Patient Diagnosis:

SQUAMOUS CELL CARCINOMA, LARGE CELL, NON-KERATINIZING, STAGE III B S/P PUNCH BIOPSY 12/15/22, SANTIAGO MEDICAL CENTER, ISABELLA;
S/P 25/25 FRACTURE ERBT 93/28/23; S/P CHEMOTHERAPY CYCLE 6 9CISPLATIN 5/4/23, BGHMC; S/P CHEMOTHERAPY II 9CARBO-PACLI, 7/13/23;
BULKY CERVIX (INELIGIBLE FOR BRACHYTHERAPY), T/C TUMOR PROGRESSION, T/C DVT
GOALS/ RESPONSE &
DATA ACTION/ NURSING INTERVENTIONS RATIONALE
Expected outcomes EVALUATION
STG: within 8 hours of Dxtc: After 8 hours of NI, the
Subjective: NI the patient will be patient
able to - Assess patient’s VS - To make sure the stability of patient’s
✓ Verbalized VS displayed adequate fluid
“sumaksakit tiyan display adequate fluid balance
ko at nasusuka” balance - understand what interventions might be
- Assess the patient’s eating helpful
✓ Verbalized vomiting as manifested by: pattern. as manifested by
after ingesting
food stable vital signs, good - reduces the risk for aspiration with stable vital signs, good skin
skin turgor, prompt Txc: eating turgor, prompt capillary
capillary refill, and - Promote proper positioning refill, and individually
Objective: individually adequate adequate urinary output
urinary output - Administer medications as
✓ Constantly guarding prescribed:
of abdomen - Mechanism of Action: reduces the STG: FULLY MET
LTG: after 72 hours of secretion of gastric acid by reversible
✓ vomited with NI the patient will be binding to histamine (H2) receptors
greenish color at able to: RANITIDINE LTG: after 10 hours of NI the
level of 700cc, 3 - Side Effects: patient was able to:
times achieve a weight within Clay-colored stools
Coughing up mucus
his/her normal BMI range Have a slight change on her
✓ with an ongoing TPN Stomach pain
weight but have not met
Dark urine
of 1400 KCAL as manifested by: within his/her normal BMI
- Nursing Responsibilities: range
✓ appears weak healthy eating patterns > Monitor signs of hypersensitivity
and choices reactions like cough, dyspnea, tightness as manifested by
in the throat or chest
healthy eating patterns and
>Administer oral drug before meals choices

> Decrease doses in renal and liver LTG: PARTIALLY MET

failure
Focus/ Nursing Dx: >Instruct patient to report sore throat,
(PE/S) fever, unusual bruising or bleeding,
tarry stools
Imbalanced Nutrition:
less than body >Instruct not to supplement therapy with
requirements r/t OTC remedies for gastric pain without
physician's advice
present condition as
evidenced by constant
vomiting - Mechanism of Action
PIPTAZ Piperacillin inhibits cell wall synthesis
Piperacillin-Tazobactam by binding to bacterial cell membranes.
Tazobactam inactivates bacterial beta-
lactamase.

- Side Effects:
Nausea
Constipation
Diarrhea
Headache
Trouble sleeping

- Nursing Responsibilities:
> Monitor signs of allergic reactions and
anaphylaxis

> Assess dizziness and confusion

>Tell pt to report adverse reactions or

superinfection promptly

>Instruct to report discomfort at IV

insertion site

- Provide a conducive - To prevent fatigability

environment for rest

Edx:
- Encouraged to do proper hand - To prevent infection
washing
- Advise patient to have - To promote relaxation
adequate rest and sleep
periods

- Educate pt the importance of - To promote lung expansion and improve

DBE oxygenation

- Advised to increase fluid - To avoid dehydration

intake if tolerated

- Encouraged to have small - To supplement body needs

meals and snacks

- Instructed to avoid foods - To prevent gastric/abdominal irritation

that can cause increase
gastric motility like spicy
foods and caffeinated drinks

- Instruct patient to report - To notify physician if severity has

any changes in severity of increased to provide resolution
abdominal pain and vomiting

- Instructed the importance of

- To keep healthy body
well-balanced, nutritious
intake
 PATHOPHYSIOLOGY

Large Cell,
On Treatment S/P
Non-
Medications Chemotherapy
keratinizing

Feeling
Abdominal Pain Appears Weak nauseated upon
ingesting
foods

3 episodes of
With an Small quantity vomiting
ongoing TPN of of snack 650cc,
1400 KCAL greenish in
color

With noted
weight loss

Imbalanced
Nutrition:

less than body

requirements