Surg East 2015 CP

Ateneo de Davao University
to the School of Nursing

A Case Study on
Obstructive Jaundice secondary to Pancreatic Head mass Malignant
Fulfillments in the reference for NCM 103 RLE
Submitted to:
Maam Nancy Bargamento RN. MN
Submitted by:
Dayanghirang, Earl John
Gulle, Christine May B.
Jamora, Janis Sushmita Marie Q.
Ledda, Lejaen Star Lyka J.
Mainopaz, Trexie Sharmaine
Mapundo, Settie Jamila
Nomus, Fritzie Beatrice
BSN 3A Group 2
September 22, 2014
TABLE OF CONTENTS
I.
Acknowledgement -------------------------------------------------------------------------1
II.
Introduction --------------------------------------------------------------------------------- 3
III.
Objectives ----------------------------------------------------------------------------------- 5
IV.
Patients Data ------------------------------------------------------------------------------- 7
V.
Genogram ----------------------------------------------------------------------------------12
VI.
Development Data ------------------------------------------------------------------------13
VII.
Definition of Complete Diagnosis------------------------------------------------------16
VIII.
Physical Assessment ---------------------------------------------------------------------18
IX.
Anatomy and Physiology----------------------------------------------------------------23
X.
Etiology and Symptomatology----------------------------------------------------------26
XI.
Pathophysiology---------------------------------------------------------------------------30
XII.
Doctors Order ----------------------------------------------------------------------------31
XIII.
Diagnostic Exam -------------------------------------------------------------------------85
XIV.
Drug Study--------------------------------------------------------------------------------116
XV.
Surgical Procedures----------------------------------------------------------------------143
XVI. Nursing Theories ------------------------------------------------------------------------147

XVII. Nursing Care Plan -----------------------------------------------------------------------151
XVIII
Prognosis--------------------------------------------------------------------------------167
XIX. Discharge Plan ---------------------------------------------------------------------------170

XX.
Recommendations -----------------------------------------------------------------------172
XX1. References --------------------------------------------------------------------------------175
ACKNOWLEDGEMENT
Before the formal beginning of this paper, the proponents would like to give
gratitude and acknowledgement to those individuals who have helped them in completing
this study; First of all, they would like to thank God Almighty, for giving them strength,
wisdom and knowledge that they used in making this case study, for all the blessings that
He has showered upon them and for the people that helped them to improve as student
nurses and to become better individuals.
They would also like to give thanks to the patient and his family for being
cooperative in their interview, for giving out necessary information that they needed and
for participating and being patient during the physical assessment.
They would also like to acknowledge the staff of Surgery East Ward at Southern
Philippines Medical Center, for being kind and hospitable, for helping them clarify the
information on the patients chart and for sharing their knowledge to the proponents.
Also, they would like to give special thanks to their clinical instructor, Mrs.
Maychel D. Ancog, RN, MN, for helping them choose the patient and for increasing their
knowledge in making this case study and for serving as their guide and mentor. All
studies during the making of this presentation would be nothing without the guidance,
help and teachings from her. To the School of Nursing Dean, Mrs. Patria V. Manalaysay,
RN, MAN, PhD and all the Faculty staff in the School of nursing that are patient in
helping them to complete this presentation.
And last but not the least; the proponents would like to give thanks to their friends
and classmates, for supporting them and helping them throughout this study by sharing
12
any information that they know to them. And to their parents who are always there to
support them physically, mentally, emotionally, financially and for encouraging them to
study and never give up in all the challenges that they are experiencing.
INTRODUCTION
The word jaundice comes from the French word jaune, which means yellow.
When we first think of jaundice what usually pops out in our minds is the yellow
13
discoloration of the skin. Yes, it is the yellowing of the skin, but not only the skin but also
the sclera in our eyes. It is not a disease, but rather a sign that can occur in several
different diseases. Now, an obstructive jaundice is a particular type of jaundice wherein a
person may experience the yellowing of the eyes and skin, abdominal pain and even
fever. One of the causes of obstructive jaundice is pancreatic head mass.
A study entitled Obstructive Jaundice- Aetiological Spectrum, Clinical, Biochemical
and Radiological Evaluation at a Tertiary Care Teaching Hospital was conducted last
2010 in India wherein 110 patients with obstructive jaundice were confirmed by
thorough history and physical examination, biochemical tests and radiological
investigations was done with final confirmation of diagnosis in histopathology. Out
of the 110 patients, 62 (56%) were male and 48 (44%) were female. The mean age of
the study population was 50.4 years old (range 3 85 years old). Malignant
obstructive was common than benign (62.73% vs 47.27%). Mass on the head of
pancreas was commonest etiology in 37 patients (33.63%).
Mass on the head of pancreas was the most common cause of obstructive jaundice
as a whole, as well as most common etiology of malignant obstruction in male patients.
In females, choledocholithiasis was the most common cause of biliary obstruction as well
as most common benign etiology. Benign causes are seen at a comparatively younger age
group compared to malignant causes (Verma, et al. 2010).
In the Philippines, according to the Philippine Star website which was updated
last October 18, 2011, there is no specific estimation of patients with obstructive jaundice
probably secondary to pancreatic head mass malignant, but in 2005 there were reportedly
1, 873 cases of it in the country.
14
During the proponents duty in Surgical East Ward at Southern Philippines

Medical Center, along with their clinical instructor, they chose patient Amber because
they wanted to apply to things they have learned in their lectures and to also know more
about the condition of the patient. They have also given great concern and care towards
the patient that is why they would want to have a deeper understanding on his condition
and to find out what are the things that, as student nurses, they could give or provide him
make his condition better.
OBJECTIVES
General Objective:
Within the 3 day exposure in Southern Philippines Medical Center Surgical East
15
Ward, the proponents should know and understand the disease process and concept of
Obstructive Jaundice probably secondary to Pancreatic head mass malignant and the
appropriate medical and nursing management regarding the condition of the chosen
client.
Specific Objectives:
Cognitive:
Analyze the clients past and present health history to identify precipitating and
predisposing factors that may contribute to the patients present condition ;
Distinguish the anatomy and physiology of the organs affected in the patients
case;
Comprehend the disease process: causes, effects, management, treatment, and

possible preventions;
Determine the pathophysiology of the condition with their rationale for

occurrence of each manifestation and the treatment modalities;
Recall three nursing theories that can be applied to the identified nursing
diagnosis of patients condition; and
Recognize the drugs prescribed to the client, their action, side effects, indications,
contraindications and nursing responsibilities given.
Psychomotor:
Collect all necessary information about the patient and his family members
related to the case study through interview and assessment;
16
Outline clients genogram or family tree to identify any heredo-familial diseases

that can be associated on the clients disease process;
Compare and contrast the three different sources of definitions of the complete
diagnosis;
Efficiently execute the physical assessment through IPPA to the patient and
identify any abnormal findings;
Deliver health teachings to the patient and his significant others for health
promotion; and
Offer care based on the various nursing care plans formulated by the proponents
and the patient himself.
Affective:
Establish rapport with the client including his family members in order to gain
trust and cooperation;
Display genuine concern and willingness in serving the patient through assisting
during ADLs;
Be involved in the course of care of the patient holistically; and
Be aware of the patients progress on the succeeding interventions given.
PATIENTS DATA
BIOGRAPHICAL
17
Patients Name: Patient Amber

Address: Del Monte, Island garden City of Samal
Age: 66.79 years old
Gender: Male
Date of Birth: September 03, 1947
Race/Ethnic Background: Filipino/ Davaoeno
Civil Status: Married
Religion: Roman Catholic
Birthplace: Cebu
REASON FOR SEEKING HEALTHCARE

Sign/s (Objective): Grimace and jaundice all over the body noted.
Symptom/s (Subjective): Sakit kaayo akong ityan verbalized by the patient
Chief Complaint (Onset): Abdominal Pain and jaundice.
Date and time of Admission: June 28, 2014 @ 10am
Vital Signs upon admission:
PR: 70 bpm
RR: 19 cpm
BP: 130/90 mmHg
TEMP: 36 C
Pain: 8/10
Admitting Physician: Dr. Honey Lee P. Tan
Admitting Diagnosis: Obstructive Jaundice probably secondary to Pancreatic
18
Head mass
Final/Principal Diagnosis: Obstructive Jaundice probably secondary to Pancreatic
Head mass Malignant
Operations: Exploratory Laparoscopy, Cholecystojejunostomy
Surgery (August 19, 2014)
Procedure: Exploratory Laparoscopy, Cholecystojejunostomy, drain
Surgeon: Dr. Chris Pales/Dr. Jaime Ocsis
Type of Anaesthesia: GETA-CEB
Institution/Health facility: Southern Philippines Medical Center
PRESENT HEALTH HISTORY

A month prior to his admission Patient Amber experienced pain in the upper right
quadrant of his abdomen. The pain was tolerable so he did not seek medical attention
right away. According to him, he had an increased level of pain tolerance so he didnt
mind taking pain relievers: mefenamic. Four days prior to admission, patient had severe
upper right quadrant pain which he said to be intolerable, he had also experience loss of
appetite and jaundice all over his body was observed by his wife, he was then advised by
his doctor to seek health care at Southern Philippines Medical Center for proper
treatment.
After having diagnosed of Obstructive Jaundice probably secondary to
pancreatic head mass the doctor advised him to have surgery.

Patient Amber was admitted June 28, 2014 @ 10am Philippines Medical Center
(SPMC) for consultation when the symptoms such as abdominal pain, loss of appetite and
jaundice. Symptoms are evaluated and verified in PQRST formula. Patient Amber was
19
confined for about 1 month and 25 days, and he was given proper treatment and
management Southern Philippines Medical Center.
PQRST
Definition
FORMULA
P
Stands
Palliative/Provocative,
Result
for Nag sige naman sakit akon tyan
which giinuman
naman
nako
ug
the patient was asked what mefenamic pero wala gihapon

does bring it on and what was nawala, unya nagyellow akon
he doing when he first noticed lawas as verbalized by patient
the symptoms.
Q
Amber.
Q stands for Quality/Quantity, Dili na makaya ang sakit bisang

which the patient was asked of giinuman na nako ug mefinamic
how intense was the pain being verbalized by the patient
felt.
R stands for Radiate, which the Sa taas banda sa akong tyan
patient was asked where the nagasakit
as
verbalized
by
pain radiates.
patient Amber.
S stands for Severity, which The pain was scaled at 8, where.
the patient was asked about The severity was at 8.
how painful he feels.

T stands for Time, which the Tulo naman ka tuig nga sigeg
patient was asked, about its sakit akon tyan kay naa koy ulcer
onset on when it first occurred, pero karon kay din a nakon
how long did it last and how makaya ang sakit ug niyellow na
frequent does it happen.
akon kalawasan
20
PAST HEALTH HISTORY

In medical history, patient Amber said that he had immunization when he was
young at their school the vaccine was for measles. He had mumps, colds, cough, and
boils as childhood illness. He had chickenpox when he was 12 years old and was
circumcised when he was 7 years old. He got into motor accident when he was 40 years
old, he was not hospitalized during that accident he only got scars in the legs and no
fractures.
Patient Amber visited hospital at their place in Samal every time he is unwell.
Three years prior to admission he had history of abdominal pain. Last March 2014 he
went to a clinic in Samal for consultation because of abdominal pain, according to Dr.
Quisada his doctor, Patient Amber had ulcer and was prescribe to take omeprazole and
amoxicillin.
FAMILY HEALTH HISTORY

Patient Amber was the seventh child of Daddy Red and Mommy Blue in the family.
Both of the patients Daddy and Mommy Blue side had a chronic and life threatening
condition such as hypertension and asthma. One of Patient Ambers siblings died from
lung disease and four of his siblings died at very young age 1-2 years old because of
cough and hyperthermia.
SOCIAL HISTORY
Patient Amber and his wife Violet live together with their eldest child Pink.
21
According to Patient Amber he never smokes and drinks alcohol. He never tried using or
selling prohibited drugs.
Patient amber wasnt involved in any organization in their place. He had good
relationship with his neighbors. He went to church every Sunday with his wife and
children. During free time he watched tv shows such as TV patrol, please be careful with
my heart and showtime.
DIET HISTORY
Patient Amber claims that he is fond of eating instant noodles such as pancit
canton, lucky me chicken flavour, he was picky when it come to vegetables he only eat
malunggay which he often mixed with his noodles. He loves drinking buko juice and eat
fruits such as lansones and santol. He has no allergy on any particular food.
MEDICATION RECONCILIATION
Medicine
Use of Medication according to patients understanding
Mefinamic acid
According to patient this med is pain reliever and he often use this
Omeprazole
Amoxicillin
whenever he had abdominal pain.

As perceived by the patient it is for ulcer
According to the patient this medicine is for infection
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Green
75 y/o
Aqua
60 y/o
Purple
57 y/o
Gold
46 y/o
Lavand
er
56 y/o
Gray
1 y/o
Silver
2 y/o
GENOGRAM
Yellow
80 y/o
Red
53 y/o
Turquois
e
53 y/o
Lime
2 y/o
Peach
1 y/o
Black
60
Bronze
62 y/o
Cyan
69 y/o
Indigo
20 y/o
White
63
Brown
60 y/o
Magenta
60 y/o
Beige
64 y/o
AMber
66 y/o
Orange
53 y/o
Blue
55 y/o
Mint
58 y/o
Fuchsia
63 y/o
Legend:
Patient
hyperthermia
Deceased
Hypertension
Asthma
Gunshot
12
Lung disease
Female
Male
Unknown cause of death
cough
13
DEVELOPMENTAL DATA
Piagets Stages of Cognitive Development

The Piaget stages of development is a blueprint that describes the stages of normal
intellectual development, from infancy through adulthood. This includes thought,
judgment, and knowledge. The stages were named after psychologist and developmental
biologist Jean Piaget, who recorded the intellectual development and abilities of infants,
children, and teens.
Stage
The
Operational
Description
Result
Formal The final stage of The

Stage Piaget's
Justification
patient The patient has increased in
theory has achieved logic, the ability to use
(Adolescence
involves an increase this stage.
deductive reasoning, and
through adulthood)
in logic, the ability
understanding
to
ideas.
use
deductive
abstract
Justified
when
reasoning, and an
patient was asked; Kabalo
understanding
ka sir kung ngano naa ka
abstract ideas.
of
diri sa hospital? ; Patient

answered; Oo, kabalo ko sa
akong
sakit,
naa
koy
problema sa pancreas.
14
Erik Eriksons Psychosocial Development Theory

Eriksons psychosocial theory of development considers the impact of external factors,
parents and society on personality development from childhood to adulthood. According
to Eriksons theory, every person must pass through a series of eight interrelated stages
over the entire life cycle.
Stage
Description
Later maturity (60 1. Adjusting
to
years old and over)
decreasing
physical
strength
and
health
2. Adjusting
to
retirement and
reduced
income
3. Adjusting
to
death
of
a
spouse
4. Establishing an
explicit
affiliation with
ones
age
group
5. Meeting social
and
civil
obligations
6. Establishing
satisfactory
physical living
arrangement
Result
Justification
The patient 1. The

patient
is
has
adjusting
to
his
achieved
current state by being
this stage.
in the hospital and
treating his illness.
2. The patient has saved
money for a sufficient
retirement plan.
3. The patients spouse
is not yet dead.
4. The patient does not
belong
to
any
affiliation.
5. The patient has civil
obligations. He is a
registered voter in
Samal and he goes to
mass every Sundays
to their local Church.
6. The patient does not
establish satisfactory
living
arrangement
but makes an effort to
improvise
physical
living arrangement.
Havighursts Developmental Tasks

Robert Havighurst developmental task is a theory that explains and emphasizes that
education is fundamental and that it continues all through life span. It states that growth
and development occurs in six stages that include middle childhood, adolescent, early
childhood, middle age and late maturity.
15
Stage
Description
Late adulthood (65 Ego Integrity

years old death)
Despair
Result
Justification
vs The patient The patient has achieved

has achieved ego integrity. This was
this stage.
justified when patient was
asked; Unsa ang mga
nabuhat nimo sa una sir?
patient answered; Daghan
kog nabuhat uy, ako gyud
nag pa daku sa akong mga
anak hantod nag ka apo
nalang sila. Ganahan ko
sa akong pamilya kay wala
gyud ko nila gina biyaan,
balos napud na sa pag
atiman nako sa ilaha.
Pasalamat pud ko na inangana sila This shows that
the patient shows pride on
what he has done to his
family. He is also proud of
the
achievements
his
children had accomplished.
He verbalized; Akong
eldest kay teacher sa
16
Magallanes, ang akong

kinamanghuran kay pulis
17
DEFINITION OF COMPLETE DIAGNOSIS
Obstructive Jaundice
Also called as posthepatic or cholestatic jaundice, occurs when bile flow is

obstructed between the liver and the intestine cause by strictures of the bile duct,
gallstones and tumors of bile duct or the pancreas.
Essentials of Pathophysiology Concepts of Altered Health States) by Carol
Matson Porth
Failure of bile to drain normally from liver caused by hepatocyte damage that
interfere with the cells ability to excrete conjugated bilirubin..
International Edition Pathophysiology (Concepts and Applications for health
professionals) by Thomas J. Nowak and A. Gordon Handford
Suppression of bile flow in canaliculi or small biliary ductiles

