LICEO DE CAGAYAN UNIVERSITY

College of Nursing

A Case Study
On

IN PARTIAL FULFILLMENT OF NCM501204

SUBMITTED TO:

Ms. Christine D. Paderange, R.N

SUBMITTED BY:

Borja, Mary Karen Rose T.

Cimacio, May Grace
Casinillo, Vincent Chris L.
Cortez, Elmar Bonniday M.

July 2009
 I. Introduction

A. Brief Description of the Disease Condition

The body is made up of many types of cells. Normally, cells grow, divide and
die. Sometimes, cells mutate (change) and begin to grow and divide more
quickly than normal cells. Rather than dying, these abnormal cells clump
together to form tumors. If these tumors are malignant (cancerous), they can
invade and kill your body's healthy tissues. From these tumors, cancer cells can
metastasize (spread) and form new tumors in other parts of the body. By
contrast, benign (noncancerous) tumors do not spread to other parts of the
body. Nasopharyngeal (say: "nay-zo-fair-in-gee-al") cancer is a malignant tumor
that develops in the nasopharynx (say: "nay-zo-fair-inks"). The nasopharynx is
the area where the back part of your nose opens into your upper throat. This is
also where tubes from your ears open into your throat.

Nasopharyngeal cancer is rare. It most often affects people who are between 30
and 50 years of age. Men are more likely to have nasopharyngeal cancer than
women. You are most likely to get this cancer if you or your ancestors came
from southern China, particularly Canton (now called Guangzhou) or Hong
Kong. You are also more likely to get this cancer if you are from a country in
Southeast Asia, like Laos, Vietnam, Cambodia or Thailand. No one knows for
sure what causes nasopharyngeal cancer. Eating salt-preserved foods (like fish,
eggs, leafy vegetables and roots) during early childhood may increase the risk
of getting this form of cancer. The Epstein-Barr virus may also make a person
more likely to get nasopharyngeal cancer. This is the same virus that causes
infectious mononucleosis (also called "mono"). You may also inherit a tendency
to get nasopharyngeal cancer.

Reason for Choosing the Case

Nasopharyngeal Cancer is one of the unusual terms for a lay person and a rare
case that a nurse would encounter. Acquisition of cognitive knowledge regarding
the topic would enable the researchers in providing optimum care for clients
suffering such and in delivering appropriate interventions that would promote
health and wellness for the client. Since our rotation is about EENT, this
condition can also be acceptable.

Statistics (Global and Local)

Cancer of the nasopharynx is a rare neoplasm in most countries. However, it
occurs at high frequencies in China and Southeast Asia. The highest incidence
rates in the SEER regions occur among the Chinese. Rates are also high in
Vietnamese and Filipino men, two groups that include persons of Chinese
heritage. Incidence rates of nasopharyngeal cancer are also available for black,
Hispanic and white men and for white women in the SEER areas. There were
too few nasopharyngeal cancers diagnosed between 1988 and 1992 in the other
racial/ethnic groups to provide meaningful incidence rates.

The average annual age-adjusted incidence rate of nasopharyngeal cancer in

Chinese men, 10.8 per 100,000, is 1.4 times greater than that of Vietnamese
men and nearly 2.8 times greater than that of Filipino men. In fact, the rate
among Filipino men, although relatively high, is the same as that for Chinese
women. Rates of one per 100,000 and lower occur in black men, Hispanic and
non-Hispanic white men and non-Hispanic white women.

The United States mortality rates for cancer of the nasopharynx reflect patterns
similar to those for SEER incidence rates. Mortality is highest in Chinese, lower
in Filipinos and lowest among blacks, Hispanics and non-Hispanic whites. No
mortality rates are currently available for Vietnamese. Incidence-to-mortality rate
ratios vary, with Chinese and Filipinos having higher incidence relative to
mortality (2.3 for men in both groups and 3.2 for Chinese women) than other
groups (ranging from about 1.7 for white Hispanic men to two for non-Hispanic
white men). Incidence and mortality rates for nasopharyngeal cancer increase
through the oldest age group, although the small number of cases precluded the
calculation of reliable rates for many populations.

The major modifiable risk factor identified for cancer of the nasopharynx is the
consumption of Cantonese salted fish, which is a common food item eaten from
early infancy onward by groups with high risk of this disease. Other possible risk
factors include extensive exposures to dusts and smoke and regular
consumption of other fermented foods. The role of Epstein-Barr virus in the
development of nasopharyngeal cancer continues to be explored.

