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A Case Study on Rectal Adenocarcinoma

I. INTRODUCTION

Rectal cancer may be of the adenocarcinoma type and usually arise from the
epithelium (the layer of cells) which lines the large intestine. The colon is part of the
large bowel. The large bowel starts at the end of the small bowel (the ileum), at the
caecum. The caecum has the appendix running off it. The start of the colon is the
ascending colon and where this rises to meet the liver (the hepatic flexure) it becomes
the transverse colon. The transverse colon goes across the upper abdomen until it
becomes adjacent to the spleen (the splenic flexure) and at this point it becomes the
descending colon. The large bowel at this point goes down the abdomen to the pelvis at
which point it becomes the sigmoid colon (because it curves in an "S" shape, sigma
being the Greek for "S"). The sigmoid colon terminates at the rectum, which acts as a
storage pouch for feces before it is evacuated through the anus.

Overall, the function of the large bowel is to absorb water from stools. When the
ileum enters its contents into the caecum, they are extremely liquid and gradually
solidify as the contents progress around the large bowel.

Rectal cancer is common but occurs very rarely in young adults. Rectal cancer
becomes more common as age increases. People in their 50s, 60s and 70s are most at
risk with sex incidence being slightly more common in females. Geographically, the
rectal cancer tumor is found worldwide, but rectal cancer is most common in areas

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A Case Study on Rectal Adenocarcinoma

which have low fiber diets. Areas of the world with high fat consumption and low fiber
consumption such as Europe, USA and Australia.
Furthermore, in the Philippines, 75% of all cancers occur after age 50 years, and
only about 3% occur at age 14 years and below. If the current low cancer prevention
consciousness persists, it is estimated that for every 1800 Filipinos, one will develop
cancer annually. At present, most Filipino cancer patients seek medical advice only
when symptomatic or at advanced stages: for every two new cancer cases diagnosed
annually, one will die within the year. It is estimated that 3050% of cancer patients in
all stages of the disease will experience pain and 7095% with advanced disease will
have significant pain, but only a fraction of these patients receive adequate treatment. In
a study on cancer pain among Filipino patients, 73% had pain related to their disease,
60% of which was persistent (43).

Causative Factors:

Hereditary Conditions: At particularly high risk of Rectal cancer are people with
hereditary conditions such as Familial Adenomatous Polyposis or Hereditary Non
Polyposis Colorectal Cancer. In these conditions, it can occur even in young
adults, e.g. late teens and early 20s.
Family History of Rectal Cancer: First degree relatives of patients with rectal
cancer have an increased risk, particularly if the relative develops rectal cancer
at a young age.
Polyps: Certain types of polyps, notably villous adenomas have a potential to
become malignant. Rectal cancer patients who have previously had a polyp in
the large bowel should undergo regular colonoscopy (ask your doctor how often).
Inflammatory Bowel Disease: Patients who suffer from ulcerative colitis, have
approximately a tenfold risk of developing the disease and should have a
colonoscopy carried out regularly.
Diet: A high fat, low fibre diet, especially if high in red meat, is the worst diet that
predisposes people to rectal cancer. People who suffer from obesity are also at
an increased risk.

The rectal cancer tumor spreads by invading the bowel wall. Once it crosses through
the muscle layer within the bowel wall, it enters the lymphatic vessels, spreading to local
and then regional lymph nodes. Sometimes rectal cancer spread via the blood stream to
the liver, which is the most common area of metastasis from this tumour. Other organs
that may be affected by blood borne spread are the lungs, less often the bones, and
even less often the brain. If a lot of tumor cells get through the bowel wall, they tend to
float around as a small amount of fluid within the abdomen and can seed the covering of

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A Case Study on Rectal Adenocarcinoma

the bowel (peritoneum). This type of seeding produces small nodules throughout the
abdomen which irritates tissues and causes the production of large amounts of ascites
(fluid). Direct spread from the rectum may attach the tumor to the bladder in males and
cause fistulas. In females it may invade the vagina or adjacent pelvic organs.

Virtually all adenocarcinomas develop from adenomas. In general, the bigger the
adenoma, the more likely it is to become cancerous. For example, polyps larger than
two centimeters (about the diameter of a nickel) have a 30-50 percent chance of being
cancerous. You can learn more about polyp size and colon cancer risk by viewing the
Polyp Size Gallery.

By the time colorectal cancer is diagnosed, it has often been growing for several
years, first as a non-cancerous polyp (adenoma) and later as cancer. Research
indicates that by age 50, one in four people has polyps.

General investigations into rectal cancer may show anaemia or an abnormal liver
function test. The blood albumin level may be low (Albumin is produced mainly in the
liver. It helps to keep the blood from leaking out of blood vessels. When albumin levels
drop, fluid may collect in the ankles, lungs, or abdomen). If liver involvement is severe
the clotting profile will be abnormal with a raised INR.

The rectal cancer symptoms that may require attention are fatigue from anaemia
and the feeling of tenesmus (wanting to open the bowels when there is no stool there
can be particularly distressing, especially when it is painful). Rectal cancer patients may
require treatment for visceral pain from liver metastases and less commonly for somatic
pain from bone metastases. If lung metastases are present there may be pleural
effusions causing breathlessness. Effusions may require drainage.

The scope and limitation of this case study was only during the hospitalization of the
patient right after his surgery, which was during our first week of duty on September 17-
18, 2010. We then gather the necessary information for this case study possible.

Furthermore, the group decided to choose this case to be presented in our clinical
instructor for this is new and interesting problem, as far as we were exposed to the
clinical area. In addition to that, our kind clinical instructor also suggests having this as
our case.

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A Case Study on Rectal Adenocarcinoma

II. GOALS AND OBJECTIVES

General Objectives:
To provide the students a guide line in caring for people with Rectal
Adenocarcinoma using the nursing process appropriately and effectively. To give
information on the readers about the nature and the extent of well differentiated
adenocarcinoma rectum disease. Lastly, to provide the general public of the new
developments in nursing care in regards of treating the disease condition.

Specific Objectives:
At the end of this study, we, the student nurses of this institution, will able to:
1. Define and identify the probable causative factors of adenocarcinoma
rectum
2. Trace the anatomy and physiology.
3. Assess the nursing history of the patient.
4. Identify the signs and symptoms of the underlying disease.
5. Formulate the nursing care plan, to achieve the maximum wellness of the
patients well as awareness on the part of the significant others.
6. To provide health teaching to the patient and significant others to improved
the former condition and prevents complication.

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A Case Study on Rectal Adenocarcinoma

III. CLIENTS PROFILE

A. Socio-demographic data
Patient X is a 26 year old male, Roman Catholic; a resident of Damilag,
Manolo Fortich, Bukidnon. Patient X worked at Del Monte Philippines as a
harvester. Patient X was admitted for the first time at Northern Mindanao
Medical Center last August 22, 2010 at 10am due to rectal pain and
weakness. He arrived at the hospital awake conscious and coherent, but
irritable.

B. Vital Signs
The patients vital signs are essential because it provides a baseline data
in determining alteration in the patient's body that may suggest underlying
disease. Any changes from the normal are considered to be an indication of
the person's state of health and provide clues to physiological functioning of
the client.
The patient had the following vital signs: Blood pressure: 130/90mmHg,
pulse rate: 110 bpm, respiratory rate: 28cpm, temperature:38.3 degrees
Celsius .He currently weighs 48 kilograms and stands 55.