Phips Medical Surgical Nursing (Health and Illness perspective) by Monahan,
Sands, Neighbor, Marek, Green
Pancreatic head mass malignant
This type of cancer develops from a cell which becomes cancerous in the
pancreatic duct. This multiplies and a tumour then develops in and around the
duct.
International Edition Pathophysiology (Concepts and Applications for health
professionals) by Thomas J. Nowak and A. Gordon Handford
18
A malignant neoplasm originating from transformed cells arising in tissues

forming the pancreas. Tissue margins are frequently poorly demarcated and
metastasis has almost always occurred.
Phips Medical Surgical Nursing (Health and Illness perspective) by Monahan,
Sands, Neighbor, Marek, Green

A disease in which malignant (cancer) cells are found in the tissues of the
pancreas. Also called exocrine cancer.
3rd edition Pathophysiology for the health professionals ny Barbara E. Gould
19
PHYSICAL ASSESSMENT
Date/time: August 23, 2014 @ 10:00am

General survey:
A gray haired patient was received lying down on bed, awake, with significant
other at bedside, conscious and not in respiratory distress and with an IVF of D5LR 1L
@110cc/hr infusing well at L metacarpal vein and PNSS 1L @KVO. He was wearing a
diaper. His body structure was thin and looks weak. He weighed 43 kg. There were no
areas of abnormality on his body, extremities were not disproportionate. There was a foul
body odor noted. Patient was oriented to time and place. Motor ability and gait was
moderate and alert. Patients mood was highly cooperative and displayed enthusiasm.
Vital Signs
Temperature
37.1 o C
PR
70 bpm
RR
18 cpm
CR
72 bpm
BP
120/80 mmHg
Head Assessment
Head was symmetrically rounded, hard and smooth. There were no lesions or
bumps noted. Shape of face is oval. Temporal arteries were not palpable and there were
no tenderness noted.
20
Skin, Hair and Nails Assessment

Skin was yellowish all over his body due to jaundice. It was wrinkled and warm
to touch. Skin turgor was delayed as it returned to its original state after 5 seconds. No
skin lesions noted. Hair was gray, straight, and shiny and length was up to the nape of the
neck. It was unkempt but distributed evenly. No dandruff was observed. Fingernails were
long and were dirty. Nails had a convex curvature of about 160 degrees angle, and
capillary refill returned in less than 2 seconds. Nail beds were pink. Nail texture was
smooth. Cuticles were also smooth and no detachment of nail plate.
Eyes Assessment
Cornea is transparent, smooth and moist with no opacities. Sclera appeared
yellowish. Irises were round and flat. Pupils were black in color and equal in size, dilated
when penlight was exposed to it and had a measurement of 2 mm. Conjunctiva was
pinkish with a few capillaries evident. Eyebrows are symmetrically aligned. Eyelashes
appeared to be equally distributed and curled slightly outward. Eyelids had no presence
of any discharges and no discoloration noted. Patient was not wearing any reading
devices. He was able to read words as far as 5 feet.
Nose Assessment
Nose was positioned midline on face, straight and uniform in color. Both nostrils
were patent when patient covered the left nare and was able to breathe to the right and
vice versa. When palpated lightly, there were no tenderness and lesions noted. Mucous
were noted. No purulent drainage noted. Nasal septum was positioned centrally with no
21
lesions or deviations along the inner nasal mucosa. No bone and cartilage deviation noted
on palpation, no tenderness noted on palpation. No tenderness noted on palpation of the
paranasal sinuses.
Mouth Assessment
Lips were pink and dry without lesions. Tongue was pinkish with white spots
present and located centrally in mouth. No lesions and bleeding noted. Only 1 tooth was
present which was yellowish in color. Gums were pink and swelling was noted. The
uvula was positioned in the midline of the soft palate. Sense of taste was not checked due
to his NPO status.
Ears Assessment
Ears are equal in size bilaterally. External ear was noted without any bleeding,
lesions or masses. Hearing function was normal on both ears as he was able to answer
accurately when he was asked a question. Auricles were smooth and symmetrical without
discoloration. Small amount of dry yellowish cerumen present on both internal ears. No
tenderness noted. The pinna recoils when folded. There is no pain or tenderness on the
palpation of the auricles and mastoid process.
Neck and Throat Assessment

The muscles of the neck are symmetrical with the head at a central position. The
patient is able to move head through a full range of motion without complaint of
discomfort or noticeable limitation. The lymph nodes were not palpable. The trachea is
placed in the midline of the neck. Thyroid was not enlarged and cant easily be palpated.
22
No edema. Moves smoothly with no crepitus. No deviations noted. No pain or tenderness

on palpation and jaw movement. Unable to swallow food.
Thorax and Lung Assessment

The chest wall is intact with no tenderness and masses. Quiet, rhythmic and
effortless respirations were manifested. Breathing pattern is smooth. His respiratory rate
is 18 cpm. Normal breath sounds were heard upon breathing in.
Heart and Peripheral Vasculature Assessment

There were no visible pulsations. Regular rate and rhythm without any murmurs.
Heart sounds were normal in cardiac landmarks. Apical pulse was 72 bpm.
Abdomen Assessment
Surface is uniform in color and no pigmentation. No rashes or lesions are present.
Has a symmetric contour and is smooth. Is normally in the midline and inverted with no
sign of inflammation, discoloration or hernia. Jackson-Pratt drain attached on right
hypochondria which had a yellowish drainage output at about 10 cc/mL per shift. There
are abdominal sounds noted with 20 counts in 5 minutes. The abdomen rises with
inhalation and falls with expiration. No tenderness noted when stomach was palpated.
Genitalia Assessment
His penis is clean, no odorous smell, no discharge and no lesions noted. No mass
noted on the scrotum, no nodules, no swelling and no tenderness noted.
23
Musculoskeletal Assessment
Muscles feel firm and smooth with no swelling, masses or tenderness noted. Arms
and legs symmetrically aligned. There were no presence of bone deformities, tenderness
and swelling. Joints were able to move smoothly. Showed body weakness through slow
movements and limited range of motion on extremities. Enable to move upper extremities
without discomfort. Flexion and extension of feet and hands were demonstrated.
Adduction and abduction of arms were demonstrated.
ANATOMY AND PHYSIOLOGY
24
The pancreas is a flat, pear-shaped gland located behind and below the stomach. It is part
of the digestive system and the endocrine system.
Structure
The pancreas is about fifteen centimetres (six inches) long. The widest section is the
head, and the narrowest part is the tail. The middle section is called the body. The
pancreas has a series of small tubes that drain into the pancreatic duct. The pancreatic
duct joins the common bile duct and empties into the upper part of the small intestine,
which is called the duodenum.
25
Exocrine cells
Most of the cells in the pancreas are exocrine cells. Exocrine cells produce and release
pancreatic juice. The juice travels through the pancreatic duct into the duodenum.
Enzymes in the pancreatic juice help digest fat, carbohydrates and protein in food.
Endocrine cells
A small portion of the cells in the pancreas are endocrine cells. They are arranged in
clusters called islets, or islets of Langerhans. The islets produce and release two
hormones into the blood that help control blood sugar level:
insulin
reduces the amount of sugar in the blood when the blood sugar is high
stimulates the liver, muscles and fatty tissues to absorb and store the extra
blood glucose
glucagon
increases the amount of sugar in the blood when the blood sugar is low
26
stimulates the liver and other body tissues to release stored glucose.
ETIOLOGY
PREDISPOSING FACTORS
Etiologic
Factor
Age
Present
Absent
Rationale
Justification
The risk of developing pancreatic
Patients age is 66
cancer increases with age. Over 80% of y/o which is in the

the cases develop between the ages of
late adulthood
60 and 80 because by this time their
stage. This
systems function is deteriorating.
predisposes the
(Source: Pancreatic Cancer; Daniel D.
clients illness.
Von Hoff, M; Douglas B. Evans, MD;

Race
Ralph H. Hruban, MD)

Studies in the United States have
The patient is
shown that pancreatic cancer is more
Asian. This does not
common in the African American
predisposes the
population than it is in the white
clients illness.
population due to socioeconomic

factors and to cigarette smoking.
(Source: Pancreatic Cancer; Daniel D.
Von Hoff, M; Douglas B. Evans, MD;
Gender
Ralph H. Hruban, MD)

Cancer of the pancreas is more
The patient is male.
common in men than in women. Men
This predisposes the

27
are more likely to smoke than women.
clients illness.
This may be
due, at least in part, to higher tobacco
use in men, which raises pancreatic
cancer risk. The difference in
pancreatic cancer risk was more
pronounced in the past (when
tobacco use was much more common
among men than women), but the gap
has closed in
recent years. (Source: John A. Chabot,
Columbia University Department of
Genetics
Surgery)
As mentioned earlier, a number of
The patient doesnt
inherited cancer syndromes increase
have family history
the risk of pancreatic cancer. These
of pancreatic
include inherited mutations in the
cancer. This does
BRCA2, FAMMM, PalB2 or Peutz-
not predisposed the
Jeghers genes. (Source: Streicher SA,
clients illness.
Yu H., Kidds MS; Risch HA. CaseControl Study of Pancreatic Cancer.

Cancer Epidemiol Biomarkers Prev
2014)
28
Precipitating
Etiologic
Factor
Cigarette
Present
Absent
smoking
Rationale
Justification
Smoking doubles the risk of pancreatic
The patient
cancer. Smoking is also associated with
doesnt smoke.
early age at diagnosis, and, very

importantly, the risk of pancreatic cancer
drops close to normal in people who quit
smoking. Simply put, cigarette smoking is
the leading preventable cause of pancreatic
cancer. Scientists think this may be due to
cancer-causing chemicals in
cigarette smoke that enter the blood and
damage the pancreas. (Source: 2012 Johns
Diabetes
Hopkins University)
Diabetes is both a symptom of pancreatic
The patient is
cancer, and long-standing adult-onset
not diabetic.
diabetes also increases the risk of

pancreatic cancer. (Source: 2012 Johns
Obesity
Hopkins University)
Obesity significantly increases the risk of
The patient is
pancreatic cancer. Carrying extra weight
not obese.
around the waistline may be a risk factor

even in people who are
29
not very overweight. (American Cancer

Diet
Society pdf)
Diets high in meats, cholesterol fried foods
The patients
and nitrosamines may increase risk, while
diet usually
diets high in fruits and vegetables reduce
include noodles.
risk. Folate may be protective. (Source:

2012 Johns Hopkins University)
Long-term inflammation of the pancreas
The patient
pancreati
(pancreatitis) has been linked to cancer of
doesnt have
tis
the pancreas. (Source: 2012 Johns Hopkins
chronic
Chronic
University)
Source: http://pathology.jhu.edu/pc/BasicCauses.php?area=ba
pancreatitis.
SYMPTOMATOLOGY
Signs and
symptoms
Abdomin
Present
Absent
al pain
Rationale
Justification
More than 80% of people with
The patient
pancreatic cancer eventually experience
experienced
some abdominal pain as the tumor
abdominal pain
grows. Pancreatic cancer can cause a
upon his
dull ache in the upper abdomen
admission.
radiating to the back. The pain may

come and go. (Source: 2012 Johns
Hopkins University)
Bloating
Some people with pancreatic cancer
The patient did not

30
have a sense of early fullness with
experience
meals (satiety) or an uncomfortable
bloating.
swelling in the abdomen. (Source:

Brunner and Suddarths MedicalSurgical Nursing 10th edition)
If the duct draining bile into the
The patient did not
colored
intestine is blocked by pancreatic
experience having
stools
cancer, the stools may lose their brown
a pale colored
color and become pale or clay-colored.
stool.
Pale-
Urine may become darker. (Source:

Brunner and Suddarths MedicalJaundice
Surgical Nursing 10th edition)

As pancreatic cancer blocks the duct
The patient
that releases bile into the intestine
experienced
(common bile duct), the ingredients of
jaundice that can
bile build up in the blood. This turns the
be seen all over his
skin and the eyes yellow, a condition
body.
called jaundice. The same blockage

causes dark urine and light-colored
stools. (Source: Brunner and Suddarths
Medical- Surgical Nursing 10th edition)
Some people with pancreatic cancer
Patients blood
blood
develop diabetes as the cancer impairs
sugar is not
sugars
the pancreas' ability to produce insulin.
elevated.
Elevated
(However, the vast majority of people

31
with a new diagnosis of diabetes do not

have pancreatic cancer.) (Source:
Brunner and Suddarths MedicalItching
Surgical Nursing 10th edition)

People with pancreatic cancer
The patient did not
sometimes report itching all over.
experience itching.
Blockage of the bile ducts is often

responsible. (Source: Brunner and
Suddarths Medical- Surgical Nursing
10th edition)
PATHOPHYSIOLOGY
Predisposing:
Precipitating:
Age
Race
Gender
Genetics
Cigarette Smoking
Diabetes
Obesity
Diet
Chronic
Pancreatitis
Tissue Margins of pancreas

poorly demarcated.
Malignant tumors invade
nearby tissues, which can
cause damage.
Pale
colored
Weight
IfJaundice
Not
Treated:
Tumor
metastasis
DEATH
Symptoms
worsen
stool
Loss
Growth of tumor
Duct
draining
into the
Blocks
flow ofbile
pancreatic
Tumor
impairs
the
pancreas
intestine
is pancreatic
blocked
byduct
enzymes
from
ability
to produce
insulin.
pancreatic
cancer.
to the duodenum.
32
Abdominal
Loss
of
pain
Blood Sugar
Appetite
Elevates
If Treated:
Radiation Therapy
Chemotherapy
Opioids
Surgery (Intraoperative
radiation therapy)
Good
Prognosis
DOCTORS ORDER
Date/ Time
Doctors Order
Rationale/
Remarks
Justification
6/ 28/14
Please admit patient to Surgery West
10 AM
GS 2 service.
Admission
is DONE
under required to assess and

observe the patient
further.
- DAT
To consume amount
DONE
33
of food tolerable by
the stomach to have
energy
-VS q 4
DONE
-Vital signs
monitoring helps in
determining baseline
values and presence
of any unusualities in
the patients
condition. This
ensures client stability
Input and Output q Shift
This is to maintain an
DONE
accurate record of the

patients intake and
output. Also, to assess
signs and symptoms
of dehydration or
fluid volume
overload.
Please attach Laboratory
Laboratory tests are
results
primarily conducted
DONE
to determine baseline
34
values and aid in

diagnosis of patients
condition.
-
Refer
Proper referral will
DONE
help the physician to

be more aware of the
patients condition
and he or she will be
able to know what
further medical
management can be
done to the patient.
6/ 30/ 14
For OR scheduling
Refer
PENDING
9:00 AM
(+) Jaundice
(-)
abdominal
DONE
patients condition
pain

able to know what
further medical
management can be
7/1/14
For OR scheduling
PENDING
35
4:23 AM
(+) Jaundice
(-)
abdominal
pain
Secure Serum Albumin Albumin
is
the DONE
smallest protein and

major protein found
in the blood. The
protein,
although
small, is too large to

filter
through
the
renal glomeruli. The

presence of albumin
in the urine is an
indicator
of
renal
disease. They are the

most
significant
component
contributing
to
the
osmotic
pressure
within the vascular
36
space. This osmotic

pressure keeps fluid
within the vascular
space,
minimizing
extravasation of fluid.
- Elevated levels are

found with nephritis,
glomerunephritis,
polycystic kidneys,
kidney tumors, and
pynelonephritis.
PT/ APTT
Prothrombin is a
DONE
vitamin K dependent
protein produced by
the liver. The
hemostasis and
coagulation system is
a homeostatic balance
between the factors
encouraging clotting
37
and the factors

encouraging clot
dissolution.
An indicator of the
effectiveness of
anticoagulant therapy
and a screening test
for bleeding
tendencies and
identifies in most of
the intrinsic and final
common clotting
pathways.
7/2/14
5:30 AM
Follow up Labs
DONE
primarily conducted
values and aid in
condition.
38
For OR scheduling
Refer
PENDING
DONE

patients condition
able to know what
further medical
management can be
9:00 AM
Secure 2 units pack for For possible blood

