I.

INTRODUCTION
This Case Study is focused on the concept of Acute Biologic Crisis. Acute
Biologic Crisis is understood as the turning point of a disease when an important
change takes place, indicating either recovery or death.

Among the cases to chose, from we chose a client with the diagnosis of Diffuse
Large B Cell Lymphoma. It is a type of Non Hodgkin’s Lymphoma specifically of the B
cell wherein cancer develops as the B cell matures.

Internationally, an estimated 14.1 million new cases of cancer occurred

worldwide. Malignant lymphoma encompasses a wide variety of distinct disease entities.
It is generally more common in developed countries and less common in developing
countries. The East Asia region has one of the lowest incidence rates of malignant
lymphoma (Cancer Research UK 2012). The incidence of malignant lymphoma around
the world has been increasing at a rate of 3-4% over the last 4 decades. Nationally,
Cancer remains a national health priority in the country with significant implications for
individuals, families, communities, and the health system. Cancer is the third leading
cause of morbidity and mortality in the country after diseases of the heart and the
vascular system (Philippine Health Statistics 2009). Furthermore, 189 of every 100,000
Filipinos are afflicted with cancer while four Filipinos die of cancer every hour or 96
cancer patients every day, according to a study conducted by the University of the
Philippines’ Institute of Human Genetics, National Institutes of Health. Lastly, locally,
malignant neoplasms of all forms is still the third leading cause of mortality in all ages
(Health Research Priorities by Dr. Victoria Lupase).

Our client presented in this case study is Mr. Roslinda, a 55-year old male in
Cubicle 8 of the Intensive Care Complex at San Pedro Hospital. He experienced loss of
sensorium and was recently diagnosed with Diffuse Large B Cell Lymphoma, Hypoxic
and Metabolic Anemia of Chronic Disease and Mixed Encephalopathy. We chose him
as our client to be presented because his illness puts him at high risk for Acute Biologic
Crisis.
 I believe that this case study in Nursing education impacts greatly on our clinical
reasoning which enhances our ability to develop nursing care plans for our clients with
Acute Biologic Crisis. With Nursing practice, our skills will be honed to deliver our care
plans with the needed care and attention in dealing with patients. Lastly, the
significance of this case in nursing research is that it provides basis in the development
of new interventions and testing its efficacy.

II. GOALS AND OBJECTIVES

GENERAL OBJECTIVE:

That in our 4-week Acute Biologic Crisis Rotation in the Intensive Care Unit of
San Pedro Hospital, we will be able to apply what we learned in real life cases or
situations and execute interventions for clients in Acute Biologic Crisis.

SPECIFIC OBJECTIVES:

To achieve our general objective, we specifically aim to:

A.) choose a client whose case is related to the subject of study,

B.) secure all the consents needed,

C.) explain the purpose of our assessment to the client,

D.) describe the client through a well- written introduction,

E.) formulate specific, measurable, attainable, realistic and time bound objectives,

F.) gather necessary data through an interview that will serve as the baseline
information for the case study,

G.) present the Data Base of the client,

H.) perform a comprehensive cephalocaudal Physical,

I.) define Diffuse B Cell Lymphoma, Hypoxic and Metabolic Anemia of Chronic
Disease

J.) review the Anatomy and Physiology of the Lymphatic System, Immune System,
Nervous System and Skeletal System

K.) trace the pathophysiology of the disease,

L.) justify the Medical management,

M.)formulate a Nursing Care Plans,

N.) present a Discharge Plan,

O.) choose a Nursing Theory appropriate for our client,

P.) supply the references used that helped for the formulation of this case study
following the APA format;

Q.) present the case study in a comprehensive manner.

III. DATA BASE

A. Demographic Data
 NAME: Roslinda, Zosimo

GENDER: Male

AGE: 55 y/o

BIRTHDAY: March 6, 1983

ORDINAL RANK: 3rd out of 4 siblings

BIRTHPLACE: Bohol

NATIONALITY: Filipino

ADDRESS: Park 5 Salvacion Panabo City

RELIGION: Catholic

CIVIL STATUS: Married

SPOUSE: Minda Robin Roslinda

NUMBER OF CHILDREN: 3

EDUCATIONAL LEVEL: College

OCCUPATION: Chemical Engineer

AVERAGE INCOME: Not Disclosed

SOCIAL STATUS: Not Disclosed

B. Clinical Data

CHIEF COMPLAINT: Change in sensorium

DATE OF ADMISSION: August 20, 2018

TIME OF ADMISSION: 4:20 pm

MANNER OF ADMISSION: Per wheelchair

WARD: ICU

ROOM/BED NUMBER: 9
TENTATIVE DIAGNOSIS: Mixed Encephalopathy

Hypoxic and Metabolic Anemia of Chronic C. P

Disease a
s
Diffuse Large B-Cell Lymphoma stage 4 t

ATTENDING PHYSICIAN: Dr. A. Lui H

e
DATE OF DISCHARGE: N/A a
l
FINAL DIAGNOSIS: Diffuse Large B Cell Lymphoma stage 4 t
h

H
istory

The client was delivered via NSVD according to his son. When asked
about his immunizations, his son claimed that he completed it. We checked for
BCG scar and it is present on his right arm. The client is hypertensive but the
date of diagnosis in unrecalled. He was a smoker and can consume 1 pack of
cigarettes per day for 30 years.

D. Present Health History

The client works as a chemical engineer for more than 20 years and was
exposed to different chemicals. On July 2017, he experienced loss of appetite,
weight loss, bloatedness and some epigastric pain. He did not consult this to a
physician and did not take any medication. On November 2017, he experienced
back pain and dysuria. He consulted this and was given medications and was
relieved. On April 2018, he underwent colonoscopy and found hypoplastic polyps.
On May 13,2018, a paravertebral mass was found and underwent a CT guided
biopsy at PGH. On July 2018, he underwent CT scan and saw multipl matted
abdominal lymph adenopathies with vascular encasement and masses on the left
adrenal gland, spleen and vertebral metastases. Four days prior to admission,
the client started having changes in sensorium and decreased level of
consciousness according to his son, which prompted admission.
Family Health History

CR
AR

BR MR SR
ZR
65 60 53
55

Legend:

Paitent Pancreatic Cancer

Girl Lymphoma

Boy Hypertension

Deceased
Narrative
 The client’s grand parents were unrecalled by the client’s son. The client’s
parents are CR and AR. CR died from pancreatic cancer and her wife AR died of
unknown cause. They have four children namely BR, MR, ZR, and SR. They are all still
alive and has currently no known diseases except for our client ZR who has
hypertension and diffused large B cell lymphoma.

IV. DEVELOPMENTAL TASK

Growing is a lifelong progression of physical, behavioral and emotional growth.
Developing a person’s attitude, values and understanding are just part for an individual
to grow. In Robert Havighurst Developmental Task Theory and Erik Erikson
Psychosocial Theory during this process each stage, the person experiences a
psychosocial crisis, which could have a positive or negative outcome of personality
development. A person must go through and achievable different stages for him grow.

Crisis Result Rationale

Generativity vs. Passed our patient’s son verbalized that his

stagnation father income is enough to provide for
their family.

Developmental Task Result Rationale

Achieving adult civic and Achieved ZR achieved his adult civic

social responsibility and social responsibility as
he is an officer in the
Disaster team in their
community.

Establishing and Achieved Client ZR is a chemical

maintaining an economic engineer, work in Saudi
standard of living and Singapore for more
than 20 years. He is also
into farming and cock
 breeding.

Assisting teenage children Achieved They spend their time

to become responsible and together, through visiting
happy adults their farm and sometimes
they being brought to his
workplace as verbalized by
his son.

Developing adult leisure- Achieved Client ZR has a lot friends,

time activities especially in their
community. An active
member of their Chapel as
verbalized by his son JR.

Relating oneself to one’s Achieved Client ZR has been

spouse as a person married for thirty years to
his wife, JR, his son
observed that both his
parents are in a good
relationship, they fight but
manage to talk and solved
their problems

Accepting and adjusting to Partially Achieved We rate him as partially

the physiologic changes or achieved because we
middle age observed that client ZR is
still trying his best to fight
and his family are there
supporting him.

Adjusting to aging parents Achieved It is achieved because our

client’s parent has long
 gone and he was able to
core with the loss as
verbalized by his son JR

V. PHYSICAL ASSESSMENT

General Survey

We conducted the physical assessment of our patient on August 28, 2018 at 8am.
With a body built of endomorph, an estimated body weight of 65 kg. The client was well
groomed but was drowsy. With an NGT French 14 inserted in his right nares. An IVF of
PNSS 1Liter + 60meq KCl @ 80 cc/hour and another line of Dopamine 400/250 @
9.7cc/hour @ right metacarpal vein. PNSS 1l @ 383cc/hour and another line of PNSS
50cc+ Albumin 20cc + Furosemide 100 @ 5cc/hour infusing at his left thumb. A blood
transfusionline of PNSS 1L @KVO rate infusing at his left brachial vein. He also has a
condom catheter attached to a urometer draining clear yellow urine.

VITAL SIGNS RESULT NORMAL RANGE REMARKS

TEMPERATURE 36.7 35.6-37.2 NORMAL

BLOOD 90/60 – 110/80 90/60-130/90 NORMAL

PRESSURE

RESPIRATORY 11-13 12-20 NORMAL

RATE

CARDIAC RATE 90-105 80-120 NORMAL

Skin

Skin is uniform tan in color, smooth and warm to touch with good skin turgor.
Skin is dry with well-trimmed nails and has pale pink nail beds noted. Capillary refill test
done with less than 2 seconds. BCG scar is present at his right arm. Edema on his left
arm with blisters and bipedal pitting edema was also noted. Bed sores on his sacrum
was also noted upon assessment.
Head

The head is rounded, normocephalic with closed fontanelles. The skull is

symmetrical and upon inspection scalp is free from dandruff, lice or lesions and upon
palpation the head has no nodules or masses and depressions. Hair is normal in
distribution. The face of the client appeared smooth with no presence of nodules or
masses. There are symmetric facial features.

Eyes

Eyebrows are aligned with symmetrical movements. Lids are symmetrical and
lashes are curled upward. The lacrimal duct is not inflamed with smooth cornea and
lens and with pale palpebral conjunctiva. The bulbar conjunctiva appeared transparent
with few capillaries evident and sclera appeared white and is anicteric while the pupil is
isochoric. Both eyes are brisk upon reaction to light. The pupils of the eyes are black
and equal in size. The iris is flat and round, PERRLA.

Ears

The pinna of the patient’s ears is symmetrical and its color is uniform with the
facial skin and aligned with the outer canthus of the eye. Tenderness, lesions and
masses were not noted. The pinna recoils after it was folded. Hearing acuity is not good.

Nose & Sinuses

The nose of the patient was at the midline and has the same color with the face.
Discharges, lesions or flaring was not noted and it was non-tender upon palpation.
Nasal septum was in midline. Nasal mucosa was pinkish in color was not swelling.
Maxillary and frontal sinuses were also non-tender when palpated.

Mouth

Patients’ lips were pale in color and dry in texture. The oral mucosa was firm and
moist, without any congenital defects and masses upon inspection. The gums and
buccal mucosa were pinkish in color without ulcerations and lesions. The tongue was in
the midline. The salivary ducts have the same color as the buccal mucosa and floor of
the moth and no inflammation and lesions noted. The soft and hard palate were pinkish
without any lesions noted. The uvula is at the midline. Tonsils were pink in color smooth
with no inflammation noted.

Pharynx
 The uvula is located in the midline, pinkish mucosa and no inflamed tonsils noted
and with positive Gag Reflex.
Neck

Neck muscles were symmetrical. A mass was noticed at the right side of the
midline of the neck near the adam’s apple. Lymph nodes were palpable. Trachea was in
the midline and spaces were equal on both sides. The thyroid gland of the patient was
not enlarged, and Jugular Vein Distention was not present.

Thorax

The thorax was symmetrical, with anterior-posterior transverse diameter ratio of

1:2. The spinal alignment was vertically aligned. There were no bulges and tenderness
noted. There was full and symmetric chest wall expansion upon assessment. Quiet,
unlabored respirations with no use of accessory muscles noted. Upon palpation, tactile

fremitus was normal. There we also no adventitious sound noted upon auscultation.

Heart

The precordium was not having any abnormal pulsation, heaves or lifts upon
assessment. Point of maximal impulse was at the apex of the heart, located at the fifth
intercostal space left of midclavicular line. Distinct S1& S2, Cardiac rate was normal and
regular in rhythm while Pulse was strong, pounding, and regular.

Breast & Axillae

Nipples are equal and brown in color with no obvious difference. No lesions,
masses, and tenderness noted. Both areolas and nipples were darker than the
surrounding skin. The axilla was dry and no discoloration was noted on both axilla, with
hair noted; foul odor, rashes, lesions, and masses were also not observed.

Abdomen

The stomach is intact and globular has an unblemished skin and is uniform in
color. A dressing was noted beside the navel. The abdomen has a symmetric contour.
There were symmetric movements caused associated with client’s respiration. With
normoactive bowel sounds but it was firm and distention was noted upon palpation.
Bladder distention was not noted upon palpation.

Genito-Urinary
 Upon assessment the patient is wearing diaper with a condom catheter attached
to a urometer. The patient’s penis is well developed but has a wound on the shaft. The
Meatus is in the midline but the scrotum was enlarged and with no pubic hair.

Extremities

The extremities are symmetrical in size and length but edema was noted on the
left arm and both legs. The extremities are symmetrical in size and length. The muscles
are not palpable with the absence of tremors.

NEUROLOGICAL ASSESSMENT

The patient was drowsy with GCS of 10. His orientation was not assessed.His
eye opening was to speech and his speech was incomprehensible. He could move his
extremities but with noticeable weakness.

VI. DEFINITION OF DIAGNOSIS

Hypoxic + Metabolic anemia of chronic disease

Anemia of chronic blood disease (ACD) develops because of chronic disorder such as
cancer, infection, inflammation, heart failure, diabetes, and stroke. It is particularly common
among elderly patient, as they often have one or more chronic disease.

Reference: Capriotti, T., Frizzel, J.K(2016) Pathophysiology.F.A Davis Company. Philadelphia

Anemia is a common consequence of chronic disease. The most common chronic

disease associated with anemia are cancer, chronic kidney failure, autoimmune disoreder and
infectious disease. In cancer anemia is reported in 30% to 90 % of patient ( Knight, Wade, &
Balducci,2004). Fatigue and malaise indicative of anemia are sometimes dismissed by health
care providers as psychosocial consequence of chronic disease.

Reference: Hannon, R.A., Pooler, C., Porth, C.M.(2010) Porth Pathophysiology. Lippincott
Williams & Wilkins
 Anemia of chronic disease is seen in the setting of chronic infection, inflammation, or
malignancy. This is characterized by low serum iron, reduced transferrin saturation, reduced
iron binding capacity, reduced red cell survival and inadequate erythropoietin response.

Reference: Wahed, A.,Dasgupta,A.(2015) Hematology and Coagulation: A Comprehensive

Review for Board Preparation, Certification and Clinical Practice. Elsevier Health Science

Encephalopathy

Encephalopathy 1.1% of adults in the general population age 55 years old and above.is
a clinical syndrome of global cognitive impairment characterized by impaired arousal, inattention,
and disorientation. Causes of encephalopathy can be tumor of the central nervous system,
metastatic, and metabolic disturbances.

Reference: Ferri, F.F.(2015) Ferri’s Clinical Advisor 2015 E-Book. Elsevier Health Science

Encephalopathy, the attention and cognitive functions such as perception, thinking and
memory are affected. Alertness tends to fluctuate between agitation and lethargy. Numerous
endogenous conditions, including cancer, nutritional and hypoxic disorder, and fluid and
electrolytes disorder may be responsible for encephalopathy in critically ill patient.

