Angeles University Foundation Angeles City College of Nursing

A CASE STUDY ON CERVICAL CANCER

Submitted by: BSN II-2 / Group 8 / Subgroup 2 Abeleda, George Smith Lumba, Chared Joy Santos, Micoh Ivan Sarmiento, Nicole Sharina Submitted to: Ma. Fe L. Mallari, RN, MAN

TABLE OF CONTENTS

Introduction Current Reasons trends for about choosing such the case disease for condition............................................ presentation Nursing Process.. Assessment. Personal Data Demographic data. Socio-economic factors.. Environmental factors.. Personal History.. Maternal-obstetric record Antepartal Preparation Significant changes. Family Health Illness History History of Past Illness.. History of Present Illness Physical Examination Diagnostic Procedures. and Laboratory Trimestral and cultural

Anatomy Physiology

and

The Patients Illness Synthesis of the disease. Definition of the disease Predisposing factors Signs and symptoms. Health Disease.. The Patient and his care Medical Management IVFs, BT, NGT feeding, etc. Drugs Diet Activity and Exercise Surgical Management Nursing Management Nursing Care Plan #1 Chronic pain related to irritation of nerve ending as evidenced by moaning every secretion of blood from the vagina. #2 Fluid volume deficient related to cervical bleeding secondary to cervical cancer as evidenced by HGB of 56g/L #3 Activity intolerance related to imbalance between oxygen supply #4 hemoglobin Ineffective as and tissue perfusion by related low to demand. decreased levels concentration evidenced HGB Promotion and Preventive Aspects of the

56g/L.

#5 Risk for impaired skin integrity related to altered circulation and pigmentation as evidenced by the pale palpebral conjunctiva, low HGB levels and pale skin color on palm area. Actual SOAPIE #1 Chronic pain related to irritation of nerve ending as evidenced by moaning every secretion of blood from the vagina. #2 Fluid volume deficient related to cervical bleeding secondary to cervical cancer as evidenced by HGB of 56g/L #3 Activity intolerance related to imbalance between oxygen supply and demand. #4 hemoglobin Ineffective as tissue perfusion by related low to decreased levels

concentration

evidenced

HGB

56g/L #5 Risk for impaired skin integrity related to altered circulation and pigmentation as evidenced by the pale palpebral conjunctiva, low HGB levels and pale skin color on palm area. Clients daily progress in the Hospital Clients Daily Progress Chart Conclusion and Recommendations Bibliography

I. INTRODUCTION A. Current trends about the disease condition In the book Cervical Cancer Research Trends, Cervical cancer is a malignancy of the cervix. Worldwide, it is the second most common cancer of women. It may be present with vaginal bleeding but symptoms may be absent until the cancer is in advanced stages, which has made cervical cancer the focus of intense screening efforts. Most scientific studies point to human papillomavirus (HPV) infection responsible for 90% of the cases of cervical cancer. There are 7 most common types of HPV 16, 18, 31, 33, 42, 52 and 58. Types 16 and 18 being the most common cause of the cancer. Treatment is with surgery (including local exicision) in early stages and chemotherapy and radiotherapy in advanced stages of the disease.
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According to Center for Disease Control and Disease Prevention (CDC), from 2000 to 2009 in the United States, incidence of cervical cancer has

Decreased significantly by 2.0% per year among women. Decreased significantly by 1.9% per year among white women. Decreased significantly by 3.0% per year among black women. Decreased significantly by 3.6% per year among Hispanic women. Remained level among American Indian/Alaska Native women. Decreased significantly by 3.0% per year among Asian/Pacific Islander

women. From 2000 to 2009 in the United States, deaths from cervical cancer have

Decreased significantly by 2.0% per year among women. Decreased significantly by 1.9% per year among white women. Decreased significantly by 2.6% per year among black women. Decreased significantly by 3.2% per year among Hispanic* women. Remained level among American Indian/Alaska Native women. Decreased significantly by 4.4% per year among Asian/Pacific Islander Based on Vanguard, researchers from the Institute of Health

women. Metrics and Evaluation, IHME, and the University of Queens, discovered from data collected on mortality and incidence for breast and cervical cancer, while more women are dying at younger ages of breast or cervical cancer in the developing world, the probability that women will die from either disease in the developed world has decreased. Organized screening has contributed to a decline in cervical cancer incidence and mortality over the past 50 years. However, women in developing countries are yet to profit extensively from the benefits of
6

screening programs, and recent trends show a resurgence of the disease in developed countries. The past 2 decades have witnessed substantial progress in our understanding of the natural history of cervical cancer and in major treatment advances. Human papillomavirus (HPV) infection is now recognized as the main cause of cervical cancer, the role of coexisting factors is better understood, a new cytology reporting terminology has improved diagnosis and management of precursor lesions, and specific treatment protocols have increased survival among patients with early or advanced disease. Current research has focused on the determinants of infection with oncogenic HPV types, the assessment of prophylactic and therapeutic vaccines and the development of screening strategies incorporating HPV testing and other methods as adjunct to cytology. These are fundamental stepping stones for the implementation of effective public health programs aimed at the control of cervical cancer. An estimated 371 000 new cases of invasive cervical cancer are diagnosed worldwide each year, representing nearly 10% of all cancers in women. In frequency, it is the seventh cancer site overall and third among women, after breast and colorectal cancer. 1 In developing countries, cervical cancer was the most frequent neoplastic disease among women until the early 1990s, when breast cancer became the predominant cancer site. (Franco, et.al, 2001)

B. Reasons for Choosing such Case for Presentation Our group was encouraged by our clinical instructor to get this case. Cervical cancer is a very curious and interesting topic. Instead of the usual cases of ectopic pregnancy and uterine bleeding in the ward, we pick this because of the challenge it presented. Cervical cancer itself is a
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challenging, intense case we rarely come by. It is the first time we encountered such case, and a severe one at that. The medications and procedures provided are a bit different than the average OB patient. Communication and the nursing care given to them are more sensitive and cautious than the usual patients we have. Moreover, cervical cancer is now a prevalent disease worldwide. A vaccine was being commercially advertised on the television few years ago. We dont know the disease condition thoroughly since we havent studied them yet in the lecture. We saw this as a chance to understand and have more than the general idea of cervical cancer.

II. NURSING PROCESS A. Assessment 1. PERSONAL DATA a. Demographic Data Name: Minnie Mouse Age: 62 years old Civil Status: Single Role/Postion in the Family: Dependent / Sister Address: San Matias, Lubao, Pampanga Date and Place of Birth: May 24, 1950 / Lubao, Pampanga Nationality: Filipino Date of Admission: January 3, 2013 b. Socio-economic and cultural factors The patient is single, never been married and never been pregnant though she had previous sexual contact. She had been
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living with her older sister who is the head of the family and is the one working. She has a good relationship with the rest of her living family. The patient is currently unemployed. She depends on the income earned by her sister. She graduated from elementary and there was no further education due to financial problems. The patient came originally from Pampanga. She knows how to fluently speak Filipino and Kapampangan. She belongs to the Roman Catholic religion and is an active participant at church mass. She uses herbal medications such as oregano, guava and sambong leaves. She also believes in quack doctors (albularyos) but she still prefer medical treatment. c. Environmental factors The patient lives together with her older sister who has a daughter working abroad. She lives in a peaceful and clean barangay in Lubao, Pampanga. 2. PERSONAL HISTORY a. Maternal obstetric record The patient is single but she did have previous sexual contact. She had never been pregnant (nulligravida). She claimed she had her menarche at age 13 years old and her menopause at 46 years old. She used to have a 28-to-30-day menstrual cycle and she never had dysmenorrhea then. b. Antepartal / Prenatal Preparation n/a c. Significant Trimestral Changes
9

n/a 3. FAMILY-HEALTH ILLNESS HISTORY The patients SO claimed that they did not know why or how their grandparents from both paternal and maternal sides of their family died. The patients uncle from the paternal side died of heart attack on 2002. Her father died of lung cancer on 2007. Her mother, who is the only child of her parents, died of Pneumonia around 1997. Her mother and youngest sibling also have hypertension.

