Вы находитесь на странице: 1из 24

UNIVERSITY OF THE CORDILLERAS

College of Nursing
Governor Pack Road, Baguio City, Philippines 2600
(+6374) 442-3316, 442-2564, 442-8219, 442-8256
E-mail: webmaster@bcf.edu.ph
Website: www.bcf.edu.ph

CASE TITLE
CERVICAL MASS PROBABLY MALIGNANT HYPERTENSION STAGE II

A Case Presented to the


College of Nursing

In Partial Fulfillment of the requirements in the Course


( Nursing Care Management 101)

Submitted By:

Al-Atefi, Belal
Baido, Zairamae
Balcanao, Charice Mae
Contaoi, Donna
Dairo, Mariam
De Ocampo, Tricia Bianca Camille
Djibril, Ahmed
Ekesae, Jena
Ilechukwu, Cynthia
Mohammed, Ayman
Panit, Garlie Ann
Rahhal, Amjad
Saleo, Aaron Abram
Talam, Cynthia

(November 20, 2019)

Noted and Approved for Presentation:


Name of Case Presentation Adviser or Panel/s

________________________
Aklbacio, Shirley
Clinical Instructor
ABSTRACT

TITLE:

AUTHOR INFORMATION:

BACKGROUND:

CASE DESCRIPTION:

CONCLUSION:


TABLE OF CONTENTS

I. Introduction ........................................................................................................................................ 3

II. Statement of Objectives ..................................................................................................................... 3

A. General Objectives .......................................................................................................................... 3

B. Specific Objectives .......................................................................................................................... 3

III. Patient’s Profile ............................................................................................................................... 3

IV. Chief Complaint............................................................................................................................... 3

V. Present History of Illness .................................................................................................................... 3

VI. Past History of Illness ...................................................................................................................... 3

VII. Family Health History ...................................................................................................................... 3

VIII. Developmental History ................................................................................................................... 4

IX. Social and Environmental History .................................................................................................. 4

X. Lifestyle and Health Practices ............................................................................................................. 4

XI. Health Assessment .......................................................................................................................... 4

A. General Survey ................................................................................................................................ 4

B. Head to Toe Assessment ................................................................................................................. 4

C. 13 Areas of Assessment .................................................................................................................. 6

XII. Diagnostics ........................................................................................................................................ 9


XIII. Comprehensive Pathophysiology................................................................................................... 10
XIV. Treatment/Management ................................................................................................................ 11
A. Drugs ........................................................................................................................................... 11
B. IV Fluids ....................................................................................................................................... 11
C. Surgery ........................................................................................... Error! Bookmark not defined.
XV. Nursing Care Plans .......................................................................................................................... 12
A. Prioritization of Problems ............................................................................................................... 12
a.1. List of Problems ................................................................................................................... 12
a.2. Basis for Prioritization...................................................................................................... 12
B. Nursing Care Plans ......................................................................................................................... 13
NCP 1: ............................................................................................................................................... 13
NCP 2: ............................................................................................................................................... 14
NCP 3: ............................................................................................................................................... 15
NCP 4: ............................................................................................................................................... 16
NCP 5: ............................................................................................................................................... 16
C. Discharged Plan............................................................................................................................... 19
XVI. Learning Insights ............................................................................................................................. 19
XVII. List of References ........................................................................................................................ 19


XVIII. Appendices ........................................................................................................................................ 19
Appendix A .............................................................................................................................................. 20
Appendix B .............................................................................................................................................. 21
Appendix C .............................................................................................................................................. 22

I. Introduction

DEFINITION, RISK, SIGNS AND SYMPTOMS, S/Sx MANIFESTED BY THE PATIENT,

ONE SENTENCE IS NOT CONSIDEERED AS A PARAGRAPH.