Reference: Baue, A.E., Berlot, B., Vincent, L.J(2013) Sepsis and Organ Dysfunction: The
Challenge Continues

Encephalopathy encompasses a spectrum of neuropsychiatric abnormalities. The

spectrum includes personality changes, impaired mental function, motor abnormalities (asterixis,
tremor, hyperactive reflexes) and altered consciousness.

Reference: Vincent, J.L., Abraham, E., Kochanek, P. etc(2011) Textbook of Critical Care E-
Book. Elsevier Health Science

Diffuse large B-cell lymphoma

lymphoma are solid tumor of lymphoid cells, and the most common type of blood cancer
in the United State, lymphoma falls into two major categories: Hodgkin's lymphoma and Non-
Hodgkin Lymphoma. Non-Hodgkins can be caused by cancerous B-cell, T-cell, or NK cells and
are classified according to cells type and aggressiveness. They usually develop among middle
age and older adults and are 50% more frequent in men than women. Children and young
adults are occasionally diagnosed with NLH; in these patients, the lymphomas are more
aggressive. Stage 4 (widespread or disseminated disease): lymphoma is outside the lymph
nodes and spleen and has spread to another area or organ such as bone marrow, bone, or
central nervous system.

Reference: Capriotti, T., Frizzel, J.K(2016) Pathophysiology.F.A Davis Company. Philadelphia

Diffuse large B-cell lymphomas are heterogenous group of aggressive germinal or post
germinal centre neoplasm. The disease occurs in all age group but is most prevalent between
60 and 70 years of age. The cause of diffuse large B- cell lymphoma is unknown. It is rapidly
evolving, multifocal, nodal and extra nodal tumor.

Reference: Hannon, R.A., Pooler, C., Porth, C.M.(2010) Porth Pathophysiology. Lippincott
Williams & Wilkins

The World Health Organization classification defines diffuse large B-cell lymphoma as a
group of proliferations of large B-cell lymphoid cells with a diffuse growth pattern. DLBCL is the
most common hematopoietic malignancy, accounting for one-third of mature B-cell neoplasm.

Reference: Younes, A., Coiffier,B.(2013) Lymphoma: Daignosis and treatment. Vol.43 of

Current Clinical Oncology. Springer Science & Business Media

VII. ANATOMY AND PHYSIOLOGY

Lymphatic System

The key functions of the lymphatic system:

 Drains excess fluids and proteins from tissues all around the body and returns
them back into the bloodstream.
 Removes waste products produced by cells.
 Fights infections.
  Absorbs fats and fat-soluble vitamins from the digestive system and transports
these into the bloodstream.

Lymph
Lymph is a fluid that circulates throughout the body in the lymphatic system. It
forms when tissue fluids/blood plasma (mostly water, with proteins and other
dissolved substances) drain into the lymphatic system. It contains a high number
of lymphocytes (white cells that fight infection). Lymph that forms in the digestive
system called chyle, this contains higher levels of fats, and looks milky white.

Lymph vessels
Walled, valved structures that carry lymph around the body

Lymph nodes
Small bean-shaped glands that produce lymphocytes, filter harmful substances
from the tissues, and contain macrophages, which are cells that digest cellular
debris, pathogens and other foreign substances. Major groups of lymph nodes
are located in the tonsils, adenoids, armpits, neck, groin and mediastinum.

Thymus
The thymus is a specialized organ of the immune system, located between the
breast bone and heart. It produces lymphocytes, is important for T cell
maturation (T for thymus-derived).

Spleen
The spleen is an organ in the upper left abdomen, which filters blood, disposes
of worn-out red blood cells, and provides a 'reserve supply' of blood. It contains
both red tissue, and white lymphatic tissue. Different parts of the the spleen
specialize in different kinds of immune cells.

The major (encapsulated) lymphatic organs are the lymph nodes, thymus and
spleen. In addition the lymphoid tissues include:

Mucosa-associated lymphoid tissue (MALT)

 These are . These nodules contain lymphocytes and macrophages which defend
against invading bacteria and other pathogens that enter these passages along
with food, air, or urine. These nodules can be solitary or grouped together in
clusters.

Major clusters of lymphatic nodules include:

 Tonsils: these are clusters of lymphatic tissue under the mucous

membrane lining of the nose, mouth, and throat. Lymphocytes and
macrophages in the tonsils provide protection against foreign substances
and pathogens that enter the body through the nose or mouth.
 Adenoids: A cluster of lymphatic tissue that hangs from the upper part of
the back of the nasal cavity. Adenoids get bigger after birth but usually
stop growing by the age of 7. Like the Tonsils, they can be removed
without significantly increased risk of infections.
 Peyer's patches: these are clusters of lymphatic nodules in the mucosa
that lines the ileum of the small intestine. They play an important role in
defending against the large number of pathogens that enter the
gastrointestinal system.

Circulation of tissue fluids

Fluid in the spaces between tissues is called interstitial fluid, or 'tissue fluid'. This
provides the cells of the body with nutrients (via the blood supply) and a means of waste
removal. Lymph is formed when the interstitial fluid is collected through tiny lymph
capillaries (see diagram), which are located throughout the body. It is then transported
through lymph vessels to lymph nodes, which clean and filter it. Lymph then flows on to
the lymphatic ducts, before emptying into the right or the left subclavian vein, where it
mixes back with blood.

Blood is enriched with oxygen (by the respiratory system) and nutrients (by the digestive
system), which are circulated all around the body (by the cardiovascular system). Some
fluid (blood plasma) leaks out into the tissues via tiny capillaries, contributing to
interstitial fluid, which eventually drains back into the lymphatic system.

Immune System

The immune system includes a variety of defenses against viruses, bacteria, fungal
infections, and parasites (such as thread worms). The lymphatic system is part of the
broader Immune System.

Innate immune system

This are the non-specific, unchanging lines of defenses which include:

 Physical and chemical barriers to pathogens.

 Producing cytokines and other chemical factors to recruit immune cells to
sites of infection.
 Activates the complement cascade to identify bacteria, activate cells and
to promote clearance of dead cells or antibody complexes.
 Identifies and removes foreign substances present in organs, tissues, the
blood and lymph, by specialized white blood cells.
 Activation of the adaptive immune system, through a process known
as antigen presentation.

Adaptive immune system

Adaptive (or acquired) immunity is where immunological memory is made after
an initial response to a new pathogen, leading to an enhanced response to future
exposure to that same pathogen. This process of acquired immunity is the basis
of vaccination. This is essential because bacteria and viruses are continually
adapting and evolving in an 'arms race' with our immune systems. Features of
the adaptive immune system include:
  Recognition of specific "non-self" antigens, during the process of antigen
presentation.
 The generation of responses tailored to destroy specific pathogens or
pathogen-infected cells.
 Development of immunological memory, in which each pathogen is
"remembered" by signature antibodies or T cell receptors. These memory
cells can be called upon to quickly eliminate a pathogen should
subsequent infections occur.

Cells of the Immune System

There are many different cell types and sub-types involved in the immune system.
Some of the main types include:

 Lymphocytes: are white cells which circulate between blood and lymph.
They play an important role in fighting infection. There are many kinds of
lymphocytes; the main types are T cells, B cells and natural killer cells.
Lymphocytes initially develop in the bone marrow. Some migrate to the
thymus, where they mature into T cells ; others mature in the bone marrow
as B cells.

B Cell Development

In the bone marrow, the Common lymphoid precursor turns into the Pre-B
lymphoblast then Naive B-cell. The Naive B-cell is then transported to the
Lymph nodes where it becomes a Germinal Cell. These germinal cells or
centroblasts will then be differentiated to a specific type of B cell.

 Neutrophils: are the most abundant type of white blood cells and are an
important part of the innate immune system. Neutrophils are a type
of phagocyte (cells which engulf and then digest, cellular debris and
pathogens). They are normally found in the blood stream, but are quickly
 recruited to the site of injury or infection following chemical signals such as
Interleukin-8.
 Macrophages: are another type of phagocyte and have a role in both the
innate and adaptive immune systems. They attack foreign substances,
infectious microbes and cancer cells. Macrophages also stimulate
lymphocytes and other immune cells to respond to pathogens.
 Dendritic cells: are antigen-presenting cells which act as messengers
between the innate and adaptive immune systems. They are usually
located in tissues in contact with the external environment such as the
skin, linings of the nose, lungs, stomach and intestines. In response to
pathogens they migrate to the lymph nodes where they interact with T
cells and B cells to initiate the adaptive immune response.

Antigens and Antibodies

Antibodies (also known as an immunoglobulins) are Y-shaped proteins produced
by B-cells,that bind to specific antigens on the surface of foreign objects such as
bacteria and viruses. This identifies and 'tags' the foreign object as 'non-self',
signalling other immune cells to attack them.

Hormones and the Immune System

There are several hormones generated by the immune system. These hormones
are generally known as lymphokines. Steroids and corticosteroids (components
of adrenaline) suppress the immune system.

Skeletal System

Vertebrae
Vertebrae are the 33 individual bones that interlock with each other to form the spinal
column. The vertebrae are numbered and divided into regions: cervical, thoracic, lumbar,
sacrum, and coccyx . Only the top 24 bones are moveable; the vertebrae of the sacrum
and coccyx are fused. The vertebrae in each region have unique features that help
them perform their main functions.

Cervical (neck) - the main function of the cervical spine is to support the weight of the
head (about 10 pounds). The seven cervical vertebrae are numbered C1 to C7. The
neck has the greatest range of motion because of two specialized vertebrae that
connect to the skull. The first vertebra (C1) is the ring-shaped atlas that connects
directly to the skull. This joint allows for the nodding or “yes” motion of the head. The
second vertebra (C2) is the peg-shaped axis, which has a projection called the odontoid,
that the atlas pivots around. This joint allows for the side-to-side or “no” motion of the
head.

Thoracic (mid back) - the main function of the thoracic spine is to hold the rib cage and
protect the heart and lungs. The twelve thoracic vertebrae are numbered T1 to T12. The
range of motion in the thoracic spine is limited.

Lumbar (low back) - the main function of the lumbar spine is to bear the weight of the
body. The five lumbar vertebrae are numbered L1 to L5. These vertebrae are much
larger in size to absorb the stress of lifting and carrying heavy objects.

Sacrum - the main function of the sacrum is to connect the spine to the hip bones (iliac).
There are five sacral vertebrae, which are fused together. Together with the iliac bones,
they form a ring called the pelvic girdle.

Coccyx region - the four fused bones of the coccyx or tailbone provide attachment for
ligaments and muscles of the pelvic floor.

Nervous System

Brain
The brain is an organ that’s made up of a large mass of nerve tissue that’s protected
within the skull. It plays a role in just about every major body system.

Some of its main functions include:

 processing sensory information

 regulating blood pressure and breathing

 releasing hormones

Cerebrum

The cerebrum is the largest part of the brain. It’s divided into two halves, called hemispheres.
The two hemispheres are separated by a groove called the interhemispheric fissure. It’s also
called the longitudinal fissure.

Each hemisphere of the cerebrum is divided into broad regions called lobes. Each lobe
is associated with different functions:

 Frontal lobes. The frontal lobes are the largest of the lobes. As indicated by their
name, they’re located in the front part of the brain. They coordinates high-level
 behaviors, such as motor skills, problem solving, judgment, planning, and attention.
The frontal lobes also manage emotions and impulse control.

 Parietal lobes. The parietal lobes are located behind the frontal lobes. They’re
involved in organizing and interpreting sensory information from other parts of the
brain.

 Temporal lobes. The temporal lobes are located on either side of the head on the
same level as the ears. They coordinate specific functions, including visual memory
(such as facial recognition), verbal memory (such as understanding language), and
interpreting the emotions and reactions of others.

 Occipital lobes. The occipital lobes are located in the back of the brain. They’re
heavily involved in the ability to read and recognize printed words, along with other
aspects of vision.

Cerebellum

The cerebellum is located in the back of the brain, just below the occipital lobes. It’s
involved with fine motor skills, which refers to the coordination of smaller, or finer,
movements, especially those involving the hands and feet. It also helps the body
maintain its posture, equilibrium, and balance.

Diencephalon

The diencephalon is located at the base of the brain. It contains the:

 thalamus

 epithalamus

 hypothalamus
The thalamus acts as a kind of relay station for signals coming into the brain. It’s also
involved in consciousness, sleep, and memory.

The epithalamus serves as a connection between the limbic system and other parts of
the brain. The limbic system is a part of the brain that’s involved with emotion, long-term
memory, and behavior.

The hypothalamus helps maintain homeostasis. This refers to the balance of all bodily
functions. It does this by:

 maintaining daily physiological cycles, such as the sleep-wake cycle

 controlling appetite

 regulating body temperature

 controlling the producing and release of hormones

Brain stem

The brain stem is located in front of the cerebellum and connects to the spinal cord. It
consists of three major parts:

 Midbrain. The midbrain helps control eye movement and processes visual and
auditory information.

 Pons. This is the largest part of the brain stem. It’s located below the midbrain. It’s a
group of nerves that help connect different parts of the brain. The pons also contains
the start of some of the cranial nerves. These nerves are involved in facial
movements and transmitting sensory information.
 Medulla oblongata. The medulla oblongata is the lowest part of the brain. It acts as
the control center for the function of the heart and lungs. It helps regulate many
important functions, including breathing, sneezing, and swallowing.

VIII. PATHOPHYSIOLOGY

A. Etiology
Predisposing Factors
Factor Present/Absent Rationale
1. Age Lymphoma is most
common in people over
60. However, some types
are more common in
children and infants.

2. Gender Women are more likely to

develop non-Hodgkin’s
lymphoma.

3. Race White Americans in the

United States are more
likely to develop some
types of lymphoma than
African-Americans or
Asian-Americans.
 4. Family History Passing of defective
genes and adaptation of
lifestyle especially of
immediate family
members.

Precipitating Factors
Factor Present/Absent Rationale
1. Exposure to Have carcinogenic
certain chemicals agents that can transform
and drugs proto-oncogenes to
(nicotine, oncogenes.
insecticides,
herbicides)
2. Radiation Have carcinogenic
agents that can transform
proto-oncogenes to
oncogenes.

