metabolism: Minimal metabolism.
Excretion: Via the urine by glomerular filtration and renal tubular
secretion (35% of an oral dose); via the bile (Up to 10%). Not
removed by dialysis; 0.5-1 hr (elimination half-life).
Indications Cloxacillin is effective against Penicillinase producing
Staphylococcus. It also acts against Strep Pyogenes,Strep
Viridans, Strep Pneumonia.
Contraindications Contraindicated in hepatic failure, Lactation, Hypersensitivity to
penicillin and pregnancy.
Side effects and Side effects
Adverse Reactions An allergic reaction Severe watery diarrhea Severe cramps Unusual bleeding Mild nausea White patches on the tongue Vaginal yeast infection Black, "hairy" tongue or sore mouth or tongue
Nursing
Responsibilities
1. Ensure right patient, ask the patient his name and check
the ID band.
2. Check the drug label before preparing the drug.
3. Check the latest doctor prescribed dosage and asks
somebody for clarifications about the dosage.
4. Check latest doctor prescribed dosage frequency.
Administer on time
5. Determine previous exposure and sensitivity to penicillins
and cephalosporins and other allergic reactions of any kind
before treatment is initiated.
6. Monitor for S&S of anaphylactoid reaction (see Appendix
G) or other signs or symptoms of hypersensitivity reaction
(see Appendix F) as with other penicillins.
7. Lab tests: Periodic assessments of renal, hepatic, and
hematopoietic function are advised in patients on long-term
therapy.
8. Be sure to let healthcare provider know if your child has any
allergies or reactions to medicine, food preservatives, or
dyes. Make sure to tell about the allergy and how it affected
your child. This includes telling about rash; hives; itching;
shortness of breath; wheezing; cough; swelling of face, lips,
tongue, or throat; or any other symptoms involved.
Patient & Family Education
Take medication around the clock, do not miss a dose, and continue taking the medication until it is finished.
Report to physician the onset of hypersensitivity reaction (see Appendix F) and superinfections.
Check with physician if GI adverse effects (nausea, vomiting, diarrhea) appear.
Do not breast feed while taking this drug.
Generic Name
Ascorbic Acid
Brand Name CELIN(Glaxo), CHEWCEE(Wyeth Lederie), CELL -C (Sarabhai),
CECON DROPS (Abbott),
Classification Vitamins
Ordered Dosage Route: PO
Dosage: 500mg
Dosage Frequency BID
Mechanism of
Action
Assists in collagen formation, tissue repair; involved in oxidation reduction reactions, other metabolic reactions.Vitamin C is involved in metabolism; carbohydrate utilization; synthesis of lipids, proteins, carnitine. It also preserves blood vessel integrity.
Indications Vitamin C is a compound that is necessary for proper growth and
health. They are needed in small amounts only and are usually
available in the normal foods that are ingested. Ascorbic
acid( vitamin C) is necessary for wound healing. Vit C plays a
major role in many oxidative and other metabolic reactions
essential for formation and stabilization of collagens,conversion of
folic acid to folinic acid, synthesis of adrenal steroids and
catacholamines.It is very important for maintanance of intracellular
tissue.
Contraindications Use of sodium ascorbate in patients on sodium restriction; use of
calcium ascorbate in patients receiving digitalis. Ascorbic acid may
be contraindicated in patients with hemolytic anemia.
Side effects and
Adverse ReactionsSide Effects
Abdominal cramps
Nausea
Vomiting
Diarrhea
Increased urination with doses exceeding 1 gram
Flushing
Headache
Dizziness
Sleepiness or insomnia
Adverse Reactions Urine acidification that may lead to crystalluria
Nursing
Responsibilities
Nursing Considerations
May give without regard to food.
Assess for clinical improvement (improved sense of well-being and sleep patterns).
Observe for reversal of deficiency symptoms (gingivitis, bleeding gums, poor wound healing, digestive difficulties, joint pain).
Patient Teachings
Abrupt vitamin C withdrawal may produce rebound deficiency.