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11

4. HISTORY OF PAST ILLNESS The patient had some instances of colds, coughs and fever during her childhood but she did not have any childhood illnesses such as chickenpox, mumps and measles. Neither the patient nor the SO can remember about the completeness of the immunizations of the patient. She has no allergies to certain drugs, food or any other environmental agents. There were also no previous hospitalizations or any serious surgeries done before. 5. HISTORY OF PRESENT ILLNESS The patients chief complaint when she arrived on 8pm of January 3, 2013 is vaginal bleeding. She came in Jose B. Lingad Memorial General Hospital as a referral from Dr. Ladel for blood transfusion due to Chemo-radiotherapy. Her admitting diagnosis is Cervical Cancer Stage IIB and Secondary anemia. According to the SO of the patient, she had a previous Dilatation and Curettage procedure shortly just after she had her menopause. It is because the lining of her uterus thickened and needed to be scraped off. Around July 2012, she had a Papanicolau smear test where a myoma was discovered. The patient underwent a Biopsy test on December 2012. She should have been admitted before the year ended but she chose not to. She wanted to be confined after the holidays ended. After the blood transfusion procedures in JBL-MGH, she is expected to be transferred at Sacred Heart Medical Hospital for radiotherapy. 6. PHYSICAL EXAMINATION PHYSICAL ASSESSMENT
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Date of Physical Assessment: January 8, 2013 General Survey Assessed/received patient lying on bed, awake, conscious, responsive, and coherent with an ongoing IVF of 1L Plain NSS at 600cc level running at 15 gtts/min infusing well at right metacarpal vein with the following vital signs: Temperature: 36.8 C Heart rate: 65 bpm Respiratory rate: 20 bpm Blood Pressure: 140/80 mmHg Patients GPTPAL: G0 P0 T0 P0 A0 L0 [Nulligravida] Skin > Pallor noted. > Good skin turgor in both upper and lower extremities; the skin returns to its previous state immediately after being tented. > Dry scaly skin Hair > Hair is gray and is evenly distributed. > Silky and smooth hair. > No areas of hair loss noted. > Thick hair strands. Nails > Trimmed clean nails. > Concave shaped; with a nail plate angle of about 160 degrees. > Smooth in texture. > Intact epidermal lining around the nails. > Capillary Refill Test less than 3 seconds. Skull and Face > Rounded (normocephalic and symmetrical with frontal, parietal and occipital prominences). > Head size is appropriate to body size.
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> No nodules or masses upon palpation. Eyes and Vision > Eyebrows and eyelashes are evenly distributed. > Eyelids are intact. > Sclera appears white. > Pale conjunctiva. > No discharges and discoloration noted. > Blink reflex intact. Ears and Hearing > Ears are symmetrical in size and in line with the outer canthus of the eyes. > Color of ears is the same with the facial skin. > No discharges and foul odor noted upon inspection. > Pinna and ear canal are clean. > Auricles are firm and recoil to previous state when folded. > No nodules or masses noted upon palpation. Nose and Sinuses > Symmetric and straight. > No watery discharges. > Has a slow uneven breathing pattern. > Not tenderness, masses and pain noted upon palpation. > Oxygen inhalation attached. Oropharynx (Mouth and Throat) > Dry and pale lips noted upon inspection. > Tongue is able to move freely and able to swallow foods. > Good oral hygiene. Neck > Jugular vein is not visible. > Muscles are equal in size with the head centered. > Slow muscle movement. > Lymph nodes are not palpable.
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Cardiovascular and Peripheral System > Skin color of palm of the hand and feet is pale. > Pale nail beds upon inspection. > Symmetric pulse volumes, full pulsations of peripheral pulses. > Heart rate is 65 beats per minute. > Blood Pressure is 140/80mmHg. > (Vital signs taken during the time of assessment on January 8, 2013 @ 7:00 am). Respiratory System > Chest is symmetric. > Skin and chest wall are intact and has uniform temperature. > No tenderness and masses noted upon palpation. > Irregular breathing pattern > No wheezing and crackles sound upon auscultation. > Full and symmetric chest wall expansion. Breasts and Axillae > Breasts are symmetrical in size; color is the same as with the abdomen. > Both nipples are symmetrical in size. > No discharges noted. > No tenderness, masses, and nodules noted upon palpation. Abdomen > Abdominal skin is intact. > Distended abdomen noted. > Presence of striae gravidarum noted. > Audible bowel sound upon auscultation. > Abdominal dullness upon percussion. > Presence of solid rounded mass noted upon palpation (left inguinal region). > Abdominal pain (pain scale of 8/10) complained. > Presence of scar at the right hypogastrium.
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Musculoskeletal Skeletal > Posture is good, able to stand straight and can walk alone properly but slowly. > Movement of muscles has coordination. > Muscles in the upper extremities are firm. Neurologic > Patient has times of looking in the distance and is slow in response when a question asked. > Patient was able to answer well when asked of her complete name, birth date and age. Urinary System > Patient usually urinates 5 times a day. Reproductive System > The patient refused to be assessed with her external reproductive organ but she verbalized that she has minimal vaginal bleeding and complain of pain when secretions are expelled. REVIEW OF SYSTEM Integumentary System The patient has no history of bruises in both upper and lower extremities. Head The patient had no history of any form of head injuries. Eyes Patient had no history of any eye problems. Ears and Hearing Patient had no history of smelly discharges on both ears, and no complaints of hearing impairment. Breast and Axillae The patient had no history of breast nodules, no enlargement, no tenderness, no pain and unusual discharges. Respiratory System
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The patient experienced slow irregular breathing patterns. Cardiovascular System The patient has a history of hypertension. Genitourinary System The patient had no history of any genital problems. Usually urinates 5 times a day. Gastrointestinal System The patient had no history of difficulty in defecation. Musculoskeletal System Patient has no history of joint pain. Neurologic System Patient had no history of any major mental problems but had episodes of mental absences.

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7. DIAGNOSTIC AND LABORATORY PROCEDURES

Date Ordered Date Results in Indications or Purposes Results Normal Values Analysis and Interpretation of results

Diagnostic / Laboratory Procedures

1. Hematolog y test

Date ordered: January 2013 Date Results: January 2013 3, of 3,

to

see

the Blood Typing: O

The

blood

type

of

the

hemoglobin content in the red blood cells Rh: (+) Hemoglobin: 50 115-155 g/L g/L

patient is Type O. The patient is Rh+. The result indicated that the haemoglobin (the ironcontaining part of blood that carries oxygen to cells) level of the patient is very low, which leads to her diagnosis anemia. Hematocrit: 0.15 g/L 0.38 0.48 g/L The level of the percentage of the red blood cells is very low, almost half of the of secondary

18

normal range, which can account for the diagnosis of secondary anemia. WBC count:18.9 5-10 x 10^9 /L The level of white blood cell count is very high since there pathogens Neutrophils: 0.45-0.65 x condition. The number of Neutrophils is higher than the normal Lymphocytes: 0.20-0.35 x range. 0.20 x 10^9 g/L 10^9 g/L Monocytes: 0.02-0.06 x The number within of the 0.77 x 10^9 g/L 10^9 g/L are due invading to her

0.03 x 10^9 g/L 10^9 g/L Platelet count: 150-400 10^9 g/L x

Lymphocytesis normal level.

357 x 10^9 g/L

The number of monocytes is within the normal range. The platelet count is within
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the

normal there

range; are no

therefore,

clotting complications that 2. Complete Blood Count Date ordered: January 2013 Date results: January 2013 to identify who 3, of 3, as preoperative test to ensure both adequate oxygen carrying capacity and Hematocrit: 0.17 g/L Like haemoglobin, the result increased from the initial result but it is still low compared to the normal WBC to count: 4.5-11 x 10^9 range, meaning the RBCs count is still very low. The WBC count decreased to acute identify and from the initial result but it is still higher than the 0.36-0. 45 g/L hemostasis a Hemoglobin: 56 123-153 g/L g/L may occur. From the first result, the level low still cells. of haemoglobin to the in to increased but it is still very compared having normal range. The RBCs are difficulty oxygen transporting

persons infection

may have an

diagnose 13.8 x 10^9 g/L g/L

anemia

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chronic illness, bleeding tendencies, and blood cell

Neutrophils: 0.84 x 10^9 g/L 0.18-0.70 10^9 g/L Lymphocytes: white 0.14 x 10^9 g/L 0.10-0.48 10^9 g/L Monocytes: 0.02 x 10^9 g/L 0-0.04 g/L

normal range, meaning it is x still fighting the invading pathogens x The neutrophil count

increased from initial result. The lymphocyte decreased x10^9 from initial result, but within the normal range. The monocyte from within but count initial the

disorders such as leukemia to monitor for and Eosinophils: blood 0.00 0-0.03 g/L to determine Basophils: 0.00 The eosinophils are within 0-0.01 g/L The basophils are within the normal range. Platelet count: 0-0.03 g/L x10^9 The bands are within the
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treatment anemia other diseases

decreased x10^9 result, normal range.

the effects of chemotherapy and blood production radiation Bands: 0.00 on cell 456 x 10^9 g/L therapy

x10^9 the normal range.

normal range. 150-400 x10^9 The g/ platelet count

increased from the initial result and went out of the normal range. It can results from anemia patient. the cancer of and the condition

3.Blood Chemistry Test

Date ordered: January 2013 Date results: January 2013 3, of 3,

Measures chemical

the Creatinine: 170.4umol/L

58-120 umol/L

The that

creatinine there is the

level

is

elevated, which may mean something kidney altering disease. 0-39 u/L The result is within the normal indicates functioning. 135.0-148.0 range normal which liver

components of blood plasma. which contains water, glucose, proteins, lipids SGPT and such calcium assess such as the minerals (Glutamate as Pyruvate Transaminase): health, 3.4 u/L 136.3 mmol/L

function, which might be a

efficacy of the Sodium:

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blood-calcium utilization bones growth of for and

mmol/L

The Sodium level is within the normal range, which might 2.20indicate normal blood pressure and volume. The Calcium level is within the normal range.

development

Calcium: 2.93mmol/L BUN

2.90mmol/L

(Blood 1.7-8.3 mmol/L The result is higher than the normal range, which indicates altered or impaired renal functioning.

Urea Nitrogen): 10.4 mmol/L

SGOT (Glutamic 0.0-40.0 u/L Oxaloacetic Transaminase): 11.9 u/L Potassium: 5.34 3.50-5.50 mmol/L mmol/L The result is within the normal range which means there is fluid equilibrium in the body. The result is within the normal range which means there is proper liver functioning.

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4. B

HBsAG Date ordered: 3, 2013 Date results: January 2013 3, of Surface January

To acute

detect Non-reactive B B

This

indicates

that

the

(Hepatitis Antigen test)

person is not infected with Hepatitis B.

hepatitis infection: hepatitis surface antigen (HBsAg), hepatitis (anti-HBc), IgM sometimes

core antibody and

hepatitis B e antigen (HBeAg)

To diagnose chronic hepatitis: HBsAg, HBV

24

hepatitis virus DNA, sometimes HBeAg

B (HBV) and

To

detect to

previous exposure hepatitis B, in a person who is immunocompr omised (when the virus can become reactivated): hepatitis (anti-HBc) total and antiHBs 5. Cross- Date Most Compatible There is no clmping that B core antibody

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matching test

ordered: January 2013 Date results: January 2013 3, of 3,

commonly done to make certain that a person needs transfusion will blood matches compatible with) his own. People of the must same type, a even receive blood blood serious, fatal, transfusion reaction can occur. to receive that (is who

()

occurred,

meaning

the

donors blood is compatible with the patient. There is no agglutination that occurred and this indicated that there is a compatible cross-match.

a No Hemolysis ()

otherwise,

6.

Cervical

---

detect Final

Undifferentiated carcinoma may indicate malignant

Biopsy

cancer of the Pathological

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cervix

or Diagnosis: Suspicious for cell

cells.

Carcinoma

is

precancerous cervix

malignant neoplasm whose cells appear to be derived from epithelium. Neoplasm is a "new growth" of the body's own of under cells, cells a no proliferation longer

lesions of the small carcinoma. Suggest

undiffentiated

immunostains for NSE Gross Microscopic description: Specimen contains brow an cm tan tissue aggregate LCA, CK, and

normal

physiologic control.

chromogranin

fragments with diameter of 1.5

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NURSING RESPONSIBILITIES CBC, Cross-matching and Hematology tests: 1. Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured. 2. Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values. 3. Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of lipidemia. 4. Apply manual pressure and dressings over puncture site on removal of dinner. 5. Monitor the puncture site for oozing or hematoma formation. 6. Instruct to resume normal activities and diet.

