Peritoneal Carcinomatosis Grand Case Study

ASCITES SECONDARY TO PERITONEAL TUBERCULOSIS, RULE OUT PERITONEAL CARCINOMATOSIS
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A Case Study Presented to the College of Health Sciences Faculty Notre Dame University Cotabato City
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In Partial Fulfillment of the Requirements for the Degree of BACHELOR OF SCIENCE IN NURSING
By
Alim, Suharto U. Ambolodto, Sandra Mae A. Cadungog, Evelyn Claire O. Gorospe, Irish Kate A. Rubi, Beverly Joy A. Sero, Valerie P. Sumampao, Diamond M. Suyom, Jessieden E.
December 13, 2012
Ascites Secondary to Peritoneal ACKNOWLEDGEMENT
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This case study would not have been provided, done and studied if not for the support of the people who unselfishly contributed their time, knowledge, skills, and effort. With grateful heart and minds, the group would like to extend their gratitude to the following: The Almighty Father, source of strength, wisdom, and knowledge for giving them hope and enlightenment, which they need to accomplish these study. Their beloved parents, for providing them financial assistance that made possible the compilation of their study and for inspiring, and giving them enough strength, and courage in pursuing their study. Lyreyann A. Cordero, RN for assisting and guiding the group in their case study and checking their case written output. The Cotabato Regional and Medical Center and staff of medicine ward for the trust and time, thus, giving us enough time to gather relevant data to our patient and the staff of emergency department for supervising us upon duty hours and assisted us on the delivery of quality nursing service. To our client and her family, for their trust, willing participation, and allowing the group to render appropriate nursing service and conduct an interview, assessment and study on her disease process. To Maureen Laurice T. Cases, RN, their adviser for critiquing and checking their work, sharing her expertise, comments, and suggestions which added to the groups knowledge improved the study.
Ascites Secondary to Peritoneal TABLE OF CONTENTS
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Page TITLE PAGE ...................................................................................................................... i i ACKNOWLEDGEMENT.............................................................................................. ii CHAPTER I INTRODUCTION Overview of the Case........................................................1 Incidence........................................................................ 1 Rationale for Choosing the Case.......................................... 2 OBJECTIVES General Objective.......................................................... 3 Specific Objectives................................................................. 3 PATIENTS HISTORY............................................................. 4
CHAPTER II
CHAPTER III CHAPTER IV
PHYSICAL ASSESSMENT............................................................... 7 General Physical Survey................................................. 7 Focus Assessment.............................................................11 REVIEW OF ANATOMY & PHYSIOLOGY............................ 13 PATHOPHYSIOLOGY .. 18 Narrative Discussion.........................................................18 Schematic Diagram............................................................ 19 COURSE IN THE HOSPITAL 21 NURSING CARE PLAN ... 28 DRUG STUDY.36 LABORATORY STUDY........... 45 PROGNOSIS .. 59 DISCHARGE SUMMARY PLAN ... 62 BIBLIOGRAPHY ... 65
CHAPTER V CHAPTER VI
CHAPTER VII CHAPTER VIII CHAPTER IX CHAPTER X CHAPTER XI CHAPTER XII CHAPTER XIII
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CHAPTER I
INTRODUCTION
Peritoneal carcinomatosis (PC) is a type of secondary cancer that affects the lining of the abdominal cavity, called the peritoneum. It occurs when cancer metastasizes from another part of the body and implants into the lining. Peritoneal carcinomatosis most commonly follows severe or untreated pancreas, ovarian, stomach, and colon cancer. Symptoms can vary, but many people experience extreme fatigue and abdominal pain. Quick, aggressive treatment in the form of medications and surgery is vital in preventing fatal complications (Jeffress, 2012). Tumor growth on intestinal surfaces and associated fluid accumulation eventually result in bowel obstruction and incapacitating levels of ascites, which profoundly affect the quality of life for affected patients. Recently, population-based studies have revealed that PC occurs relatively frequently among patients with colorectal cancer (CRC). Risk factors for developing PC have been identified: right-sided tumor, advanced T-stage, advanced N-stage, poor differentiation grade, and younger age at diagnosis (Klaver et. al, 2012). Peritoneal carcinomatosis represents a devastating form of cancer progression with a very poor prognosis (Kusamura et. al, 2010). In Germany, 66,000 new cases are diagnosed every year. Up to 25% of those patients develop a peritoneal carcinomatosis (Sugarbaker et. al, 2007). Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are playing an ever increasing role in the treatment of peritoneal carcinomatosis (Austin et. al, 2012).
Ascites Secondary to Peritoneal Although survival benefit of this procedure has been reported in numerous literatures, this treatment is still not widely accepted worldwide because of the necessity of long learning curves for application of these techniques and high postoperative mortality and morbidity rates (Mizumoto, 2012). Most patients with this condition will not live much longer than two years without treatment. The shortest time they usually survive is only
six months. According to the peritoneal carcinomatosis survival rate statistics, 17% of the patients who received treatment died after surgery (Peritoneal Health, 2010). The most common cause of peritoneal carcinomatosis in women is ovarian cancer. Two-thirds of women with ovarian cancer present with abdominal dissemination of disease, the standard management of which comprises surgical debulking followed by chemotherapy (Johnson, 1993). The researchers chose this case because they wanted to know more about this type of cancer since this case has long been considered a fatal clinical entity, rarely seen and treated palliatively, thus it will help and add additional learnings from what they had already learned from their past concept, thus, this study will help them give appropriate health teachings for their future clients with the same cancer called peritoneal carcinomatosis.
CHAPTER II
OBJECTIVES
General Objective: This case study aims to understand the disease process of Peritoneal Carcinomatosis and to learn about its aftermath in the human body; thereby helping us, the student nurses to be guided on how to deal with clients with the said condition, especially the implementation of nursing care.
Specifically, the study aims to: 1. Organize patients data to establish good background information. 2. Review the health history. 3. Understand the definition of Peritoneal Carcinomatosis. 4. Determine the signs & symptoms and complications manifested by the patient. 5. Discuss the normal functioning of the Gastrointestinal System. 6. Present the pathophysiological basis of the disease. 7. Study the different laboratory and diagnostic tests. 8. Understand the significance of specific medications given to the patient. 9. Formulate and prioritize different nursing care plans. 10. Impart appropriate health teachings to the patient and as well as to the family. 11. Discuss discharge plan and prognosis for the continuity of care. 12. Assist future researches that they may use the output as basis for further research.
CHAPTER III
PATIENTS HISTORY
NAME: AGE: SEX: CIVIL STATUS: NATIONALITY: ADDRESS: DATE OF BIRTH: RELIGION: OCCUPATION:
Ms. Bella 23 years old Female Single Filipino RH 4, Cotabato City November 30, 1989 Roman Catholic Housewife
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DATE/TIME OF ADMISSION: PREVIOUS ADMISSION: ATTENDING PHYSICIAN: ADMITTING V/S:
December 5, 2012 / 11:10 am November 22-30, 2012 Nelson P. Gilapay, MD T: 36.5C RR: 25 bpm Ht: 51 HR: 98bpm BP: 120/90 mmHg Wt: 42 kg
CHIEF COMPLAINT: ADMITTING DIAGNOSIS:
Abdominal distention Ascites secondary to Peritoneal Tuberculosis, rule out Peritoneal Carcinomatosis
Ascites Secondary to Peritoneal Past Illness History
Long before, the patient was living a simple and happy life. She experienced childhood illness such as German measles during her fourth grade. She loves chicken so much and does not necessarily do exercise. She formerly worked as a clerk. Years passed by, this young lady turns into a lovely maiden, August 2012; she was admitted and delivered her first child, a baby girl, via Normal Spontaneous Vaginal Delivery at Cotabato Regional and Medical Center. She claimed to have regular prenatal visit in the same institution. She had no extraordinary qualms during her pregnancy. Two months after her delivery, she noticed to have constipation for few days and took one dose of laxative (Dulcolax). However, constipation persists and abdominal distention was observed by her and her family. Despite of these manifestations, they did not immediately seek any medical attention. One month prior to admission, patient consulted a private physician and requested for abdominal CT scan but failed to comply. Last November 22, 2012, she was admitted with chief complaints of constipation and abdominal distention. She was diagnosed with peritoneal carcinomatosis. She was then discharged last November 30, 2012, with take home medications of Furosemide 40mg 1 tablet once a day, Spironolactone 25mg 1 tablet for twice a day, Vitamin B complex + Folic acid + Ferrous sulfate 1 capsule twice daily, and Vitamin C (Poten cee) 1 tablet twice a day, Ciprofloxacin 500mg 1 tablet twice daily, and Domperidone 1 tablet three times a day, and was encouraged to increase fiber in the diet.
Ascites Secondary to Peritoneal Present Illness History
She was supposed to come back for follow up checkup on December 5, 2012 but a day before her follow up checkup, she was hurriedly brought to the same hospital due to progressive abdominal distention and difficulty of breathing, and was admitted.
Family History On the clients mother side, she claimed a positive history of hypertension, and her uncle died a year ago from liver cirrhosis, but no idea about the health history on her father side.
CHAPTER IV
PHYSICAL ASSESSMENT
Appearance and Behavior