C. Health Pattern Assessment


1. History of Present Illness
The client was brought to the hospital due to pain at the rectum and
weakness.
Five months prior to admission, patient noted pain during
defecation associated with some bleeding and changes in the character of
stool. Patient tolerated condition until one month prior to admission patient
sought consultation and was admitted at the hospital and had undergone
anoscopy with biopsy and was then diagnosed well differentiated rectal
adenocarcinoma. He was advised to undergone surgery. Patient then had
undergone Abdomino-perineal subsection surgery (Miles procedure) last
September 14, 2010, Tuesday at 8am.
Patient X has no previous hospitalization and surgeries. Patient is
taking Amoxicillin 500mg for three times as an antibiotic and Mefenamic
acid 500mg for three times a day to relieve pain and is eating vegetables
and some fruits and have enough rest to manage his health condition. He

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A Case Study on Rectal Adenocarcinoma

is a tobacco user for 13 years and can consume 10 sticks of cigarette per
day. He is also an alcoholic drinker for 13 years and can consume 5
bottles of drinking beverages twice a day. Patient X also drinks
coffee/cola/tea for 15 years and can consume 8 bottles twice a day.
Patient X also had taken recreational drugs such as marijuana for
sometimes. He has no known food and drug allergies. Patient X appears
to be weak and irritable.

2. Nutrition
During pre -hospitalization, the client is used to eat spicy foods as
well as fruits and vegetable. He drinks five liters of water a day.
During hospitalization, Patient X was on a general liquid diet, he
consumed 1/2 of share with fair appetite. The client seldom drinks water
amounting to 680 ml for 8 hours and was taking Enervon C 500mg once
daily as a vitamin supplement. He was hooked with 1 liter D5LR regulated
at 30gtts/min. Patient X has Jackson Pratt drainage and with colostomy
bag attached.

3. Elimination Pattern
Pre-hospitalization, Patient X defecates 2 times daily with formed
brown stool and soft in consistency until patient felt discomfort during
defecation, he has hemorrhoids hence patient sought medical advice, but
during hospitalization after the surgery patient has a colostomy bag
attached.
Pre-hospitalization, Patient X urinates five times a day with yellow
colored urine with no problem in control but during hospitalization after the
surgery patient has a distended bladder thats why he was catheterized
with a straight catheter with a urine output of 200 ml for 8 hours.

4. Activity Exercise Pattern (pre -hospitalization)


Patient X is incorporating his exercise in his leisure activities like
playing basketball.

A. Activity -Exercise Pattern (while confined)


Describe the patient's functional abilities

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A Case Study on Rectal Adenocarcinoma

a. Feeding: total independence


b. Bathing: assist with person
c. Toileting: assist with device
d. Bed mobility: assist with person
e. Dressing: assist with person
f. Grooming: total independence
g. General mobility: dependent
h. ROM: limited
I. Ambulation: assist with person

The patient can't do all the activity exercise because of his


condition. Toileting is done at the bedside for the patient has a colostomy
bag attached to him and a straight catheter to drain urine.

5. Cognitive-Perceptual Pattern
Patient X understands and speaks Visayan language without
speech deficit. Patient X finished his secondary education at St. Jude
Academy but failed to pursue to college due to financial constraint. He has
no learning difficulties and change in memory. Patient has a pain felt in his
rectum, pre- hospitalization. Post-operatively Patient X has a pain felt at
the right lower quadrant area of the abdomen (where colostomy bag is
placed) with a pain scale of 8/10 lasting for 30 minutes from the onset
during passage of fecal material and upon movement. He is taking his
pain medication (tramadol) to relieve such pain.

6. Sleep -Rest Pattern


Pre-Hospitalization, Patient X usually sleeps for 8-10 hours without
any sleep disturbances but while confined, he verbalized that he has a
problem in sleeping at night. Listening to music in his cell phone is an
effective tool for him to sleep at night

7. Self-perception and Self-concept Pattern


Patient X said that he is always tired. He feels that he is weak and
is not happy in his condition for he cannot do the usual things he used to
do before.

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A Case Study on Rectal Adenocarcinoma

8. Role -Relationship Pattern


His family specifically his brothers and sisters are the people who
helped him during hospitalization since Patient X is still single. His family
felt very sad regarding his condition and pitied him a lot. Although they
cannot always visit at the hospital due to distance and financial problems
as well but they see to it that patient was well provided either physically
and/or emotionally. Patient X has a history Diabetes Mellitus on his father
side.

9. Coping-stress tolerance Pattern


Patient X seldom experience stress but whenever he has he
subject his self in sleeping and watching T.V for relaxation but during
hospitalization Patient X experiences stress because of his condition and
find sleeping as a way of coping with it.

10. Value Belief pattern


Patient X is a Roman Catholic. To him it is important as it had
helped him when he has a problem. He seldom goes to church but he
prays to God as part of his religious practices

D. Physical Assessment
1. Neurologic Assessment

Level of consciousness Conscious

Orientation Oriented

Emotional state Worried/anxious (sometimes)

2. Head

Head Normocephalic

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A Case Study on Rectal Adenocarcinoma

Facial movement Symmetrical

Fontanels Closed

Hair Fine

Scalp Clean

3. Eyes

Lids Symmetrical

Periorbital region Non edematous

Conjunctiva pink

Cornea & lens Opacity R/L

Sclera Anicteric

Pupils Equal in size

Reaction to light Brisk R/L

Reaction to accommodation Uniform to constriction

Visual acuity Grossly normal

Peripheral vision Intact/full

4. Ears

External pinnae Normoset

External canal No discharge

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A Case Study on Rectal Adenocarcinoma

Tympanic membrane Intact

Gross hearing normal

5. Nose

Mucosa Pinkish

Patency Both patent

Gross smell Normal/symmetrical

Sinuses No tenderness presence

6. Mouth

Lips Pallor

Mucosa Pinkish

Tongue Midline

Teeth Missing Teeth

Gums pinkish

7. Pharynx

Uvula Midline

Tonsils Not inflamed

Posterior pharynx No inflammation is present

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8. Neck

Trachea Midline

Thyroids non-palpable

9. Skin

General color Pallor

Texture Rough

Turgor Firm

Tempareture warm

10. Abdomen

General Presence of colostomy bag

Configuration Symmetrical

Bowel sound Hypoactive (3 clicks)

Percussion Tympanitic

11. Cardiovascular Status

Precordial area Flat

Point of maximal impulse(PMI) 5th intercostal

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A Case Study on Rectal Adenocarcinoma

Apical & rhythm Tachycardia (110bpm)

Heart sound Regular

Peripheral pulse Symmetrical & regular

Capillary refill 3 seconds

12. Respiratory Status

Breathing pattern Tachypnea (28cpm)

Shape of chest AP2:L1

Lung expasion Symmetrical

Percussion Resonant

Breath sound Vesicular

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IV. ANATOMY AND PHYSIOLOGY

The colon is made up of 6 parts all working collectively for a single purpose.
Their purpose is ridding the body of toxins that have entered the body from food
sources, environmental poisons, or toxins produced within the body. The colons role is
to transfer nutrients into the bloodstream through the absorbent walls of the large
intestine while pushing waste out of the body. In this process, digestive enzymes are
released, water is absorbed by the stool, and a host of muscle groups and beneficial
microorganisms work to maintain the digestive system.

Overview of the Colons Anatomy

The colon is approximately 4.5 feet long, 2.5 inches wide, and is a muscular tube
composed of lymphatic tissue, blood vessels, connective tissue, and specialized
muscles for carrying out the tasks of water absorption and waste removal. The tough
outer covering of the colon protects the inner layer of the colon with circular muscles for

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propelling waste out of the body in an action called peristalsis. Under the outer muscular
layer is a sub-mucous coat containing the lymphatic tissue, blood vessels, and
connective tissue. The innermost lining is highly moist and sensitive, and contains the
villi- or tiny structures providing blood to the colon.

