September 5, 2018

AURFELI TAGANAHAN-EMPERIO, MD, DPPS

Chief of Hospital
Central Mindanao University

Ma’am/Sir:

Greetings!

The undersigned is a fourth- year Nursing Student of Central Mindanao University- College of Nursing. As part of the Nursing course
requirement, I will be conducting a Pilot Study of my thesis entitled: “Nurses Clinical Practice On Documentation: Nurses Notes &
Carrying Out Doctors Order In Hospitals of Southern Bukidnon”.

In connection to this, I would like to ask permission from your good office to allow researcher to administer the Pilot testing. This activity is to
check the validity and reliability of the research instrument.

Favorable approval regarding this matter would be of great help to my professional undertakings.

Thank you and may the Father bless us always.

Respectfully yours,

KEITH WESLEY C. YBUT

Level IV Nursing Student
Central Mindanao University

Noted:

THERESA LINDA C. NARRETO, RN, MSN

Research Adviser
Recommending Approval:

THERESA LINDA C. NARRETO, RN, MSN

Research Coordinator, CON
Approved by:

PILAR V. DOMAGSANG, RN, MAN ELAINE RUTH U. SUMAY, RN, MAN

Dean, College of Nursing Chief Nurse
August 15, 2018

MR. EDGARDO TORNIADO, CPA, CGM

Office of the President
Adventist Medical Center
Valencia City, Bukidnon

Ma’am/Sir:

Greetings!

The undersigned is a third- year Nursing Student of Central Mindanao University- College of Nursing. As part of the Nursing course
requirement, I will be conducting a Pilot Study of my thesis entitled: “Nurses Clinical Practice On Documentation: Nurses Notes &
Carrying Out Doctors Order In Hospitals of Southern Bukidnon”.

In connection to this, I would like to ask permission from your good office to allow researcher to administer the Pilot testing. This activity is to
check the validity and reliability of the research instrument.

Favorable approval regarding this matter would be of great help to my professional undertakings.

Thank you and may the Father bless us always.

Respectfully yours,

KEITH WESLEY C. YBUT

Level IV Nursing Student
Central Mindanao University

Noted:

THERESA LINDA C. NARRETO, RN, MSN

Research Adviser

Recommending Approval:

THERESA LINDA C. NARRETO, RN, MSN

Research Coordinator, CON
Approved by:

PILAR V. DOMAGSANG, RN, MAN MR. EDGARDO TORNIADO, CPA, CGM

Dean, College of Nursing President

June 18, 2018

SISTER HENRIETA ESMERO, SD

Administrator
St. Joseph Southern Hospital
Maramag, Bukidnon

Thru: Channels

Ma’am/Sir:

Greetings!

The undersigned is a third- year Nursing Student of Central Mindanao University- College of Nursing. As part of the Nursing course
requirement, I will be conducting a Pilot Study of my thesis entitled: “Compliance of Hemodialysis patients to therapeutic regimen in
Bukidnon”.

In connection to this, I would like to ask permission from your good office to allow researcher to administer the Pilot testing. This activity is to
check the validity and reliability of the research instrument.
Favorable approval regarding this matter would be of great help to my professional undertakings.

Thank you and may the Father bless us always.

Respectfully yours,

REYNA MAE M. QUIÑO

Level III Nursing Student
Central Mindanao University

Noted:

FANNY LUDZ Q. SAGPANG, RN, MAN, MBA

Research Adviser

Recommending Approval:

THERESA LINDA C. NARRETO, RN, MSN

Research Coordinator, CON
Approved by:

PILAR V. DOMAGSANG, RN, MAN SISTER HENRIETA ESMERO, SD

Dean, College of Nursing Administrator

June 18, 2018

ROSELYN PORTEZA, RN
Supervisor-Hemodialysis Unit
Adventist Medical Center
Valencia City, Bukidnon
Thru: Channels

Ma’am/Sir:

Greetings!

The undersigned is a third- year Nursing Student of Central Mindanao University- College of Nursing. As part of the Nursing course
requirement, I will be conducting a Pilot Study of my thesis entitled: “Compliance of Hemodialysis patients to therapeutic regimen in
Bukidnon”.

In connection to this, I would like to ask permission from your good office to allow researcher to administer the Pilot testing. This activity is to
check the validity and reliability of the research instrument.

Favorable approval regarding this matter would be of great help to my professional undertakings.

Thank you and may the Father bless us always.