ARRANGE FROM WORLDWIDE/INTERNATION, NATIONAL, LOCAL DATAS

II. Statement of Objectives


A. General Objectives

B. Specific Objectives

III. Patient’s Profile


Name : Patient X
Ethnic Background : Ilocano
Civil Status : Child
Religion : Roman Catholic
Occupation : Child

Admitting Diagnosis : PCAP-C


Final/Principal Diagnosis :
Date and Time Admitted : October 8, 2018, 12:00pm

IV. Chief Complaint

V. Present History of Illness

VI. Past History of Illness

According to the patient she had no history of accident or trauma, she only
recalled having minor illness such as cold, cough, fever when she was still young and
she remedied it with (OTC) over the counter medicine. She also verbalized that
she developed he(HPN) Hypertension on 2016.

VII. Family Health History


The patient verbalized to have familial history of HPN only or her mother's
family especially her mother and sister. Her mother developed her hypertension
when she was pregnant with her second baby. Aside from that her sister developed
her hypertension on 2014 her first baby. Other than that, no family health history was
noted.

VIII. Developmental History

The patient is the 2nd daughter of the 3 siblings which are composed of two
female and one brother. She is 66 years old which is under Ego Integrity Despair
according to Erik Erikson's Developmental theory. Basing on her statements, she is
developing her despair. She verbalized that when she was diagnosed with cervical
mass, she took it for granted in rather injured the pain instead of undergoing biopsy
for the past 8 months as advised. She didn't also informed family members during the
first diagnosis because she thought that her disease will just go away on its own.

CITE SOURCE FOR THE THEORY AND INCLUDE WHAT STAGE BETWEEN TRUST AND MISTRUST THE
PATIENT BELONGS TO. JUSTIFY BASED ON OBSERVATIONS YOU SAW DURING THE ROTATION.

IX. Social and Environmental History

The patient is a nonsmoker and non alcoholic beverage drinker. No


verbalized vices noted. How ever, she is being exposed to air pollutants she is living in
Manila her son-in-law is also a smoker. She is renting a house near a highway with her
daughter's family. She is also taking jeepneys every time she goes out from the
house.

The patient has two daughters. she is currently living with her one daughter
who is a teacher and her son-in-law who is an Engineer. She verbalized that she has
good relationship to her family, friends and relatives as well.

X. Lifestyle and Health Practices

She were living in the city together with her sons, daughters and
grandchildren because apparently they were separated. She consumed her time
taking care to her grandchildren.

XI. Health Assessment

A. General Survey

B. Head to Toe Assessment

1. Head The head of the client is round; normocephalic and


symmetrical. There are no nodules, masses, depressions,


and pain when palpated. The hair is well distributed, and
oiliness noted.

2. Eyes Blinking reflex is present, sclera is white in color, pupils are


equally round and slightly reactive to light and
accommodation using pen light. No uncoordinated eye
movement observed when 6 fields of gaze was done.
Mucous membranes are moist and light pink. No lesions or
any foreign bodies seen on both eyes.

3. Ears Auricles are symmetrical and has the same color with his
facial skin. When palpating for texture, the auricles are
mobile, firm and not tender. The pinna recoils when folded.
During the assessment of Watch tick test, the client was
able to hear ticking in both ears.

4. Nose and sinuses Symmetrical in shape, straight and uniform in color. There
was no presence of discharge or flaring. When lightly
palpated, there were no tenderness and lesions

5. Mouth Oral mucosa is slightly present, no lesions noted, tonsils are


not inflamed. Lips were slightly dry with no cracks present.

6. Neck Able to perform full range of motion through


demonstrating proper flexion and extension of neck.
Carotid pulse are bilaterally symmetrical, full and strong
pulses, jugular vein is not distended. Thyroid is located
midline, no enlargement noted, trachea is located
midline.

7. Chest Symmetrical in shape. Good skin turgor. Apical pulse


heard strong with regular beat. No adventitious sound
heard upon auscultation both anterior and posterior lung
sound. Breathes effortless. Good chest expansion
observed.

8. Cardiac Palpable Apical pulse the rate or the beats per minute is
not within the normal range, regular but weak, no murmur
noted. The apical pulse is auscultated at the left mid-
clavicle line, fifth intercostal space. The cardiac sounds
were regular but difficult to auscultate.

9. Breast No abnormal pigmentation noted, nipple is one shade


darker than the rest of her skin tone, no abnormal
discharges. Client has a rounded shape breast and no
chest retraction. No masses or nodules palpated in the
breast all the way through the axilla.

