Case Study (Nasopharyngeal Cancer)

8/14/2019 Case Study (Nasopharyngeal Cancer)

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I. Introduction

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 androots) 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.

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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.

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Nurse-centered Objectives:

The group aims:

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.

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II. Nursing Assessment

Personal Data

Mr. Split, 74 years old, married and a father of 7 children. Offspring of Mr. and Mrs. Choco

Split, he was born on December 31, 1934 in Angeles Pampanga, and at this point in time, he

resides in Timog Park, Angeles. He is a Filipino-born citizen. He was admitted last September

18, 2008 in Angeles Medical Center (AMC).

Mr. Split is a jeepney operator and he is the sole provider for their means of living. His children,

mostly married, some are presently unemployed and contribute to the burden on financial matters

to the family of orientation.

Mr. Split has a lifestyle of eating food that should or not allowed to him such as foods that are

high amounts in sugar and low density cholesterol. Besides that Mr. Split is also attached to

cigarette smoking. He also worked as a painter of houses for living for the past 20 years.

History of Past Illness

Mr. Splits last check-up was done 3 years ago and was diagnosed to have nasopharyngeal

cancer. Prior to this, he has also been diagnosed to have Diabetes Mellitus Type 1 and PulmonaryTuberculosis. According to his daughter, his first admission in the hospital was September 18,

2008.

History of Present Illness

One (1) month PTA, Mr. Split experienced difficulty of breathing, and anorexia lasting for 1

week. A week PTA, he still experienced difficulty of breathing, and anorexia associated plus

muscle weakness with easy fatigability but still he did not seek medical attention. A day PTA, he

still experienced the same signs but this time he decided to seek medical attention.

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Family Health Illness History

Mr. Split

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Legend:

= Male = Diabetes Mellitus = Tuberculosis

= Female = Cancer = Deceased


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III.Physical Examination

Angeles Medical Center (AMC) (September 18, 2008)

Upon admission:

(+) body weakness accompanied by difficulty of breathing and anorexia.

Physical Examination:

Drowsy, coherent, afebrile, in respiratory distress, pale palpable conjunctiva, (+) irregular

mass on nasal area, (+) rales, no murmur, normal abdominal bowel sounds, pale nail bed,

weak pulses.

1st Assessment (September 20, 2008)

General Appearance:

Received pt in a fowlers position with contraptions. Pt is with body odor and with minimal foul

breath odor. Pts speech is slightly incomprehensive.

Vital Signs:

T: 36.4 C RR: 29 cpm

PR: 87 bpm BP: 120/80 mmHg

Physical Assessment:

Integument

Noted dryness

Presence of tattoo in the right arm

Poor skin turgor

Capillary refill test: delayed return in pink color (3 seconds)

Presence of scars on the lower extremities

Head

Hair generally white

Presence of patches of hair loss

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IV.Diagnostic and Laboratory Procedures

Procedures done to the Client

Nursing responsibilities:

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Diagnostic/

Laboratory

Procedures

Date Ordered/

Date Result(s)

Released

Indication(s)/

Purposes(s)Result(s)

Normal Values

(units used in the

hospital)

Analysis and interpretation of results

Blood Chemistry 09/18/08

09/19/08

To assess a wide

range of conditionsand the function of

organs. Often, blood

tests check

electrolytes, the

minerals that help

keep the body's fluid

levels in balance, and

are necessary to help

the muscles, heart,

and other organs

work properly. To

assess kidney

function and blood

sugar, blood tests

measure other

substances.