Generic Name
25 % Albumin vial
Brand Name Commonly used brand name(s): Albuminar-25; Albuminar-5; Albutein 25%; Albutein 5%; Buminate 25%; Buminate 5%; Plasbumin-25; Plasbumin-5.
Classification
Ordered Dosage Route: IVTT
Dosage: 25% albumin vial
Dosage Frequency Transfuse in 4 hours
Mechanism of
Action
Blood volume expander—Albumin is an important regulator of the
volume of circulating blood. It accounts for 70 to 80% of the colloid
oncotic pressure of plasma. An infusion of albumin 5% is
oncotically equivalent to an equal volume of human plasma and
increases blood volume by an amount approximately equal to the
volume of albumin infused; albumin 25% is oncotically equivalent
to approximately 5 times the volume of human plasma and draws
into the circulation an amount of fluid approximately 3.5 times the
volume of albumin infused. Albumin provides a
temporary increase in blood volume, which reduces
hemoconcentration and blood viscosity.
IndicationsAlbumin (Human), Human Albumin Grifols® 25% is indicated:
a. For the prevention and treatment of hypovolemic shockb. in conjunction with exchange transfusion in the treatment of
neo-natal hyperbilirubinemiac. Concentrated Albumin (Human) solutions (e.g., 25%) have
also been used successfully to induce diuresis in some patients with acute nephrosis who were refractory to other forms of treatment. However, Albumin (Human) has no role in the management of chronic nephrosis.
d. More dilute Albumin (Human) solutions (e.g., 5%) have been used as pump priming fluids during cardiopulmonary bypass. However, an adequate blood volume can also be maintained during bypass with crystalloid as the only priming fluid without a significant difference in the clinical outcome achieved.
ContraindicationsContraindicated in patients with severe anemia or cardiac failure in the presence of normal or increased intravascular volume.The use of Human Albumin Grifols® 25% is contraindicated in patients with a history of allergic reactions to albumin.
Side effects and
Adverse ReactionsRare- Nausea, fever, chills, flushing, hives, skin rash, itching, headache, breathing difficulty, rapid heartbeat or allergic reactions may occasionally occur.Potentially Fatal : Anaphylactic shock.
Nursing
Responsibilities
1. Ensure right patient, ask the patient his name and check
the ID band.
2. Check the drug label before preparing the drug.
3. Check the latest doctor prescribed dosage and asks
somebody for clarifications about the dosage.
4. Check latest doctor prescribed dosage frequency.
Administer on time
5. This product is usually given in a hospital setting.
6. Inform patients being treated with Albumin (Human) 20%
about the potential risks and benefits with its use
7. Discontinue immediately if allergic symptoms occur (e.g.
skin rashes, hives, itching, breathing difficulties, coughing,
nausea, vomiting, fall in blood pressure, increased heart
rate).
8. Inform patients that Albumin (Human) 20% is a derivative of
human plasma and may contain infectious agents that
cause disease (e.g., viruses, and theoretically, CJD agent).
9. Inform patients that the risk that Albumin (Human) 20%
may transmit an infectious agent has been reduced by
screening plasma donors for prior exposure for certain
viruses, by testing the donated plasma for certain virus
infections and by inactivating and/or removing certain
viruses during manufacturing .
Nursing Theory Definition Rationale
1. Florence Nightingale
(Environmental theory)
She stated in her
nursing notes that
nursing "is an act of
utilizing the environment
of the patient to assist
him in his recovery"
(Nightingale
1860/1969), that it
involves the nurse's
initiative to configure
environmental settings
appropriate for the
gradual restoration of
the patient's health, and
that external factors
associated with the
patient's surroundings
affect life or biologic and
physiologic processes,
and his development.
Nurses should assist the
client during his/her recovery. If
ever they are not able to give him
the most ideal environment there
is, it is the nurse’s duty to give
him the comfort as part of our
care. Such ways include the good
sanitation where the client stays;
it includes cleaning the area
always, attending to her
immediate needs, and keeping
environment suitable for client’s
recovery.
