Republic of the Philippines

Cebu Normal University

College of Nursing
S.Y. 2016-2017

A CASE OF M.E.

Submitted by:
Alinsug, Dan Kyle
Bangquiao, Honey Sheen
Bano, Maureen Kate
Bargamento, Princess Aliza
Carilo, Fritz Gabriel
Compuesto, Kryztal Joyce
Handayan, Cheryl
Lasaca, Kristel Jane
Menor, Jessa Marie
Mula, Trystan Francis
Phua, Shawntel Tracy Hayes

Clinical Instructors:

Maam Ma. Mayla Imelda Lapa

Maam April Kyle Inabangan
Sir Francis Archangel Milloren

GROUP ONE BATCH 2018

NOVEMBER 2016

INTRODUCTION
 Cervical cancer is the second leading cause of cancer cases and deaths
among Filipino women because of inadequate access to screening and
treatment services. It occurs when abnormal cells on the cervix grow out of
control. Cervical cancer is caused by a virus called Human Papilloma Virus
(HPV). The virus spreads through sexual contact. Most women's bodies are
able to fight HPV infection. But sometimes, the virus leads to cancer due to
other environmental factors. Some factors that place any woman at high risk
are if that woman smokes, have had many children, used birth control pills
for a long time, have HIV infection, or multiple sex partners.

According to annual statistical report, as of 2015, the cervical cancer is

deemed as the second leading cancer cases and deaths among Filipino
women. Despite the establishment of Millennium development goals, which
includes aiming to improve maternal health, there is still considerably a high
number of women experiencing gynecologic diseases. This can be attributed
to a lot of factors including lack of access to screening and treatment
services, awareness. Even attitude plays a role. Filipinos are stubborn:
shrugging off subtle signs and symptoms and refusing to go to the hospital
until they experience severe signs and symptoms.

Cervical cancer is an abnormal and out of control growth of cells in the

cervix. This is cause by a virus called Human Papilloma Virus, which is
transmitted through sexual contact. Most women are actually able to fight
HPV infection; but some factors caused by lifestyle of environment aggravate
the existing infection, which leads to cervical cancer. Some of these factors
are smoking, long-term use of pills, grandmultiparity, HIV infection and
multiple sex partners. Genetic predisposition has also shown to be a
contributor but the recent cases revealed that most of cervical cancer cases
now are caused by lifestyle.

From the World Cancer Research Fund International, as of 2015, out of

all the cancer cases worldwide, 4% are diagnosed with cervical cancer, which
is approximately 528,000 people. The American Cancer Society has released
an estimated statistics for cervical cancer: 1) about 12,990 new cases of
invasive cervical cancer will be diagnosed. 2) About 4,120 women will die
from cervical cancer. According to the Philippine Council for Health Research
and Development, Approximately 12 Filipino women die of cervical cancer
every day. It is the second most common cancer among women in the
Philippines. About 6,000 women are diagnosed with the disease each year
and about 4,349 die of the disease annually. The figures are undeniably high
taking into account that, cervical cancer is preventable and curable in its
early stages. (De los Reyes, 2008).

This case was chosen among others as a form of validation of the

members acquired knowledge after almost 3 years in nursing school. It also
helped the group develop the necessary knowledge, skills needed in caring
for a cancer patient, which could be useful in caring for other terminally ill
patients in the future. Most importantly, it helped the members envision
themselves in the patients shoe, how it feels to be diagnosed with a disease
with extremely high morbidity. In short, studying this case helped the
members empathize more with the patient and inspired the members to give
care with knowledge and sincere compassion and truly live out the colleges
vision and mission

HISTORY AND ASSESSMENT

General Assessment

A case of M.E , female , 51 years old , married ,housewife , Roman Catholic ,

from Dumanjug ,Cebu , was referred by Barili hospital ,admitted at November
11 2016 around 9:35pm by ambulance at Vicente Sotto Medical center with a
complaints of right lower quadrant abdominal pain , (+) bloody vaginal
discharges , clubbing of nails noted , good skin turgor, generalized body
weakness noted ,lethargic ,lying on bed most of the time , with FBC attached
to urine bag , with oxygen via facemask @ 8-10L/min , with ISA at right
arm ,skin is warm to touch ,anicteric sclera , pale palpebral , clear breath
sounds, with palpable mass @ right lower quadrant , at first day patient was
able to respond to questions asked by the student nurse , on the 4 th day of
assessment the patient was unable to respond to questions , irritable ,4
times seizure attack, no urine output for 2 days , with receiving vital signs of
T-37.5C ,PR-95bpm,RR-28cpm ,BP-180/100mmHg, pain score of 4/10.