B. Objectives of the study

The main concern of this study is:
• to have a better understanding about the causes of nasopharyngeal
cancer.
• to determine the medical and surgical treatment that has given to the
disease entity.
• to perform well our role as student nurses in the treatment and achieving
the optimum level of health of the patient.
• to enhance our nursing skills most importantly focusing on promotive and
preventive nursing measures.

C. Scope and Limitations

The scope of the study are as follows:
• The patient must be admitted at Cagayan de Oro Medical Center.
• The patient must have an informant.
• The student must have the consent coming from the family to make the
client as a subject of the study.
• The scope of the study includes the patient’s profile, the developmental
data, the health history of the patient, the history of present illness, the
nursing assessment, the anatomy and physiology of the involved
structures, the pathophysiology of the condition, the patient’s diagnosis,
the diagnostic exams, the nursing management, the medical management
 and the recommendation and the patient’s prognosis as evaluated by the
student nurse conducting this study.
• The different references were also part of this study, which encompasses
the use of the different pathophysiology books, nursing care plan books
and other sources which served as guide throughout the study.

The limitations of the study are as follows:

• Interaction with the client was limited to 2 days of care only. The first
interaction was on July 6, 2009 at Cagayan de Oro Medical Center during
the first day of duty and July 7, 2009 for our last duty. The interaction was
limited only on the days the patient was confined to the Hospital.
• The information gathered were based on the legal informants, and the
client himself who may still be subjected for further critique in terms of
validity and reliability.
• The discussion on the pathophysiology is focused on the principal
diagnosis and the signs and symptoms manifested by the client.

II. HEALTH HISTORY

A. Patient’s Profile
Name: Egberto Villanueva
Age: 70 years old
Address: Lot 7 Block 14 Phase 2, Miguel Manolo Fortich
Bukidnon
Sex: Male
Civil Status: Married
Birthdate: April 24, 1939August 25,
Birthplace: Manolo Fortich Bukidnon
Nationality: Filipino
Occupation: Retired Supervisor in Del Monte Philippines
Religion: Roman Catholic
Educational Attainment: Graduate of Agricultural in Central Mindanao
University
Date of admission: July 6, 2009
Allergies: No known allergies to food and drugs
Temperature: 36.8 º C
Pulse Rate: 70 bpm
Respiratory Rate: 23 cpm
Blood Pressure: 130/80 mmHg
Height: 5’5”
Weight: 125 pounds
Attending Physician: Dr. Abas
Diagnosis: Nasopharyngeal Carsinoma

Type 2 Diabetes Mellitus Concentrated/ HCVD Infected wound 2nd digit Left
Foot.Chief complaint: For chemotherapy 4th patient was diagnosed with
Nasopharyngeal carcinoma there started 1st chemotherapy his march 2009
B. HISTORY OF PRESENT ILLNESS and CHIEF COMPLAINT
Last March 2009, the patient has been in session of Chemotherapy.
and last March was his first. The patient is also having a Diabetic and has a
maintenance of the following medication : Galdos tab OD and Litizak 500mg Tab
OD.
The patient was admitted for his 4th session and scheduled on
Chemotheraphy under Doctor Abas. Was admitted 6:30 am, July 6, 2009.

III. DEVELOPMENTAL DATA

Psychosocial Theory
Our personality traits come in opposites. We think of ourselves as
optimistic or pessimistic, independent or dependent, emotional or unemotional,
adventurous or cautious, leader or follower, aggressive or passive. Many of these
are inborn temperament traits, but other characteristics, such as feeling either
competent or inferior, appear to be learned, based on the challenges and support
we receive in growing up.
Erik Erikson organized life into eight stages that extend from birth to death
(many developmental theories only cover childhood). Since adulthood covers a
span of many years, Erikson divided the stages of adulthood into the experiences
of young adults, middle aged adults and older adults. While the actual ages may
vary considerably from one stage to another, the ages seem to be appropriate for
the majority of people.