10. Abdomen Has soft, globular, non-distended abdomen. Partly the


skin is brownish with no retraction noted at the upper
abdomen. With good bowel sound and peristaltic
movement through auscultation.

11. Genitals No lesions noted. No inflamed nodules within the genitals


and inguinal. With light spotting observed. Pain present
when palpated around the upper portion of mons pubis.


12. Musculoskeletal No visible tremors noted, Upper extremities are bilaterally
symmetrical. Both arms can stretch, flex, rotate and extend
with minimal assistance. No signs of lesions and bruises
noted. Lower extremities are symmetrical. Both legs can
flex, extend and bend with minimal assistance. Needs
assistance in ADL.

13. Integumentary Her skin tone is even from head to toe. It has a good skin
turgor. The nails are pinkish with a capillary refill of 1-2
second when pressure is applied on the nail bed. The skin
is warm to touch and no lesion or bruises observed.

C. 13 Areas of Assessment

1. Psychosocial and Psychological Status

Patient X is a married 66 years old female, but 32 years ago, she had an
unformal separation with her husband. Her religion is Born again Christian, and they
do not observe any religious practices that may adversely affect her health care.
According to our patient, her separation with her husband does not affect her
because she is happy taking care of her grand children.

2. Mental and Emotional Status

The patient is conscious and oriented to the current time, place, and date.
She speaks Ilocano and tagalog. She acts accordingly with her age. She can
answers questions properly. She is anxious with her condition because she is not with
her children. The only one with her as a watcher is her sibling.

3. Environmental Status

Patient X originally lives in Asingan, Pangasinan but she is currently living in


Manila with her daughter’s family. They rent house in Manila made of concrete with
three rooms, two comfort rooms, and a kitchen adjacent to it. It has also five
windows at the living room and kitchen, and one in each rooms. The apartment is 2
meters away from their neighboring house. Their drinking water source is from a
water refilling station and the daily used water is from manilad. She is not working
anymore, she is just taking care of her grand children.

The patient was admitted at Gynecology ward at Baguio General Hospital


and Medical Center, with her sibling as her watcher. The ward has adequate
lighting, comfortable room temperature and a clean comfort room.

4. Sensor Status
a. Visual Status

There is no known visual deficit like color blindness, nearsightedness, farsightedness, or


astigmatism through Snellen’s chart.

b. Auditory

She can distinguish voice, does not have any hearing problems and no auditory


device through voice whisper.

c. Olfactory Status

The patient is able to discriminate an odor from the other odor.

d. Gustatory Status

The patient cannot able to identity sweet, salty and sour foods rather she only tastes
bitterness with the food that she eats

e. Tactile Status

She was able to determine and differentiate sharp and dull, light and firm touch, able
to perceive heat, cold, pain in proportion to stimulus, able to differentiate common
objects by touch by doing necessary procedure.

5. Motor Status

She is slightly immobilized due to pain. The pain coming from her hypogastric region.
At sometimes, she'd need help with her sitting up and sitting down.

6. Thermoregulatory Status (Axillary site) normal range 36.5-37.5

Date Time Temperature


October 3, 2019 3:00pm 36.6 c
6:00pm 36.5 c
10:00pm 36.3 c
October 4, 2019 3:00pm 36.4 c
6:00pm 36.5 c
10:00pm 36.3 c
October 5, 2019 3:00pm 36.5 c
6:00pm 36.5 c
10:00pm 36.6 c

7. Respiratory Status

Date Time RR SP02


October 3, 2019 3:00pm 21 cpm 97%
6:00pm 19 cpm 96%
10:00pm 21 cpm 98%
October 4, 2019 3:00pm 20 cpm 98%
6:00pm 20 cpm 99%
10:00pm 19 cpm 99%
October 5, 2019 3:00pm 21 cpm 98%
6:00pm 20 cpm 98%
10:00pm 21 cpm 97%


8. Circulatory Status

Date Time CR Blood Capillary


Pressure
3pm 99bpm 160/100
October 3, 6pm 99bpm 160/90
2019 10pm 98bpm 170/100

3pm 100bpm 180/100


October 4, 6pm 99bpm 160/90
2019 10pm 99bpm 160/100

3pm 97bpm 170/100


October 5, 6pm 95bpm 180/100
2019 10pm 99bpm 160/90

9. Nutritional Status

Prior to admission, the patient normally drinks 7-8 glasses of water a day. She claims
that she normally eats three times a day. Her diet usually composes of rice, processed food,
meats, soup and salty food like junk food.