Respectfully yours,

REYNA MAE M. QUIÑO

Level III Nursing Student
Central Mindanao University

Noted:

FANNY LUDZ Q. SAGPANG, RN, MAN, MBA

Research Adviser

Recommending Approval:

THERESA LINDA C. NARRETO, RN, MSN

Research Coordinator, CON
 Approved by:

PILAR V. DOMAGSANG, RN, MAN ROSELYN PORTEZA, RN

Dean, College of Nursing Supervisor-Hemodialysis Unit
June 18, 2018

ROSELYN PORTEZA, RN
Supervisor-Hemodialysis Unit
Adventist Medical Center
Valencia City, Bukidnon

Thru: Channels

Ma’am/Sir:

Greetings!

The undersigned is a third- year Nursing Student of Central Mindanao University- College of Nursing. As part of the Nursing course
requirement, I will be conducting a Pilot Study of my thesis entitled: “Compliance of Hemodialysis patients to therapeutic regimen in
Bukidnon”.

In connection to this, I would like to ask permission from your good office to allow researcher to administer the Pilot testing. This activity is to
check the validity and reliability of the research instrument.

Favorable approval regarding this matter would be of great help to my professional undertakings.

Thank you and may the Father bless us always.

Respectfully yours,

REYNA MAE M. QUIÑO

Level III Nursing Student
Central Mindanao University

Noted:
FANNY LUDZ Q. SAGPANG, RN, MAN, MBA
Research Adviser

Recommending Approval:

THERESA LINDA C. NARRETO, RN, MSN

Research Coordinator, CON
Approved by:

PILAR V. DOMAGSANG, RN, MAN ROSELYN PORTEZA, RN

Dean, College of Nursing Supervisor-Hemodialysis Unit
1. 1. Non-melanoma skin cancer BY OSAMA ELZAAFARANY ASSISTANT LECTURER OF CLINICAL ONCOLOGY MEDICAL RESEARCH
INSTITUTE-ALEXANDRIA UNIVERSITY MAY 2015
2. 2. Epidemiology:  Non-melanoma skin cancer is the most commonly occurring cancer in the United States.  BCC is the more common type
of the two non-melanoma types.  It was estimated that 2,152,500 persons were treated for non-melanoma skin cancers in 2006; [ Rogers
HW, Weinstock MA, Harris AR, et al.: Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 146 (3):
2837, 2010 ].  Although the two types of non-melanoma skin cancer are the most common of all malignancies, they account for less than
0.1% of patient deaths caused by cancer.
3. 3. Risk Factors  Epidemiologic evidence suggests that exposure to ultraviolet (UV) radiation and the sensitivity of an individual’s skin to UV
radiation are risk factors for skin cancer.  Skin cancer are more likely to occur in individuals of light complexion who have had substantial
exposure to sunlight.  Skin cancers are more common in the southern latitudes of the Northern hemisphere.  The immune system may play
a role in pathogenesis of skin cancers; Organ transplant recipients receiving immunosuppressive drugs are at an elevated risk of skin cancers,
particularly SCC.  Arsenic exposure also increases the risk of cutaneous SCC.  Serologic evidence from a population based case-control
study has shown a possible association between infection with the human papilloma virus (HPV) genus beta-species 1 and SCC: Patel AS,
Karagas MR, Perry AE, et al.: Exposure profiles and human papillomavirus infection in skin cancer: an analysis of 25 genus betatypes in a
populationbased study. J Invest Dermatol 128 (12): 288893, 2008.
4. 4. Other types of malignant disease of the skin include the following:  Cutaneous T-cell lymphomas (e.g., mycosis fungoides).  Kaposi
sarcoma.  Extra-mammary Paget disease.  Apocrine carcinoma of the skin.  Metastatic malignancies from various primary sites
5. 5. Basal Cell Carcinoma  About three times more common than SCC in non- immunocompromised patients.  It usually occurs on sun
exposed areas of skin, and the nose is the most frequent site.  the most characteristic clinical presentation is the asymptomatic nodular or
nodular ulcerative lesion that is elevated from the surrounding skin, has a pearly quality, and contains telangiectatic vessels.  Has a tendency
to be locally destructive.  Hig-hrisk areas for tumor recurrence after initial treatment include the central face (e.g., periorbital region, eyelids,
nasolabial fold, or nosecheek angle), postauricular region, pinna, ear canal, forehead, and scalp.
6. 6.  Morpheaform sub-type: specific subtype of BCC, this subtype typically appears as a scar-like, firm plaque. Because of indistinct clinical
tumor margins, the morpheaform type is difficult to treat adequately with traditional treatments.  BCC is slow growing and rarely metastasize.
 Pathology: BCCs are composed of non- keratinizing cells derived from the basal cell layer of the epidermis.  Molecular biology: BCC often
have a characteristic mutation in the patched 1 tumor suppressor gene (PTCH1).
7. 7. Squamous Cell Carcinoma  Also tend to occur on sun-exposed portions of the skin, such as the ears, lower lip, and dorsa of the hands. 
SCC that arise in areas of non sun-exposed skin or that originate de novo on areas of sun-exposed skin are prognostically worse because
they have a greater tendency to metastasize than those that occur on sun-exposed skin that develop from actinic keratosis.  More aggressive
than BCCs and have a range of growth, invasive, and metastatic potential.  Composed of keratinizing cells.  Predisposing factors: 
Chronic sun damage.  Sites of prior burns.  Arsenic exposure.  Chronic cutaneous inflammation as long standing skin ulcers.  Sites of
previous x-ray therapy.
8. 8.  SCC in situ (Bowen disease): is a non-invasive lesion. It may be difficult to distinguish it pathologically from a benign inflammatory
process. The risk of development into invasive SCC is low, reportedly in the 3% to 4% range.
 Actinic Keratosis: are potential precursors of SCC, but the rate of progression is ‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
 extremely low, and the vast majority do not become SCCs. These typically red, scaly patches usually arise on areas of chronically sun-
.exposed skin and are likely to be found on the face and dorsal aspects of the hand
9. 9. Diagnostic workup:  Basal cell carcinoma (BCC) rarely metastasizes, thus, a metastatic workup is usually not necessary.  Regional lymph
nodes should be routinely examined in all cases of SCC, especially for high-risk tumors appearing on the lips, ears, perianal and perigenital
regions, or high-risk areas of the hand.  In addition, regional lymph nodes should be examined with particular care in cases of SCCs arising
in sites of chronic ulceration or inflammation, burn scars, or sites of previous radiation therapy treatment.
10. 10. Staging:  There are separate staging systems in the 7th edition of the American Joint Committee on Cancer’s (AJCC) AJCC Cancer
Staging Manual for carcinomas of the eyelid versus other skin surfaces.  The staging system for non-eyelid skin cancers is primarily designed
for squamous cell carcinomas (SCCs).  The staging system for carcinoma of the eyelid addresses carcinomas of all histologies.
11. 11. Risk features that should be evaluated for non-eyelid carcinomas
12. 12. Eye lid carcinoma (T) classification:
13. 13.  Patients with a primary cutaneous SCC or other cutaneous carcinoma with no evidence (i.e., clinical, radiologic, or pathologic) of