Patients History

On June 26 2016, patient was admitted to St. Vincent Hospital with chief
complaint of abdominal pain on right upper and lower quadrants, with pain
score of 10/10; patient stayed there for 8 days diagnosed with gastritis and
UTI. Further examination revealed 5 small myomas. M.E. chose surgical
method as treatment of choice: Total abdominal hysterectomy
salphingooophorectomy. Her doctor advised her to undergo chemotherapy,
which she refused due to financial constraints. On the first week of October,
patient was rushed to Tabunok Hospital with chief complaint of vomiting; she
stayed there for 5 days with the diagnosis of gastritis and UTI and pain score
of 10/10. After discharge, the pt.s vomiting reoccurred accompanied with
vaginal bleeding. She decided to seek health care at Barili Hospital and was
admitted for 7 days with the same diagnosis: UTI and gastritis. One day prior
to admission, M.E. went for scheduled follow up check-up with complaint of
persistent pain, thus, referred to Vicente Sotto Memorial Medical Center. She
was admitted to VSMMC last November 11, 2016 @9:35 PM with admitting
impression of 1) Cervical cancer stage 1B1 with tumor persistence 2) Anemia
secondary to malignancy.

M.E.s menarche was when she was 14 years old. Her usual periods
last for 3-4 days at moderate amounts. The patient had 5 sexual partners: 3
boyfriends and 2 husbands. Her first coitus happened way back when she
was 24 years old. No contraceptive used. Positive for pap smear test taken
may 16, 2016. Patient is the 7th of 10 children. She has history of
Hypertension on the paternal side of her family. Her first marriage resulted to
1 child; she didnt have any child on her second marriage.

The patient does not smoke, does not drink alcoholic beverages, does
not illegal drugs, is fully immunized and has maintenance drug for her
hypertension.

Central Nervous System

Patient is lethargic and weak, very irritable, not oriented to place and time
but oriented to person, weak grasps on left and right hands, presence of pain
on her Right lower quadrant, restless.

Cardiovascular System

Pulse rate is irregular and strong , present S1 and S2 heart sounds , blood
pressure taken while lying (180/100mmHg),warm upper and lower
extremities , clubbing of fingers noted ,negative Homans sign.

Respiratory System

Patient has symmetrical chest , with irregular shallow respiration ,absent

cough , normal breath sounds , with O2 via facemask 8-10L/min

Gastrointestinal System

Patient prescribed diet is low salt , low fat , vomiting (4 times) with greenish-
black color ,unable to feed self due to weakness , (+) bruise lips , last stool
output dated Monday (nov.14 2016) ,hard ,brownish color, distended
abdomen

Integumentary System

Pallor skin, warm temperature, intact skin integrity, good skin turgor, (-)
edema, (+) bruises on the lips

Urinary System
Patients last urine output dated November 14 2016(Monday) with yellow
color and moderate amount, on November 15 2016 FBC attached to urine
bag: no urine output for 2 days.

Musculoskeletal System

Patient was very dependent, needs assistance in doing ADLs, (+) seizure
attacks-4 times, normal gait, no assistance devices, normal posture and no
deformities

Reproductive System

Patient starts menarche at the age of 14 years old, with 3 days duration,
coitarche -24 years old, no contraceptives used, menopause at the age of 46
years old, no sexually transmitted disease, with positive vaginal bleeding

ANATOMY AND PHYSIOLOGY

The female reproductive system is designed to carry out several functions.

It produces the female egg cells necessary for reproduction, called the
ova or oocytes. The system is designed to transport the ova to the site
of fertilization.
Conception, the fertilization of an egg by a sperm, normally occurs in
the fallopian tubes.
The next step for the fertilized egg is to implant into the walls of the
uterus, beginning the initial stages of pregnancy. If fertilization and/or
implantation does not take place, the system is designed to
menstruate (the monthly shedding of the uterine lining).

Parts

External

-Labia minora & majora

-Bartholins glands

-Clitoris

Internal

-Vagina

-Uterus (Cervix & Corpus)

-Fallopian tubes
Anatomy and Physiology of the Cervix

The cervix is the lower, narrow part of a womens uterus, or womb. The
cervix connects the main body of the uterus to the vagina, or birth canal.