3. Weakened Weakened thus more

immune system susceptible to mutation.
(HIV)
 4. Autoimmune Anomalies of the cell
Disease make it more at risk of
mutating

5. Viral Infections Destroys cells which

(HIV, EBV) makes them more
susceptible to mutation

B. Symptomatology
Symptom Present/Absent Rationale
1. Painless, swollen Infiltration with malignant
lymph nodes cells (metastases)
brought to the node with
the lymph flowing from
an area
2. Abdominal pain Lymphomas that start or
grow in the abdomen
(belly) can
cause swelling or pain
in the abdomen. This
could be from lymph
nodes or organs such as
the spleen or liver
enlarging, but it can also
 be caused by the build-
up of large amounts of
fluid.
3. Loss of appetite An enlarged spleen
might press on the
stomach, which can
cause a loss of
appetite and feeling full
after only a small meal.
4. Persistent fatigue Malignant cells make use
of the body’s energy
supply to proliferate

5. Fever It is because of a release

of chemicals into the
blood that raise your
body temperature
(similar to when you
have an infection)

6. Night sweats
It is the body’s reaction
to your temperature
rising to above a normal
level (fever). Night
sweats may also be a
response to some of the
abnormal hormones and
proteins produced by the
lymphoma cells.
 7. Unexplained Malignant cells make use
weight loss of the body’s energy
supply to proliferate

C. Schematic Diagram
Predisposing Factors Precipitating Factors

 Age  Exposure to
Carcinogenic
 Gender chemicals
agent
 Race  Radiation
 Family History  Autoimmune
Normal B-cell Disease
 Weakened immune
system
DNA damage
 Viral infection

Activation of growth Inactivation of tumor Alteration in genes that

promoting oncogenes suppressor cells control apoptosis

Cell mutation

Fatigue and weight Mutated B-cells

loss are vascularized
Enlarged lymph
Invasion into lymph nodes nodes and epigastric
and blood vessels pain (splenomegaly)

Transportation and with

other blood elements

Arrest in capillary
bed of organs

Adherence of
cancer cells

Escape from
vessels
 Establish microenvironment
and growth into organ

Brain Bone

Impaired brain
function Vertebrae (T11, Bone marrow
T12, L1
Encephalopathy Reduced
DOB, impaired production of RBC
bladder and bowel and WBC
Changes in
movement
sensorium and
seizures

Hypoxia Infection

Shock Sepsis

If treated If not treated

Maintenance of Multiple organ

physiological failure

Poor prognosis Death

D. Narrative

The predisposing and precipitating factors will lead to the exposure of the cell, in
this case, the B-cell, to carcinogenic agents. These carcinogenic agents will then cause
DNA damage which will result to activation of growth promoting oncogenes, inactivation
of tumor suppressor genes and alteration in genes that cause apoptosis. This will then
cause the B-cell to mutate. These mutated B-cells will then be vascularised and
eventually invade into the lymph nodes and blood vessels. This causes swelling of
lymphnodes and epigastric pain because of the splenomegaly. Once these mutated B-
cells invade the lymph nodes and blood vessels these becomes a medium of
transportation to them thus they are able to interact with other blood elements. They will
then arrest in capillary beds of a random organ and adhere to the cells of these organs.
Once they escape from vessels they can finally establish a microenvironment and
growth in the organ into metastases. In our patient’s case, his lymphoma has
metastasized to the bone specifically the vertebrae as well as the brain but it has not yet
been confirmed. Bone metastasis can result to different dysfunctions depending to
where the metastasis is but in our client’s case the metastasis has lead to the bone
marrow being unable to produce enough RBC and WBC as evidenced by his laboratory
exams. The low RBC can put the patient at risk for hypoxia and eventually shock while
the decreased WBC can put him at risk of infection, especially pneumonia, and
eventually sepsis. Metastasis to the vertebrae specifically T11, T12 and L1 can also
cause difficulty of breathing, impaired bowel or bladder function because they play a
part in these physiological processes. On the other hand, brain metastasis, which has
not yet been confirmed, could cause brain damage which leads to encephalopathy and
is manifested through our client’s change in sensorium and seizures.

IX. MEDICAL ORDER

August 20, 2018 Pls. admit under Dr. Lui
 Secure consent
 DAT
 PNSS1L @ 140 cc/hour fast drip
200 cc now
  VS every 4 I&O every shift
 Labs
1. CBC, blood type now
2. Creatinine now
3. Electrolytes + Mg now
4. Albumin now
5. CBG now
6. ECG now
7. Blood CS x2 site now
8. VA once
9. Chest x-ray AP
10. ABG with electrolyte
 O2 at 2L/min nasal cannula
 Secure 2 units blood
 Transfuse once available after
cross matching
 Increase IV rate to 160cc/hour
 Please facilitate movement of
blood transfusion and transfuse
once available
August 21, 2018

8 am Conferred with Dr. Lui

 Repeat serum creatinine + ionized
calcium
 Refer ionized calcium, do serum
calcium

12:20pm  Repeat creatinine as ordered

 Review of PNSS1L x 6 hour,

 please give furo 40 mg IV after
every cycle of PNSS

 Facilitate blood transfusion of at

least 2 units pack RBC

 Fast drip 500cc

 Repeat serum creatinine and

calcium
 Albumin 20 % 50 cc IV infusion
every 12 each for 4 hours
 For pre & post albumin and BT
assessment
 For close I & O monitoring
 Decrease IVF to KVO rate on BT
 For assessment prior to increase
VS every hour for now
 I&O every 4 hour
 Hydration round every 4 hour
 Increased IVF rate 160cc/ hour x 4
hours
 Fast drip 200cc now and recheck
BP
 Maintain IVF at 160cc/ hour after
fast drip x 4 hours then reassess
 May proceed with BT of available
pack RBC

 Decrease IVF to KVO while in BT

3:45 pm

10:30 pm

August 22, 2018

3am  Facilitate repeat serum creatinine

this 5 am

5am  Follow up s. electrolyte and s.

creatinine result this 6:30am

 Strictly no dairy in diet

 No food supplements
 IVF rate of PNSS of 160cc/hour
7:57am
decrease D5W to KVO
 Reassess after 1 hour
  May give furo 40 mg IV now
 Increase IVF PNSS to 160cc/ hour

 Facilitate Blood Transfusion

8am
 Decrease IVF to KVO once
ongoing Blood Transfusion
 For post BT assessment
 Measure I & O accurately

3pm
 Continue hydration at 110cc while
not hooked to BT
 Discontinue KCl tab confirmed by
Dr. Leano

 Increase IVF rate to 200 cc/hour

3:45 pm

 Fast drip 200cc now and recheck

blood pressure
 Maintain IVF at 160cc/hour after
fast drip x 4 hours then reassess
  Facilitate giving furo, may give furo
as long as systolic BP >100
7:30 pm
 Dr. Jen Togonon (nephron) pls.
refer
 Nephrology
1. Repeat electrolyte today STAT
10:30pm include Mg
2. Strict I&O every shift
3. Increase IVF rate to 180cc/ hour
4. Get full minute of heart rate
5. Reassess IVF after
 For repeat serum creatinine

 Start D5H2O 40cc/hour as side

drip then give furo IVTT

 Repeat serum Mg

 Include serum creatine

11:20 pm

August 23, 2018

11:45  Repeat serum creatinine

August 24,2018

5am  Please insert 3-way catheter

 Repeat s. creatinine and calcium
conferred by Dr. Lui

 Conferred Dr. Leano

6am
 Monitor I & O accurately

 Rounds with Dr. Hereda

 Suggest to hold Bisulfate for now

9am due to worsening of renal function

 Maintain hydration

 Please insert NGT and start OF

feeding

 Maintain IVF at 300cc

Conferred with Dr. Lui

 Dr. Roa out please refer to Dr.

 Brato for evaluation

August 25, 2018

 Maintain 300cc x 4
 Start OF 2,00 kcal/ day
 Conferred with Dr. Lui
 Please carry out Dr. Brato suggest
 For repeat chest x-ray today
 CBG every 8 hour

 Albumin 20% 50 cc + Furo 100g +

PNSS 50 cc at 10cc/ hour

10:10
 Discussed the need of internal
jugular catheter insertion for
adequate hydration and
monitoring, possible for
hemodialysis

 Please transfer service back to Dr.

Leano

 For serum ionized calcium – HOLD

 Continue albumin at 10 cc/hour

 Maintain IVF rate of 300cc
reassess 2 hours after
9:45 pm

ICU

August 26, 2018

9:30 Rounds with Dr. Leano

 Transfer patient to ICU

 Please transfer patient to ICU

9:41
 Secure consent

 Monitor every hour

 O2 at 3L/ min via nasal cannula

 OF 2,000 kcal

 Still for stool exam x 3

 Follow-up serum electrolyte + Mg

 1. PNSS1L at 340cc/ hour
2. PNSS 50 cc + Albumin 20
% 50 cc + Furo 100mg at 5
cc/hour
3. D5W500 at KVO
 CBG every 8 hours
 Will inform for Dr. Lui, Leano

August 27, 2018

12:50 am  Shift D5W500 to PNSS1L + 60

meq KCl at 80 cc/hour
 Decrease PNSS to 280 cc/ hour
 Review of IVF
1. PNSS at 280cc/hour
2. PNSS + 60 meq KCl at 80
cc/hour
3. PNSS + Albumin 20 % 50
cc + furo 100mg at 5 cc/
hour
4. Cumulative of 367.4 cc/
hour
5. Dopamine 400/250 at 1
mkd (2.4 cc/hour)
 Start MgSO4 500 mg + 30 cc
PNSS slow IV push every 6 hours
x 2 doses

8am
 Increase O2 4L/ min via nasal
cannula
9:30
 Repeat CBC
 Discontinue Dexamethasone oral

2:30pm  For repeat serum potassium and

calcium

3pm  Blood CS x 2 sites now

 Sputum GSCS

 Dr. Lui informed and updated

 Secure 1unit pack RBC of patient

blood type and transfuse once
properly cross match

Rounds with Dr. Leano

 For routine ionized calcium

tomorrow
 Increased cumulative IVF
400cc/hour
 For serum electrolyte + Mg at 12
noon tomorrow ( routine)
5:30pm  Hold repeat serum potassium and
calcium tomorrow
  Do serum electrolyte as ordered

Conferred with Dr. Leano

 Hold ionized calcium

7pm

August 28, 2018

4am  Please shift to calcium/ dairy free

OF
 Free water flushing of 140cc
 Repeat serum sodium at 12pm
today

7am  Transfuse 1unit pack RBC at 12

noon after repeat sodium is
extracted

 Pre & post BT assessment

Rounds with Dr. Togonon

2pm  May transfuse available blood unit
available as ordered
 Agree with repeat serum creatinine
Review of fluids
 1. Dopamine 400/250 at 5 mkd (12.2
cc/ hour)
2. PNSS at 383cc/hour
3. PNSS 50cc + 20% albumin +
100mg furo at 80cc/ hour
4. PNSS at KVO (10 cc/hour)
Total: 413.2 cc/hour
 Plan to decrease IVF rate to 250
cc/hour if okay with AP
 Continue free PO flushing 140 cc
every hour until further order
 Repeat serum sodium tomorrow
am include CBC

9:30 pm

Conferred with Dr. Togonon

 Decrease IVF cumulative rate to
300
 Increase Furo drip to 10 cc/hour

10pm

August 29,2018

8:18am  Repeat serum sodium at 12 noon

 Continue free H2O flushing until 12
noon
Rounds with Dr. Lui
9am  Include serum albumin in next
blood extraction
 Bed sore precaution
Conferred with Dr. Togonon
 Revise free H2O flushing to 130 cc
q hourly for 10 hours
10:04am  Include serum calcium in next
blood extraction
 Decrease IVF cumulative rate to
200cc/hour
Confirmed with Dr. Togonon
 Decrease IVF rate to 140 cc/ hour
 Repeat serum calcium tomorrow

Rounds with Dr. Togonon

 Free water flushing 200 cc now per
6:20 pm NGT
 Cycle albumin cocktail

8pm

August 30, 2018

6:30am  Include repeat serum potassium in

 today’s blood extraction
 Decrease O2 at 2L/ min via nasal
cannula, maintain O2sat > 95%
9am  Maintain IV cumulative rate of
140cc/hour

Rounds with Dr. Lui

 May not reinsert NGT
 May have soft diet
9:49am
 Ready for transport to room of
choice

 Start KCl DRIP 40 meq KCl +

PNSS at 80cc/hour x 2 cycle

 Repeat serum potassium after 2nd

10:14 am cycle

 Maintain IVF cumulative rate of

140cc/hour

Conferred with Dr. Leano

 For correction of hypokalemia – no
clearance nephron
 Observe strict aspiration
precaution

Rounds with Dr. Togonon

 Add 6 scoop of Beneprotein to

10:22 lugaw/ rice per meal

4:30pm

August 31, 2018

7am  Include CBC in today’s lab

 Incorporate 100mg Furo + albumin

10am drip at succeeding drops at
10cc/hour

 New prep. 200mg Furo + 1 vial

albumin + 50 cc PNSS at 10cc/
hour

 Facilitate repeat serum potassium

post 2nd unit KCl drip as ordered

 Decrease furo to 5cc/hour

Conferred with Dr. Leano

11am
 Decrease IVF to 80cc/hour,
incorporate 40 meq KCl to present
fluid
 Repeat serum electrolyte with Mg
11:55 tomorrow AM include CBC, SGPT,
 APTT
September 1,2018

5:45am  Maintain albumin and Furo cocktail

at 5cc/hour
 Maintain BP >100/60

Rounds with Dr. Leano

 Include serum creatinine in lab.
1:30 pm today

 Continue KCl drip x 2 more cycle

2pm  MgSO4 2g + 20cc D5W x 24 hours

 Repeat potassium and Mg

 Cranial CT-Scan with contrast now

 Increase cumulative to 180cc/hour

 Creatinine 48 hours post scan

2:45 pm

9pm

September 2,2018

6am  Creatinine 48 hours post CT Scan,

include CBC, Sodium, Potassium,
Magnesium, Calcium, Albumin
  Chest X-ray tomorrow
 Insert NGT, start of 2000 kcal in 7
divided feeding

 Electrolyte and Mg now

 Include ammonia in next blood

10am extraction – hold

 Delay electrolyte and Mg

12
Rounds with Dr. Togonon
 Add 6 scoops of Beneprotein to
feeding

6:30pm

September 3, 2018

6am  Labs for today CBC, serum

electrolyte + Mg, albumin,
creatinine and Chest X-ray

Round with Dr. Leano

11:20am
 ABG now

Dr. Anuta informed

 Secure 1 unit of pack RBC of
1:35pm patients blood type and transfuse
 once available

 Secure clearance from all services

for lumbar tap

2pm
 For bleeding and clotting time

2:40pm

September 4, 2018

12:40  PBS smear

 CBG to BID

Rounds with Dr. Anuta

 If lumbar puncture can’t be done
1pm
 For cranial MRI + contrast
 CBC with pH count now

 Facilitate cranial MRI with contrast

 Secure 1 unit pack RBC of patient

3:25pm blood type transfuse after proper
cross matching with same BT
order
5pm
 FOBT

 Increase albumin + Furo to

 10cc/hour

 IVF cumulative at 40cc

September 5, 2018

7:15 am Rounds with Dr. Lui

 For MRI today
 Trans out to room per request

Rounds with Dr. Leano

 Remove catheter
11:45 am  For transfer to private room

Procedure

Capillary blood glucose Blood glucose monitor blood glucose

changes, testing allows for quick
response to high blood sugar or low blood
sugar

Arterial Blood Gas ABG is done for our client, mainly to

evaluate gas exchange and to determine
the acid-base level of the blood.

Electrocardiography Routinely used to assess the electrical

 and muscular function of the heart

Blood Transfusion Blood transfusion is performed to client

ZR to treat anemia and to make sure that
there is enough oxygen.

Foley Catheter catheterization is a medical procedure

used to drain and collect urine from the
bladder. It is inserted to our client to
prevent urinary retention and measure
accurately his output.

Nasogastric Intubation Used for feeding and administering oral

drugs.

Peripheral Blood Smear The Peripheral Smear test is done for our
client to measure the level of Parasite
Growth in the blood and also to detect
Anemia and Blood Cancer

Magnetic Resonance Imaging A scanning technique for creating

detailed images of the internal body
structure and to measure brain structure
and function

Intake and Output Fluid balance monitoring is the recording

of intake and output of fluid. These
measurements are important to help
evaluate client ZR fluid and electrolyte
imbalance, to suggest various diagnoses
and allow prompt intervention to correct
any imbalances.

Vital Sign Monitoring the pulse, respiratory rate,

 blood pressure, and temperature are
essential to us in identifying deterioration
in our client

X. Medical Management
A. Actual Diagnostic and Laboratory Tests

Hematology – These are series of tests of the peripheral blood that gives information
about the hematologic system and many other organ systems. This test may be
particularly helpful in determining whether you have too few red blood cells, which
causes anemia.