Late Adulthood: 55 or 65 to Death

Ego Development Outcome: Integrity vs. Despair
Basic Strengths: Wisdom
Erikson felt that much of life is preparing for the middle adulthood stage
and the last stage is recovering from it. Perhaps that is because as older adults
we can often look back on our lives with happiness and are content, feeling
fulfilled with a deep sense that life has meaning and we've made a contribution to
life, a feeling Erikson calls integrity. Our strength comes from a wisdom that the
world is very large and we now have a detached concern for the whole of life,
accepting death as the completion of life.
On the other hand, some adults may reach this stage and despair at their
experiences and perceived failures. They may fear death as they struggle to find
a purpose to their lives, wondering "Was the trip worth it?" Alternatively, they may
feel they have all the answers (not unlike going back to adolescence) and end
with a strong dogmatism that only their view has been correct.
The significant relationship is with all of mankind—"my-kind."
As of for our client we thought that he had reached this stage and
overcome it positively. There are problem’s that he successfully overcome with
his own strength and knowledge.

Developmental Task Theory

Robert Havighurst defines a developmental task as one that arises at a
certain period in our lives, the successful achievement of which leads to
happiness and success with later tasks; while leads to unhappiness, social
disapproval, and difficulty with later tasks. He recognized that each human has
three sources for developmental tasks. They are:
• Tasks that arise from physical maturation: Learning to walk, talk, control of
bowel and urine, behaving in an acceptable manner to opposite sex,
adjusting to menopause.
 • Tasks that arise from personal values: Choosing an occupation, figuring
out ones philosophical outlook.
• Tasks that have their source in the pressures of society: Learning to read,
learning to be responsible citizen.
The developmental tasks model that Havighurst developed was age dependent
and all served pragmatic functions depending on their age.
• Age 60 and over (Late Maturity)
Adjusting to decreasing physical strength and health. Adjusting to retirement
and reduced income. Establishing an explicit affiliation with one’s age group.
Adopting and adapting social roles in a flexible way. Establishing satisfactory
physical living arrangements.
IV. Medical Management
A. Medical orders and rationale

7/6/09

6:00 am RATIONALE

Pls. admit to station 4 ➢ Endorsement of patient to the

station

IVF: 0.9 NaCl 1L at 30gtts/min ➢ To maintain patients fluid

balance
to

➢ To determine, evaluate and

For CBC in AM diagnose pt. condition and to
visualize if there are
abnormalities.

7/7/09 RATIONALE

For chemothrapy ➢ shrink tumors , destroy cells that

have spread to other parts of the
body or control tumor growth..
Chemotherapy works by
interfering with the growth and
reproductive process of cancer
cells.
 ➢ To maintain patients fluid
Continue IV hydration balance

➢ This is not to alter the chemicals

Cover iv tubing with black tape use in chemotherapy

Refer accordingly to check appropriate order

Laboratory Results
 CBC
RESULT NORMAL RANGE INTERPRETATION
WBC 8,200 5,000-10,00 /MM3 Normal
RBC 3.4 4.35-5.90 /MM3 Low red blood cells
Hgb 10.7 13.7-167 g.Dl Bone marrow insufficiency

indicates anemia
Hct 33.1 40.5- 49.7 VOLS %
PLATELET 348,000 144,000-372,000 normal
MCV 96.0 79.7-97.06 normal
MCH 32.4 26.1-33.3 pq normal
MCHC 33.5 32.2-35.0 q/dl normal
DIFF. COUNT
Neutrophils 69 43.4-76.2% normal
Lymphocytes 19 17.4-46.2% normal
Decreased ability to
regulate immune function
Monocytes 10 4.5-10.5%
and repair body tissues
Eosinophil 1.4 2-3% normal
Basophil 0.2 0-0.5% normal

V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

Anatomy and Physiology of the Human Respiratory System

The respiratory system consists of all the
organs involved in breathing. These
include the nose, pharynx, larynx, trachea,
bronchi and lungs. The respiratory system
does two very important things: it brings
oxygen into our bodies, which we need for
our cells to live and function properly; and it
helps us get rid of carbon dioxide, which is
a waste product of cellular function. The
nose, pharynx, larynx, trachea and bronchi
all work like a system of pipes through which the air is funneled down into our
lungs. There, in very small air sacs called alveoli, oxygen is brought into the
bloodstream and carbon dioxide is pushed from the blood out into the air. When
something goes wrong with part of the respiratory system, such as an infection
like pneumonia, it makes it harder for us to get the oxygen we need and to get rid
of the waste product carbon dioxide. Common respiratory symptoms include
breathlessness, cough, and chest pain.