Blood Chemistry test 1. Inform the patient this test can assist in evaluating the amount of hemoglobin in the blood to assist in diagnosis and monitor therapy. 2. Obtain a history of the patient's complaints, including a list of known allergens, especially allergies or sensitivities to latex. 3. Obtain a history of the patient's cardiovascular, and gastrointestinal, systems; hematopoietic, hepatobiliary, immune, respiratory

symptoms; and results of previously performed laboratory tests and diagnostic and surgical procedures. 4. Note any recent procedures that can interfere with test results. 5. Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals

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6. Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some discomfort during the venipuncture. 7. Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. 8. There are no food, fluid, or medication restrictions unless by medical direction. 9. If the patient has a history of allergic reaction to latex, avoid the use of equipment containing latex. 10. Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. 11. Observe standard precautions, and follow the general guidelines. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection. Perform a venipuncture; collect the specimen in a 5-mL lavender-top (EDTA) tube. An EDTA Microtainer sample may be obtained from infants, children, and adults for whom venipuncture may not be feasible. The specimen should be mixed gently by inverting the tube 10 times. The specimen should be analyzed within 24 hr when stored at room temperature or within 48 hr if stored at refrigerated temperature. If it is anticipated the specimen will not be analyzed within 24 hr, two blood smears should be made immediately after the venipuncture and submitted with the blood sample. Smears made from specimens older than 24 hr may contain an unacceptable number of misleading artifactual abnormalities of the RBCs, such as echinocytes and spherocytes, as well as necrobiotic white blood cells. 12. stop Remove the needle and apply direct pressure with dry gauze to bleeding. Observe/assess venipuncture site for bleeding or

hematoma formation and secure gauze with adhesive bandage.

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13. 14.

Promptly transport the specimen to the laboratory for processing A report of the results will be sent to the requesting HCP, who will

and analysis. discuss the results with the patient. Cervical Biopsy 1. Do not eat or drink anything for 8 hours prior to the procedure. 2. After procedure, advice patient to rest and avoid strenuous activity for 24 hours. 3. May have some bleeding or discharge from your vagina for several days postsurgery. A sanitary napkin or pad may be worn. Tampons should not be used for a month or more after the surgery. 4. Leave packing in place until physician permits removal (usually 12-14 hours). 5. Monitor vaginal bleeding. 6. Sexual intercourse is discouraged for 4-6 weeks. 7. Showers and baths are OK. 8. A postoperative exam takes place at six weeks.

III. ANATOMY AND PHYSIOLOGY (FEMALE REPRODUCTIVE SYSTEM) The reproductive role of a female is much more complex than that of the male. Not only must she produce the female gametes (ova), but her body must also nurture and protect a developing fetus during nine months of pregnancy. Functions are: Produces eggs (ova). Secretes sex hormones. Receives the male spermatazoa during sexual intercourse. Protects and nourishes the fertilized egg until it is fully developed. Delivers fetus through birth canal.
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Provides

nourishment to the baby through milk secreted by mammary glands in the breast.

Anatomy (External Female Organ) Physiology (External Female Organ) Mons Pubis a.k.a. Mons Veneris that protects the pubic bone and vulva from the impact of sexual intercourse. After puberty, it is covered by pubic hair (responsible for not easily harboring the microorganisms in the vagina. Prepuce of Clitoris protective cover of glans of clitoris. Glans of Clitoris a short erectile organ above the vagina that is responsible for sexual excitation or pleasure. Vestibule the gland at the point where vagina and vulva join that secretes lubricating substance. It consists of 3 parts: o Urethral Opening a.k.a. Meatus that drains urine from the bladder. o Clitoris functions sexual pleasures. o Vestibule of Vagina a.k.a. Vaginal Introitus that is for the vaginal entrance. Openings of Paraurethral connected to the urethra and lubrication.

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Labium a fleshy and liplike structure folds that protect the openings from bacterial invasion. It has: o Labia Majora elongated hair covered skin folds that are responsible for lubrication. o Labia Minora smaller folds enclosed by the labia majora and their function is to protect the vagina and urethra openings. And they also produce lubricant. Vagina receives penis and semen during mating, and passageway of childbirth and menstrual flow. Hymenal Caruncle a.k.a. Hymen, a membrane which partially covers the vaginal passage. Opening of Greater Vestibular Gland a.k.a. Bartholins Glands, the two glands at the side of the vagina and between the vulva that secretes a lubricating substance. Vestibular Fossa a.k.a. Navicular Fossa, a small cavity of between the vaginal orifice and fourchette. Frenulum of Labium the fold connecting the two labia minora posteriorly. Posterior Labia Commissure rear joining of the labia majora above the perineum. Perineal Raphe ridge along the median line that runs forward from the anus. Anus a.k.a. Anal Orifice, in which feces passes through.

Anatomy (Internal Female Organ)

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Physiology (Internal Female Organ) Ovaries paired shape of almonds. It produces ova (singular, ovum), or eggs. The two ovaries present in each female are held in place by the following ligaments: o Broad Ligament is a section of the peritoneum that drapes over the ovaries, uterus, ovarian ligament, and suspensory ligament. It includes both the mesovarium and mesometrium. The mesovarium is a fold of peritoneum that holds the ovary in place. o Suspensory Ligament anchors the upper region of the ovary to the pelvic wall. Attached to this ligament are blood vessels and nerves, which enter the ovary at the hilus. Ovarian Ligament anchors the lower end of the ovary to the uterus.

The following two tissues that cover the outside of the ovary: o o Germinal Epithelium is an outer layer of simple epithelium. Tunica Albuginea is a fibrous layer inside the germinal epithelium.

The inside of the ovary, or stroma, is divided into two indistinct regions: o Outer Cortex and the Inner Medulla embedded in the cortex are saclike bodies called ovarian follicles. Each ovarian follicle consists of an immature oocyte (egg) surrounded by one or more layers of cells that nourish the oocyte as it matures.

33

Follicular Cells the surrounding cells if they make up a single layer, or granulosa cells, if more than one layer is present.

Uterine tubes (oviducts) transport the secondary oocytes away from the ovary and toward the uterus (the ovaries consist of primary oocytes, which develop into secondary oocytes). The following regions characterize each of the two uterine tubes (one for each ovary): o Infundibulum is a funnel-shaped region of the uterine tube that bears fingerlike projections called fimbriae. Pulsating cilia on the fimbriae draw the secondary oocyte into the uterine tube. Ampulla is the widest and longest region of the uterine tube. Fertilization of the oocyte by a sperm usually occurs here. Isthmus is a narrow region of the uterine tube whose terminus enters the uterus.

Wall of the Uterine Tube consists of the following three layers: o o Serosa a serous membrane, lines the outside of the uterine tube. Middle Muscularis consists of two layers of smooth muscle that generate peristaltic contractions that help propel the oocyte forward. Inner Mucosa consists of ciliated columnar epithelial cells that help propel the oocyte forward, and secretory cells that lubricate the tube and nourish the oocyte.

Uterus a hollow and pear-shaped organ that is to house, nourish and expel the fetus during delivery; and for menstrual flow. It composes 3:
o o

Body or Corpus the main body part of the uterus. Fundus superior rounded region above the entrance of the uterine tubes. Isthmus slightly constricted portion that joins the corpus to the cervix.

Uterus is held in place by the following ligaments:

o

Broad ligaments - fold of peritoneum supporting the uterus, extending from the uterus to the wall of the pelvis on either side. Utero-sacral ligaments - a part of the thickening of the visceral pelvic fascia beside the cervix and vagina; called also Petit's Ligament. 34

Round ligaments - a fibromuscular band attached to the uterus near the uterine tube, passing through the inguinal ring to the labium majus. Cardinal (lateral cervical) ligaments - part of a thickening of the visceral pelvic fascia beside the cervix and vagina, passing laterally to merge with the upper fascia of the pelvic diaphragm.

Wall of the Uterus consists of the following three layers:

o

Perimetrium is a serous membrane that lines the outside of the uterus. Myometrium consists of several layers of smooth muscle and imparts the bulk of the uterine wall. Contractions of these muscles during childbirth help force the fetus out of the uterus. Endometrium is the highly vascularized mucosa that lines the inside of the uterus. If an oocyte has been fertilized by a sperm, the zygote (the fertilized egg) implants on this tissue.

Endometrium itself consists of two layers:

Stratum Functionalis (functional layer) is the innermost layer (facing the uterine lumen) and is shed during menstruation. Stratum Basalis (basal layer) is permanent and generates each new stratum functionalis.

Vagina (birth canal) serves both as the passageway for a newborn infant and as a depository for semen during sexual intercourse. It consists of the following layers:
o o

Outer Adventitia holds the vagina in position. Middle Muscularis consists of two layers of smooth muscle that permit expansion of the vagina during childbirth and when the penis is inserted. Inner Mucosa has no glands. But bacterial action on glycogen stored in these cells produces an acid solution that lubricates the vagina and protects it against microbial infection. The acidic environment is also inhospitable to sperm. The mucosa bears transverse ridges called rugae.

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Anatomy (Female Internal Cervix)

Physiology (Female Internal Cervix) Cervix is the 3rd lower portion of the uterus, neck like part (uteri cervix), narrowed where it joins of the top end of the vagina. Cylindrical in shape and protrudes through the upper anterior vaginal wall. It has cervical mucus that is made of 90% of water, depending on the water content which varies during the menstrual cycle that functions as barrier. It usually contains electrolytes, mainly Calcium, Sodium, and Potassium, organic components such as amino acids and soluble proteins. It is also composed of zinc, copper, iron, manganese, and selenium elements. After menstrual period, the external os is blocked by mucus that is thick and acidic and it undergoes a series of changes in position and texture of cervix uteri and wall.

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Hormonal Regulation of Oogenesis and Menstrual Cycle

Three estrogens circulate in the bloodstream: (1) estradiol, (2) estrone, and (3) estriol. All have similar effects on their target tissues. Estradiol is the most abundant estrogen, and its effects on target tissues are most pronounced. It is the dominant hormone prior to ovulation. In estradiol synthesis, androstenedione is first converted to testosterone, which the enzyme aromatase converts to estradiol. The synthesis of both estrone and estriol proceeds directly from androstenedione. Estrogens have multiple functions that affect the activities of many tissues and organs throughout the body. Among the important general functions of estrogens are (1) stimulating bone and muscle growth, (2) maintaining female secondary sex characteristics, such as body hair distribution and the location of adipose tissue deposits, (3) affecting central nervous system (CNS) activity (especially in the hypothalamus, where estrogens increase the sexual drive), (4) maintaining functional accessory reproductive glands and organs, and (5) initiating the repair and growth of the endometrium.