Nor Result
Result Interpretation/
Compon mal (09-05- Nursing
Rationale (08-20-
ent Ran 18) Significance Responsibilities
18)
ge

‘This is a Prior:
test to
Low  Explain the
measure
the total -A Low purpose and

amount of hemoglobin what to

level expect.
hemoglobi
indicates
n, and thus  No food or
Hemoglo anemia,
120- 83 g/L 110g/L recent fluid
the iron
bin hemorrhage,
160 restrictions.
status and
g/L or fluid
oxygen-  Check the
retention,
carrying causing doctor's
hemodilution order.
capacity of
the blood During:
 The red  Do not take
blood cell the blood
count is an sample from
important hand or arm
test with
Low
because receiving
the number -A depressed IVF.
4.0-
Red of red count may  The
5.0 indicate
Blood blood cells 3.2710^ tourniquet
10^ 12/L 3.9710^ anemia, fluid
Cells (RBCs) overload, or should be
12/L 12/L
you have hemorrhage less on a
can affect beyond 24 minute.
hours
how much  Do not
oxygen squeeze the
your punctured
tissues site rightly.
receive.  Wipe away
the first drop
Mean
of blood.
Corpuscula
After:
r
Hemoglobi  Label the
n. The Low specimen.
MCH 28- MCH test  Secure the
33 measures 25.4 pg -A Low MCH results.
pg level may
the amount indicate  Note for
27.8 pg
of anemia inflammation
hemoglobi of punctured
n in the site.
average  Render
red blood health
 cell. teachings
such as to:
Mean
a. eat
Corpuscula
foods
r Volume.
rich in in
The MCV
In Aug. 20 iron, folic
test
82- the result is acid or
MCV measures 77.6 fl low which
98 fl vitamin
the size of 84 fl indicate
anemia B12 such
the
as green
average
leafy
red blood
vegetabl
cell.
es,
Mean seafood
Corpuscula and
r beans.
Hemoglobi
n
Concentrat
ion. In Aug. 20
the result is
33- Measures
Decreased
MCHC 36 average which
32.7
g/L hemoglobi g/L Indicates
31 hemoglobin
n
g/L deficiency
concentrati
on within
100ml or 1
dl of
packed
RBCs
 It is used
to detect
infection or
inflammati
4.8-
White on and to
10.8 6.3
Blood monitor a Normal
10^ 10^9/L 7.7
Cells client’s 10^9/L
9/L
response
to adverse
effects of
therapies.

These High
neutrophils
89% - If a person
are an
has
integral heightened
part of our levels of
immune neutrophils in
their body,
system the disorder
and is known as
through a neutrophilic
Neutroph 40- leukocytosis.
process 62%
il 70% This condition
called is a normal
chemotaxis physical
response to
, they
an event,
reach any such as
place infection,
injury,
where an
inflammation,
infection some
has medications,
occurred. and certain
types of
 leukemia
 Neutrophil
s are
powerful
white
blood
cells that
destroy
bacteria
and fungi

This test
measures
the number
4%
of
lymphocyte
s (a type of Low
decrease
white blood
lymphocyte
cell) in counts can
blood. It is occur after a
Lymphoc 19- cold or
used to 21%
yte 48% another
evaluate infection, or
and be caused by
manage intense
physical
disorders
exercise.
of the
blood or
the
immune
system.

Monocyt 3- A second 16% High

-It indicates
 e 9% line of that An
defense, increased
number of
increasing
monocytes in
in chronic the blood
infections. (monocytosis)
occurs in
Monocytes
response to
are chronic
responsibl 6% infections, in
autoimmune
e for
disorders, in
attacking blood
and disorders,
breaking and in certain
cancers.
down
germs or
bacteria
that enter a
person's
body.

Low
 Phagocyti
c, destroy -may be
antigen- decreased by
stress
antibody response;
Eosinoph 2- complexe due to
1% trauma,
il 8% s before shock, burns,
they can surgery,
harm the mental
distress,
body. Cushing's
Eosinophil Syndrome
s are
responsibl
 e for
destroying 1%
parasites
and
cancer
cells, and
they are
part of an
allergic
response.
A type of
WBC that
fights
parasitic
0-
reactions,
Basophil 0.5 0% Normal
prevents
%
blood clots, 0%
mediates
allergic
reactions.

The
hematocrit
shows the Low

0.37 oxygen-
-Low
Hematoc - carrying Hematocrit
capacity of 0.25% suggests
rit 0.45
anemia,
% the blood.
hemodilution,
This value or massive
also tells blood loss
whether
the blood
 is too thick
or too thin.

Useful as a
measurem
ent of red
blood cells
only if the
hydration
of the 0.33%
client is
normal.

A platelet
count may
be used to
screen for
or 38
10^9/L
diagnose
various

150- diseases Low

Platelet 400 and 158
conditions - it indicates
Count 10^ 10^9/L thrombocytop
9/L that affect enia
the number
of platelets
in the
blood. It
may be
used as
part of the
workup of
 a bleeding
disorder, b
one
marrow
disease,
or excessiv
e clotting
disorder, to
name just
a few.

Chemistry (Serum Creatinine, BUN, Sodium, Potassium, Calcium, Albumin)- it can

help determine if there's an electrolyte imbalance in the body

Componen Normal Result Result Nursing

Rationale 09/03/18 Responsibilties
ts Values 8/23/18

The Prior:
kidneys
129.38  Explain the
49.0-115.0 maintain
Creatinine umol/L procedure.
umol/L the blood
increases  Explain the
creatinine
purpose and what
in a
to expect.
normal
 range.  No food or fluid
Creatinine restrictions.
has been  Check the doctor's
found to order.
be a fairly  Notify the
reliable laboratory and
indicator 98.93 physician of
of kidney umol/L medications the
Normal
function patient is taking
that may affect test
results; they may
be restricted.
During:

 Do not take the

blood sample from
hand or arm with
receiving IVF.
 The tourniquet
should be less on
a minute.
 Do not squeeze
the punctured site
tightly.
 Wipe away the first
drop of blood.
After:

 Label the
specimen.
 Secure the results.
 Note for
 inflammation of
punctured site.
 If a hematoma
develops at the
venipuncture sire,
apply warm soaks.
 For hypokalemia,
encourage the
patient to eat
foods rich in
potassium such as
banana and green
vegetables
 For high
creatinine, instruct
patient to limit
foods rich in
sodium and
phosphorus.
 For low calcium,
encourage patient
to eat foods rich in
calcium and
vitamin D
For low albumin,
encourage patient to
eat foods rich in
protein such as nuts,
egg, and dairy
products.

Sodium Sodium 136

136-145
testing is mmol/L
 mmol/L a part of Normal
the
routine
lab
evaluation
of most
people as
part of an
electrolyte
panel or a
basic
metabolic 144
mmol/L
panel. Normal
These
may be
ordered
during an
annual
physical
or when
someone
has non-
specific
health
complaint
s.

Your 3.3
3.6-5.1 doctor mmol/L
Potassium
mmol/L may want decreased

you to get Potassium

 a blood level may
test to indicate
check for kidney
potassium disease and
levels if diabetic
4
she ketoacidosis
mmol/L
suspects Normal
you’re
having
health
issues like
kidney
disease,
high blood
pressure,
diabetic
ketoacido
sis (a
serious
complicati
on of
diabetes),
any
condition
treated
with
diuretics
(drugs
that force
the body
to shed
 water and
sodium
and cause
you to
pee a lot

 To
evalua
te
endocr
ine
2.96
functio
mmol/L
n,
Decreased
calciu
m - A low
metab calcium 1.94
olism, level may mmol/L

2.12-2.52 and result from

Calcium acid- a problem
mmol/L
base with the
balanc parathyroid
e. glands, as
 To well as from
guide diet, kidney
therap disorders,
y in or certain
patient drugs
s with
renal
failure,
renal
 transpl
ant,
endocr
ine
disord
ers,
cardia
c
diseas
e and
skeleta
l
disord
ers.

To
evaluate
the level
of
magnesiu 0.73
(aug 20, 0.68
m in your
mmol/L
blood and 2018)
Magnesiu 0.74-1.03 to help mmol/L decrease
m mmol/L decrease it
determine
indicates
the cause it indicates
damage
of damage kidneys
abnormal kidneys

levels of
magnesiu
m, calciu
m and or
 potassium

amount
of this
21 g/L
protein in
- Low
the clear albumin
liquid levels
can also
portion of
be seen
the blood in
inflammat
ion,
shock,
and
malnutriti
on. They
may be
August seen with
29,2018 condition
35-50g/L s in
Albumin 17.56g/L which the
decrease body
does not
properly
absorb
and
digest
protein,
such as
Crohns
disease
or celiac
disease,
or in
which
large
volumes
of protein
are lost
 from the
intestines

To detect
an
elevated
level of
ammonia
in the
Sept 2 2018
blood; to
41.30umol/L
help
High
investigat
elevated
e the
level of
cause of
11-32 ammonia in
Ammonia changes
umol/L the blood
in
that may be
behavior
caused by
and
severe liver
conscious
disease ,kid
ness; to
ney failure
support
the
diagnosis
of
hepatic en
celopathy

Procalcito
nin is a 0.19
Procalciton Normal
<0.5 ng/ ml substance
in
produced
by many
 types of
cells in
the body,
often in
response
to infectio
ns but
also in
response
to tissue
injury

Urinalysis – reveals a significant amount of preliminary information about the kidneys

and metabolic processes

Date component Normal Interpretation Nursing

Range Rationale Result and Responsibili
Significance ties

August  Explain
21, Urine flowcytometry to the
2018
patient
The number High about
of WBCs in
An increased the test,
urine
0-17 sediment is number of its
WBC normally low 45 ul WBCs seen in
uL purpose
WBCs can be the urine under
a microscope and how
a
contaminant, and/or positive it is
such as test for
 those from leukocyte done.
vaginal esterase may • Inform
secretions indicate an
the
infection or
inflammation patient
somewhere in that the
the urinary tract
test will
Normally, a Collecting of
few RBCs urine
0-11
RBC are present in 30 ul High specimen.
uL
urine -Do it mid
sediment stream
clean catch.
Normally, in
men and
Follow up
women, a
the
few epithelial
cells can be
found in the
urine
sediment. In
urinary tract
0-11 conditions 5 ul Normal
Epith. cells
uL such as
infections,
inflammation,
and
malignancies,
an increased
number of
epithelial
cells are
present.

Casts are
cylindrical + coarse
cast 0-1 particles 1 Granular,
sometimes Hyaline
found in urine
that are
 formed from
coagulated
protein
released by
kidney cells.

In healthy
people, the
bacteria 0-111 9 Normal
urinary tract
is sterile

Physical Exam

Normal urine
color is due
to the
presence of a
Yellow pigment
(light/pale called
color to urochrome. Yellow Normal
dark/deep Urine color
amber) varies based
on the urine
concentration
and chemical
composition.

Hazy It is observed in
patient who
Clear or have UTI,Lesion
Clarity
cloudy of kidney,
urethra and
Gouty Arthritis

Reaction 4.5-8 5 Normal

This test
simply
Specific 1.005- indicates how
gravity 1.025 concentrated
the urine is
and reflects
 the hydration
status of the
client. 1.015 Normal

Chemical Analysis

Glucose is
normally not
present in
urine. When
Glucose glucose is negative Normal
present, the
condition is
called
glucosuria.

The protein
test pad
provides a -this is often a
rough sign of kidney
estimate of disease.
the amount of Healthy kidneys
albumin in do not allow a
the urine. significant
Albumin amount
makes up of protein to
protein about 60% of Tace pass through
the total their filters. But
protein in the filters damaged
blood. by kidney
Normally, disease may
there will be let proteins such
no protein or as albumin leak
a small from the blood
amount of into the urine.
protein in the
urine.
 Arterial Blood Gas can be used to assess gas exchange and acid base status and can
determine electrolytes level

Componen Normal Nursing

Rationale
Date t Range Result Responsibilities

08/29/18 Pretest
pH is a
measurement  Explain
7.57
of the the test
this may
7.35- acidity/alkalinit procedur
PH indicate to
7.45 y of the blood, e and
kidney failure,
reflecting the the
UTI,
number of purpose
Respiratory
hydrogen ions of the
Alkalosis and
present. . test.
Vomiting
 Assure
pCO2 (partial
the
pressure of 35 mmhg
patient
carbon Normal
that
dioxide) reflect
arterial
35-45 s the amount
puncture
PCO2
mmhg of carbon
is similar
dioxide gas
to other
dissolved in
blood
the blood.
tests
she or
he might
80-100 PO2 (partial
have
PO2 pressure of
mmhg had.
oxygen) reflect
 s the amount
of oxygen gas Intratest
dissolved in
 .Adhere
the blood. It 56.7 mmhg
to
primarily Low
standar
measures the
d
effectiveness
precauti
of the lungs in
ons.
pulling oxygen
into the blood
Posttest
stream from
the  Monitor
atmosphere. the
punctur
Bicarbonate is
e site
a primary
every 5-
substance that
10min
influences the
for at
acid-base
32.6 least 30
balance of
mmol/L min
body fluids. It
high followin
21-28 is considered
HCO3 g the
mmol/L a strong buffer
test for
when
bleeding
examining the
.
arterial gases
 Check
and is an
for signs
accurate
of nerve
indicator of the
impairm
conditions
ent
involving the
 regulation of distal to
the pH of the the
body fluids. punctur
e.
Total CO2
 Apply
content is a
pressur
measurement
e for at
of all the CO2
least 5-
in the blood.
10 min
23-30 33.7
TCO2 to the
mmol/L Most of this is
mmol/L
in the form of arterial
High
bicarbonate punctur
(HCO3), e site.
controlled by  Explain
the kidney. that
some
Base
bruising,
excess (BE) is
discomf
the mmol/L of
ort, and
base that
swelling
needs to be 10.7 mmo/L
may
(-2)–(+2) removed to high
B.E. appear
mmol/L bring the pH. It
at the
is used as an
site and
indicator of the
that
degree of
warm
metabolic
moist
disturbance.
compre
Oxygen sses
70-
O2 Sat. saturation can
100%
(SO2) measur alleviate
 es the this.
percentage of 93 %  Monitor
hemoglobin normal for signs
which is fully of
combined with infection
oxygen. .

Sodium
testing is a
part of the
routine lab
evaluation of
most people
as part of an
electrolyte
panel or a 129
basic mmol/L
138-146
Sodium metabolic Low sodium
mmol/L
panel. These may indicate
may be endocrine or
ordered during metabolic
an annual disorders
physical or
when
someone has
non-specific
health
complaints.

3.5-4.5 Your doctor

Potassium 3
mmol/L may want you
mmol/L
to get a blood
 test to check decreased
for potassium
Potassium
levels if she
level may
suspects
indicate
you’re having
kidney
health issues
disease and
like kidney
diabetic
disease, high
ketoacidosis
blood
pressure,
diabetic
ketoacidosis
(a serious
complication
of diabetes),
any condition
treated with
diuretics
(drugs that
force the body
to shed water
and sodium
and cause you
to pee a lot

To evaluate 1.63 mmol/L

1.15- endocrine high calcium

Calcium 1.33 function,

mmol/L calcium
metabolism,
and acid-base
 balance.

Glucose Is 105 mg/dl

carried to the high glucose
74-100 blood stream
Glucose
mg/dl to provide
energy to all
cell

The
hematocrit
shows the
oxygen-
carrying
capacity of the
blood. This
value also tells
whether the

Hct 38-51 % blood is too 24 %

thick or too low
thin.

Useful as a
measurement
of red blood
cells only if the
hydration of
the client is
normal

cHgb 12-17 Chromogranin 8.2 g/dl

 g/dl B is a low
emerging
biomarkers for
in heart failure
patient

To help 1.65 mmol/L

0.56-
investigate the high
LAC 1.39
cause of a
mmol/L
blood clot

The kidneys 1.96 mg/dl

maintain the high creatinine
blood level signifies
creatinine in a impaired
normal range. kidney
0.51-
Creatinine has function or
Creatinine 1.19mg/
been found to kidney
dl
be a fairly disease
reliable
indicator of
kidney
function.