2. Adaptation Model
(Callista Roy)
The major concepts are
the person or group as
an adaptive system; the
environment as internal
and external stimuli;
health as being and
becoming whole and
integrated; and nursing
The theory is applicable to the patient
since it is focused to the adaptation
ability of the patient that can greatly
affect the recovery of the patient. In the
patient’s condition, it is very important
that he’ll be able to have a fast recovery
because recovering would mean that the
patient will be able to go back to the
things that he used to do before his
admission and be able to continue on
as the art and science of
promoting adaptation.
The philosophic and
scientific assumptions
are basic underlying
concepts. The model
aims to direct nursing
practice, research and
education. The
widespread us of the
model in each of these
areas is well
documented, for
example, in all areas of
practice, all levels of
education, and in
quantitative and
qualitative research.
with his life. However, the patient has
already accepted his condition and is
slowly trying to live a normal life despite
of his condition.
3. Core, Care, Cure
Theory
(Lydia E. Hall)
Hall’s theory of
nursing involves three
interlocking circles, each
representing one aspect
of nursing. The care
aspect represents
intimate bodily care of
the patient. The core
aspect deals with the
innermost feelings and
motivations of the
patient. The cure aspect
tells how the nurse
helps the patient and
The patient cannot fully do the
things he usually does when he
still has both arms and somehow
needs the assistance of the
nurse. The support coming from
his family motivates him to
comply with the therapy. While
we nurses did our part by
providing him the care that he
needs including the therapeutic
communication, body language
that he deserves.
family through the
medical aspect of care.
The main tool the nurse
uses to help the patient
realize her or her
motivations and to grow
in self-awareness is that
of reflection.
DATE &
TIME
CUES NEED NURSING
DIAGNOSIS
OBJECTIVES OF
CARE
NURSING INTERVENTIONS EVALUATION
September
15,
2011
@
4:00 PM
SUBJECTIVE:
“sakitakoangsugatdi
risatiil”, as
verbalized by the
patient.
OBJECTIVE:
patient
complains of
pain at the
right thigh;
post skin
graft;
grimace face
noted;
guarding
behavior at
the site of
C
O
G
N
I
T
I
V
E
P
E
R
C
E
P
T
U
Pain related to post
surgical procedure
secondary to Skin
Grafting
®Pain is a subjective
state which varies on
how the client
perceives it as well as
on the client’s level of
pain threshold. Pain
is commonly
observed in client’s
who undergone
surgery since trauma
is being induce to the
client couple with
breakage in the
continuity of the
different levels of
That within our 2
hours span of care
our patient will be
relieve from pain as
evidenced by:
a. Pain scale will
be reduce from
moderate to mild
or absence of
pain;
Pain scale:
0 Absent:
1 to 3 Mild;
4 to 7 Moderate
7 to 10 Severe
b. Demonstrate
techniques that
can help to
1. Medicate patient with the
prescribed analgesics as ordered
such as Ketorolac and Tramadol;
evaluate and document patient’s
response through the pain scale.
®Drug administration of analgesics
will aid in relieving the pain, thus
decreasing the severity of the pain.
2. Perform comfort measures passive
range of motion of the hands and
the like.
®These measures reduce muscle
spasm, redistribute pressure on
body parts and help patient focus
on non-pain related subjects.
3. Plan activities with the patient to
provide distraction, such as
reading, talking, and other
September 15, 2011
@
6:00 pm
GOAL MET
After rendering different
sets appropriate,
comprehensive and
systematic nursing
interventions our client was
able to relieve from pain as
evidenced by:
a. pain scale of 1 out of 3
which signifies reduction
of pain intensity from
moderate to mild;
b. able to perform
pain;
motion is
done in a
slow manner;
Pain
Characteristic
s:
Severity: 4
Pain Scale
o Mild: 1
to 3
o Moder
ate: 4
to 6
o Sever
e: 7 to
10
Location:
Right thigh
Duration:
Continuous
A
L
P
A
T
T
E
R
N
body’s tissues. In due
to this existence our
body’s normal
reaction to this
situation is pain.