OR use
DONE
transfusion in case of
bleeding.
7/ 3/ 14
- for OR scheduling
PENDING
- Please print Labs and secure Laboratory tests are
DONE
5:30 am
(+) Jaundice
albumin
primarily conducted
39
values and aid in

condition.
- PT/ APTT
Prothrombin is a
DONE
vitamin K dependent
protein produced by
the liver. The
hemostasis and
between the factors
and the factors
encouraging clot
dissolution.
An indicator of the
effectiveness of
for bleeding
tendencies and
40

common clotting
pathways.
- Refer
DONE

patients condition
able to know what
further medical
management can be
7/ 3/ 14
9:30 am
For PTT/ APTT
Prothrombin is a
DONE
vitamin K dependent
protein produced by
the liver. The
hemostasis and
between the factors
and the factors
41
encouraging clot
dissolution.
An indicator of the
effectiveness of
for bleeding
tendencies and
common clotting
pathways.
Albumin
A protein that is
DONE
formed within the

liver. It makes up
approximately 60% of
the total protein. Its
effect within the
blood is to maintain
colloidal osmotic
42
pressure.
-
Refer
DONE

patients condition
able to know what
further medical
management can be
7/4/14
Still for OR scheduling
DAT
PENDING
(+) Jaundice
(-) Fever
7/6/14
To consume amount
DONE
the stomach to have
energy
-
Refer
DONE
DONE

patients condition
43
able to know what

further medical
management can be
7/7/14
DAT
To consume amount
DONE
9:52 am
the stomach to have

energy
-
Refer
PENDING
DONE

patients condition
able to know what
further medical
management can be
7/8/14
DAT
To consume amount
DONE
the stomach to have
energy
-
Refer
PENDING
DONE
44

patients condition
able to know what
further medical
management can be
7/9/14
IVF PNSS iL @KVO
A normal saline is a
DONE
sterile non pyrogenic

solution for fluid and
electrolyte
replenishment and it
contains no
antimicrobial agents.
-
Vit K. 10 mg IVTT q 8
It promotes
DONE
prothrombin and it
helps in coagulation.
Continue meds
To continue treating
DONE
the patient.
-
Repeat PT APTT post
This is done to re-
3 days
evaluate the condition
DONE
of the client.
-
3-4 eggs whites/ meal
One of the
DONE
45
source of
-
Refer
albumin
DONE

patients condition
able to know what
further medical
management can be
7/10/14
PENDING

DONE
10:30 am
-
Refer

patients condition
able to know what
further medical
management can be
7/11/14
Refer
PENDING
DONE
46

patients condition
able to know what
further medical
management can be
7/12/14
8:00am
Refer
PENDING
DONE

patients condition
able to know what
further medical
management can be
7/13/14
7:50pm
Refer
PENDING
DONE

patients condition
47
able to know what

further medical
management can be
7/14/ 14
DAT
To consume amount
DONE
3:00 am
the stomach to have

energy
For APTT, PT today
Prothrombin is a
DONE
vitamin K dependent
protein produced by
the liver. The
hemostasis and
between the factors
and the factors
encouraging clot
dissolution.
An indicator of the
effectiveness of
48
for bleeding
tendencies and
common clotting
pathways.
Refer
DONE

patients condition
able to know what
further medical
management can be
-
For PT APTT today
Prothrombin is a
DONE
vitamin K dependent
protein produced by
the liver. The
hemostasis and
49
between the factors
and the factors
encouraging clot
dissolution.
An indicator of the
effectiveness of
for bleeding
tendencies and
common clotting
pathways.
A protein that is
-
DONE
For Serum Albumin,

formed within the
Direct & indirect
liver. It makes up
Bilirubin
50
approximately 60% of
the total protein. Its
effect within the
blood is to maintain
colloidal osmotic
pressure.
7/16/14
DAT
To consume amount
DONE
3:20am
the stomach to have

(-) fever
energy
Still for APTT, PT
Prothrombin is a
DONE
vitamin K dependent
protein produced by
the liver. The
hemostasis and
between the factors
and the factors
encouraging clot
dissolution.
51
An indicator of the
effectiveness of
for bleeding
tendencies and
common clotting
pathways.
Refer
DONE

patients condition
able to know what
further medical
management can be
DAT
7/17/14
To consume amount
DONE
the stomach to have
52
3:00 am
energy
Add 3 egg whites/
(+)Jaundice
meal
(-) abdominal
pain
(-)fever
One of the
DONE
source of
Please refer to Dietary
albumin
service for nutritional
build up prior to OR
DONE
patients condition
(-)DOB

able to know what
further medical
management can be
Refer
DONE
DONE

patients condition
able to know what
further medical
management can be
53
7/18/14
DAT
To consume amount
DONE
11:00am
the stomach to have

(+) Jaundice
(-) Fever
energy
Continue meds
DONE
the patient.
-
PENDING

Refer
DONE

patients condition
able to know what
further medical
management can be
7/19/ 14
DAT
To consume amount
DONE
the stomach to have
energy
LABS: Crea, Na+,
K+,
primarily conducted
DONE
values and aid in
54
condition.
CBC
CBC
evaluates
blood
cells,
the DONE
the
number of different
types
of
cells,
its
appearance and size.

And
to
have
baseline data for the

need
of
further
management.
UA
DONE
- A test done in order
to
analyze
urine.
Analysis of urine can

provide
important
health clues. It can be

used to detect certain
diseases
such
as
diabetes,
gout,
and
other
metabolic
disorders as well as
55
kidney disease.
CXR
-Chest X-ray provides DONE

data about the heart,
and lungs, including
its size and shape.
ECG
Diagnostic tool that is
DONE
routinely used to
assess the electrical
and muscular
functions of the heart.
While it is a relatively
simple test to
perform, the
interpretation of the
ECG tracing requires
significant amounts of
training.
7/20/14
Follow up lab results
DONE
primarily conducted
56
values and aid in

condition.
For OR scheduling
7/21/14
DAT
PENDING
To consume amount
DONE
the stomach to have
energy
Continue Meds
DONE
the patient.
-
Follow up Lab results
DONE
primarily conducted
values and aid in
condition.
7/22/14
DAT
To consume amount
DONE
9:00 am
the stomach to have

(-) fever
(-) DOB
energy
PENDING
(+) Jaundice
(-) abdominal
57
pain
7/23/14
DAT
To consume amount
DONE
9:00 am
the stomach to have

(-) fever
energy
(-) DOB
(+) Jaundice
Add 3 egg whites/
PENDING
-
meal
One of the
DONE
source of
albumin
(-) abdominal
pain
(-) cough
7/24/14
DAT
To consume amount
DONE
9:00 am
the stomach to have

(-) fever
(-) DOB
energy
-
To continue
DONE
Continue meds
treating the
7/25/14
9:00 am
DAT
patient.
To consume amount
DONE
the stomach to have
58
energy
PENDING
-
DAT
To consume amount
DONE
7/26/14
the stomach to have

(-) fever
energy
PENDING
(-) DOB
(+) Jaundice
3-4 egg whites/ meal
(-) abdominal
pain
7/27/14
One of the
DONE
source of
-
DAT
albumin
To consume amount
DONE
the stomach to have
energy
7/28/14
9:00 am
DAT still with egg
To consume amount
whites
DONE
the stomach to have

(-) fever
energy
59
(-) DOB

Start Diphenhydramine
(+) Jaundice
PENDING
-
1 amp IVTT OD @ HS
DAT
For allergic
DONE
reactions
To consume amount
DONE
7/29/14
the stomach to have

5:50 am
energy
(-) fever
PENDING
-
(-) DOB
DONE
Continue meds
treating the
patient.
(+) Jaundice
7/30/14
To continue
DAT
To consume amount
DONE
the stomach to have
energy
-
Refer
PENDING
DONE

patients condition
able to know what
60
further medical
management can be
8/1/14
DAT
To consume amount
DONE
7:50am
the stomach to have

(-) fever
(-) DOB
energy
-
Still on Heplock
For BT or
DONE
medication
(+) Jaundice
(-) abdominal
purposes
-

DAT
pain
PENDING
To consume amount
DONE
the stomach to have
energy
-
Refer
PENDING
DONE

patients condition
able to know what
further medical
61
management can be
8/2/14
11:05 am
Refer to Internal
Medicine for CP
clearance
DONE
patients condition
able to know what
further medical
management can be
To consume amount
-
DONE
DAT
8/3/14
the stomach to have

(-) fever
(-) DOB
energy
-
Continue meds
To continue
DONE
treating the
(+) Jaundice
(-) abdominal
patient.
-
DAT
DONE
pain
(-) cough
8/4/14
To consume amount
DONE
62
3:45pm
the stomach to have
energy
-
Refer to Internal
Medicine for CP
clearance
DONE
patients condition
able to know what
further medical
management can be
-
DONE
Refer to Anesth for

early pre op evaluation
patients condition
able to know what
further medical
management can be
8/4/14
ANESTHESIA PRE
DONE
OP ORDERS
4:20 pm
-
Follow up availability
For Blood
DONE
63
of FFP 4cc, 2 packs of
Transfusion,
RBC of patients blood
during
type and properly
operation.
crossed matched
To secure 1 unit of
for emergency
whole pack blood at
use, in case of
patients blood type
Blood
and properly crossed
transfusion
DONE
matched
Start FeSO4 + Folic
Acid 1 cap BID PO
Treatment of
DONE
iron
deficiency
anemia and
helps the body
to produce and
maintain new
8/5/14
9:00 am
Continue high protein
cells.
Required for the
diet
structure, function
DONE
and regulation of the

bodys tissues and
organs.
64
Continue meds
To continue
DONE
treating the
8/6/14
8:00 am
Continue high protein
patient.
Required for the
diet
structure, function
DONE

bodys tissues and
organs.
-
Continue meds
To continue
DONE
treating the
8/7/14
4:10pm
DAT with high protein
patient.
To consume amount
diet
DONE
the stomach to have

energy
-
Continue meds
- To continue treating
DONE
the patient.
8/8/14
8:30 am
Still for ECG
Diagnostic tool that is
DONE
routinely used to
assess the electrical
and muscular
functions of the heart.
While it is a relatively
simple test to
perform, the
65
interpretation of the
ECG tracing requires
significant amounts of
training.
8/10/14
Still for creatinine
- Creatinine levels are DONE

measured
8:30 am
to
check
kidney function and

to screen for kidney
damage. This test is
also use to monitor
treatment of kidney
disease
or
kidney
function while you

are on certain drugs.
8/11/14
3:00pm
IM
Suggest albumin
Therapy of
Albumin
correction 28 g/L with
deficiency
albumin 20% 50 cc +
Furosemide 10g
-
Furosemide
for acute
pulmonary
edema.
66
3-4 egg whites per
One of the
DONE
meal
source of
Repeat serum albumin
albumin
This is done to DONE
re-evaluate the
condition of
4:00pm
Start albumin 20%
the client.
Therapy of
50cc + Furosemide 10
Albumin
g IV to run in 4hours q
deficiency
12
DONE
Furosemide
for acute
pulmonary
8/12/14
Continue Albumin
edema.
To continue
DONE
treating the
-
High protein diet
patient.
Required for
DONE
the structure,
function and
regulation of
the bodys
tissues and
-
Still for CP clearance
organs.
Preparation
DONE
prior to OR, if
67
the patient is
qualified for
-
8/13/14
-
the procedure
To consume
DONE
DAT
amount of
8:00am
food tolerable
by the
stomach to
-
High protein diet
have energy
Required for the
DONE
structure, function
bodys tissues and
organs.
8/14/14
Continue recent meds
To continue
DONE
treating the
-
Incorporate 3 white
eggs/ meal
patient.
One of the
DONE
source of
albumin
Repeat s. albumin
without fail

re-evaluate the
condition of
Continue albumin
the client.
To continue
DONE
treating the
68
8/15/14
9:13 am
For repeat serum
albumin
patient.
re-evaluate the
condition of
To cardiac monitor
the client.
- Device that shows
DONE
the electrical and

pressure waveforms
of the cardiovascular
system for
measurement and
treatment.
Parameters specific to
respiratory function
can also be measured.
Because electrical
connections are made
between the cardiac
monitor and the
patient, it is kept at
the patient's bedside.
8/17/14
4-5 white eggs per

meal
One of the
DONE
source of
69
8:50 am
albumin
High protein diet
Required for the
DONE
structure, function
bodys tissues and
organs.
-
Repeat CBC,
-CBC evaluates the DONE
creatinine, Na, K
blood
cells,
the
number of different
types
of
cells,
its
appearance and size.

And
to
have
baseline data for the

need
of
further
management.
-Blood sodium testing
is
used
to
detect
hyponatremia
or
hypernatremia
associated
with
dehydration,
and
edema,
variety
of
70
diseases.
-Blood
Potassium
testing
helps
in
monitoring levels of
potassium that are too
high
(hyperkalemia)
or
too
low
(hypokalemia). These
tests
are
screen
done
for
to
an
electrolyte imbalance.
It may be ordered to
determine if a disease
or condition involving
the brain, lungs, liver,
heart, kidney, thyroid,
or adrenal glands is
causing
or
exacerbated
being
by
sodium deficiency or
excess. It may also be
ordered
to
monitor
71
patients
taking
medications that can

affect
sodium
and
potassium levels, such

as diuretics.
-Creatinine levels are

measured
to
check
kidney function and

also use to monitor
treatment of kidney
disease
or
kidney
function while you

Continue meds
To continue
DONE
treating the
patient.
8/18/14
10:30am
Schedule patient for
DONE
Open Billary surgery

tomorrow 8/19/14; 8-1
72
pm
NPO post-midnight
To reduce the risk of
DONE
aspiration, and to
avoid regurgitation of
the contents into the
airways.
DONE
IVF D5LR iL @120cc

- Hypertonic solutions
are those that have an
effective
osmolarity
greater than the body

fluids. This pulls the
fluid into the vascular
by osmosis resulting
in
an
increase
vascular volume. It
raises
intravascular
osmotic pressure and

provides
electrolytes
fluid,
and
calories for energy.
73
DONE
MEDS:
1. Cefoxitin 1g IVTT
PTOR ANST then
q8
Used to
prevent
2. Omeprazole 40g
bacterial
OD on NPO
infections
It decreases
the amount of
acid produce
in the stomach
and increases
Full body bath
tomorrow
gastric pH.
It prevents
infections and
for hygienic
purposes in
preparation to
8/18/14
Start PNSS + 60 mEqs

KCL @ 60cc/o x 1
OR
It is an
isotonic
74
11:30am
-
cycle
solution and is
Pre op Anesthesia
used to replace
orders
fluids in
K: 3.4
dehydration.
-
NPO post-midnight
8/18/14
9:00 pm
-
To reduce the
risk of
aspiration, and
to avoid
regurgitation
of the contents
into the
airways.
VS q 4 then endorsed
to OR
Vital signs
DONE
monitoring
helps in
determining
baseline
75
values and
presence of
any
unusualities in
the patients
condition.
This ensures
client stability
-
IVF D5LR iL 120cc

once on NPO
- Hypertonic solutions DONE

are those that have an
effective
osmolarity
greater than the body

fluids. This pulls the
fluid into the vascular
by osmosis resulting
in
an
increase
vascular volume. It
raises
intravascular
osmotic pressure and

provides
electrolytes
fluid,
and
calories for energy.
76
Insert another line with In case of Blood

PNSS iL @KVO rate
DONE
transfusion
(BT line, G18)
MEDS:
Omeprazole 40 mg
IVTT PTOR
-
It decreases
the amount of
DONE
acid produce
in the stomach
and increases
-
Check patency of IV
gastric pH.
In preparation for the
lines PTOR please
possibility to have
DONE
blood transfusion
during the procedure
-
DONE
Labs for PT, APTT, S.

primarily conducted
albumin STAT
values and aid in
condition.
77
In preparation
DONE
General and oral

for the surgery
hygiene
8/ 19/14
POST OP
ANESTHESIA
11:50am
ORDER
Exploratory
Cholecystectomy
To PACU then Surgery