Component Normal Rationale

Date Result
 Range

09/03/18 pH is a measurement of
the acidity/alkalinity of
PH 7.35-7.45 the blood, reflecting the 7.43
number of hydrogen Normal
ions present. .

pCO2 (partial pressure

of carbon 39.5 mmhg

dioxide) reflects the Normal

35-45
PCO2 amount of carbon
mmhg
dioxide gas dissolved in
the blood.

PO2 (partial pressure of

oxygen) reflects the
amount of oxygen gas
dissolved in the blood.
80-100
PO2 It primarily measures 97.7 mmHg
mmhg
the effectiveness of the Normal
lungs in pulling oxygen
into the blood stream
from the atmosphere.

Bicarbonate is a
primary substance that

21-28 influences the acid-

HCO3 26
mmol/L base balance of body
mmol/L
fluids. It is considered a
Normal
strong buffer when
examining the arterial
 gases and is an
accurate indicator of the
conditions involving the
regulation of the pH of
the body fluids.

Total CO2 content is a

measurement of all the
CO2 in the blood.
23-30 27.2
TCO2
mmol/L Most of this is in the
mmol/L
form of bicarbonate
Normal
(HCO3), controlled by
the kidney.

Base excess (BE) is the

mmol/L of base that
needs to be removed to
(-2)–(+2)
B.E. bring the pH. It is used
mmol/L
as an indicator of the 2.1 mmol/L
degree of metabolic elevated
disturbance.

Oxygen saturation
(SO2) measures the
percentage of
O2 Sat. 70-100%
hemoglobin which is 98.2%
fully combined with normal
oxygen.
Coagulation Test - Coagulation tests measure your blood’s ability to clot, and how long
it takes to clot. Testing can help your doctor assess your risk of excessive bleeding or
developing clots (thrombosis) somewhere in your blood vessels.

Exam Result Nursing Responsibilities

Date
09/03/1 Clotting time 4 min 45  Assess the site for redness,
8 seconds bruising and phlebitis
Bleeding time 2  If phlebitis is present apply
minutes warm compress for treatment
3o
seconds Follow the physician’s advice
regarding your medication
Protime 12
Control seconds

Protime 15.4
seconds

INR 1.24

% activity 76.3%

APTT control 31.4

seconds

APTT 35.6
seconds

Chest PA/Lateral- A chest radiograph, colloquially called a chest X-ray, or chest

film, is a projection radiograph of the chest used to diagnose conditions affecting
the chest, its contents, and nearby structures.
Type Rationale Result Result Result Interpre Nursing
of (8/21/18 (8/28/18) (9/03/18) tation/ Responsibilities
Test ) Signific
ance

Chest It is a - -Pulmonary - no Indicate Pre-test:

PA common Pneumo congestion significant s that
procedure nia with and/ edema change in patient -Check the
used to pleural pulmonary has a medical order
demonstrat perfusio - Bilateral congestion pulmon
e the n ,bilater pleural and ary -Properly identify
appearance al effusion pneumonia proble
considered the patient.
of the lungs, m thus
mediastinu - pleural needs
thickening -Explain the
m, bony treatme
thorax, nt purpose and
diaphragm, procedure of
chest wall, obtaining a chest
cardiac
silhouette, x-ray and assure
and thyroid the patient that
gland the test is
painless.

-Instruct the
patient to
remove clothing
to the waist and
to put on a
hospital gown.

-Instruct patient
to remove all
metal objects like
jewellery and
pins.

-Inform the
patient that no
discomfort is
associated with
chest
radiography.

Intra-test

-Tell the patient

that he or she
will be asked to
take a deep
breath and hold
it while the x-ray
films are
obtained.

Post-test

-Document the
date and time
the test was
done.

-Give health
teachings such
as to:

a. get plenty of
rest;

b. drink plenty of
fluids; and

c. practice
 proper cough
etiquette

Stool Exam- A stool analysis is a series of tests done on a stool (feces) sample to help
diagnose certain conditions affecting the digestive tarct These conditions can include
infection (such as from parasites,bascteria,virus), poor nutrient absorption, or cancer.

Result Result Significance

8/26/18 8/29/18
Having too much fat in your stool is called
Color Brown Greenish steatorrhea. If you have too much fat in
Brown your stool, it may be a sign that food is
moving through your digestive system

Consistency Soft Soft without being broken down and absorbed

properly. This is called malabsorption.
-No - Fat globules
(++) Having a fecal fat test is the best way to
Others parasite
find out if you have malabsorption.
seen
CT scan of the Head/ Brain,Abdomen, - A cranial CT scan is a diagnostic tool used
to create detailed pictures of features inside your head, such as your skull, brain,
paranasal sinuses, ventricles, and eye sockets.

Date TEST IMPRESSION NURSING INTERVENTIONS

August CT scan of -Mediastinal Before procedure

20, Chest/ Lymphadenoma
2018 Thorax  Instruct to remove
> aortic and coronary jewelries and any metal
arteries objects
>mixed osteoblastic and  Check for any allergies.
lytic vertebral  Instruct client not to eat
8 hours before the
metastases of T11,T12 laboratory test
and L1 During procedure

 Instructed that he may

be ask to hold his breath
09/01/1 CT scan of - Negative Cranial CT After Procedure
the Head /
8 Brain Scan  Increase Oral Fluid as
tolerated
09/03/1 CT Scan -Multiple matted  Instruct to report for
8 Of whole Abdominal delayed reaction such as
Abdomen Lymphadenoma and rashes, hypertension,
vascular encasement palpitations

-Minimally enhancing
Masses, Left Adrenal
Gland and Spleen
Metastatic Foci

-Mild Splenomegaly

-Mixed Osteolytic and

Blastic Vertebral
Metastases of T11,T12
and L1

Fecal Occult Blood Test - The fecal occult blood test (FOBT) is a lab test used to
check stool samples for hidden (occult) blood.Occult blood in the stool may indicate
colon cancer or polyps in the colon or rectum though not all cancers or polyps bleed.

Date Rationale Result

09/05/ It can be a sign of a problem in Positive

18 your digestive system such as a
growth, or polyp, or cancer in the
colon or rectum

Possible Laboratory and Diagnostic Tests

>Joint Fluid Analysis- It can be used to draw fluid out of the affected joint and examining
it

>MRI or magnetic resonance imaging is a radiology techinque scan- that uses

magnetism, radio waves, and a computer to produce images of body structures.
 XI. DRUG STUDY

Date ordered August 29, 2018

Generic Name Pregabalin

Brand Name Lyrica

Drug Anticonvulsant, antineuralgic, analgesic

Classification

Mechanism of Binds to calcium channel sites in CNS tissue, inhibiting excitatory

Action neurotransmitter release. Exerts antinociceptive, anticonvulsant
activity.
Therapeutic Effect: Decreases symptoms of painful peripheral
neuropathy; decreases frequency of partial seizures.

Actual Dosage 75 mg 1 tab every other day

Suggested PO: ADULTS, ELDERLY: Initially, 50 mg 3 times/day. Maximum: 300

Dosage mg/day, increased dose based on efficacy and tolerability.

Indication Adjunctive therapy in treatment of partial-onset seizures.

Management of neuropathic pain associated with diabetic peripheral
neuropathy or spinal cord injury. Management of postherpetic
neuralgia. Management of fibromyalgia.

Contraindicatio None known.

n
HF, renal impairment, cardiovascular

disease, diabetes, history of angioedema,

pts at risk for suicide.

Side Effects Dizziness, drowsiness, ataxia, peripheral edema.Weight gain, blurred

vision, diplopia, difficulty with concentration, attention, cognition;
tremor, dry mouth, headache, constipation, asthenia. Abnormal gait,
confusion, incoordination, twitching, flatulence, vomiting, edema,
myopathy

Adverse Abrupt withdrawal increases risk of seizure frequency in pts with

Effects seizure disorders; withdraw gradually over a minimum of 1 wk

Drug DRUG: Alcohol, barbiturates, narcotic

Interactions
analgesics, other sedative agents may increase sedative effect.

Nursing 1. Do not crush or chew caps

Responsibilitie 2. Give without regards to meal
s 3. Provide increase fluid, bulk in diet for constipation
4. Avoid activities that requires alertness
5. Tell patient to avoid alcohol

Date ordered August 29, 2018

Generic Name Dexamethasone

Brand Name Dexticort

Drug Long acting glucocorticoid. Corticosteroid

Classification

Mechanism of Suppresses neutrophil migration, decreases production of

Action inflammatory mediators, reverses increased capillary permeability.
Decreases inflammation. Suppresses normal immune response.

Actual Dosage 10mg IV q8

Suggested Prophylaxis of nausea and vomiting associated with cytotoxic therapy

Dosage
Adult: Prevention: 10-20 mg 15-30 minutes before admin of
chemotherapy on each treatment day. For continuous infusion
regimen: 10 mg every 12 hr on each treatment day. For midly
emetogenic regimen: 4 mg every 4-6 hr

Indication Used primarily as an anti-inflammatory or immunosuppressant agent

in a variety of diseases (e.g., allergic, inflammatory autoimmune).
Antiemetic, treatment of croup, dexamethasone suppression test
 (indicator consistent with suicide and/or depression), accelerate fetal
lung maturation. Treatment of acute mountain sickness, high altitude
cerebral edema.

Contraindicatio Hypersensitivity; active untreated infections; ophthalmic use in viral,

n fungal disease of the eye

Side Effects Inhalation: Cough, dry mouth, hoarseness, throat irritation. Intranasal:
Burning, mucosal dryness. Ophthalmic: Blurred vision. Systemic:
Insomnia, facial edema (cushingoid appearance [“moon face”]),
moderate abdominal distention, indigestion, increased appetite,
nervousness, facial flushing, diaphoresis. Occasional: Inhalation:
Localized fungal infection (thrush). Intranasal: Crusting insidenose,
epistaxis, sore throat, ulceration of nasal mucosa. Ophthalmic:
Decreased vision; lacrimation; eye pain; burning, stinging, redness of
eyes; nausea; vomiting. Systemic: Dizziness, decreased/ blurred
vision. Rare: Inhalation: Increased bronchospasm, esophageal
candidiasis. Intranasal: Nasal/pharyngeal candidiasis, eye pain.
Systemic: Generalized allergic reaction (rash, urticaria); pain,
redness, swelling at injection site; psychological changes; false sense
of well-being; hallucinations; depression.

Adverse Long-term therapy: Muscle wasting (esp. arms, legs), osteoporosis,

Effects spontaneous fractures, amenorrhea, cataracts, glaucoma, peptic ulcer
disease, HF. Ophthalmic: Glaucoma, ocular hypertension, cataracts.
Abrupt withdrawal following long-term therapy: Severe joint pain,
severe headache, anorexia, nausea, fever, rebound inflammation,
fatigue, weakness, lethargy, dizziness, orthostatic hypotension.

Drug DRUG: Amphotericin may increase hypokalemia. May increase

Interactions digoxin toxicity caused by hypokalemia. CYP3A4 inducers (e.g.,
carbamazepine, phenytoin, rifampin) may decrease concentration.
CYP3A4 inhibitors (e.g., ketoconazole), macrolide antibiotics may
increase concentration. May decrease effects of oral antidiabetic
agents. Live virus vaccines may decrease pt’s antibody response to
vaccine, increase vaccine side effects, potentiate virus replication.
HERBAL: Cat’s claw, echinacea may increase immunosuppressant
effect. FOOD: Interferes with calcium absorption. LAB VALUES: May
increase serum glucose, lipids, sodium levels. May decrease serum
calcium, potassium, thyroxine, WBC.
Nursing 1. Observe 10 rights of drug administration
Responsibilitie 2. Monitor Intake and Output, weigh daily.
s 3. Observe for peripheral edema
4. Assess patient for level of consciousness
5. Monitor respiratory and lung sounds
6. Monitor serum electrolytes
7. Administer with meal to prevent gastric irritation

Date ordered August 29, 2018

Generic Name Calcium Carbonate

Brand Name Calvit

Drug Calcium Supplement

Classification

Mechanism of Essential for function, integrity of nervous,

Action
muscular, skeletal systems. Plays an

important role in normal cardiac/renal

function, respiration, blood coagulation,

cell membrane and capillary permeability.

Assists in regulating release/storage

of hormones/neurotransmitters. Neutralizes/

reduces gastric acid (increases pH).

Actual Dosage 1 tab OD at night

Suggested 1-2 tablet daily

Dosage

Indication Prevention & treatment of osteoporosis, OA & osteomalacia; Ca

insufficiency & as dietary supplement during pregnancy & lactation,
pre- & postmenopause.

Contraindicatio All preparations:

n Calcium-based renal calculi, hypercalcemia,

ventricular fibrillation. Calcium

chloride: Digoxin toxicity. Calcium gluconate:

Neonates: Concurrent IV use

with ceftriaxone

Side Effects PO: Chalky taste. Parenteral: Pain, rash, redness, burning at injection

site; flushing, nausea, vomiting, diaphoresis, hypotension. PO: Mild

constipation, fecal impaction, peripheral

edema, metabolic alkalosis (muscle pain, restlessness, slow

respirations, altered taste). Calcium carbonate: Milkalkali

syndrome (headache, decreased appetite, nausea, vomiting, unusual

fatigue).Urinary urgency, painful urination

Adverse Hypercalcemia: Early signs: Constipation, headache, dry mouth,

Effects increased thirst, irritability, decreased appetite, metallic taste, fatigue,
weakness, depression. confusion, drowsiness, hypertension,
photosensitivity, arrhythmias, nausea, vomiting, painful urination.

Drug Hypercalcemia may increase digoxin toxicity. Oral form may decrease
Interactions
absorption of biphosphonates (e.g., risedronate), calcium channel
blockers, tetracycline derivatives, thyroid products.

Nursing 1. Assess for milk-alkali syndrome

Responsibilitie 2. Assess for hypercalcemia
s
3. Assess for constipation
4. Avoid enteric coated tablets within 1 hour
5. Tell patient to have an adequate intake of vitamin D

Date ordered August 29, 2018

Generic Name Paracetamol

Brand Name Biogesic

Drug Central analgesic. Non-narcotic analgesic, antipyretic.

Classification

Mechanism of Paracetamol exhibits analgesic action by peripheral blockage of pain

Action impulse generation. It produces antipyresis by inhibiting the
hypothalamic heat-regulating centre. Its weak anti-inflammatory
activity is related to inhibition of prostaglandin synthesis in the CNS.

Actual Dosage 500mg 1 tab q4 prn for fever

Suggested 0.5-1 g 4-6 hrly. Max: 4 g daily.

Dosage

Indication Mild to moderate pain and fever

Contraindicatio Hypersensitivity to
n
sulfonamides, severe renal/hepatic disease,

adrenal insufficiency, hypochloremic

acidosis, hypokalemia, hyponatremia,

long-term administration in pts

with chronic noncongestion angle-closure

glaucoma.

Side Effects Hypersensitivity reaction.

Adverse Anorexia, nausea, diaphoresis, fatigue

Effects
within first 12–24 hrs. Later Signs

of Toxicity: Vomiting, right upper quadrant

tenderness, elevated hepatic function

tests within 48–72 hrs after ingestion.

Drug May reduce serum levels w/ anticonvulsants (e.g. phenytoin,

Interactions barbiturates, carbamazepine). May enhance the anticoagulant effect
of warfarin and other coumarins w/ prolonged use. Accelerated
absorption w/ metoclopramide and domperidone. May increase serum
 levels w/ probenecid. May increase serum levels of chloramphenicol.
May reduce absorption w/ colestyramine w/in 1 hr of admin. May
cause severe hypothermia w/ phenothiazine.

