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N42 Group 3

Jaybmizh H. Boniao
Hepaloma -Introduction

Estela Marie Roa Salupan

Nursing Health History.,.,.,

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Liver cancer (hepatocellular carcinoma) is a cancer arising from the liver. It is also known as primary liver cancer or hepatoma. The liver is made up of different cell types (for example, bile ducts, blood vessels, and fatstoring cells). However, liver cells (hepatocytes) make up 80% of the liver tissue. Thus, the majority of primary liver cancers (over 90%-95%) arises from liver cells and is called hepatocellular cancer or carcinoma. Causes of Hepatocellular carcinoma accounts for most liver cancers. This type of cancer occurs more often in men than women. It is usually seen in people ages 50 - 60.

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The disease is more common in parts of Africa and Asia than in North or South America and Europe. Hepatocellular carcinoma is not the same as metastatic liver cancer, which starts in another organ (such as the breast or colon) and spreads to the liver. In most cases, the cause of liver cancer is usually scarring of the liver (cirrhosis). Cirrhosis may be caused by: alcohol abuse, certain autoimmune diseases of the liver, diseases that cause long-term inflammation of the liver, hepatitis B or C virus infection, Too much iron in the body (hemochromatosis).

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Patients with hepatitis B or C are at risk for liver cancer, even if they do not have cirrhosis. Signs and Symptoms of hepatoma are abdominal pain or tenderness, especially in the upper-right part, easy bruising or bleeding, enlarged abdomen, yellow skin or eyes (jaundice). Physical examination may show an enlarged, tender liver. The tests include: abdominal CT scan which is an imaging method that uses x-rays to create crosssectional pictures of the belly area and stands for computed tomography, abdominal ultrasound which is an imaging procedure used to examine the internal organs of the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys, liver biopsy a test that takes a sample of tissue from the liver for examination, liver enzymes (liver function tests)

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which is a common tests that are used to evaluate how well the liver is working, liver scan which uses a radioactive material to help determine how well the liver or spleen is working and serum alpha fetoprotein a test can be done to measure the amount of AFP in your blood. Some high-risk patients may get periodic blood tests and ultrasounds to see whether tumors are developing. Treatment is aggressive surgery or a liver transplant can successfully treat small or slow-growing tumors if they are diagnosed early. However, few patients are diagnosed early.

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Chemotherapy and radiation treatments are not usually effective. However, they may be used to shrink large tumors so that surgery has a greater chance of success. Sorafenib tosylate (Nexavar), an oral medicine that blocks tumor growth, is now approved for patients with advanced hepatocellular carcinoma. Prognosis is the usual outcome is poor, because only 10 - 20% of hepatocellular carcinomas can be removed completely using surgery.

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If the cancer cannot be completely removed, the disease is usually fatal within 3 - 6 months. However, survival can vary, and occasionally people will survive much longer than 6 months. Possible Complications Gastrointestinal bleeding, Liver failure, Spread (metastasis) of the carcinoma. Preventing and treating viral hepatitis may help reduce your risk. Childhood vaccination against hepatitis B may reduce the risk of liver cancer in the future. Avoid drinking excessive amounts of alcohol. Certain patients may benefit from screening for hemochromatosis. If you have chronic hepatitis or known cirrhosis, periodic screening with liver ultrasound or measurement of blood alpha fetoprotein levels may help detect this cancer early.

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Defination of Terms
Protooncogenes- A normal gene which, when altered by mutation, becomes an oncogene that can contribute to cancer. Proto-oncogenes may have many different functions in the cell. Some proto-oncogenes provide signals that lead to cell division. Other proto-oncogenes regulate programmed cell death (apoptosis) Alpha fetoprotein AFP- is a protein normally produced by the liver and yolk sac of a fetus. AFP levels decrease soon after birth. AFP probably has no normal function in adults.

N42 Group 3

Jaybmizh H. Boniao
Hepaloma -Introduction

Estela Marie Roa Salupan

Nursing Health History.,.,.,

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A detailed account of the case and family history are used in conjunction with physical assessment to complete the patient history. Accumulated data from our chosen patient through verbal interviews, interactions with the significant others and medical records review were gathered last August 24, 2011 and completed on August 24, 2011 the same day. With the aid of ethical guidelines for conducting nursing research on our patient based on ethical principles of confidentiality; which pertains to the duty to respect privileged information, we therefore withhold the name of our patient Thus we shall addressed him as Patient P, who was confined last August 20, 2011 at exactly 4:30pm at Butuan Medical Hospital, Blue station.