Bibliography:
Smeltzer,S.,Bare,B,.
et al Brunner and
Suddarths Textbook
of Medical Surgical
Nursing
Bare,B.,RN,MSN,
Cheever, K,
K, PhD, RN,
Hinkle, J.,
PhD, RN,
alleviate pain
such as deep
breathing
exercises.
distraction techniques.
®These heighten one’s
concentration upon non-painful
stimuli to decrease one’s
awareness and experience of pain.
4. Eliminate additional stressors or
sources of discomfort whenever
necessary or possible.
®Patient may experience an
exaggeration in pain or a
decreased ability to tolerate painful
stimuli if the environmental,
intrapersonal and intra-psychic
factors are further stressing them.
5. Teach the patient on relaxation
exercises, breathing exercises or
even music therapy.
®Techniques are used to bring
about a state of physical and
mental awareness and tranquility.
The goal of these techniques is to
relaxation techniques
such as deep breathing
exercises which helps in
alleviating pain.
Quality:
Burning
with
medication/s
of: Ketorolac;
and Tramadol
for pain.
reduce tension, subsequently
reducing pain.
6. Provide rest periods especially to
the client after performing those
activities which may aid in
alleviating the pain.
®This facilitates comfort, sleep and
relaxation. In a cyclic fashion,
feeling of pain may lead towards
the occurrence of fatigue and even
exhaustion, thus resting period is
very much essential.
7. Help the patient in a comfortable
position, and use pillows to splint or
support painful areas as
appropriate.
®This aid in reducing spasm at the
site of pain, preventing worsening
of painful stimulation and
experience.
8. Provide anticipatory instruction on
pain causes, appropriate prevention
and relief measures.
®Knowledge about what to expect
can help the patient develop
effective coping strategies for pain
management.
9. Instruct patient to report existence
or feeling of pain.
®Relief measures to be instituted
as early as possible.
10. Instruct the patient to evaluate and
even report effectiveness of
measures used.
®Pain relief strategies can be
modified, to promote more
satisfactory comfort levels.
DATE &
TIME
CUES NEED NURSING
DIAGNOSIS
OBJECTIVES OF
CARE
NURSING INTERVENTIONS EVALUATION
September
15,
2011
@
3:00
PM
S/O:
Hiding altered
body part with
the use of
clothing.
Refusal to talk
about the
altered body
part.
Changes in
social
behavior.
When asked
about his
amputated
S
E
L
F
P
E
R
C
E
P
T
I
O
N
Body Image
Disturbance related
to Permanent
Alterations in
structure and
function.
® Amputation is a
reconstructive
procedure that alters
the patient's body
image. The nurse
encourages the
patient to look at, feel
and care for the
altered body part.
Within our 8 hours
span of nursing care,
our patient will be able
to demonstrate
enhanced body image
as evidenced by:
Ability to look
at, touch and
talk about
the altered
body part.
Able to
enhance self
esteem.
1. Note sign of grieving/indicators of
severe or prolonged depression.
®To evaluate need for counseling
and/or medications.
2. Observe interaction of patient with
significant others.
®Distortion in body image may be
unconsciously reinforced by family
members.
3. Listen to patient’s comments and
responses to the situation.
®Different situations are upsetting
to different people, depending on
individual coping skills.
4. Note withdrawn behavior and the
September 15, 2011
@
11:00 pm
GOAL PARTIALLY MET
After our 8 hours span of
nursing care, our patient
was able to demonstrate
enhanced body image as
evidenced by:
Able to look at,
touch and talk about
the altered body
arm, he
avoids the
topic.
He would feel
irritated when
interviewed
about his
amputated
arm compared
to other
topics.