1. Age, Sex, and Race 2. Body Build 3. Posture and Gait -23 years old, Female, Asian -Ectomorphic; emaciated -Coordinated movement when sitting and walking with difficulty. 4. Hygiene and Grooming -Slightly clean and neat, unfixed hair, untrimmed nails 5. Dress 6. Odor of the body and breath 7. Signs of distress 8. Apparent state of health -Appropriate for age, place and climate -Slight foul smell noted on body and breath -Mild respiratory distress -Use accessory muscles when breathing, anxious, pain scale of 6/10. 9. Attitude 10. Affect and mood -Cooperative with treatment -Cooperative with treatment, expresses feelings regarding her condition 11. Speech 12. Thought Process -Understandable, moderate pace, clear tone -Conscious, oriented, coherent, follows direction
Ascites Secondary to Peritoneal Skin Fair skin. Has smooth skin texture, no presence of wounds. Hair is well distributed on both parts of the body, nails are untrimmed. Skin returns back after 3-4 seconds when doing skin turgor; warm to touch.
Head Skull is oval, smooth skull contour, uniform consistency, no tenderness palpated, absence of nodule or mass with symmetrical facial features and movements.
Eyes Eyebrows are evenly distributed, symmetrically aligned, equal movements of the eye; eyelashes are equally distributed, curved and slightly outward. Eyelids skin is intact, closes symmetrically, bilateral blinking, bulbar conjunctiva is clear with tiny vessel, and palpebral conjunctiva is pink with no discharge. Sclera appears moist.
Ears Ears are symmetrical, color same as face, firm and not tender; Pinna coils after it folded. Presence of mass, lesions, lacerations, bruises, swelling was not seen upon inspection. No unusual discharge noted.
Mouth Slightly dry lips, yellowish teeth, pale gums, no swelling noted; Tongue is pink in color, no lesions, no tenderness, no palpable nodules, uvula is position on midline of soft palate. Tonsils are not inflamed, slight halitosis noted upon assessment.
Ascites Secondary to Peritoneal Nose Nose is symmetrical and straight, without nasal discharge, uniform in color, not tender, no lesions; nasal septum is intact and located in the midline. External surface of the patients nose is smooth and oily.
Neck Patient can move his neck freely without any difficulty. No lesions, masses, deformities noted upon inspection. No neck vein enlargement.
Chest/Lungs Chest and lung expansion symmetry are equal, with mild respiratory distress, intercostals spaces are equal but labored; respiratory, rhythm and depth are even, respiratory rate of 25 breaths/min, evident use of accessory muscles when breathing.
Abdomen Patients abdomen is distended. Abdominal girth is 93 cm. Scars noted on her right lower quadrant of the abdomen due to paracentesis, and left lower quadrant of the abdomen due to biopsy procedure. Have palpable masses at all quadrants of the abdomen.
Genito-urinary Has regular urination. No indwelling catheter present.
Upper extremities Patients upper limbs, shoulders and arms were symmetrical but thin. No
Ascites Secondary to Peritoneal
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deformities and swelling noted. No tenderness on the bones of the wrists and fingers and no structural deviations.
Lower extremities Patients lower limbs are symmetrical but thin. No deformities and swelling noted.
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FOCUS ASSESSMENT
Abdominal Assessment A. INSPECTION
1. Skin Color of the abdomen is same with other parts of the body; smooth and shiny in texture with visible veins observed. 2. Umbilicus Flat, centrally located at the midline; pale in color. 3. Contour Distended and round in contour. 4. Symmetry Abdomen is symmetrical upon inspection. 5. Enlarged organs No enlarged organs based on diagnostic tests. 6. Peristalsis No peristalsis noted upon inspection. 7. Pulsation No pulsation noted upon observation.
B. AUSCULTATION 1. Bowel sounds Hypoactive bowel sounds heard in all four quadrants upon auscultation.
Ascites Secondary to Peritoneal C. PERCUSSION 1. Entire Abdomen Dullness noted in all quadrants of the abdomen.
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D. PALPATION 1. Measure Abdominal Girth 93cm
E. Special Maneuvers
1. Assess for possible ascites Has visible veins observed upon inspection; ascites noted. 2. Testing for shifting dullness Positive for shifting dullness, dullness of percussion shifts as patient was turned from side to side. 3. Testing for fluid wave Positive fluid wave transmitted from one abdominal wall side to the other side upon placing a hand on one side of the abdomen, then pressing the opposite side of the abdomen with the other hand, shifting the fluid.
CHAPTER V
REVIEW OF ANATOMY & PHYSIOLOGY
The Abdomen and the Gastrointestinal System
The abdomen (commonly called the belly) is the body space between the thorax (chest) and pelvis. The diaphragm forms the upper surface of the abdomen. At the level of the pelvic bones, the abdomen ends and the pelvis begin. The abdomen contains all the digestive organs, including the stomach, small and large intestines, pancreas, liver, and gallbladder. These organs are held together loosely by connecting tissues (mesentery) that allow them to expand and to slide against each other. The abdomen also contains the kidneys and spleen. Many important blood vessels travel through the abdomen, including the aorta, inferior vena cava, and dozens of their smaller branches. In the front, the abdomen is protected by a thin, tough layer of tissue
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called fascia. In front of the fascia are the abdominal muscles and skin. In the rear of the abdomen are the back muscles.
Abdominal organs Digestive tract: Stomach, small intestine, large intestine with cecum and appendix Accessory organs of the digestive tract: Liver, gallbladder and pancreas Urinary system: Kidneys and ureters - but technically located in retroperitoneum outside peritoneal membrane Other organs: Spleen
Introduction to the gastrointestinal system
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls. The primary purpose of the gastrointestinal tract is to break food down into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then
Ascites Secondary to Peritoneal absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of faeces).
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The Peritoneum The peritoneum is the serous membrane that forms the lining of the abdominal cavity or the coelomit covers most of the intra-abdominal (or coelomic) organs in amniotes and some invertebrates (annelids, for instance). It is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum both supports the abdominal organs and serves as a conduit for their blood and lymph vessels and nerves. The abdominal cavity (the space bounded by the vertebrae, abdominal muscles, diaphragm and pelvic floor) should not be confused with the intraperitoneal space (located within the abdominal cavity, but wrapped in peritoneum). The structures within the intraperitoneal space are called "intraperitoneal" (e.g. the stomach), the structures in the abdominal cavity that are located behind the intraperitoneal space are called "retroperitoneal" (e.g. the kidneys), and those structures below the intraperitoneal space are called "subperitoneal" or "infraperitoneal" (e.g. ththe bladder). The peritoneal membrane is a semi-permeable membrane that lines the abdominal wall (parietal peritoneum) and covers the abdominal organs (visceral peritoneum). The membrane is a closed sac in males. The fallopian tubes and ovaries open into the peritoneal cavity in females. The size of the membrane approximates the body surface
Ascites Secondary to Peritoneal area (1-2 m2). There are about 100 cc of transudate that is contained in the cavity in normal individuals. A. Blood Supply The parietal peritoneum derives its blood supply from the arteries in the abdominal wall. This blood drains into the systemic circulation. The visceral peritoneum is supplied by blood from the mesenteric and celiac arteries which drain into the portal vein. B. Lymphatics Subdiaphragmatic lymphatics are responsible for 80% of the drainage from the peritoneal cavity. The drainage is then absorbed into the venous circulation through the right lymph duct and the left thoracic lymph duct. A
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balance of solutes and fluid in the interstitial tissue is maintained by absorption of fluid from the peritoneal cavity. The average lymphatic rate of absorption in the PD patient is 0.5-1.0 ml/min. Factors that affect the rate of absorption are respiratory rate, posture, and intra-abdominal pressure.
Layers Although they ultimately form one continuous sheet, two types or layers of peritoneum and a potential space between them are referenced: The outer layer, called the parietal peritoneum, is attached to the abdominal wall. The inner layer, the visceral peritoneum, is wrapped around the internal organs that are located inside the intraperitoneal space. The potential space between these two layers is the peritoneal cavity; it is filled
Ascites Secondary to Peritoneal with a small amount (about 50 mL) of slippery serous fluid that allows the two layers to slide freely over each other.
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The term mesentery is often used to refer to a double layer of visceral peritoneum. There are often blood vessels, nerves, and other structures between these layers.
Subdivisions There are two main regions of the peritoneum, connected by the epiploic foramen (also known as the omental foramen or foramen of winslow): The greater sac (or general cavity of the abdomen), represented in red in the diagrams above. The lesser sac (or omental bursa), represented in blue. The lesser sac is divided into two "omenta": The lesser omentum (or gastrohepatic) is attached to the lesser curvature of the stomach and the liver. The greater omentum (or gastrocolic) hangs from the greater curve of the stomach and loops down in front of the intestines before curving back upwards to attach to the transverse colon. In effect it is draped in front of the intestines like an apron and may serve as an insulating or protective layer. The mesentery is the part of the peritoneum through which most abdominal organs are attached to the abdominal wall and supplied with blood and lymph vessels and nerves.
CHAPTER VI
PATHOPHYSIOLOGY
Narrative Explanation:
Peritoneal Carcinomatosis is a broad description in which multiple tumors develop in, and line the peritoneal abdominal cavity and linings. This description is used in conjunction with cancers and conditions of appendix, colon, gall bladder, ovaries, mesothelioma, pancreas, Pseudomyxoma Peritonei, rectal, sarcomas, small bowel, and stomach. When tumor develops from the peritoneum, it is referred to as Primary Peritoneal Surface Malignancy. Occasionally, a tumor far from the abdomen or a bone cancer can result in peritoneal carcinomatosis after cancerous cells invade lymph nodes and the bloodstream. Symptoms of Peritoneal Carcinomatosis may initially be detected by appearing on as a diffused thickening of the peritoneum on a CT scan. The appearance of ascites refers to the accumulation of fluid within the peritoneal cavity and may occur for a variety of conditions including post operative inflammation or to cancer. The most common symptoms of peritoneal carcinomatosis include acute or chronic aches,cramps, bloating, and full-body fatigue. Many symptoms are caused when excess fluid accumulates in the abdominal cavity, a direct consequence of nearby tumor activity. Other problems such as breathing difficulties, digestive problems, and chest pains may be present as well, depending on the extent and location of the original cancer.
Ascites Secondary to Peritoneal Schematic Diagram:

Predisposing Factors Age (23 yrs. old) Gender (Female) Heredity Precipitating Factors Environmental conditions Lifestyle Other health conditions
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Damage to DNA in cell nucleus
Cell death
Cell Cycle Alteration
Carcinogenesis
Increased production and proliferation of enzymes and hormones
New and rapid growth Palpable masses on the abdomen
Dissemination from the primary tumor
Invasion in the GIT Mechanical effects: Tumor implants compress the bowel by their volume Imbalance between production and absorption of fluid Ascites (Abdominal distention: Girth-93cm) Compression and elevation of the diaphragm Damaged to surrounding tissues and nerve compression as tumor grows
Bowel obstruction
Pain
Paracentesis
DOB
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Systemic effects: Body cannot synthesize amino acids
Altered protein metabolism
Weight loss (From 50 kg to 42 kg)
Cachexia (muscle wasting)
Peritoneal Carcinomatosis
CHAPTER VII
COURSE IN THE HOSPITAL
DATE & TIME December 5, 2012 11:10 am
SIDE NOTES Problem: Ascites secondary to Peritoneal TB, r/o Peritoneal carcinomatosis
ORDERS Admit with consent under the service of green team. Monitor vital signs every hour and record. Small frequent feedings. MIO every 4 hours and record.
RATIONALE -Admission for referral of care.
-For close monitoring and to watch out for any unsualities. -To prevent gastrointestinal reflux. -Provides information about fluid status, circulating volume and replacement needs.
IVF: D5LR 1L @ KVO -Replacement therapy; to (microset) support fluids and electrolytes in the body. Laboratory: -To use as baseline information in comparison to next repeated laboratory exams. -A screening test to provide information about the cellular components of the patients blood; to determine presence of any abnormalities or disorders. -Acid- fast bacilli, to identify pathogenic organisms present in the peritoneal fluid, as well as,
CBC, BT
AFB peritoneal fluid
Ascites Secondary to Peritoneal to identify the antimicrobial therapy that is best suited for the particular micobacteria identified. Medications: Ceftriaxone 1mg IVTT every 12 hours ANST -An antibiotic Cephalosphorin, for treatment of susceptible infection. -An H2 receptor antagonist, used to decrease gastric secretion.
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Ranitidine 50mg IVTT every 8 hours
Metoclopramide 10mg IVTT every 8 hours PRN for vomiting Multivitamins + Amino acid 1 capsule once a day
-An antiemetic, for management of nausea and vomiting associated with various GI disorders. -To prevent low levels of vitamins, folic acid, and amino acids in the body.
For paracentesis, secure -Secure consent, because the procedure to be done is consent an invasive procedure. Continue medication management Refer December 5, 2012 5:00 pm (-) obstruction seen Surgical notes; Thank you for the referral seen and examined A/P carcinomatosis vs. PTB For: CEA -Carcinoembryonic antigen, a test performed when cancer is suspected but not yet diagnosed and especially when doctor suspects that cancer has metastasized. -Thyroid stimulating hormonetest, is a test that measures the amount of
TSH
Ascites Secondary to Peritoneal thyroid stimulating hormone in the blood. FT4 -FT4, a test used to determine if the thyroid gland is functioning properly; aids in diagnosing hyperthyroidism or hypothyroidism. -A screening test for cancer; (main use: tumor marker) -Initial losses or gains reflect changes in hydration but sustained losses suggest nutritional deficit. -To assess levels electrolytes in the body. -An imaging test to visualize the organs and structures inside the abdomen. -PPD (purified protein derivative), test used to diagnose tuberculosis. -An imaging study to help determine and reveal if there are any extensive pathologic processes present in the patients lung or any associated ribs fracture. -A procedure to take out fluid that has collected in the peritoneal cavity.
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For CA-19-9
Weight patient
9:30 pm
For serum Na, K, Ca For abdominal x-ray, supine upright
December 6, 2012 12:00 mn
(-) DOB, Conscious, coherent
For PPD
For chest x-ray PA
7:00 am
For UR provided paracentesis
Ascites Secondary to Peritoneal 5:00 pm Paracentesis done, no backflow Will repeat paracentesis tomorrow December 7, 2012 8:00 am (-) BM for 3 days (+) thirsty IVF to follow:D5LR 1L at 20 gtts/min Multivitamins + minerals (supplement) 1 vial OD x 12 hours December 7, 2012 Paracentesis failed Biopsy done -Replacement therapy; to support fluids and electrolytes in the body. -To supplement the diet with additional vitamins and minerals -Biopsy is a medical test that involves removal of tissue in order to examine it for a type disease.
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Dressing done of punctured sites; send slides and specimens. For cell block and cytology
-To promote healing of the punctured site and prevent infection; For laboratory analysis. -A diagnostic test used to look for cancers and precancerous changes. It may also be used to look for viral infections in cells. -For treatment of constipation. -Will repeat paracentesis because the first attempt failed. - A test to visualize the organs and structures within the abdomen.
December 8, 2012
(-) BM (-) DOB
Lactulose 30cc TID Still for paracentesis
1:45pm
(+) dyspnea
Management for diagnostic laparotomy Refer back to surgery O2 intubation at 4L/min via nasal cannula
-To supply oxygen to the patient.
Ascites Secondary to Peritoneal High back rest Tramadol drip: tramadol 100 mg 1amp + D5W 500cc x 24 hours Refer for any unusualities December 9, 2012 9:00am (+) DOB (+) abdominal distenetion and pain Patients relative appraised of patients Condition Standby intubation set VS q hour to include O2 saturation For close watch -To inform the family about the patients condition. -As preparation for a certain procedure. -To carefully monitor the patients condition. -To carefully monitor the patient and for immediate referral for any unusualities. -Replacement therapy; to support fluids and electrolytes in the body. -To enhance lung expansion and ventilation. - A narcotic-like pain reliever used to treat moderate to severe pain.
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9:40pm
IVF TF: D5LR 1L @ 20 gtts/ min Monitor VS q hourly December 10, 2012 8:00am (+) abdominal distention (-) tenderness, organomegaly (+) fluid wave Family appraised of patients condition Continue supportive care Refer if with problem Still for referral to surgery O2 @ 3L/min
-To provide oxygen and support ventilation.
Ascites Secondary to Peritoneal 9:00am (+) abdominal distention For repeat paracentesis tomorrow For general liquids -To provide the body nutrition in liquid form, also to prepare for diagnostic procedure and severe illness.
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Thank you for referral Patient seen and examined History reviewed For referral to service consultant Refer IVF TF: PNSS 1L @ 20 gtts/min Albumin 25% 50cc+ furosemide 20mg x 2 hours q12hours December 11, 2012 7:00 am (-) DOB (-) Chest pain (+ )Distended abdomen (+) Fluid wave IVF TF: D5LR 1L at 20 gtts/min Suggest paracentesis today For serum electrolytes -Replacement therapy; to support fluids and electrolytes in the body. -A procedure to take out fluid that has collected in the peritoneal cavity. -A laboratory test to determine the electrolytes level in the body. To start once paracentesis done -An isotonic solution; used to support fluids and electrolytes in the body. -Albumin and Furosemide therapy helps improve fluid balance in the body by dieresis. -For further assessment and to contain information, thus, help diagnose the patients condition.
Refer
Ascites Secondary to Peritoneal Rounds with Dr. Tolentino Plan for diagnostic laparoscopy once decided Refer once with consent Refer accordingly
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-To know if patient agreed with the planned diagnostic procedure.
CHAPTER VIII
NURSING CARE PLAN # 1
HRP
NSG. Dx Ineffective breathing pattern r/t decreased lung compliance secondary to ascites (Dec.7, 2012)
AMB
PATHOPHYSIOLOGY The accumulation of fluid may cause breathing difficulties by compressing the diaphragm. A person with ascites has a swollen, rounded stomach. The skin on the abdomen is tight. The size of the abdomen is related to the amount of fluid present. Ascites may extend as far as the chest cavity. The presence of the fluid adds pressure to the lungs and may cause the individual to experience difficulty breathing.
CLIENT OUTCOME Within the shift, patient will breathe with minimal difficulty as evidenced by not using accessory muscle and RR within normal range.
NURSING INTERVENTIONS 1. Monitor vital signs.
RATIONALE
EVALUATION
E X C H A N G I N G
Subjective: -Medyo nahihirapan akong huminga, malaki kasi tong tiyan ko, as verbalized. Objective: -RR: 25 bpm -Nasal flaring noted -DOB noted -Uses accessory muscles -Abdominal distention noted due to ascites -Abdominal girth of 93 cm
-To watch out for abnormalities, assess condition. -To relieve pressure on the diaphragm.
2. Place on semifowlers position with arms supported with pillows. 3. Maintain calm attitude while dealing with client and to significant others. 4. Encourage adequate rest and sleep periods between activities. 5. Instructed to avoid overeating/ gasforming foods.
Goal not met, patients respiratory rate was 27 bpm, evident use of her accessory muscles when breathing.
-To limit the level of anxiety.
-To limit fatigue and preserve energy. -They can cause abdominal distention, thus, will aggravate difficulty of breathing.
Ascites Secondary to Peritoneal NURSING CARE PLAN # 2
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HRP
NSG. Dx
AMB
PATHOPHYSIOLOGY
CLIENT OUTCOME
NURSING INTERVENTIONS
RATIONALE
EVALUATION
E X C H A N G I N G
Deficient fluid volume r/t active fluid volume loss (ascites: third spacing) (Dec.7, 2012)
Subjective: Kadalasan talaga gusto kong tubig. Objective: -Abdominal distention (ascites) - Muscle weakness -Poor skin turgor
Ascites is the accumulation of fluid in the peritoneal cavity. Third spacing occurs when too much fluid moves from the intravascular to interstitial space causing a reduced blood volume in intravascular space.
Within the shift, the patient will able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill.
1. Note possible condition that may create a fluid volume deficit such as fluid restriction, vomiting or use of diuretics. 2. Monitor vital signs, noting low blood pressuresevere hypotension, rapid heartbeat, and thready peripheral pulses. 3. Compare usual and current weight. 4. Measure abdominal girth.
-Help identify and prevent further fluid deprivation. -Changes in vital signs are associated with fluid volume loss and/or hypovolemia. -To note for any significant fluid gain or loss. -To note for the extent of fluid retention in the abdomen. -To avoid excessive water retention and further fluid shifting (ascites). -To note for significant fluid loss and gain.
Goal partially met. The patient was able to maintain fluid volume at a functional level as evidenced by good vital sign, but skin turgor was still poor (3-4 sec).
5. Instruct the client to avoid foods very high in sodium content. 6. Monitor Intake and output accurately.
7. Instruct patient to avoid drinks -To reduce effects of containing caffeine e.g. diuresis. beverages and coffee. 8. Change position frequently. -To reduce pressure on fragile skin and tissues.
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HRP
F E E L I N G
NSG. Dx
Acute pain r/t abdominal fullness secondary to ascites (Dec.8,2012)
AMB
Subjective: Masakit ang tiyan ko ngayon as verbalized -pain scale of 6/10 Objective: -pale and weak looking -with limited movements noted -facial grimace noted -diaphoresis noted
PATHOPHYSIOLOGY
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress.
CLIENT OUTCOME
Within the shift, client will report pain is relieved or controlled and demonstrate use of relaxation skills and diversional activities.
NURSING INTERVENTONS
1. Allow patient to verbalize pain.
RATIONALE
-Pain is subjective that can only be felt by the person affected. -Promotes relaxation and helps refocus attention.
EVALUATION Goal met, client appears calm and relaxed, pain was decreased from 6/10 to 3/10; verbalized, Medyo hindi na masakit ngayon.
2. Provide non-pharmacologic comfort measures such as repositioning, back rub and diversional activities such as listening to music and conversing about pleasant things. 3. Encourage use of stress management skills or complementary therapies such as guided imagery and therapeutic touch. 4. Observe or monitor signs and symptoms associated with pain, such as BP, HR, temp., color and moisture of skin, restlessness, and ability to focus. 5. Provide rest periods to facilitate comfort, sleep, and relaxation.
-Enables patient to participate actively in nondrug treatment of pain and enhances sense of control. - Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.
- Pain may result in fatigue, which may result in exaggerated pain and exhaustion.
31
HRP E X C H A N G I N G
NSG. Dx Altered bowel elimination: Constipation r/t decreased motility of GI tract (Dec. 8, 2012)
AMB Subjective: -Hindi parin ako nakakabawas simula ng naadmit ako as verbalized. -Reports decreased frequency of bowel movement Objective: -Abdominal distention noted due to ascites -Abdominal girth of 93 cm -Limited fluid intake of 1000mL -Inadequate fiber intake due to loss of appetite
PATHOPHYSIOLOGY Constipation is a condition characterized by infrequent or hard bowel movements, or having difficulty passing bowel movements. Also known as irregularity, Constipation can include pain when having a bowel movement, an inability to go after trying for more than ten minutes or having no bowel movement after more than three days.