Hct > 32.7

Platelet Count > 759

Hgb (Hemoglobin)>9.5

WBC (White Blood

Cells)>27.9

Lymhocytes > 10

Granulocytes > 90%

Glucose (FBS) > 138.6

BUN > 13.72

Creatinine > 0.78

Potassium > 3.6

Sodium > 143

@m: 40.0 54.0

@m: 140 - 440

@m: 14 18 g/dl

@m: 4.3 10.0 x 1/l

@m: 28.0 48.0

@m: 44.2 80.2(x 10/1)

@76 - 111 mg/dl

@7 - 21 mg/dl

@0.5 - 1.69 mg/dl

@3.5 - 5.0

@136 - 145 mmo/L

Hematocrit level as shown are below the

standard values.Platelet count is above the average level.

Hemoglobin level is lower than the

established normal values.

White blood cells are higher than the

usual amount.

Lymphocytes are below the average

levels.

Granulocytes are beyond the normal

values.

Glucose levels in the patients body are

within normal values.

Results show that BUN is at averagelevels.

Result shows that creatinine are at

normal values.

Potassium is at the normal values.

Result shows that sodium levels are

within regular values.


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inform patient on the procedure to be done. Explain the details on what and how the procedure is going to be administered.

let client sign a waiver or a consent before starting the procedure.

provide the best possible nursing care for the patient who is to undergo a procedure.

inform patient that the test would be done for the better of the patients condition.

inform the patient with the results of the procedure done, explain the implications of each result, client has the right to know.

Nursing Responsibilities:

Inform the patient about the procedure

Ask the patient to remove any radiopaque objects (jewelry, belts, or metal buttons).

Assist patient to wear a gown.

Assist patient when positioning.

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Diagnostic/ Laboratory

ProceduresIndication(s)/ Purposes(s)

Normal Values

(units used in the hospital)Analysis and interpretation of results

Chest X-ray Commonly used to detect

abnormalities in the lungs, but

can also detect abnormalities in

the heart, aorta, and the bones of

the thoracic area. Metallic

objects, such as jewelry are

removed from the chest and neck

areas for a chest x-ray to avoid

interference with x-ray

penetration and improve

accuracy of the interpretation.

Minimal Pulmonary Tuberculosis on left lateral

portion of the lungs


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Note pertinent findingssuch as the presence of a pacemaker or an artificial joint.

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V. The Patient and His Illness

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.

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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

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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:

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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.

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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 presenceof 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.

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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 Cushings syndrome.

Hyperkalemia a manifestation caused by Cushings syndrome.

Hypertension a manifestation caused by Cushings syndrome.

Hypervolemia a manifestation caused by Cushings syndrome.

Immunosupression a manifestation caused by Cushings 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.

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Schematic Diagram (Book-based)

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Predisposing Factors:


Men are more likely to have nasopharyngeal cancer

than women

Chinese or Asian ancestry Hereditar

Precipitating Factors:

Eating salt-preserved foods (like fish, eggs, leafy

vegetables and roots) during early childhood

Cigarette smoking

Alcohol abuse Poor Oral Hygiene


Occu ational Ex osure chemicals es . asbestos

Nasopharyngeal Cancer/Lung Cancer

Chronic cough

Osteoporosis

Atelectasis

Chest wall pain

Irritation and obstruction of airway

CushingsSyndrome

Immunosupression

Hypertension

Hyperglycemia

Hypervolemia

Hyperkalemia

Pleural Effusion

Squamous Cell Carcinoma Small Cell Carcinoma Adenocarcinoma Large Cell Carcinoma

Sputumroduction

Invasion of theleural cavit

Pneumonitis

Hemoptysis

Pneumonia

Anorexia

Formation of benign bronchial

e ithelium tissue

Transformation benign

tissue to neoplastic tissue

Weight Loss

Shortness ofbreath

Wheezing

Lesions erode tothe blood vessels

Compression ofthe esophagus

Difficulty inswallowin

Hoarsenessof voice

Irritation of thelaryngeal nerve

Metastases tothe liver

Triggering of painrece tors

Shortness ofbreath

Dyspnea

Vena cavasyndrome

Facial, arm, andtrunk swellin

Distendedneck veins

Chest pain

Venous stasis

Synthesis ofbioactive products

Invasion of themediastinum


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Schematic Diagram (Client-centered)