-
S
E
L
F
C
O
N
C
E
P
T
P
A
T
T
E
The loss of an
extremity may come
as a shock even if the
patient was prepared
preoperatively. The
patient's behavior
and expressed
feelings reveal how
the patient is coping
with the loss and
working through the
grieving process.
the patient who is
accepted as a whole
person is more
readily able to
resume responsibility
for self care, self
concept improves
and body image
changes as accepted.
Bibliography:
Verbalize
understandin
g of body
changes.
use of denial.
®may be normal response to
situation or may be indicative of
mental illness.
5. Visit patient frequently and
acknowledge the individual as
someone who is worthwhile.
®Provides opportunities for
listening to concerns and
questions.
6. Assist in correcting underlying
problems.
®To promote optimal
healing/adaptation.
7. Encourage verbalization of and role
– play anticipated conflicts.
®To enhance handling of potential
situations.
8. Set limits on maladaptive behavior
and assist patient to identify
positive behaviors.
part.
Able to enhanced
self esteem.
Patient was not able
to verbalized
understanding of
body changes.
R
N
Brunner &Suddarth’s
Textbook of Medical
– Surgical Nursing
11th edition
®To aid in recovery.
9. Help patient to select and use of
clothing.
®To minimize body changes and
enhance appearance.
10. Provide information at patient’s
level of acceptance.
®To allow for easier assimilation.
DATE &
TIME
CUES NEED NURSING
DIAGNOSIS
OBJECTIVES OF
CARE
NURSING INTERVENTIONS EVALUATION
September
17,
2011
@
3:00
PM
SUBJECTIVE:
“Katolakoangsugat”
as verbalized by
the patient.
OBJECTIVE:
Open wound
Not covered
with dressing
Redness,
Swelling and
purulent
discharges
noted.
N
U
T
R
I
T
I
O
N
A
L
M
E
T
A
B
O
L
I
C
P
A
T
T
E
R
N
Impaired Skin
Integrity related to
humidity and
moisture secondary
to STSG
®The integument
acts as a
protective barrier
from
environmental
insults including
trauma, radiation,
harsh
environmental
conditions and
infection.
Bibliography:
Brunner'sand
Suddarth's
Textbook of
Medical-Surgical
Nursing(2008)
.
Within our 5 hours
span of care the
patient will be able to
improve skin integrity
as evidenced by:
a. Demonstrate
behaviors to
promote healing
and prevent
complication.
b. Absence of
discharges in the
wound.
c. Cope with the
activities of daily
living.
1. Discuss Importance of
adequate nutrition especially,
Increase intake of fluids,
proteins and vitamins.
®These provide patient
information how nutrition
could elevate his chances of
a faster recovery and wound
healing.
2. Instruct not to scratch the
wound.
®This provides patient a
guide towards a proper skin
management technique
minimizing more skin trauma.
3. Emphasize principles of
asepsis especially hand
washing.
®To avoid possible infection
thus hindering the wound
healing process
4. Demonstrate wound care
technique such as wound
cleansing and dressing
changing.
®To provide the patient on
the correct procedures and
techniques of wound caring.
5. Reinforce initial dressing/
September 17, 2011
@
8:00 PM
GOAL PARTIALLY MET
At the end of 5 hours span of
care the patient was able to
improve skin integrity as
evidenced by:
a. Demonstrated
behavior to promote
healing and prevent
complications such not
touching the wound.
b. There were minimal
discharges noted.
c. Able to cope with ADL.
DATE &
TIME
CUES NEED NURSING
DIAGNOSIS
OBJECTIVES OF
CARE
NURSING INTERVENTIONS EVALUATION
September
16,
2011
@
S/O:
Open
wound at
right leg.
H
E
A
L
Risk for infection
related to surgical
procedure secondary
to Fore Quarter
Amputation
Within our 5 hours
span of nursing care,
my patient will be free
from infection as
evidence by:
1. Administer antibiotics such as
Cefazolin as ordered.
®To kill microorganisms that
may predispose infection.
September 16,
2011
@
8:00 pm
3:00
PM
WBC of
23.67
Redness,
swelling
and
purulent
discharge
s at
incision.