Structure

Ectocervix- part of the cervix that can be seen from inside the vagina
during a gynecologic examination.

Endocervix- is a tunnel through the cervix, from the external os into

the uterus.

The endocervical canal is the passageway from the uterus to the

vagina.

The 2 main types of cells in the cervix are:

Columnar cells line the endocervical canal. They are glandular cells
that make mucus. They are called columnar cells because they are tall
and shaped like columns.

Squamous cells line the ectocervix and vagina. They are flat and thin
like the scales on a fish.

Function

The function of the cervix is to allow flow of menstrual blood from the
uterus into the vagina, and direct the sperms into the uterus during
intercourse.

Cervix Conditions

Cervical cancer: Most cervical cancer is caused by infection by the human

papillomavirus (HPV). Regular Pap tests can prevent cervical cancer in
most women.

Cervical incompetence: Early opening, or dilation, of the cervix during

pregnancy that can lead to premature delivery. Previous procedures on
the cervix are often responsible.

Cervicitis: Inflammation of the cervix, usually caused by infection.

Chlamydia, gonorrhea, and herpes are some of the sexually transmitted
infections that can cause cervicitis.
 Cervical dysplasia: Abnormal cells in the cervix that can become cervical
cancer. Cervical dysplasia is frequently discovered on Pap test.

Cervical intraepithelial neoplasia (CIN): Another name for cervical

dysplasia.

Cervix polyps: Small growths on the part of the cervix where it connects
to the vagina. Polyps are painless and usually harmless, but they can
cause vaginal bleeding.

Pelvic inflammatory disease (PID): Infection of the cervix, known as

cervicitis, may spread into the uterus and fallopian tubes. Pelvic
inflammatory disease can damage a woman's reproductive organs and
make it more difficult for her to become pregnant.

Human papillomavirus (HPV) infection: Human papillomaviruses are

a group of viruses, including certain types that cause cervical cancer.
Less dangerous types of the virus cause genital and cervical warts.

ANATOMY AND PHYSIOLOGY OF THE KIDNEY

>The kidneys are part of the urinary system. There are 2 kidneys in the
body, one on either side of the spine under the lower ribs, deep inside the
upper part of the abdomen.

>The kidneys are bean-shaped organs. They are about 12 cm (45 in) long, 6
cm (23 in) wide and 3 cm (12 in) thick. A layer of fatty tissue holds the
kidneys in place against the muscle at the back of the abdomen.

FUNCTION

>The main function of the kidneys is to filter water, impurities and wastes
from the blood.

>The kidneys also act as endocrine glands. They make these hormones:

Erythropoietin stimulates the bone marrow to make RBCs.

Calcitrol, a form of Vitamin D, helps the colon absorb calcium from the
diet.
 Renin helps control blood sugar.

PARTS

Gerotas fascia is a thin, fibrous tissue on

the outside of the kidney. Below Gerotas
fascia is a layer of fat.

The renal capsule is a layer of fibrous

tissue that surrounds the body of the kidney,
inside the layer of fat.

The cortex is the tissue just under the renal

capsule.

The medulla is the inner part of the kidney.

The renal pelvis is a hollow area in the

centre of each kidney where urine collects.

The renal artery brings blood to the kidney.

The renal vein takes blood back to the body after it has passed through the
kidney.

The renal hilum is the area where the renal artery, renal vein and ureter
enter the kidney.

The nephrons are the millions of small tubes inside each kidney. Each
nephron has 2 parts. Tubules are tiny tubes that collect the waste materials
and chemicals from the blood moving through the kidney. The corpuscles
contain a clump of tiny blood vessels called glomeruli that filter the blood as
it moves through the kidney. The waste products are passed through the
tubules to the collecting ducts, which drain into the renal pelvis.
THE ANATOMY AND PHYSIOLOGY OF THE PERITONEAL CAVITY

The peritoneal cavity is a potential space between

the parietal and visceral peritoneum.

It contains only a thin film of peritoneal fluid,

which consists of water, electrolytes, leukocytes and
antibodies.

The fluid serves two main functions:

It acts as a lubricant, enabling free movement

of the abdominal viscera.

The antibodies fight infection.