The Upper Airway and Trachea

When you breathe in, air enters your body
through your nose or mouth. From there, it
travels down your throat through the larynx (or
voicebox) and into the trachea (or windpipe)
before entering your lungs. All these structures
act to funnel fresh air down from the outside
world into your body. The upper airway is
important because it must always stay open for
you to be able to breathe. It also helps to
moisten and warm the air before it reaches
your lungs.

The Lungs
The lungs are paired, cone-shaped organs which take up most of the space in
our chests, along with the heart. Their role is to take oxygen into the body, which
we need for our cells to live and function properly, and to help us get rid of
carbon dioxide, which is a waste product. We each have two lungs, a left lung
and a right lung. These are divided up into 'lobes', or big sections of tissue
separated by 'fissures' or dividers. The right lung has three lobes but the left lung
has only two, because the heart takes up some of the space in the left side of our
chest. The lungs can also be divided up into even smaller portions, called
'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other by
membranes. There are about 10 of them in each lung. Each segment receives its
own blood supply and air supply.
Air enters your lungs through a system of pipes called the bronchi. These pipes
start from the bottom of the trachea as the left and right bronchi and branch many
times throughout the lungs, until they eventually form little thin-walled air sacs or
bubbles, known as the alveoli. The alveoli are where the important work of gas
exchange takes place between the air and your blood. Covering each alveolus is
a whole network of little blood vessel called capillaries, which are very small
branches of the pulmonary arteries. It is important that the air in the alveoli and
the blood in the capillaries are very close together, so that oxygen and carbon
dioxide can move (or diffuse) between them. So, when you breathe in, air comes
down the trachea and through the bronchi into the alveoli. This fresh air has lots
of oxygen in it, and some of this oxygen will travel across the walls of the alveoli
into your bloodstream. Travelling in the opposite direction is carbon dioxide,
which crosses from the blood in the capillaries into the air in the alveoli and is
then breathed out. In this way, you bring in to your body the oxygen that you
need to live, and get rid of the waste product carbon dioxide.

Blood Supply
The lungs are very vascular organs, meaning they receive a very large blood
supply. This is because the pulmonary arteries, which supply the lungs, come
directly from the right side of your heart. They carry blood which is low in oxygen
and high in carbon dioxide into your lungs so that the carbon dioxide can be
blown off, and more oxygen can be absorbed into the bloodstream. The newly
oxygen-rich blood then travels back through the paired pulmonary veins into the
left side of your heart. From there, it is pumped all around your body to supply
oxygen to cells and organs.

The Pleurae
The lungs are covered by smooth
membranes that we call pleurae. The pleurae
have two layers, a 'visceral' layer which sticks
closely to the outside surface of your lungs,
and a 'parietal' layer which lines the inside of your chest wall (ribcage). The
pleurae are important because they help you breathe in and out smoothly,
without any friction. They also make sure that when your ribcage expands on
breathing in, your lungs expand as well to fill the extra space.

The Diaphragm and Intercostal Muscles

When you breathe in (inspiration), your muscles need to work to fill your lungs
with air. The diaphragm, a large, sheet-like muscle which stretches across your
chest under the ribcage, does much of this work. At rest, it is shaped like a dome
curving up into your chest. When you breathe in, the diaphragm contracts and
flattens out, expanding the space in your chest and drawing air into your lungs.
Other muscles, including the muscles between your ribs (the intercostal muscles)
also help by moving your ribcage in and out. Breathing out (expiration) does not
normally require your muscles to work. This is because your lungs are very
elastic, and when your muscles relax at the end of inspiration your lungs simply
recoil back into their resting position, pushing the air out as they go.

The Respiratory System and Ageing

The normal process of ageing is associated with a number of changes in both the
structure and function of the respiratory system. These include:
• Enlargement of the alveoli. The air spaces get bigger and lose their
elasticity, meaning that there is less area for gases to be exchanged
across. This change is sometimes referred to as 'senile emphysema'.
• The compliance (or springiness) of the chest wall decreases, so that it
takes more effort to breathe in and out.
 • The strength of the respiratory muscles (the diaphragm and intercostal
muscles) decreases. This change is closely connected to the general
health of the person.

All of these changes mean that an older person might have more difficulty coping
with increased stress on their respiratory system, such as with an infection like
pneumonia, than a younger person would.
Pathophysiology (Book-based and Client-centered)

Definition of the Disease

Nasopharyngeal cancer is a disease in which malignant (cancer) cells form in the
tissues of the nasopharynx.