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BIOGRAPHY Patient P is 51 years old, male, married, stands 5 feet and 4 inches tall and weigh 60 kgs. He is a Filipino and a Roman Catholic by faith and was born on April 3, 1960 at Purok-25 Tungao, Butuan City, through Normal Spontaneous delivery with the help of mananabang in their place. He is eldest of the 7 children in the family. Regarding immunization, he cannot recall whether or not he had his immunization. He is the 3rd child among the 6 siblings in the family. FAMILY HISTORY Basing on patients health history, his wife said, wala may nagka-ingon ana sa ilang pamilya, maski sa una pa, highblood ra man ang common nga sakit sa among pamilya.

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INFANCY AND CHILDHOOD According to Patient P he was breastfed by her mother until the age of 1 year old. During also this period, he claimed having only minor illnesses, Hangga, hilanat, sip-on ug ubo ra ang akong naagian nga mga sakit sa gamay pako ug wala pud gyud ko na hospital sukad-sukad. Patient P started to have physical attraction towards the opposite sex at the age of 16 according to him, daghan pud koy gipangulitawhan sauna.

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EDUCATIONAL ATTAINMENT Patient P is an elementary graduate at Mabuhay Elementary School, Butuan City. He did not pursue his high school education due to financial constraints and decide to help his father working at the farm together with his other siblings. USUAL DAILY PATTERN According to patuent P he usually wakes up at 4 to 5 oclock in the morning and sleeps more often at 10 oclock in the evening. Thus, the patient sleeps for about 7 to 8 hours per day. With regards to patients urination and defecation, he verbalized, muabot ug 4 hangtud 6 ko mangihi sa usa ka adlaw Sa akong paglibang kada-adlaw man ko malibang kada buntag.

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USUAL DIET Kasagaran gyud nagakaon ko ug isda ug mga gulay, bulad ug ginamos panagsa rami mag-karne, he verbalized. Patient P had no known history of food allergies. With regards to Patients fluid intake, Patient P verbalized pinakadaghan nga baso nga tubig nga akong ma-inom kay hangtud 10 ka baso sulod sa usa ka adlaw, hing-inom gyud ko ug tubig. RECREATION AND LIKES Patient P likes to go to sabungan every Sunday. He also likes to play hantak with his friends.

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HYGIENE According to Patient P he takes a bath daily, ayha ko moadto sa basakan, maligo gyud ko, he verbalized. He brushes teeth once a day, trim nails once a week and sometimes washes his hand before and after eating. EXERCISES Permi man ko galihok sa akong lawas kada adlaw sa basakan, maski diri sa balay, lihok gihapon, as verbalized. VICES When being asked about any vices, Patient P said, na, perti gyud ko mo-inom. He also admitted that he started drinking alcoholic beverages at the age of 13 until now usahay, kada adlaw na gyud ko maka-inom, labi na ug manghagad na akong mga barkada, he also smokes and according to him, na, mga tunga sa kaha siguro akong mahurot sa isa ka adlaw.

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ONSET OF ILLNESS It was on August 7, 2011 at around 7 oclock in the evening when Patient P felt pain on his abdomen specifically at the Right Lower Quadrant. According to him, dili nako masabot ang kasakit, basta sakit gyud. Mrs. P verbalized kadtong misakit iya tiyan, paimnon lang nako ug ininit na tubig unya haplasan dayon nako ang iyang tiyan. Patient P suffered the pain on his abdomen for almost a week, until on August 19, 2011, his wife decided to send him to a Physician for check-u because he observed that Patient P is pale and the sclera is yellowish. So they went to Dr. Ds clinic here in Butuan City and the doctor advised them to go to a hospital for ultrasound

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The day after, August 20, 2011 Mrs. P decide and brought Patient P to the hospital because Patient P claimed severe pain and headache. He was admitted at Butuan Medical Center at around 4:30 oclock in the afternoon with Chief Complaint of Epigastric Pain for 2 weeks, yellowish sclera for 1 week. His admitting Vital Signs were as follows: Temperature- 37.9oC Pulse- 85 bpm RR-24 cpm Blood Pressure- 90/60 mmHg with Dr. L as his admitting Physician with the admitting order of: Please admit TPR every shift NPO CBC, BT

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TEST
Hemoglobin
DEFINITION

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RESULT

UNIT

REFERENGE RANGE

INTERPRETATIO N

CLINICAL SIGNIFICANCE

A substance contained within the RBC and is responsible for their color. It has the unique property of combining reversibly with oxygen and is the medium by the oxygen is transported within the body.

95

G/L

125 155

Decreased

Below-average concentration of the oxygen-carrying hemoglobin proteins in your blood. Low hemoglobin is referred to as anemia.

