Document1

CHAPTER I

CASE OVERVIEW

Introduction

Hepatoma is the one of the most common cancer in the world with 1

Million new cases diagnosed every year. Roughly 20,000 new cases are

diagnosed every year in United States. It is more frequent in men and

Oriental-Americans. The average age at the time of diagnosis is 60

years. Cancer of the liver can grow for a long time without causing

any problems. Most patients are diagnosed in advanced stages. If left

untreated, or if it fails to respond to treatment, liver cancer can

spread to the rest of normal liver, causing liver failure, and also

to lymph glands in the abdomen and lungs.

This is the case of Ms. L. C., 88 years old, from Manjuyod,

Negros Oriental, who was admitted last April 12, 2011 at Negros

Oriental Provincial Hospital due to edema on lower extremities,

weakness and epigastric pain. She was diagnosed with Hepatoma Right

Lobe Metastasis Lungs Right-side Hypertrophy by Dr. V. J. T. She was

attended to, and medicated, and has underwent several laboratory exams

yet her condition worsened due to poor prognosis.

Though the case was personally given by the clinical instructor,

the presenters find reasons to continue with the case. First, it is a

unique and interesting case, knowing that it is about cancer which is

a rare case a student nurse can encounter and handle. Secondly, health

history of the patient is quite enough to support the diagnosis,

especially the manifestations and laboratory results. And lastly, they

take this as a challenge since they have not yet had any discussion on

oncology in their year level that would hopefully help in the

understanding and analysis of Hepatoma.

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Objectives

In this clinical paper, the presenters have the following goals:

1. Describe the structure of a cell and the process of cell

proliferation and differentiation, discuss the normal anatomy and

physiology of the related systems which are the respiratory,

cardiovascular and systems and how their functions are altered in

the presence of Hepatoma, Right Lobe Metastasis Lungs, and Right-

sided Hypertrophy.

2. Show the current health status of the patient through thorough

physical assessment, laboratory examinations, as well as

diagnostic procedures of which the patient underwent.

3. Relate theories from books and other sources with the actual data

gathered from the patient during interaction and assessment.

4. Create a comprehensive pathophysiology to trace the pathogenesis

of the disease processes starting from the precipitating and

predisposing etiologic factors down to the complications,

including the clinical manifestations and their corresponding

interventions.

5. Formulate SMART nursing care plans that are effective and

efficient in enhancing the well-being of the patient and

alleviating the progression of the disease, and prioritize them

accordingly.

6. Justify all medical and nursing actions applied to the patient.

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Scope

The gathering of data and patient interaction was done for 4hours

during the clinical exposure and on the final visit later in the

afternoon of same day. Within this clinical paper is the discussion of

the information related to the care and condition of the patient

during her present hospitalization; the contents include the physical

assessment, laboratory results with their corresponding

interpretations, background of the normal anatomy and physiology of

the affected systems, theoretical background of the admitting

impression in connection to the patient’s status and manifestations,

the pathophysiology designed to trace the progression of the disease

process and the measures provided to solve each existing problems and

manifestations, the effectiveness of these interventions reflected on

the progress notes, and proposed discharge planning for the promotion

of the patient’s well-being.

Limitations

In the process of making this clinical paper, the group

encountered some limitations which are the following:

1. No data about the patient’s grandparents were gathered

because those people died before she was born and was not

told by her parents about their causes of death.

2. Health history and other pertinent data were only limited

to the patient’s responsiveness and SO’s knowledge.

3. Discussion on the pathology of the disease, particularly

Hepatoma, is limited only to the presentors’ own

understanding through researching since the topic cancer

was not yet included in their classroom discussions.

4. Some laboratory exams were taken only once, so tracking

of the disease progression is also limited.

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CHAPTER II

CASE DATA AND INFORMATION

BIOGRAPHICAL DATA

Name: L. C.

Address: Manjuyod, Negros Oriental

Age: 88 years old

Gender: Female

Birthplace: Manjuyod, Neg. Or., via home delivery

Birth Date: August 10, 1922

Civil Status: Single

Religion: Roman Catholic

Nationality: Filipino

Educational Attainment: Elementary Undergraduate

Health care financing: none

Date of Admission: April 12, 2011 at 10:26 PM

Final Diagnosis: Hepatoma Right Lobe, Metastasis Lungs Right-sided

Hypertrophy

Physician: Dr. V. J. T.