The colon is actually just another name for the large intestine. The shorter of the
two intestinal groups, the large intestine, consists of parts with various responsibilities.
The names of these parts are: the transverse colon, ascending colon, appendix,
descending colon, sigmoid colon, and the rectum and anus.

Parts of the Colon:

Transverse, Ascending, and Descending Colons

The transverse, ascending, and descending colons are named for their physical
locations within the digestive tract, and corresponding to the direction food takes as it
encounters those sections. Within these parts of the colon, contractions from smooth
muscle groups work food material back and forth to move waste through the colon and
eventually, out of the body. The intestinal walls secrete alkaline mucus for lubricating
the colon walls to ensure continued movement of the waste.

The ascending colon travels up along the right side of the body. Due to waste
being forced upwards, the muscular contractions working against gravity are essential
to keep the system running smoothly. The next section of the colon is termed the
transverse colon due to it running across the body horizontally. Then, the descending
colon turns downward and becomes the sigmoid colon, followed by the rectum and
anus.

Ileocecal and Cecum Valves

The ileocecal valve is located where the small and large intestines meet. This
valve is an opening between the small intestine and large intestine allowing contents to
be transferred to the colon. The cecum follows this valve and is an opening to the large
intestine.

The Rectum and the Anus

The rectum is essentially a storage place for waste and is the final stop before
elimination occurs. The "tone" of the muscles of the anal sphincter and a persons ability
to control this skeletal-muscular system are vital for regulating bowel movement urges.
When elastic receptors within the rectum are stimulated, these nerves signal that

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defecation needs to occur. In other words, these muscle and nerve groups convey when
a bowel movement is necessary but allow a person to control when waste will actually
be removed, as the final step in the digestive process. The anus is the last portion of the
colon, and is a specialized opening bound with elastic membranes, sensitive tissues,
and muscles and nerves allowing it to stretch for removing bowel movements of varying
sizes. If, for example, you suffer from constipation, these tissues can become damaged
and lose their ability to function normally if waste has to be forced out or remains in the
body for prolonged periods. So its definitely good practice to keep things moving along
at a regular pace. Ideally, you should have two bowel movements per day but at least
once a day is pretty good; anything less than that could spell trouble for not only your
digestive health but general health as well.

Physiology of the Colon

To summarize, approximately 500 ml (milliliters) of food pass through the colon


daily. The various sections of the digestive tract absorb and remove water, propel waste
throughout the long system of muscular tubes, work to keep the body alkalized, and
accommodate the colonization of billions of beneficial microorganisms to aid us in
breaking down waste matter. Regardless of the depth of your knowledge regarding the
colons functions, please realize the importance of its functions for promoting overall
health. Be good to your body on the inside as well as out by following a healthful diet,
drinking ample of water, and keeping all your biological systems well maintained with
stimulating exercise and by getting plenty of rest.

The Colon and Rectum

The colon and rectum perform vital functions in the last phases of digestion.
Digestion first begins in the mouth where food is chewed into smaller pieces and
swallowed. The food travels down the esophagus to the stomach where it is further
broken down by gastric juices and sent to the small intestine. The small intestine
continues to break down the contents in addition to absorbing most of the nutrients,
including carbohydrates, proteins and vitamins. Once the contents have passed through
the small intestine, the material has become mostly liquid and is moved into the colon,
which measures about 5 feet long. The main function of the colon is to absorb water
and dehydrate the leftover material, forming semi-solid matter, or stool. The colon
moves the stool into the approximately 6-inch long rectum, which acts as a holding
chamber, until it is ready to be expelled through the anus.

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V. PATHOPHYSIOLOGY

Predisposing Factors:
Precipitating Factors: LEGEND:
Smoking for 13 years
Predisposing Factors
Alcohol consumption for Presence of non-
13 years malignant mass Precipitating Factors
Sedentary lifestyle Changes in the bowel
Internal hemorrhoids habit Disease Process
Treatment (either through
medication or surgery)
Alteration in the normal cell
Diagnostic Examination

Surgery effects

Signs and symptoms


Mutation in DNA mismatches repair genes Proto-oncogens transforms to oncogenes
Bodys Compensatory Mechanism

Negatively affects the DNA repair Tumor suppressor genes is turned off inactivation of the adenomatous
Polyposis coli gene

Proliferation of affected cell Quick abnormal cell growth and division Allows unchecked cellular
replication at the crypt surface

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Inability to control proliferation DNA repair genes is inactivated Increased cell division causing further mutations
of affected cells

Increases survival and proliferation of cancer cells Activation of the k-ras oncogene

P53 mutations which prevent apoptosis


Spreads out from the colon

Prolong lifespan of affected cells

Continuous replication of affected cells

Increases number of malignant cells

Invades the epithelium of the bowel


wall
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mucosa in the large intestine regenerates Forms epithelium composed of genetically Transformation takes place among the stem
altered cells located in the superficial cell population at the crypt base
portions of the mucosa
crypt cells migrate from the base to the surface
Transformed stem cell replicated
abnormal cells spreads laterally and
undergoes differentiation and maturation downward to form new crypts

monoclonal conversion produces the


monocryptal adenoma
loss of proliferation control Connects to pre-existing crypts and
replaces them

expands early by crypt fission

extends to adjacent crypts

Abdomino-peritoneal subsection
Formation of malignant tumor in epithelial tissue
surgery (Miles procedure)

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Crosses the muscularis mucosa


Presence of Presence of NPO state
Anoscopy with colostomy surgical Abnormal
biopsy done bag wound. decrease
revealing rectal Extends to the terminal end of the colon in
Possible
new growth lymphocy
increase in
probably tes 7.1
acid
malignant Proliferates to anus and 7.9
1. dulcolax 20g production
IVTT TID within the
GI lining
Affects rectum creating 2. simethicone
Ultrasound done ano-rectal mass 500,g PO TID Ketoste
Susceptible ril 1cap.
September 3, Activation
to infection PO BID
2010 revealing of pain 1.omeprazol
rectal mass mediators e 20mg PO
every 6
1. cefuroxime 1.5gm IVTT hours
every 8 hours
1. celecoxib 1.5gm IVTT 2. ranitidine
2. cefroxitin 7g IVTT every 8 every 6 hours 500mg IVTT
tumor tends to Rectal Compression hours every 8 hrs.
bleed or Due to obstruction urinary 2. paracetamol 60mg
ulcerating mass bladder 3. amikacin 500mg IVTT IVTT every 6 hours
every 12 hours
3. ketorolac 30mg IVTT
4. ciprofloxacin 500mg PO every 8 hours
Urine every 8 hours
retention 4. tramadol 500mg IVTT
5. metronidazole 500mg every 6 hours
hematochezia PO every 8 hours

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1. Bladder
distention
1. Increase BP of
Loss of blood 2. oliguria
130/90 mmHg

2. increase in RR 1. abdominal
of 28 cpm distention.
2. Changes in
3. increase in HR bowel
of 110bpm movement catheterization
1. Body weakness

2. Abnormal
decrease of hgb Decrease cardiac output
11.7 and hct 34.0

3. Pallor Colostomy is
Decrease tissue perfusion performed
going to the GI

1 unit of PRBC
Acid production within the GI lining
given

Ferrous sulfate 20mg


GI irritation
PO every 6 hours

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MILES PROCEDURE ( Abdomino-perineal sub-section surgery)

A laparoscopic abdominoperineal resection, also called a Miles procedure. The


patient evidently has colon cancer, and the procedure is used to site a colostomy. It's
considered to be a minimally invasive laproscopic surgery, usually to treat cancer
occurring in the lower end of the sigmoid colon, where the sigmoid colon, anus and
sphincter muscles are removed. Nursing care requirements would be much the same as
for any patient with a newly created stoma, and of course the wound care needed for
the surgical site. The laproscopic punctures in the abdominal wall would need minimal
care, since they would be very small and usually rapidly heal. They tend to cause very
little discomfort to the patient, as a matter of fact. There are four of those sites as a rule.
The patient is usually far more overwhelmed by the changes in lifestyle that the stoma
will necessitate.