Ordinarily, the peritoneal cavity is only of capillary

thinness; however, it is referred to as a potential
space because excess fluid can accumulate in the peritoneal cavity resulting
in the clinical condition of ascites.
LABORATORY STUDIES

Clinical Chemistry Report

November 11, 2016

Test Result Reference Interpretation

Uric Acid 16.8 mg/dL 3.0 8.0 mg/dL Increase cell
death due to
cancer
SGPT 17 U/L 5.0 50 U/L Within normal
limits
Magnesium 2.2 mg/dL 1.2 2.2 mg/dL Within normal
limits

November 12, 2016 @ 4:11 AM

Test Result Reference Interpretation

Urea 130.92 mg/dL 7.00 18.68 Indicates kidney
mg/dL dysfunction
Creatinine 22.11 mg/dL 0.6 1.1 mg/dL Indicates kindey
dysfunction
SGOT 37.79 U/L 0.0 31.0

November 12, 2016 @ 2:48 PM

Test Result Reference Interpretation

Urea 131.68 mg/dL 7.00 18.68 Indicate kidney
mg/dL dysfunction
Creatinine 23.77 mg/dL 0.6 1.1 mg/dL Indicates kidney
dysfunction
SGOT 19.10 U/L 0.0 31.0 Within normal
limits

Hematology

November 12, 2016

Complete Blood Result Reference Interpretation
Count
WBC Count 13.99 x 10^9/L 4.5 11.0 x This can result
10^9/L from bacterial
infection and
inflammation
Hemoglobin 93.0 g/L 120.0 150.0 g/L This can result
from blood loss;
anemia
Hematocrit 0.28 L/L 0.37 0.47 L/L This can result
from anemia,
bleeding,
destruction RBC,
malnutrition, too
little iron, vitamin
B12, and vitamin
B6 in diet, and
too much water
in the body
MCV 84.2 fL 81.0 99.0 fL Within normal
limits
MCH 28.2 pg 27 31 pg Within normal
limits
RBC Count 3.30 x 10^12/L 4.0 5.2 x This can result
10^12/L from RBC
destruction,
sudden bleeding,
kidney failure,
nutritional
deficiency, and
chronic
inflammatory
disease such as
cancer
MCHC 33.5 g/L 32 36 g/L Within normal
limits
RDW 12.8 11.6 14.6 Within normal
limits
MPV 9.2 fL 7.2 11 fL Within normal
limits
Platelet Count 346 x 10^9/L 150 400 x Within normal
10^9/L limits
Differential Count Result Reference Interpretation
Neutrophils 87.6 % 40 74 % This can result
from acute
infection and
acute stress
Lymphocytes 7.4 % 19 48 % Indicates low
infection
resistance and
susceptible to
infections like
tumors and
cancers, can also
lead to damage
of various body
organs
Monocytes 3.6 % 39% Within normal
limits
Eosinophils 1.0 % 07% Within normal
limits
Basophils 0.4 % 02% Within normal
limits

November 14, 2016 @ 8:14 PM

Electrolytes-Stat Result Reference Interpretation

Test
Sodium 126.5 mmol/L 135-148 mmol/L Due to conditions
such as vomiting,
excessive
sweating, and
decreased
sodium intake
Potassium 5.28 mmol/L 3.50- 5.30 Within normal
mmol/L limits
Chloride 97.9 mmol/L 98- 107 mmol/L Due to
dehydration,
excessive
sweating,
vomiting,
 respiratory
acidosis which
happens when
your lungs cant
remove enough
carbon dioxide
out of your body
Ionized Calcium 1.03 mmol/L 1.13- 1.32 Indicates kidney
mmol/L failure and
malnutrition

November 15, 2016

Arterial Blood Gas

Result Reference Interpretation

Temperature 36.7 C Within normal
limits
pH 7.391 7.35 7.45 Within normal
limits
PCO2 21.3 mmHg 35 45 Indicates
hyperventilation,
hypoxia, and
anxiety
P02 67 mmHg 80 105 Indicates
decreased
oxygen levels in
the body,
hypoventilation,
anemia, heart
decompensation
BEef -12.21 mmol/L -3 - -2 mmol/L Indicates lactic
acidosis,
ketoacidosis,
ingestion of
acids, and
possibility of
shock
HCO3 13.0 mmol/L 22 26 mmol/L Indicates
 metabolic
acidosis,
respiratory
alkalosis, shock
SPO2 93.7 % 95 98 % Indicates
hypoxemia
ULTRASOUND REPORT

May 26,2016

IMPRESSION:

Cervical mass consistent with malignancy

Thin endometrium
Multiple small myoma uteri, intramural
Left adnexal mass consider a hydro salpinx
Atrophic left ovary

November 16, 2016

ULTRASOUND WHOLE ABDOMEN

CONCLUSION:

Ascites
Upper limits of normal size kidneys associated with bilateral mild
hydronephrosis and proximal hydroureters
Normal sonographic evaluation of the liver (14.2 cm), gallbladder (7.3
x 3.0 cm; wall thickness 0.1 cm), pancreas (7.3 x 2.8 cm) and spleen
Unfilled urinary bladder with Foley catheter balloon
Incidental note of pleural effusion, right lung
June 2, 2016

IMPRESSION:

Lobulated heterogeneously enhancing cervical mass, as described.

Myoma uteri
Bilateral enlarged iliac lymph nodes likely metastatic
 Atherosclerotic vessel disease

Surgical Pathology Report

Breast Ultrasound

June 1, 2016

IMPRESSION:

BI- RADS CATEGORY 1- NEGATIVE

No mammographic evidence of malignancy
Recommend 1 year follow-up
SURGICAL MANAGEMENT

IDEAL and ACTUAL:

Total Abdominal Hysterectomy and Bilateral Salpingo-Oopherectomy is

the removal of the uterus including the cervix as well as the tubes and
ovaries using an incision in the abdomen. A hysterectomy is the surgical
removal of the uterus .It may be a total removal, as removing the body and
cervix of the uterus or partial, also called supra-cervical. Salphingo refers
specifically to the fallopian tubes, which connect the ovaries to the uterus.
Oophorectomy is the surgical removal of an ovary or ovaries.

Hysterectomy is often performed on cancer patients or to relieve

severe pelvic pain from endometriosis or adenomyosis. It is also used as a
last resort for postpartum obstetrical hemorrhage uterine fibroids that cause
heavy or unusual bleeding.

The main goal of TAHBSO is to remove benign diseases, to decrease

risk of development of ovarian pathology, and decreases the need for future
procedures.

ADVANTAGES AND DISADVANTAGES:

Hysterectomy has been found to be associated with increased bladder

function problems, such as incontinence.

When the ovaries are also removed, estrogen levels will fall. This
removes the protective effects of estrogen on the cardiovascular and
skeletal system.

A menopausal woman has a three times greater risk of developing

cardiovascular disease such as atherosclerosis, peripheral artery
disease or of having a heart attack when compared to premenopausal
women
TECHNIQUE:

1. A lower midline incision is made vertically (up and down) in the skin with a
No. 10 scalpel.

2. Dissection is done through the subcutaneous tissue with Bovie cautery.

3. The midline between the rectus muscles is appreciated and the fascia is
incised.

4. Some clinicians performing a total abdominal hysterectomy may elect to

use a transverse skin incision called a Pfannenstiel incision placed just above
the symphysis pubis (pubic bone).

Pfannensteil incision in suprapubic area

5. In the transverse incision approach in total abdominal hysterectomy the

subcutaneous tissue is dissected with Bovie cautery

6. Skin flaps are raised superiorly toward the skin to allow exposure of the
midline of the rectus muscles.

7. Occasionally in large patients receiving total abdominal hysterectomy,

the rectus muscles are cut to afford better exposure

8. After the midline fascia is dissected or the rectus muscles are cut, the
peritoneum is appreciated and grasped with forceps on either side of the
midline (never with hemostats to avoid trapping bowel inadvertently).

9. If possible, the uterus is grasped and pulled out of the incision and
superiorly toward the umbilicus (belly button) to expose the anterior uterine
surface.

10. The peritoneum at the cervicovesical fold is incised transversely (side-to-

side) close to where it attaches to the uterus.

11. Blunt finger dissection is used in total abdominal hysterectomy to

appreciate the avascular (without blood vessels) plane in the posterior leaf of
the broad ligament.

12. This is performed until the round ligament and fallopian tubes are
appreciated.
13. The round ligament on each side is then controlled by placing an Ochsner
clamp on it and dividing it after a mattress 0 absorbable suture has been
placed on the right and left round ligaments to ligate the ovarian vessels.