37

38

The purpose of these cycles is to produce an egg and to prepare the uterus for the implantation of the egg, should it become fertilized. The ovarian cycle consists of three phases: 1. Follicular Phase describes the development of the follicle, the meiotic stages of division leading to the formation of the secondary oocytes, and the secretion of estrogen from the follicle. 2. Ovulation, Occurring at midcycle is the ejection of the egg from the ovary. 3. Luteal Phase describes the secretion of estrogen and progesterone from the corps luteum (previously the follicle) after ovulation. The menstrual (uterine) cycle consists of three phases: 1. Proliferative phase describes the thickening of the endometrium of the uterus, replacing tissues that were lost during the previous menstrual cycle. 2. Secretory phase - follows ovulation and describes further thickening and vascularization of the endometrium in preparation for the implantation of a fertilized egg. 3. Menstrual phase (menstruation, menses) describes the shedding of the endometrium when implantation does not occur. The activities of the ovary and the uterus are coordinated by negative- and positive-feedback responses involving gonadotropin releasing hormone (GnRH) from the hypothalamus, follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary, and the hormones estrogen and progesterone from the follicle and corpus luteum. A description of the events follows): 1. Hypothalamus and anterior pituitary initiate the reproductive cycle: The hypothalamus monitors the levels of estrogen and progesterone in the blood. In a negative-feedback fashion, low levels of these hormones stimulate the hypothalamus to secrete GnRH, which in turn stimulates the anterior pituitary to secrete FSH and LH. 2. Follicle develops: FSH stimulates the development of the follicle from primary through mature stages. 3. Follicle secretes estrogen: LH stimulates the cells of the theca interna and the granulosa cells of the follicle to secrete estrogen. Inhibin is also secreted by the granulosa cells. 4. Ovulation occurs: Positive feedback from rising levels of estrogen stimulate the anterior pituitary (through GnRH from the hypothalamus) to produce a sudden midcycle surge of LH. This high level of LH stimulates meiosis in the primary oocyte to progress toward prophase II and triggers ovulation.

39

5. Corpus luteum secretes estrogen and progesterone: After ovulation, the follicle, now transformed into the corpus luteum, continues to develop under the influence of LH and secretes both estrogen and progesterone. 6. Endometrium thickens: Estrogen and progesterone stimulate the development of the endometrium, the inside lining of the uterus. It thickens with nutrient-rich tissue and blood vessels in preparation for the implantation of a fertilized egg. 7. Hypothalamus and anterior pituitary terminate the reproductive cycle: Negative feedback from the high levels of estrogen and progesterone cause the anterior pituitary (through the hypothalamus) to abate the production of FSH and LH. Inhibin also suppresses production of FSH and LH. 8. Endometrium either disintegrates or is maintained, depending on whether implantation of the fertilized egg occurs, as follows:
o

Implantation does not occur: In the absence of FSH and LH, the corpus luteum deteriorates. As a result, estrogen and progesterone production stops. Without estrogen and progesterone, growth of the endometrium is no longer supported, and it disintegrates, sloughing off during menstruation. Implantation occurs: The implanted embryo secretes human chorionic gonadotropin (hCG) to sustain the corpus luteum. The corpus luteum continues to produce estrogen and progesterone, maintaining the endometrium. (Pregnancy tests check for the presence of hCG in the urine).

Menopause is the cessation of menstruation. This usually occurs in women between the ages of 45 and 50. Some women may reach menopause before the age of 45 and some after the age of 50. In common use, menopause generally means cessation of regular menstruation. Ovulation may occur sporadically or may cease abruptly. Periods may end suddenly, may become scanty or irregular, or may be intermittently heavy before ceasing altogether. Markedly diminished ovarian activity, that is, significantly decreased estrogen production and cessation of ovulation, causes menopause.

PATHOPHYSIOLOGY (NARRATIVE FORM)

40

Cancer of the cervix typically originates from a dysplastic or premalignant lesion previously present at the active squamous columnar junction. The transformation from mild dysplastic to invasive carcinoma generally occurs slowly within several years, although the rate of this process varies widely. Carcinoma in situ is particularly known to precede invasive cervical cancer in most cases. In different reported series of patients with untreated carcinoma in situ who were followed up for many years, invasive carcinoma developed in about 30% of patients at 10 years and in about 80% of patients at 30 years. However, the carcinoma-in-situ lesion may regress after the initial diagnosis; such an occurrence was reported in 17 (25%) of 67 patients who were followed up for at least 3 years. Progression to invasive carcinoma becomes established and is considered irreversible once the malignant process extends through the basement membrane and invasion of the cervical stroma occurs. Multiple local growth patterns of invasive cervical cancer have been described, with combination growth patterns being common. The patterns include the following: exophytic, nodular, infiltrative, and ulcerative. The exophytic variety is the most common growth pattern. It usually arises from the exocervix and is often polypoid or papillary in form. Exophytic cervical cancer may result in a large, friable, bulky mass that involves only the superficial aspect of the cervix and has the tendency for excessive bleeding. The nodular variety typically arises in the endocervix and grows through the cervical stroma into confluent, firm masses that cause the cervix and isthmus to expand. Large, nodular-type tumors that circumferentially involve the endocervical region and large, exophytic-type tumors that originate from the endocervix and extend into the endocervical canal result in what has been referred to as a barrelshaped cervix. The infiltrative growth pattern leads to a stone-hard cervix that may be predicated to have minimal visible ulcerations or an exophytic mass. Infiltrative exocervical lesions tend to invade the vaginal fornices and the upper part of the vagina. On the other hand, infiltrative endocervical lesions tend to extend into the corpus and the lateral parametrium.

41

IV. THE PATIENTS ILLNESS Synthesis of the Disease 1. DEFINITION OF THE DISEASE The third most common cancer of the female reproductive system, cervical cancer is classified as either preinvasive or invasive. Preinvasive cancer is curable 75% to 90% of the time with early detection and proper treatment. If untreated (and depending on the form in which it appears), it may progress to invasive cervical cancer. With invasive cancer, cancer cells penetrate the basement membrane and can spread directly to contiguous pelvic structures or disseminate to distant sites by lymphatic routes. In 95% of cases, the histologic type is squamous cell carcinoma, which varies from well-differentiated cells to highly anaplastic spindle cells; only 5% are adenocarcinomas. Invasive cancer usually occurs in patients between ages 30 to 50, although in rare cases it can occur in those younger than age 20. One of the most important advances in the early diagnosis and treatment of cancer of the cervix was made possible by the observation that this cancer arises from precursor lesions, which begin with the development of atypical cervical cells. These atypical cells gradually progress to carcinoma in situ and to
42

invasive cancer of the cervix. Atypical cells differ from the normal cervical squamous epithelium. There are changes in the nuclear and cytoplasmic parts of the cell and more variation in cell size and shape (i.e., dysplasia). Carcinoma in situ is localized to the epithelial layer, whereas invasive cancer of the cervix spreads to deeper layers.

Stages of Gynecologic Cancer Stage Description Rarely used; refers to 0 preinvasive lesions Cancer is confined to organ in I which it originated Cancer involves some of the II structures surrounding the organ of origin Regional spread of cancer with lymph node involvement Distant spread of cancer with metastasis

III IV
States, 6th Ed, p.1004

Source: Porth, Carol Mattson. Pathophysiology: Concepts of Altered Health

2. PREDISPOSING FACTORS Risk factors include early age at intercourse, multiple sexual partners, a promiscuous partner, smoking and a history of STDs. Previous Herpesvirus 2 and other bacterial or viral venereal infections may also be a factor. 3. SIGNS AND SYMPTOMS

43

In the early stages, the patient may possibly manifest abnormal vaginal bleeding, persistent vaginal discharge and postcoital pain and bleeding. woman. In the advanced stages, there might be already pelvic pain, vaginal leakage of urine and stool from a fistula, anorexia, weight loss and anemia. Many women describe the pelvic pain ranging from a dull ache to sharp pains that can last hours. It can be mild or severe. 4. HEALTH PROMOTION AND PREVENTIVE ASPECTS OF THE DISEASE Get a regular Pap smear. The Pap smear can be the greatest defenses for cervical cancer. The Pap smear can detect cervical changes early before they turn into cancer. Limit the amount of sexual partners you have.Studies have shown women who have many sexual partners increase their risk for cervical cancer. They also are increasing their risk of developing HPV, a known cause for cervical cancer. Quit smoking or avoid secondhand smoke. Smoking cigarettes increases your risk of developing many cancers, including cervical cancer. Smoking combined with an HPV infection can actually accelerate cervical dysplasia. Your best bet is to kick the habit. If you are sexually active, use a condom. Having unprotected sex puts you at risk for HIV and other STD's which can increase your risk factor for developing cervical cancer. The vaginal discharge may be foul smelling, watery, thick, or contain mucus. It varies from woman to

44

Follow up on abnormal Pap smears. If you have had an abnormal Pap smear, it is important to follow up with regular Pap smears or colposcopies, whatever your doctor has decided for you. If you have been treated for cervical dysplasia, you still need to follow up with Pap smears or colposcopies. Dysplasia can return and when undetected, can turn into cervical cancer.

Get the HPV vaccine. If you are under 27, you may be eligible to receive the HPV vaccine, which prevents high risk strains of HPV in women. The HPV vaccine, Gardasil, was approved by the FDA to give to young girls as young as 9. The vaccine is most effective when given to young women before they become sexually active.

45

V. THE PATIENT AND HER CARE A. MEDICAL MANAGEMENT a. IVFs, BT, Oxygen Therapy, etc.
DATE MEDICAL MANAGEMEN T/ TREATMENT IVF No. 1 Plain NSS 1L regulated @ 15gtts/min Date performed: January 3, 2013 ORDERED/ DATE PERFORMED/ DATE CHANGED Date ordered: January 3, 2013 Plain NSS contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L. It contains 154 mEq/L Sodium and Chloride. It is isotonic, which is same with the osmolarity of our body fluids. For isotonic volume expander and electrolyte replacement. Used because it has little to no effect on the tissues and make the person feel hydrated preventing hypovolemic shock or hypotension. BT No. 1 Date ordered: One unit of packed red Used to replace fluids in dehydration To give intravenous fluids to the patients suffering from salt and water deprivation. Patient was able to avoid episodes of hypovolemic shock and doesnt feel dehydrated. GENERAL DESCRIPTION INDICATION(S)/ PURPOSES CLIENTS RESPONSE TO TREATMENT

46

January 3, 4U PRBC properly typed and crossmatched Date performed: January 3, 2013 2013

blood cells has the same amount of oxygen carrying red blood cells as a unit of whole blood. For each unit of RBCs transfused, the average 70 kg adults hemoglobin will usually increase by 1 g/dL the and their hematocrit by 2-3 percent. Packed red blood cells have a hematocrit between 70% and 80%, so they are among the most viscous of the blood products to transfuse.

IVF No. 2 Plain NSS 1L regulated @ 15gtts/min

Date ordered: January 4, 2013 Date changed: January 4, 2013

Plain NSS contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L. It contains 154 mEq/L Sodium and Chloride. It is isotonic, which is same with the

To give intravenous fluids to the patients suffering from salt and water

Patient was able to avoid episodes of hypovolemic shock and doesnt feel dehydrated.