regional or distant metastases are divided into the following two stages:  Stage I for tumors measuring 2 cm or less in size.  Stage II for
tumors measuring more than 2 cm in size.  In instances where there is clinical concern about extension of the tumor into bone and radiologic
evaluation has been performed (and is negative), these data may be included to support the stage I versus stage II designation.  Tumors that
are 2 cm or less in size can be upstaged to stage II if they contain two or more high-risk features.  Stage III patients are those with either of
the following:  Clinical, histologic, or radiologic evidence of one involved lymph node measuring 3 cm or less in size.  Tumor extension into
bone; namely, the maxilla, mandible, orbit, or temporal bone.  Stage IV patients are those with any of the following:  Tumor with direct or
peri-neural invasion of skull base or axial skeleton.  Two or more involved lymph nodes.  Single or multiple involved lymph nodes
measuring more than 3 cm in size.  Distant metastases.
14. 14. Treatment of Basal Cell Carcinoma of the Skin  Treatment options include the following: 1. Excision with margin evaluation. 2. Mohs
micrographic surgery. 3. Radiation therapy. 4. Curettage and electrodesiccation. 5. Cryosurgery. 6. Photodynamic therapy. 7. Topical
fluorouracil (5FU). 8. Imiquimod topical therapy. 9. Carbon dioxide laser
15. 15. Excision with margin evaluation  Surgical margins ranging from 3 -10 mm, depending on the diameter of the tumor.  Excision has been
compared in randomized trials to radiation therapy, Mohs micrographic surgery, photodynamic therapy (PDT), and cryosurgery Their overall
assessments favored excision. • In a single-center trial, 360 patients with facial BCCs <4 cm in diameter were randomly assigned to excision
VS radiation therapy. • RTx was : 55% interstitial brachytherapy, 33% contact radiation therapy, and 12% conventional external beam radiation
therapy. • Excisional margins, assessed during surgery by frozen section during the procedure in 91% of cases, had to be at least 2 mm, with
re-excision if necessary. • At 4 years (mean follow-up of 41 months), the actuarial failure rates (confirmed persistent or recurrent tumor) were
0.7% and 7.5% in the surgery and radiation therapy arms, respectively (P = .003). • The cosmetic results were also rated as better after
surgery by both patients and dermatologists, and also by three independent judges. At 4 years, 87% of surgery patients rated cosmesis as
good versus 69% of radiation therapy patients. Petit JY, Avril MF, Margulis A, et al.: Evaluation of cosmetic results of a randomized trial
comparing surgery and radiotherapy in the treatment of basal cell carcinoma of the face. Plast Reconstr Surg 105 (7): 254451, 2000.
16. 16. Mohs micrographic surgery  Principle: specialized technique used with the intent to achieve the narrowest margins necessary to avoid
tumor recurrence, while maximally preserving cosmesis. The tumor is microscopically delineated, with serial radial resection, until it is
completely removed as assessed with real-time frozen sections.  Indications: 1. tumors in cosmetically sensitive areas; (e.g., eyelid
 periorbital area, nasolabial fold, nose-cheek angle, posterior cheek sulcus, pinna, ear canal, forehead, scalp, fingers, and genitalia). 2. Tumors
that have recurred after initial excision.
17. 17. Radiation therapy  Indicated for lesions that would otherwise require difficult or extensive surgery (e.g., nose or ears); as it eliminates the
need for skin grafting when surgery would result in an extensive defect.  Can also be used for lesions that recur after a primary surgical
approach.  Contra-indicated in : • Xeroderma pigmentosum. • basal cell nevus syndrome. • Scleroderma.
18. 18. Curettage & electrodesiccation (electro-surgery)  Principle: sharp curette is used to scrape away the tumor down to its base, followed by
electrodesiccation of the lesion base.  Indication: superficial lesions of the neck, trunk, and extremities that are considered to be at low-risk
for recurrence.  Evidence:  In a large, single-center case series of 2,314 previously untreated BCCs managed at a major skin cancer unit. 
The 5-year recurrence rate of BCCs of the neck, trunk, and extremities was 3.3%.  However, rates increased substantially for tumors larger
than 6 mm in diameter at other anatomic sites.  Silverman MK, Kopf AW, Grin CM, et al.: Recurrence rates of treated basal cell carcinomas.
Part 2: Curettage electrodesiccation. J Dermatol Surg Oncol 17 (9): 7206, 1991.
19. 19. Topical fluorouracil (5FU)  Topical 5FU (5% cream) may be useful in specific limited circumstances. It is a FDA-approved treatment for
superficial BCCs in patients for whom conventional methods are impractical, such as individuals with multiple lesions or difficult treatment
sites.  Safety and efficacy in other indications have not been established.  Given the superficial nature of its effects, non-visible dermal
involvement may persist, giving a false impression of treatment success. In addition, the brisk accompanying inflammatory reaction may cause
substantial skin toxicity and discomfort in a large proportion of patients.
20. 20. Treatment for Recurrent BCC of the Skin  Most recurrences occur within 5 years, with about 18% of recurrences are diagnosed beyond
that point.  Patients who develop a primary BCC are also at increased risk of subsequent primary skin cancers because the susceptibility of
their sun damaged skin to additional cancers persists (field carcinogenesis).  Age at diagnosis of the first BCC (<65 years), red hair, and