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VI. LABORATORY RESULTS

A. Hematology Report
September 16, 2010
Test Results Reference Values Interpretation

Hgb 11.7 13.7-16.7 g/dL Abnormal decrease


of hemoglobin may
indicate existing
anemia.

Hct 34.0 40.5-49.7 gm% Abnormal decrease


of hematocrit may
indicate existing
anemia.

WBC 18.5 5,000-10,000 It is beyond normal


cell/mm3 the normal range.
Increase in the
WBC count may
indicate infection.

RBC 4.11 4.7-6.1 10^6/uL Normal

MCV 82.7 80.0-96.0 fL Indicates


normocytic anemia

MCH 28.5 27.0-31.0 pg Normal

MCHC 34.2 32.0-36.0% Normal

RDW-CV 12.0 12.0-17.0% Normal

PDW 10.8 9.0-16.0fL Normal

MPV 9.5 8.0-12.0fL Normal

Differential count:

Lymphocytes 7.1 18-45% Low in lymphocytes


may put client at
risk in developing
infection

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A Case Study on Rectal Adenocarcinoma

Monocytes 6.3 4-8% Normal

Eosinophil 2.6 2-3% Normal

Platelet count 212 144,000-372,000 Normal


cell/mm3

Neutrophil 84.0 43.4-76.2% Beyond the normal


range thus indicate
high level of stress
that is placed on
the body. Another
cause is a sudden
infection from
bacteria. Damage
or inflammation of
tissues can also
lead to high
neutrophil count.

Basophils 0.0 0.0-2.0% Normal

September 15, 2010

Test Results Reference Values Interpretation

Hgb 11.5 13.7-16.7 g/dL Abnormal decrease


of hemoglobin may
indicate existing
anemia .

Hct 32.4 40.5-49.7 gm% Abnormal decrease


of hematocrit may
indicate existing
anemia.

WBC 15.7 5,000-10,000 It is beyond normal


cell/mm3 the normal range.
Increase in the
WBC count may

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A Case Study on Rectal Adenocarcinoma

indicate infection.

RBC 3.87 4.7-6.1 10^6/uL Indicates anemia

MCV 83.7 80.0-96.0 fL Indicates


normocytic anemia

MCH 29.7 27.0-31.0 pg Normal

MCHC 35.1 32.0-36.0% Indicates


normochromic
anemia

RDW-CV 12.5 12.0-17.0% Normal

PDW 9.2 9.0-16.0fL Normal

MPV 8.6 8.0-12.0fL Normal

Differential count:

Lymphocytes 7.9 18-45% Low in lymphocytes


may put client at
risk in developing
infection

Monocytes 6.3 4-8% Normal

Eosinophil 0.3 2-3% Eosinopenia may


indicate the
presence of
infection or an
inflammatory
process in the
body.

Platelet count 182 144,000-372,000 Normal


cell/mm3

Neutrophil 85.5 43.4-76.2% Beyond the normal


range thus indicate
high level of stress
that is placed on

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A Case Study on Rectal Adenocarcinoma

the body. Another


cause is a sudden
infection from
bacteria. Damage
or inflammation of
tissues can also
lead to high
neutrophil count.

Basophils 0.0 0.0-2.0% Normal

B. Ultrasound Report

September 3, 2010

Finding: liver is normal in size and echopattern, no mass, nor calcification seen.
Intrahepatic bile ducts are not dilated. Gall bladder is 4.20 cm x1.40cm. No intraluminal
changes noted. Pancreas and spleen are unremarkable right and left kidneys measures
9.31 cm x 3.92 cm and 4.98 cm x 4.65 cm, with parenchymal thickness of 1.3 cm and
1.5 cm respectively. Central echocomplex are intact with well define sinus parenchymal
junctions. Urinary bladder is moderately distended and defines of intraluminal echoes.
Prostatic gland is unremarkable.

There is on ill define hypoechoic mass posterior to the urinary bladder measure 5.6 cm
x 2.7cm.

Diagnose: Hypoechoic mass posterior to the urinary bladder may be rectal mass
severe fecal matter. No remarkable ultrasound findings in the liver, spleen, gallbladder,
pancreas, kidneys, urinary bladder and prostate.

C. Procedure: anoscopy with biopsy

Impression: rectal new growth probably malignant

Description microscopic:

Microsections of the rectal mass disclose malignant neoplasm forming


glands and cibriform pattern penetrating thru muscularis propia, these neoplastic
glands are lined by neoplastic columnar cells with hyperchromatic and

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A Case Study on Rectal Adenocarcinoma

pleomorphic nuclei, prominent nucleoli and scanty to moderate cytoplasm facial


areas of hemorrhage and necrosis are observed.

D. Prothrombin Time. It checks for blood clotting problems.

Results Reference Value Interpretation


Control Prothrombin 13.7 11.8 15.1 Normal
Prothrombin time 14.1 10.2 15.2 seconds Normal
Percent Activity 97.2 70 100% Normal
APTT 36.8

E. Urinalysis

September 16, 2010 Impression: The color of the urine as


well as its appearance and pH may
Color: amber
suggest no problems but it shows that
Clarity: hazy
its low urine specific cavity may suggest
pH: 6.5
Aldosteronism (very rare), Excessive
specific gravity: 1.025
fluid intake, Diabetes insipidus - central,
Chemical properties: Diabetes insipidus - nephrogenic, Renal
failure, Renal tubular necrosis or Severe
protein: trace
kidney infection (pyelonephritis).
glucose: negative
Normally, urine should be not contained
ketones: trace with foreign contents thus, composition
blood: +3 of epithelial cells, pus cells may indicate

Sediments the presence of infection. Furthermore,


presence of RBC in the urine may
Epithelial cells: occasional suggest hematuria which is abnormal
Pus cells: 2.5 and should be treated as soon as
RBC: numerous to count possible.

Bacteria: few

26
A Case Study on Rectal Adenocarcinoma

VII. DRUG STUDY

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

GI: nausea, vomiting,


GENERIC NAME: Replaces iron stores 1. You may experience
Treatment for iron > Use cautiously with constipation, epigastric
Ferrous sulfate needed for RBC these side effects: stomach
deficiency anemia renal disease. pain, black stools and
development, energy upset or diarrhea
BRAND NAME: Feosol diarrhea
and oxygen transport
2. Report when sign and
utilization
CLASSIFICATION:
> Contraindicated with symptoms worsen.
Iron supplements
Helps to form hgb in the allergy to ferrous sulfate
3. Warn the patient does
DOSAGE: 20mg reticulo endothelial cells
stool may be darker.
for storage and
ROUTE:PO
eventual conversion to 4. Give with meals if GI
usable forms of iron. upset occurs.

FREQUENCY: every 6
hours

27
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

CNS: headache, 1. Report when sign and


GENERIC NAME: Analgesia and
Management for > Use cautiously with dizziness, insomnia symptoms worsen.
celecoxib inflammatory activities
acute pain renal disease.
related to inhibition of
DERMATOLOGIC: rash 2. Take drug with food if GI
BRAND NAME:
c0x-2 enzyme
upset occurs.
Celebrex
GI: nausea and
> Contraindicated with vomiting 3. Establish safety
CLASSIFICATION:
hypersensitivity to measures if CNS or visual
analgesia celocoxib disturbances occur.