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Predisposing Factors:


Men are more likely to have nasopharyngeal cancer

than women

Chinese or Asian ancestry Hereditar

Precipitating Factors:

Eating salt-preserved foods (like fish, eggs, leafy

vegetables and roots) during early childhood

Cigarette smoking

Alcohol abuse Poor Oral Hygiene


Occu ational Ex osure chemicals es . asbestos

Nasopharyngeal Cancer/Lung Cancer

Formation of benign bronchial

e ithelium tissue

Transformation benign

tissue to neoplastic tissue

Chronic cough(September 20,

2008

Irritation and obstruction of airwaySputum

roduction

Shortness of

breath

Wheezing

Anorexia(August 2008)

Weight Loss

Compression of

the esophagus

Difficulty in

swallowinHoarseness of voiceSe tember 20, 2008

Irritation of the

laryngeal nerve

Invasion of the

mediastinum Chest wall pain(September 20, 2008)

Invasion of the

leural cavit

Triggering of

ain rece tors


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VI.The Patient and His Care

Medical Management

a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy, etc.

Medical Management

Treatment

Date Ordered, Date

Performed, Date

Changed/ D/C

General DescriptionIndication(s) or

Purpose(s)

Clients Response to

the treatment

D5LRS Date ordered:09/18/08

Date started:

09/18/08

Lactated Ringer's solution is a solutionthat is isotonic with blood and intended

for intravenous administration. It is a

nonpyrogenic solution for fluid and

electrolyte replenishment and caloric

supply in a single dose container for

intravenous administration.

Severe dehydration,hypovolemia, replace ECF

loss, shock, diabetic

ketoacidosis

Responded positively

D5NSS Date ordered:

09/18/08

Date started:

09/18/08

Isotonic sodium chloride with a 5%

dextrose. It is typically the first fluid

used when dehydration is severe

enough to threaten the adequacy of

blood circulation and is the safest fluid

to give quickly in large volumes.

mediacations, flush, maintain patency

of intravenous access device

Replaced extracellular fluid

volume, hyponatremia,

diabetic ketoacidosis,

diluent for

Responded positively

D5NM Date ordered:

08-19-08Date performed:

08-19-08

Have a greater concentration of solutes

than plasma.It is the solution that draw fluid out of

the intracellular and interstitial

compartments into the vascular

compartment, expanding vascular

volume

To supply fluid and

electrolyte balance for thepatients need.

It is also used as a passage

way in giving medication

to the patient.

Complies positively

Oxygen therapy Date ordered:

09-18-08

Date performed:

09-18-08

Changed:

09-19-08

09-20-08

Oxygen therapy is

being prescribed for clients with mild or

severe anemia because of their blood

has a reduced capacity for oxygen

Helps to prevent tissue

hypoxia and lessens the

workload of the heart as it

struggles to compensate for

the lower hb level

Complies positively

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IVF


Select venipuncture site.

Clean site using circular motion from inner to outer with alcohol.

Apply tourniquet.

Anchor vein by stretching skin; insert bevel up to 20 30 degree angle.

Watch for blood return in flashback chamber of the catheter.

Advance needle another inch; then advance catheter into the vein until hub is at the venipuncture site.

Stabilize the catheter and release tourniquet.

Remove needle stylet and attach tubing or saline lock to catheter hub. Flush with saline to verify patency.

Secure catheter and apply sterile dressing (gauze or transparent) to site.

Oxygen Therapy


Explain the procedure to the patient.

Check the doctors order.

Monitor the clients vital signs.

Check equipment patency.