Hematocrit

This is the volume of the red cells ion blood, expressed as fraction of the total volume of the blood.

0.28

0.36 0.48

Decreased

A low hematocrit is found in anemia. It is caused by: Decreased production: if your body does not make erythropoietin or your bone marrow does not work properly, you may become anemic. Increased destruction Blood loss

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White Blood Cell

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Leukocytes or white cells are responsible for the defense of the organism

27.80

10^9/L

5.0-10.10

Increased

Bone marrow depression, infection

Red Blood Cell

These cells are nonnucleated, biconcave discs that are filled with hemoglobin. The primary function of these cells is to carry oxygen from the lungs to the body cell.

3.99

10^12/L

3.5-5.6

Normal

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MCV

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The mean corpuscular volume or MCV is the measure of the average red blood cell volume that is reported as part of a standard complete blood count.

69.0

fL

82-92

Decreased

Microcytic anemia, iron deficiency anemia, hypocromic anemia, thalassemia

MCH

That mean corpuscular hemoglobin or mean cell hemoglobin is measure of a mass of hemoglobin contained by a red blood cell. It is reported as a part of a standard complete blood count. it is calculated by dividing the total mass of hemoglobin by the RBC count

23.8

Pg

27-32

Decreased

Microcytic anemia, iron deficiency anemia

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MCHC

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PLATELET

The mean corpuscular hemoglobin concentration or, MCHC, is the measure of concentration of hemoglobin in a given volume of packed RBC. It is reported as part of a standard complete blood count. One of the irregular cell fragments of blood; involved in clotting.

345

G/L

320-380

Normal

298

10^9/L

150-400

Normal

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Differential Count

The blood differential test measures to relative numbers of WBC in the blood. It also includes information about abnormal cell structure and the presence of immature cells.

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NEUTROPHILS

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0.8 These granulocytes have 4 very thin light staining granules. The nucleus is frequently multi-lobed with lobes connected to thin strands of nuclear material. These cells are capable of phagocytizing foreign cells, toxins and viruses.

0.50-0.70

Increased

Inflammatory disease or response, granulocytic leukemia, and other malignancies, acute stress response, bacterial infection

LYMPHOCYTES

0.1 These cells play an 0 important role in our immune response. The Tlmphocytes act against virus infected cells. The Blymphocytes produce antibodies.

0.20-0.40

Decreased

Corticosteroids, immunosuppressive drug

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MONOCYTES

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These cells leave the blood stream to become macrophages. As a monocyte or macrophage, these cells are phagocytic and defend the body against viruses. The granules contain digestive enzymes that are particularly effective against parasitic worms in the larval form. These cells also phagocytize anti-gen antibody complexes.

0.06

0.02-060

Normal

EOSINOPHILS

0.07

0.02-0.05

Increased

Allergic reactions, parasitic infections, cancers, pernicious anemia

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MONOCYTES

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These cells leave the blood stream to become macrophages. As a monocyte or macrophage, these cells are phagocytic and defend the body against viruses. The granules contain digestive enzymes that are particularly effective against parasitic worms in the larval form. These cells also phagocytize anti-gen antibody complexes.

0.06

0.02-060

Normal

EOSINOPHILS

0.07

0.02-0.05

Increased

Allergic reactions, parasitic infections, cancers, pernicious anemia

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BASOPHILS The basophilic granules in

0.005-0.01

these cells are large, stain deep blue to purple, and are often so numerous they mask the nucleus. These granules contain histamines (cause vasodilatation) and heparin (anticoagulant).

Blood Type : O+ Remarks:HBsAg=NonReactive UTZ, whole abdomen U/A

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Property/Consti tuents COLOR Definition

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Result

Reference/Value

Interpretation

Clinical Significance

Urine color ranges from pale yellow to deep amber the result of a pigment called urochrome and how diluted or concentrated the urine is.

Dark Yellow

Light straw to dark amber yellow

Normal

TRANSPARENCY

cloudy

Clear

Not Normal

Indicates presence of protein in urine.

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Ph It is hydrogen concentration of the urine. It is a measurement of the acid or alkaline status of the urine.

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6.0

4.5-8.0

Normal

Acid urine associated with diabetes mellitus, diarrhea, and dehydration. Alkaline urine is found on patients with UTI, and chronic renal failure.

SPECIFIC GRAVITY

It is the measurement of the urine.

1.010

1.005-1.030

Normal

Increased urine specific gravity are caused by increased concentration of various substances contributing to urine and increased water loss in the body.