14. The clamps are then removed on either side of the fundus of the uterus.

15. The gynecologist palpates the cervix with two fingers to gain an
appreciation of the position of the bladder.

16. The bladder is then bluntly dissected off the uterus with a gauze-covered
finger caudally (towards the feet).

17. Care must be taken when doing a total abdominal hysterectomy to keep
the blunt dissection in the midline to avoid inadvertently tearing the vessels
in the broad ligament.

18. The dissection is carried downward until the vaginal wall can be
compressed between the gynecologists fingers.

19. The uterus is the pulled forward and the posterior surface is visualized to
insure that it is not adherent to the rectum.

20. The uterus is grasped with a tenaculum and rotated slightly to one side
to expose the uterine vessels.

21. Two Ochsner clamps are then placed at 45 degrees to the uterus and slid
down onto the uterine vessels.

22. The uterine vessels are incised with a Metzenbaum scissors and the
vascular pedicle doubly ligated with silk suture.

23. The similar procedure to ligate the uterine vessels is performed on the
opposite side.

24. Teale forceps are applied to the cervical tissue at the level of the vagina.

25. The posterior cervical peritoneum is incised and gently bluntly

downward.

26. The incision is carried circumferentially around the cervix.

27. The uterus is held forward the posterior vaginal wall is incised using
curved scissors.

28. The anterior and posterior walls of the cut vagina are grasped by Teale
forceps.
29. The lateral edges of the cut vagina are sutured together with figure of
eight absorbable zero sutures.

30. The rest of the vaginal opening is then closed with additional figure of
eight absorbable zero sutures.

31. The reapproximated vagina is the released from the Teale forceps to
visualize any bleeding points.

32. The peritoneum is then closed with a running absorbable suture (general
surgeons almost never close the peritoneum after abdominal surgery)

33. Fascia is reapproximated using either a running or interrupted large

suture.

34. Subcutaneous tissue may be closed using absorbable 2-0 or 3-0 suture.

35. The skin is closed using staples or sutures to complete the total
abdominal hysterectomy.

COMPLICATIONS:

Early:

Heavy blood loss requiring blood transfusion

Bowel injury
Bladder injury
Blood clot in lung
Anesthesia problems (such as breathing or heart problems)
Need to change to abdominal incision during surgery
Wound pulling open (dehiscence)
Collection of blood (hematoma) at the surgery site needing surgical
drainage

Late:

Difficulty urinating. This is more common after removal of lymph

nodes, ovaries, and structures that support the uterus (radical
hysterectomy).
 Weakness of the pelvic muscles and ligaments that support the vagina,
bladder, and rectum. Kegel exercises may help strengthen the pelvic
muscles and ligaments. But some women need other treatments,
including additional surgery.

Continued heavy bleeding. Some vaginal bleeding within 4 to 6 weeks

following a hysterectomy is expected. But call your doctor if bleeding
continues to be heavy.

Some women may experience early menopause.

The formation of scar tissue (adhesions) in the pelvic area.

SURGICAL MANAGEMENT

INTRAJUGULAR CATHETER

IDEAL:

Central venous access allows the placement of various types of

intravenous (IV) lines to facilitate the infusion of fluids, blood products, and
drugs and to obtain blood for laboratory analysis. It is also an essential
procedure in patients in whom placement of a line in a peripheral vein is
impossible. A central line may be the only means of venous access in such
cases.
 The jugular veins are reliable access sites for temporary and
permanent venous cannulation to support hemodynamic monitoring, fluid
and medication administration, and parenteral nutrition. Jugular venous
access can also be used for the placement of inferior vena cava filters and
other venous devices.

Internal jugular venous access is commonly used in situations that

require reliable tip positioning for immediate use, such as drug
administration or transvenous pacing. The jugular veins are one of the most
popular sites for central venous access due to accessibility and overall low
complication rates, and are the preferred site for temporary hemodialysis.

ADVANTAGES AND DISADVANTAGES:

Central venous catheterization via the internal jugular vein has a lower
incidence of pneumothorax compared to catheterization via the subclavian
vein, and it can be easily compressed after catheter removal or after
unintentional arterial puncture. Ultrasound can be a valuable adjunct for IJV
cannulation, because the incidence of anatomical variants may be as high as
8.5%. Subclavian vein catheterization is more comfortable for awake patients
and less prone to contamination from respiratory secretions, particularly in
patients with tracheotomies.

TECHNIQUE:

Infiltrate local anesthetic all around the site, working down toward the
vein.
 Flush each port of the central line with saline or heparin saline, and
close off each line except the distal (usually brown) line; the wire
threads through this line.