East once stable
jejunostomy
drain
DONE
-
NPO temporarily
To reduce the
DONE
risk of
aspiration, and
to avoid
regurgitation
of the contents
into the
airways.
A solution that
-
DONE
IVF PLR
contains isotonic
iL@100cc;IVTF
concentrations of
D5LR@ same rate
electrolytes in water
for injection. It is
78
used for parenteral

replacement of
extracellular losses of
fluid and electrolytes.
Vital signs monitoring DONE
-
VS q 15x2 q4 then
helps in determining
after
baseline values and
presence of any
unusualities in the
patients condition.
This ensures client
stability
PNSS@KVO rate
It is an isotonic
DONE
solution and is used to

replace fluids in
dehydration.
-
LABS: S. Na, K, Ca+,
-Blood sodium testing DONE
Mg, Crea + Alkaline
is
to
detect
PO4 @ PACU
hyponatremia
or
used
hypernatremia
associated
with
dehydration,
and
edema,
variety
of
79
diseases.
-Blood
Potassium
testing
helps
in
monitoring levels of
potassium that are too
high
(hyperkalemia)
or
too
low
(hypokalemia). These
tests
are
screen
done
for
to
an
electrolyte imbalance.
It may be ordered to
determine if a disease
or condition involving
the brain, lungs, liver,
heart, kidney, thyroid,
or adrenal glands is
causing
or
exacerbated
being
by
sodium deficiency or
excess. It may also be
ordered
to
monitor
80
patients
taking
medications that can

affect
sodium
and
potassium levels, such

as diuretics.
-Creatinine levels are

measured
to
check
kidney function and

also use to monitor
treatment of kidney
disease
or
kidney
function while you

Meds
1. Paracetamol 1g IV
Management
DONE
of moderate to
infusion
severe pain
when
combined with
81
opioid
2. Parecoxib Na
analgesia.
To relieve
40mg/5ml vial 40mg
from post op
IVTT OD x2 doses to
pain
DONE
start tom am
DONE
3. Celecoxib 200 mg/cap
1 cap BID PO x 3 once
It reduces
inflammation,
on SD
-
relieves pain.
To fight
4. Continue Cefoxitin 1g
against the
IVTT q 8
bacterial
infection in
the body
particularly in
aiding urinary
tract
infections,
respiratory
tract infection
and
5. Continue Omeprazole
40mg slow IVTT OD
septicemia.
It decreases
DONE
the amount of
82
acid produce
in the stomach
and increases
-
Epidural Anesthesia:
gastric pH.
It is to relieve
Prep 0.125 % + 1mg
the patient
MgSO4 x 2 doses
1st dose given @ OR
2nd dose: 8/20/14, then
from pain at
pull out epidural
surgery. It is
catheter
injected in the
DONE
the time of the
spinal cord to
numb a
-
Morphine precautions
please
portion.
A narcotic
DONE
opioid
analgesic, that
provides pain
I & O q hourly x 24
hours
relief.
This is to
DONE
maintain an
accurate
record of the
patients
intake and
output. Also,
83
to assess signs
and symptoms
of dehydration
or fluid
volume
-
O2 inhalation @ 8
L/min via T piece
overload.
Oxygen is
DONE
used as a
medical
treatment in
both chronic
and acute
cases, and can
be used in
hospital, prehospital or
entirely out of
hospital,
dependent on
the needs of
the patient and
their medical
professionals'
opinions.
84
Keep patient
thermoregulated
To keep the
DONE
patients
temperature in
Moderate high back
rest
normal range
For lung
DONE
expansion, to
facilitate easy
breathing and
prevention of
pressure
ulcers.
8/ 19/ 14
DONE
Patient intubated, fully

awake with stable VS;
12:13pm
100% O2 saturation
12:55 pm
Give Ketorolac 30mg IVTT

now
Reduces
DONE
intensity of
pain stimulus,
reduces
intraocular
8/21/14
Maintain on NPO
inflammation.
DONE
aspiration, and to
9:00 am

85
airways.
Kabiven 1400 kcal/day
It provides energy and DONE
24 hours
amino acids into your

blood stream when a
person cannot eat
normally.
Continue meds
To continue
DONE
the treatment
-
Encourage sitting on
bed
of the patient
For lung
DONE
expansion, to
facilitate easy
breathing and
prevention of
pressure
ulcers.
6:50pm
ANESTHESIA
NOTES
Epidural analgesia
given 2nd dose
Morphine precaution
please
DONE
To relieve pain
A narcotic
DONE
opioid
analgesic, that
provides pain
86
relief.
This is to
DONE
I & O q shift and

maintain an
record
accurate
record of the
patients
intake and
output. Also,
to assess signs
and symptoms
of dehydration
or fluid
volume
VS q 4
overload.
Vital
signs DONE
monitoring
helps
in
determining
baseline
values
and
presence
of
any
unusualities in
the
patients
87
condition.
This
ensures
client stability
and
preparedness
for any future
surgical
procedure.
Monitoring
vital
signs
indicates
patients state
of health and
helps
in
determining
health
deviations.
Continue other pain
meds with strict
DONE
the treatment
compliance
-
To continue
of the patient
To continue
DONE
Continue antibiotics
the treatment
of the patient
88
To prevent
DONE
Change dressing
infection or
Still on NPO
contamination
DONE
aspiration, and to
8/22/14
4:55 am

airways.
(-) fever
(-) DOB
(-) abdominal
pain
-
Continue TPN
It provides
DONE
energy and
amino acids
into your
blood stream
when a person
cannot eat
-
Continue meds
normally.
To continue
DONE
the treatment
of the patient
To prevent
DONE
infection
To promote
DONE
Change dressing
Remove Foley catheter
89
for bladder
-
training
The patient is
DONE
Remove NGT
able to
Refer
swallow
Proper referral
DONE
will help the

physician to
be more aware
of the patients
condition and
he or she will
be able to
know what
further
medical
management
can be done to
the patient.
CLINICAL CHEMISTRY
90
This test is a quantitative measure of exactly how much albumin is lost in the
urine thereby indicates the extent of kidney damage.
Date Ordered: 07/3/14; 11:33 am
Exam
Clinical significance
Result
Normal values
Nursing
responsibilities
Albumin
LOW
17.39
35.00- 50.00
1. Explain the test
> Albumin is the smallest
procedure and the
protein and major protein
purpose of the test.
found in the blood. The
2. Tell the patient
protein, although small, is
that no fasting is
too large to filter through
required
the renal glomeruli. The
procedure.
presence of albumin in the
3.
urine is an indicator of renal
clients knowledge
disease. They are the most
of the test.
significant
component
4. Instruct not to
contributing to the osmotic
discard any urine
pressure within the vascular
over the 24 hour
space. This osmotic pressure
time period.
keeps
5. Teach the client
fluid
within
the
for
Assess
the
vascular space, minimizing
not
strenuous physical
- Elevated levels are found
activity during the
with
collection
nephritis,
to
the
undergo
91
glomerunephritis, polycystic
procedure.
kidneys, kidney tumors, and
6.
pynelonephritis.
interfering drugs, if
Withhold
possible,
for
48
hours before the

test begins.
HEMATOLOGY
This test is used to evaluate the adequacy of the extrinsic system and the common
pathway in the clotting mechanism. It measures the clotting ability factors I (fibrinogen),
II (prothrombin), V, VII, and X.
Exam
Rationale
Normal
Result
Reference
Clinical
Significance
Prothrombin Time
PT Patient
Prothrombin is a vitamin K
11.8-15.1
26.6
dissolution.
An indicator of the effectiveness 25.4-38.4
68.8
NORMAL
dependent protein produced by

the liver. The hemostasis and
coagulation
system
is
homeostatic balance between

the factors encouraging clotting
and the factors encouraging clot
APTT
HIGH
92
(Activated
of anticoagulant therapy and a
Partial
screening
test
for
bleeding
Thromboplas tendencies and identifies in

tin Time)
most of the intrinsic and final

common clotting pathways.
Date Ordered: 07/3/14; 07:02 pm

Exam
Result
Normal values
Nursing
responsibilities
Albumin
LOW
20.46
35.00- 50.00
1. Explain the test
procedure and the
2. Tell the patient
that no fasting is
required
procedure.
3.
clients knowledge
of the test.
significant
component
4. Instruct not to
discard any urine
over the 24 hour
time period.
for
Assess
the
the
93
keeps
fluid
within
the
5. Teach the client
not
strenuous physical
activity during the
with
collection
nephritis,
to
undergo
procedure.
6.
pynelonephritis.
Withhold
possible,
for
48
hours before the

test begins.
HEMATOLOGY
Exam
Rationale
Normal
Result
Reference
Clinical
Significance
Prothrombin Time
PT Patient
Prothrombin is a vitamin K 11.3-15.3
12 seconds
NORMAL

coagulation
system
is
a
94

APTT
dissolution.
(Activated
Partial
screening
test
for
44.2
HIGH
bleeding

tin Time)

CLINICAL MICROSCOPY
This test can reveal a significant amount of preliminary function about the kidneys and
other metabolic processes. It is part of routine monitoring in patients with chronic renal
disease and some metabolic diseases.
Exam
Rationale
Normal
Result
Reference
Clinical
Significance
Urine Examination
Color
The color of normal urine Light Yellow AMBER

ranges from light yellow to deep
to Deep
amber. Color depends on the
Amber
NORMAL
patients state of hydration, diet,

medication,
regimen
and
exposure to other substances

95
that may contribute to unusual

Appearance
color or odor.
Turbid urine may contain red or
CLEAR
CLOUDY NOT NORMAL
white cells, bacteria, fat or chyle

and may reflect renal infection.
Chemical Analysis
Protein
The color of normal urine Light Yellow AMBER

to Deep
Amber
NORMAL

medication,
regimen
and

pH
color or odor.
Urine pH is an indication of the
4.5-8.0
5.0
NORMAL
1.015
NORMAL
kidneys ability to help maintain

balanced
hydrogen
ion
Specific
concentration in the blood.

Specific Gravity is a 1.010-1.025
Gravity
reflection of the concentration
Glucose
ability of the kidneys.

Glucose in urine is used as an NEGATIVE NEGATIV NORMAL
indicator of diabetes
Urine Flowcytometry
RBC
The color of normal urine
E
0-11/ uL
21
HIGH

96

medication,
regimen
and

WBC
color or odor.
Turbid urine may contain red or
0-11/ uL
NOT NORMAL
white cells, bacteria, fat or chyle

Epithelial
and may reflect renal infection.

Large numbers of squamous
Cells
cells
may
contamination
0-11/ uL
indicate
of
the
urine
specimen, but large numbers of

either the transitional or renal
tubular cells may indicate a
Cast
serious disease process.

Presence of numerous cast in
0-1 / uL
the urine is a solid evidence of

generalized
renal
disease,
nephrotic disease, hypertension,

Bacteria
and viral infection.

Presence of bacteria in the urine 0-111/ uL
72
NORMAL
is higher than normal; it means

that an individual is suffering
from infection.
BLOOD CHEMISTRY
97
These tests are done to screen for an electrolyte imbalance. It may be ordered to
determine if a disease or condition involving the brain, lungs, liver, heart, kidney, thyroid,
or adrenal glands is causing or being exacerbated by a sodium deficiency or excess. It
may also be ordered to monitor patients taking medications that can affect sodium and
potassium levels, such as diuretics.
Date Ordered: 07/20/14; 10:43pm
Exam
Result
Normal values
Nursing
responsibilities
Sodium
LOW
134
136.10-155
mmol/L
Tell the patient

that there is no
> Sodium ions are necessary
fluid
or
for regulation of blood and
restriction.
food
body fluids, transmission of

nerve
impulses,
activity,
and
metabolic
heart
certain
functions.
Maintains optimal salt and

water balance in the body.
Potassium
NORMAL
3.70
> Potassium is important in

never
function
and
in
3.5-5.5
1. Tell the patient
mmol/L
that there is no
fluid
or
influencing osmotic balance
restriction.
between
2.
interstitial
cells
fluid.
and
It
the
is
Instruct
patient
to
food
the
avoid
98
important
in
maintaining
opening
and
fluid and electrolyte balance
closing
of
hand
in the body.
after a tourniquet is
applied.
Creatinine
NORMAL
>
64.49
Creatinine
levels
53-115 mmol/L Tell the patient that
are
there is no fluid or
measured to check kidney
food restriction.
function and to screen for

kidney damage. This test is
also
use
to
monitor
treatment of kidney disease

or kidney function while
you are on certain drugs.
HIGH
Alkaline
38-126.00
These cells line the biliary 362.00
Phosphatase collecting
system.
This
1. Instruct the
patient
to
pe BPO for
enzyme is excreted into the
12
bile. Enzymes of ALP are
prior to the
greatly increases in both
test.
extrahepatic
and
hours
2. Assess
99
intrahepatic
obstructive
medication
biliary disease and cirrhosis.
history and
specifically
check
for
IV albumin
administrati
on
within
the past 10
days.
HEMATOLOGY
Exam
Rationale
Normal
Reference
Result
Clinical
Significance
100
Prothrombin Time
PT Patient
Prothrombin is a vitamin K 11.3-15.3

12 .5
NORMAL
seconds

coagulation
system
is

APTT
dissolution.
(Activated
Partial
screening
test
for
43.7
HIGH
bleeding

tin Time)


Exam
Result
Normal values
Nursing
responsibilities
Albumin
LOW
18.15
35.00- 50.00
1. Explain the test
procedure and the
2. Tell the patient
that no fasting is
required
for
the
101
procedure.
3.
clients knowledge
of the test.
significant
component
4. Instruct not to
discard any urine
over the 24 hour
time period.
keeps
5. Teach the client
fluid
within
the
Assess
not
strenuous physical
activity during the
with
collection
nephritis,
to
the
undergo
procedure.
6.
pynelonephritis.
Withhold
possible,
for
48
hours before the

test begins.
102
HEMATOLOGY
Exam
Rationale
Normal
Result
Reference
Clinical
Significance
Prothrombin Time
APTT
(Activated
Partial
screening
test
for
51.5
HIGH
bleeding

tin Time)

HEMATOLOGY
Exam
Rationale
Normal
Result
Reference
Clinical
Significance
Prothrombin Time
APTT
(Activated
44.8
HIGH
103
Partial
screening
test
for
bleeding

tin Time)

Date Ordered: 08/15/14; 3:46pm

Exam
Result
Normal values
Nursing
responsibilities
Albumin
LOW
19.89
35.00- 50.00
1. Explain the test
procedure and the
2. Tell the patient
that no fasting is
required
procedure.
3.
clients knowledge
of the test.
significant
component
4. Instruct not to
discard any urine
over the 24 hour
time period.
keeps
5. Teach the client
fluid
within
the
not
for
Assess
to
the
the
undergo
104
strenuous physical
activity during the
with
collection
nephritis,
procedure.
6.
pynelonephritis.
Withhold
possible,
for
48
hours before the

test begins.
HEMATOLOGY
This test is used to evaluate anemia, leukemia, reaction to inflammation and infections,
peripheral blood cellular characters, state of hydration and dehydration, polycythemia,
hemolytic disease.
Exam
Rationale
Normal
Result
Reference
Clinical
Significance
CBC + PLT
Hemoglobin Hemoglobin
is
the
major 135-175 g/L
116 g/L
LOW
component of the red blood cell

and functions to transport O2. It
also acts to buffer CO2 formed
during
metabolic
Hemoglobin
levels
activity.
are
105
important in the detection and

follow
up
of
anemia
and
polycythemia. The Hemoglobin

value is used in the calculation
Hematocrit
of MCH and MCHC.