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9:31AM

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Albumin: Trail Sugar: Negative

S/E Ay 4:55 oclock in the afternoon the Doctors order were as follows: Start IVF with D5LR Fast drip 200cc then 300cc gtts/ min. Ranitidine 1 ampule IVTT STAT then every 8 hours

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Generic Name: Ranitidine Classification: Anti-ulcer agents, Histamine H2 antagonists Action: Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. Ranitidine bismuth citrate has some antibacterial action against H. pylori. Indication: Treatment and prevention of heartburn, acid indigestion, and sour stomach. Contraindications: Hypersensitivity, Cross-sensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance. Use cautiously in renal impairment, geriatric patients (more susceptible to adverse CNS reactions), pregnancy or lactation. Side Effects: Confusion, dizziness, drowsiness, hallucinations, headache, arrhythmias, altered taste, black tongue, constipation, dark stools, diarrhea, druginduced hepatitis, nausea, decreased sperm count, impotence, gynecomastia, agranulocytosis, Aplastic Anemia, neutropenia, thrombocytopenia, pain at IM site

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Nursing Considerations: 1. Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. 2. Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid. 3. Inform patient that it may cause drowsiness or dizziness. 4. Inform patient that increased fluid and fiber intake may minimize constipation. 5. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional promptly. 6. Inform patient that medication may temporarily cause stools and tongue to appear gray black. At 4:59 oclock in the afternoon, Doctors order made by Dr. L was as follows: Hyoscine N-Butylbromide 1 ampule IVTT STAT

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Generic Name: Hyoscine N-Butylbromide Classification: Anti-infectives Action: Inhibit muscarinic actions of acetylcholine on autonomic effectors innervated by postganglionic cholinergin neurons. May affect neural pathways originating in the inner ear to inhibit nausea and vomiting. Indication: Spatic states, delirium, preanesthetic sedation, and obstetric amnesia with analgesic. To prevent nausea and vomiting from motion sickness. Contraindication: In patient with angle closure glaucoma, obstructive uropathy, obstructive disease of the G.I tract, asthma, chronic pulmonary disease, myasthenia gravis. Use cautiously in patient with autonomic neuropathy, hyperthyroidism, coronary artery disease.

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Side Effects: Disorientation, irritability, constipation, dry mouth, nausea, vomiting, epigastric distress. Nursing Consideration: 1. Overdose may cause curare like effects, such as respiratory paralysis. 2. Raise side rails as a precaution because some patients become temporarily excited or disoriented and some develop amnesia or become drowsy. Reorient patient. 3. Alert patient to possible withdrawal signs and symptoms (nausea, vomiting, headache and dizziness). Ceftriaxone 1 amp IVTT every 8 hours (ANST)

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Generic Name: Ceftriaxone Classification: Anti-infective Action: Third-generation cephaloporins that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. Indication: UTIs; lower respiratory tract gynecologic, bone and joint, intraabdominal, skin, and skin-structure infections; septicemia. Contraindication: Hypersensitivity to drug or other cephaloporins. Use cautiously in breastfeeding women and in patient with history of colitis and renal insufficiency. Side Effects: Fever, headache, dizziness, diarrhea, pain, phlebitis. Nursing Consideration: 1. Ask for any hypersensitivity to drug. 2. Culture and sensitivity test before giving first dose. 3. Tell patient to report adverse reactions promptly.

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Refer to surgery STAT for further evaluation for abdominal pain and tenderness at RLQ At 5:30 oclock in the afternoon, Dr. Ls order was referred to Dr. D from surgery department for further evaluation. Dr. D had the order of: Advised to continue medication And at 6 oclock in the evening, Dr. L ordered the following: Close watch Refer for any unusualities Stand by dopamine At 8:25 oclock in the evening, the same Doctor had the following order: Start Metronidazole 500mg IV drip every 8 hours

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Generic Name: Metronidazole Classification: Anti-infective, antitrichomonal and amebicide , antibiotic Actions: Synthetic compound with direct trichomonal and amebicidal activity as well as antibacterial activity against anaerobic bacteria and some gramnegative bacteria. Indications: Acute with susceptible anaerobic bacteria; preoperative, intraoperative, postoperative prophylaxis for patients undergoing colorectal surgery Contraindications: Hypersensitivity to metronidazole; pregnancy (do not use for trichomoniasis in first trimester); use cautiously with CNS diseases, hepatic disease, candidiasis, blood dyscrasias, lactation Side Effects: Fatigue, unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, G.I upset, incontinence, darkening of the urine. Nursing Considerations: 1. Avoid use unless necessary. Metronidazole is carcinogenic in some rodents. 2. Avoid alcohol and alcohol containing drug. 3. Be aware that your urine may appear dark; this is expected.