Source of information: Patient: 20%

SO: 30%

Patient’s chart: 50%__

100%

CHIEF COMPLAINT

“Abtik paman ni siya atong Enero-Pebrero, makalakaw-lakaw pa gud

ni siya; nikalit lang man siya ug kaluya, dayon mao lagi ning iyahang

dire (referring to the abdomen) nidako man, nisamot pud ang hubag sa

iyang batiis,” as verbalized by the patient’s sister.

PRESENT HEALTH HISTORY

One month prior to admission, patient started to experience

swelling on lower extremities, epigastric pain and body weakness. She

consulted a local physician and was medicated. By end week of March,

her condition worsened. She became bed-ridden and her abdomen became

bigger and harder. The edema on her lower extremities also worsened,

and was associated with pitting. April 12, 2011, at around 9:00 in the

evening, patient was brought to Bais District Hospital due to the

worsening condition. She was received at the Emergency Department and

was hooked with IVF of D5NS at 15gtts/min. She was then referred

immediately to Negros Oriental Provincial Hospital via ambulance. She

was then admitted at 10:26 PM in the said hospital.

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PAST HEALTH HISTORY

Childhood illness: fever, common cough and colds

Childhood immunization: no knowledge about patient’s immunizations

Hospitalizations: present is the first hospitalization

Surgeries: has not undergone any surgery, both minor and major

Allergies: no known allergy to foods

Accidents and Injuries: no history of accidents and injuries

Serious Illnesses: no known serious illnesses by history

Medications: uses herbal medicines like mayana, decoction of guava

leaves, heated atis leaves and pound malunggay cloves

Recent Travel: no other travel outside Negros Oriental than

transportation from Manjuyod to Dumaguete for hospitalization

FAMILY HEALTH HISTORY

Legend:

- female

- male

- patient

AW - alive and well

LP - Liver Problem

+ - deceased

OA - Old Age

Hem - Hematemesis

HTN - hypertension

OD - occasional dyspnea

JP - joint pain

93,+ 105,+

LP OA

82,+ 80,AW 78,JP, 78,OD

Hem HTN

Interpretation:

Patient’s mother died at the age of 93 due to liver problem. Her

father died at 105 years old due to old age. She has 4 siblings. Her

sister next to her died at the age of 82. They do not know the exact

problem, yet they claimed that she vomited blood. The only male among

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her siblings has been experiencing joint pain and hypertension. The

youngest has been having difficulty in breathing occasionally. Data

about the patient’s grandparents were not taken due to her limited

ability to speak and SO has no knowledge about such.

PSYCHOSOCIAL PROFILE

Health Practices and Belief: Patient believes in the effectiveness

of herbal medicine and that prayers can heal sickness/illnesses.

Usually use herbal medicines to cure illnesses like cough,

bruises, and wounds. She also believes in quack doctors and

“hilots”.

Typical Day: Patient usually wakes up at around 5:00 in the morning

and drinks coffee with bread for breakfast. Then she walks around

the house, and does her gardening activity. After which, she goes

to market with a “nigo” filled with dried tobacco leaves for

business. She takes “pot-pot” as her transportation to get

there. She goes home for lunch at around 12:00 and takes her

rest after eating for about 30 minutes to an hour. She goes to

market again to continue selling. She arrives home at around 5:00

in the afternoon. She eats her dinner with her niece, who lives

with her as her adopted, at around 6:00-7:00 in the evening.

She watches TV at night and retires to bed sometimes at

9:00PM, but usually by 8:00PM. By March, she started to become

weak and eventually went into being bed-ridden.

Nutritional Patterns: Patient usually eats vegetables in a menu of

“law-oy” and fish, most often, dried salty fish and “ginamos”.

