TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

CLINICAL CASE ANALYSIS

Name of Patient Patient X Age: 61 Gender: Female

Address Bigbiga Mayantoc, Tarlac Date Admitted 01/09/22
Diagnosis Cervical Cancer

NURSING HISTORY

Past Health History:

 She has no known allergies to any drugs or food

 Patient was a smoker, “about 4-5 sticks per day”
 Patient had engaged in sexual intercourse before the age of 18
 Had unprotected sex
 Multiple sexual partners
 Patient had poor utilization of screenings for HPV and Cervical CA
 She was taking medications for hypertension as there were times where her blood pressure was high. Patient stopped taking
medications as her BP has stabilized up until now.
 Patient rarely comes for check ups

Family Health History:

 On her Maternal side, they have a history of Cervical Cancer.

 A history of Hypertension was found on her Paternal side.

Present Health History:

 August 28, 2022:
 Patient was having problems with urination such as experiencing pain
Vaginal Discharge was observed
Pain on her Leg and Pelvic Area
  September 1, 2022:
 Patient was admitted after the results of ordered laboratory test results came out. Her Initial Vital signs were:
BP of 110/ 70 mmHg, PR of 99 bpm, RR of 19 cpm, temperature of 36.8 degree Celsius. Her facial expression suggests that she
was experiencing pain.

PATHOPHYSIOLOGY
DIAGNOSTIC PROCEDURES

Pap smear (Pap test)

Indication: This test looks for precancers, cell changes on the cervix that might become cervical cancer if they are not treated
appropriately.
DIAGNOSTIC DATE INDICATION RESULT ANALYSIS AND NURSING
PROCEDURE PERFORMED INTERPRETATION RESPONSIBILITIES

PAP SMEAR SEPTEMBER Detection of Epithelial Cell Human Before procedure:

1 ,2022 precancers and abnormality was Papillomavirus is - Secure
cell changes in the detected and the leading cause patient’s
cervix. confirmed. of cervical cancer. consent
Infection and - Obtain
replication of patient’s
infected cells has health history
provided the path - Ask for the list
for continuous of patient’s
replication of Viral current
DNA, slowly medications
infecting nearby - Avoid
cells. interfering
factors
- Empty the
bladder
- Explain the
procedure

After the procedure:

- Cleanse the
perineal area
- Provide
sanitary pad
- Provide
information
about the
recommended
frequency of
screening
- Answer any
questions by
the patient or
 family
member.

DIAGNOSTIC DATE INDICATION RESULT ANALYSIS AND NURSING

PROCEDURE PERFORMED INTERPRETATION RESPONSIBILITIES

HPV Test September 1, 2022 An HPV test looks Presence of Human Before procedure:
for DNA from HP. Human Papillomavirus is - Secure
HPV test looks for papillomavirus was the leading cause patient’s
the virus (human detected of cervical cancer. consent
papillomavirus) that Infection and - Obtain
can cause cell replication of patient’s
changes. infected cells has health history
provided the path
for continuous - Explain the
replication of Viral procedure
DNA, slowly
infecting nearby After the procedure:
cells. - Provide
information
about the
recommended
frequency of
screening
- Answer any
questions by
the patient or
family
member,

MEDICAL MANAGEMENT

MEDICAL DATE PERFORMED GENERAL INDICATION CLIENT’S REACTION

 MANAGEMENT DESCRIPTION

Chemotherapy N/A Chemotherapy is a Often used to treat N/A

drug treatment that cancer
uses powerful
chemicals to kill fast-
growing cells in the
body.

MEDICAL DATE PERFORMED GENERAL INDICATION CLIENT’S REACTION

MANAGEMENT DESCRIPTION
N/A Cancer treatment that To kill cancer cells and N/A
Radiotherapy uses high doses of shrink tumors.
radiation to kill cancer
cells and shrink tumors.

NAME ROUTE MECHANISM INDICATION CONTRAINDICATION SIDE EFFECTS NURSING

OF DOSAGE OF ACTION RESPONSIBILITIES
DRUG AND
FREQUENCY

Cisplatin Intravenous Platinum Chemotherapy Anemia Loss of Taste -Ask patient if he/she is
coordination drug that Acute Leukemia allergic to the drug and if
100 mg/m² q4 compound contains Severe Infection Diarrhea he/she has any other
weeks that inhibits platinum. It is allergies
DNA used to slow Nausea
synthesis; or stop cancer -Get medical history
cross-links cell growth. Vomiting
and -Observe the rights to
denatures Loss of appetite medication administration
strands of
DNA; disrupts
DNA function
 by covalently
binding to
DNA bases;
can also
produce DNA
intrastrand
cross-linking
and breakage