Meds:
Cefazolin
T
H
P
E
R
C
E
P
T
I
O
N
-
H
E
A
L
T
H
® Surgery
traumatizes the body
by disrupting
protective
mechanisms and
homeostasis.
Bibliography:
Brunner &Suddarth’s
Textbook of Medical
– Surgical Nursing
11th edition
Verbalize
interventions
that may
prevent
infection.
Absences of
redness,
swelling and
purulent
discharges at
post-op site.
2. Wash hands before and after
handling the client.
®To deter the spread of
microorganism.
3. Wear gloves when handling
patient.
®Using gloves does not just
protect the health worker but
also prevent contamination to
the wound.
4. Monitor the wound for redness,
swelling, pain, discharges and
heat.
®This may signify that an active
inflammatory response to local
area is present
5. Clean and dry surrounding
tissue of lesion.
®Adjacent areas that are
unclean may potentiate skin
breakdown.
GOAL MET
After our 5 hours
span of nursing
care, our patient
was free from
infection as
evidenced by:
Verbaliz
ed:
“walanankog
inagunitanak
oangsugatug
nagahugasn
apudkougka
mot.”
Absenc
e of
redness
,
swelling
M
A
N
A
G
E
M
E
N
T
P
A
T
T
E
R
N
6. Replace soiled linens in contact
with lesions
®Soiled linens are good medium
for microbial growth
7. Instruct to avoid scratching the
healing lesions
®Healing wound is usually itchy.
8. Avoid unnecessary contact with
the lesion
®It decreases the potentiality of
acquiring infection
9. Monitor vital signs
®Increase in vital signs,
especially temperature may
indicate inflammatory response.
10. Provide/encourage balanced
diet, emphasizing proteins to
feed the immune system.
®Immune function is affected by
protein intake, the balance
between omega-6 and omega-3
and
dischar
ges at
post-op
site.
fatty acid intake, and adequate
amounts of vitamins A, C, and E
and the minerals zinc and iron. A
deficiency of these nutrients
puts the client at an increased
risk of infection.
11. Review individual nutritional
needs, appropriate exercise
program, and need for rest.
®Enhance immune system
function and healing.
DATE &
TIME
CUES NEED NURSING
DIAGNOSIS
OBJECTIVES OF
CARE
NURSING INTERVENTIONS EVALUATION
September
17,
2011
@
4:00
PM
SUBJECTIVE:
“Ayawgunitiangako
angsugatkaybasig”
As verbalized by
patient.
OBJECTIVE:
presence of
wound at
right thigh
appears
worried
guarding
behavior
S
E
L
F
-
P
E
R
C
E
P
T
I
O
N
S
E
L
F
-
C
O
N
C
E
P
T
P
A
Fear related to
physical threat
secondary surgical
procedure (Skin
Grafting)
® Fear is a strong
and unpleasant
emotion caused by
the awareness or
anticipation of pain,
or danger. The
factors that
precipitate fear are
fear of pain; bodily
injury and surgical
complication are
common to most
people.
Bibliography:
Lewis,S.et al
(2007)Medical-
Surgical Nursing:
Assessmentand
Management of
Clinical Problem
Within our 2 hours span
of nursing care, patient
will be able to manifest
a reduction or absence
of fear as evidence by:
demonstrate
understanding
through use
of effective
coping
behaviors and
resources
and;
Appear relax.
1. Determine what the patient is
fearful of by careful and thoughtful
questioning.
® The external sources of fear can
be identified and current responses
can be assessed.
2. Determine the degree of fear and
the measures the patient uses to
cope with fear.
® This helps determine the
effectiveness of coping strategies
used by patient.
3. Reinforce the idea that fear is a
normal and appropriate response to
situations when pain, danger, or
loss of control is anticipated or
experienced.
® Knowledge serves to reduce
unrealistic expectations.
4. Assist the patient in identifying
strategies used in the past to deal
with fearful situations. These
measures may be helpful or
comforting.