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Start dopamine at 10-15 gtts/min. Generic Name: Dopamine Classification: Adrenergics Action: Stimulates dopaminergic and alpha and beta receptors of the sympathetic nervous system. Action is dose-related; large doses cause mainly alpha stimulation. Indication:To treat shock and correct hemodynamic imbalances, to improve perfusion to vital organs, to increase cardiac output, to correct hypotension. Contraindication: In patient with uncorrected tachyarrhythmias, pheochromocytoma, or ventricular fibrillation. Use cautiously in patient with occlusive vascular disease, cold injuries, diabetic ebdarterities, and arterial embolism in pregnant patient. Side Effects: Headache, hypotension, nausea, vomiting, tachycardia, dyspnea.

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Nursing Consideration: 1. Tell patient to report adverse reaction promptly. 2. Check urine output often. 3. After drug is stopped, watch closely for sudden dropped in blood pressure. August 21, 2011 Doctor L order for this day: Facilitate ultrasound Follow-up meds On the same day at 9:50 oclock in the evening the orders are the following: Administer O2 3L per minute Maintain Dopamine drip at 15 micro/min.

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August 22, 2011, the same doctor ordered: For Hepa B surface Antigen Secure and transfuse 1 unit of packed RBC of patient blood type properly screened and crossmtached. Transfuse for 4 hours The same doctor had the order on August 23, 2011, 8 oclock in the morning: D/C Ceftriaxone and metronidazole D/C ranitidine Tramadol + PCM (algeria) PRN

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9:45AM

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Generic Name: Tramadol Classification: Analgesics Action: Centrally acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin. Indication: Moderate to moderately severe pain. Contraindiaction: Hyperesensitivity to opioids, in breastfeeding women, and in those with acute intoxication, from alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic drugs. Side Effects: Nausea, constipation, vomiting, dyspepsia, dry mouth, diarrhea, abdominal pain, anorexia, flatulence

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9:50AM

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Nursing Considerations: 1. Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. 2. Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended doses. 3. Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects. 4. Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously received opioids for more than 1 wk; may cause opioid withdrawal symptoms. 5. Prolonged use may lead to physical and psychological dependence and tolerance, although these may be milder than with opioids. This should not prevent patient from receiving adequate analgesia. Most patients who receive tramadol for pain d not develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve pain.

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Ensure 4 scoop + 200 mL water QID Omeprazole 20mg/tab 1 tab OD Generic Name: Omeprazole Classification: Anti-ulcer Action: Omeprazole is converted to active metabolites that irreversibly bind and inhibit H+-K+-ATPase (an enzyme on the surface of gastric parietal cells). It inhibits transport of hydrogen ions into the gastric lumen. Omeprazole increases the gastric pH and reduces gastric acid formation. Indication: Shot-term treatment for erosive esophagitis and symptomatic gastroesophageal reflux disease (GERD) poorly responsive to other treatment. Omeprazole is used for the long-term treatment of pathologic hypersecretory conditions and active duodenal cancer. It is a maintenance healing of erosive esophagitis. Omeprazole can also be used in the treatment of H. pylori associated with duodenal ulcer and active benign gastric ulcers. It is also used in the prevention and treatment of NSAID-induced ulcers.

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9:55AM

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Contraindications: Hypersensitivity to drug; use cautiously in patients with hypokalemia and respiratory alkalosis. Side Effects: Headache, Diarrhea, Abdominal pain, Nausea, Dizziness, Asthenia (loss of strength), Vomiting, Constipation, Upper respiratory tract infection, Back pain, Rash, Cough Nursing Considerations: 1. Give before meals 2. Do not crush or chew tablets, swallow whole 3. Evaluate for therapeutic response like relief of gastrointestinal symptoms 4. Question if gastrointestinal discomfort, nausea, and diarrhea occurs. 5. Report headache

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9:57AM

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On August 24, 2011 was the very first interaction we had with Patient P and decided to be the Patient for our MINI PAR. This day, we observed that he is weak and claiming for abdominal pain which according to him is 10 when scaled it his breathing pattern was 34 cpm and had recently removed his oxygen inhalation because he prefer not to have it. At around 8 oclock in the morning, Dr. L had the Doctors order of the following: May go home anytime after BT continue supportive management Advised to position himself to comfort as always

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9:59AM

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This day, we had rendered care to Patient P by positioning himself according to his comfort we encouraged and taught him to do deep breathing exercises. We also instructed Mrs. P to always monitor Patient P and maintain him in his preferred position. We also instructed her to limit patients fluid intake as ordered by the Physician. At around 11 oclock, Patient P decided to refuse to have blood transfusion and decided to go home. He was discharged at around 4 oclock in the afternoon with the final diagnosis of HEPATOCELLULAR CARCINOMA.