CLIENT OUTCOME Within the shift, patient will be able to establish or regain an elimination pattern as evidenced by bowel movement with at least normal consistency, thus, participate and understand the appropriate interventions or solutions in order to relieve self from constipation.
NURSING INTERVENTIONS INDEPENDENT: 1. Auscultate abdomen for presence and location of bowel sounds and its characteristics. 2. Note color, odor, consistency, amount, and frequency of previous stool. 3. Identify factors (eg. Medications, bedrest, diet) that may cause or contribute to constipation. 4. Encourage on high fiber foods, and suggest warm stimulating fluids. 5. Encourage on light exercises as tolerated.
RATIONALE
EVALUATION
-This reflects the bowel activity.
-This provides baseline comparison, promotes recognition of changes. -Assessing causative factor is an essential first step in teaching and planning for improved bowel elimination. -To improve consistency of stool and facilitate passage. -Influences bowel elimination by improving muscle tone and stimulating peristalsis. -May be necessary to gently stimulate peristalsis/ stool evacuation.
Goal not met, patient was still unable to regain her bowel movement.
DEPENDENT: 6. Administer laxative or stool softeners as ordered.
32
HRP
NSG. Dx Imbalanced nutrition less than body requirements related to feeling of being full and malabsorption (Dec.11, 2012)
AMB
PATHOPHYSIOLOGY The client perceived that there is no space in her stomach thats why she didnt take lots of food. Her nutritional needs was very high due to poor eating habits. She seems to have poor nutritional status.
CLIENT OUTCOME Within 8 hours of nursing interventions the client will be able to regain weight and verbalize understanding of causative factors when known and necessary inteventions
NURSING INTERVENTIONS Assess weight, age, body build, strength, activity/ rest level Auscultate bowel sounds. Note characteristics of stool. Weigh weekly and document results. Encourage to verbalize feelings and concerns Discuss eating habits including food preferences, intolerance, aversions Determine psychological factors
RATIONALE
EVALUATION
E X C H A N G I N G
Subjective: Hanggang apat na kutsara lang kaya kong kainin kasi feeling ko wala ng mapaglagyan pagkain sa tyan ko as verbalized. Objective: -Weakness noted -Poor muscle tone -Decreased subcutaneous fat/ muscle mass
-Use as comparative baseline
-To identify if bowel movement is present for peristalsis
-To monitor effectiveness of dietary plan -To know the real concern/ feeling of the client.
Goal partially met, the clients nutritional status enhances as evidenced by verbalization of Medyo naging okay na ako ngayon, may lakas na ako and having an energy during the conduct of assessment and during or within the activity period.
-To appeal to client likes/ desires.
-To assess body image and congruency with reality
33
HRP F E E L I N G
NSG. Dx Mild anxiety related to threat/ changes in health status secondary to peritoneal tuberculosis
AMB Subjective: Kinakabahan ako sa kalagayan ko ngayon, as verbalized.
Objective: - -Awake with (Dec.8, 2012) blank stare - -Focus on self - Pale and weak looking -Limited movements noted -Diaphoresis noted
PATHOPHYSIOLOGY Mild anxiety speaks for itself. Basically your body's natural warning system telling you to go on alert when there is no actual cause for alarm.Even though mild anxiety is slighter in terms of effects, it still can be a heavy baggage especially if it occurs more often than you think. On the case of our client she was anxious about her current condition, if there will be a good prognosis or not. Those suffering from mild anxiety will usually only suffer from the physical and mental symptoms.
CLIENT OUTCOME Within the shift, client will be able to appear relaxed and report anxiety is reduced to a manageable level.
NURSING INTERVENTIONS 1. Explore clients feelings. 2. Allow/ encourage client to speak openly about fears and concerns. 3. Establish a therapeutic relationship, conveying empathy and unconditional positive regard 4. Acknowledge anxiety or fear. Do not deny or reassure that everything will be alright 5. Monitor and record vital signs.
RATIONALE
EVALUATION
-To know what/ how Goal met, client does client really feels. was able to expressed -To let him express feelings and what are those he concerns; think that makes him appears relaxed worry. and verbalized, Mas okay sa -To let patient feel that ngayon kesa hes not alone and to kanina. avoid the contagious effect or transmission of anxiety.
-Not to let client assure herself and blame anyone if something happen.
-To identify physical responses associated with both medical and emotional conditions.
34
HRP F E E L I N G
NSG. Dx Anticipatory grieving related to perceived potential death (Dec.11, 2012)
AMB Subjective: Malala na daw tong sakit ko, as verbalized. Objective: -Weakness noted Alterations in sleep pattern
PATHOPHYSIOLOGY
Grieving is an intellectual and emotional responses and behaviors by which the individual and family work through the process of modifying self concept based on the perception of potential loss. Since patients illness has a poor prognosis, and chance of survival is minimal, it is normal that the patient and family mourn.
CLIENT OUTCOME
Within the shift, the client will be able to identify and express feelings appropriately.
1. Establish rapport to the client.
RATIONALE
-To establish trust and cooperation to the client. - Promotes and encourages realistic dialogue about feelings and concerns. - Patient may feel supported in expression of feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation. - Patient/SO benefit from factual information. Individuals may ask direct questions about death, and honest answers promote trust and provide reassurance that correct information will be given. -Possibility of remission and slow progression of disease and/or new therapies can offer hope for the future.
EVALUATION
Goal met, client and family were able to verbalize understanding of the dying process and feelings of being supported in grief work.
2. Provide open, nonjudgmental environment. Use therapeutic communication skills. 3. Encourage verbalization of thoughts/concerns and accept expressions of sadness, anger, rejection. Acknowledge normality of these feelings.
4. Reinforce teaching regarding disease process and treatments and provide information as requested/ appropriate about dying. Be honest; do not give false hope while providing emotional support. 5. Identify positive aspects of the situation.
35
HRP M O V I N G
NSG. Dx Self-care deficit r/t lack of motivation in performing good hygiene. (Dec.7, 2012)
AMB Subjective: Hindi ko na magawang maligo at magayos ng katawan ko dahil sa sakit ko, as verbalized. Objective: -discomfort noted -dry skin -slight unpleasant body odor noted
PATHOPHYSIOLOGY Self-care deficit is described as an impaired ability to perform complete feeding, bathing/ hygiene, dressing and grooming or toileting activities. Since the patient has weakness, its hard for her to move and do daily activities thats why selfcare is often depleted.
CLIENT OUTCOME Within the shift, the client will be able to cooperate in the practice of good and proper hygiene.
NURSING INTERVENTIONS 1. Establish rapport to the client.
RATIONALE -To establish trust and cooperation to the client. -To discover barriers to participation.
EVALUATION Goal met, client and family were able to participate in promoting good hygiene to the patient by giving him a bed bath.
2. Encourage to verbalize feelings and concerns. 3. Assist on adaptation to accomplish activities of daily living.
-To encourage client and build on successes.
4. Provide -Enhances communication among coordination and those who are continuity of care. involved in caring for assisting the client. 5. Allow sufficient time for the client to accomplish task to fullest extent of ability. -To enhance clients capabilities and promote independence.
CHAPTER IX
DRUG STUDY # 1
GEN. NAME C E F T R I A X O N E BRAND NAME R O C E P H I N DRUG CLASS MODE OF ACTION CONTRAINDICATION ACTUAL DOSE USUAL DOSE SIDE EFFECTS NURSING RESPONSIBILITIES
INDICATION
C E P H A L O S P O R I N
Inhibits bacterial wall synthesis, thus, promoting osmotic instability which eventually leads to bacterial cell death.
-Used to treat infection caused by staphylococcus, streptococcus, E.coli, and other susceptible microorganis m. Skin to skin structure infection and biliary tract infection.
1. Observe the 10Rs of ContraCeftriaxone Ceftriaxone Signs of administering drugs indicated for 1gm q12 1-2 gms allergy: skin (RIGHT: client, patients who ANST ( ) once a day rashes, fever. medication, dosage, have known route, time, hypersensitive Hematologic: documentation, health to cephalosleukopenia, education, to refuse, porins and reversible assessment, evaluation). any of its thrombo2. Assess patients previous components. penia sensitivity reaction to cephalosporins. Digestive: 3. Monitor for signs of nausea, allergic reaction. vomiting, 4. Monitor vital signs before anorexia, and after giving the drug diarrhea esp. HR,RR,BP. Report changes. 5. Explain that the patient may experience the following side effects: nausea, diarrhea. 6. Encourage patient to report for signs of abnormalities.
Ascites Secondary to Peritoneal DRUG STUDY # 2
37
GEN. NAME R A N I T I D I N E
BRAND NAME Z A N T A C
DRUG CLASS Histamine (H2) receptor antagonist
MODE OF ACTION Inhibits the action of histamine at H2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion that stimulates by food, insulin, histamine, cholinergic agonist, gastrin, and pentagastrin.
INDICATION -Short-term treatment of active duodenal ulcer; treatment of gastroesophageal reflux disease; short-term treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions (postoperative hypersecretion) ; heartburn.
CONTRAINDICATION -Contraindicated with allergy to ranitidine. Use cautiously with impaired renal or hepatic function.
ACTUAL DOSE Ranitidine 50mg IVTT q8
USUAL DOSE Ranitidine 25-50mg IV twice or thrice daily
SIDE EFFECTS CNS: Headache, malaise, dizziness CV: Tachycardia, bradycardia GI: Constipation, diarrhea, abdominal pain, hepatitis Hematologic: Leukopenia, granulocytop enia, thrombocyto penia,pancyt openia Local: Pain at IV site, phlebitis
NURSING RESPONSIBILITIES 1. Observe the 10Rs of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation). 2. Monitor vital signs and watch out for abnormalities such as tachycardia or bradycardia. 3. Monitor intake and output. 4. Explain to hat she may experience the following side effects: headache, malaise. 5. Check laboratory results for abnormalities and refer to the physician. 6. Check the insertion site for phlebitis. 7. Encourage to report immediately for any signs of abnormalities.
38
GEN. NAME M E T O C L O P R O M I D E
BRAND NAME P L A S I L
DRUG CLAS S Antiemetic
MODE OF ACTION
INDICATION
CONTRAINDICATION -Contraindicated witha llergy to metoclopramid e; GI hemorrhage; Mechanical obstruction or perforation; fluid overload, and renal impairment
ACTUAL DOSE Metoclopromide 10mg IVTT q8 PRN for vomiting
USUAL DOSE Metoclopromide 1amp IV q 6-8
SIDE EFFECTS CNS: restlessness, drowsiness, fatigue, insomnia, dizziness, anxiety
NURSING RESPONSIBILITIES 1. Observe the 10Rs of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation).
It binds to dopamine D2 receptors where it is a receptor antagonist, and is also a mixed 5-HT3 receptor antagonist/ 5-HT4 receptor agonist. The antiemetic action of metoclopramide is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone (CTZ) in the CNSthis action prevents nausea and vomiting triggered by most stimuli. At higher doses, 5HT3 antagonist activity may also contribute to the antiemetic effect. The gastroprokinetic activity of metoclopramide is mediated by muscarinic activity, D2 receptor antagonist activity and 5-HT4 receptor agonist activity. The gastroprokinetic effect itself may also contribute to the antiemetic effect.
-Disturbances of GI motility -For nausea andvomiting
CV: transient 2. Check history: allergy hypertension to metoclopramide, GI hemorrhage, mechanical GI: nausea obstruction and diarrhea or perforation. 3. Monitor BP carefully during IV administration. 4. Monitor intake and output. 5. Tell patient that she may experience the said side effects: drowsiness, nausea, dizziness.
39
GEN. NAME M U L T I V I T A M I N S + A M I N O A C I D S
BRAND NAME
DRUG CLASS
MODE OF ACTION Multivitamin is a combination of many different vitamins that are normally found in foods and other natural sources.Many act as coenzymes or catalysts in numerous metabolic processes. It also works by providing extra vitamins, folic acid, and amino acids to the body when you need more than what you get in your diet.
INDICATION Treating or preventing low levels of vitamins, folic acid, and amino acids in the body.
CONTRAINDICATION -Contraindicated if you are allergic to any ingredient in multivitamins with folic acid/amino acids and if you have high blood levels of arginine (argininemia).
ACTUAL DOSE Multivitamins + Amino acids 1cap OD
USUAL DOSE Multivitamins 1cap daily
SIDE EFFECTS Allergic reactions: Rash, hives, itching, difficulty breathing, tightness in the chest, swelling of the mouth, face, lips, or tongue
NURSING RESPONSIBILITIES 1. Observe the 10Rs of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation). 2. Take multivitamins with folic acid/amino acids by mouth with or without food. If stomach upset occurs, take with food to reduce stomach irritation.
N U T R I W E L L
Multivitamins and supplements
3. Take multivitamins with folic