Instruct the client and visitors about the hazard

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b. Pharmacotherapy

Name of drugs

Generic Name/ Brand Name

Date Ordered, Date taken/Given,

Date Changed/ D/ C

Dosage, Frequency

and Route

General Action, Mechanism

of Action

Clients Response to the

Medication

Cefuroxime

(Zegen)

Date ordered:

09/18/08

Date started:

09/18/08

750 mg IV q8 Haematopoietic Agents

Second generation

cephalosporins that inhibits

cell-wall synthesis, promoting

osmotic instability; usually

bactericidal.

The client responded well to

the medication


Observe 10 Rs of drug administration.

Before administration, ask patient if he is allergic to penicillins.

Name of drugs



Date Changed/ D/ C

Dosage, Frequency

and Route


of Action


Medication

Piperacillin Na, Tazobactam Na

(Piptaz)

Date ordered:

09/18/08

Date started:

09/18/08

2.25 g IV infusion q8 Penicillin

Inhibits cell-wall synthesis

during bacterial multiplication.


the medication


Observe 10 Rs of drug administration.

Name of drugs



Date Changed/ D/ C

Dosage, Frequency

and Route


of Action


Medication

Human Insulin

(Humulin R)

Date ordered:

09/18/08

10 units SQ stat Antidiabetics The client responded well to

the medication

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Date started:

09/18/08

Increases glucose transport

across muscle and fat cell

membranes and reduce glucose

level. Helps convert glucose to

glycogen; triggers amino acid

uptake and conversion to

protein in muscle cells;

stimulates triglyceride

formation and inhibits release

of free fatty acids from adipose

tissue; and stimulateslipoprotein lipase activity,

which converts circulating

lipoproteins to fatty acids.


Ask the patient if she/he ever had any allergic reaction with Tranexamic Acid.

Name of drugs



Date Changed/ D/ C

Dosage, Frequency

and Route


of Action


Medication

Epoetin

(Renogen)

Date ordered:

09/19/08

Date started:

09/19/08

4, 000 units SQ today Haematopoietic Agent

Mimics effect of erythropoietin.

Functions as a growth factor

and as a differentiating factor,enhancing RBC production.


the medication


Ask patient if he/she ever had allergy to Mefenamic acid

Ask patient if he/she has a history of heart attack, stroke or blood clot.

Name of drugs Date Ordered, Date taken/Given, Dosage, Frequency General Action, Mechanism Clients Response to the

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Generic Name/ Brand Name Date Changed/ D/ C and Route of Action Medication

Methyldopa hydrochloride

(D50-50)

Date ordered:

09/18/08

Date started:

09/18/08

1 vial IV Anti-Hypertensive

Unknown. Thought to inhibit

the central vasomotor centers,

thereby decreasing sympathetic

outflow to the heart, kidneys,

and peripheral vasculature.


the medication AEB a

decrease in blood pressure

from 140/90 to 120/80.


Ask patient if he/she is allergic to FeSO4

Ask the patient if he/she is taking any other drugs

Ask the patient if he/she had multiple blood transfusions

c. Diet

Type of DietDate Ordered/ Date Started/

Date Changed

Indication(s) or

Pupose(s)General Description

Clients Response & or reaction

to the Activity

Diet as Tolerated DO: 08-18-08 Maintaining dietary

nutrition needed for

the patient.

Is ordered when the patients

appetite/ ability to eat and

tolerated for certain foods may

change.

Complies positively


Provide oral hygiene before and after meal.

Advise client to take nutritious foods especially foods rich in iron

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VII.Nursing Care Plans

Ineffective Airway Clearance

Assessment Nursing DiagnosisScientific

ExplanationObjectives

Nursing

InterventionsRationale Evaluation

Subjective cues:

"Magkasakit yaknyan mangisnawa

nang, lalu na pag

sasabi ya" as

verbalized by the

SO

Objective cues:

Dyspnea

Restlessness

Use of accessory

muscle

Cough

Nasal flaring

Prolonged

expiratory phase

Ineffective airway

clearance r/t tissuenecrosis located in

nasal area AEB

dyspnea,

restlessness, use of

accessory muscle,

cough, and nasal

flaring.