Predisposing Factors
• People who are between 30 and 50 years of age
• Men are more likely to have nasopharyngeal cancer than women
• Chinese or Asian ancestry
• Hereditary

Precipitating Factors
• Eating salt-preserved foods (like fish, eggs, leafy vegetables and roots)
during early childhood
• Cigarette smoking
• Alcohol abuse
• Poor Oral Hygiene
• Long Term Sun Exposure
• Occupational Exposure (chemicals esp. asbestos)

Signs and Symptoms with Rationale

• Anorexia – is a decreased sensation of appetite caused by the
complications of compression of the esophagus.
• Atelectasis – is a collapse of lung tissue affecting part or all of one lung
because of presence of fluid in the lungs.
• Chest pain – pain caused by the obstruction of the vena cava.
• Chest wall pain – pain caused by the invasion of the pleural cavity irritating
nerve fibers.
• Chronic Cough – caused by sputum production brought by the irritation of
the bronchioles.
 • Difficulty in swallowing – condition caused by the compression of the
esophagus.
• Distended neck veins – caused by the obstruction of the vena cava.
• Dyspnea – caused by the invasion of the pleural space.
• Facial, arm, and trunk swelling – caused by the obstruction of the vena
cava.
• Hemoptysis – is the expectoration of blood caused by lesions in the blood
vessels.
• Hoarseness of voice – caused by the irritation of the laryngeal nerve.
• Hyperglycemia – a manifestation caused by Cushing’s syndrome.
• Hyperkalemia – a manifestation caused by Cushing’s syndrome.
• Hypertension – a manifestation caused by Cushing’s syndrome.
• Hypervolemia – a manifestation caused by Cushing’s syndrome.
• Immunosupression – a manifestation caused by Cushing’s syndrome.
• Osteoporosis – caused by high levels of cortisol.
• Pneumonia – condition caused by the invasion of the pleural space and it is
characterized by inflammation and abnormal alveolar filling with fluid.
• Shortness of breath – caused by the irritation and obstruction of airway.
• Venous stasis – caused by the obstruction of the vena cava.
• Weight loss – caused by dysphagia and the metastases in the liver.

Note: Items marked in RED were experienced by the client.

 Schematic Diagram (Book-based)

Predisposing Factors: Precipitating Factors:

• People who are between 30 and 50 years of age • Eating salt-preserved foods (like fish, eggs,
• Men are more likely to have nasopharyngeal leafy vegetables and roots) during early
cancer than women childhood
• Chinese or Asian ancestry • Cigarette smoking
• Hereditary • Alcohol abuse
• Poor Oral Hygiene
• Long Term Sun Exposure
• Occupational Exposure (chemicals esp.

Formation of benign
bronchial epithelium tissue

Transformation benign
tissue to neoplastic tissue

Nasopharyngeal Cancer/
Lung Cancer

Squamous Cell Carcinoma Small Cell Carcinoma Adenocarcinoma Large Cell Carcinoma

Chronic cough Sputum Irritation and obstruction of airway Lesions erode to Hemoptysis
production the blood vessels

Shortness of Wheezing Invasion of the Triggering of Chest wall

breath pleural cavity pain receptors
Atelectasis
Pleural Effusion
Invasion of the Synthesis of Dyspnea
mediastinum bioactive products
Pneumonitis
Vena Cushing’s
cava Syndrome
Irritation of the Compression of Pneumonia
laryngeal the esophagus Shortness of Hyperglycemia
breath
Hypertension
Hoarseness Difficulty in Facial, arm, and
of voice swallowing trunk swelling
Hypervolemia
Chest pain
Metastases to Anorexia Hyperkalemia
the liver
Distended
neck veins Osteoporosis
Weight Loss

Venous stasis Immunosupression

Schematic Diagram (Client-centered)

Predisposing Factors: Precipitating Factors:

• People who are between 30 and 50 years of age • Eating salt-preserved foods (like fish, eggs,
• Men are more likely to have nasopharyngeal leafy vegetables and roots) during early
cancer than women childhood
• Chinese or Asian ancestry • Cigarette smoking
• Hereditary • Alcohol abuse
• Poor Oral Hygiene
• Long Term Sun Exposure
• Occupational Exposure (chemicals esp.