acid/amino acids with a full glass of water (8 oz/240 mL). 4. Explain that she may experience the following side effects: rash, difficulty breathing.
5. Encourage to report
immediately for any signs of abnormalities.

GEN. NAME M U L T I V I T A M I N S + M I N E R A L S BRAND NAME S U P P L E M E N T S DRUG CLASS MODE OF ACTION Multivitamin and minerals are used to provide vitamins and minerals that are not taken in through the diet. Multivitamin and minerals works by treating vitamin or mineral deficiencies caused by illness, pregn ancy, poor nutrition, digestive disorders, certain medications, and many other conditions. INDICATION CONTRAINDICATION -Contraindicated if you are allergic to any ingredient in multivitamins and minerals and any of its components. ACTUAL DOSE Multivitamins + Minerals (Supplements) 1 vial OD x 12hours USUAL DOSE Multivitamins + Minerals 1 vial once or twice a day SIDE EFFECTS Less serious side effects: upset stomach, headache, unusual or unpleasant taste in your mouth Allergic reaction: Hives, difficulty breathing, swelling of your face, lips, tongue, or throat.
40
NURSING RESPONSIBILITIES 1. Remember the 10Rs of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation). 2. Monitor for manifestations of hypersensitivity appearance promptly. 3. Do not take this medication with milk, other dairy products, calcium supplements, or antacids that contain calcium. Calcium may make it harder for your body to absorb certain ingredients of the multivitamin. 4. Check for nutritional deficiencies. 5. Encourage to report immediately for any signs of abnormalities.
Multivitamins and supplements
Dietary supplement for the treatment and prevention of vitamin and mineral deficiencies.
41
GEN. NAME L A C T U L O S E
BRAND NAME L I L A C
DRUG CLASS Laxative Ammoni a reduction drug
MODE OF ACTION Metabolism of lactulose by bacteria results in reduced colonic pH which stimulates peristalsis & decreases stool transit time. In turn, decreased water reabsorption from the feces further facilitates the passage of soft, well-formed stools. Increased osmotic pressure of fecal material secondary to an increase in colonic organic acids results in accum. of fluid from surrounding tissues, helping to soften stool mass.
INDICATION Treatment of constipation. Prevention and treatment of portalsystemic encephalopathy
CONTRAINDICATION
ACTUAL DOSE
USUAL DOSE
SIDE EFFECTS
NURSING RESPONSIBILITIES
-Contraindicated to patients with allergy to lactulose, lowgalactose diet. -Use cautiously with diabetes, pregnancy and lactation.
Lactulose Lactulose GI: 30cc TID 30cc Transient syrup flatulence, OD HS distention, intestinal cramps, belching, diarrhea, nausea Other: Acid-base imbalance
1. Observe the 10Rs of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation). 2. Instruct that this drug may be taken with fruit juice or milk to increase palatability. 3. Do abdominal examination, check bowel sounds, and serum electrolyte levels. 4. Do not administer if patient has already pass out stool especially if stool is liquid. 5. Monitor intake and output. 6. Tell patient that she may experience these side effects: flatulence, intestinal cramps, nausea) 7. Report if unusualities occur.

GEN. NAME T R A M A D O L BRAND NAME T R A M A L DRUG CLASS Analgesic, opioid analgesic MODE OF ACTION Binds to opiate receptors in the CNS causing inhibition of ascending pain pathway s, altering the perception of and response to pain; also inhibits the reuptake of norepinephri ne and serotonin, which also modifies the ascending pain pathway . CONTRAINDICATION Hypersensitivity to tramadol, opioids, or any component of the formulation; opioiddependent patients; acute intoxication with alcohol, hypnotics, centrallyacting analgesics, opioids, or psychotropic drugs. ACTUAL DOSE Tramadol drip: tramadol 100 mg 1amp + D5W 500cc x 24 hours USUAL DOSE Tramadol 50 - 100 mg IV every 4 - 6 hours SIDE EFFECTS
Dizziness Nausea Drowsiness Dry mouth Constipation Headache Sweating Vomiting Itching Rash Atelectasis
42
INDICATION Moderate to severe acute or chronic pain and in painful diagnostic or therapeutic measures.
NURSING RESPONSIBILITIES 1. Observe the 10Rs of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation). 2. Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. 3. Assess BP & RR before and periodically during administration. 4. Assess bowel function routinely. 5. Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and pneumonia. 6. Instruct client to report any adverse reaction to the physician or nurse.