Nursing 1. Monitor temperature of patient.

Responsibilitie
s 2. Monitor CBC, liver and renal functions for toxicity.

3. Instruct watcher to have the patient take with food or milk to

minimize GI upset.

4. Instruct watcher to not coadminister with a high carbohydrate meal;

absorption rate may be significantly retarded.

5.Assess allergic reactions: rash, urticaria; if these occur, drug may

have to be discontinued.

6. Instruct watcher to report nausea and vomiting, cyanosis, shortness

of breath and abdominal pain as these are signs of toxicity.

7. Report paleness, weakness and heart beat skips, abdominal pain,

jaundice, dark urine, itchiness or clay-colored stools.

8. Tell watcher to avoid using multiple preparations containing

acetaminophen. Carefully check all OTC products.

9. Tell watcher to notify for fever lasting for more than 3 days

10. Assure that N-acetylcysteine should be available as a specific

antidote.

Date ordered August 29, 2018

Generic Name Potassium Chloride

Brand Name Kalium

Drug Electrolyte supplement

Classification
Mechanism of Necessary for multiple cellular metabolic
Action
processes. Primary action is intracellular.

Therapeutic Effect:╇ Required for

nerve impulse conduction, contraction of

cardiac, skeletal, smooth muscle; maintains

normal renal function, acid-base

balance

Actual Dosage 40meqs KCl+ pnss 1L 80cc/hr x2 cycles; KCl tab 1 tab BID

Suggested PO Prophylaxis: 20 mEq/day. Treatment: 40-100 mEq/day in 2-4

Dosage divided doses. Max: 40 mEq/dose; 150 mEq daily. Dosage is
individualised based on serum K levels. IV Dose and rate of
administration are dependent upon the ECG and serum K levels.
Max: 2-3 mEq/kg/day

Indication Hypokalemia

Contraindicatio Severe renal impairment,

n
adrenal insufficiency, hyperkalemia.

Side Effects Nausea, vomiting, diarrhea,

flatulence, abdominal discomfort with distention,

phlebitis with IV administration

(particularly when potassium concentration

of greater than 40 mEq/L is infused). Rash.

Adverse Hyperkalemia (more common in elderly,

Effects
pts with renal impairment) manifested as

paresthesia, feeling of heaviness in lower extremities, cold skin,

grayish pallor,

hypotension, confusion, irritability, flaccid

 paralysis, cardiac arrhythmias.

Drug Increased risk of hyperkalaemia with ACE inhibitors (e.g. captopril),

Interactions angiotensin II receptor antagonists, ciclosporin. May enhance
ulcerogenic effect of solid oral dosage forms of K chloride with
anticholinergic agents. May further decrease plasma K concentration
with glucose infusion.
Potentially Fatal: Increased risk of hyperkalaemia with potassium-
sparing diuretics (e.g. spironolactone, amiloride, triamterene)

Nursing 1. Monitor I&O ratio and pattern in patients receiving the

Responsibilitie parenteral drug. If oliguria occurs, stop infusion promptly and
s notify physician.
2. Lab test: Frequent serum electrolytes are warranted.
3. Monitor for and report signs of GI ulceration
4. Monitor patients receiving parenteral potassium closely with
cardiac monitor. Irregular heartbeat is usually the earliest
clinical indication of hyperkalemia.
5. Be alert for potassium intoxication

Date ordered August 29, 2018

Generic Name Meropenem

Brand Name Meroget

Drug Anitbiotic
Classification

Mechanism of Binds to penicillin-binding proteins. Inhibits

Action
bacterial cell wall synthesis.Bactericidal.

Actual Dosage 1g q 8 give up to 10 days

Suggested IV Susceptible infections 0.5-1 g 8 hrly via IV inj over approx 3-5 min
Dosage or infused over approx 15-30 min.
Indication Treatment of multidrug-resistant infections;

meningitis in children 3 mos and

older; intra-abdominal infections; complicated

skin/skin structure infections

caused by susceptible S. aureus, S. pyogenes,

S. agalactiae, S. pneumoniae, H.

influenzae, N. meningitidis, M. catarrhalis,

E. coli, Klebsiella, Enterobacter,

Contraindicatio Anaphylactic reaction

n
to other beta-lactams

Side Effects Diarrhea, nausea,

vomiting, headache, inflammation at injection

site. Oral candidiasis,

rash, pruritus. Constipation, glossitis.

Adverse Antibiotic-associated colitis, other superinfections

Effects
(abdominal cramps, severe

watery diarrhea, fever) may result from

altered bacterial balance in GI tract. Anaphylactic

reactions have been reported.

Seizures may occur in those with CNS

disorders (e.g., brain lesions, history of

seizures), bacterial meningitis, renal impairment.

Drug None significant.

Interactions
Nursing 1. Lab tests: Perform C&S tests prior to therapy. Monitor
Responsibilitie periodically liver and kidney function.
s 2. Determine history of hypersensitivity reactions to other beta-
lactams, cephalosporins, penicillins, or other drugs.
3. Discontinue drug and immediately report S&S of
hypersensitivity
4. Report S&S of superinfection or pseudomembranous colitis
5. Monitor for seizures especially in older adults and those with
renal insufficiency

Date ordered August 29, 2018

Generic Name Tramadol

Brand Name Tramal

Drug Analgesic
Classification

Mechanism of Binds to mu-opioid receptors, inhibits

Action
reuptake of norepinephrine, serotonin,

inhibiting ascending and descending

pain pathways. Therapeutic Effect:╇

Reduces pain

Actual Dosage 50mg 1 tab q8 RTC

Suggested PO Moderate to severe pain 50-100 mg 4-6 hrly. Extended-release

Dosage tab: 50-100 mg 1-2 times/day. Max: 400 mg/day.

Indication Management of moderate to moderately

 severe pain. Extended-Release:

Around-the-clock management of moderate

to moderately severe pain for

extended period.

Contraindicatio Acute alcohol intoxication, concurrent

n
use of centrally acting analgesics, hypnotics,

opioids, psychotropic drugs, hypersensitivity

to opioids. ConZip, Severe/

acute bronchial asthma, hypercapnia,

significant respiratory depression.

Side Effects Dizziness, vertigo, nausea, constipation, headache, drowsiness.

Vomiting,pruritus, CNS stimulation (e.g., nervousness,

anxiety, agitation, tremor, euphoria,mood swings, hallucinations),

asthenia,diaphoresis, dyspepsia, dry mouth, diarrhea.Malaise,
vasodilation,anorexia, flatulence, rash

Adverse Seizures reported in pts receiving tramadol within recommended

Effects dosage range. May have prolonged duration of action, cumulative
effect in pts with hepatic/renal impairment, serotonin
syndrome(agitation, hallucinations, tachycardia, hyperreflexia).

Drug Alcohol, other CNS depressants

Interactions
may increase CNS depression. Carbmazepine decreases
concentration/effects. CYP2D6 inhibitors (e.g.,

paroxetine), CYP3A4 inhibitors (e.g., erythromycin), triptans, selective

serotonin reuptake inhibitors(SSRIs), tricyclic antidepressants

may increase risk of seizures, risk of serotoninsyndrome

Nursing 1. Observe 10 rights in administering a medication
Responsibilitie 2. Determine previous hypersensitivity reactions to penicillins,
s
cephalosporins, and other allergens prior to therapy.
3. Obtain specimens for culture and sensitivity prior to therapy. First
dose may be given before receiving results.
4. Assess bowel pattern before and during treatment as
pseudomembranous colitis may occur
5. Report haematuria or oliguria as high doses can be nephrotoxic
6. Assess respiratory status

Date ordered August 30, 2018

Generic Name Dopamine

Brand Name Dopamine HCl

Drug Cardiac Stimulatant; Vasopressor

Classification

Mechanism of Stimulates adrenergic and dopaminergic

Action
receptors. Effects are dose dependent.

Lower dosage stimulates dopaminergic

receptors, causing renal vasodilation.

Higher doses stimulate both dopaminergic

and beta1-adrenergic receptors, causing

cardiac stimulation and renal vasodilation.

Actual Dosage 0.5mkd

Suggested IV Initial: 2-5 mcg/kg/min, increased gradually up to 5-10 mcg/kg/min.

Dosage Seriously ill patient: Up to 20-50 mcg/kg/min

Indication Acute heart failure

Contraindicatio Pheochromocytoma,
n
ventricular fibrillation. Hypersensitivity to

sulfites.

Side Effects Headache, arrhythmias, tachycardia,

anginal pain, palpitations, vasoconstriction,

hypotension, nausea, vomiting,

dyspnea. Piloerection

(goose bumps), bradycardia, widening

of QRS complex

Adverse High doses may produce ventricular arrhythmias.

Effects
Pts with occlusive vascular

disease are at high risk for further compromise

of circulation to extremities,

which may result in gangrene. Tissue

necrosis with sloughing may occur with

extravasation of IV solution.

Drug May have increased effects

Interactions
with vasopressors, vasoconstrictive

agents. COMT inhibitors may increase

level/effects.
Nursing 1. Monitor blood pressure, pulse, peripheral pulses, and urinary
Responsibilitie output at intervals prescribed by physician.
s 2. Report reduced urine flow rate in absence of hypotension;
ascending tachycardia; dysrhythmias; disproportionate rise in
diastolic pressure (marked decrease in pulse pressure); signs
of peripheral ischemia (pallor, cyanosis, mottling, coldness,
complaints of tenderness, pain, numbness, or burning
sensation).
3. Monitor vital signs and urine flow, other indices of adequate
dosage and perfusion of vital organs include loss of pallor,
increase in toe temperature, adequacy of nail bed capillary
filling.

Date ordered September 1, 2018

Generic Name Citicoline

Brand Name Kemodyn

Drug Dietary supplement

Classification

Mechanism of Citicoline increases blood flow and O2 consumption in the brain. It is

Action also involved in the biosynthesis of lecithin.

Actual Dosage 1g IV q6

Suggested Up to 1 g/day
Dosage

Indication Acute ischemic stroke

 Alzheimer's disease

Cerebral insufficiency

Other diseases of the brain

Contraindicatio Hypersensitivity
n

Side Effects Headache

Dizziness

Shaking of hands or feet

Sleeplessness

Change in pulse rate

Change in blood pressure

Diarrhea

Nausea

Stomach pain

Injection site pain

Blurred vision

Adverse
Effects

Drug None
Interactions

Nursing 1. May be taken with or without food

Responsibilitie 2. supplement should not be taken in the late afternoon or at night
s because it can cause difficulty sleeping.
3. Special attention should be paid for administration
4. Contact the physician immediately if allergic reaction such as
hives, rash, or itching, swelling in face or hands, mouth or throat,
chest tightness or trouble breathing are experienced.
5. Therapy should be started within 24 hours of a stroke.
Date ordered September 1, 2018

Generic Name Magnesium Sulfate

Brand Name MgSO4

Drug Anatacid; Anticonvulsant; Electrolyte; Laxative

Classification

Mechanism of Magnesium sulfate increases peristaltic activity by causing osmotic

Action retention of fluids, thus resulting in bowel evacuation.

Actual Dosage MgSo4 2g + 250cc D5W x 24 hrs

Suggested 1 g (8.12 mEq or 2 mL of the 50% solution) every 6 hr for 4 doses or

Dosage based on serum magnesium levels.

Indication Treatment/prevention of hypomagnesemia;prevention and treatment

of seizures in severe preeclampsia or eclampsia; pediatric acute

nephritis,

treatment of arrhythmias due to hypomagnesemia

Contraindicatio Appendicitis, symptoms of appendicitis, ileostomy, intestinal

n obstruction, severe renal impairment, HF, colostomy, hypersensitivity,
ileostomy, intestinal obstruction, undiagnosed rectal bleeding. Heart
block, myocardial damage, renal failure.
Side Effects Antacid: Chalky taste, diarrhea,

laxative effect.╇ Occasional:╇ Antacid:

Nausea, vomiting, stomach

cramps. Antacid, laxative: Prolonged

use or large doses in renal impairment

may cause hypermagnesemia (dizziness,

palpitations, altered mental status,

fatigue, weakness).

Adverse Magnesium as antacid, laxative has no

Effects
known adverse reactions. Systemic use

may produce prolonged PR interval,

widening of QRS interval. Magnesium

toxicity may cause loss of deep tendon

reflexes, heart block, respiratory paralysis,

cardiac arrest

Drug May decrease absorption of

Interactions
quinolones, tetracycline, bisphosphonates.

May increase effects of antihypertensives.

Nursing 1. Check BP and pulse q10–15 min or more often if indicated.

Responsibilitie 2. Lab tests: Monitor plasma magnesium levels in patients
s receiving drug parenterally
3. Cardiac arrest occurs at levels in excess of 25 mEq/L. Monitor
calcium and phosphorus levels also.
4. Early indicators of hypermagnesemia include cathartic effect,
profound thirst, feeling of warmth, sedation, confusion,
depressed deep tendon reflexes, and muscle weakness.
5. Monitor respiratory rate closely.
6. Depression or absence of reflexes is a useful index of early
magnesium intoxication.
7. Check urinary output, especially in patients with impaired
 kidney function.
8. Observe patients receiving drug for hypomagnesemia for
improvement in these signs of deficiency: Irritability, choreiform
movements, tremors, tetany, twitching, muscle cramps,
tachycardia, hypertension, psychotic behavior.
9. Drink sufficient water during the day when drug is administered
orally to prevent net loss of body water.

Date ordered September 1, 2018

Generic Name Spirinolactone

Brand Name Aldactone

Drug Potassium sparing Diuretic; Antihypertensive; Antihypokalemic

Classification

Mechanism of Interferes with sodium reabsorption by

Action
competitively inhibiting action of aldosterone

in distal tubule, promoting sodium

and water excretion, increasing potassium

retention.

Actual Dosage 25 mg tab 1 tab

Suggested As adjunct: Initially, 25 mg once daily to max 50 mg daily. May

Dosage reduce to 25 mg every other day if 25 mg once daily dose is not
tolerated.
Indication Management of edema associated with excessive aldosterone
excretion or with

HF; hypertension; cirrhosis of liver with edema or ascites,

hypokalemia, nephrotic

syndrome, severe HF; primary hyperaldosteronism.

Contraindicatio Acute renal insufficiency,anuria, hyperkalemia, Addison’s disease,

n concomitant use with eplerenone.

Side Effects Hyperkalemia (in pts with renal

insufficiency, those taking potassium supplements),

dehydration, hyponatremia,

lethargy. Nausea, vomiting,

anorexia, abdominal cramps, diarrhea,

headache, ataxia, drowsiness, confusion,

fever

Adverse Severe hyperkalemia may produce arrhythmias,

Effects
bradycardia, EKG changes

(tented T waves, widening QRS complex,

ST segment depression). May proceed to

cardiac standstill, ventricular fibrillation.

Cirrhosis pts at risk for hepatic decompensation

if dehydration, hyponatremia

occurs

Drug ACE inhibitors (e.g., captopril), potassium-containing medications,

Interactions
potassium supplements may

increase risk of hyperkalemia. May increase

half-life of digoxin. NSAIDs may

 decrease antihypertensive effect.

Nursing 1. Check blood pressure

Responsibilitie 2. Lab tests: Monitor serum electrolytes (sodium and potassium)
s 3. Assess for signs of fluid and electrolyte imbalance, and signs
of digoxin toxicity.
4. Monitor daily I&O and check for edema
5. Weigh patient under standard conditions before therapy begins
and daily throughout therapy.
6. Observe for and report immediately the onset of mental
changes, lethargy, or stupor in patients with liver disease.
7. Adverse reactions are generally reversible with discontinuation
of drug.