® This helps the patient to focus on
fear as a real and natural part of life
that has been and can continue to
be dealt with successfully.
5. Discuss resumption of activity.
September 17,
2011
@
6:00 pm
GOAL MET
Within our 2
hours span of
nursing care,
patient was able
to manifest a
reduction of fear
as evidenced by:
a. Demonstrated
understanding
through the
use of
effective
coping
behavior
(relaxation
exercises)
b. appeared
relax;
DISCHARGE PLAN
Medications
Instruct patient to continue taking Ranitidine H2 inhibitor and Celecoxib an
NSAIDs drug
Inform client to take her medications on time, or as directed for the full course
of therapy.
Educate the patient about the side effects of Ranitidine such as; diarrhea,
headache, nausea, dizziness and constipation, Celecoxib such as;headache
and sore throat.
Instruct patient and significant others not to stop taking the prescribed
medications for the full course of therapy even if the patient already feels better
or unless being approved by the patient’s attending physician.
Instruct patient to check the labels of medicines before taking it.
Exercise
Explain to client the value of exercise in our body like active ROM.
Encourage the patient to have adequate rest and sleep.
Instruct the patient that exercises performed should be within normal limits.
Treatment
Instruct the client to continue drug therapy as ordered.
Discuss to the client the complications of her sickness.
Instruct the patient to report to the physician promptly any changes on health
condition. Such as allergic reactions, high blood pressure or all of the
unusualities that may happen to her.
Health Teachings
Instruct the patient to do daily hygiene and grooming, which includes daily body
bath and hand washing.
Teach the patient and family how to promote healthy lifestyle like regular
exercises and having adequate resting periods.
Educate the family about the importance of maintaining the cleanliness of their
surrounding environment.
Inform the family of the patient about his condition and the necessary information
for his treatment.
Advice the patient to avoid strenuous activities until full recovery is achieved.
Instruct patient’s significant others to provide emotional and social support to the
patient.
Teach patient how to do proper wound dressing.
Follow up check-up after a week.
Instruct patient the frequency of taking medications.
Outpatient Orders
Instruct patient and significant others to have follow-up check-up.
Encourage patient and significant other to notify the physician immediately if any
unusalities in the health status have occurred.
Encourage the patient to comply with all the regimen and instructions given to him.
Continue medication as ordered.
Diet
Inform the patient and significant others the importance of following a healthy diet
such as avoid drinking too much alcohol, low fatty foods, salty foods and increase
iron intake such as ampalaya, raisins and liver.
Instruct patient to increase oral fluid intake.
Instruct patient to minimize intake of goitrogenic foods such radish, and other
green leafy vegetables.
Spirituality
Encourage the patient to understand her situation whatever may happen .
Advice the patient to keep on praying and never lose hope if any negative results
will arise.
Sexuality
Advice the patient and significant other to refrain from doing sexual intercourse
for the first few weeks of post surgery.
PROGNOSIS
GOOD FAIR POOR JUSTIFICATION
Onset of the
illness
√ The onset of the illness was gradual as the
presence of mass on his right arm lasted for
3months. In terms of management, He was able to
consult his doctor about it and respond to
medications and surgery therefore had no delay
on proper medical consultation
Duration of illness √ For the past 3months the patient ignored his mass
on the right arm and did respond to treatment.
However, when he noticed that the mass is
beginning to grow larger and he has difficulty in
moving his arm because of it, he decided to
consult a doctor and undergoes a surgery.
Precipitating
factors
√ Lifestyle and diet, because the patient is lack of
nutrients and the patient is in low class. And he’s
living in the farm which is far from the city proper.
Willingness to take
medications and
treatment
√ The patient is willing to take proper treatments
accordingly since the surgery. They can afford the
medicines and treatment needed for the
improvement of her condition.
Age √ Age do have a direct effect in the condition
itself.However, the prevalence of
rhabdomyosarcomamost common in children ages
one to five, and is also found in teens aged 15 to
19. According to statistics, by 3% of all childhood
cancers are rhabdomyosarcomas.The patient is
14 years old.