GEN. NAME A L B U M I N BRAND NAME A L B U M I N A R DRUG CLASS Plasma expanders Blood derivatives MODE OF ACTION Provides increase in intravascular oncotic pressure and causes mobilization of fluids from interstitial into intravascular space. CONTRAINDICATION -Contraindicated with allergy to albumin and any of its components, with severe anemia and ACTUAL DOSE Albumin 25% 50cc + furosemide 20mg x 2 hours q12hours USUAL DOSE Albumin 25% vials: 2-3 ml/ minute maximum SIDE EFFECTS Fever Chills Flushing Hives, Skin Rash Itching Headache Nausea Breathing Difficulty Rapid Heart Rate
43
INDICATION For plasma volume expansion and maintenance of cardiac output in the treatment of certain types of shock or impending shock; may be useful for burn, ARDS, peritonitis, and ascites. Unless the condition responsible for hypoproteinemi a can be corrected, albumin can only provide symptomatic relief of supportive treatment.
NURSING RESPONSIBILITIES 1. Observe the 10Rs of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation). 2. Monitor vital signs and watch out for abnormalities. 3. Monitor intake and output. 4. Explain to the parents that he may experience the following side effects: fever, chills, nausea. 5. Check laboratory results for abnormalities and refer to the physician. 6. Watch out for symptoms of overdose, such as: hypervolemia, CHF, pulmonary edema. 7. Encourage to report immediately for any signs of abnormalities.
44
GEN. NAME
BRAND NAME
DRUG CLASS Loop Diuretic
MODE OF ACTION Inhibits sodium & chloride reabsorptio n at the proximal tubules, distal tubules and ascending loop of henle leading to excretion of water together with sodium, chloride and potassium.
INDICATION -Treatment of fluid accumulation such as ascites, edema associated with CHF,hepatic cirrhosis, renal disease.
CONTRAINDICATION - Hypersensitivity to furosemide, sulfonylureas, or any other drugs. Contraindicated in patients with anuria, hyponatremia or hypovolemia.
ACTUAL DOSE Albumin 25% 50cc + furosemide 20mg x 2 hours q12hours
USUAL DOSE Furosemide 20-40mg IV everyday of one to two times a day
SIDE EFFECTS
Low blood
NURSING RESPONSIBILITIES 1. Observe the 10Rs of administering drugs (RIGHT: client, medication, dosage, route, time, documentation, health education, to refuse, assessment, evaluation). 2. Check the BP first before administration. 3. Monitor Intake and Output of the patient. 4. Explain that she may experience these side effects: dizziness, nausea. 5. Instruct client to report any signs of side effects.
F U R O S E M I D E
L A S I X
pressure Dehydration and electrolyte depletion Orthostatic HPN Pruritus Vertigo Dizziness Fever Nausea Vomiting Constipation Oral and gastric irritation Diarrhea Increased blood sugar and uric acid levels may also occur.
CHAPTER X
LABORATORY STUDY # 1 DETERMINATION

HEMATOLOGY (December 5, 2012) WBC
ACTUAL VALUE
NORMAL VALUE
SIGNIFICANCE/INTERPRETATION
NURSING RESPONSIBILTY
Explain the procedure & purpose of performing the procedure, and that is to determine infection & its severity because of the disease. This test is very important as baseline data. Tell patient as well as watcher that the test requires a blood sample and explain who will perform the venipuncture. Give health teachings on patients diet and medication that may contribute to the result of the test. Based on the result, instruct patient to eat nutritious foods especially rich in vitamins, minerals and iron, such as fish, vegetables, and fruits. Advise to have adequate rest and sleep periods.
17.2 x 109/ L
4.0-10.0 x 109/ L
Increased; indicative of impending infection or inflammation in the body due to disease process. Normal; good oxygenation in the blood, may decrease because of disease process. Normal; good circulation of oxygen in the blood. Normal;there is good hydration status in the patients body; good oxygen supply. Increased; or thrombocytosis, may result from iron deficiency anemia or inflammatory disorders.
RBC
4.51 x 1012/L
4.50-5.4 x 1012/L
HGB
118 g/L
115-155 g/L
HCT
0.38 957 x 109/L
0.36-0.47 100-300 x 109/L
PLT
MCV
84.0 fL
86-100 fL
Decreased; MCV measures the ratio of hematocrit to RBC count. May indicate iron deficiency anemia Normal; MCH gives the hemoglobin to RBC ratio. Normal: MCHC measures the ratio of hemoglobin weight to hematocrit.
MCH
26 pg
26-31 pg
MCHC
340g/L
310-375 g/L
46
RDW
12.1 %
11.6-13.7 %
Normal; RDW determines the measurement of RBCs. Increased; may indicate infection, inflammatory processes during physical stress, or with tissue necrosis.
Stress out the importance of taking multivitamins as prescribed by the physician. Educate about the importance of medications and treatment regimen. Note for any abnormalities on findings and refer the results to the physician.
Differential Count Neutrophils
80 %
40-70 %
Lymphocytes Monocytes Eosinophils Basophils
10 %
19-42 %
Decreased; may signal infection in the body and/or anemia. Normal; may increase because of illness disease. Decreased; signals infection because of illness. Normal; aids in determining specific conditions.
9.0 %
3.0-9.0 %
1.0 %
2.0-8.0 %
0%
0-5.0 %
Ascites Secondary to Peritoneal LABORATORY STUDY # 2
47
DETERMINANTS CLINICAL CHEMISTRY (November 23, 2012)

Creatinine
ACTUAL VALUE
73.4 umol/L
NORMAL VALUE
53-97 mmol/L
SIGNIFICANCE/ INTERPRETATION
Explain the procedure & purpose of performing the procedure, and that is to help diagnose the occurrence of disease and if there are complications, to test effectiveness of medications and find treatments for the disease. Explain the procedure to the client that the medical technician will get sample of her blood for testing. Give health teachings on patients diet and medication that may contribute to the result of the test. Instruct patient to eat nutritious foods especially rich in vitamins, minerals and proteins, such as fish, vegetables, and fruits. Also, instruct to eat nutritious food that helps in cleansing the kidney. Strictly monitor the intake and output.
Normal; indicates that the kidneys are able to properly remove all creatinine. May increase if dehydrated or took certain medications. Normal; indicates that liver and kidneys are functioning well. Low levels of ALT are normally found in the blood. But when the liver is damaged or diseased, it releases ALT into the bloodstream, which makes ALT levels go up. Most increases in ALT levels are caused by liver damage. Normal; indicates no liver damage. High levels may indicate severe MI, severe infectious mononucleosis or alcoholic cirrhosis. Low levels indicate hemolytic anemia, metastatic hepatic tumors or fatty liver.
SGPT/ALT
333.4 nKat/L
0-517 nKat/L
SGOT/AST
383.4 nKat/L
0-517 nKat/L
ALP (Alkaline phosphatase)
1300.3 nKat/L
700-1630 nKat/L
Normal;indicates no liver or bone disease. ALP test measures the amount of alkaline phosphatase released from the tissues into the blood and is a marker of the hepatobilary system function. Moderate increase indicates acute biliary obstruction. Low levels are linked to hypophosphatasia and protein or magnesium deficiency. Decreased;may be indicative of certain diseases such as GI disease, protein deficiency, neoplastic disease, malnutrition or malabsorption.
Total Protein
62 g/L
64-83 g/L
48
Albumin
33 g/L
35-52 g/L
Decreased; may indicate that not enough protein is being absorbed in the body, may also reflect diseases such as malnutrition or ascites.
Advise to have adequate rest and sleep periods. Stress out the importance of taking multivitamin and supplements as prescribed by the physician. Note for any unusualities on findings and refer the results to the physician.
Globulin
29 g/L
20-35 g/L
Normal;Globulin carries essential metals through the bloodstream and carries them to the various parts of the body and helps the body to fight infections. Globulin proteins include enzymes, antibodies and more than 500 other proteins. High levels indicate tuberculosis. Low levels indicate GI disease, malnutrition, or malabsorption. Decreased;A low A/G ratio reflects overproduction of globulins, due to chronic infections, liver and kidney disease, fatty necrotic liver, rheumatoid arthritis, leukemia, increased amount of nonspecific protein, and autoimmunity disorders. On the other hand, a high A/G ratio suggests under production of immunoglobulin; this is seen in genetic deficiencies and in cases of nephrosis, liver dysfunction, acute hemolytic anemia, and hypogammaglobulinemia / agammaglobulinemia.
A/G Ratio
1.1
1.7-2.2
49
DETERMINANTS
ACTUAL VALUE
NORMAL VALUE
INTERPRETATION / SIGNIFICANCE
NURSING RESPONSIBILITY
URINALYSIS (November 23, 2012)

Color Yellow Pale yellow to amber None or 08mg/dL Normal; color may change due to diet and drugs. 1. Instruct patient to void into a clean, dry container. 2. Sterile disposable container should be used always. 3. Cover all specimens tightly, label properly and send immediately to the laboratory. 4. Observe standard precaution when handling the specimen. 5. Avoid the specimen to be exposed to extreme temperature such as sunlight or heat. 6. The specimen should be preserved if not to send to laboratory to have accurate results.
Albumin
(+)
Abnormal; an increase in urinary albumin excretion is indicative of increased permeability of the filters of the kidney called, glomerulus which due caused by some kidney damage. Normal; normally, glucose is not present in the urine because it is reabsorbed from the renal tubules.
Sugar
(-)
None or 0.08mml/L (0-25mg/dL) Clear to slightly hazy Acidic
Transparency
Cloudy
Abnormal; cloudy urine may be caused by crystal deposits, white cells, epithelial cells or fat globules. Normal; pH measures how acidic or alkaline the urine is. Sometimes urine pH is affected by certain treatments. Normal; this checks the amount of substance in the urine. When you drink lots of fluid your specific gravity becomes low. When you are dehydrated your specific gravity becomes high. Normal; there should be no yeast cells and bacteria or parasites in the urine, if present; it means that there is infection. Normal; normally, there is no blood in the urine. One of the common causes of RBC in the urine is infection or inflammation of the urinary tract itself (cystitis).
pH Specific Gravity
Acidic
1.025
1.003-1.060
Pus Cells
0-2/hpf
Females: None or 5-10/hpf None or 05/hpf
RBC
0-2/hpf
50
Amorphous Urates
111
None
Increased; Amorphous Urates indicates uric acid crystals in the urine. Higher than acceptable levels of uric acid crystals in urine can be caused by gout, cardiovascular disease, diabetes, uric acid stone, urolithiasis, and metabolic syndrome. Increased; may suggest inflammation within the bladder, but they may also originate from the skin and could be contaminated. Sometimes, it is normal not to have any epithelial cells present in a urine sample or to have occasional numbers of any of the three cell types. Large numbers of squamous cells may indicate contamination of the urine specimen, but large numbers of either the transitional or renal tubular cells may indicate a serious disease process.
7. Note for any unusualities on findings and refer the results to the physician.
Epithelial Cells
11
None to few
51
DETERMINANTS PERITONEAL FLUID ANALYSIS (November 26, 2012) Glucose Lactate dehydrogenase
ACTUAL VALUE
NORMAL VALUE
INTERPRETATION / SIGNIFICANCE
NURSING RESPONSIBILITY
Explain the procedure & purpose of performing the procedure, and that is to help distinguish between types of peritoneal fluid and help diagnose the cause of fluid accumulation (ascites). Explain that in this procedure, a local anesthetic is applied to the area of operation and then a catheter is routed from the skin into the peritoneal cavity. As soon as this is done, the peritoneal fluid will start to flow out. Monitor vital signs prior to the procedure. Advise to empty the bladder first before the procedure becausethis is a lengthy test. Note for any unusualities on findings and refer the results to the physician.
7.40 mmol/L
4.2-6.2 mmol/L
Increased; may indicate tuberculosis and/or malignancy; could be low in malignant ascites
Increased; Elevated levels of LDH and changes in the ratio of the LDH isoenzymes usually indicate some type of tissue damage. LDH levels typically will rise as the cellular destruction begins, peak after some time period, and then begin to fall.
2025 U/L
36-229.1 U/L
Total protein
6.6
7.3-21.1 g/dL
Decreased; may be indicative of a symptom of a disease,

infection or an underlying condition. When there is inadequate protein intake, the body begins to breakdown muscle to obtain enough amino acids for the synthesis of serum albumin.
Albumin
4.20 g/dL
< 1.1 g/dL
Increased; to distinguish exudates and transudates.