Date ordered September 2, 2018

Generic Name Ivrabadine

Brand Name Coralan

Drug Anti Anginal

Classification

Mechanism of Heart rate lowering agent that works through selective and specific
Action inhibition of the cardiac pacemaker If current that controls the
spontaneous diastolic depolarisation in the sinus node and regulates
heart rate.

Actual Dosage 5 mg tab 1 tab BID

Suggested Initially, should not exceed 5 mg bid. Increase if necessary to 7.5 mg

Dosage bid after 3-4 wk. Titrate downward to as low as 2.5 mg bid, if patient
develops bradycardia symptoms (e.g. dizziness, fatigue) or resting
heart rate is persistently <50 beats/min.

Indication Angina Pectoris; Chronic Heart Failure; CAD

Contraindicatio Resting heart rate <70 beats/min prior to treatment, cardiogenic

n shock, acute MI, severe hypotension (<90/50 mmHg), sick sinus
syndrome, SA block, unstable or acute heart failure, pacemaker
dependent, unstable angina, 3rd degree AV block. Severe hepatic
impairment.

Side Effects Bradycardia, hypertension, atrial fibrillation, and temporary vision

disturbance (flashes of light). dizziness, weakness, or fatigue

Adverse Luminous phenomena in the visual field (phosphenes), blurred vision,

Effects bradycardia, other cardiac arrhythmias, syncope, hypotension,
asthenia, fatigue, headache, dizziness, nausea, constipation,
diarrhoea, dyspnoea, muscle cramps, skin reactions, angioedema,
hyperuricaemia, eosinophilia, elevated blood-creatinine
concentrations.

Drug QT prolongation may be exacerbated by heart rate reduction w/ QT-

Interactions prolonging drugs (e.g. quinidine, disopyramide, pimozide,
ziprasidone). Concentration may be reduced w/ CYP3A4 inducers
(e.g. rifampicin, barbiturates, phenytoin) and may require ivabradine
dose adjustment.

Nursing 1. Caution should be exercised in patients with abnormal heart

Responsibilitie rhythm, high blood pressure, stroke.
s 2. Monitor regularly for atrial flutter occurrence while taking this
medication.
3. May cause blurred vision, do not drive a car or operate
machinery while taking this medication

Date ordered September 2, 2018

Generic Name Levetiracetam

Brand Name Keppra

Drug Pyrrolidine derivative; Anticonvulsant
Classification

Mechanism of Exact mechanism unknown. May inhibit

Action
voltage-dependent calcium channels; facilitate

GABA inhibitory transmission; reduce

potassium current; or bind to synaptic

proteins that modulate neurotransmitter

release.

Actual Dosage 10 mL BID

Suggested Initially 500 mg bid, may be increased up to 1,500 mg bid. Dose may
Dosage be increase or decrease to 500 mg bid every 2-4 wk.

Indication Adjunctive therapy of partial onset, myoclonic,

and/or primary generalized tonicclonic

seizures

Contraindicatio Hypersensitivity to levetiracetam or other pyrrolidone derivatives.

n

Side Effects Drowsiness, asthenia, headache, infection, dizziness, pharyngitis,

pain,depression, anxiety, vertigo, rhinitis, anorexia. Amnesia,

emotional lability, cough, sinusitis, anorexia, diplopia.

Adverse Acute psychosis, seizures have been reported.

Effects
Sudden discontinuance increases

risk of seizure activity. Serious dermatological

reactions, including Steven-Johnson

syndrome and toxic epidermal necrolysis

have been reported.

Drug None known

Interactions

Nursing 1. Assess patient duration, location and characteristic of seizure

Responsibilitie activity
s 2. Monitor patient behavior
3. Monitor for dizziness or nausea
4. May administer without regards to meals
5. Do not crush, break or chew.

Date ordered September 2, 2018

Generic Name 0.9 % Sodium Chloride

Brand Name Plain Normal Saline Solution (PNSS)

Drug Isotonic Intravenous Solution

Classification

Mechanism of
Action
The osmolality is entirely contributed by electrolytes, the solution
remains within the ECF, does not cause red blood cells to shrink or
swell and it expands the ECF volume

Actual Dosage 1 liter @ 58cc/hr

Suggested Individualized dosage

Dosage

Indication Used for hydration and preventing hypovolemic shock or hypotension,

replace extracellular fluid

Contraindicatio Heart failure, pulmonary edema, renal impairement, sodium retention

n

Side Effects Irritation or swelling where the shot was given, pain

Adverse Febrile response, infection at the site, venous thrombosis,

Effects extravasation, hypovolemia

Drug Corticosteroid- increase in sodium and water retention

Interactions
Lithium- increase renal elimination of lithium

Nursing 1. Do not administer if container is damaged

Responsibilitie 2. Properly label the IV
s 3. Be alert for fluid overload
4. Check for the presence of bubbles in the IV
5. Observe aseptic technique in changing IV fluid
6. Monitor signs of infiltration
7. Monitor signs of phlebitis and infection
8. Check the condition of the tubing
9. Check the level of the IV
10. Check and regulate the drop rate

Date ordered September 3, 2018

Generic Name Furosemide

Brand Name Lasix

Drug Diuretic
Classification

Mechanism of Enhances excretion of sodium, chloride, potassium by direct action at

Action ascending

limb of loop of Henle. Produces diuresis, lowers B/P.

Actual Dosage 40mg post BT IV

Suggested 20-50 mg via IM or slow IV inj, may increase by increments of 20 mg

Dosage 2 hrly. Doses >50 mg must be given via slow IV infusion. Max: 1,500
mg daily.

Indication Treatment of edema associated with HF and renal/hepatic disease;

 acute pulmonary edema. Treatment of hypertension,

either alone or in combination with other antihypertensives.

Contraindicatio Anuria
n

Side Effects Increased urinary frequency/ volume. Nausea, dyspepsia, abdominal

cramps, diarrhea or constipation, electrolyte disturbances.Dizziness,

light-headedness, headache, blurred vision, paresthesia,

photosensitivity, rash, fatigue, bladder spasm, restlessness,
diaphoresis.Flank pain.

Adverse Vigorous diuresis may lead to profound

Effects
water loss/electrolyte depletion, resulting in hypokalemia,
hyponatremia, dehydration.Sudden volume depletion may result in
increased risk of thrombosis, circulatory collapse, sudden death.
Acute hypotensive episodes may occur, sometimes several

days after beginning therapy. Ototoxicity (deafness, vertigo, tinnitus)

may occur, esp. in pts with severe renal impairment. Can

exacerbate diabetes mellitus, systemic lupus erythematosus, gout,

pancreatitis. Blood dyscrasias have been reported.

Drug Amphotericin B, nephrotoxic, ototoxic medications may increase

Interactions
risk of nephrotoxicity, ototoxicity. May increase risk of lithium toxicity.
Other medications causing hypokalemia may increase risk of
hypokalemia.

Nursing 1. Observe patients receiving parenteral drug carefully; closely

Responsibilitie monitor BP and vital signs.
s 2. Monitor for S&S of hypokalemia
3. Monitor BP during periods of diuresis
4. Sudden alteration in fluid and electrolyte balance may
precipitate significant adverse reactions.
5. Lab tests: Obtain frequent blood count, serum and urine
electrolytes, CO2, BUN, blood sugar, and uric acid values
6. Monitor I&O ratio and pattern.
7. Monitor urine and blood glucose & HbA1C closely in diabetics
and patients with decompensated hepatic cirrhosis.
 8. Excessive dehydration is most likely to occur in older adults

Date ordered September 3, 2018

Generic Name Albumin

Brand Name Albumax

Drug Plasma Protein Faction

Classification

Mechanism of Blood volume expander. Provides increase in intravascular

Action
oncotic pressure, mobilizes fluids into intravascular

space.

Actual Dosage Albumin + Furo to 10cc IVF comminuted @ 40cc

Suggested Initially 2 mL/kg, a subsequent dose of 1 mL/kg, may be repeated

Dosage after 15-30 min if initial dose is inadequate.

Indication Used for plasma volume expansion,maintenance of cardiac output in

treatmentof shock or impending shock. May be useful in treatment of
severe burns, adult respiratory distress syndrome(ARDS),
cardiopulmonary bypass, hemodialysis.

Contraindicatio None
n

Side Effects Hypotension. High dose in repeated therapy: altered vital

signs, chills, fever, increased salivation, nausea, vomiting, urticaria,

 tachycardia.

Adverse Fluid overload may occur, marked by increased B/P, distended neck
Effects veins. Pulmonary edema may occur, evidenced by labored
respirations, dyspnea, rales, wheezing, coughing. Neurologic changes
that may occur include headache, weakness, blurred vision,
behavioural changes, incoordination, isolated muscle twitching.

Drug None known

Interactions

Nursing 1. Monitor BP, pulse and respiration, and IV albumin flow rate.
Responsibilitie 2. Lab tests: Monitor dosage of albumin using plasma albumin
s 3. Observe closely for S&S of circulatory overload and pulmonary
edema
4. If S&S appear, slow infusion rate just sufficiently to keep vein
open, and report immediately to physician.
5. Observe for bleeding points that did not bleed at lower BP with
injuries or surgery and as BP rises.
6. Monitor I&O ratio and pattern.
7. Report changes in urinary output

Date ordered September 5, 2018

Generic Name Omeprazole

Brand Name Acifre

Drug Proton pump Inhibitor

Classification

Mechanism of Inhibits hydrogen-potassium adenosine triphosphatase (H1/K1 ATP

Action pump), an enzyme on the surface of gastric parietal cells.

Actual Dosage 40mg q12 AC

Suggested 40 mg once daily infused over 20-30 min or slow inj over 5 min until
Dosage oral admin is possible

Indication Short-term treatment (4–8 wks) of erosive esophagitis (diagnosed by

endoscopy), symptomatic gastroesophageal reflux disease (GERD)
poorly responsive to other treatment. H. pylori–associated

duodenal ulcer (with amoxicillin and clarithromycin). Long-term

treatment of pathologic hypersecretory conditions,treatment of active
duodenal ulcer or active benign gastric ulcer. Maintenance healing of
erosive esophagitis.

Contraindicatio Hypersensitivity to other proton pump inhibitors

n

Side Effects Headache.Diarrhea, abdominal pain,

nausea. Dizziness, asthenia (loss of strength, energy), vomiting,

constipation, upper respiratory tract infection, back pain, rash, cough.

Adverse Pancreatitis, hepatotoxicity, interstitial nephritis occur rarely.

Effects

Drug Increased risk of hypomagnesaemia w/ diuretics. May increase INR

Interactions and prothrombin time w/ warfarin. Increased risk of digoxin-induced
cardiotoxic effects. May increase plasma concentration
benzodiazepines (e.g. diazepam), clarithromycin and methotrexate.
Decreased absorption of itraconazole, ketoconazole, posaconazole,
dasatinib, iron salts. May prolong elimination of diazepam, cilostazol,
phenytoin and ciclosporin. May reduce the antiplatelet effect of
clopidogrel. Potentially Fatal: May decrease plasma concentrations
and pharmacological effects of rilpivirine, nelfinavir and atazanavir.

Nursing 1. Consider 10 rights of drug administration

Responsibilitie 2. Monitor therapeutic effectiveness and adverse reactions
s 3. Assess GI system, bowel sounds for pain and swelling
4. Report for occurrence of headache
5. Instruct to limit activities that do not require alertness

Date ordered September 5, 2018

Generic Name Rebamipide

Brand Name Mucosta

Drug Antacid
Classification

Mechanism of Rebamipide is a mucosal protective agent and is postulated to

Action increase gastric blood flow, prostaglandin biosynthesis and decrease
free oxygen radicals

Actual Dosage 1tab TID

Suggested 100 mg tid, in the morning, evening and before bedtime

Dosage

Indication Treatment of gastric mucosal lesions (erosion, bleeding, redness &

edema) in acute gastritis & exacerbation of chronic gastritis; gastric
ulcer. Prevention of NSAID-induced gastropathy.

Contraindicatio Pregnancy and lactation. Elderly

n

Side Effects Rarely hypersensitivity reactions; GI disturbances; increased SGOT,

SGPT, γ-glutamyl transferase, alkaline phosphatase & BUN levels;
leukopenia; mammary gland expansion, nonpuerperal lactation,
menstrual disorder, dizziness, edema & foreign body feeling in the
pharynx.

Adverse Dizziness, drowsiness, dry mouth, constipation, diarrhoea, abdominal

Effects distention, nausea, vomiting, eructation; ALT, AST and BUN
elevation, oedema, hyperbilirubinaemia; gynaecomastia, induction of
lactation, menstrual disorders, hot flushes; leucopenia, leucocytosis,
thrombocytopenia; rash, urticaria, eczema

Drug None known

Interactions

Nursing 1. Monitor for adverse reactions

Responsibilitie 2. Administer drug with meals
s 3. Check BP after administering drug
Date ordered September 5, 2018

Generic Name Silver Sulfadiazine

Brand Name Flammazine

Drug Topical Antibiotic

Classification

Mechanism of Acts only on the cell membrane and cell wall to produce its
Action bactericidal effect. A specific mechanism of action has not been
determined.

Actual Dosage Flammazine cream on Left arm

Suggested Applied directly to the wound in a layer of at least 2-3 mm thick

Dosage

Indication Prevention & treatment of infections in burns & other types of wounds
& infected skin lesions

Contraindicatio Hypersensitivity. Liver damage & oliguria.

n

Side Effects Leukopenia, Skin rash

Adverse Leukopenia, Skin rash

Effects

Drug None known

Interactions
Nursing 1. Clean burn wound first before applying
Responsibilitie 2. Change dressing every 2-3 days
s 3. Reapply cream every 24 hours.
XII. NURSING MANAGEMENT

A.NURSING CARE PLAN

Patient’s Name: ZR Age/Gender: 55/M Room: ICU 9

CC: Changes in Sensorium AP: Dr.A. Lui

Diagnosis: Diffused Large B-cell Lymphoma

DATE CUES NE NURSING OBJECTIVE OF NURSING EVALUATION

/TIME ED DIAGNOSIS CARE INTERVENTIONS

S Subjective: C Altered After 30 minutes 1. Monitor Vital Signs Sept. 03 2018

O Comfort:Pain of nursing R: if the Blood pressure, @ 8:30 pm
E Objective:
G related to interventions the Heart rate and
GOAL
P -Grimace Face N compression of client will be free temperature increases it
PARTIALLY
I Metastasis of from pain as indicates pain
T -Restlessness MET
T Spinal nerves. evidenced by: 2. Provide a quiet
-Non Labored
E I Rationale: environment. After 30
breathing a Normal Vital
V Spinal nerves t11, R: Additional stressors minutes of
M -Bedsore on the Signs
E T 12 and L1 are can intensify patient’s nursing
back b restless
B P responsible for perception and tolerance interventions
-medication: c. absence of
E protecting the of pain. the client is
E Tramadol100 mg 1 grimace face
R spinal cord which 3. Administer Pain free from pain
tab , Flammazine
R C helps vertebrae medication as prescribed as evidenced
Cream
 -CT Scan result of E support the R: to Aid in the patients by;
Mixed Osteoblastic P weight.When there pain
03, a. Normal Vital
and Lytic T is compression it 4. Change position q2
Signs
Metastases of T11, U puts pressure in the R: To prevent further
Temp: 37.1
T12 and L1 A bones thus having pressure thus causing
2 HR: 82 bpm
L pain and altered pain
Vital signs of: RR:13cpm
0 comfort is present
BP: 90/60
Temp: 36.8*C
1 mmHg
HR: 90bpm b. calm
8
c.still presence
RR: 11cpm
of grimace face
BP: 90/60mmHg
@
Atheana Joyce
Basillo, St. N