Ineffective airway

clearance is theinability to clear

secretions or

obstruction from the

respiratory tract to

maintain a clear

airway in which

partial or complete

blockage of the

breathing tubes to

the lungs.

Obstruction of the

airway can be due to

different causes

including foreign

bodies, allergic

reactions, infections,

anatomicalabnormalities and

trauma. The onset of

respiratory distress

may be sudden with

cough. There is

often agitation in the

early stage of

airway obstruction.

After 3 hours of NI,

pt will be able toverbalize

understanding of

cause and

therapeutic

management

regimen and

demonstrate

behaviors to

improve or maintain

clear airway.

Establish rapport

Position head to

facilitate airway

Elevate head of

bed

Encourage deep-

breathing and

coughing exercise

Increase fluid

intake

Support

reduction/cessatio

n of smoking

To get the trust of

the pt.

To open or

maintain open

airway in at-rest or

com promised

individual

To take advantage

of gravity

decreasing

pressure on the

diaphragm and

enhancing

drainage

To maximize

effort in

expectorating

secretions Hydration can

help liquefy

viscous secretions

and improve

secretion

clearance

To improve lung

function

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Impaired Physical Mobility



Nursing


Subjective cues:

Magkasakit kung

gagalo, as

verbalized by the

patient.

Objective cues:

with limited

movements

limited ability to

perform gross/fine

motor skills

with difficulty

turning

with slowed

movements

Impaired physical

mobility related to

decreased muscle

strength a

manifested by the

patients limited

movements, limited

ability to perform

gross/fine motor

skills, difficulty

turning, and slowed

movements.

Impaired physical

mobility is

limitation in

independent,

purposeful physical

movement of the

body or of one or

more extremities.

Mobility is also

related to body

changes from aging.

Reduction in muscle

strength and

function, stiffer and

less mobile joints

affecting balance

can significantly

compromise the

mobility of elderly

patients.

Restricted

movement affects

the performance ofmost activities of

daily living (ADLs.)

After 3 hours of

nursing intervention,

the pt. will be able

to participate in

ADLs and desired

activities as

evidenced by an

increase in the pt.s

movements, ability

to perform

gross/fine motor

skills, can turn

easily, and an

increase in motor

agility.

establish rapport

monitor and

record VS

advise pt. to haveadequate rest

encourage pt to eat

foods rich in

carbohydrates

advise pt. to do

deep breathing

advise pt. to take

adequate fluid

intake

encourage pt. to

rest between

activities

encourage pt. to

engage in ROM

exercise

to gain

cooperation

for baseline data

to regain strength

to increase energy

level

to promote energy

to prevent

dehydration

to promote energy

and regain

strength

to reduce fatigue

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Fatigue



Nursing


Subjective cues:

Medyu

mangalambut ku,

as verbalized by the

patient.

Objective cues:

appears weak

decreased ability

in performing

activities

with compromised

concentration

Fatigue related to

poor physical

condition as

manifested by the

patient appears

weak, a decreased

ability in

performing

activities, and

compromised

concentration.

An overwhelming

sustained sense of

exhaustion and

decreased capacity

for physical and

mental work at

usual level

Fatigue is a

subjective complaint

with both acute and

chronic illnesses. In

an acute illness

fatigue may have a

protective function

that keeps the

person from

sustaining injury

from overwork in a

weakened condition.

As a common

symptom, fatigue is

associated with a

variety of physical

and psychological

conditions.

After 3 hours of


the patient will

verbalize an

understanding

regarding the health

teachings on how to

conserve energy as

evidenced by the

patient appears

strong, an increase

in the ability to

perform activities,

and has the ability to

concentrate fully.