The hematocrit is a test that 0.40-0.52
indicates
the
proportions
RBC Count
relative
LOW
Decreased:
plasma
and
A Low count in
measures
the
hematocrit may
volume of the blood in percent
result in having
that is compromised of the red
anemia.
RBCs.
of
0.35
This
blood cell
Measures
the
volume
and 4.20-6.10
3. 59
LOW
amount of erythrocytes in the
Decrease
blood. Red blood cells play a
RBC count may
critical role in the transport of
be due to the
both
result of red cell
oxygen
dioxide.
and
carbon
in
loss by bleeding
or
hemolysis,
failure
of
marrow
production,
or
may be due to
secondary
106
dilution factors
(intravenous
fluids) Increase
in RBC count
may
be
the
result
of
primary
polycythemia
including stress.
RBC count is
normally higher
in
individuals
residing at high
WBC Count Measures
the
amount
and
5.0-10.0
10.74
altitudes.
HIGH
volume of leukocytes present in
An
elevated
the blood. This test evaluates
WBC
alterations in the total WBC
commonly
count that may be caused by
signals
inflammation, infection, tissue
infection,
necrosis or leukemic neoplasia.
as an abscess,
count
such
meningitis,
appendicitis, or
tonsillitis.
A
107
high count may

also result from
leukemia
tissue
due
and
necrosis
to
burns,
myocardial
infarction,
or
gangrene.
A
low
WBC
count indicates
bone
marrow
depression that
may result from
viral
infection
or from toxic
reactions.
DIFFERENTIAL COUNT
Neutrophil
Neutrophils
quickly
55-75
78
HIGH
congregate at a focus of
Decreases
in
infection,
attracted
by
neutrophils
are
cytokines
expressed
by
known
as
activated endothelium, mast
neutropenia.
cells, and macrophages.
Presence
They are the most abundant
bacterial
of
108
type of white blood cells in
infections such
healthy adults and form an
as typhoid fever
integral part of the immune
and
system. They react within one
and many viral
hour of tissue injury and are
diseases,
hallmark
including
of
acute
inflammation.
brucelosis
hepatitis,
influenza,
rubella, mumps.
An
overwhelming
infection
can
also deplete the

bone marrow of
neutrophils and
lead
Lymphocytes
Lymphocytes comprise about
20-35
12
to
neutropenia.
LOW
25% of all the leukocyte
population.
increase in the
They
secrete
general
antibodies and are involved in
number
the immune system response
lymphocytes is
and regulation.
known
This
test
evaluates
the
of
as
lymphocytosis
109
presence of bacterial or viral
whereas
infection in the blood or
decrease
is
immune system.
lymphocytopeni
a.
Increased by:
Infection
s
Immune
diseases
Decreased by:
Severe
debilitating
illness: heart
failure, renal
failure,
advanced TB
Defective
lymphatic
Monocytes
Monoytes
are
highly
2-10
6.0
circulation
NORMAL
phagocytic cells capable of
A decreased or
engulfing
bacterial
increased level
organisms and viral infected
of monocytes in
cells. It cites the infection in
the blood may
large
110
the
tissues
and
indicate
divide/differentiate
into
bacterial or viral
dendritic
invasion in the
macrophages
and
cells to elicit an immune
body.
response.
Increased
number
indicates
there's
that
some
kind of infection
present
Eosinophil
Eosinophils are involved in
1-8
NORMAL
allergic reaction. This test
Increased by:
indicates
the
hypersensitivity
bodys
to
certain
Allergic
disorders:
substances and foreign bodies.
asthma, food,
drug
sensitivity
Skin
diseases
Neoplast
ic diseases
Parasitic
infections
111
Decreased by:
Stress
response
-Cushings
Basophil
They are type of wbcs with
0-1
syndrome
NORMAL
coarse granules that stain blue

when exposed to basic dye.
Basophils normally onstitute
1% or less of the total wbc
count but may increase and
decrease in certain diseases.
Platelet Count Platelet count is often ordered
as
a standard part
of a
150-400
252
NORMAL
Increased
complete blood count, which
(thrombocytosis
may be done as part of an
):
annual physical examination.
can result from
This test is used to evaluate,
hemorrhage,
diagnose,
up
infectious
disorders,
disorders,
drug
deficiency
and
bleeding
purpura/petechiae,
follow
iron
induced
thrombocytopenia,
anemia,
idiopathic
thrombocytopenia
inflammatory
112
purpura,
intravascular
disseminated
disorders
coagulation,
Decreased
leukemia, and chemotherapy
(thrombocytope
management
nia):
of
malignant
disease.
Can result from

aplastic
or
hypoplastic
bone
marrow,
vit
B12
deficiency, folic
acid deficiency,
enlarged spleen,
DIC,
or
mechanical
injury
MCH
Mean Corpuscular hemoglobin 25.70-32.20
33.3
to
platelets.
HIGH
is a measure of the mass of
Increased:
hemoglobin contained by a red
Macrocytic
blood cell.
anemia
Decreased:
Microcytic
MCHC
Mean Corpuscular hemoglobin 32.30-36.50
33.2
anemia
NORMAL
113
concentration is a measure of
Decreased:
the
Hypochromic in
concentration
hemoglobin
in
the
of
given
microcytic
volume of pacced red blood
anemias.
cell.
Normal:
This test gives a rough guide
Normochromic
to what shade of RBC will be.
in
macrocytic
anemias, due to
the larger cell
size.
MCV
Mean Corpuscular volume is a
79-92.20
97.3
HIGH
measure of the average red
Increased:
blood cell volume that is
Macrocytic
reported as part of a standard
anemia
complete blood count. It is in
Decreased:
the MCV measurement that
Microcytic
determines the classification of
anemia
an anemia.
BLOOD CHEMISTRY
These tests are done to screen for an electrolyte imbalance. It may be ordered to
determine if a disease or condition involving the brain, lungs, liver, heart, kidney, thyroid,
114
or adrenal glands is causing or being exacerbated by a sodium deficiency or excess. It

may also be ordered to monitor patients taking medications that can affect sodium and
potassium levels, such as diuretics.
Exam
Result
Normal values
Nursing
responsibilities
Sodium
LOW
134
136.10-155
mmol/L
Tell the patient

that there is no
> Sodium ions are necessary
fluid
or
for regulation of blood and
restriction.
food
body fluids, transmission of

nerve
impulses,
activity,
and
heart
certain
metabolic
functions.
Maintains optimal salt and

water balance in the body.
Potassium
NORMAL
3.40
> Potassium is important in

never
function
and
in
3.5-5.5
1. Tell the patient
mmol/L
that there is no
fluid
or
influencing osmotic balance
restriction.
between
2.
interstitial
important
cells
and
fluid.
in
It
the
is
maintaining
fluid and electrolyte balance
Instruct
patient
to
opening
closing
food
the
avoid
and
of
hand
115
in the body.
after a tourniquet is
applied.
Creatinine
NORMAL
>
53.00
Creatinine
levels
are
measured to check kidney
53-115 mmol/L Tell the patient that

there is no fluid or
food restriction.
function and to screen for

kidney damage. This test is
also
use
to
monitor
treatment of kidney disease

or kidney function while
you are on certain drugs.
116

Exam
Result
Normal values
Nursing
responsibilities
Albumin
LOW
17.98
35.00- 50.00
1. Explain the test
procedure and the
2. Tell the patient
that no fasting is
too large to filter through the
required
renal
procedure.
glomeruli.
The
for
3.
clients knowledge
of the test.
significant
component
4. Instruct not to
discard any urine
over the 24 hour
time period.
keeps
5. Teach the client
fluid
within
the
Assess
the
not
strenuous physical
activity during the
with
collection
nephritis,
to
the
undergo
117
procedure.
6.
pynelonephritis.
Withhold
possible,
for
48
hours before the

test begins.
118
DRUG STUDY
Generic Name
Ketorolac
Brand name
Classification
Dosage
Toradol
Nonsteroidal anti-inflammatory agents, nonopioid analagesics
Doctors order 30mg IVTT
Mechanism/action
Factory dose: 30mg/amp1 amp IM

Inhibits prostaglandin synthesis, producing peripherally mediated
/kinetics
analgesia. Also has antipyretic and anti-inflammatory properties.

Therapeutic effect: Decreased pain reduces intraocular inflammation.
Readily absorbed from GI tract after administration . Protein binding
99% largely metabolized in liver. Primarily excreted in urine. Not
removed by hemodialysis. Half life: 2-8 hours (increased in renal
Indication
impairment in elderly)
Short-term management of moderately severe, acute pain requiring
opioid-level analgesia.
Contraindication
Treatment post op inflammation following incisional refractive surgery.

Hypersensitivity to the drug or allergic symptoms. Advanced renal
impairment, active peptic ulcer disease, chronic inflammation of GI
Side effects
tract, GI bleeding/ulceration.
Headache, nausea, abdominal cramps/pain, dyspepsia, heart burn,
indigestion, constipation, stomatitis, vomiting, flatulence.
119
Nasal: nasal discomfort, rhinalgia increased lacrimation, throat irritation,

rhinitis.
Adverse effect
Ophthalmic: ocular irritation, keratitis.

Peptic ulcer, GI bleeding, severe hepatic reaction, jaundice,
Drug interaction
nephrotoxicity, renal impairment, fever, chills, joint pain.

May decrease effects of antihypertensive, diuretics.
Aspirin NSAIDS other salicylates may increase risk of GI side effects,
bleeding. May increase risk of bleeding with heparin, oral
anticoagulants, thrombolytics.
May increase concentration risk of toxicity of lithium. May increase risk
Nursing
of methotrexate toxicity.
1. Asses onset, type, location, duration of pain.
responsibilities
2. Obtain baseline renal/hepatic function test.

3. Give undiluted as IV push. Give over at least 15 sec.
4. Monitor urinary output, daily pattern of bowel activity.
5. Observe occult of blood loss.
6. Assess for therapeutic response: relief pain, stiffness, swelling,
increased joint mobility, reduced joint tenderness, and improved grip
strength.
7. Be alert of signs of bleeding.
8. Instruct client to avoid aspirin, alcohol during therapy.
9. Instruct client to avoid tasks that requires alertness motor skills until
response to drug is establish.
10. Store medicine in a dry and warm environment.
120
Source:
Saunders Nursing drug handbook 2014 page 650-652
Generic Name
Parecoxib Sodium
Brand name
Classification
Dosage
Mechanism/action
Dynastat
Anti-inflammatory and antirheumatic products
40 mg IVTT q 12hours
NSAIDs inhibit cyclooxygenase (COX)enzymes, which areinvolved in
/kinetics
the synthesis of prostaglandins and thereby reduce painand

inflammation.Oral NSAIDs are used post-operatively but when patients
areunable to tolerate oral medications or requirea faster onset of
Indication
analgesia, parenteral administration may be preferred.

Used for the prevention and treatment of pain. It can be used to relieve
pain and reduce inflammation (swelling and soreness) which may occur
after surgery.
Although Dynastat can relieve the symptoms of pain and inflammation,
Contraindication
it will not cure your condition.

Hypersensitivity to sulfonamides, severe hepatic impairment,
aspirin/anti-inflammatory allergy, active peptic ulcer or GI bleeding,
inflammatory bowel disease, moderate to severe CHF, ischaemic heart
disease, peripheral arterial disease, cerebrovascular disease, following
Side effects
CABG.
Gastrointestinal - Ulcer and gastrointestinal bleeding.
Liver - Jaundice and abnormal liver function.
121
Heart - Heart failure, heart attack, slow heart rate, high/low blood
pressure and abnormal heart rhythm.
Hypersensitivity - Swelling, rash, itching and difficulty in breathing.
Miscellaneous - Back pain, low platelet counts, disturbed sleeping and
Adverse effect
decreased urination.
Metabolism and nutrition disorders: anorexia, hyperglycaemia
Musculoskeletal and connective tissue disorders: arthralgia
Nervous system disorders: cerebrovascular disorder
Psychiatric disorders: agitation
Renal and urinary disorders: renal failure acute
Respiratory, thoracic and mediastinal disorders: embolism pulmonary
Skin and subcutaneous tissue disorders: ecchymosis, urticaria
Drug interaction
Nursing
Vascular disorders: hypertension aggravated, hypotension postural

Alcohol and diuretics decreases the effect of the drug
1. Assess for patients health history, caution should be exercised in
responsibilities
patients with history of dehydration, high blood pressure, liver or kidney

disease, gastrointestinal bleeding, ulcer, sugar, any infection.
2. Instruct patient not drive or operate machinery while taking the
medication because this cause dizziness.
3. Instruct the patient to report if he notices any skin rash, including
hives, raised red, itchy spots.
4. Do not administer if the patient has history of hypersensitivity to
NSAIDS.
5. Explain to the patient the common side effects and adverse effect and
what are the signs and symptoms he should watch out.
122
6. Store in a cool place.

7. Document administration on medication.
8. Assess patients response to medication.
9. Monitor for occurrence of side effect.
Source:
10. Dispose the vial and sharps properly.

Saunders Nursing drug handbook 2014
Generic name
Omeprazole/sodium bicarbonate
Trade name
Classification
Dosage
Prilosec, Zegerid
Gastrointestinal agent; proton pump inhibitor
Doctors order: 40mg OD
Gastroesophageal Reflux, Erosive Esophagitis, Duodenal Ulcer
adult: PO 20 mg once/d for 48 wk
Gastric Ulcer:
adult: PO 20 mg b.i.d. for 48 wk
Hypersecretory Disease:
adult:PO 60 mg once/d up to 120 mg t.i.d.
Duodenal Ulcer Associated with H. pylori
adult:PO 40 mg once/d for 14 d, then 20 mg/d for 14 d, in combination
Mechanism/
with clarithromycin 500 mg t.i.d. for 14 d

An antisecretory compound that is a gastric acid pump inhibitor.
123
action/kinetics
Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase

enzyme system [the acid (proton H+) pump] in the parietal cells.
Increases gastric pH, reduces gastric acid production.
Rapidly absorbed from GI tract. Protein binding 95%. Primarily

distributed into gastric parietal cells. Metabolized extensively in liver.
Primarily excreted in urine. Unknown if removed by hemodialysis. Half
Indication
life: 0.5 1 hr (increased in hepatic impairment)

Used for treating acid-induced inflammation and ulcers of the stomach
and duodenum; gastroesophageal reflux disease (GERD); erosive
esophagitis, heartburn; prevention of upper gastrointestinal bleeding in
critically ill patients; and Zollinger-Ellison Syndrome. It also is used in
combination with antibiotics for eradicating H. pylori infection of the
Contraindication
stomach.
Long-term use for gastroesophageal reflux disease, duodenal ulcers;
Side Effects
lactation.
Drowsiness
Adverse Effects
fast, racing, or uneven heartbeat
mood or mental changes
muscle spasms (tetany) or twitching seizures
nausea or vomiting
trembling
CNS:Headache, dizziness, fatigue.

GI:Diarrhea, abdominal pain, nausea, mild transient increases in liver
124
function tests.
Urogenital:Hematuria, proteinuria.
Skin:Rash.
Drug Interaction
Blurred vision
confusion
dryness of the mouth
flushing
headache
increased sweating
Angina
Constipation
Flatulence
Omeprazole potentially can increase the concentrations in blood of

diazepam (Valium), warfarin (Coumadin), and phenytoin (Dilantin) by
decreasing the elimination of these drugs by the liver.
The absorption of certain drugs may be affected by stomach acidity.
Therefore, omeprazole as well as other PPIs reduce the absorption and
concentration in blood of ketoconazole (Nizoral) and increase the
absorption and concentration in blood of digoxin (Lanoxin). This may
reduce the effectiveness of ketoconazole or increase digoxin toxicity.
Through unknown mechanisms, omeprazole may increase blood levels of
125
saquinavir and reduce blood levels of nelfinavir and atazanavir, drugs that
are used for treating patients with infection caused by the human
immunodeficiency virus (HIV). Accordingly, the dose of saquinavir may
need to be reduced to avoid toxicity, and the doses of nelfinavir and
Nursing
atazanavir may need to be increased to maintain efficacy.