Attach a syringe to the large needle provided, and then proceed as

follows:
right femoral line: find the arterial pulse and enter the skin 1 cm
medial to this, at a 45 angle to the vertical and heading parallel to the
artery. Advance slowly, aspirating all the time, until you enter the vein

right jugular line: palpate the carotid artery with your left hand,
covering the artery with your fingers. Insert the needle 0.51 cm
laterally to the artery, aiming at a 45angle to the vertical. When the
needle is in the vein, ensure that you can reliably aspirate blood.
Remove the syringe, keeping the needle very still.

Insert the central line over the wire. When the central line is 2 cm away
from the skin, slowly withdraw the wire back through the central line
until the wire tip appears from the line port. Hold the wire here while
you insert the line. Leave a few centimeters of the line outside the
skin. Withdraw the wire and immediately clip off the remaining port.

Attach the line to the skin with sutures. Tie loosely so as not to pinch
the skin; this causes necrosis and detachment of the line. Clean the
skin around the line once more, dry, and cover with occlusive
dressings.

Ensure that you can aspirate blood from each lumen of the line, then
flush each lumen with saline or heparin saline.

Order a chest x-ray to check for line position and pneumothorax if a

jugular or subclavian line has been inserted. Femoral lines do not
require an x-ray.
COMPLICATIONS:

Early:

Failure to place the catheter

Arterial puncture
Catheter malposition

Late:

Pneumothorax
Subcutaneous hematoma
Hemothorax
Asystolic cardiac arrest
DISCHARGE PLANNING

Clients Initials: M.E.

Diagnosis: 1) Cervical cancer stage 3 with persistent tumor 2) Anemia
secondary to malignancy
Destination: Dumanjug, Cebu
Transportation: ambulatory

Medications: Instruct patient to comply with the following take home

medications:
Neobloc 100 mg 1 tab PO OD for
Multivitamins + Ferrous Sulfate 1 tab PO BID

Exercise:
>Instructed patient to provide a peaceful relaxing, comfortable and
well-ventilated room.
>Instructed patient to provide a stress free environment.
>Instructed patient to follow the prescribed meal plan.
>Instructed to provide clean environment to prevent lodging of
infectious microorganisms

Treatment: Dialysis twice a week to cleanse the blood because the

kidneys function is severely impaired
Chemotherapy and radiation to kill cancer cells and stop it from
metastasizing from other parts of the body.
Encourage patient to take supplemental drinks, which are ideal
for increasing protein and carbohydrate without increasing volume of foods
to eat
Emphasize importance of coming to scheduled follow up
checkups

Health Education: To attain the best possible rehabilitation, the patient and
significant others must cooperate. Thus, its important to teach the following:
>Role of nutrition in the recovery process
>Types of food to eat, especially the ones that show promising results
against cancer cells based on researches
>Importance and types of exercise to maintain muscle strength and
mass
>Patient is counseled regarding importance of eating meals on time
and in a relaxed
setting.
>Instructed patient to avoid any strenuous or heavy activities.

Observable signs and symptoms: Instruct M.E. to look out for the
following signs and symptoms and immediately seek the help of a health
care professional
 >vaginal bleeding or discharges
>persistent abdominal pain
>vomiting (excluding side effect of chemotherapy)
>unable to void
>lethargy
>seizures
>increased BP
>Dyspareunia

Dietary Prescription: Recommend the following nutrient-dense foods to

maintain ideal body weight:
>Foods that are high in carbohydrate (starchy fruits and vegetables),
high in protein (soya milk, egg white, etc.), rich in vitamins and minerals
(green, leafy vegetables and fruits)
>Fruits and vegetables that are proven to fight cancer cells according
to research such as malunggay, guyabano, mangosteen, etc.

Spirituality: M.E. is Roman Catholic; advise pt. to join a healing mass if she
can tolerate. Encourage to express anger, grief, or thoughts about present
condition to God as an emotional outlet. Also encourage the S.O. to pray for
the patients recovery and make an effort to spend quality time with M.E.
regularly
PROGNOSIS
The patient is already on cervical cancer, stage 3 and has started
exhibiting signs of metastasis. Proposed IJ catheter insertion for hemodialysis
as palliative care was declined as well as suggested chemotherapy due to
financial problems. Her kidneys are severely impaired and quick examination
of the pt. will certainly not yield good results. Thus, the patient will inevitably
expire.