Environmental
factors
√ He is living in a farm where He defines well. That
farm is far from the city proper. However there’s a
barangay health center near it, and far from
hospital but the patient chose to admit herself at
SPMC in Davao.
Family Support √ The patient’s family is very supportive throughout
the treatment regimen of the patient.He is also
frequently visited by his relatives to look out for his
condition.
Total 2 2 3
Computation:
Poor: (2*3)/7 = 0.86
Fair: (3*2)/7 = 6/7 = 0.86
Good: (3*2)/7 = 6/7 = 0.86
Total: 2.58
General Prognosis:
1-1.6 = POOR
1.7-2.3 = FAIR
2.4-3.0 = GOOD
General Prognosis:
As shown by the calculated results with their respective
points, the general prognosis of the client is GOOD. The
patient has a good chance of recovering from his condition
of having a rhabdomyosarcoma because of his age,
presence of only two precipitating factors, compliance to
some treatment regiment, and family support. Most
rhabdomyosarcomaoccurs at the age 15 to 19. They are
usually found by patients who feel a lump at their
arms,legs, and jaws or after undergoing a physical
examination. It is easily treated through surgery. As of now
the patient has improved in terms of his health as
evidenced by amputation
RECOMMENDATION
To the Patient
She must be wary of abnormalities that are developing in her body like in the event when she observed that there was a mongo sized growth in her neck then she must have sought a medical advice. She should be wearing protective equipment when handling hazardous substances and be fearful of the consequences of not doing so for this is one of the suspected factors that made her sick. The patient must realize that her condition is uncommon.
Hypocalcaemia must not be experienced by the client by taking calcium supplements as prescribed by the doctor. She can monitor apical pulse, blood pressure, & temperature at least every 4 hours. She must report palpitations, dyspnea, vertigo, or chest pain. She can keep her environment quiet & cool, change bed linens, & bath frequently.
She can elevate the head at night & use an eye lubricant. If photophobia is present, dark glasses or eye patches can be worn. If she cannot close the eyelids completely, she can tape the lids close with nonallergenic tape. If pressure behind the eye continues, she can undergo a doctor prescribed steroid therapy. She can take doctor prescribed diuretics to decrease edema around the eye.
The client must report if there is an increase or recurrence of symptoms. She must have a regular follow-up. The client must inspect the incision area and report if there is redness, tenderness, drainage, and swelling to a member of a healthcare team. She can expect mood changes as a result of hyperthyroidism.
To the pt.’s family
Her family must encourage her to visit a physician & support her financially. They can try to hide their financial incapability to avoid discouraging her from undergoing a treatment and warn her of the larger cost of treating a severe disease.
The family must be suspicious of recent weight loss & an increased appetite. The most important thing for them to watch out for is pt. diaphoresis even when the environmental temperature is comfortable for them.
To the Community
The community must promote a positive atmosphere despite of the advanced stage of the disease. They must contain the backing out from the treatment thoughts of the patient’s mind. Her surrender in the treatment program must be related by them to her as an avenue for the worsening of her condition. They must let her realize that her condition is uncommon but controllable. They must give employment that is healthy in order for the people to have lesser chances of working in environment with toxic chemicals.
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Table of Contents
I. Acknowledgement 01
II. Introduction 02
III. Objectives 04
IV. Patient’s Data 07
V. Genogram 09
VI. Family Background / Health History 10
VII. Developmental Data 14
VIII. Physical Assessment 22
IX. Definition of Complete Diagnosis 26
X. Anatomy and Physiology 31
XI. Etiology 39
XII. Symptomatology 41
XIII. Pathophysiology 43
XIV. Doctors Order 46
XV. Diagnostic Exam 54
XVI. Drug Study 77
XVII. Nursing Theories 101
XVIII. Nursing Care Plan 103
XIX. Prognosis 125
XX. Discharge Plan 128
XXI. Recommendation 131
XXII. Reference 133