Formation of benign
bronchial epithelium tissue

Transformation benign
tissue to neoplastic tissue

Nasopharyngeal Cancer/
Lung Cancer
Chronic cough
(September 20, Sputum Irritation and obstruction of airway Invasion of the Triggering of
2008) production pleural cavity pain receptors

Shortness of Wheezing Invasion of the

breath mediastinum Chest wall pain
(September 20, 2008)

Irritation of the Compression of

laryngeal the esophagus

Hoarseness of voice
Difficulty in
(September 20, 2008)
swallowing

Anorexia
(August 2008)

Weight Loss

VI. NURSING ASSESSTMENT

 *********NURSING REVIEW CHART********
Name: Egberto Villanueva
Vital Signs:
Pulse: 70bpm BP: 130/80mmhg Temp: 36.8ºC Respi: 23cpm Weight: 125
pounds Height: 5’5”
EENT : Alopecia
 impaired vision  blind  pain X hard of hearing
 reddened  drainage  gums  deaf Hearing loss reported
 burning  edema  lesion teeth
 no problem
Change in appetite and
RESP: horseness of voice
 asymmetric  tachypnea
 apnea  rales cough Wheezing sound
 barrel chest  bradypnea
 shallow  rhonchi  sputum
 diminished dyspnea Afebrike 36.8 ºC
 orthopnea  labored BP 130/80 mmHg
X wheezing  pain  cyanotic Polyuria
 no problem
IV site : 0.9 NaCl @
CARDIO VASCULAR 30gtts/min
 arrhythmia  tachycardia  numbness
 diminished pulses  edema  fatigue
 irregular  bradycardia  murmur
 tingling  absent pulses  pain
X no problem

GASTRO INTESTINAL TRACT

 obese  distention  mass
 dysphagia  rigidity  pain
X no problem

GENITO-URINARY and GYNE

pain  urine color / vaginal bleeding Muscle pain reported
 hermaturia / discharge  noctoria and itchiness skin with
X no problem poor skin turgor.
NEURO
 paralysis  stuporous unsteady  seizures Rashes noted
 lethargic  comatose  vertigo tremors
 confused  vision  grip
X no problem
Generalized weakness
MUSCULOSKELETAL and SKIN and weight loss
 appliance  stiffness X itching  petechiae
 hot  drainage  prosthesis swelling Constipation reported
 lesion X poor turgor  cool  deformity
 wound X rash  skin color  flushed
 atrophy  pain  ecchymosis X dry
 no problem Muscle pain in
lower extremities
reported and
itching skin with
poor skin tuger
**********NURSING ASSESSMENT II********
SUBJECTIVE OBJECTIVE
COMMUNICATION: “ sukad atong nasakit ko halap þ glasses languages
þ Hearing Loss na ako pananaw og ga contact lens hearing aide
glasses lisod ko ug dungog kay R L
þ visual changes naay nag tubo sa ako Pupil size _2-3mm_ speech difficulties
denied dalunggan” as verba- Reaction _PERRLA_
lized by th pt.
OXYGENATION: Comments:
dyspnea “kani adto ga sigarilyo, Resp. regular þ irregular
smoking history karon wala nah, dugay Description ___patient has irregular respiration –
___20 yrs ago___ na kaau, 20 yrs ago” 23 cpm with normal range of (16-29)
cough as verbalized by the
sputum pt. R Symmetrical
þ denied L Symmetrical
CIRCULATION Comments : “ usahay mag
þ chest pain sakit akong dughan karon Heart Rhythmþ regular irregular
leg pain lang wala ka naa man Ankle edema _____NONE_______________
þ numbness of tambal ug sakit akong
extremities kalawasan or luya kung Pulse Car Rad DP Fem
denied mag tindog ko” as ver- R ______√_____70bpm_ _√__ _√____________
balized by the pt. L ______√_____70bpm √__ _√____________
Comments: ___All pulses are palpable

NUTRITION
Diet : Diabetic diet Comments: “walajud ko gana dentures þ none
N V mukaon permi kay
Character lain man akong Full Partial With Patient
þ recent change in pan lasa, tu-ig nani
weight, appetite siya mao dili ko Upper
swallowing nahan kaon usahay” Lower
difficulty verbalized by the
denied patient
ELIMINATION: Bowel sounds hypoactive
Usual bowel pattern urinary frequency Comments : Has audible
___once a day _ _5 times a day_____ bowel sound when aus- Abdominal distention
þ constipation urgency cultate the abdomen part Present [] yes [] no
of the pt., the usual bowel Uri
remedy dysuria ne*(color,
____________ hematuria sound hashypoactive
consistency, odor)
Date of last BM Incontinence that is extremely soft and no foley bag catheter in
infrequent place
_____ July 4, 2009 __ þ polyuria
diarrhea foley in place *if they are in place?
character denied ____no
ne________