1. Monitor urinalysis for hematuria and proteinuria. Periodic liver function
Responsibilities
tests with prolonged use.

2. Report any changes in urinary elimination such as pain or discomfort
associated with urination, or blood in urine.
3. Report severe diarrhea; drug may need to be discontinued.
4. Assess other medications patient may be taking for effectiveness and
interactions (especially those dependent on cytochrome P450 metabolism
or those dependent on acid environment for absorption).
5. Monitor therapeutic effectiveness and adverse reactions at beginning of
therapy and periodically throughout therapy.
6. Assess GI system: bowel sounds every 8hours, abdomen for pain and
swelling, appetite loss.
7. Monitor hepatic enzymes: AST, ALT, increased alkaline phosphatase
during treatment.
8. Assess knowledge/teach appropriate use of this medication,
interventions to reduce side effects, and adverse symptoms to report.
9. Caution patient to avoid alcohol, salicylates, ibuprofen: may cause GI
irritation
10. Report severe headache, unresolved severe diarrhea, or changes in
126
respiratory status.
Generic Name:
MULTIVITAMINS
Brand name:
Optilets, Therabid, Theragran
Classification:
Vitamins, multiple
Dosage:
1 cap od po
Mode of Action:
Needed for adequate metabolism
Indication:
Prevention and treatment of vitamin deficiencies
Contraindication:
Precaution: Pregnancy
Drug interactions:
None
Adverse Reaction:
Upset stomach, headache
127
Nursing Responsibilities:
1. Administer liquid multivitamins. It should be diluted

2. Instruct client that chew tabs should be chewed, not swallowed
whole
3.Evaluate therapeutic response: check each individual vitamin for
guidelines
4. Teach patient/family that adequate nutrition must be maintained
to prevent further deficiencies. To comply with regimen
5. Intruct client never to take more dose of a multivitamin unless
its prescribed by the physician.
6. Read the label of any multivitamin product before
administering. Many multivitamin products also contain minerals
such as calcium, iron, magnesium, potassium, and zinc. Minerals
(especially taken in large doses) can cause side effects such as
tooth staining, increased urination, stomach bleeding, uneven
heart rate, confusion, and muscle weakness or limp feeling.
7. Store this medication at room temperature away from moisture
and heat. Keep the liquid medicine from freezing.
8. Store multivitamins in their original container. Storing
multivitamins in a glass container can ruin the medication.
9. Assess for allergic reactions and side effects of the drug.
10. Assess for overdose symptoms. It may include stomach pain,
vomiting, diarrhea, constipation, loss of appetite, hair loss, peeling
skin, tingly feeling in or around your mouth, changes in menstrual
periods, weight loss, severe headache, muscle or joint pain, severe
back pain, blood in your urine, pale skin, and easy bruising or
bleeding.
Source:
Mosby's Drug 2011 edition

http://www.emedicinehealth.com/drugmultivitamin/article_em.htmReference
128
Generic Name:
Diphenhydramine
hydrochloride
Brand Name:
Classifications:
Benadryl
Antihistamine
Antimotion-sickness drug
Antiparkinsonian
Cough suppressant
Sedative-hypnotic
1 capsule soft gel -25mg
Competitively blocks the effects of histamine at H1-receptor
sites, has atropine-like, anti-pruritic, and sedative effects.
Relief of symptoms associated with perennial and seasonal
allergic rhinitis; vasomotor rhinitis; allergic conjunctivitis;
mild, uncomplicated urticaria and angioedema; amelioration
of allergic reactions to blood or plasma; dermatographism;
adjunctive therapy in anaphylactic reactions
Active and prophylactic treatment of motion sickness
Night time sleep aid
Parkinsonism (including drug-induced
parkinsonism and extrapyramidal reactions), in the elderly
intolerant of more potent drugs, for milder forms of the
disorder in other age-groups, and in combination with
centrally acting anticholinergic anti-parkinsonian drugs
Syrup formulation: Suppression of cough due to colds or
allergy
Contraindicated with allergy to antihistamines, third
trimester of pregnancy, lactation.
Use cautiously with narrow-angle glaucoma, stenosing
peptic ulcer, symptomatic prostatic hypertrophy, asthmatic
attack, bladder neck obstruction, pyloroduodenal obstruction,
pregnancy; elderly patients who may
be sensitive to anticholinergic effects.
Possible increased and prolonged anticholinergic effects
with MAOIs
Risk of increased sedation with alcohol, CNS depressants;
avoid this combination
CNS: Drowsiness, sedation, dizziness, disturbed
coordination, fatigue, confusion, restlessness, excitation,
nervousness, tremor, headache, blurred vision, diplopia
CV: Hypotension, palpitations, bradycardia, tachycardia,
extrasystoles
GI: Epigastric distress, anorexia, increased appetite and
weight gain, nausea, vomiting, diarrhea or constipation
GU: Urinary frequency, dysuria, urinary retention, early
Dosage:
Mechanism of Action:
Indications:
Contraindications:
Drug Interactions:
Adverse Reaction:
129
menses, decreased libido, impotence

Hematologic: Hemolytic anemia, hypoplastic anemia,
thrombocytopenia, leukopenia, agranulocytosis,
pancytopenia
Respiratory: Thickening of bronchial secretions, chest
tightness, wheezing, nasal stuffiness, dry mouth, dry nose,
dry throat, sore throat
1. Asses for allergy to any antihistamines.

2. Assess for other disorders such as narrow-angle glaucoma,
stenosing peptic ulcer, symptomatic prostatic hypertrophy,
asthmatic attack, bladder neck obstruction, and
pyloroduodenal obstruction.
3. Assess for the skin color, lesions, texture; orientation,
reflexes, affect; vision examination.
4. Assess for the vital signs of the client ( pulse, BP,
respiratory rate) and auscultate for adventitious sounds;
bowel sounds
5. Recheck the laboratory results of the client (CBC with
differentials)
6. Administer with food if GI upset occurs.
7. Administer syrup form if patient is unable to take tablets.
8. Monitor patient response, and arrange for adjustment of
dosage to lowest possible effective dose.
9. Instruct to avoid alcohol; serious sedation could occur.
10. Inform client that dizziness, drowsiness, sedation may
occur (use caution in driving or performing of tasks)
11. Report difficulty breathing, hallucinations, tremors, loss
of coordination, unusual bleeding or bruising, visual
disturbances, irregular heartbeat.
Generic Name:
Vitamin K
Brand Name:
Classifications:
Dosage:
Mechanism of Action:
Phytonadione
Vitamins and minerals
Injection: 10mg
Promotes hepatic synthesis of clotting factors II, VII, IX, X
(exact mechanism is unknown)
anticoagulant-induced prothrombin deficiency caused by
Indications:
130
Contraindications:
Drug Interactions:
Adverse Reaction:
coumarin or indanedione derivatives;

prophylaxis and therapy of hemorrhagic disease of the
newborn;
hypoprothrombinemia due to antibacterial therapy;
hypoprothrombinemia secondary to factors limiting
absorption or synthesis of vitamin K, e.g., obstructive
jaundice, biliary fistula, sprue, ulcerative colitis, celiac
disease, intestinal resection, cystic fibrosis of the pancreas,
and regional enteritis;
other drug-induced hypoprothrombinemia where it is
definitely shown that the result is due to interference with
vitamin K metabolism, e.g., salicylates.
Hypersensitivity to any component of this medication.
Temporary resistance to prothrombin-depressing
anticoagulants may result, especially when larger doses of
phytonadione are used. If relatively large doses have been
employed, it may be necessary when reinstituting
anticoagulant therapy to use somewhat larger doses of the
prothrombin- depressing anticoagulant, or to use one which
acts on a different principle, such as heparin sodium.
Anaphylaxis with too-rapid IV administration (has
resulted in death)
Dyspnea
Cyanosis
Erythematous skin eruptions
Pruritus
Scleroderma-like lesions
Flushing
Hyperbilirubinemia (in premature neonates)
Hypotension
Injection site reactions
Taste alterations
1. Assess client for any signs of hypersensitivity.
2. Educate client that adverse reactions to the drug may
occur.
3. Carefully regulate IVF with vitamin K. Rapid IV
administration may cause potentially fatal
anaphylaxis
4. Protect the medication from light; agent is rapidly
degraded
5. Monitor patient constantly. Severe reactions,
including fatalities, have occurred during and
immediately after IV injection (see ADVERSE
EFFECTS).
6. Lab tests: Baseline and frequent PT/INR.
131
7. Frequency, dose, and therapy duration are guided by

PT/INR clinical response.
8. Monitor therpeutic effectiveness which is indicated
by shortened PT, INR, bleeding, and clotting times,
as well as decreased hemorrhagic tendencies.
9. Be aware that patients on large doses may develop
temporary resistance to coumarin-type
anticoagulants. If oral anticoagulant is reinstituted,
larger than former doses may be needed. Some
patients may require change to heparin.
10. Educate patient/family maintain consistency in diet
and avoid significant increases in daily intake of
vitamin Krich foods when drug regimen is
stabilized. Know sources rich in vitamin K:
Asparagus, broccoli, cabbage, lettuce, turnip greens,
pork or beef liver, green tea, spinach, watercress, and
tomatoes.
Generic Name
Ferrous Sulfate
Iberet Folic-500
Brand Name
Classification
Iron Preparation
132
General Action
Elevates the serum iron concentration which then helps to form High
or trapped in the reticuloendothelial cells for storage and eventual
conversion to a usable form of iron.
Dose & Route
FeSO4+Folic acid 1 cap BID PO
Indications or
Purposes
Prevention and treatment of iron deficiency anemias. Dietary

supplement for iron.
Side Effects
Dizziness, nausea and vomiting, nasal congestion, dyspnea,

hypotension, muscle cramps, flushing, hyperventilation, cardio
vascular collapse.
Contraindications
Hypersensitivity, severe hypotension.
Nursing
Responsibilities
1. Advise patient to take medicine as prescribed.

2. Obtain patient history including drug history and any
hypersensitivity.
3. Note for adverse reactions.
4. Give between meals with water.
5. Eggs and milk inhibits absorption.
6. Monitor daily pattern of bowel and stool consistency.
7. Caution patient to make position changes slowly to minimize
orthostatic hypotension.
8. Advise patient to consult physician if irregular heartbeat,
dyspnea, swelling of hands and feet and hypotension occurs
9. Inform patient that angina attacks may occur 30 min. after
administration due reflex tachycardia.
10. Encourage patient to comply with additional intervention for
hypertension like proper diet, regular exercise, lifestyle
changes and stress management.
133
Generic
Generic
Name
Name Magnesium Sulfate
Furosemide
Magnesium Sulfate
Brand Name
Generic Name
Brand Name
Classification
BrandGeneral
Name Action
Mefoxin
Apo-Furosemide (CAN)
Furosemide Special (CAN)
Lasix
Loop diuretic
Furosemide
Cefoxitin inhibits reabsorption of Na and chloride mainly in
the medullary portion of the ascending Loop of Henle. Excretion
of potassium and ammonia is also increased while uric acid
excretion is reduced. It increases plasma-renin levels and
secondaryAntibiotics
hyperaldosteronism may result. Furosemide reduces
Classification
Cephalosporin;
BP in hypertensives as well as in normotensives. It also reduces
before
diuresis
has set including
in.
General Action Used topulmonary
treat manyoedema
kinds of
bacterial
infections,
severe or
Dose & Route
40
mg
life-threatening
Anticonvulsantforms.
Dose & Route
1mg IVTT q8
Indications or
Oral, IV: Edema associated with CHF, cirrhosis, renal
Purposes
disease is a broad-spectrum cephalosporin antibiotic,
Indications
or
This medication
Classification
Purposes
prescribed for serious infections such as respiratory tract infection,
infection,
IV: Acutesepticemia,
pulmonary and
edema
urinary tract
others. It works by fighting
against the bacteria in the body.
of many
Oral: enzyme
Hypertension
systems
involved inofneurochemical
Side Effect
Cofactor
Local
ReactionsSwelling
(inflammation)
vein.
Side Effectstransmission
Fluid
and
electrolyte
imbalance.
and muscular excitability; prevents or controls
by blocking
neuromuscular
transmission;
attractsitching,
and
seizures
Allergic
ReactionsRash, hives,
flushing,
Rashes,
photosensitivity,
nausea,
diarrhoea,
retains
water
in
the
intestinal
lumen
and
distends
bowel
toblurred
eosinophilia, fever, difficulty in breathing, and other allergic
promote
mass
movement
and headache,
relieveand
constipation.
vision,
dizziness,
hypotension. Bone marrow
reactions
including
anaphylaxis,
angioedema.
depression (rare), hepatic dysfunction.
General Action Heart- Low blood pressure.
Hyperglycaemia, glycosuria, ototoxicity.
Gastrointestinal- Diarrhea, nausea and vomiting.

Potentially Fatal: Rarely, sudden death and cardiac arrest.
Central
Nervous SystemMyastheniadepletion
gravis. can cause cardiac
Hypokalaemia
and magnesium
Blood-arrhythmias.
Eosinophilia, decrease in white blood cells, platelets,
Contraindicationsanemia,
and
Severe sodium
and water depletion, hypersensitivity to
1 mg MgSO4 x 2bone
dosesmarrow depression.
sulphonamides
and
furosemide,
hypokalaemia,
Liver hyponatraemia,
Function- Elevations
in liver enzymes.
precomatose
states associated with liver
Dose & Route
cirrhosis, anuria or renal failure.
Contraindication Hypersensitivity.
s
Addisons disease.
1) cefoxitin
Reduce dosage
if given
with other
antihypertensives;
Nursing
1. Use
cautiously
in patients
hypersensitive
to
or eclampsia
Nursing IM: Preeclampsia
readjust dosage
gradually as BP responds.
134
Responsibilities
2) Administer with food or milk to prevent GI upset.
Indications or
3) Give early in the day so that increased urination will not
Responsibilities
penicillin; cross-sensitivity has occurred in about 10% of such

patient. Also use cautiously in patients with a history of GI
disease, particularly colitis, because of an increased risk of
pseudomembranous colitis.
2.
If possible, obtain culture and sensitivity test results, as

ordered, before giving drug.
3.
For IV use, reconstitute 1g with 10 ml of sterile water for

injection or 2g with 10 to 20 ml of diluent.
4.
For IV injection, administer slowly over 3 to 5 minutes

through tubing of a flowing compatible IV solution
5.
For intermittent infusion, further dilute with 50 to 100 ml of

D5W or normal saline solution.
6.
For continuous high-dose infusion, add cefoxitin to IV

solutions of D5W, normal saline solution, or dextrose 5% in
normal saline solution.
7.
Discard unused drug after 24 hours if stored at room

temperature or after 1 week if refrigerated.
8.
Be aware that powder or solution may darken during storage, a

change that doesnt reflect altered potency
9.
Be aware that an allergic reaction may occur a few days after

therapy starts.
10. Monitor BUN and serum creatinine levels for early signs of
nephrotoxicity. Also monitor fluid intake and output;
decreasing urine output may indicate nephrotoxicity.
11. Assess patients bowel pattern daily; severe diarrhea may
indicate pseudomembranous colitis.
12. Assess for pharyngitis, ecchymosis, bleeding, and arthralgia;
they may indicate a blood dyscrasia.
135
Generic name
Brand name
Paracetamol
Acetaminophen
Classification
Central analgesic; non-narcotic analgesic, antipyretic
Dosage
Mechanism/action
1 gram IV infusion x 3 cycles

Appears to inhibit prostaglandin synthesis in the CNS and to a
/kinetics
lesser extent, block pain impulses through peripheral actions. Acts

centrally on hypothalamic heat regulating center, producing
peripheral vasodilation.
Indication
Contraindication
Relief of mild to moderate pain, fever.

IV: Management of moderate to severe pain when combined with
opioid analgesia.
Severe hepatic impairment or severe active liver disease.
Side effects
Bloody or black tarry stools
Bloody or cloudy urine
Fever with or without chills
Pain in the lower back
Adverse effect
Pinpoint red spots in the skin

Jaundice
Sore throat
136
Skin rash, hives or itching

Oliguria
Diarrhea
Nursing
responsibilities
Nausea and vomiting

1. Give without regard to meals.
2. Assess onset, type, location and duration of pain.
3. Advice not to drink alcoholic beverages.
4. Watch out for any signs of allergic reactions.
5. Be alert about the risk of hepatoxicity.
6. Monitor Vital signs.
7. Monitor Intake and Output.
Source:
www.healthmad.com
137
SURGICAL PROCEDURE
Procedure
Description
Rationale
Nursing
Responsibilities
Exploratory
Exploratory laparoscopy has oft
To
1.Determine
Laparoscopic
en been used for diagnostic
decompress
of
Cholecystojejunostom purposes to view the abdomen
his gall-
involvement
y Drain
after abdominal trauma and in
bladder, by
organs/tissues,
cases of abdominal illness.
diverting his
age/developmental
Laparoscopy is a term given to a
bile into his
level,
General Endotracheal
group of operations that are
jejunum
state of health.
Anesthesia:
performed with the aid of a
R:
inhalation anesthesia
camera placed in the abdomen.
anticipatory guidance
technique in which
extent
surgical
and
to
of
general
provide
in postoperative care.
anesthetic and
Cholecystojejunostomy usually
2. Identify
respiratory gases pass
is performed as palliation for
underlying
through a tube placed
malignant obstruction of the
condition/pathology
in the trachea through
distal bile duct. The jejunum is
R:which may affect
the mouth or nose.
tbrought up to the gallbladder,
healing/recovery
CEB (caudal epidural
usually bypassing the jejunum
3. Ascertain
block): anesthesia
through the transverse
presence/severity of
below the pelvis,
mesocolon. It may be performed
perioperative
138
induced by injecting
either to an intact loop of
complications
an anesthetic into the
jejunum (loop
development
sacral portion of the
cholecystojejunostomy) or to a
postoperative
spinal canal
Roux-en-Y loop of jejunum
complications.
(Roux-en-Y
cholecystojejunostomy), and is
carried out with one or two
layers of sutures, depending on
surgeons preference.
and
of
R: that can prolong

recovery.
4. Assess nutritional
status and current
intake.
R: to determine if
nutrition is adequate
to support healing.
5. Evaluate
clients
cognitive
and
emotional
state,
noting presence of
postoperative
changes,
including
confusion,
depression,
apathy,
expression
of
helplessness.
R:
to
determine
139
possible
psychological
interferences.
6. Instruct patient to
have
optimal
nutrition
and
adequate
protein
intake.
R:
to
provide
positive
nitrogen
balance,
aiding
in
healing
and
to
achieve general good

health.
7. Encourage
early
ambulation
and
regular exercise.
R:
to
promote
circulation, improve
strength, and reduce
risks associated with
immobility.
8. Recommend
140
alternating
activity
with adequate rest.