She eats corn, not rice. She has a regular eating pattern and

complete 3 meals a day, no snacks in between. She uses spoon for

eating. She can consume a maximum of 2 glasses of water after

meal. She started to loss her appetite when she became ill. She

can barely consume her food served on a plate. She also started

to lose weight.

Activity and Exercise: She goes up and down from their room by a 5-

step stair and walks around the house every morning and does

her gardening. She does not walk anywhere else, she just ride

“pot- pot” for transportation. By the time she became weak, she

seldom go downstairs, until she became bedridden.

Elimination Pattern: She urinates 2-3 times a day with dark colored

urine, about a glass in quantity, and defecates usually once a

day and sometimes never at all. When she became bedridden, she

wears diaper. She seldom defecates, usually every other day. She

uses 2-3 diapers a day, and gets changed by the help of her

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adopted daughter.

Sleep/rest: She usually gets 9hours of sleep at night time and

30minutes to an hour at noon. She has no sleep disturbance; she

only wakes when she urinates. During the occurrence of the

problem, her sleeping pattern changed. She cannot sleep well at

night. She complains of abdominal pain associated with difficulty

in breathing.

Personal Habits: She is neither a smoker nor an alcoholic, yet she

experienced drinking once when she was adolescent.

Occupational and Socioeconomic Health Pattern: Her income in selling

tobacco is their major source of money for their daily

consumptions. Her nieces and nephews sometimes give her money or

goods. Her siblings also share some food to her when they have

enough. When she became weak, she stopped selling; her other

family members supports her in the needs and expenses.

Environmental Health Patterns: She lives in a separate house just

beside her sister’s. With her is her adopted daughter, her niece,

who helps around. The house is a small 2-storey hut, with a

“sinibit” roof. The stair leading to their bed room has 5 steps

made of bamboo. She sleeps on a wooden bed, covered with a

“banig”, beside her adopted daughter. The surrounding is a non-

cemented land with few trees and plants. Their source of water is

“flowing” where they connected a hose directly towards their

household. They use pour flush as their toilet facility. The

house location is just near the street, with other neighboring

houses. The market is about 15meters away.

Cultural influences and religious/spiritual influences: She believes

in quack doctors and “hilots”, but she believes most in God.

Their family has a tradition of not taking a bath on Wednesdays

and Fridays because for them this may cause illnesses and death

of a family member. She goes to Church on Sundays with her

adopted and sometimes with her sister.

Sexual pattern: Patient never got married, but experienced having

suitors and boyfriends during her adolescence. (Detailed

information about this was not taken due to limited ability to

speak, and her sister has no knowledge about it).

Social Support: She is well-loved by her siblings, nieces and

nephews. She receives all types of support from her family, may

it be physiological, emotional, or spiritual. They share with one

another what they have and solve problems immediately.

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REVIEW OF SYSTEMS

Assessment (April 16, 2011 at 8AM) Assessment (April 16, 2011 at 4AM)

General Survey

Pt. is 88 years old, female,

oriented to place and person only,

appears emaciated, awake and

responsive to verbal communication,

with slurred speech in a low tone

voice, but unable to maintain eye

contact; scratching on elbows

noted; wearing adult diaper; with

ongoing IVF of D5NM 1L running at

KVO rate, infusing well at left

metacarpal vein, with a level of

800mL; O2 therapy of 2-4L/min via

nasal cannula, and NGT passing into

the right nostril.

Vital signs of: 36. 2 °C, afebrile;

87 bpm, regular but weak; 22 cpm,

deep, with use of accessory

muscles; 110/70 mmHg

INTEGUMENTARY SYSTEM

Skin

-Inspection: jaundice noted on

palms and soles, sagging skin on

upper extremities, shiny skin

surfaces on edematous lower

extremities noted; visible

muscle wasting

-Palpation: rough skin texture

on upper extremities, smooth on

lower extremities; warm to

touch; pitting noted on lower

extremities edema of grade 2

Hair

-Inspection: body hair noted all

over, but with less hair growth

on lower extremities

Nails

-Inspection: pale, intact, firm,

adhere well to nail bed, and

absence of clubbing; cuticles

are pale as well as nail beds;

-Palpation: poor capillary

refill of 3 seconds on upper

extremities, (lower extremities

General Survey

Condition worsened associated with

rigidity on upper lip, inability to

open eyes, blood stains noted in

oral area, inability to speak,

unresponsive to verbal command;

still with ongoing IVF of D5NM 1L

running at KVO rate, infusing well

at left metacarpal vein, with a

level of 300mL; O2 therapy of 2-

4L/min via nasal cannula, and NGT

passing into the right nostril.