MGT. OF HEALTH ILLNESS: Briefly describe the patient’s ability to follow treatments
alcohol þ denied (diet, meds, etc) for chronic problems (if present)
(amount, frequency) _______________N/A_____________________
“kaniadto kato mayo pa ako lawas” _______________________________________
SBE Last Pap Smear : N/A __
LMP: N/A

SUBJECTIVE OBJECTIVE
SKIN INTEGRITY: Comments :
þ dry “ ga katol ni ako panit þ dry cold þpale
lagi, taga kalot nako flushed warm
ako moist cyanotic
*
þ itching likod kay murag ma rashes, ulcers, decubitus (describe size, location,
paksi na panit” as ver- drainage) : presence of rashes noted at the right
other balized by the pt. lower quadrant at the back extremities of the pt.

denied
ACTIVITY/SAFETY Comments: “ ala man kani
convulsion lang mag tindod og LOC and orientation Awake, conscious, and
dizziness tanaw ko sa kasakit coherent_. Oriented to date, time and
limited motion sa ako lawas hasta place.______________________________
of joints murag akong bukog Gait: Walker Cane Other
Limitation in ga apil ug sakit” steady unsteady __________________
ability to as verbalized by the sensory and motor losses in face or
þ ambulate pt. extremities:NONE________________________
bathe self _ ROM limitations _Patient has no limits on
other range of motion_______
denied
COMFORT/SLEEP/AWAKE:
pain Comments: þ facial grimaces
(location, “All mayo man pud guarding
Frequency akung pag tulog mao other signs of pain_Generalized_____
remedies) na ako amapay ron” weakness___________________________________
nocturia as verbalized by the ____________________
sleep difficulties patient. þ side rail release form signed
( 60 + years)
þ denied ________no side rail________________
COPING:
Occupation _____None___________ Observed non-verbal behavior _patient is responsive
000Members of household __2 members___ during our interview
Most supportive person: Irene Villanueva (daughter). The person and his phone number that can be
Reached any time __none________________
Date Diagnostic/Laboratory Date
Date Done IV Fluids/Blood Date Disc.
Oredered Exams Ordered
7/76/09 HGT test 7/6/09 7/6/09 PNSS
7/6/09 Creatinine 7/6/09
7/6/09 CBC 7/06/09
VII. NURSING MANAGEMENT
**********IDEAL NURSING CARE PLAN********
Fatigue

Assessment Nursing Diagnosis Objectives Nursing Interventions Rationale

Subjective cues: Fatigue related to poor After 3 hours of nursing • Establish rapport • to gain cooperation
“maglisod jud ko ug physical condition as intervention, the patient • for baseline data
tindog”, as verbalized by manifested by the patient will verbalize an • Monitor and record vital
the patient. appears weak, a decreased understanding regarding the signs • to conserve energy
ability in performing health teachings on how to • Encourage pt. to sit
Objective cues: activities, and conserve energy as instead of standing in
• appears weak compromised evidenced by the patient performing activities
• decreased ability in concentration. appears strong, an increase • Advise pt. to have
performing activities in the ability to perform adequate rest • to regain strength
• with compromised activities, and has the • Encourage pt. to perform
concentration ability to concentrate fully. ROM exercises • to reduce fatigue
• Encourage pt. to eat
carbohydrates-containing
food • to increase energy level
• Encourage pt. to do focus
breathing • to promote energy
Disturbed Energy Field

Assessment Nursing Diagnosis Objectives Nursing Interventions Rationale

Subjective cues: Disturbed energy field After 3 hours of nursing • establish rapport • to gain cooperation
“Mao nang maglisod ko related to slowing of intervention, the pt. will • for baseline data
ug tindog, dayon mag energy flow as manifested verbalize a sense of • monitor and record VS
lakaw2x”, as verbalized by the pt. appears weak, relaxation as evidenced by • advise pt. to have • to regain strength
by the patient. with low tone speech, and the pt. appears strong, high adequate rest
with compromised toned speech and the • encourage pt. to eat • to increase energy level
Objective cues: concentration secondary to ability to concentrate. foods rich in
• appears weak illness. carbohydrates • to promote energy
• low tone speech • advise pt. to do deep
• compromised breathing • to prevent dehydration
concentration • advise pt. to take
adequate fluid intake • to promote energy and
• encourage pt. to rest regain strength
between activities • to strengthen own inner
• allow pt. to have period resources
of independency
 “ga luya akong lawas murag apil ang bukod, hago au mag lihok” as
S
verbalized by the patient.