DOSAGE: 1.5gm 4. Take only the prescribed


dosage.
ROUTE:IVTT

FREQUENCY: every 6
hours

28
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

CNS: seizures 1. Report when sign and


GENERIC NAME: Interferes with bacterial
Prophylactic for > Use cautiously with symptoms worsen.
cefuroxime cell wall synthesis and
infection(surgical renal disease. GI: nausea and
division by binding to all
infection) vomiting 2. Monitor neurologic status
BRAND NAME: Zegen
cell wall causing cell
particularly sign of
death. Hematologic disorder:
CLASSIFICATION: impending seizures
> Contraindicated with

Anti infective hypersensitivity to Hemolytic anemia 3. Monitor kidney and liver


cefuroxime function test
DOSAGE: 1.5 gm
4. Advise the patient to
ROUTE: IVTT
report CNS changes

5. Advise patient to
FREQUENCY: every 8
immediately report bleeding
hours
tendencies.

29
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

1. Report when sign and


GENERIC NAME: Produces analgesia
Relieve pain in > Use cautiously with symptoms worsen.
paracetamol effects, blocking the
some surgical renal disease. CV: myocardial damage
pain impulses by
wounds 2. Do not exceed
BRAND NAME: Naprex
inhibiting prostaglandin CNS: headache
recommended dosage.
(pain mediators)
CLASSIFICATION:
> Contraindicated with GI: hepatotoxicity and 3. Avoid using multiple
allergy to paracetamol nephrotoxicity
analgesia preparation containing
naprex
DOSAGE: 60g
4. Give drug with food if GI
ROUTE:IVTT
upset occurs

5. Discontinue if
FREQUENCY: every 6
hypersensitivity occurs.
hours

30
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

CNS headache, 1. Report when sign and


GENERIC NAME: Block the formation of
Treatment for heart > Use cautiously with dizziness symptoms worsen.
omeprazole acid production
burns and some renal disease.
ulcers GI: diarrhea, abdominal 2. Obtain baseline of liver
BRAND NAME:
pain, nausea and function test and monitored
Prilosec
vomiting periodically dosage therapy.
> contraindicated with
CLASSIFICATION:
allergy to omeprazole Respiratory: URI 3. Maintain supportive
Proton pump inhibitor symptoms treatment as appropriate for
underlying problem
DOSAGE: 20mg
4. Provide additional
ROUTE:PO
comfort measure to alleviate
discomfort from GI effects
and headache.
FREQUENCY: every 6
hours

31
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

CNS: headache 1. Report when sign and


GENERIC NAME: Bactericidal; inhibits
Treatment for > Use cautiously with symptoms worsen.
cefoxitin sodium su\synthesis of bacterial
infections renal disease. GI: nausea and
cell wall causing cell
vomiting, diarrhea 2. Culture infection and
BRAND NAME:
death.
arrange for sensitivity tests
Nefoxin
GU: nephrotoxicity
before and during therapy if
> Contraindicated with
CLASSIFICATION: expected is not seen.
allergy to cefoxitin

antibacterial 3. Discontinue if
hypersensitivity occur
DOSAGE: 7g
4. Report if side effects
ROUTE:IVTT
worsens

FREQUENCY: every 8
hours

32
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

CNS: headache 1. Report when sign and


GENERIC NAME: Competitively inhibits
Treatment for > Use cautiously with symptoms worsen.
ranitidine hydrochloride the action of histamine
ulcers renal disease. CV: tachycardia
at the h2 receptors of
2. Administer oral drug with
BRAND NAME: Zantac
the parietal cells of the GI: constipation,
meals and at bedtime.
stomach. diarrhea, nausea and
CLASSIFICATION:
> Contraindicated with vomiting. 3. Decrease dosage in renal
Histamine H2
allergy to ranitidine and liver damage.
antagonist

4. Provide concurrent
DOSAGE:500mg
antacid therapy to relieve
ROUTE:IVTT pain.

FREQUENCY: every 8 5. Administer IM dose in


hours undiluted, deep into large
muscle.

33
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

CNS: ototoxicity 1. Report when sign and


GENERIC NAME: Bactericidal; inhibits
Treatment for > Use cautiously with symptoms worsen.
amikacin sulfate protein synthesis in
infections caused renal disease. CV: palpitations
susceptible strains of
by susceptible 2. Culture for infection and
BRAND NAME: Amikin
g(-) bacteria and GI: nausea and
strains in g(-) arrange for sensitivity tests
functional integrity of vomiting, anorexia,
CLASSIFICATION: bacteria. before and during therapy if
bacterial cell membrane > Contraindicated with diarrhea
aminoglycoside expected is not seen.
appears to be disrupted allergy to amikacin

DOSAGE: 500mg 3. Ensure that the patient is


well hydrated before and
ROUTE:IVTT
during drug therapy.

4. Report pain at injection


FREQUENCY: every
site.
12 hours

34
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

CNS: headache 1. Report when sign and


GENERIC NAME: Bactericidal; interferes
Treatment for > Use cautiously with symptoms worsen.
ciprofloxacin with DNA replication in
infections caused renal disease. GI: nausea and
susceptible bacteria
by g(-) bacteria vomiting, diarrhea 2. Culture for infection and
BRAND NAME: Cipro
preventing cell
arrange for sensitivity tests
reproduction Other: rash, fever
CLASSIFICATION: before and during therapy if
> Contraindicated with to
antibacterial expected is not seen.
ciprofloxacin

DOSAGE: 500mg 3. Encourage patient to


complete full course of
ROUTE:PO
therapy

4. Monitor clinical response;


FREQUENCY: every 8
if no improvement is seen
hours
relapse occur, repeat
culture and sensitivity.

35
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

CNS: headache, 1. Report when sign and


GENERIC NAME:
Treatment for acute > Use cautiously with dizziness, ataxia symptoms worsen.
metronidazole Bactericidal; inhibits
infection with renal disease.
DNA synthesis for
susceptible GI: unpleasant metallic 2. Take full course of drug
BRAND NAME: Flagyl
specific anaerobes
anaerobic bacteria. taste, anorexia, nausea therapy
causing cell death
CLASSIFICATION: and vomiting.
> Contraindicated with 3. Take drug with food if GI
antibacterial
hypersensitivity to upset occurs.
DOSAGE:500mg metronidazole
4. Your urine may be darker
ROUTE:PO color than usual; this is
expected.

FREQUENCY: every 8 5. Report to health care


hours provider if GI upset worsens

36
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

GENERIC NAME: Reduces total acid load Constipation. Prep. > Ileus, intestinal Abdominal discomfort, 1. Advise patients to take
dulcolax in the GI tract, elevates for hemorrhoids obstruction, acute diarrhea. plenty of water to prevent
gastric pH, strengthens and anal fissures. surgical abdominal constipation
the gastric, mucosal conditions, severe
2. Be alert for adverse
BRAND NAME: barrier, and increases dehydration.
reactions of the drug.
Bisacodyl esophageal sphincter
tone. 3. Monitor and evaluate
CLASSIFICATION:
drug effectiveness.
laxatives
4. Warn patients to avoid
hazardous tasks that
DOSAGE: 20g require alertness.