47

osmolarity of our body fluids. For isotonic volume expander and electrolyte replacement.

deprivation. Used to replace fluids in dehydrati on and go with blood transfusions . Used because it has little to no effect on the tissues and make the person feel hydrated preventing hypovolemi c shock or hypotension .

48

BT No. 2 3U PRBC properly typed and crossmatched

Date ordered: January 4, 2013 Date changed: January 4, 2013

One unit of packed red blood cells has the same amount of oxygen carrying red blood cells as a unit of whole blood. For each unit of RBCs transfused, the average 70 kg adults hemoglobin will usually increase by 1 g/dL the and their hematocrit by 2-3 percent. Packed red blood cells have a hematocrit between 70% and 80%, so they are among the most viscous of the blood products to transfuse.

To increase the oxygencarrying capacity in anemic patients.

Patients hemoglobin increased by 6g/L. Her pulse rate has reached within normal limits.

IVF No. 3 Plain NSS 1L regulated @ 15gtts/min

Date ordered: January 5, 2013 Date changed: January 5,

Plain NSS contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L. It contains 154 mEq/L Sodium and Chloride. It is isotonic,

To give intravenous fluids to the patients suffering from salt

Patient was able to avoid episodes of hypovolemic shock and doesnt feel dehydrated.

49

2013

which is same with the osmolarity of our body fluids. For isotonic volume expander and electrolyte replacement.

and water deprivation. Used to replace fluids in dehydrati on and go with blood transfusions . Used because it has little to no effect on the tissues and make the person feel hydrated preventing hypovolemi c shock or hypotension

50

BT No. 3 1U PRBC properly typed and crossmatched

Date ordered: January 5, 2013 Date changed: January 5, 2013

One unit of packed red blood cells has the same amount of oxygen carrying red blood cells as a unit of whole blood. For each unit of RBCs transfused, the average 70 kg adults hemoglobin will usually increase by 1 g/dL the and their hematocrit by 2-3 percent. Packed red blood cells have a hematocrit between 70% and 80%, so they are among the most viscous of the blood products to transfuse.

. To increase the oxygencarrying capacity in anemic patients.

Patients hemoglobin increased by 6g/L. Her pulse rate has reached within normal limits.

IVF No. 4 Plain NSS 1L regulated @ 15gtts/min

Date ordered: January 6, 2013 Date changed: January 6,

Plain NSS contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L. It contains 154 mEq/L Sodium and Chloride. It is isotonic,

To give intravenous fluids to the patients suffering from salt

Patient was able to avoid episodes of hypovolemic shock and doesnt feel dehydrated.

51

2013

which is same with the osmolarity of our body fluids. For isotonic volume expander and electrolyte replacement.

and water deprivation. Used to replace fluids in dehydrati on and go with blood transfusions . Used because it has little to no effect on the tissues and make the person feel hydrated preventing hypovolemi c shock or hypotension

52

. BT No. 4 4U PRBC properly typed and crossmatched Date changed: January 6, 2013 Date ordered: January 6, 2013 One unit of packed red blood cells has the same amount of oxygen carrying red blood cells as a unit of whole blood. For each unit of RBCs transfused, the average 70 kg adults hemoglobin will usually increase by 1 g/dL the and their hematocrit by 2-3 percent. Packed red blood cells have a hematocrit between 70% and 80%, so they are among the most viscous of the blood products to transfuse. BT No. 5 4U PRBC Type O properly Date changed: Date ordered: January 6, 2013 One unit of packed red blood cells has the same amount of oxygen carrying red blood cells as a unit of whole blood. To increase the oxygencarrying capacity in anemic 53 Patients hemoglobin increased by 6g/L. Her pulse rate has reached within normal limits. To increase the oxygencarrying capacity in anemic patients. Patients hemoglobin increased by 6g/L. Her pulse rate has reached within normal limits.

typed and crossmatched

January 7, 2013

For each unit of RBCs transfused, the average 70 kg adults hemoglobin will usually increase by 1 g/dL the and their hematocrit by 2-3 percent. Packed red blood cells have a hematocrit between 70% and 80%, so they are among the most viscous of the blood products to transfuse.

patients.

IVF No. 5 Plain NSS 1L regulated @ 15gtts/min

Date ordered: January 8, 2013 Date changed: January 8, 2013

Plain NSS contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L. It contains 154 mEq/L Sodium and Chloride. It is isotonic, which is same with the osmolarity of our body fluids. For isotonic volume expander and electrolyte replacement.

To give intravenous fluids to the patients suffering from salt and water deprivation. Used to replace

Patient was able to avoid episodes of hypovolemic shock and doesnt feel dehydrated.

54

fluids in dehydrati on and go with blood transfusions . Used because it has little to no effect on the tissues and make the person feel hydrated preventing hypovolemi c shock or hypotension .

55

NURSING RESPONSIBILITIES: Plain NSS (IVF) 1. Verify the doctors order. 2. Know the type, amount and indication of IV therapy. 3. Practice strict asepsis. 4. Inform client and explain purpose of therapy. 5. PRIME IV tubing to expel air. This will prevent air embolism. 6. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton swab. 7. Monitor patient frequently for: a. Signs of infiltration / sluggish flow b. Signs of phlebitis / infection c. Dwell time of catheter and need to be replaced d. Condition of catheter dressing 8. Check the level of the IVF. 9. Correct solution, medication and volume. 10.Check and regulate the drop rate to ensure administration of proper volume of IV fluid as ordered. 11.Change the IVF solution if needed. Packed RBC (Blood Transfusion) 1. Verify the physicians written order and make a treatment card according to hospital policy. 2. Observe the 10 Rs when preparing and administering any blood or blood components. 3. Explain the procedure/rationale for giving blood transfusion to reassure patient and significant others and secure consent. Get patient histories regarding previous transfusion. 4. Explain the importance of the benefits on Voluntary Blood Donation (RA 7719- National Blood Service Act of 1994). 5. Request prescribed blood/blood components from blood bank to include blood typing and cross matching and blood result of transmissible Disease. 6. Using a clean lined tray, get compatible blood from hospital blood bank.

56

7. Wrap blood bag with clean towel and keep it at room temperature. 8. Have a doctor and a nurse assess patients condition. Countercheck the compatible blood to be transfused against the crossmatching sheet noting the ABO grouping and RH, serial number of each blood unit, and expiry date with the blood bag label and other laboratory blood exams as required before transfusion. 9. Get the baseline vital signs- BP, RR, and Temperature before transfusion. Refer to MD accordingly. 10.Give pre-meds 30 minutes before transfusion as prescribed. 11.Do hand hygiene before and after the procedure. 12.Prepare equipment needed for BT (IV injection tray, compatible BT set, IV catheter/ needle G 19/19, plaster, torniquet, blood, blood components to be transfused, Plain NSS 500cc, IV set, needle gauge 18 (only if needed), IV hook, gloves, sterile 22 gauze or transplant dressing, etc. 13.If main IVf is with dextrose 5% initiate an IV line with appropriate IV catheter with Plain NSS on another site, anchor catheter properly and regulate IV drops. 14.Open compatible blood set aseptically and close the roller clamp. Spike blood bag carefully; fill the drip chamber at least half full; prime tubing and remove air bubbles (if any). Use needle g.18 or 19 for side drip (for adults) or g.22 for pedia (if blood is given to the Y-injection port, the gauge of the needle is disregarded). 15.Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle, from BT administration ser and secure with adhesive tape. 16.Close the roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion is going on. 17.Transfuse the blood via the injection port and regulate at 10-15gtts/min initially for the first 15 minutes of transfusion and refer immediately to the MD for any adverse reaction. 18.Observe/Assess patient on an on-going basis for any untoward signs and symptoms such as flushed skin, chills, elevated temperature, itchiness, urticaria, and dyspnea. If any of these symptoms occur, stop the transfusion, open the IV line with Plain NSS and regulate accordingly, and report to the doctor immediately. 57

19.Swirl the bag gently from time to time to mix the solid with the plasma N.B one B.T set should be used for 1-2 units of blood. 20.When blood is consumed, close the roller clamp, of BT, and disconnect from IV lines then regulate the IVF of plain NSS as prescribed. 21.Continue to observe and monitor patient post transfusion, for delayed reaction could still occur. 22.Re-check Hgb and Hct, bleeding time, serial platelet count within specified hours as prescribed and/or per institutions policy. 23.Discard blood bag and BT set and sharps according to Health Care Waste Management (DOH/DENR). 24.Fill-out adverse reaction sheet as per institutional policy. 25.Remind the doctor about the administration of Calcium Gluconate if patient has several units of blood transfusion (3-5 more units of blood).

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b. Drugs

Name of drugs; Generic name, Brand name Tranexamic acid (Cyklokapron, Lysteda)

Date ordered Date performed Date changed Date Ordered: January 4, 2013 Date Taken: January 4, 2013 Date Ordered: January 4, 2013 Date Taken: January 4,5,7, 2013

Route od administrati on Dosage & freq of admin 500mg 1cap OD Anti-fibrinolytic drug It was ordered because it is thought to treat heavy bleeding. General Action Indication or Purposes Clients response to the meds w/ actual S/E

Bleeding was reduced.

calcium gluconate

1 amp IV injection

Treating conditions arising from calcium deficiencies such as hypocalcemic tetany, hypocalcemia r/t hypoparathyroidi

Aids in antagonizing the cardiac toxicity.

Lab tests shown that the patient's calcium level became normal.

59

furosemide (Lasix)

Date Ordered: January 4, 2012 Date Taken: January 4,5,6,7, 2012 Date Ordered: January 8, 2013 Date Taken: January 8, 2013

1 vial IV injection OD T>38c

sm. Inhibits sodium and chloride reabsorption.

It is for excretion of potassium and ammonia is increased while uric acid excretion is reduced. Thought to stimulate alpha2 receptors and inhibit the central vasomotor centers, decreasing sympathetic outflow to the heart, kidneys. Inhibits influx of

Potassium is excreted and ammonia level is increased and uric acid of patient become more stable. Decreased in blood pressure (120/80).

clonidine (Catapres)

75mg 1 tab SL Anti-hypertensive oral drug

amlodipine besylate (Norvasc)

Date Ordered: January 8,

5mg 1 tab BID oral

Calcium antagonist Antihypertensive

Decreased in blood patient from

60

transmembrane pressure of the

2012 Date Taken: January 8, metoprolol succinate (Lopressor) 2012 Date Ordered: January 8, 2013 Date Taken: January 8, 2013 50mg 1 tab BID oral

drug

calcium ions into vascular smooth muscle and cardiac muscle. Selectivity blocking the beta1 receptors in the heart, and use in performance anxiety, social anxiety disorder and other anxiety disorders. Used for relief of headache aches and pain. Also used in management of severe pain and

160/100 to 130/80.