Hazel M. Gultiano Physical Assessmentwith Manelyn P. Chato

Kevin Hulen G. Udarbe Anatomy and Physiology - Liver

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10:00AM

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Physical assessment is an essential part of the health history. A complete and well informed physical assessment needs a good and open conversation approach, both the student nurse and the client. The field requires the use of four senses, namely, the sense of sight, hearing, touch and the sense of smell through inspection, palpation, percussion, and auscultation in a cephalocaudal manner. It is conducted in a systematic and efficient manner that results in the fewest position changes for the client. There are some of the purposes of the Physical assessment. To obtain baseline data about the clients functional abilities; To supplement, confirm or refute data obtain in the nursing history; To obtain data that will establish nursing diagnosis and plan of care; To evaluate the physiologic outcome of health care and thus the progress of the clients health problem; To make clinical judgment about the clients health status; To identifies areas for health promotion and disease prevention.

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10:01AM

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The physical assessment of Patient P was done on August 24, 2011 at around 8:00 AM; it was during our clinical duty at medical ward, blue station at Butuan Medical Center. To aid with the assessment, the student nurses used the following instruments: BP apparatus, thermometer, wristwatch with second hand, penlight notebook and ballpen. General survey: Received patient lying on bed, awake with IVF #7 Plain LR at the level of 650 ml, regulated at 30gtts/min.; hooked at left metacarpal vein, infusing well. Patient P was weak-looking. He is responsive and communicates well. He stands 54 and weight 60 kg. His vital signs were as follows: temperature36.1C, pulse rate- 84 bpm, respiratory rate- 34 bpm and blood pressure90/60 mmHg.

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Body part (head to toe) Skin Inspection

10:02AM

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Palpation

Percussion

Auscultation

Patient Ps skin is yellowish in color, cold and dry. Hair skin is well distributed.

Head

Patients head was round in shape. With head circumference of 53 cm. His hair is black in color, dry and well distributed.

Patient has good skin turgor as evidenced by skin returns immediately to its original position within 1 second after pinching it. Patient has no report of pain or any abnormalities felt.

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Nose

10:03AM

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Mouth

External nose color is the same as face. External nares were round and symmetrical in shape. Nose hairs are also present. Can breathe through one nostril when the other nostril is pressed. Patient P has a thin and pale color lips and slightly dry. Set of tooth is incomplete with floss at the upper part of molar and the oral mucosa was pale. The teeth were yellowish in color.

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Neck

10:04AM

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Thorax lungs

Head movements were smooth, controlled and coordinated. He was able to perform range of motion of the head such as when Patient P was asked to turn his head upward and downward, left and right with any restrictions. and Respiratory rate is 34 breaths per minute in relaxed position.

Carotid pulse can be felt upon palpation at 84 bpm. Trachea was palpable and positioned in midline.

Theres no any alterations noted. The patient has clear sound during inhalation and exhalation.

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10:05AM

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Abdomen (IAPP)

Abdomen was flat. With abdominal circumference of 79 cm.

Abdomen was dull.

Patient X has as apical pulse of 83 beat per minute. Normal heart sounds were heard such as lubb-dubb sounds. Bowel sound is 22, which is in normal range.

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Genitalia

10:06AM

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According to Patient P, he usually urinates 4-6 times a day with minimal amount without difficulties. According to Patient P, he defecates once a day without difficulties.

Anus

Back

Patient P can stand erect. He is able to perform some of the range of motion such as lateral bending and flexion.

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10:07AM

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Upper Extremities

The upper extremities were symmetrical in size. He was able to perform range of motion when instructed such as flexion, extension, external rotation and circumduction. Nail plates are flat and nail beds are yellowish in color, dry and brittle.

Both arms were cold when touch. Right and left radial pulse was palpable and recorded at the rate of 84 beat per minute. Capillary refill is within 4 second.

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10:08AM

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Lower Extremities

Lower extremities were symmetrical in size. He was able to flex and extend both legs as instructed. Nail beds are yellowish in color, dry and brittle.

Skin was cold clammy when touched. Patient Ps capillary refill return within 4 second.