ROUTE: IVTT

FREQUENCY: TID

37
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

GENERIC NAME: Normalizes metabolic Prevention and Hypocalcaemia, hypocalcaemia 1. Instruct patients to have
ketosteril process, promotes therapy of damages disturbed amino acid proper hygiene
recycling product due to faulty or metabolism
BRAND NAME: 2. Monitor serum Ca level
exchange. Reduces ion deficient protein
Ketoanalogues and
concentration of metabolism in 3. Always assess for
amino acids
potassium, magnesium chronic renal bleeding tendencies
CLASSIFICATION: and phosphate. insufficiency.
4. Monitor BP and RR
Hemostatic

DOSAGE: 1 cap

ROUTE: PO

FREQUENCY: BID

38
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

GENERIC NAME: Causes the Relief of painful Not recommended for None significant 1. Assess pt. for abdominal
Simethicone coalescence of gas symptoms of infant colic. Use pain, distention and bowel
bubbles. Does not excess gas in the cautiously in abdominal sounds prior to and
BRAND NAME: Degas
prevent the formation of GI tract that may pain. periodically throughout
CLASSIFICATION: gas. occur course of therapy.
Antiflatulents postoperatively or
2. Assess frequency of
as a consequence
DOSAGE: 1 tab 500mg belching and passage of
of: Air swallowing
flatus.
ROUTE: PO

FREQUENCY: TID

39
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

1. Assess type, location,


and intensity of pain before
GENERIC NAME Binds to mu-opioid Moderate to Hypersensitivity, pts. CNS: dizziness,
and 2-3 hrs after
tramadol hydrochloride receptors. Inhibits moderately severe Who are intoxicated with headache, malaise,
administered.
reuptake of serotonin pain. alcohol. sleep disorder,
BRAND NAME: Ultram
and norepinephrine in weakness 2. Assess BP and RR
CLASSIFICATION: the CNS. before and periodically
GI: constipation,
analgesic during administration.
nausea, abdominal
DOSAGE: 500mg pain, flatulence, 3. Assess bowel function
vomiting routinely. Prevention of
ROUTE: IVTT
constipation should be
GU: urinary retention
FREQUENCY: Every 6 instituted with increased
hours Derm.: sweating intake of fluids and bulk and
with laxatives to minimize
constipation effects.

40
A Case Study on Rectal Adenocarcinoma

DRUG ORDER
(Generic name, brand
MECHANISM OF CONTRAINDICATIONS ADVERSE EFFECTS NURSING
name, classification, INDICATIONS
ACTION OF THE DRUG RESPONSIBILITIES/
dosage, route,
PRECAUTIONS
frequency)

Contraindicated in CNS: drowsiness, 1. Use cautiously in patients


patients hypersensitive sedation, dizziness, with hepatic or renal
GENERIC NAME: Unknown. Produces Short term
to drug and in those with headache. impairment or cardiac
ketorolac anti-inflammatory, management of
active peptic ulcer decompensation.
analgesic, and moderately severe, CV: edema,
BRAND NAME: disease, recent GI
antipyretic effects, acute pain for hypertension, 2. Carefully observe
Toradol bleding or perforation,
possibly by inhibiting single-dose palpitations, patients with coagulopathies
advanced renal
CLASSIFICATION: prostaglandin treatment. arrhythmias and in those taking
impairment risk for renal
Nonsteroidal anti- synthesis. anticoagulants.
impairment from volume GI: nausea, dyspepsia,
inflammatory drugs
depletion, suspected or GI pain, diarrhea, peptic 3. NSAIDs may mask signs
DOSAGE: 30mg confirmed ulceration, vomiting, and symptoms of infection
cerebrovascular constipation, flatulence, because of their antipyretic
ROUTE: IVTT
bleeding, hemorrhagic stomatitis. and anti-inflammatory
FREQUENCY: every 8 diathesis, incomplete actions.
Hematologic:
hours hemostasis, or high risk
decreased platelet 4. Notify physician for
of bleeding.
adhesion. bleeding tendencies.

41
A Case Study on Rectal Adenocarcinoma

VIII. NURSING CARE PLAN

ASESSMENT DATA NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective and Objective) (Problem and Etiology) RATIONALE

INDEPENDENT:
Subjective: Ineffective breathing Short Term Goals: 1. Assist client on semi-fowlers Short Term Goals:
kapoyan ko,.. murag pattern related to After 15 minutes of position. Goals met. After 15 minutes of
mag.apas ko ug ginhawa alterations of clients thorough nursing R To promote proper lung thorough nursing intervention,
usahay as verbalized by the normal oxygen supply intervention, the client will expansion. the client was able to establish
patient. and demand ration be able to: normal breathing pattern from
Establish normal 2. Instruct client and/or clients 28cpm to 24 cpm, and
Objective: breathing pattern SO to avoid wearing of tight demonstrated different kinds
Abnormal increase of from 28cpm to 24 clothes. of techniques to relief
RR of 28cpm cpm R To avoid compromising restlessness and feeling of
Restless Demonstrate the lungs to expand to its breathless.
Abnormal decrease of different kinds of maximum level.
hemoglobin of 11.5 techniques to relief Long Term Goals:
Abnormal decrease of restlessness and 3. Allow client bed rest in Goals met. After 8 hours of

hematocrit of 32.4 feeling of between activities. thorough nursing intervention,


breathless. R To conserve energy and the client was able to maintain

42
A Case Study on Rectal Adenocarcinoma

to avoid overexertion. breathing pattern within the


normal range (23cpm).
Long Term Goals: 4. Encourage slower/ deeper
After 8 hours of thorough respirations, use of pursed-lip
nursing intervention, the technique.
client will be able to: R To assist client in
Maintain breathing taking control of the
pattern within the situation ad to reduce
normal range (12 anxiety level.
24cpm)
DEPENDENT:
1. Perform blood transfusion 1
unit of PRBC 450 ml.
R To replace loss of blood
within the body.

43
A Case Study on Rectal Adenocarcinoma

ASESSMENT DATA NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective and Objective) (Problem and Etiology) RATIONALE

INDEPENDENT: Short Term Goals:


Subjective:
Acute Pain related to Short Term Goals: 1. Apply hot and cold compress. Goals partially met. After 30
sakit dapit sa akong
presence of surgical At the end of 30 mins. of R - To provide comfort mins. of nursing intervention,
samad, as verbalized by the
wound secondary to thorough nursing care, the the patient was able to
patient.
colostomy. patient will be able to: 2. Perform back rubbing. appear restful, established
Pain scale of 8/10 R - To promote relaxation. and maintained BP of 90-
Verbalize pain is 120/60-80mmhg
Objective: relieved with a pain 3. Assist client in deep (120/80mmHg), demonstrated
scale of 0/10. breathing and splinting use of relaxation skills and
Presence of
Appears restful. exercise. diversional activities but failed
Colostomy
Establish and R - To promote maximum to verbalize pain is relieved
Facial grimace
maintain BP of 90- lung expansion and to with a pain scale of 0/10
restless
120/60-80mmhg control sensation of pain. (3/10).
irritable
Demonstrate use of
BP of 130/90 mmHg
relaxation skills and 4. Assist client in early
diversional activities ambulation.
like proper breathing R - To prevent thrombus

44
A Case Study on Rectal Adenocarcinoma

and splinting formation and promote


exercises. return of bowel movement.

5. Encourage client in
diversional activities like
listening music to his
cellphone.
R To divert the clients
attention to the activity
rather to the pain felt.

DEPENDENT:

1. Administer tramadol 500mg


via IVTT every 6 hours,
ketorolac 30mg via IVTT
every 8 hours and celecoxib
1.5mg via IVTT every 6
hours, as ordered.
R Blocks pain mediators.

45
A Case Study on Rectal Adenocarcinoma

ASESSMENT DATA NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective and Objective) (Problem and Etiology) RATIONALE

INDEPENDENT:
Subjective: Impaired Physical Short Term Goals: 1. Instruct client and/or clients Short Term Goals:
Galisod ko og lihok ky sakit Mobility related to After 1 hour of thorough SO in the use of side rails or Goals met. After 1 hour of
akong samad, as verbalized presence of surgical nursing interventions, the pillows. nursing interventions the
by the patient. wound. patient will be able to: R - for position changes/ patient was able to verbalized
Verbalize transfers. understanding of situation and
Objective: understanding of individual treatment regimen
Limited range of situation and 2. Support the affected parts. and safety measures and
motion individual treatment R: to maintain position of demonstrated techniques that
Slowed movement regimen and safety function and reduce risk of enable resumption of
Difficulty turning to measures. pressure ulcers. activities.
sides Demonstrate
techniques that 3. Schedule activities with
enable resumption adequate rest periods during
of activities. the day.
R: to reduce fatigue.