initial BCC on the upper extremities appear to be associated with higher risk of subsequent new BCCs.  Mohs micrographic surgery is
commonly used for local recurrences of BCC.
21. 21. Treatment for Advanced & Metastatic BCC  Cisplatin, alone or in combination with other drugs, is the most commonly reported systemic
therapy and appears to be associated with the best tumor response rates.  A variety of other agents have been reported but have low
associated response rates, including cyclophosphamide, vinblastine, 5FU, methotrexate, and doxorubicin.  Since there is no standard
therapy, clinical trials are appropriate if available.  Hedgehog/PTCH1signaling pathway inhibitor Vismodegib was approved by FDA at 2012
foe advanced BCC.  Orally administered Hedgehog pathway inhibitor (GDC0449) has produced objective responses in patients with
advanced or metastatic sporadic BCC.
22. 22. Treatment of Squamous Cell Carcinoma of the Skin  Localized squamous cell carcinoma (SCC) of the skin is a highly curable disease. 
Absent high-quality evidence from controlled clinical trials, the management of clinically localized cutaneous SCC is based upon case series
and consensus statements from experts.  Treatment options include the following: 1. Surgical excision with margin evaluation. 2. Mohs
micrographic surgery. 3. Radiation therapy. 4. Curettage and electrodesiccation. 5. Cryosurgery.
23. 23. Surgical excision with margin evaluation  Excision is probably the most common therapy for SCC.  This traditional surgical treatment
usually relies on surgical margins ranging from 4 -10 mm, depending on the diameter of the tumor and degree of differentiation.  In a
prospective case series of 141 SCCs, a 4mm margin was adequate to encompass all subclinical microscopic tumor extension in more than
95% of well- differentiated tumors up to 19 mm in diameter.  Wider margins of 6 -10 mm were needed for larger or less-differentiated tumors
 or tumors in high-risk locations (e.g., scalp, ears, eyelids, nose, and lips).  Re-excision may be required if the surgical margin is found to be
inadequate on permanent sectioning. Brodland ‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
DG, Zitelli JA: Surgical margins for excision of primary cutaneous squamous cell carcinoma. J Am Acad Dermatol 27 (2 Pt 1): 2 418, 1992.
]PUBMED Abstract[
24. 24. Radiation therapy  Radiation therapy is a logical treatment choice, particularly for patients with primary lesions requiring difficult or
extensive surgery (e.g., nose, lip, or ears).  Radiation therapy eliminates the need for skin grafting when surgery would result in an extensive
defect.  Cosmetic results are generally good, with a small amount of hypopigmentation or telangiectasia in the treatment port.  Radiation
therapy can also be used for lesions that recur after a primary surgical approach.  Radiation therapy is avoided in patients with conditions
that predispose them to radiation-induced cancers, such as xeroderma pigmentosum or basal cell nevus syndrome.  Although radiation
therapy, with or without excision of the primary tumor, is used for histologically proven clinical lymph node metastases and has been
associated with favorable disease-free survival rates, However it is difficult to know the impact of nodal radiation on survival.
25. 25. Treatment for Recurrent SCC of the Skin  SCCs have definite metastatic potential, and patients should be followed regularly after initial
treatment.  Overall, local recurrence rates after treatment of primary SCCs ranged from about 3% - 23%, depending upon anatomic site. 
About 58% of local recurrences manifest within 1 year, 83% within 3 years, and 95% within 5 years.  The metastatic rate for primary tumors
of sun-exposed skin is 5%; for tumors of the external ear, 9%; and for tumors of the lip, 14%. Metastases occur at an even higher rate for
primary SCCs in scar carcinomas or in non-exposed areas of skin (about 38%).  About 69% of metastases are diagnosed within 1 year, 91%
within 3 years, and 96% within 5 years.  Tumors that are 2 cm or larger in diameter, 4 mm or greater in depth, or poorly differentiated have a
relatively bad prognosis and even higher local recurrence and metastasis rates than those listed.
26. 26.  Reported rates also vary by treatment modality, with the lowest rates associated with Mohs micrographic surgery, but at least some of
the variation may be the result of patient selection factors; no randomized trials directly compare the various local treatment modalities. 
Recurrent non-metastatic SCCs are considered high risk and are generally treated with excision, often using Mohs micrographic surgery. 
Radiation therapy is used for lesions that cannot be completely resected.  As is the case with BCC, patients who develop a primary SCC are
also at increased risk of subsequent primary skin cancers because the susceptibility of their sun-damaged skin to additional cancers persists.
27. 27. Treatment for Metastatic & Advanced SCC  As is the case with BCC, metastatic and far advanced SCC is unusual, and reports of
systemic therapy are limited to case reports and very small case series with tumor response as the endpoint.  Cisplatin-based regimens
appear to be associated with high initial tumor response rates.  High response rates have also been reported with the use of 13-cis- retinoic
acid plus interferonalpha-2a.  Since there is no standard therapy, clinical trials are appropriate if available.
28. 28.  The main source of this presentation is: National Cancer Institute: PDQ® Skin Cancer Treatment. Bethesda, MD: National Cancer
Institute. Date last modified <4/28/2015>. Available at: http://cancer.gov/cancertopics/pdq/treatment/skin/HealthProfessional