Treatment in heart failure.

The patient didn't show any signs of anxiety

paracetamol/ Acetaminoph en

Date Ordered: January 8, 2012 Date Taken: January 8, 2012

300mg IV injection q4

Analgesic

Decreased temperature to

and other minor 36.8 from 39

61

providing palliative care.

62

NURSING RESPONSIBILITIES Tranexamic acid (Cyklokapron)

1. Unusual change in bleeding pattern should be immediately reported to the physician. 2. For women who are taking Tranexamic acid to control heavy bleeding, the medication should only be taken during the menstrual period. 3. Tranexamic Acid should be used with extreme caution in CHILDREN younger than 18 years old; safety and effectiveness in these children have not been confirmed. 4. The medication can be taken with or without meals. 5. Swallow Tranexamic Acid whole with plenty of liquids. Do not break, crush, or chew before swallowing. 6. If you miss a dose of Tranexamic Acid, take it when you remember, then take your next dose at least 6 hours later. Do not take 2 doses at once. 7. Inform the client that he/she should inform the physician immediately if the following severe side effects occur: 8. Severe allergic reactions such as rash, hives, itching, dyspnea, tightness in the chest, swelling of the mouth, face, lips or tongue o Calf pain, swelling or tenderness o Chest pain o Confusion o Coughing up blood o Decreased urination o Severe or persistent headache o Severe or persistent body malaise o Shortness of breath o Slurred speech o Slurred speech o Vision changes
Calcium gluconate

1. Give 1 to 1.5 hours after meals if GI upset occurs. 2. Warm solution to body temperature before giving it. 3. After injection, keep patient recumbent for 15 minutes. 4. Monitor calcium levels frequently. 5. Tell patient to report anorexia, nausea, vomiting, constipation, abdominal pain, dry mouth, thirst or polyuria.
furosemide (Lasix)

63

1. To prevent nocturia, give in the morning. Give second dose if ordered early in the afternoon, 6 to 8 hours after morning dose. 2. Monitor fluid intake and output and electrolyte, BUN, and carbon dioxide levels. 3. Watch for signs of hypokalemia, such as muscle weakness and cramps. 4. Advise patient to immediately report ringing in the ears, severe abdominal pain, or sore throat and fever; these symptoms may indicate toxicity. clonidine (Catapres) 1. Dont crush, break, or allow patient to chew extended release tablets. 2. Give last dose immediately before bedtime. 3. Monitor blood pressure and pulse rate frequently. Dosage is usually adjusted to patients blood pressure and tolerance. 4. Stop drug gradually by reducing dosage over 2 to 4 days to avoid rapid rise in blood pressure, agitation, headache and tremor. 5. Inform patient that dizziness upon standing can be minimized by rising slowly from a sitting or lying position and avoiding sudden position changes amlodipine besylate(Norvasc) 1. Monitor blood pressure frequently during initiation of therapy. Because drug-induced vasodilation has a gradual onset, acute hypotension is rare. 2. Give drug without regard for food. metropolol succinate(Lopressor) 1. Give drug with or immediately after meal. 2. Always check patients apical pulse before giving the drug. If its slower than 60 beats/minute, withhold the drug and call prescriber immediately.

64

3. Monitor blood pressure frequently; drug masks common signs and symptoms of shock. paracetamol/acetaminophen 1. Give drug without regard for food. 2. Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose.

65

c. Diet Date Ordered/ Date Type of diet Performed/ Date Changed Diet as tolerated Date Ordered: January 3, 2012 - january 7, 2013 Date Taken: January 3 2012 - january 7, 2013 Client can now tolerate any food he/she desires that is nutritious, if this will not lead to any complication and if the client needs further monitoring tests. Diet as tolerated is a term that indicates that the gastrointestinal To stay healthy Rice, Lutong and moderation (Any food as long as the pt can eat) The in his patient regular pattern of foods General description Indications or purpose Specific foods taken Client response to the diet

just kamatis, Lugaw was able to eat eating healthy and fruits.

consisting

66

tracts is tolerating food and is ready for advancement to the next stage. Nothing Orem Per Date ordered: January 8, 2013 Date taken: Jauary 8, 2013 Nothing by mouth; dont take in any type of food or liquid by mouth. To vomiting being and the avoid while sedated aspirates vomitus Nothing mouth by Patient did not vomit.

into lungs.

67

NURSING RESPONSIBILITIES Diet as Tolerated 1. Check the Doctors Order 2. Explain the Indication and purpose of the diet to the patient. 3. Explain the Impostance of Right Nutrition to the Patient / SO. 4. Check the Clients choice of food. 5. Encourage the Patient to eat Nutritious foods and Fruits. 6. Recommend the Patient to avoid eating Junk Foods and drinking Sodt Drinks. 7. Recommend the Patient to perform Oral Hygiene every after meal. Nothing Per Orem 1. Check doctors order. 2. Assure IV fluid therapy if patient is NPO> 3. Instruct SO not to give anything through the mouth. 4. Assess clients condition. 5. Assure that nothing is taken through the mouth( either liquid or solid. 6. Place NPO sign on bed where the patient or SO can always see it. 7. Remove foods or drinks on patients bedside. 8. Observe patients response on the diet. 9. Monitor clients condition D. Activity/Exercise (Not available) B. SURGICAL MANAGEMENT (Not available) C. NURSING MANAGEMENT 1. Nursing Care Plan

68

Assessment S: sakit ang tiyan ko, as verbalized by the patient. >Pain scale 8/10. O>Guarding/protect ing the affected site >Facial grimace noted >Reduced interaction >Moaning during excretion of blood from the vagina >Acitis (excessive fluid in peritoneum)

Nursing Diagnosis Chronic pain related to irritation of nerve ending as evidenced by moaning every secretion of blood from the vagina.

Scientific Explanation Almost all parts of the body are covered with nerve endings that are each programmed to respond to a specific kind of unpleasant sensation. They require a certain intensity of stimulation before they react and will lie silent until this level is reached. some peripheral receptors may respond to several different types of stimulus, including strong mechanical and thermal stimuli, and are often sensitized in time by repeated application of stimuli. These so-called polymodal nociceptors

Objectives Short term: After 1 hour of nursing interventions the patient will be able to verbalize and demonstrate proper techniques to relieve pain. Long term: After 1 week of nursing intervention the patient will be able to demonstrate and initiate behavioral modifications of lifestyle and appropriate use of therapeutic interventions as evidenced by patient being able to verbalize the divisionary therapy.

Intervention 1. Established rapport 2. Monitored V/S. 3. Assessed for referred pain as appropriate.

Rationale To gain trust of patient. To obtain baseline data To help determine possibility of underlying condition. To promote circulation and help lessen the pain.

Expected Outcome After 1 hour of nursing interventions the patient shall be able to verbalize and demonstrate proper techniques to relieve pain. After 1 week of nursing intervention the patient shall be able to demonstrate and initiate behavioral modifications of lifestyle and appropriate use of therapeutic interventions as evidenced by patient being able to verbalize the divisionary therapy.

4. Provided cutaneous stimulation; e.g., heat/cold, massage. 5. Provided nonpharmacologi c comfort measures and diversional activities. 6. Instructed and encouraged used of relaxation technique such as focus

Promotes relaxation and helps refocus attention.

To destruct attention and reduce tension.

69

may also be sensitive to chemical stimuli, such as low pH. It is believed that some of these types of receptor are also located in deeper tissues. Since we know that some receptors can be made more likely to be activated by a number of mechanisms including the chemical environment it is theorized that some types of chronic pain may arise from this so called peripheral sensitization. Source: Pathophysiolog y of chronic pain by James L. Henry Ph.D.

breathing. 7. Provided cutaneous stimulation; e.g., heat/cold, massage. 8. Provided comfort measures and quiet Environment 9. Evaluate pain relief/ control at regular intervals. Adjust medication regimen as necessary. 10. Administered analgesic as indicated by the physician.

May decrease inflammation, muscle spasms, reducing associated pain. To promote nonpharmacologic al pain management. Goal is maximum pain control with minimum interference with ADLs. A wide range of analgesics and associated agents may be employed around the clock to manage the pain.

70

Assessment S: dumudugo habang umiihi ako, as verbalized by the patient. O: >Pallor noted >Feeling of dizziness noted >Irritability when asked a question >Dry skin mucus membrane noted >Hematology: HGB (low) 56g/L normal range: 123153; HCT (low) 0.17%

Nursing Diagnosis Fluid volume deficient related to cervical bleeding secondary to cervical cancer as evidenced by HGB of 56g/L

Scientific Explanation A low hemoglobin measurement usually means that the person has anemia. Common causes include excessive bleeding, deficiency of iron, Vit.B12, folic acid, destruction of red cells by antibodies or mechanical trauma. Hemoglobin levels are also decreased due to cancer. Fluid volume in the blood affects the hemoglobin values. If there is decreased hemoglobin, there is also decreased blood volume. This is

Objectives Short term: After 1hr of nursing interventions the patient will be able to verbalize understanding of causative factors and purpose of individual therapeutic interventions. Long term: After 1 week of nursing intervention the patient will be able to demonstrate behaviors to monitor and correct deficit such as monitoring input and outtake and agreeing to

Intervention 1. Established rapport to the patient. 2. Monitored V/S. 3. Discussed factors in related to occurrence of deficit 4. Encouraged fluid intake to 3000 ml a day, unless contraindicate d.

Rationale To gain trust and cooperation. To obtain baseline data. To inform the patient of her condition. It flushes kidneys/bladd er of bacteria and debris but may result in water intoxication/flu id overload if not monitored closely. To monitor the amount of fluid taken and removed do as to detect any abnormalities.

Expected Outcome After 1hr of nursing interventions the patient shall be able to verbalize understanding of causative factors and purpose of individual therapeutic interventions. After 1 week of nursing intervention the patient shall be able to demonstrate behaviors to monitor and correct deficit such as monitoring input and outtake and agreeing to blood

5. Encouraged and demonstrate accurate monitoring of I&O.

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further evidenced by pallor and dry skin mucus.

blood transfusion 6. Monitor daily weight of patient

transfusion To detect any change brought about by the excessive release of fluid in the body. Necessary for fluid volume replacement For immediate referral of any S&S that may be a sign of hypovolemic shock. Usually indicates arterial bleeding that required aggressive therapy.

7. Regulated IVF level (D5LR) accurately. 8. Instructed S&S indicating in need for immediate or further evaluation. 9. Evaluated CFAC (Color, Frequency, Amount, and Consistency) of vaginal bleeding e.g. bright red with red clots. 10. Infused PRBC with IVF as ordered by the

Useful in evaluating blood losses/ replacement needs.