4. Assist client in early

46
A Case Study on Rectal Adenocarcinoma

ambulation.
R To gradually promote
physical mobility.

5. Assist client in passive ROM.


R to gradually initiate
mobility while promoting
venous return.

DEPENDENT:
1. Administer medications prior
to activity as needed for pain
relief. (tramadol 500mg via
IVTT every 6 hours and
ketorolac 30mg via IVTT
every 8 hours, celecoxib
1.5mg via IVTT every 6
hours), as ordered.
R: To permit maximal
effort/involvement in
activity.

47
A Case Study on Rectal Adenocarcinoma

ASESSMENT DATA NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
RATIONALE
(Subjective and Objective) (Problem and Etiology)

INDEPENDENT:
Subjective: Short Term Goals:
Impaired Skin Integrity 1. Keep area clean and dry. Short term Goals:
katol dapit diri sa akong At the end of 8 hours of
related to surgical R - To assist bodys natural
samad, as verbalized by the nursing care, the patient
incision secondary to Goals partially met. After 8
process of repair and
patient. will be able to:
colostomy. hours of nursing intervention,
preventing proliferation of
the patient was able to be free
Achieved and microorganisms.
from any complications such
maintain timely
Objective: as dehiscence and
wound healing. 2. Assist client in turning to sides
evisceration but failed to
Presence of surgical Be free from any R - to prevent further skin
achieved and maintain timely
complications such breakdown and promote
wound at the abdomen
wound healing.
as dehiscence and comfort.
Rashes
Redness on site evisceration.
3. Stretch wrinkled linens
promptly to avoid moisture.
R Moisture potentiates
skin breakdown.

48
A Case Study on Rectal Adenocarcinoma

4. Proper aseptic wound


dressing.
R - To facilitate fast wound
healing and prevent
infection.

DEPENDENT:

1. Administer ketosteril 1 capsule


PO BID, as ordered.
R It contains amino acid
which helps in the process
of healing.

49
A Case Study on Rectal Adenocarcinoma

ASESSMENT DATA NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective and Objective) (Problem and Etiology) RATIONALE

INDEPENDENT:
Risk Factors: Risk for infection Short Term Goals: 1. Perform/promote meticulous Short-Term Goals:
Presence of surgical related to tissue After 30 minutes of nursing hand washing by caregivers
wound at the abdomen destruction as interventions the patient and client. Goals met. After 30 minutes of
Environmental evidenced by the will be able to: R: Prevents cross nursing interventions, the
Exposure presence of surgical Verbalize contamination/bacterial patient was able to verbalize
Poor personal hygiene wound at the abdomen. understanding of colonization. understanding of individual
individual causative/risk causative/risk factor, identified
factor. 2. Maintain strict aseptic interventions to
Identify interventions o technique with prevent/reduce risk of
prevent/reduce risk of procedures/wound care. infection, and demonstrated
infection. R: Reduces risk of bacterial techniques, lifestyle changes
Demonstrate infection to promote safe environment.
techniques/lifestyle
changes to promote 3. Provide health teachings
safe environment. about the risk of developing
infection within the course of
treatment.

50
A Case Study on Rectal Adenocarcinoma

R: It educates client and


will gain more his
cooperation in abstaining
from the occurrence of
infection.

4. Instruct client and/or clients


SO to avoid frequent
exposure of the wound.
R: to avoid exposure thus
hampering the medium of
acquiring infection.

DEPENDENT:

1. Administer cefuroxime,
paracetamol, ceroxitin,
ciprofloxacin, metronidazole
in its appropriate time and
dosage, as ordered.
R Act as prophylaxis
against infection.

51
A Case Study on Rectal Adenocarcinoma

ASESSMENT DATA NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective and Objective) (Problem and Etiology) RATIONALE

INDEPENDENT:
Subjective: Activity Intolerance Short Term Goals: 1. Increase exercise/activity Short Term Goals:
Luya gyod ko karon daun (Level III) related to After 45 minutes of levels gradually; teach Goals met. After 45 minutes of
mas ganahan ko naa sa imbalance between thorough nursing methods like stopping to rest thorough nursing intervention
higdaanan, as verbalized by oxygen supply and intervention, the client will for 3 minutes. the client was able to
the patient. demand. be able to: R To conserve energy and Verbalize the willingness to
Verbalize the gradually enhance activity participate in necessary
Objective: willingness to tolerance activities, demonstrated
Weakness or body participate in different identified techniques
malaise necessary activities 2. Assist client in early to enhance activity tolerance
Abnormal decrease of Demonstrate ambulation. and demonstrated a decrease
hemoglobin of 11.5 different identified R To help client in in physiologic signs of
Abnormal decrease of techniques to developing activity intolerance as evidenced by
hematocrit of 32.4 enhance activity tolerance. normal heart rate (100pbm)
Pallor skin tolerance and normal blood

Abnormal increase of Demonstrate a 3. Provide health teaching about pressure(120/90).

BP 130/90 mmHg decrease in the necessity in developing

Abnormal increase of physiologic signs of tolerance to various activities

52
A Case Study on Rectal Adenocarcinoma

heart rate of 110bpm intolerance as R To educate the client


evidenced by and to gain full cooperation
normal heart rate for intended activities.
and normal blood
pressure. 4. Promote comfort measures
and provide relief of pain
through imagery and
diversional activities.
R To enhance ability to
participate in activities

DEPENDENT:
1. Perform blood transfusion 1
unit of PRBC 450 ml.
R To replace loss of blood
within the body.

53
A Case Study on Rectal Adenocarcinoma

ASESSMENT DATA NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective and Objective) (Problem and Etiology) RATIONALE

INDEPENDENT:
Subjective: Hyperthermia related to Short- Term Goals: 1. Promote surface cooling by Short Term Goals:
Init kaayu aq paminaw increase metabolic rate After 45 minutes of means of tepid sponge bath. Goals met. After 35 minutes of
maam, as verbalized by teh secondary to rectal thorough nursing R Heat loss by thorough nursing interventions
patient. adenocarcinoma interventions, the patient evaporation and , the patient manifested a
will manifest: conduction. decreased in surface
temperature from 38.3 to 37.5.
Objective: Decreased surface 2. Maintain bedrest. And demonstrated behaviour
Increased in body temperature from R - To reduce metabolic to promote normothermia such
temperature above 38.3 to 37.5 demands/oxygen as promoting surface colling
normal range of 38.3C Demonstrate consumption. by means of tepid sponge
Warm to touch behaviour to bath.
Flushed skin promote 3. Discuss importance of
normothermia such adequate fluid intake. Long Term Goals:
as promoting R - To replace fluid from Goals met. After 8 hours of
surface cooling by insensible loss thorough nursing intervention,
means of tepid the client was able to maintain
sponge bath. 4. Promote cool and well- body temperature within the

54
A Case Study on Rectal Adenocarcinoma

ventilated environment. normal range (37.5).


Long Term Goals: R To avoid worsening of
After 8 hours of thorough the heat felt by the client.
nursing intervention, the
client will be able to: 5. Instruct client and/or clients
Maintain normal SO to avoid wearing of thick
body temperature clothes.
(36.5 37.5) R To provide cool
surface of client and
prevent further water loss
through perspiration.
DEPENDENT:
1. Administer antipyretics such
as Paracetamol, 500 mg, PO,
every 6 hours as ordered.
R To find relief of
hyperthermia.
COLLABORATIVE:
1. Provide high-calorie diet.
R - To meet increased
metabolic demands.