NAME OF ROUTE MECHANISM INDICATION CONTRAINDICATION SIDE EFFECTS NURSING

DRUG DOSAGE OF ACTION RESPONSIBILITIES
AND
FREQUENCY

Topotecan Intravenous Binds to Indicated for Hypersensitivity Constipation -Ask patient if he/she is
topoisomerase combination reaction allergic to the drug and if
Hycamtin 0.75 mg/m² IV I to produce therapy with Diarrhea he/she has any other
infused over double strand cisplatin which Pregnant allergies
Antineoplastics 30 mins x3 breaks in DNA works by Nausea
days w/ slowing or Breastfeeding -Get medical history
combination stopping the Vomiting
therapy with growth of Bone marrow -Observe the rights to
cisplatin 50 cancer cells. depression Weakness medication administration
mg/m² every
21-day cycle -Avoid missed doses

Nursing Care Plans

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Altered sleeping After 6 hours of Assist the patient To minimize After 6 hours of
pattern related to pain proper nursing before sleeping on occurrence of pain carrying out the
“I can’t sleep well and discomfort as interventions, the finding the best and discomfort appropriate nursing
because of this manifested by struggle patient will: position of comfort during sleep interventions, the
painful sensation, it in maintaining sleep for the patient. patient exhibited and
feels like burning state and expression of -state the progression completed the
and shooting pains, I tiredness secondary to of comfort and pain standard number of
only slept for about 4 chemotherapy relief Use of non- To decrease reliance hours of sleep, as
hours” pharmacologic to medicines for pain evidenced by having 6-
-Achieve at least 6-7 interventions as relief and increasing 8 hours of sleep, not
Objective: hours of sleep per distraction for pain: comfort. fatigued during
night Music Therapy and daytime, and a more
-Daytime Fatigue Relaxation positive mood. Goal is
-show signs of met.
-Sleepiness during progression from
the day regarding daytime Instruct the patient’s To decrease pain
fatigue significant other to leading the way for
-Eyebags perform a massage comfort, relaxation,
on the different parts and ease tension.
-Altered mood of the patient’s body

Encourage the To immediately

patient to state, address the patient’s
notify, and verbalize concerns preventing
if problems or the occurrence of
concerns occur complications.
regarding the sleep
disturbance.
 INDEPENDENT:

Administer
prescribed
To initiate sleep if
medication for pain
there is still difficulty
after dependent
interventions

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Imbalanced After 8 hours of proper 1.Monitor and To be used for After 8 hours of proper
Nutrition: Less than nursing interventions, Measure the patient’s comparison and nursing interventions,
“I don’t feel like body requirements the patient will weight whether patient the patient’s appetite
eating right now, related to lack of improve nutritional response/interventions has increased, thus
considering that you intake and diet, as well being able to eat the
appetite secondary are working.
served me my as understanding of the recommended diet.
chemotherapy
favorite food, I don’t importance of Patient also displayed
know why” maintaining proper 2.Promote a Noise-free room, well and understood
nutrition. conducive feeding ventilated, and proper knowledge regarding
environment positioning of patient the importance of
Objective: while feeding can maintaining proper
induce appetite and nutrition. Goal is met
Nauseated after promote the intake of
eating food
Decrease in Food 3.Encourage Family Slowly serving food
and Fluid intake members to bring again that the patient
food according to loves to eat can
Unintentional weight
loss what the patient increase appetite,
usually eats. caloric intake thus
Weakness promoting weight
 gain.

4. Provide a diverse
diet according to the Fruits which can be
patient’s nutritional peeled such as
needs. banana, thoroughly
washed vegetables,
bottled, or boiled
water can be of great
help in providing safe
and supplementation
for nutrition. A
patient can eat soft
and plain foods such
as toast and cereal.

5.Instruct patient to Caffeinated beverages

avoid caffeinated tend to make us feel
beverages such as full without even
coffee. actually ingesting
food, thus
contributing more to
the nutritional
imbalance and lack of
appetite.

6.Encourage proper A clean mouth

oral hygiene enhances the taste of
food and promotes a
good appetite.
 7.Educate the patient To impart knowledge
regarding the and information to
importance of eating patient, which she
healthy foods as well will carry even after
as the vitamins and her discharge to the
minerals that our Hospital.
body needs to
function properly

8. Refer the patient Dieticians can assess

to a dietician the patient’s nutritional
status and nutritional
needs. They can even
recommend food to
support nutritional gaps.

Nursing Responsibilities:
Palliative Care:

• Emotional Support
• Relaxation Techniques
• Management of Symptoms (Pain, Fatigue, Nausea, Vomiting, Appetite Loss)
• Sleep problems
• Prevention of Complications due to treatment side effects: (lowered immune system function, upset stomach, dehydration, mouth
sores
• Management of Anxiety
• Relief of Pain and any possible discomfort
• Providing appropriate nutrition
• Proper Hydration

Name of Student
Date Submitted C.I.’s Signature

Form No.: TSU-COS-SF-04 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1