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physician.

Assessment S: none O: >Pallor >Abnormal heart rate: 49bpm >Slow movements >Hematology: HGB (low) 56g/L >V/S noted HR: 49 bpm; RR: 16 cpm

Nursing Diagnosis Activity intolerance related to imbalance between oxygen supply and demand.

Scientific Explanation Because there is decreased haemoglobin, the oxygen being delivered to the cells is also decreased resulting to decreased cell nourishment. There will be reduced ATP production, thus, less energy. And because the patient is generally feeling weak, there will be activity intolerance.

Objectives Short term: After 1 hour of nursing interventions the patient will be able to verbaliaze understanding of techniques in evaluating activities. Long Term: After 1 week of nursing intervention patient will be able to demonstrate a decrease in physiological signs of intolerance such as pulse and

Intervention
1. Established rapport to the patient. 2. Monitored V/S. 3. Assessed cardio pulmonary response to physical activity. 4. Identify activity needs versus desires to evaluate appropriatenes s 5. Plan care to carefully balance rest periods with activity.

Rationale
To gain trust and cooperation. To obtain baseline data. To provide adequate knowledge on the patient. To enhance patients ability to participate in activity.

Expected Outcome After 1 hour of nursing interventions the patient shall be able to verbalize understanding of techniques in evaluating activities.

After 1 week of nursing interventions the patient shall be able to To give an demonstrate a decrease in appropriate schedules of physical rest and intolerance activity. such as pulse and To give hemoglobin knowledge to levels within

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hemoglobin levels within normal range.

6. Demonstrate simple exercises and routines to patient.

the patient on easy ways to have exercise and motivate patient to do exercises. To gradually condition the body and prevent stagnation of circulation of blood. To assess if when to tone down activities given. To guide patient in the demonstration.

normal range.

7. Increase exercise level gradually.

8. Note client reports of weakness. 9. Assist client in learning and demonstrating appropriate safety measures. 10. Evaluate level of understanding

To assess if the patient has understood the teachings being implemented. To aid in the distribution of oxygen to the body by replacing the blood loss in the vaginal secretions.

11. Transfuse blood as ordered. 2. Provide oxygen as ordered To prevent over

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exertion.

Assessment S: none O: >HGB level (low) 56g/L >Pail nail beds >Pale palpebral conjunctiva >Low pulse rate 46 bpm >Dry scaly skin

Nursing Diagnosis Ineffective tissue perfusion related to decreased hemoglobin concentration as evidenced by low HGB levels 56g/L

Scientific Explanation Due to decreased haemoglobin that will lead to decreased intravascular volume, there will be decrease in cardiac output. Antidiuretic hormones will be secreted which will lead to increased heart rate and increased volume, therefore increasing

Objectives Short term: after 1 hour of nursing intervention the patient will be able to verbalize understanding of condition therapy given. Long term: after 1 week of nursing intervention the patient will be able to increase tissue perfusion such as HGB level within

Intervention 1. Establish rapport 2. Monitor V/S 3. Identify changes related to systemic or peripheral situations in circulation (e.g. altered mentation). 4. Monitor I&O

Expected Outcome To gain trust After 1 hour of of patient. nursing intervention To record the patient baseline data. shall be able to verbalize To identify the understanding causes of of condition tissue therapy given. perfusion After 1 week of nursing intervention the patient Shall be able to increase To identify if tissue there is a perfusion such decrease in as HGB level the fluid within normal retention of range and the body of pulse rate Rationale 75

cardiac output. But there is continued loss of volume which will decrease cardiac output and thus, decreasing tissue perfusion.

normal range and pulse rate returns to normal levels.

the patient. 5. Provide psychological support for patient such as staying at the bedside of the patient. 6. Encouraged Quiet restful atmosphere. To prevent any signs of anxiety.

returns to normal levels.

To prevent any agitation of the patient that may cause an increase in the vital signs. To prevent further complications that might occur with the activities. To promote circulation for the patient.

7. Caution client to avoid activities that increase cardiac workload. 8. Elevate HOB

76

Assessment S: none O: >Dry scaly skin >HGB level low 56g/L >Dry lips >Pale palpebral conjunctiva >Pale colored skin on the palm area. >Pail nail beds

Nursing Diagnosis Risk for impaired skin integrity related to altered circulation and pigmentation as evidenced by the pale palpebral conjunctiva, low HGB levels and pale skin color on palm area.

Scientific Explanation Skin is the primary defense of the body that protects us from invading pathogens. A healthy skin is moist and intact. The patient has dry, scaly skin, thus, making her more prone to friction which may result to impairment of skin integrity.

Objectives Short term: After 1 hour of nursing intervention the patient will be able to identify individual risk factors. Long term: After 3 days of nursing intervention the patient will be able to demonstrate behaviors and techniques to prevent skin

Intervention 1. Establish rapport 2. Monitor V/S 3. Inspect skin surfaces

4. Observed for reddened/blanch ed areas and

Expected Outcome To gain trust After 1 hour of patient. of nursing intervention To record the patient baseline data. shall be able to identify To inspect the individual risk integrity and factors. hydration of the skin of After 3 days the patient of nursing and to note intervention any the patient underlying shall be able lesions that to are present. demonstrate behaviors and Reduces techniques to likelihood of prevent skin progression breakdown. Rationale

77

breakdown.

institute treatment immediately. 5. Massage bony prominences gently and avoid friction when moving client. 6. Provide adequate covers.

of skin breakdown. To prevent patient for getting any pain upon moving the patient. To protect patient from any drafts and to promote further circulation. To provide comfort for the patient.

7. Keep bedclothes dry and keep bed free from wrinkles, crumbs.

78

Actual SOAPIEs SOAPIE 1 Subjective Cue: sakit ang tiyan ko, as verbalized by the patient. Pain scale 8/10. Objective Cues: * Guarding/protecting the affected site * Facial grimace noted * Reduced interaction * Moaning during excretion of blood from the vagina * Acitis (excessive fluid in peritoneum) ASSESSMENT: Chronic pain related to irritation of nerve ending as evidenced by moaning every secretion of blood from the vagina. PLANNING: Short term: After 1 hour of nursing interventions the patient was able to verbalize and demonstrate proper techniques to relieve pain. Long term: After 1 week of nursing intervention the patient was able to demonstrate and initiate behavioral modifications of lifestyle and appropriate use of therapeutic interventions as evidenced by patient being able to verbalize the divisionary therapy. INTERVENTIONS: Established rapport Monitored V/S Assessed for referred pain as appropriate. Provided cutaneous stimulation; e.g., heat/cold, massage. Provided nonpharmacologic comfort measures and diversional activities.

79

 Instructed and encouraged used of relaxation technique such as focus breathing. Provided cutaneous stimulation; e.g., heat/cold, massage. Provided comfort measures and quiet physician. EVALUATION:

environment. Evaluate pain relief/ control at regular intervals. Adjust medication regimen as necessary Administered analgesic as indicated by the

After 1 hour of nursing interventions the patient shall be able to verbalize and demonstrate proper techniques to relieve pain. After 1 week of nursing intervention the patient shall be able to demonstrate and initiate behavioral modifications of lifestyle and appropriate use of therapeutic interventions as evidenced by patient being able to verbalize the divisionary therapy.

SOAPIE 2 Subjective Cue: dumudugo habang umiihi ako, as verbalized by the patient. Objective Cues: * Pallor noted * Feeling of dizziness noted * Irritability when asked a question * Dry skin mucus membrane noted * Hematology: HGB (low) 56g/L normal range: 123-153; HCT (low) 0.17%

80

ASSESSMENT: Fluid volume deficient related to cervical bleeding secondary to cervical cancer as evidenced by HGB of 56g/L PLANNING: Short term: After 1hr of nursing interventions the patient will be able to verbalize understanding of causative factors and purpose of individual therapeutic interventions. Long term: After 1 week of nursing intervention the patient will be able to demonstrate behaviors to monitor and correct deficit such as monitoring input and outtake and agreeing to blood transfusion INTERVENTIONS: Established rapport to the patient. Monitored V/S. Discussed factors in related to occurrence of deficit Encouraged fluid intake to 3000 ml a day, Encouraged and demonstrate accurate monitoring of I&O. Monitored daily weight of patient Regulated IVF level (D5LR) accurately. Instructed S&S indicating in need for immediate or further evaluation. Evaluated CFAC (Color, Frequency, Amount, and Consistency) of vaginal bleeding. Infused PRBC with IVF as ordered by thephysician. EVALUATION: After 1hr of nursing interventions the patient was able to verbalize understanding of causative factors and purpose of individual therapeutic interventions.

81

After 1 week of nursing intervention the patient was able to demonstrate behaviors to monitor and correct deficit such as monitoring input and outtake and agreeing to blood transfusion

SOAPIE 3 Subjective Cue: none Objective Cues: * Pallor * Abnormal heart rate: 49bpm * Slow movements * Hematology: HGB (low) 56g/L * V/S noted HR: 49 bpm; RR: 16 cpm ASSESSMENT: Activity intolerance related to imbalance between oxygen supply and demand. PLANNING: Short term: After 1 hour of nursing interventions the patient will be able to verbaliaze understanding of techniques in evaluating activities. Long Term: After 1 week of nursing intervention patient will be able to demonstrate a decrease in physiological signs of intolerance such as pulse and hemoglobin levels within normal range. INTERVENTIONS: Established rapport to the patient. Monitored V/S. Assessed cardio pulmonary response to physical activity. Identify activity needs versus desires to evaluate appropriateness.

82

 Plan care to carefully balance rest periods with activity. Demonstrate simple exercises and routines to patient. Increased exercise level gradually. Noted client reports of weakness. Assisted client in learning and demonstrating appropriate safety measures. Evaluated level of understanding Transfused blood as ordered. Provided oxygen as ordered EVALUATION: After 1 hour of nursing interventions the patient was able to verbalize understanding of techniques in evaluating activities. After 1 week of nursing interventions the patient was able to demonstrate a decrease in physical intolerance such as pulse and hemoglobin levels within normal range. SOAPIE 4 Subjective Cue: none Objective Cues: * HGB level (low) 56g/L * Pail nail beds * Pale palpebral conjunctiva * Low pulse rate 46 bpm * Dry scaly skin ASSESSMENT: ineffective tissue perfusion related to decreased hemoglobin concentration as evidenced by low HGB levels 56g/L

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PLANNING: Short term: after 1 hour of nursing intervention the patient will be able to verbalize understanding of condition therapy given. Long term: after 1 week of nursing intervention the patient will be able to increase tissue perfusion such as HGB level within normal range and pulse rate returns to normal levels.