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ASESSMENT DATA NURSING DIAGNOSIS GOAL AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective and Objective) (Problem and Etiology) RATIONALE

Ineffective tissue INDEPENDENT:


Subjective: perfusion (GI) related to Short term Goals: 1. Provide health teaching about Short term Goals:
gasakit usahay akong tiyan inadequate hemoglobin After 45minutes of the necessity of participating Goals met. After 45minutes of
as verbalized by the patient. concentration in blood. thorough nursing of these identified activities. thorough nursing intervention,
intervention, the client will R To gain full cooperation the client was be able to
Objective: be able to: of the client in improving establish a blood pressure
Abnormal increase of Establish a blood circulation. within the normal range
BP of 130/90 mmHg. pressure within the (120/80mmHg), demonstrated
Abnormal decrease of normal range 2. Assist client on early behaviors/lifestyle changes to
bowel sounds (3 clicks) (90/60 ambulation. improve circulation and
Restless 120/80mmHg) R- Early ambulation will verbalized willingness to
Demonstrate promote venous return. participate in behavioral
behaviors/lifestyle changes.
changes to improve 3. Assist client in doing passive
circulation. range of motion. Long term Goals:
Verbalize R Help in promoting After 16 hours of thorough
willingness to venous return. nursing intervention, the client
participate in was able to maintain blood

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A Case Study on Rectal Adenocarcinoma

behavioral changes. 4. Encourage rest after meals. pressure on its normal range
R to maximize blood flow (120/80mmHg) and improved
Long term Goals: to stomach, enhancing bowel sounds from 3 clicks.
After 16 hours of thorough digestion.
nursing intervention, the
client will be able to: 5. Elevate the lower extremities
Maintain blood within the cardiac reserve.
pressure on its R To promote effective
normal range venous return.
(90/60
120/80mmHg) INDEPENDENT:
Improve bowel 1. Administer Ferrous Sulfate
sounds from 3 clicks 20mg PO every 6 hours.
to 5 clicks. R - Iron supplements in the
production and maturation
of RBC.

2. Perform blood transfusion 1


unit of PRBC 450 ml.
R To replace loss of blood
within the body.

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IX. DISCHARGE PLANNING

Medications
1. Advice patient to continue taking medications needed to maintain a normal
functioning of the body and maintain homeostasis. The treatment regimen
ordered by the doctors must be followed strictly and should not be stopped to
prevent the aggravation of the condition. The full course of antibiotics should be
followed.
2. Advice the patient to observe the any reaction towards the given medications and
signs that needs to call the attention of the physician.

Exercise
1. Encourage patient to have an active and passive ROM because it will promote
blood circulation and to improve muscle strength in order to promote total range
of motion.

Treatment:
1. Instruct patient to consult the physician first if what activities must he/she avoid
or put into limits.
2. Encourage patient to compliance of medication regimen to promote optimal
health.

Health Teachings:
1. Importance of personal hygiene to prevent infection.
2. Intake of nutritious foods like vegetables and fruits and intake of foods that is rich
in fiber such as green leafy vegetables and pineapple, also increased fluid intake
to prevent constipation.
3. Strict compliance of medication regimen to promote wellness.
4. Immediate report to the physician if unusualities occur.

Out-Patient:
1. Return to OPD for further check-up if whether it is improving or not. Also, for
early diagnosis of any other underlying conditions.

Diet:

1. Encourage client to eat nutritious or healthy foods such as fruits and vegetables
and foods that are high in fiber such as green leafy vegetables, wheat, cereal
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and pineapple. Suggest client also to consult to a dietary physician to know what
the correct dietary intake he must maintain are.

Spiritual:

1. Advise client to pray and have faith in God always because God is the most
powerful of all He knows what happened and He will never leave us.

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X. RELATED LEARNING EXPERIENCE

In our duty experiences in Surgical Ward at Northern Mindanao Medical Center


(NMMC) weve encounter so many kind of things, which are often unexpected and were
full of lessons that must be inculcated in our hearts and minds. It was also a first time for
all of us to witness and render our care to the patient who is with stapler suture in
cephalic area, who had 3-way catheter, with colostomy, and with Hemovac drainage.
Scary it may seem but it was a significant learning experience for us.

In our first duty in Surgical ward we committed so many kinds of errors and we
are all guilty for that but for that errors weve learn a lot and gradually we are learning to
improve our work in order to follow the mission of the nursing profession, which is to
give care to the patient. Weve learn that not at all the times we will be perfect on what
we will be doing, weve learn that the patients admitted in the Surgical Ward are mostly
confined due to vehicular accident. Other cases were those required for surgery. thus,
they need more attention and we need to be more careful in the provision of the care
they needed. Ideally, we must have referred the patient to registered advisers so that
there will be a comprehensive advise to the client and to the significant others as well
but because due to the institutional policies and time constraints, we failed to do it as
well and have done modification through giving him ample information.

In our skills, weve improve the common procedures and common work for what
we are doing like calculating the drops of the IVF either it is micro drops or macro drops
that is being administered in our patients and also monitoring the intake and output to
our patients, monitoring patient during blood transfusion and doing correctly
administration of medication via IVTT.

In making this case study, it strengthens us and really proves that in everything that we
do, learning is always there for us, waiting to be grasped and to be well-digested. I know
for the fact that this study requires a lot of sacrifices and fortunately we did survive all
the things we have done. My great felicitation and commemoration to my Clinical
Instructor, Ma. Liwayway Salcedo,RN, MN who gave us the motivation to be serious in
the clinical area in order to promote the proper and appropriate care towards our
patient. It was truly enjoyable because we have a clinical instructor who is very much
approachable and mindful. Though we have life threatening patient, she still there to
make some inspiring words and cheer us. She makes us calm when we get nervous.
She treats us like her own daughters and son.

We extend our thanks to our PCI, Ms. Arnie Echaves, who taught and gave us
the inspiration to do things well. She just not do things to comply with the requirements

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A Case Study on Rectal Adenocarcinoma

but has done it with passion and whole heartedly. We also appreciate to the nursing
staff for attending to our question properly whenever we have some clarifications.

Furthermore, we have all learned new procedures and know more the apparatus
used by the clinical area. We also appreciate the peri-operative care in the ward and
dealing patiently to our patients needs.

And last we learn the real value of being a student nurse that we should control
our temper, our emotion while we are on our patients side, we have to adjust the in
environment where we belong it is because we didnt know the feelings of the watchers
and more importantly our patient. Patient must not be only a patient but he/she should
be my/our patient. Thank you

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A Case Study on Rectal Adenocarcinoma

XI. REFERENCE

BOOKS:

Nurses Pocket Guide 11th edition (Diagnoses, Prioritized interventions, and


Rationales)

By: Marilyn E. Doenges, Mary Frances Moorhouse and Alice C. Murr

Nursing 2003 Drug Handbook 23rd edition

By: Springhouse Lippincott Williams and Wilkins

Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th edition

By: Joyce Black and Jane Hokanson Hawks

WEB:

http://coloncancer.about.com/od/typesofcancer/a/Adenocarcinoma.htm

http://jjco.oxfordjournals.org/content/32/suppl_1/S52.full

http://www.alpharubicon.com/med/vitalssn.htm

http://www.google.com/images?hl=en&biw=1128&bih=721&gbv=2&tbs=isch%3A1&sa=
1&q=Abdomino-
perineal+subsection+surgery+procedure&aq=f&aqi=&aql=&oq=&gs_rfai=

http://answers.yahoo.com/question/index?qid=20081221030633AAVfM7o

http://www.wikipedia.com

http://www.scribd.com

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