Establish rapport

Monitor and

record vital signs

Encourage pt. tosit instead of

standing in

performing

activities

Advise pt. to have

adequate rest

Encourage pt. to

perform ROM

exercises

Encourage pt. to

eat carbohydrates-

containing food

Encourage pt. to

do focus breathing

to gain

cooperation

for baseline data

to conserve energy

to regain strength

to reduce fatigue

to increase energy

level

to promote energy

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Chronic Pain



Nursing


Subjective cues:

"Mahigit neng pilan

banwa ing keng

arung na" as

verbalized by the

SO

Objective cues:

Facial mask

Self-focusing

Reduced

interaction with

people

Guarding behavior

restlessness

Chronic pain r/t

Chronic physical

disability AEB

facial grimace, self-

focusing, guarding

behavior and

restlessness

Chronic pain is

unpleasant sensory

and emotional

experience arising

from actual or

potential tissue

damage or described

in terms of such

damage, constant or

recurring without an

anticipated or

predictable end and

duration of greater

than 6 months.

Chronic pain may

be classified as

chronic malignant

pain or chronic

nonmalignant pain.

In the former, the

pain is associated

with a specific cause

such asnasopharyngeal

cancer. A tumor that

presses on bones,

nerves, or organs

can cause pain.

After 4 hours of NI,

the patient

verbalizes

acceptable level of

pain relief and

ability to engage in

desired activities.

Establish rapport

Evaluate pain

behaviors

Encourage pt to

take medicine

religiously

Note lifestyle

effect of pain such

as depression

Assist client to

learn breathing

techniques

to gain

cooperation

to determine

client's response to

chronic situation to lessen pt's

suffering from his

chronic pain

to know the

contributing factor

of his chronic pain

condition

to assist in muscle

and generalized

relaxation

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Disturbed Energy Field



Nursing


Subjective cues:

Balamu pane kung

mapagal

panamdaman, as

verbalized by the

patient.

Objective cues:

appears weak

low tone speech

compromised

concentration

Disturbed energy

field related to

slowing of energy

flow as manifested

by the pt. appears

weak, with low tone

speech, and with

compromised

concentration

secondary to illness.

Disruption of the

flow of energy

surrounding a

persons being that

results in a

disharmony of the

body, mind, and/or

spirit.

After 3 hours of


the pt. will verbalize

a sense of relaxation

as evidenced by the

pt. appears strong,

high toned speech

and the ability to

concentrate.

establish rapport

monitor and

record VS

advise pt. to haveadequate rest

encourage pt. to

eat foods rich in

carbohydrates

advise pt. to do

deep breathing

advise pt. to take

adequate fluid

intake

encourage pt. to

rest between

activities

allow pt. to have

period of

independency

to gain

cooperation

for baseline data

to regain strength

to increase energy

level

to promote energy

to prevent

dehydration

to promote energy

and regain

strength

to strengthen own

inner resources

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VIII.Discharge Plan

Topic: How to achieve health and wellness.

Time allotment: 1 hour

Venue: At the Eastwing of AMC; room 207

Objective Content Time Allotment Teaching Strategy Evaluation

After 1 hour of health

teachings, the patient

will be able to verbalize

understanding regarding

topics that are given.

Teaching

patient:

the right

nutritious

food

especiallythe

importance

of takingiron with

regards to

her present

condition.

to have an

adequate

exercise

every day

to have a

proper

hygiene topromote

wellness.

20 mins.

15 mins.

15 mins.

Discussion

----------

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IX.Learning Derived

Comparatively, our rotation in Angeles Medical Center is much different from the previous

rotations we had. Since it is a private hospital, all of us experienced the so called culture shock

because we just had our duties from government/district hospitals. The setting in AMC is much

ideal considering the more advanced facilities and equipments it has.

The hospital staff is able to balance consideration and appropriate interventions to each and

every patient.

We have learned that the clients status in life should not be the basis of our fullness in rendering

services to them. After all, everyone deserves a fair treatment whatever aspect it may be.

Documents

Case Study (Nasopharyngeal Cancer)