INTERVENTIONS: Established rapport Monitored V/S Identified changes related to systemic or peripheral situations in circulation (e.g. altered mentation). Monitored I&O Provided psychological support for patient such as staying at the bedside of the patient. Encouraged Quiet restful atmosphere. Cautioned client to avoid activities that increase cardiac workload. Elevated HOB To promote circulation for the patient. EVALUTATION: After 1 hour of nursing intervention the patient was able to verbalize understanding of condition therapy given. After 1 week of nursing intervention the patient was able to increase tissue perfusion such as HGB level within normal range and pulse rate returns to normal levels.

SOAPIE 5
84

Subjective Cue: none Objective Cues: * Dry scaly skin * HGB level low 56g/L * Dry lips * Pale palpebral conjunctiva * Pale colored skin on the palm area. * Pail nail beds ASSESSMENT: Risk for impaired skin integrity related to altered circulation and pigmentation as evidenced by the pale palpebral conjunctiva, low HGB levels and pale skin color on palm area. PLANNING: Short term: After 1 hour of nursing intervention the patient will be able to identify individual risk factors. Long term: After 3 days of nursing intervention the patient will be able to demonstrate behaviors and techniques to prevent skin breakdown. INTERVENTIONS: Established rapport Monitored V/S Inspected skin surfaces Observed for reddened/blanched areas and institute treatment immediately. Massaged bony prominences gently and avoided friction when moving client. Provided adequate covers. To protect patient from any drafts and to promote further circulation. Kept bedclothes dry and keep bed free from wrinkles, crumbs.

85

EVALUTATION: After 1 hour of nursing intervention the patient was able to identify individual risk factors. After 3 days of nursing intervention the patient was able to demonstrate behaviors and techniques to prevent skin breakdown.

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VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL 1. Clients Daily Progress Chart ADMISSION 01-03-2013

DAYS Nursing Problems > Chronic pain related to irritation of nerve ending as evidenced by moaning every secretion of blood from the vagina >Fluid volume deficient related to cervical bleeding secondary to cervical cancer as evidenced by

01-04-2013

01-05-2013

01-06-2013

01-07-2013

01-08-2013

***

***

HGB of 56g/L >Activity intolerance related to imbalance between oxygen supply and demand >Ineffective tissue perfusion related to decreased hemoglobin concentration as evidenced by low HGB levels 56g/L

***

***

*** >Risk for impaired skin integrity related to altered circulation and pigmentation as evidenced by the pale palpebral conjunctiva,

***

low HGB levels and pale skin color on palm area Vital Signs Temperatur e T=11-7am: 37 =73pm: 37 =3-11pm: 37.2 PR=11-7am: 80bpm =73pm: 80bpm =3-11pm: 82bpm RR=11-7am: 18bpm =73pm: 20bpm =3-11pm: 22bpm BP=11-7am: 130/70mmHg =7-3pm: 120/60mmHg =3-11pm: 130/70mmHg T=11-7am: 37.2 =73pm: 36.2 =3-11pm: 37 PR=11-7am: 84bpm =73pm: 76bpm =3-11pm: 82bpm RR=11-7am: 22bpm =73pm: 26bpm =3-11pm: 28bpm BP=11-7am: 130/80mmHg =7-3pm: 120/60mmHg =3-11pm: 140/70mmHg T=11-7am: 37 =73pm: 37 =3-11pm: 37.2 PR=11-7am: 74bpm =73pm: 80bpm =3-11pm: 88bpm RR=11-7am: 30bpm =73pm: 30bpm =3-11pm: 26bpm BP=11-7am: 160/100mmH g =7-3pm: 150/80mmHg =3-11pm: 130/60mmHg T=11-7am: 37.2 =73pm: 36.2 =3-11pm: 36.4 PR=11-7am: 76bpm =73pm: 76bpm =3-11pm: 84bpm RR=11-7am: 36bpm =73pm: 32bpm =3-11pm: 30bpm BP=11-7am: 130/90mmHg =7-3pm: 120/60mmHg =3-11pm: 120/70mmHg T=11-7am: 36.2 =73pm: 36.4 =3-11pm: 36.4 PR=11-7am: 60bpm =73pm: 62bpm =3-11pm: 70bpm RR=11-7am: 18bpm =73pm: 20bpm =3-11pm: 24bpm BP=11-7am: 120/60mmHg =7-3pm: 120/60mmHg =3-11pm: 150/70mmHg T=11-7am: 36.8 =73pm: 37 =3-11pm: 37.2 PR=11-7am: 65bpm =73pm: 76bpm =3-11pm: 82bpm RR=11-7am: 20bpm =73pm: 20bpm =3-11pm: 22bpm BP=11-7am: 140/80mmHg =7-3pm: 180/100mmH g =3-11pm: 150/70mmHg

Pulse rate

Respiratory rate

Blood pressure

Diagnostic /

Laboratory Procedures Hematology Test Blood Typing: O Rh: (+) Hemoglobin: 50 g/L Hematocrit: 0.15 g/L WBC count:18.9 Neutrophils: 0.77 x 10^9 g/L Lymphocytes : 0.20 x 10^9 g/L Monocytes: 0.03 x 10^9 g/L Platelet count: 357 x 10^9 g/L Complete Blood Count Hemoglobin:

56 g/L Hematocrit: 0.17 g/L WBC count: 13.8 x 10^9 g/L Neutrophils: 0.84 x 10^9 g/L Lymphocytes : 0.14 x 10^9 g/L Monocytes: 0.02 x 10^9 g/L Eosinophils: 0.00 Basophils: 0.00 Bands: 0.00 Platelet count: 456 x 10^9 g/L

Blood Chemistry Test

Creatinine: 170. 4umol/L SGPT (Glutamate Pyruvate Transaminas e): 3.4 u/L Sodium: 136.3 mmol/L Calcium: 2.93mmol/L BUN (Blood Urea Nitrogen): 10.4 mmol/L SGOT (Glutamic Oxaloacetic Transaminas e): 11.9 u/L HBsAG test Crossmatching Test Potassium: 5.34 mmol/L Non-reactive Compatible

Cervical Biopsy

() No Hemolysis () Final Pathological Diagnosis: Suspicious for small cell undiffentiate d carcinoma. Suggest immunostain s for LCA, CK, NSE and chromograni n Gross Microscopic description: Specimen contains tan brow tissue fragments with an aggregate diameter of 1.5 cm

Medical Managemen t Plain NSS 1L IVFs Plain NSS 1L Plain NSS 1L Plain NSS 1L ---Plain NSS 1L

4U PRBC BTs Diet

3U PRBC

1U PRBC

4U PRBC

4U PRBC Type O

---

Diet as Tolerated

***

***

***

***

***

Nothing Per Orem

**

VII. CONCLUSION AND RECOMMENDATION Tremendous strides have been made in reducing the rate of cervical cancer. However, women continue to be afflicted by a disease that is potentially preventable and curable. The women who remain most susceptible to the development of cervical cancer are those who are lost to screening or who do not receive screening at all. Therefore, family physicians must remain vigilant by screening all appropriate women with routine Pap smears. The key to preventing invasive cervical cancer is to detect any cell changes early, before they become cancerous. Regular pelvic examinations and Pap smears are the best way to do this. How often a woman should have a pelvic exam and Pap smear depends on her individual situation. Because of the rarity of the condition, each case must be managed on its merits with the use of multidisciplinary team. As is known, it is much easier to prevent than to cure a disease. Many lives can be saved if a few simple things are taken care of: carrying a healthy life, making periodic tests to detect disease, and beginning of sexual life at an age appropriate and finding a stable sexual partner. Also, self-treatment is not appropriate for cancer under most circumstances. Without medical treatment, the cancer will continue to grow and spread. Eventually vital body organs will not be able to function properly because the cancer will take their oxygen and nutrients, crowd them out, or injure them. The result is very often death. Although self-treatment is inappropriate, there are things a woman can do to reduce the physical and mental stresses of cancer and its treatment. Maintaining good nutrition is one of the best things a woman can do. We recommend this case study to all students in the health profession, especially to those whose studies are related to the obstetric-gynecological topic that is cervical cancer. We also recommend this to the physicians, nurses and all other members of the health care team who are taking care of patients who have cancer of the cervix. This cases tudy contains information regarding

a certain case of a woman who had just been diagnosed of cervical cancer and was given the initial treatment of blood transfusion. VIII. BIBLIOGRAPHY A. Textbook References/Primary References:

Porth, Carol Mattson. Pathophysiology: Concepts of Altered Health States, 6th Ed. Lippincott- Raven Publishers. P. 1002-1005; 2002 Nursing: Understanding Diseases. Lippincott Williams & Wilkins. p. 112114; 2008 Lippincott Manual of Nursing Practice Series: Pathophysiology . Lippincott Williams & Wilkins. p.426-427; 2007 Nursing 2013 Drug Handbook. Lippincott Williams and Wilkins. 2013

B. Electronic Research/Secondary References:

https://www.novapublishers.com/catalog/product_info.php? products_id=5620 http://www.cdc.gov/cancer/cervical/statistics/trends.htm http://www.vanguardngr.com/2011/09/more-women-are-dying-of-breastcervical-cancers-in-developing-countries-research/ http://www.ecmaj.ca/content/164/7/1017.full http://www.medicalhealthtests.com/articles/376/blood-tests/mchhematology-test.html http://www.surgeryencyclopedia.com/Ce-Fi/Complete-BloodCount.html#b

http://www.ehow.com/how_5771668_interpret-blood-chemistry-testresults.html http://labtestsonline.org/understanding/analytes/hepatitis-b/tab/test http://www.nurseslearning.com/courses/nrp/labtest/course/section4/index .htm http://medicaldictionary.thefreedictionary.com/Blood+Typing+and+Crossmatching http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gynecolog y/cervical_biopsy_92,P07767/ http://www.glowm.com/? p=glowm.cml/section_view&articleid=230#26011 http://www.oralcancerfoundation.org/facts/detailed_biopsy.htm http://nursingcrib.com/medical-laboratory-diagnostic-test/completeblood-count-cbc-normal-values-and-nursing-considerations/ http://wiki.answers.com/Q/Nursing_responsibilities_for_patient_before_an d_after_Complete_blood_count http://www.thirdage.com/hc/p/101091/cervical-cone-biopsy-what-toexpect http://elizarivera.com/Chapter30%20-%20Female%20Reproductive.pdf http://cancer.about.com/od/cervicalcancer/a/preventcervical.htm http://cancer.about.com/od/cervicalcancer/a/cervcancrsympt.htm http://nursingcrib.com/drug-study/tranexamic-acid/ http://www.livestrong.com/article/205546-what-is-the-meaning-of-diet-astolerated/#ixzz2HrjFpShR