Hazel M. Gultiano Physical Assessmentwith Manelyn P. Chato

Kevin Hulen G. Udarbe Anatomy and Physiology - Liver

Irvin G. Sofocado Victor Emmanuel TyPathophysiology on Hepatocellular Carcinoma

Candice Fatima R. Manile NCP Prioritization Nursing Care Plan

Irvin G. Sofocado PathophysiologyHepatocellular Carcinoma

Candice Fatima R. Manile NCP Prioritization and Nursing Care Plan

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NCP #
1

11:15AM

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PROBLEM

DATE IDENTIFIED

DATE EVALUATED

Ineffective breathing pattern related to liver August 24, 2011 August 24, 2011 enlargement secondary to Hepatocellular Carcinoma
Doenges, Metal Nursing Care Plans, Guidelines for Individuality, Edition 7, pp. 238 240

Altered Tissue Perfusion related to reduction of cellular components necessary for the delivery of oxygen/nutrients to the cells

August 24, 2011 August 24, 2011

Acute Pain related to Liver enlargement secondary to Hepatocellular Carcinoma

August 24, 2011 August 24, 2011

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11:16AM

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Subjective: Punga kayo i-ginhawa Objective cues: RR- 34bpm Use of accessory muscles to breathe Nasal flaring Irritable Nursing Diagnosis: ineffective Breathing Pattern related to Liver Enlargement secondary to Hepatocellular carcinoma. Planning: Within 4 hours of nursing interventions, the patient will be able to demonstrate use of technique to promote and enhance breathing.

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INTERVENTION

11:16AM

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RATIONALE For baseline data and for future comparison

Monitor vital signs

Determine presence of physical For the nurse to give the appropriate condition that would cause breathing nursing intervention impairment Assess respiratory rate depth and effort Rapid shallow respiration may be present due to hypoxia Assess for concomitant pain/discomfort This condition may restrict or limit effort

Assess changes in level of consciousness Changes in mentation may reflect hypoxemia

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11:17AM

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Keep the head of the bed elevated and To facilitate breathing by reducing position the patient on the side pressure on the diaphragm Demonstrate how to do deep breathing Aid in lung expansion and relaxation

instruct to loosen clothing neck/chest and abdominal areas Encourage adequate rest period

from Facilitates breathing/chest expansion

To prevent fatigue and consumption of energy

Collaborative: Administer supplemental oxygen via nasal prevent/treat hypoxia cannula 3L/min to

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11:17AM

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EVALUATION: After 4 hours of nursing interventions, the patient was be able to demonstrate use of technique to promote and enhance breathing.

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11:18AM

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Subjective: Objective cues: Pallor of skin Dry hair Brittle nails Cold extremities Capillary refill- 4 seconds Nursing Diagnosis: Altered Tissue Perfusion related to reduction of cellular components necessary for the delivery of oxygen/nutrients to the cells. Planning: Within 2 hours of nursing interventions, the patient will be able to demonstrate adequate perfusion as individually appropriate. E.g. Vital signs, good capillary refill, adequate urine output.

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INTERVENTION

11:18AM

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RATIONALE

Monitor Vital signs, assess capillary refill, Provides information about degree/adequacy color of skin/mucous membranes, nail beds. tissue perfusion and helps to determine need of interventions. Monitor respiratory effort, auscultate breath Presence of dyspnea, crackles may reflect sounds noting adventitious sounds. developing CHF due to prolonged cardiac strain/compensatory elevation of cardiac output. Elevate head of bed as tolerated. Enhances lung expansion to maximize oxygenation for cellular uptake. NOTE: may be contraindicated if hypotension is present. Encourage to avoid use of heating pacts or Thermoreceptors in the dermal tissue may hot water bottles. Measure temperature of dulled due to oxygen deprivation. bath water with a thermometer.

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11:19AM

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Encourage quiet, restful atmosphere.

Conserves energy/lowers oxygen demands.

tissue

Exercise caution in use of hot water Tissues may be have decreased bottles or heating pads. sensitivity due to ischemia, and heat also increases the metabolic demands if already compromised tissues. Encourage smoking cessation, provide Smoking causes vasoconstriction and information/refer to stop-smoking may further compromise perfusion. programs. Advice to take green leafy vegetables To aid in promoting oxygen carrying rich in iron such as ampalaya, components of the cell. malunggay, and liver and/or iron supplements.

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11:19AM

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Encourage to increase fluid intake as Promote adequate urine output. tolerated. Remind not to do strenuous activities. Prevent increase of oxygen demand.

Collaborative: Monitor laboratory studies. E.g Hgb/Hct Identifies deficiencies and treatment and RBC count, ABGs. needed to response to therapy. Administer whole blood/packed RBCs, Increase number of oxygen-carrying blood products as indicated. Monitor cells corrects deficiencies to reduce risk closely for transfusion complications. of hemorrhage Administer supplemental oxygen as Maximize oxygen transport to the indicated. tissues.

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11:20AM

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EVALUATION: After 2 hours of nursing interventions, the patient was able to demonstrate adequate perfusion as individually appropriate. E.g. Vital signs, good capillary refill, adequate urine output.