Values above 1.1 g/dL are considered evidence of a transudate.
Globulin
2.40g/dL
2.4-4.5 g/dL
Normal; Globulins are proteins that include gamma

globulins (antibodies) and a variety of enzymes and carrier/transport proteins. Low globulin levels signify a type of protein deficiency; high levels mean chronic infections.
52
DETERMINANTS
ACTUAL VALUE 127 U/ml
NORMAL VALUE 0.35 U/ml
SIGNIFICANCE/ INTERPRETATION Increased: indicates that the cancer antigen is increased in colon, upper gastrointestinal (GI), ovarian, and other gynaecologic cancers: pregnancy, peritonitis.
NURSINGINTERVENTION Explain the procedure and the purpose of performing such procedure, and that is to determine infection because of the disease, that this test is very important as baseline data. Tell patient as well as watcher that the test requires a blood sample and explain who will perform the venipuncture. Give health teachings on patients diet that may contribute to the result of the test. Based on the result, instruct the patient to eat nutritious foods especially rich in iron, such as fish, vegetables, and fruits. Advise to have adequate rest and sleep periods. Stress out the importance of taking multivitamins as prescribed by the physician.
Immunology
CA 12-5 (November 28, 2012)
53
DETERMINANTS
ACTUAL VALUE
NORMAL VALUE
NURSINGINTERVENTION
Immunology
(December 6, 2012) Free T4 0.95 0.58-1.64 ug/dl
Normal; indicates that thyroid hormone feedback system is functioning well. This test was done to evaluate thyroid function. The free T4 test is a newer test that is not affected by protein levels. Since free T4 is the active form of thyroxine, the free T4 test is thought by many to be a more accurate reflection of thyroid hormone function. Normal; indicates normal functioning of the thyroid. T4 will be ordered along with a TSH to give a more complete evaluation of the adequacy of the thyroid hormone feedback system. These tests are usually ordered when a person has symptoms of hyper or hypothyroidism. Explain the procedure and the purpose of performing such procedure, and that is to evaluate thyroid function, determine possibility of cancer, diagnosis of certain illness or to monitor the effectiveness of treatment. Tell patient as well as watcher that the test requires a blood sample and explain who will perform the venipuncture. Give health teachings on patients diet that may contribute to the result of the test. Educate on the importance of strict compliance to medication and treatment regimen. Advise to have adequate rest and sleep periods. Advise to eat nutritious foods necessary to improve health and to hasten recovery.
TSH
4.08
0.34-5.60 U/ml
CEA (Carcinoembryonic Antigen)
531.12
0-3 ng/ul
Increased; can indicate possible cancerous activity.

Increased CEA levels may also indicate some noncancer-related conditions, such as some forms of inflammation, cirrhosis, and peptic ulcer. A CEA test is ordered when the patients symptoms suggest the possibility of cancer. CEA is an embryonic protein which could be secreted in adult as well, if there is any abnormality in protein producing organs, especially liver, but similar protein can also be secreted if there is a presence of cancer.
54
DETERMINANTS
ACTUAL VALUE
NORMAL VALUE
NURSINGINTERVENTION
Electrolytes
(December 11, 2012) Serum Na 126.6 135-148 mmol/L Decreased; indicates an electrolyte disturbance in which
the sodium concentration in the serum is lower than normal. Sodium is the dominant extraellular cation and cannot freely cross the cell membrane. Hyponatremia is most often a complication of other medical illnesses in which excess water accumulates in the body at a higher rate than can be excreted (for example in congestive heart failure, syndrome of inappropriate antidiuretic hormone, SIADH or polydipsia. Normal; Potassium testing is frequently ordered, along with other electrolytes. The most common cause of hyperkalemia is kidney disease, but many drugs can decrease potassium excretion from the body and result in this condition. Hypokalemia can occur if someone has diarrhea and vomiting or if is sweating excessively. Potassium can be lost through the kidneys in urine; in rare cases, potassium may be low because someone is not getting enough in their diet. Explain the procedure and the purpose of performing such procedure, and that is to determine electrolyte imbalance in the body due to disease process Tell patient as well as watcher that the test requires a blood sample and explain who will perform the venipuncture. Because of electrolyte imbalance, initial treatment consists of slow correction of the hyponatremia via fluid restriction. To restore calcium to a normal level, advise patient to eat calcium-rich foods or calcium supplements on a regular basis or as prescribed. Advise to eat nutritious foods necessary to improve health and to hasten recovery.
Serum K
3.91
3.5-5.3
mmol/L
Serum Ca
1.02
1.13-1.32 mmol/L
Decreased; indicates an electrolyte imbalance.

Hypocalcaemia either occurs as a result of too much calcium loss or insufficient calcium intake through food. Early symptoms of low serum calcium include frequent muscle cramps and joint pains. In addition to this, inability to perform tiresome activities, fatigue, brittle nails, and yellowness of teeth also occur as a result of abnormally low level of calcium in the blood stream.
Ascites Secondary to Peritoneal DIAGNOSTIC TESTS
55
ABDOMINAL ULTRASOUND (November 23, 2012)