R: to reduce fatigue.
9. Encourage client
to adhere to medical
regimen and followup care
R: to monitor healing
process and provide
for timely
intervention as
needed.
10. Always clean
surgical site with
antiseptic.
R: To prevent
infections
NURSING THEORIES
141
Self-Care Deficit Theory

Dorothea Orems model is a constellation of three interrelated theories. These are
nursing systems self-care, and self-care deficit. The focus of Orems model is to enhance
the persons ability for self-care and this also extends to the care of dependents. A
persons self-care deficits are the result of environmental situations. There are three
systems that exist within this professional nursing practice model.
1. Wholly compensatory system nurse provides total care
2. Partially compensatory system nurse and patient share responsibility for care
3. Educative-development system - client has primary responsibility for personal
health, with nurse acting as a consultant.
The patient belongs to the wholly compensatory system. The patient still needs full
care and guidance through the significant others and the medical staff. Even on the
patients ADL before and after hospitalization. Full care must be rendered for patient to
be able to coup up to his needs and to be able to have quality of life.
Philosophy and Science of caring

Caring in Nursing
According to Watson (2001), part of her theory are four major concepts.
Watsons four major concepts
1.
Human being
Human being refers to .. a valued person in and of him or herself to be
cared for, respected, nurtured, understood and assisted; in general a philosophical
142
view of a person as a fully functional integrated self. He, human is viewed as

greater than and different from, the sum of his or her parts.
2.
Health
Watson adds the following three elements to WHO definition of health:
3.
A high level of overall physical, mental and social functioning

A general adaptive-maintenance level of daily functioning
The absence of illness (or the presence of efforts that leads its absence)
Environment/society
According to Watson, caring (and nursing) has existed in every society. A
caring attitude is not transmitted from generation to generation. It is transmitted
by the culture of the profession as a unique way of coping with its environment.
4. Nursing
Nursing is concerned with promoting health, preventing illness, caring for the
sick and restoring health. It focuses on health promotion and treatment of
disease. She believes that holistic health care is central to the practice of caring in
nursing.
She
defines
nursing
as..
a human science of persons and human health-illness experiences that are

mediated by professional, personal, scientific, esthetic and ethical human
transactions.
In relation to the patient, we would like to relate it to Jean Watsons explanation

on human being. Significance of the value of life is focused. Patients value of life is
essential for caring. In fact patients condition needs more attention, than any other cases.
143
As nurses, our main goal is to alleviate, prevent and care our patients. In practice to Jean
Watsons theory. We give importance to those in need. And we give focus to those who
need the most as we value the ones we care. Noting that every patient is important,
because we want to nurture the life of every human being.
Fourteen Basic Human Needs

Virginia Henderson developed the Fourteen Basic Human Needs Theory upon
which nursing care is based. Henderson defined nursing in terms of the function of the
nurse in assisting the individual in the performance of activities contributing to health or
its recovery that the patient would perform if he had enough strength in a way that it will
help her achieve homeostasis as soon as possible.
The 14 components
1.
2.
3.
4.
5.
6.
7.
Breathe normally.
Eat and drink adequately.
Eliminate body wastes.
Move and maintain desirable postures.
Sleep and rest.
Select suitable clothes-dress and undress.
Maintain body temperature within normal range by adjusting clothing and
modifying environment
8. Keep the body clean and well groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others.
10. Communicate with others in expressing emotions, needs, fears, or opinions.
11. Worship according to ones faith.
12. Work in such a way that there is a sense of accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover, or satisfy the curiosity that leads to normal development and
health and use the available health facilities.
As nurses we would asses and help alleviate the condition of the patient. Next, is being a
helper to the patient. Last, is to be a partner with the patient. By these, the patients needs
144
which includes breathing normally, eating and drinking adequately, eliminating body
wastes, moving and maintaining desirable postures, sleeping and resting, being welldressed, having the right body temperature, having good hygiene are met. We are being
part of the patients care and recovery to improve patients quality of life.
145
NURSING CARE PLAN
Date and
Cues
Time
August 22, Objective:
2014
Fatigue
73 shift
Jaundice
all over the
9:00am
body
Vital
signs:
T - 36o C; PR
- 70 bpm; RR
- 19 cpm; BP
130/90
mmHg
Needs
A
C
T
I
V
I
T
Y
E
X
E
Nursing
Diagnosis
Ineffective tissue
perfusion
r/t
decrease
in
hemoglobin in the
blood
R: Red blood
cells are produced
in
the
bone
marrow which is
the soft tissue in
the center of most
bones. Red blood
Objective of Care
Nursing Intervention
After 3 days of 1) Monitor vital signs,

nursing care, patient
assess capillary refill,
will be able to:
skin color / mucous
membranes, nails.
a) Indicate
R: provides information
adequate
about the degree / adequacy
perfusion such of tissue perfusion and help
as vital signs determine the need for
within clients intervention.
normal range, 2) Elevate the head of bed
free from pain,
as tolerated.
and absence of R: increased lung expansion
Evaluation
After 3 days of
nursing
intervention,
patient was able
to:
a) Demonstrate
adequate
perfusion
such as vital
signs of T 37.1o C; PR 146
Laboratory
result:
Hemoglobin
- 116 g/L
(Normal
range: 135175 g/L)
Hematocrit 0.35 (Normal
range: 0.400.52)
RBC Count 3.
59
(Normal
range: 4.206.10)
R
C
I
S
E
P
A
T
T
E
R
N
cells carry oxygen

edema.
to all parts of your b) Increase
body. When your
hemoglobin
red blood cell (or
level at normal
hemoglobin)
range
count is low, parts
of your body do
not get enough
oxygen to do their
work.
This
condition is called
anemia and can
make you feel
very
tired.
Anemia
is
a
condition in which
the number of red
blood cells or
their
oxygencarrying capacity
is insufficient to
meet physiologic
needs, which vary
by
age,
sex,
altitude, smoking,
and
pregnancy
status. It is a
symptom of an
underlying
condition, such as
loss of blood
and maximize oxygenation

70 bpm; RR to cellular needs. Note:
18 cpm; BP contraindicated if there is
120/80
hypotension.
mmHg, free
3) Monitor
respiratory
from pain
effort: auscultation of
and absence
breath
sounds
of edema.
adventitious notice.
GOAL MET!
R: dyspnea, heart problems b) Wasnt able
because of the rush shows
to
secure
old
heart
strain
/
laboratory
compensatory increase in
result
of
cardiac output.
hematology.
4) Investigate complaints GOAL UNMET!
of
chest
pain
/
palpitations.
R: cellular ischemia affects
myocardial tissue / potential
risk of infarction.
5) Provide
supplemental
oxygen as indicated.
R: to maximize the transport
of oxygen to tissues.
6) Administer antimicrobial
agents as ordered.
R: to treat the infection and
subsequently decrease the
release of inflammatory
mediators
7) Administer vasopressors
(e.g.
dopamine,
147
components,
elements
inadequate or lack
of
nutrients
needed for the
formation of the
red blood cells,
resulting
in
decreased oxygencarrying capacity
of
blood
(Doenges, 1999).
norepinephrine)
and
positive inotropic agents
(e.g. dobutamine) if
ordered
R: to maintain adequate
perfusion
pressure
and
cardiac output.
8) Eat
green
leafy
vegetables and cooked
red meat
R: to obtain the iron, folic
acid and vitamins needed to
build and maintain red blood
cells.
9) Encourage to drink a
glass of orange juice
R: to help increase iron
absorption.
10) Encourage to take iron
tablets as prescribed by
the physician.
R: to help raise red blood
cell count.
148
Date/
Time
August
22, 2014
7:003:00pm
Cues
Needs
Subjective:
"Dili jud nako
kaya
itulon
akoang gikaon"
as verbalized.
Objective:
-
43
kg
- Weakness of
muscles
required
for
swallowing or
mastication;
poor
muscle
tone
N
U
T
R
I
T
I
O
N
A
L
M
E
T
A
B
O
L
I
C
decreased
proteins
as
evidenced
by
loss
of
subcutaneous
P
fat/ muscle mass A
T
abnormal T
laboratories:
E
Albumin:
17 R
g/L
normal: N
Nursing
diagnosis
Imbalanced
nutrition: Less
than
body
requirements r/t
inability
to
ingest or digest
food
R: The elderly
likewise
experience
problems
in
nutrition related
to
lack
of
financial
resources,
cognitive
impairments
causing them to
forget to eat,
physical
limitations that
interfere with
preparing food,
deterioration of
their sense of
taste and smell,
reduction
of
gastric secretion
Objectives of care
Nursing interventions
Evaluation
After 3 days of
nursing
care,
patient will be able
to:
a. Demonstrate
progressive
weight
gain
toward goal.
b. Display
normalization of
laboratory
values and be
free of signs of
malnutrition as
reflected
in
Defining
Characteristics.
c. Verbalize
understanding of
causative factors
when known and
necessary
interventions.
d. Demonstrate
behaviors,
lifestyle changes
to regain and/or
maintain
appropriate
1. Determine clients ability to

chew, swallow, and taste food.
Evaluate teeth and gums for poor
oral health, and note denture fit,
as
indicated.
R: All factors that can affect
ingestion and/or digestion of
nutrients.
2.
Note
occurrence
of
amenorrhea, tooth decay, swollen
salivary glands, and report of
constant
sore
throat
R: suggesting bulimia/ affecting
ability
to
eat.
3.
Monitor
weight;
measure/calculate body fat and
muscle mass via triceps skin fold
and
mid-arm
muscle
circumference
or
other
anthropometric measurements
R:
to
establish
baseline
parameters.
4. Note age, body build, strength,
activity/rest
level,
etc.
R: Helps determine nutritional
needs.
4. Observe for absence of
subcutaneous fat/muscle wasting,
loss of hair, fissuring of nails,
After 3 days of
nursing
intervention,
goal is partially
met. There is no
progressive
weight
gain
toward goal and
the
laboratory
values are still
not normal and
free of signs of
malnutrition. The
patient was able
to
verbalize
understanding of
causative factors
when known and
necessary
interventions and
demonstrate
behaviors,
lifestyle changes
to regain and/or
maintain
appropriate
weight.
149
35.00 - 50.00
g/L
Hemoglobin:
116 g/L normal:
135 - 175 g/L
Electrolytes:
Sodium:
134
mmol/L
Normal-136.10155
Alakaline
phosphatase:
362
Normal:
38126.00
that
accompanies
aging
and
interferes with
digestion, and
social isolation
and
boredom
that cause a lack
of interest in
eating.
Nurses Pocket
Guide
by
Doenges,
Moorhouse and
Murr
weight.
delayed healing, gum bleeding,

swollen
abdomen,
etc.,
R: that indicate protein-energy
malnutrition.
5. Provide diet modifications, as
indicated. For example: Refer to
nutritional resources to determine
suitable ways to optimize clients
intake of protein, carbohydrates,
fats, calories within eating
style/needs;
Formula
tube
feedings; parenteral nutrition
infusion.
R: To meet nutritional needs if
client is unable to swallow.
6. Encourage client to choose
foods/have family member bring
foods that seem appealing
R:
to
stimulate
appetite.
7. Encourage use of lozenges and
so
forth
R: to stimulate salivation when
dryness
is
a
factor
9. Weigh regularly/graph results
R: to monitor effectiveness of
efforts
10.
Consult
with
dietitian/nutritional support team,
as
necessary
R: for long-term needs.
150
Date/
Time
August
22, 2014
7:00am
3:00pm
Cues
Subjective:
Makalihok
man ko ug
maghinayhinay lang pero
kailangan lang
nako ug tabang
labi na
mubangon ug
mutindog. As
verbalized.
Objective:
- Slowed
movements
- Limited
range of
motion
- Body
weakness
- Functional
level:
2- requires
help from
another
person for
assistance,
supervison,
and teaching
Needs
A
C
T
I
V
I
T
Y
E
X
E
R
C
I
S
E
P
A
T
T
E
R
N
Nursing
diagnosis
Impaired
physical
mobility related
to decreased
muscle strength
R: Mobility is
also related to
body changes
from aging,
loss of muscle
mass, reduction
in muscle
strength and
function, joints
becoming
stiffer and less
mobile, and
gait changes
affecting
balance can
significantly
compromise
the mobility of
elder patients
thus resulting
to impaired
physical
mobility.
Objectives of care
Short term:
Nursing interventions
Evaluation
1.
Establish rapport to the After 8 hours of

client and family.
span of care,
After 8 hours of
goal is met. The
nursing care the patient R: Establishing rapport to the patient was able
will be have improved client and family will enable to verbalize his
physical mobility as
the nurse to gain the confidence understanding of
evidenced by:
situation or risk
and cooperation of the client.
2. Reassess ability to carry out factors and
a.) Verbalization of
individual
ADLs
(e.g.,
feeding,
understanding of
treatment
dressing, grooming, bathing regimen and
situation or risk
and ambulating) on regular safety measures,
factors and
basis.
individual treatment
demonstrate d
regimen and safety
the techniques
R: To determine the aspect of
measures.
or behaviors that
ADL that is difficult to the
b.) Demonstrate
enable
patient.
techniques or
resumption of
3. Change position at least
behaviors that
activities,
every two hours and more
enable resumption of
participate in
often.
activities.
ADLs and
R:
Reduces
risk
of
tissue
c.) Participate in
desired
ischemia and bedsores.
ADLs and desired
activities,
4.
Note
emotional/behavioural
activities.
maintained and
responses to problems of
d.) Maintain or
improved
immobility.
improve strength
strength and
and function of
function of
R: Feelings of frustration or
affected and/ or
affected and/ or
powerlessness may impede
compensatory part.
compensatory
attainment of goals.
part.
5. Assist or have client
reposition self on regular
151
schedule as dictated by
individual situation. Instruct
in use of side rails.
Nurses Pocket
Guide by
Doenges,
Moorhouse and
Murr
R: Aids in retaining neuronal

pathways, enhancing
proprioception and motor
response.
6. Support affected body parts
or joints with pillow, rolls,
or foot supports.
R: To maintain position of
function and reduce risk of
pressure ulcers.
7. Encourage participation in
slef-care; diversional, or
recreational activities.
R: Enhances self-concept and
sense of independence.
8. Identify energy-conserving
techniques for ADLs.
R: limits fatigue, maximizing
participation.
9. Set goals with client for
increasing participation in
activities, exercises or
position changes.
R: Promotes sense of
expectation of progress and
provides some sense of
152
independence.
10. Encourage clients/SOs
involvement in decision
making as much as possible.
R: Enhances commitment to
plan, optimizing outcomes.
153
Date and
Time
Cues
August 22, Objectives:

2014
Impaired
73 shift
capability to
put on or
9:00 am
take
off
clothing
Inabil
ity
to
ambulate
autonomous
ly
Inabil
ity to bathe
self
independent
ly
Inabil
ity to dress
self
Needs
A
C
T
I
V
I
T
Y
E
Nursing
Diagnosis
Objective of Care
Self care deficit r/t After

performing
decreased strength nursing
and endurance
interventions,
the
patient will be able
R:
Medical to:
conditions
that a) maximize the
could lead to self
self
care
care deficit are as
activities,
follows:
particularly,
cerebrovascular
bathing,
accident, stroke,
hygiene,
multiple sclerosis,
dressing,
renal
dialysis,
grooming,
rheumatoid
feeding
and
arthritis, and a lot
toileting
more. The deficit b) promote
may be the result
independence.
of
transient c) Patient safely
limitations, such
performs
(to
as those one might
maximum
experience while
ability)
selfrecuperating from
care activities
surgery; or the
Evaluation
1) Determine exact cause

of each deficit. For
instance,
weakness,
visual problems, and
cognitive impairment.
R: Varied etiological factors
may require more specific
interventions to enable selfcare.
After performing
nursing
interventions, the
patient
wasnt
able to:
a) Maximize the
self care
activities of
daily living
The patient was
2) Evaluate capability and able to:
level of deficit (04
scale) to perform ADLs b) Promote
such
as
feeding,
independence
dressing, grooming, and c) Patient safely
bathing,
toileting,
performs (to
transferring,
and
maximum
ambulating on regular
ability) selfbasis.
care activities
R: The patient may only GOAL
need support with some self- PARTIALLY
care measures. Also help in MET!
anticipating and development
154
autonomous
ly
Inabil
ity to feed
self
independent
ly
Poor
personal
hygiene
X
E
R
C
I
S
E
P
A
T
T
E
R
N
result
of
progressive
deterioration that
erodes
the
individuals
ability
or
willingness
to
perform
the
activities required
caring for himself
or herself.
Source:
http://nscultimatex.blogspot
.com/2010/11/self
-care-deficitbathinghygiene.ht
ml
for managing patient needs.