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11:20AM

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Subjective: Sakit akong tiyan, 10 gyud sa imung gi ingon Objective cues: Grimace RR- 34bpm Diaphoretic Guarding behavior Irritable Nursing Diagnosis: Acute Pain related to Liver enlargement secondary to Hepatocellular Carcinoma Planning: Within 2 hours of nursing interventions, the patient will be able to demonstrate use of relaxation skills as indicated for the patients situation.

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INTERVENTION

11:21AM

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RATIONALE To have a baseline data to monitor alterations Pain is a subjective experience and cannot be felt by others

1. Monitor skin color and vital signs 2. Identify patients description of pain

3. Obtain patients assessment of pain, the To rule out worsening of underlying location, onset/duration, frequency, quality condition/ development of and intensity. complications 4. Encourage to promote adequate rest To prevent fatigue periods 5. Encourage and demonstrate to do deep To assist in muscle and to promote breathing exercise relaxation

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6. Teach to do splinting technique

11:22AM

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This procedure may alleviate pain and somehow promote relaxation non-pharmacological pain

7. Provide comfort measures such as touch and To promote repositioning every 2 hours management 8. Encourage to do pursed-lip breathing

> To assist patient in taking control of the situation > To promote self relaxation

9. Encourage to position self in comfort

Collaborative: 1. Administer Tramadol + PCM (algeria) PRN

Centrally acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin.

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11:23AM

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Evaluation: Goal Met. After 2 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills as indicated for the patients situation as evidenced by performing deep breathing exercises , pursed lip breathing and doing the splinting technique.

Naphlyn Montero Beranados Nisas

Discharge Plan

Irvin G. Sofocado

Learning Outcome

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11:24AM

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M-(medication) E-(Environment) Encouraged to stay in clean, calm, and environment that is conducive for recovery. Encouraged to have proper ventilation in order to promote relaxation. Encouraged to stay in an environment that is safe and free from falls and injury. Advised to significant others to always arrange things on the house to avoid accident to the patient. Advised to significant others to keep those things those are sharp to avoid accident to patient. T-(Treatment) Informed patient to have a follow up check up. Reminded patient to return if there is presence of complications.

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11:26AM

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H-(Health teaching) Encouraged to wash her hand before and after eating or touching dirty things. Instructed to avoid doing strenuous activities. Encouraged to have adequate rest periods. Encouraged to take 8-10 glasses of water a day for hydration as tolerated. Stressed the importance of proper hygiene like hand washing, toileting, tooth brushing. Encouraged deep breathing and coughing exercises among the patient. Instructed to keep back dry and change cloth if wet. Encouraged to quit smoking and alcohol drinking as this may worsen his condition.

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11:27AM

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O-(Observable signs & symptoms) Instructed to seek physician/visit the nearest health center if exacerbation of condition occurs. D-(Diet) Reminded to eat fruits and green leafy vegetables. Foods rich in iron, protein and carbohydrates such as meat, nuts to promote healing. Encouraged to eat foods rich in iron like, ampalaya, malunggay, and liver. S-(Spiritual) Advised patient to keep on believing in God so that he could be spiritually motivated. Encouraged to constantly participate to religious activities so that his faith could be more strengthened. Counseled significant other to provide spiritual and emotional support as this is greatly needed by the patient for the acceptance of his condition.

Naphlyn Montero Beranados Nisas

Discharge Plan

Irvin G. Sofocado

Learning Outcome

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1:00 PM

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2:00 PM

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Introduction

Nursing Health History

Physical assessment

Anatomy & Physiology

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1:00 PM

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2:00 PM
NCP #2

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Cues : O > 4 days post partum with episiotomy > Pale looking > Diaphoresis > Hemoglobin of 74; normal ranges 125- 175 > Hematocrit of 0.23; normal range 0. 36 0.48. Nursing Diagnosis: Ineffective tissue perfusion, cardiopulmonary related to decreased Hemoglobin concentration in the blood.

Planning: Within 3 of nursing interventions the patient will be able to verbalize Understanding of condition, therapy regimen and when to contract the health care provider.

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2:00 PM

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Interventions and Rationale: Independent Measures: 1. Assess the general patient condition of the patient. To render appropriate interventions. 2. Note presence / degree of dyspnea, cyanosis, hemoptysis. To assess causative / contributing factors 3. Review the laboratory result To assess causative/ contributing factors| 4. Monitor vital signs, heart sounds and cardiac rhythm. To assess the patient condition 5. Encourage quit, restful atmosphere To conserves energy/ lowers tissue with demands.