During hospitalization, the patient's food was being served in the hospital, and she
was advised by the doctor to her full diet. According to her, she does not consumed most
of the food that is being served due to bitterness of taste. She eats bread and chocolatey
drinks

10. Elimination Status

Prior to admission, patient urinates 6 times a day and defecates 1-2 times a day.
During hospitalization, the patient usually urinates 8 times minimally a day and defecates
once a day. During her stay at the Gyne Ward, she was not able to defecate during her first
day but is able to do so on the second day.

11. Sleep, Rest and Comfort Status

Prior to admission, she normally sleeps 5-6 hrs. in a day. According to our patient,
Sometimes she gets tired because of taking of her grandchildren.During her stay at the
hospital, she was able to have 3-4 hrs. of sleep. She said that she will not able to sleep
comfortably because of the noise and the lights at the hospital.

12. Fluids and Electrolytes Status

Prior to admission, the patient drink 7-8 glasses daily. Aside from water she also drinks
soda, juice and coffee.

The patient was received with an on going IV of PNSS 1L x 16 hours. The patient
claims that she does not have any feeling of thirst. Her skin turgor was normal, and she had


moist mouth and mucous membranes. She did not show any signs of dehydration.

13. Integumentary Status

Skin color is normal. Skin is warm to touch. Nails and hair are well kept by the patient.
There are no lesion or bruises observed.


XII. Diagnostics

Diagnostic Significance/Purpose of the Date of


Description of the Procedure Findings & Implications
Procedure Procedure Procedure
.

10
XIII. Comprehensive Pathophysiology

PREDISPOSING FACTORS PRECIPITATING FACTORS

Age(29 days),weather,gender Environment

Inhalation of microbes

Invation of lower respiratory tract

Immunologic response

Antigen and antibody reaction

Mucosal Irritation Dilation of the blood vessels

Unproductive cough Increased blood flow

Consolidation of the lungs Swelling of body tissues

Increase capillary permeability

Escape of plasma

Swelling/edema

Narrowing of airway

Increased respiration Impaired swallowing

Ineffective breathing pattern Compromised lung expansion Risk for aspiration

Excess or deficit oxygenation and/ or

carbon dioxide elimination in the capillary membrane

Impaired gas exchange Ineffective breastfeeding

Lack of required daily nutrition

Risk for nutritional imbalance

11
XIV. Treatment/Management

A. Drugs

DRUG NAME MECHANISM OF ACTION INDICATION / CONTRAINDICATION ADVERSE EFFECT NURSING


RESPONSIBILITIES

B. IV Fluids

12
XV. Nursing Care Plans

A. Prioritization of Problems

a.1. List of Problems

1. Acute pain related to disease process as evidenced by 5/10 pain scale, sighing
and sleep disturbance.

2. Sleep pattern disturbance related to environmental and physiological factors as


evidenced by inadequate sleep and urinary urgency.

3. Knowledge deficit related to perception limitation of the disease information.

4. Risk for Activity intolerance related to pain in the hypogastric region.

5. Risk for infection related to tissue damage as evidenced by minimal vaginal


bleeding and cervical punch biopsy.

a.2. Basis for Prioritization

NURSING DIAGNOSES JUSTIFICATION


1. Acute pain related to This should be the top priority because according to
disease process as Maslow’s Hierarchy of needs, this is a biological
evidenced by 5/10 pain requirement for human survival making it an urgent
scale, sighing and sleep problem. The physiologic needs of the patient is
disturbance greatly affected by pain and can disturb the
patient’s emotional and mental wellbeing.