3) Monitor
impulsive
behavior or actions
indicative of altered
judgment.
R: May signify the need for
supplementary interventions
and management to ensure
safety or security.
4) Note the need for
assistive devices.
R: This enhances autonomy
in performing Activities of
Daily Living.
5) Avoid performing things
for patient that patient
could accomplish for
self, but offer help as
appropriate.Permit
as
much independence as
feasible.
R: Even though assistance is
necessary
in
avoiding
frustration, these individual
may become afraid and
dependent. It is imperative
for patient to do as much as
possible for self to sustain
self-esteem
and
uphold
recuperation.
155
6) Educate family and

significant others to
promote autonomy and
to intercede if the patient
becomes tired, are not
capable to carry out task,
or become extremely
aggravated.
R: This displays caring and
concern but does not hinder
with patients efforts to attain
autonomy.
7) Persuade independence,
but intercede when the
patient is not able carry
out self-care activities.
R: A suitable level of
assistive care can avoid harm
with
activities
without
causing disappointment.
8) Persuade or use energyconservation techniques.
R: Saves energy, decreases
fatigue,
and
improves
patients
capability
to
execute tasks.
9) Persuade patient input in
planning schedule.
R: Patients worth of life is
improved when wishes or
156
likes
are
consideration
activities.
taken
in
into
daily
10) Persuade
significant
other to permit patient to
perform
self-care
measures as much as
possible.
R: Reinstitutes feeling of
independence and promotes
self-esteem and improves
rehabilitation process. Note:
This may be very hard and
discouraging
for
the
significant other or caregiver,
depending on extent of
disability and time needed
for patient to accomplish
activity.
157
Date and
Cues
Time
Date:
Objective:
August
JP Drain
22, 2014
attached to
73
right
9:00 am
hypochondri
a.
T: 36.8
Need
H
E
A
L
T
H
P
E
R
C
E
P
T
I
O
N
H
E
A
L
T
H
M
A
N
A
G
Nursing Diagnosis
Objective of Care
Risk for infection After

performing
r/t the presence of nursing interventions,
JP Drain.
the patient will be
able to:
Rationale: The JP a. To gain knowledge
drain site may be
of proper infection
painful.
Patient
control.
may have trouble b. To gain knowledge
lying on the side
of proper site care.
with your JP drain. c. To maintain the
The JP drain site
site as clean as
may leak. The JP
possible.
drain may be
pulled out by
accident.
The
tubing may get
blocked, crack, or
break. The tubing
may damage to
patients
tissue.
Patient may have a
scar. The JP drain
site
may
get
infected.
This
infection
could
spread inside the
body.
http://www.drugs.c
om/cg/jacksonpratt-drain-
Evaluation
1. Note risk factors for

occurrence of infection
(e.g.
compromised
host, skin integrity,
environmental
exposure)
R: Risk factors may
lead to invasion of
bacteria inside the site.
After
performing
nursing interventions,
the patient was able to:
a. was able to gain
knowledge of proper
infection control.
b. was able to gain

knowledge of proper
2. Observe
signs
of site care.
infection at insertion
site. R: Signs of c. maintain the site as
infection may lead clean as possible as
discomfort and pain to seen.
the patient.
Goal Met
3. Assess and document
skin conditions around
insertion,
noting
inflammation
and
drainage. R: To be able
to gather information
and
notify
the
physician of possible
infection of the JP
drain site.
4. Monitor for signs and
symptoms of sepsis:
158
E
M
E
N
T
P
A
T
T
E
R
N
care.html
Fever and chills. R:

Fever and chills are
signs of infection.
5. Encourage patient and
significant others to
perform proper hand
washing before meals
and after using the
toilet.
R: To minimize the
spread of infection.
6. Assist
patient
in
cleaning the JP Drain
site.
R:
To
minimize
infection in the site.
7. Maintain
aseptic
technique with any
procedures.
Provide
wound
care
as
appropriate.
R: Prevents entry of
bacteria and reduces
risk of infection.
8. Promote rest.
R:
Rest reduces
159
metabolic process,
allowing oxygen and
nutrients to be used for
healing.
avoid pressure on JP
Drain site.
R: JP Drain movement
can
cause
tissue
trauma and may lead
to inflammation.
report immediately any
signs and symptoms of
inflammation on the site.
R:
Early
detection
prompts intervention to
avoid
serious
complications.
160
PROGNOSIS
161
Criteria
Onset
of
Poor
Fair
Good
the
illness
Justification
The patient was admitted at Southern
Philippines Medical Center (SPMC)
last June 28, 2014.

Duration
of
A month prior to his admission Patient
illness
Amber experienced pain in the upper

quadrant of his abdomen. Until four
days prior to admission, patient had
severe upper quadrant pain which he

said to be intolerable. In May 2014 he
was advice by his doctor to seek
health care at Southern Philippines
Medical Center (SPMC) with the chief
complaint of abdominal pain and
jaundice last June 28, 2014 and was
Environmental
hospitalized.
The patient lives in the Del Monte,
factors
Island garden City of Samal which has
a lot of coconut trees, that has

peaceful and clean environment in the
surroundings.
His family is very supportive in this
Family support
time of crisis. They assured that the

patient wont face the problem alone.
The family has also knowledge about

his condition. They usually go with
the patient during his check-up,
162
constantly reminds him to take a rest.
TOTAL
Computation:
Poor
1x1=1
Fair
3x2=6
Good
Normal
Range:
Poor= 1.01.6
2x3=6
-------------------------------------------------Total:
13 / 7 = 1.9
The patient is rated 1.9, because of this, his prognosis is rated as

FAIR. This means that his chance of recovery from the illness is at
risk.
Fair= 1.72.3
We gave health teachings to provide appropriate and effective nursing

care. With a proper teaching comes a productive knowledge to the
patient to know its preventive measures along with responsibility and
Good=
2.4-3
sense of will, the patient could direct herself away from

complications.
163
DISCHARGE PLAN
Medication
Exercise
>Instruct the client

to refrain from
taking
any
medication
or
supplement
not
prescribed by the
physician.
>Encourage
the
client to avoid from
lifting
heavy
objects or doing
strenuous
housework.
Plan
with his tolerable
tasks.
>Inform the client

to take all drugs
prescribed by the
physician according
to
given
instructions.
Health
Teachings
Hygiene
>Inform
the >Encourage the
significant other significant other
to assist the to assist the
client on his client to do daily
personal
oral
hygiene
hygiene.
especially after
meals.
>Instruct the
significant other >Encourage the
>Encourage
the to ensure safety significant other
client
to
have and cleanliness to assist the
ample rest or one in
the client
when
nap within the day. surroundings.
bathing.
>Encourage
the
>Explain to the client to exercise
client
the within
physical
importance
of limit.
taking in prescribed
medications.
>Encourage
the
client
to
do
>Inform the client activities of daily
about
the living.
>Instruct
the
significant other
to position the
patient on her
side every 2
hours to avoid
bed sores and
aspiration.
Outpatient Orders
Diet
>Instruct the client to

immediately seek the
assistance
of
a
physician or reliable
health care agent if he
experience
Abdominal
pain,
Bloating,
PaleColored
stools,
Jaundice,
Elevated
Blood Sugars and
Itching.
>Encourage the
client to consume an
adequate amount of
fluids, calories, protein
and vitamins each day to
maintain a desirable
weight and activity level.
> Encourage the client to

have small, frequent
meals throughout the day
(five to six meals/snacks
total), with each having a
>Instruct the client to rich source of protein.
>Inform
the visit the doctor to
client to perform have a followup > Encourage the client to
proper
hand check-up after a week limit food intake.
washing
when
> Instruct the client
dressing
the
avoid
alcoholic
surgical incision.
beverages
and
always
>Regular
consultation with the drink plenty of fluid.
doctor and contact in
164
medications
indicated for home
regimen,
their
purpose,
side
effects
and
its
adverse reactions,
route and frequency
of administration
>Explain to the
significant
others
the
importance
of
knowing
the
patients diet.
>Inform
cases of emergency
> Encourage client to
significant others situation
have low-fat diet. Eating
&
client
boneless chicken breast
significant about
and most fish fish helps
providing clean
keep meals low in fat.
and
healthy
environment
>Instruct
client
to
comply with the dietary
prescription.
165
RECOMMENDATIONS
To Patient & the Family

The patient is encouraged to express his own thoughts and feelings, concerning
on how he perceives his condition that affect his life and his expected duration until his
recovery. The patients cooperation and willingness is expected for the procedures that he
may undergo. He is advised to take part in complying with therapeutic regimen designed
for his recovery. He should realize the importance of complying with his medication and
the benefits this practice would bring to the improvement of his well-being. Moreover, he
must not hesitate on seeking medical assistance whenever he feels the signs and symptoms,
which may be due to other health illness. He should not lose his hope and believe on his
creator. The patients family plays an important role in the patients illness and recovery.
The family should help the patient by giving him support and encouragement for the
betterment of the condition. They should be the patients source of strength and inspiration
as he undergoes different procedures. We also recommend the family to be open with the
teachings that the student nurses would impose to them because it could help them to live
life more functionally. With their full cooperation and participation, they will be able to
fully understand the basic health concepts that they could apply in their daily lives.
To the Student Nurses

The student nurses should have the responsibility to promote health by
educating the patient especially the significant other in the hospital during the duty with
166
all necessary solutions and make them aware of certain factors in the environment that
could affect their well-being. What lies in their hands is to teach them and emphasized to
them the means of elevating their health status. They must be equipped with necessary
information with regards to the illness. They should master the procedures and health
teachings that he/she would render to the client. The student must work quick and
effective to be able to accomplish ones specific objective and the tasks that have been
assigned. Also, they must assess the patient properly to come up with a correct nursing
intervention to avoid complications.
To the Clinical Instructors

The proponents recommend that they continue guiding the student nurses to help
them improve their skills and knowledge about the concept fluid & electrolyte imbalance.
They should also continue being role models to the student nurses to serve as their
inspiration and motivation to do their work enthusiastically and passionately. As clinical
instructors they should know the limitations of the students and understand them.
To the Health Care Provider

The institution should continue to play their role in the community in the
dissemination of information regarding health programs that they would implement so as
to gain cooperation, participation and trust from the family and client. The institution
should provide good relationship between the health care provider and the client. They
should provide proper treatment and care for the client.
167
To the School of Nursing of the Ateneo de Davao University

The school should Continue to train and mold students with knowledge and
skills as well as good values. They should continue to expose the students to different
area to allow the students to experience the various fields of nursing and be able to apply
this learning to wherever it may lead them. Also to acquire more skills that will be
beneficial as they continue to practice their chosen vocation.
168
REFERENCES
Books:
Deglin, J. H., et al. 2010. Daviss Drug Guide for Nurses 12th Ed.
deWit, S. 2012. Medical - Surgical Nursing: Concepts & Practice
Gould, B. E. 2006. 3rd Ed. Pathophysiology for the Health Professions
Long, B., et al. 1993. 3rd Ed. Medical - Surgical Nursing: A Nursing Process
Approach
Marieb, E. 2012. Human Anatomy and Physiology 9th ed
Nowak, T. J. and Handford, A. G. 2003. 3 rd Ed. Pathophysiology: Concepts and

Applications for Health Care Professional
Porth, C. M. 2010. Essentials of Pathophysiology: Concepts of Altered Health

States
Smeltzer S. C. and Bare, B. G. 1992. 7 th Ed. Brunner and Suddarths Textbook of

Medical-Surgical Nursing
Smeltzer, S. C. and Bare, B. G. 2004. Brunners and Suddarths Medical Surgical

Nursing 10th Edition
Internet
http://www.onhealth.com/jaundice/page2.htm
http://www.liverandpancreas.co.uk/the-management-of-obstructive-jaundice.php
http://ispub.com/IJTM/7/2/13053
169
http://www.philstar.com/health-and-family/738095/cancer-pancreas-deadliest-
cancer
http://www.webmd.com/cancer/pancreatic-cancer/pancreatic-cancer-symptoms
http://pathology.jhu.edu/pc/BasicCauses.php?area=ba
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/P045.ht
ml
http://www.annualreviews.org/doi/abs/10.1146/annurev.nu.15.070195.002223?
journalCode=nutr
http://www.mims.com/Philippines/drug/info/human%20albumin%2020percent
%20behring%20%28low%20salt%29/
http://www.drugs.com/mmx/albumin-human.html
http://www.drugs.com/pro/albumin-human.html
http://www.medicinenet.com/furosemide/article.htm
http://nurseslabs.com/furosemide-lasix-drug-study/
http://www.emedicinehealth.com/drug-cefoxitin/article_em.htm
http://www.medindia.net/doctors/drug_information/cefoxitin.htm
http://books.google.com.ph/books?
id=vJjv0U6o8YEC&pg=PA197&lpg=PA197&dq=cefoxitin+nursing+consideratio
ns&source=bl&ots=hUnyRidf3u&sig=jahs1PismqE4JMa1oY4SVkGBhI&hl=en&sa=X&ei=wPIWVPPgD82F8gXivIGQCw&
ved=0CDoQ6AEwBA#v=onepage&q=cefoxitin%20nursing
%20considerations&f=false
http://www.medicinenet.com/albumin-injection/article.htm
170

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Ateneo de Davao University

to the School of Nursing

Obstructive Jaundice secondary to Pancreatic Head mass Malignant

Fulfillments in the reference for NCM 103 RLE

Patients Data ------------------------------------------------------------------------------- 7

Development Data ------------------------------------------------------------------------13

Definition of Complete Diagnosis------------------------------------------------------16

Physical Assessment ---------------------------------------------------------------------18

Anatomy and Physiology----------------------------------------------------------------23

Etiology and Symptomatology----------------------------------------------------------26

Doctors Order ----------------------------------------------------------------------------31

Diagnostic Exam -------------------------------------------------------------------------85

XVI. Nursing Theories ------------------------------------------------------------------------147

XIX. Discharge Plan ---------------------------------------------------------------------------170

XX1. References --------------------------------------------------------------------------------175

During the proponents duty in Surgical East Ward at Southern Philippines

Comprehend the disease process: causes, effects, management, treatment, and

Determine the pathophysiology of the condition with their rationale for

Outline clients genogram or family tree to identify any heredo-familial diseases

Be involved in the course of care of the patient holistically; and

Be aware of the patients progress on the succeeding interventions given.

Patients Name: Patient Amber

REASON FOR SEEKING HEALTHCARE

PRESENT HEALTH HISTORY

After having diagnosed of Obstructive Jaundice probably secondary to

pancreatic head mass the doctor advised him to have surgery.

the patient was asked what mefenamic pero wala gihapon

Q stands for Quality/Quantity, Dili na makaya ang sakit bisang

how painful he feels.

PAST HEALTH HISTORY

FAMILY HEALTH HISTORY

Use of Medication according to patients understanding

whenever he had abdominal pain.

Unknown cause of death

Piagets Stages of Cognitive Development

Formal The final stage of The

theory has achieved logic, the ability to use

involves an increase this stage.

deductive reasoning, and

in logic, the ability

patient was asked; Kabalo

ka sir kung ngano naa ka

diri sa hospital? ; Patient

Erik Eriksons Psychosocial Development Theory

The patient 1. The

Havighursts Developmental Tasks

Late adulthood (65 Ego Integrity

vs The patient The patient has achieved

Magallanes, ang akong

DEFINITION OF COMPLETE DIAGNOSIS

Also called as posthepatic or cholestatic jaundice, occurs when bile flow is

Suppression of bile flow in canaliculi or small biliary ductiles

Pancreatic head mass malignant

A malignant neoplasm originating from transformed cells arising in tissues

Sands, Neighbor, Marek, Green

Date/time: August 23, 2014 @ 10:00am

Skin, Hair and Nails Assessment

Neck and Throat Assessment

No edema. Moves smoothly with no crepitus. No deviations noted. No pain or tenderness

Thorax and Lung Assessment

Heart and Peripheral Vasculature Assessment

ANATOMY AND PHYSIOLOGY

The risk of developing pancreatic