8PM
DATE CUES NE NURSING OBJECTIVE OF NURSING EVALUATION
/TIME ED DIAGNOSIS CARE INTERVENTIONS

S Subjective: A Ineffective tissue After 1 day of 1. Monitor Vital signs Sept. 4, 2018
perfusion: nursing
E Objective: C R: Obtain baseline data. GOAL
peripheral related interventions the
PARTIALLY
P  O2 OF T to reduced client will have 2. Assist with position
MET
2L/min via capability of the effective tissue changes.
T I
nasal bone marrow to perfusion as After 1 day of
R: Gently repositioning
E cannula V produce red blood evidenced by; nursing
patient from a supine to
 (+) cells interventions
M I a. Absence of sitting/standing position
weakness the client
paleness, can reduce the risk for
B  (+) altered T manifested
orthostatic BP changes.
consciousne Rationale: b. Absence of effective tissue
E Y Older patients are more
ss cold clammy skin, perfusion as
When malignant susceptible to such
R  (+) weak - evidenced by;
cells metastasize to c. Increased HgB, drops of pressure with
pulses on all E the bone, it impairs position changes. a. Increased
extremities d. Maintain SPO2
the bone marrow to Hgb Of 97
03, X within normal 3. Promote
 Pale skin be able to produce
 Cold clammy E range of 96-100% active/passive ROM b Maintained
WBC as well as
skin exercises. SPO2 of 99%
RBC thus reducing e. Vital signs with
2  Edema on R the vehicles to normal range of R: Exercise prevents however, there
lower deliver oxygen to venous stasis and further was still
0 C Temp:
extremities the other parts of circulatory compromise.
c. Presence of
1 and right I the body resulting HR: 60-100bpm
4. Administer paleness
arm to ineffective tissue
8 S RR: 16-20cpm medications as
 Presence of perfusion. d. Presence of
prescribed to treat
slow healing E PR: 60-100bpm cold clammy
underlying problem. Note
lesions on skin
@ BP: 120/80- the response.
back
140/90mmHg e. Vitals signs
 HgB: 93 P R: These medications
of
 Metabolic facilitate perfusion for
3PM A
Alkalosis most causes of Temp: 37.1*C
T impairment.
 Transfused HR: 112bpm
PRBC T 5. Provide oxygen
RR: 22cpm
 SPO2 of therapy as necessary.
E
98% PR:110bpm
 Vital signs R
R: This saturates BP:
of:
N circulating hemoglobin 90/50mmHg
Temp: 36.8*C
and augments the
HR: 90bpm efficiency of blood that is
reaching the ischemic Allana Trebajo
RR: 11cpm tissues. St.N

PR: 88bpm 6. Position patient

properly in a semi-
BP: 90/60mmHg
Fowler’s to high-Fowler’s
as tolerated.

R:Upright positioning
promotes improved
alveolar gas exchange.

7. Elevate edematous
legs as ordered and
ensure that there is no
pressure under the knee.

R: Elevation improves
venous return and helps
minimize edema.
Pressure under the knee
limits venous circulation.

8. Apply support hose as

 ordered.

R: Wearing support hose

helps decrease edema.

9. Observe for signs of

deep vein thrombosis,
including pain,
tenderness, swelling in
the calf and thigh, and
redness in the involved
extremity.

R: Thrombosis with clot

formation is usually first
detected as swelling of
the involved leg and then
as pain.

Date Cues Ne Nursing Objective of Care Implementation Evaluation

Time ed Diagnosis

A O- N Fluid Volume That within 2 weeks 1.) Monitor vital signs GOAL PARTIALLY
Excess r/t span of nursing care, R- to provide baseline data MET
U LABS: U Decrease albumin the patient will have and to especially assess
level decreased fluid After 2 weeks span
G -CT Scan T sinus tachycardia and of nursing care, the
(7/5/18) retention as evidence
U R by: increased BP patient have
 Left Adrenal decreased fluid
R: Albumin is 2.) Monitory input and output
S gland mass I retention as
responsible for the closely
 Spleen mass R- to detect the degree of evidenced by:
T T oncotic pressure A. Balanced I and O
(mild
splenomegaly) which helps retention of the pt. A. Intake
28 I 1061cc
 Mixed maintain fluids in B. VS within normal 3.) Auscultate lungs for
osteolytic & the blood vessels. range adventitious sounds Output 935cc
2 O
blastic Reduced albumin C. Maintain clear R-to assess for fluids (+126)(9/5/18
0 vertebral N levels will decrease lung sounds
present in the lungs )
metastases D. Decrease signs of
oncotic pressure
1 T11 T12 & L1 A edema 4.) Elevate edematous
and the fluids in the
extremities
8 -Albumin L blood vessels R-Elevation increases B. VS:
(8/29/18): would go out and Temp:36.7
7AM - venous return to the heart
17.56g/L (35- cause edema CR:102
50g/L) and in turn decrease
M Reference: RR:13
edema
-Edema on Left E BP:100/70
arm and both Call, D.(2005). The 5.) Administer diuretics as
legs T role of albumin and prescribed
fluids in the body. R-Diuretics aids in the C. Clear lung
-Clear lung A Retrieved on excretion of excess body sounds
sounds September 10, D. No decrease
B fluids in edema
2018. Retrieved at:
 O http://www.vetfolio. 6.) Administer and regulate
com/veterinary- Albumin drip
Vital Signs: L practice-issues/the- R-to help fluid stay within Michael E.
role-of-albumin- Puente,St.N
Temp: 36.7 I vasculature and to
and-fluids-in-the- normalize the pt’s albumin
BP: 90/60 C body
level
RR-12
7.) Reposition client every 2
CR- 90 P hours
R-Repositioning prevents
I and O: A fluid accumulation in
I=2610cc T dependent areas

O=2310cc T
(+300)
E
-IVF of PNSS Reference:
1Liter + 60meq R
Wayne, G.(2016). Excess
KCl @ 80 N fluid volume. Retrieved on
cc/hour
September 10, 2018.
- PNSS 50cc+
Retrieved at
Albumin 20cc +
Furosemide 100 https://nurseslabs.com/excess
@ 5cc/hour -fluid-volume/

DATE CUES NE NURSING OBJECTIVE OF NURSING EVALUATION

/TIME ED DIAGNOSIS CARE INTERVENTIONS

S Subjective: C Altered Level of After 1 day of 1. Assess level of Sept. 4, 2018

consiousness nursing consciousness
E Objective: O GOAL MET
related to increased interventions the and
P  weakness G Calcium levels client will maintain neuromuscular After 1 day of
 (+) altered level of cognition status, including nursing
T N
consciousne R: A high level of as evidenced by; muscle tone, interventions
E ss; GCS I calcium in the blood, strength, and the client
a. Free from
9(Moderate called hypercalcemia, movement. maintained
M T may become a physical
disability R: Nerve and level of
medical emergency. harm
B  Restless I muscle activity is cognition as
This disorder is most b. Relax body
 weak pulses depressed. evidenced by:
E V commonly caused by movement
on all Lethargy and a. patient was
cancer. and facial
R extremities E fatigue can free from
In the brain, calcium expression
 Cold clammy is thought to play a progress to physical
c. VS within
skin particular significant convulsions or injuries
normal
03,  Presence of P role in both health coma
range b. calm and
lesions on and disease. In 2. Review laboratory
E relaxed
back normal amounts, values
2  ABG 8/29/18 R calcium apparently R:assess c. VS:
Hypercalcem triggers signalling
0 C contributing Temp:36.7
pathways essential
ia: 1.63 factors of
1 mmol/L E for certain type of impairment CR:102
Increased memory; in excess, 3. Monitor Cardiac
8 P RR:13
Creatinine calcium is thought to rate and rhythm
cause brain damage. BP:100/70
level: 1.96 T R: Overstimulation
Calcium is
mg/dL of cardiac muscle
@ U intracellular
 SPO2 of occurs with Hillary Jane
messenger capable
98% A resultant R.Reginio, St.N
of activating many
dysrhythmias and
 Vital signs cell functions.
3PM L ineffective cardiac
of:
contraction.
Temp: 36.8*C Reference: 4. Raise side rails
HR: 90bpm P Agarwal, A. (2017, R: protect patient
October 3). The from occurring
RR: 11cpm A
Effects of too much injury
PR: 88bpm T Calcium in the 5. Assess I and O
Brain. Retrieved R: Maintain fluid
BP: 90/60mmHg T
from: and nutritional
 Edema on E https://www.livestro balance
Left arm and ng.com/article/3901 6. Provide means of
R
both legs 85-the-effects-of- communication to
N too-much-calcium- patient
in-the-brain/. R: promote
Retrieved on: normalization of
 September 10,2018 stimuli
Ref: Doengens,M. et al
(2014). Sensory
perception. Nurses
Pocket Guide 13th
Company Philadelphia
Pensylvania

DATE CUES NE NURSING OBJECTIVE OF NURSING EVALUATION

/TIME ED DIAGNOSIS CARE INTERVENTIONS

S Subjective: N Imbalanced That within 1 1.monitor and record GOAL

nutrition: less than week of nursing intake and output PARTIALLY
E Objective: U
body requirement interventions the MET
R: to determine
P T related to disease client will be able
nutritional and After 1 week of
process to:
T - 65 kg R elimination problems nursing
Rationale: a) client interventions
E -Pale skin I 2. Note real, exact
maintain the client;
Adequate nutrition weight; do not estimate
M -Cold clammy skin T weight
is essential to meet a. maintained
B -ectomorph I the body’s b) consume R: These weight
-1,800 kcal/ day demands. Cancer adequate anthropomorphic b. consumed
E O
- Albumin17.5 g/L cells also needs to nourishme assessments are vital adequate
R N adapt their nt that they need to be nourishment
N: 35-50 g/L
metabolism to c) free of accurate. These will be c. free from
A
-calcium 1.94 survive and multiply sign of used as basis for sign of
03, mmol/L L under the malnutritio caloric and nutrient malnutrition
metabolically n requirements
N: 2.12-2.52 -
compromised
mmol/L
2 M conditions provided
-hgt 335 mg/dL by the tumor 3. Promote proper
0 E
microenvironment. positioning
Vital signs of:
1 T Tumor cells alter
R: Elevating the head of
Temp: 36.8*C their metabolism to
8 A bed 30 degrees aids in
maintain
HR: 90bpm swallowing and reduces
B unregulated cellular
RR: 11cpm risk for aspiration with
proliferation and Maria Susan
@ O eating
survival, but this Orlanes St. N
PR: 88bpm
L transformation 4. Provide a pleasant
BP: 90/60mmHg leaves them reliant environment.
3PM I
on constant supply
C R: A pleasing
of nutrients and
atmosphere helps in
P energy. decreasing stress.

A Reference:

T Fadaka, A.,
Ajiboye, B.,Ojo, O.,
T
etc(2017) Biology
E of glucose
metabolization in
R
cancer cells.
N Elsevier Science
Direct
XIII. NURSING THEORY

Dorothea Orem (Self Care Deficit Theory)

Dorothea Orem’s theory is built on an idea

that when a patient is capable to care for
him/her, then they should. However, when
a patient is not capable to care for him/her,
then the nurse can provide guidance.
(Coldwell Foster & Janssen, 1990).
According to Orem nursing is a human
service, it focus on one person with the
inabilities to maintain continuous health
care.

The theory is applicable to our patient because as our patient is diagnosed with Diffused
Large B cell Lyphoma Stage IV and as a student nurse it is our role to take care of the
patient who can’t perform the basic task in life and on the ways. We can suggests
interventions to the family on how they can take care of the patient

Margaret Jean Watson (Philosophy and Science of Caring

Her philosophy was on how

nurse’s expresses care to the
patient.
She adds that caring is central to
nursing practice.

We also choose the theory of

human caring because as what
Watson had said the disease might
be cures, but illness would remain
without caring and heath is not
attained or achieved. We can provide comfort, privacy and safety precautions that can
help them.
DISCHARGE PLANNING( METHOD)

 Instructed to comply medications at

home as ordered at the correct time
religiously.

 Pregabalin 75 mg 1 tab every other

day

 Calvit 1 tab OD @ night

 Paracetamol 500mg 1 tab q4 prn for

fever

 Tramadol 50mg 1 tab q8 RTC

 Aldactone 25 mg tab 1 tab

MEDICATIONS
 Coralan 5 mg 1 tab BID

 Furosemide 40 mg 1 tab

 Omeprazole 40 mg q12 AC

 Mucosta 1 tab TID

 Flammazine cream on Left arm

 If any adverse reactions occur, contact

the physician immediately. Keep a list of
all the medicines taken and bring it all
the times.

 Instructed to perform low- impact

exercises that involves stretching and
passive range of motion, such as, arm
circling, leg raises, etc.
  Advised to rest when the client feels it is
needed.
EXERCISE
 Suggested to maintain a healthy weight.

TREATMENT  Instructed to apply a bandage on skin

lesions to keep it moist and it would
promote faster healing

HYGIENE  Advised to observe proper hygiene

through observation daily routine
hygienic measures, such as taking a
bath regularly, keeping nails well
trimmed, washing hands thoroughly
especially before and after eating and
using the bathroom.

OUT- PATIENT  Attend follow- up check up at attending

physician’s clinic (Dr. Liu) at least within
one week after discharge, to monitor for
the progress of diagnosis.

 Advised to isolate from others who are

sick as the client is at risk for contracting
a severe infection.

DIET  Instructed the client to include food that

are rich in fiber, low fat, and rich in
vitamins and minerals, such as, fruits,
vegetables and meat for protein.
PROGNOSIS

According to the National Cancer Institute, approximately 93% of the patients

diagnosed with regionally contained lymphoma survive for five years. More evolved
diagnostic methods and the latest findings in the field continue to increase patient
survival possibilities. About 65,500 new cases of lymphoma are diagnosed in the US
every year; about 20,000 die from the disease. The average age of death is 75;
women are more likely to survive than men. In stage 1, cancer is limited to a group of
lymph nodes, usually in the neck or armpits; in stage 2, usually more than two
groups of lymph nodes are involved. Stage 3 is diagnosed when cancer has spread
to a series of lymph node groups; and in stage 4, the cancer has already spread to
organs and bone marrow, in addition to the lymphatic system.

The International Prognostic Index (IPI) was first developed to help doctors
determine the outlook (prognosis) for people with fast-growing (aggressive)
lymphomas. However, it has proven useful for most other lymphomas as well (other
than slow-growing [indolent] follicular lymphomas, which are discussed below). The
index depends on 5 factors:

 The patient’s age

 The stage of the lymphoma

 Whether or not the lymphoma is in organs outside the lymph system

 Performance status (PS) – how well a person can complete normal daily
activities

 The blood (serum) level of lactate dehydrogenase (LDH), which goes up with the
amount of lymphoma in the body

Good prognostic factors Poor prognostic factors

Age 60 or below Age above 60

Stage I or II Stage III or IV

No lymphoma outside of lymph nodes, or Lymphoma is in more than 1 organ of

lymphoma in only 1 area outside of lymph the body outside of lymph nodes
nodes

PS: Able to function normally PS: Needs a lot of help with daily
activities

Serum LDH is normal Serum LDH is high

Our client falls under 4 out of 5 of the criteria for poor prognosis .With that, we
can conclude that our client has poor prognosis

REFERENCES

Books:

Capriotti, T. Frizzell, J. (2016) Pathophysiology introductory concepts

and clinical perspectives. F.A. Davis Company. 1915 Arch Street
Philadelphia, PA 19103

deWit, S. Kumagai, C. (2013) Medical- surgical nursing concepts and

practice 2nd edition. Elsevier Saunders. 3251 Riverport Lane St.
Louis, Missouri 63043