– Generalized weakness noted upon moving

O
– decreased pertinence in an activity
– increase in physical complaints

Fatigue related to altered body chestry(chemotherapy)

A

At the end of 2 days, the client will be able to verbalize improved

P
sense of energy

1. Determine level of ability to stand, move about and

the amount of assistance necessary
2. Provide environment conducive to improvement of
fatigue
I
3. Provide diversional activities
4. Encourage pt. to develop assertiveness skills
prioritizing goals/activity
5. Encourage independence in performing activities

At the end of 2 days, objective met, client reported improved sense

E
of energy.
 “katol akong likod sa bukton” as complained by the patient
S

– Distension of skin surface

O – Destruction of skin layers
– Invasion of body structure

Skin integrity impaired related to radiation

A

At the end of 2 days, the client will be able to verbalize feeling of

P
increased in self-esteem and to damage situation.

Independent:
1. Palpate skin lesions for size, shape,
consistency, texture, temperature and
hydration.
2. Expose lesions/ulcer to air and light as
indicated
I 3. Monitor for sign of complications in
wound healing, infection
4. Check for proper fit clothing
5. Identify safety factors for use of
equpment
Dependent:
6. Apply medication as indicated (cream)

At the end of 2 days, objective met, patient verbalized feeling of

E
increased self-esteem and ability to manage stimulation
 Reported altered sensation
S

– loss of weight with low food intake

O
– show no interest in food noted

Nutrition altered, less than body requirement related to sudden

A change in appetite.

At the end of 2 days, the client will demonstrate behavior, lifestyle

P
changes to regain appropriate weight.

Independent:
1. Note food intolerance
2. Auscultate bowel sounds and pts. oral hygiene
3. Note total calorie intak; maintain dietary intake, time
I and pattern of eating
4. Promote adequate intake of fluid
5. Weigh daily and document result
Dependent:
6. Administer medication agent

At the end of 2 days, objective met, patient demonstrated behavior,

E
life style changes to regain weight.
 ************HEALTH TEACHING**********

MEDICATION Instruct the patient to follow the medication regimen as indicated to

promote pharmacological effects. It should be prescribed by the doctor.

EXERCISE
Instruct the patient to have a ROM exercises daily as tolerated. Which
increases energy level and anxiety of the patient.

Instruct the patient to properly do an oral hygiene 3xdaily to increase

food appetite and to maintain hygiene. Patient also is advised not to
TREATMENT drink hot fluids that may irritate the pharynx and esophagus. Encourage
to drink water 8 glasses per day.

Encouraged patient to have a follow-up check up 1 week after

OUTPATIENT discharged. Under supervision of Dr. Abas. This to monitor the condition
of the patient.

Encouraged patient to maintain the diabetic diet which is low sugar

DIET
content . Increase fluid intake and nutritious foods.
VIII. REFERRALS AND FOLLOW-UP
The patient was referred to Dr. Abas.. The significant others of the
patient was also advised to continue medication at home and was also advised
to keep back dry always to prevent from worsening the disease. And also the
client was instructed to come back for follow up check up a week after
discharged.

IX. PROGNOSIS AND EVALUATION

Criteria Good Prognosis Poor Prognosis
A. Onset of Illness √
B. Duration of illness ✔
A. Precipitating
✔
Factors
A. Attitude towards
taking medications ✔
and treatment
A. Financial ✔
A. Family Support ✔

On the criteria listed above it shows that the prognosis of the patient is
good because the majority of the criteria falls under good prognosis. His onset of
illness was poor because it was in late stage and cannot be treated with
medications and duration of illness was also good. Precipitating factors was also
good because the author has identified the said factors that contributed to the
client’s disease condition. Attitude towards taking medication and treatment were
also good because the patient exhibits interest in taking religiously his
medications as well as following the doctor’s indicated treatment regimen. Family
support was good because the significant others were always there in the
hospital supporting him.