CASE PRESENTATION

PATHOPHYSIOLOGY:
Non-modifiable factors:
-age, heredity, environment,
previous colon disease.

Excess fat converts normal

flora to the intestines over
time.

Stress stimulates parasympathetic function secretion to

enzyme proteinase

Modifiable factors:
- nutrition, stress, bowel
habits.

Fecal matter retention due to infrequent defecation

Irritating to intestinal
lining
Inflammation

Excess Fat converts normal flora to the intestines

over time
Polymorphic leukocytes causes
abscessing
Widens inflammation and
necrosis
Repeating process over
time causes dysplasia then genetic mjutation to
Ulcerating lesion
the cellular DNA

Cancer cells lodge into lesions, invade

then hide on blood components to avoid
immune detection.

Cancer cells destroy surrounding tissues

gains access to lymphatic vessels

Metastasis to liver

Signs & Symptoms:

Elevated ALT and AST, yellow skin

Signs and Symptoms:

-Growth of tumor in the skin
-Constipation

Reference:

Assessment

Brief
Explanation of
the Problem

Goals and
Objectives

Nursing
Interventions

Rationale

Criteria for
Evaluation

S: Medyo
nahihilo at
nahihhirapan
ding huming
at tsaka
madali akong
napapagod.

Anemia is a
symptom of an
underlying
condition, such as
loss of blood
components,
elements
inadequate or lack
of nutrients
needed for the
formation of red
blood cells,
resulting in
decreased oxygencarrying capacity
of blood (Doenges,
1999)

GOAL: The patient

will be able to
have an effective
peripheral tissue
perfusion

Objectives:
LTO: After 72
O: Vital signs
hours nursing
taken as: BP:
interventions the
90/50mmhg.
patient will be
RR: ,PR: ,T:
able to have an
.
effective tissue
perfusion as
RBC Count:
manifested by:
3.85
a. Stable RBC,
According to
x10^12/L
Hgb, Hct
NANDA, ineffective
Hgb: 116 g/L peripheral tissue
count (within
perfusion is the
Hct: 0.345.
normal
Capillary refill decrease in blood
levels)
circulation to the
b. Absence of
of 2-3
periphery that
signs and
seconds,
may cause
symptoms of
conjunctival
compromise
anemia
pallor noted. health.
On CBR with

Dx:
1. Monitor and
record Vital
Signs.

2.

3.

Tx:
4.

5.

LTO: After 72

>serves as a baseline
hours of nursing
data for any significant
interventions:
changes in the
Fully met if;
patients condition

a. The patient
have a
Reviewed
> Normal value s
laboratory
indicate adequate
stable RBC,
studies such
tissue perfusion.
HCT AND
as
Indicates Effectiveness
Hgb within
hemoglobin
of nursing
normal
,hematocrit
interventions.
levels
and RBC
b. Absence of
signs and
Assess patient > To have a baseline
general
data and note any
symptoms
condition
abnormal findings.
of anemia
Partially met if:
a. RBC, Hct
and Hgb
> It replenishes iron
Administered
stores in the body and
increased
Sangobion itab corrects hemoglobin
but not
deficit by increasing
TID
within
hemoglobin levels
normal
> Maintain and
levels
increase circulating
b. Still with
blood volume to
Anemia
1 unit PRBC
maximize tissue

BRPS
P1:
Ineffective
Tissue
Perfusion
related to
anemia
a. Activity
Intolera
nce
related
to easy
fatigabili
ty

Reference:
Doenges, M.E.
(2010). Nurses
Pocket Guide.
Diagnoses,
Prioritized
interventions and
Rationales. F.A.
Davis Compay.
Philadelphia. Pp.
608-614

transfused
STO: After 8 hours
of nursing
interventions the
patient will be
able to:
6. Administer IV
fluids as
a. Have an
ordered.
increase in
RBC, Hct and
Hgb within
7. Maintain on
bedrest
normal
levels.
b. Have an
8. Provide safety
adequate
by raising side
tissue
rails
perfusion as
manifested
by capillary
9. Provide
refill of 1-2
supplemental
seconds, no
oxygen as
pallor
indicated.
c. no difficulty
of breathing, Edx:
no easy
10.
Encoura
fatigability
ge quiet and
and

perfusion

> Maintain and

increase circulating
volume to maximize
tissue perfusion
> Restricted activity
reduces oxygen
demands of the heart
and other organs.
> Weakness, fatigue
and restlessness are
signs of hypoxia which
may cause injury to
the patient.

Not met if:

a. RBC, Hct,
and Hgb
remains the
same level
and no
increase.
b. Still with
Anemia
STO: after 8
hours of nursing
intervention:

Fully met if:

a. Have an
increase in
> to maximize the
RBC, Hct
transport of oxygen to
tissues.
and Hgb
within
normal
levels.
b. Have an
adequate
> To conserve energy and
tissue
lower tissue oxygen

dizziness.

perfusion as
manifested
by capillary
11.
Instructe >Straining further
refill of 1-2
d to avoid
needs an increase in
seconds, no
straining
oxygen demand
pallor
c. no difficulty
12.
Taught
>Promotes lung
of
on proper DBE expansion and
breathing,
increase O2 supply in
no easy
the body
13.
Eat foods
>To increase the
fatigability
rich in iron
capacity of the RBC to
and
except raw
carry O2 in the body,
and uncooked
dizziness.
except raw foods since
the patient has a
fruits and
Partially met if:
cancer, unseen
vegetables
a. Have an
bacteria in raw foods
increase in
might compromise the
patients status.
RBC, Hct
and Hgb
within
normal
levels.
b. Have an
adequate
tissue
perfusion as
restful
atmosphere

demands.

manifested
by capillary
refill of 1-2
seconds, no
pallor
c. Still with
minimal
difficulty of
breathing,
easy
fatigability
and
dizziness.
Not met if:
a. No
improveme
nt in
general
condition
References:
Doenges, M.E. (2010). Nurses Pocket Guide. Diagnoses, Prioritized interventions and Rationales. F.A. Davis Compay. Philadelphia.
Pp. 608-614

Drug Study. (2010). Retrieved by http://www.studymode.com/essays/Drug-Study-527723.html