2. Sleep pattern disturbance This is the second priority because it will cause further
related to environmental weakness/stress that will not contribute in achieving
and physiological factors fast recovery of the patient and may lead to
as evidenced by alteration of immune system. Sleep patterns can be
inadequate sleep and affected by environment especially in the hospital
urinary urgency setting where noise, lighting, frequent monitoring and
treatments are always present. Enough time of sleep
is necessary for the healing process of the patient.
3. Knowledge deficit related This is our third priority because knowledge plays an
to perception limitation of influential and significant part of a patient’s life and
the disease information. recovery. Absence or deficiency of cognitive
information related to specific topic, Lack of specific
information necessary for client to make informed
choices regarding condition, treatment and lifestyle
changes.
4. Risk for Activity intolerance This is our fourth priority in rendering interventions to
related to pain in the because it compromises effective oxygen transport
hypogastric region. and the individual will have insufficient physiological
or psychological energy to endure or complete
necessary or desired activities of daily living.
5. Risk for infection related This is our last priority because the patient is at risk for
to tissue damage as being invaded by pathogenic organisms due to the
evidenced by minimal punch biopsy.
vaginal bleeding and
cervical punch biopsy.

13
B. Nursing Care Plans
ALIGN OBJECTIVE DATAS WITH THE CORRESPONDING NURSING INTERVENTION

NCP 1:
Assessment Explanation of the Objective Nursing Intervention Rationale Evaluation
Problem
SUBJECTIVE: EXPLANATION OF THE STG: NURSING INTERVENTION RATIONALE
PROBLEM
“Lagi kong iniinda >After 2 hours of nursing
itong sakit ng puson intervention, patient will
ko” as verbalized by be able to verbalize and
the patient. demonstrate methods
that provide relief and
rats oain from 5 to 4/10
OBJECTIVE:

>Presence of sharp LTG:


pain at the
hypogastric region >After 4 hours of nursing
intervention, patient will
>Rated pain of 5/10 able to:
using numerical pain
scale occuring -follow prescribed
evrytime she moves pharmacological regimen

>Sighing gestures -perform self care


noted activities with progestve
effectiveness
>Poor appetite noted
-rates pain 3/10

14
>BP160/100

>Sleeo disturbance
noted

NURSING DIAGNOSIS:

Acute Pain Related


to Disease Process as
Evidenced By 5/10
pain scale, sighing
and sleep
disturbances

NCP 2:
Assessment Explanation of the Objective Nursing Intervention Rationale Evaluation
Problem

15
NCP 3:
Assessment Explanation of the Objective Nursing Intervention Rationale Evaluation
Problem
Subjective: Knowledge deficit is a STO: Within 4 hours of  Assess level of  Identifies reas of lack of STO: GOAL MET
lack of cognitive nursing intervention, the understanding of the knowledge or
“hindi ko kasi alam information or patient will be able to disease process, misinformation and After 4 hours of nursing
na mag co psychomotor skills verbalize understanding expectations, prognosis provides opportunity intervention, the
complicate ang sakit required for health of concern and possible treatment to give additional patient was be able to
ko’’ as verbalized by recovery, maintenance, options. information as necessary. verbalize
the patient. or health promotion. LTO: Within 8 hours of understanding of
Learning may involve nursing intervention, the  Determine client ability  To assess readiness to learn concern
Objective: client will verbalize and individual learning
any of the three to learn
- Lack of source of domains: cognitive understanding of the need.
information domain (intellectual disease process.
 To establish knowledge to LTO: GOAL MET
activities, problem  Identify information be included in the learning After 8 hours of nursing
- verbalized solving, and others); having to do with
inaccurate process intervention, the client
affective domain emotions, attitude and
information (feelings, attitudes, value verbalized
belief); and psychomotor understanding of the
- inaccurate follow-  To make the client feel disease process.
domain (physical skills or  Determine the client
through instruction respected and competent
procedures) perception of needs by
- questioning of relating the information
health care to the client’s
team and personal desires, needs,
incorrect task values and beliefs
performance

Nursing diagnosis:  Determine the client’s  To facilitate learning or


method of accessing recall.

16
Knowledge deficit information and include
related to in teaching plan
perception limitation
of the disease  Provide an environment  This can arouse
information that is conducive to
interest/limit sense of being
learning overwhelmed.

