Академический Документы
Профессиональный Документы
Культура Документы
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
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
________________________
Aklbacio, Shirley
Clinical Instructor
ABSTRACT
TITLE:
AUTHOR INFORMATION:
BACKGROUND:
CASE DESCRIPTION:
CONCLUSION:
1
TABLE OF CONTENTS
I. Introduction ........................................................................................................................................ 3
2
XVIII. Appendices ........................................................................................................................................ 19
Appendix A .............................................................................................................................................. 20
Appendix B .............................................................................................................................................. 21
Appendix C .............................................................................................................................................. 22
I. Introduction
B. Specific Objectives
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.
3
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.
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.
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.
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.
A. General Survey
4
and pain when palpated. The hair is well distributed, and
oiliness noted.
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
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.
5
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
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.
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
4. Sensor Status
a. Visual Status
b. Auditory
She can distinguish voice, does not have any hearing problems and no auditory
6
device through voice whisper.
c. Olfactory Status
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.
7. Respiratory Status
7
8. Circulatory Status
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
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.
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.
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
8
moist mouth and mucous membranes. She did not show any signs of dehydration.
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.
9
XII. Diagnostics
10
XIII. Comprehensive Pathophysiology
Inhalation of microbes
Immunologic response
Escape of plasma
Swelling/edema
Narrowing of airway
11
XIV. Treatment/Management
A. Drugs
B. IV Fluids
12
XV. Nursing Care Plans
A. Prioritization of Problems
1. Acute pain related to disease process as evidenced by 5/10 pain scale, sighing
and sleep disturbance.
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:
14
>BP160/100
>Sleeo disturbance
noted
NURSING DIAGNOSIS:
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
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
(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
XVIII. Appendices
20
Appendix A
Approval/Request Letter
21
Appendix B
Interview Guides
22
Appendix C
Others (just specify)
23