Western Mindanao State University

College of Nursing
Zamboanga City
Alternative Learning System
Related Learning Experience

ASSESSMENT ANATOMY PHYSIOLOGY PATHOPHY ANALYSIS

(ABNORMAL DATA) SIOLOGY
SUBJECTIVE DATA ORGANS INVOLVED DIGESTIVE SYSTEM • Include FINDINGS INTERPRETATION
Subjective cues: DIGESTIVE SYSTEM (Gallbladder) the The patient is a 72-year-old woman
Upon assessment, the Mother
Rectum General Function diagram diagnosed with rectal adenocarcinoma.
verbalized that, “Nupwede gat
iyo mobe-mobe, unrato lang iyo • Controls Defecation – of the Based on the assessment, the patient
ta kansa si ta mobe iyo dimiyo
fecal continence is following: experienced several manifestations that are
kwerpo kabar hinde gat iyo
bunamente ta pwede mobe maintained by significant • Pathogen all related to her disease condition.
dimiyo pyes”.
anatomic structures such as esis • High CEA Test – this test
Objective cues: rectal folds, puborectalis • Life- determines the presence of cancer in
PHYSICAL ASSESSMENT
muscle, the internal and threateni the large intestine and rectum. A
• Patient is awake and
oriented but is slow to external anal sphincters, ng high amount indicates that the
respond and anal valves. Rectal pathways cancer is still present in one’s body.
• Difficulty in moving
muscularis exhibiting Having a high amount also indicates
extremities due to his
condition peristaltic waves and infection of the colorectal area,
• Patient feels fatigued relaxation of the internal chronic smoking, and drinking.

VITAL SIGNS
• Blood Pressure: 140/70
mmHg (N: 120/80 mmHg)
• Heart Rate: 87 bpm (N:
60-100 bpm)
• Respiratory Rate: 19 btm
(N: 12-20 btpm)
• Temperature: 37.2 (N:
36.5-37.2C)
• O2 Saturation: 98 (N: 95-
100)
LAB FINDINGS
• Carcinoembryonic antigen
test – 4.36 (N:<3 mg/mL)
HISTORY
• Undergone sigmoid loop
colostomy and Diagnostic
Laparoscopy to treat
Colorectal Adenocarcinoma
stage IIIB (CT3N1Mx).
• 3 months prior to
consultation, patient
experienced rectal fullness
with association to watery
stools and fetal
incontinence. He also
exhibited weight loss.
and external anal sphincter Since the patient has a higher than
are responsible for normal (4.36) CEA level, it may
stimulating defecation. The suggest that the cancer is still
puborectalis muscle also present in the patient and that the
allows the rectum to disease if further aggravating the
straighten. client’s condition.
• Fatigue, Weight Loss – Patients
with rectal adenocarcinoma usually
stems from fatigue as the local
growth of tumor provides a mass
effect which leads to the
compression of the stomach. The
compression of the stomach
decreases that appetite of the patient
since there will be little space for
food to be digested. This causes
weight loss to the patient, thus,
decreasing their body’s energy
supply, and this will lead to having
lower energy supply which causes
the client’s physical energy to have
a higher demand than supply. This
• 1 month prior to admission, will cause the patient to be fatigued
condition persisted with and lethargic due to the exhaustion
hematochezia and goat-like
of energy in the body. Weight loss
stools.
can also be seen as the client is not
DIAGNOSTIC
meeting their daily nutrient
PROCEDURES
requirements.
• Assessment
• Melena and Watery Stools –
• Physical Exam
patients with colorectal carcinoma
• Exploratory Laparotomy
often experience Black Tarry stools,
• CEA are often indicative of rectal
adenocarcinoma. In the rectum,
rectal adenocarcinoma is usually
present in cases where cancer will
now invade the rectal sphincter,
muscles, vessels, and nerves. This
complication will lead to black tarry
stools during as bleeding may have
undergone the digestion process.
LABORATORY EXAMINATION
INDICATIONS
Component Value Indicati
on
CEA 4.36 High
than
normal
(N: <3)

1. High CEA – CEA measures the

client’s potential for cancer and if
has spread to other parts of the body

SIGNIFICANCE OF ABNORMAL
RESULTS
1. Due to the patient’s condition, it was
possible that several signs and
symptoms that are noted. The
client’s complaint of rectal mass
along with the current finding of
having an elevated
carcinoembryonic antigen result.
 These assessments and tests indicate
the patient’s main diagnosis, which
is rectal adenocarcinoma, as he is
exhibiting the indications.
2. Melena and weight loss indicate the
progression of the disease. Melena
may be due to the growth of the
tumor in the rectum and it can also
progress to being metastatic wherein
immune cells release cytokines
which leads to metabolic
abnormalities and high energy use,
thus, induces weight loss to the
patient.
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