NCP 4:
Assessment Explanation of the Objective Nursing Intervention Rationale Evaluation
Problem

NCP 5:
ASSESSMENT EXPLANATION OF THE OBJECTIVES GOALS NURSING INTERVEMTION RATIONALE EVALUATION
PROBLEM

OBJECTIVE: Infection accure if there STG: Dx: STG (goal met)


is any disruption in the
 Undergone itegrity of body’s surface After 2 hours of nursing  Assessed for presence,  These represents a break in  After 2 hours of
cervical intervention patient will existence of and history the body’s normal first line nursing
barierr such as skin or
punch biopsy verbalize understanding of risk factors such as of defense intervention
 Minimal mucous membrane is a tissue damage  Patients with poor patient was
potential site for invasion of individual causative/risk
vaginal  Assessed and monitor nutritional status maybe able to
bleeding of microorganism.The factors nutritional status, weight, anergic or unable to verbalize
noted break may be the result history of weight loss. muster a cellular immune understanding
response to pathogens of individual
17
of an accidental injury LTG: making them susceptible causative/risk
resulting in abbrasions, to infection. factors
penetrating wounds and After 5 hours of nursing  Monitored white blood
intervention patient will cell count (WBC)
medical procedures, this
demonstrate technique,  An increasing WBC count LTG(goal met)
bypassing the host’s indicate the body’s effort
NURSING DIAGNOSIS: lifestyle changes to
primary immune defense TX: (INDEPENDENT) to combat pathogens.  After 5 hours of
 Risk for system. promote safe nursing
infection environment  Demonstrated proper intervention
relted to tissue handwashing  Frction and running water patient was
damaged as effectively remove able to
evidenced by Source: microorganisms from demonstrate
minimal  Identified the risk factors hands,thus preventing technique,
vaginal Pathophysiology, of inspection such as: transmission of it. lifestyle changes
bleeding and concepte of altesed tissue damage,  Identifying risk factors helps to promote safe
cervical health status, portn, C , immunosuppression, a patient to prevent the environment
punch biopsy 6th contact with contagious occurrence of infection.
agents

(DEPENDENT)

 If infection
occurs,administer
antibiotics as prescribed
 Antimicrobial drugs
include
antibacerial,antifungal,anti
parasitic and anti viral
EDX: agents.All of these agents
are either toxic to the
 Taught her to wash pathogens or retard the
hands often,especially pathogen’s growth.
after toileting,before
meals and before and
18
after administering self  Patient can spread
care. infection from one part of
 Encouraged fluid intake the body to another as
of 2- 3L of water per day well as pick up surface
(unless contraindicated). pathogens;hand washing
 Instructed the patient to reduces these risks.
take full course of  Fluids promote diluted
antibiotic even if urine and frequent
symptoms improve or emptying of
disappear bladder,reducing stasis of
 Encouraged to use urine,in turn, reduces risk of
antiseptic feminine wash bladder infection or UTI.
as indicated  Not completing the entire
 Advised to intake protein course of antibiotic
and calorie rich-foods regimen can lead to drug
resistance in the
pathogens and
reactivation of symptoms.
 This maintain optimal
nutritional status.

19
C. Discharged Plan

HEALTH TEACHINGS

DIET/NUTRITION 1 Advicesed to maintain a diet of fruits and


vegetables especially high in carotenoid like yams,
kales, spinach, tomatoes etc and food high in folic
acid like legumes, whole grains, fruit, vegetables etc ,
this hence the immune system.
2. increase fluid intake during the day and decrease
at bedtime.
ACTIVITY 1. Advise to have plenty of rest
2. Advise client not to do strenuous activities.
3 Encourage physical activities consistent with the
patients energy level.
MEDICATION 1.Discussed on the importance of strict adherence to
medication regime to ensure complete healing.
2. Instructed to follow proper instruction on medication
prescribed by the physician.
3 Encourage to come for check up regularly and to
report any untoward signs.

XVI. Learning Insights

XVII. List of References

XVIII. Appendices

20
Appendix A
Approval/Request Letter

21
Appendix B
Interview Guides

22
Appendix C
Others (just specify)

23

Вам также может понравиться