The liver is normal in size and echopattern. The intrahepatic ducts are not dilated. There are no focal mass lesions seen. The gallbladder is distended. There are no intraluminal stones seen. Wall is not thickened. The common duct is not dilated. The pancreas and spleen are normal in size and echopattern. There are no solid nor fluid-filled mass lesions seen. The right kidney measures 11.0 x 3.4 cms while the left measures 10.0 x 4.2 cms. The cortical echoes exhibit normal echogenicity and show good distinction of its corticomedullary junctions. The pelvocalyceal systems are intact. No ectasia norlithiasis seen. There are no focal renal mass lesions detected. The uterus is not dilated. The urinary bladder is distended without intravesical lithiasis seen. The uterus is normal in size with an intact endometrium. No abnormal uterine/adnexal mass seen. Fluid collection is seen in the peritoneal cavity. There are omental cakes and thickening of the peritoneal lining.
Impression: Omental cake / Peritoneal thickening, consider peritoneal carcinomatosis vs. peritoneal tuberculosis Massive ascites Normal sonogram of the liver, gallbladder, pancreas, spleen, kidneys, urinary bladder and uterus.
56
ABDOMINAL CT SCAN (November 27, 2012)
Multiple plain & contrast enhanced axial CT images of the whole abdomen show the following findings:
The liver, gallbladder, pancreas, spleen and adrenals are normal. There are no enhancing mass lesions seen. The intrahepatic and pancreatic ducts are not dilated. Both kidneys exhibit good excretory functions. No ectasia, masses nor lithiasis seen. The ureters and urinary bladder are opacified and maintains its normal course and configurations. There are distended fluid-filled intestinal loops seen. However, no evident intraluminal masses are seen. There are thickening noted in the peritoneal lining seen in the left. Fluid density is seen in the abdominal cavity, with the uterus and ovaries floats within. There are no septations noted. There are no enlarged intra abdominal / retroperitoneal nodes seen. The mesentery, vascular and osseus structures are unremarkable.
Impression: Ascites with thickened peritoneal lining, left possibilities of inflammatory (Tuberculosis) vs. Carcinomatosis are considered.
57
TRANSVAGINAL TRANSABDOMINAL ULTRASOUND (November 29, 2012) The uterus is anteverted with smooth contour and homogenous echopattern measuring 5.5 x 2.3 x 3.3 cm (The cervix measures 2.6 x 19 x 1.3 cm with homogenous stoma and distinct endocervical canal). The endometrium is hyperechoic measuring 0.2 cm thick with intact subendometrial halo. The right ovary measures 3.0 x 1.7 x 1.8 cm. The left ovary measures 2.5 x 1.8 x 1.8 cm. Theres massive anechoic free fluid in the cul de sac. The omentum is converted into a heterogenous mass measuring 18 x 10 cm.
Impression: Normal uterus Thin endometrium Normal ovaries Consider GI pathology
Ascites Secondary to Peritoneal CHEST AP (December 10, 2012): There are no active lung infiltrates seen Heart is not enlarged Diaphragm is elevated Bony thorax is unremarkable
58
Impression: Elevated Diaphragm
MISCELLANEOUS REPORT (November 25, 2012): Specimen Submitted: Peritoneal Fluid Final Report: No growth after 48 hours incubation Gram Stain: No organism seen AFB: None found
CHAPTER XI
PROGNOSIS
CRITERIA
VERY GOOD (5)
GOOD (4)
FAIR (3)
POOR (2)
VERY POOR (1)
JUSTIFICATION
Severity/ Nature of disease
Financial Status
Ms. Bellas disease is difficult to treat and is fatal. Onset of disease is rapidly progressive and for now, only supportive care can be rendered. Though they are able to comply and provide financial support minimally, they are now referred to service consultant because of heavy expenses. The family of the patients partner supports her most of the time. Her parents seldom visit her and buy for her medicines. The patient is cooperative and participative to treatment regimen, though weak and sometimes irritable. Most of the appropriate treatment and resources are available.
Family Support
Patient factor
Availability & accessibility of appropriate treatment
Ascites Secondary to Peritoneal Respective Numerical Values: Very Good= 5 Standard Rating: Very Good = 4.20 5.00 Good = 3.41 4.20 Fair = 2.61 3.40 Poor = 1.81 2.60 Very Poor = 1.0 1.80 Good = 4 Fair = 3 Poor = 2 Very Poor=1
60
Formula: Rate x Frequency No. of Criteria Computaion: Very Good: Good: Fair: Poor: Very Poor: 5x0= 4x1= 3x2= 2x1= 1x1= 0 4 6 2 1 13 5 criteria = 2.60 or POOR
General Prognosis:
Based on the criteria, Ms. Bella has poor prognosis with a result of 2.60. Specifically, she has scores of zero (0) in very good; two (1) in good; two (2) in fair; one (1) in poor and one (1) in very poor.
Ascites Secondary to Peritoneal In general, the client has a poor prognosis due to the onset, severity and progression of the disease and complications secondary to her health problems. Peritoneal carcinomatosis represents a devastating form of cancer progression with a very poor prognosis. It is the most common terminal feature of abdominal cancers. peritoneal cancer can be hard to detect in the early stages. That's because its symptoms are vague and hard to pinpoint. When clear symptoms do occur, the disease has often progressed. Care at this time is focused on relieving symptoms and quality of life issues post-treatment.
61
CHAPTER XII
DISCHARGE SUMMARY PLAN I. MEDICATION Instruct patient and watcher to administer the prescribed medications on a right dose, frequency and time. RATIONALE: To meet the therapeutic effect of the drug and prevent over dosage of the medication. Explain the purpose of the medication. RATIONALE: This will provide information to both the client and the parent as to why the patient needs to take the prescribed medication. Explain the indication and possible side effects brought by each of the drug. RATIONALE: This will give awareness on both the patient and the watcher to prevent panic when side effects are experienced by the client. Instruct the client and watcher that when adverse effect occurs and if there are any unusualities consult the physician immediately. RATIONALE: To prevent any complications and give appropriate interventions II. EXERCISE Encourage client not to do strenuous activities and limit activities within own capacity as possible. RATIONALE: Activities that require great muscle strength should be avoided to prevent injury and fatigue.
Ascites Secondary to Peritoneal III. TREATMENT Instruct to maintain the prescribed medication as regularly as ordered by the physician. RATIONALE: To have a pace of supportive care.
63
Let the patient and family know that they should maintain a conducive, peaceful, and non-stressful environment. RATIONALE: To promote relaxation and good palliative care. Explain to the client and family the need for heightened quality of life until her last days. RATIONALE: To make the client and family aware that the care does not end in the hospital and that their participation is a must in the continuation of care. IV. HYGIENE Encourage the client to observe proper hygiene like taking a bath everyday, hand washing before and after performing activities especially when having meals and brushing of teeth every after meal. RATIONALE: Hygiene promotes comfort and cleanliness to the client and it also increases the sense of wellness. V. OUT PATIENT FOLLOW-UP If possible, instruct the patient to follow physicians order on when to consult for checkup. RATIONALE: To enable the physician to evaluate patients condition.
Ascites Secondary to Peritoneal Advise the family to supervise the patient properly. RATIONALE: To take note for any unusualities and can be referred immediately. VI. DIET Inform the family that the patient must receive adequate & proper nutrition (especially high fiber diet). Eat fruits and green leafy vegetables.
64
RATIONALE: To modify patients diet and prevent further complication. VII. SEXUAL ACTIVITY Instruct patient that sexual intercourse is not recommended. RATIONALE: Care is focused on supportive and emotional care.
CHAPTER XIII
BIBLIOGRAPHY
Austin, F., Mavanur, A., Sathaiah, M., Steel, J., Lenzner, D., Ramalingam, L., Holtzman, M., Ahrendt, S., Pingpank, J., Zeh, H., Bartlett, D., & Choudry, H. (2012). Peritoneal Carcinomatosis. Retrieved December 11, 2012 from, http://pmppals.org/peritoneal-carcinomatosis.html Brunner, L. S. &Suddarths D.S. (2008). Medical-Surgical Nursing 11th& 12th edition, Volume 1 & 2. Doenges, M., Moorhouse, M., &Murr A. (2002). Nursing Care Plans: Guidelines for Individualizing patient care 6th edition. Gould, B. (2007). Pathophysiology for the Health Professionals 3rd edition. Gulanick, M., Klopp, A., Galanes, S., Gradishar, D., &Puzas, M. (1994). Nursing Care Plan 3rd edition. Hoofnagle JH. Peritoneal Carcinomatosis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 151. Jeffress, D. (2012). What Is Peritoneal Carcinomatosis? Retrieved December 10, 2012 from, http://www.wisegeek.com/what-is-peritoneal-carcinomatosis.htm Johnson, RJ.(1993). Radiology in the management of ovarian cancer. Retrieved December 11, 2012 from, http://radiology.rsna.org/content/221/1/173.full Karch, A. (2007). Lippincotts Nursing Drug Guide. Kusamura, S., Baratti, D., Zaffaroni, N., Villa, R., Laterza, B., Balestra, MR., & Deraco, M. (2010). Pathophysiology and biology of peritoneal carcinomatosis. Retrieved December 12, 2012 from, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999153/ McCann, J. (2004). Handbook of Diseases 3rd edition.
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Mizumoto, A., Canbay, E., Hirano, M., Takao, N., Matsuda, T., Ichinose, M., & Yonemura, Y. (2012). Gastroenterology Research and Practice Volume 2012 Retrieved December 10, 2012 from, http://www.hindawi.com/journals/grp/2012/836425/ Peritoneal Health Guide (2010). Peritoneal Carcinomatosis Survival Rate. Retrieved December 11, 2012 from, http://peritoneal-health.info/peritoneal-carcinomatosis-survival-rate/ Sugarbaker, PH., Esquivel, J., & Sticca, R., (2007). Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin:a consensus statement. Retrieved December 11, 2012 from, http://www.ncbi.nlm.nih.gov/pubmed/17072675 Electronic resources: http://bestpractice.bmj.com/bestpractice/monograph/750/basics/pathophysiology. http://www.medicinenet.com/peritonealtuberculosis /page4.htm http://www.streetdirectory.com/travel_guide/111734/medical_conditions/ peritoneal carcinomatosis _a_ in_history.html http://www.who.int/mediacentre/factsheets/fs328/en/index.html - WHO 2012 http://www.ehow.com/list_6329814_signs-symptoms-peritonealcarcinomatosis.html

Peritoneal Carcinomatosis Grand Case Study

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ASCITES SECONDARY TO PERITONEAL TUBERCULOSIS, RULE OUT PERITONEAL CARCINOMATOSIS

December 13, 2012

Ascites Secondary to Peritoneal ACKNOWLEDGEMENT

Ascites Secondary to Peritoneal TABLE OF CONTENTS

CHAPTER III CHAPTER IV

DATE/TIME OF ADMISSION: PREVIOUS ADMISSION: ATTENDING PHYSICIAN: ADMITTING V/S:

CHIEF COMPLAINT: ADMITTING DIAGNOSIS:

Ascites Secondary to Peritoneal Past Illness History

Ascites Secondary to Peritoneal Present Illness History

Appearance and Behavior

Genito-urinary Has regular urination. No indwelling catheter present.

Ascites Secondary to Peritoneal

Ascites Secondary to Peritoneal

Abdominal Assessment A. INSPECTION

D. PALPATION 1. Measure Abdominal Girth 93cm

REVIEW OF ANATOMY & PHYSIOLOGY

The Abdomen and the Gastrointestinal System

Ascites Secondary to Peritoneal

Introduction to the gastrointestinal system

Ascites Secondary to Peritoneal Schematic Diagram:

Damage to DNA in cell nucleus

Cell Cycle Alteration

Increased production and proliferation of enzymes and hormones

New and rapid growth Palpable masses on the abdomen

Dissemination from the primary tumor

Ascites Secondary to Peritoneal

Systemic effects: Body cannot synthesize amino acids

Altered protein metabolism

Weight loss (From 50 kg to 42 kg)

Cachexia (muscle wasting)

COURSE IN THE HOSPITAL

DATE & TIME December 5, 2012 11:10 am

RATIONALE -Admission for referral of care.

AFB peritoneal fluid

Ranitidine 50mg IVTT every 8 hours

For serum Na, K, Ca For abdominal x-ray, supine upright

December 6, 2012 12:00 mn

(-) DOB, Conscious, coherent

For chest x-ray PA

For UR provided paracentesis

(-) BM (-) DOB

Lactulose 30cc TID Still for paracentesis

-To supply oxygen to the patient.

-To provide oxygen and support ventilation.

-To know if patient agreed with the planned diagnostic procedure.

NURSING CARE PLAN # 1

NURSING INTERVENTIONS 1. Monitor vital signs.

-To limit the level of anxiety.

Ascites Secondary to Peritoneal NURSING CARE PLAN # 2

Ascites Secondary to Peritoneal NURSING CARE PLAN # 3

Ascites Secondary to Peritoneal NURSING CARE PLAN # 4

-This reflects the bowel activity.

DEPENDENT: 6. Administer laxative or stool softeners as ordered.

Ascites Secondary to Peritoneal NURSING CARE PLAN # 5

-Use as comparative baseline

-To identify if bowel movement is present for peristalsis

-To appeal to client likes/ desires.

-To assess body image and congruency with reality

Ascites Secondary to Peritoneal NURSING CARE PLAN # 6

AMB Subjective: Kinakabahan ako sa kalagayan ko ngayon, as verbalized.

Ascites Secondary to Peritoneal NURSING CARE PLAN # 7

NSG. Dx Anticipatory grieving related to perceived potential death (Dec.11, 2012)

Ascites Secondary to Peritoneal NURSING CARE PLAN # 8