Level of orientation not assessed

due to inability to speak

Vital signs of: 38.9 °C, febrile;

96 bpm, regular but weak; 28 cpm,

deep, use of accessory muscles;

90/60 mmHg

---SAME---

---SAME--

---SAME---

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not assessed due to presence of

nail polish)

HEENT

Head and face

-Inspection: head size

appropriate to age, white hair

evenly distributed on scalp;

less facial movements upon

communication,

-Palpation: scalp slightly

mobile, no lessions

Eyes

-Inspection:pallor conjunctivae

noted

(visual acuity, accommodation

and extraoccular movement not

assessed due to patient’s

inability to maintain eye

opening)

Nose

-Inspection: nose located

midline with symmetrical nares,

nasal flaring noted, no

drainage, with O2 cannula

connected, and NGT inserted into

right nares

Neck and Throat

-Inspection: lips midline,

symmetrical, appears dry with

cracks noted; has 6 teeth,

yellow discoloration noted; neck

erect and midline; (gag reflex

not assessed due to inability to

open mouth widely, and tolerance

to procedures)

-Palpation: no lumps or masses

on neck

RESPIRATORY SYSTEM

-Inspection: trachea located

midline, no deviation; bulging

of chest on right side noted,

use of accessory muscles noted

upon breathing, nasal flaring

noted, with O2 therapy of

2-4L/min via nasal cannula; with

---SAME---

Additional: jaw jutting noted

---SAME---

---SAME---

---SAME---

Additional: rigidity on upper lip

noted, with blood stains in the oral

area

---SAME---

Additional: breathing through mouth

noted; with RR of 28 cpm, deep, use of

accessory muscles

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RR of 22 cpm, deep, with use of

accessory muscles

Auscultation:Diminished

peripheral sounds on right lung

field

CARDIOVASCULAR SYSTEM

-Inspection: visible carotid

pulsation, observable neck vein

distention, positive pulsation

at epigastric area noted,

visible blood vessels on

extremities

-Palpation: bounding heart beat

on apex, weak peripheral pulses,

pulse on lower extremities

nonpalpable; with a pulse rate

of 87 bpm, regular but weak

-Auscultation: loud heart beat,

no extra heart sound heard; with

a BP reading of 110/70 mmHg

ABDOMEN

-Inspection: Caput medusa noted

extending from the umbilicus;

umbilicus midline and inverted

with no discharges;positive

pulsation noted, rounded abdomen

with assymetrical contour

-Auscultation: hypoactive bowel

sounds on all quadrants: 1 on

LLQ, 2 on RLQ, 1 on RUQ, and 1

on LUQ

-Palpation: hard and rigid

MUSCULOSKELETAL SYSTEM

-Inspection: measurement of

extremities are the following:

Right arm length of 69 cm with a

circumference of 17.5 cm; Left

arm length of 69 cm with a

circumference of 18 cm; Right

leg is 80cm in length and 42.5cm

in circumference; Left leg is

81cm in length and 41cm in

circumference; asterixis noted

on both arms and hands

-Palpation: pitting noted on

lower extremities edema of grade

---SAME---

-with a PR of 96 bpm, regular but

weak; with a BP of 90/60 mmHg

---SAME---

---SAME---

Additional: 0 muscle strength on both

upper and lower extremities, no active

range of motion & no palpable muscle

contraction (paralysis)

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2; muscle strength on lower

extremities is 0, no active

range of motion & no palpable

muscle contraction (paralysis);

2 on upper extremities, reduced

active range of motion & no

muscle resistance

(posture, gait, balance and

coordination not assessed due to

patient’s inability to stand and

walk)

NEUROLOGIC SYSTEM

Cerebral Functions

-awake, responsive to verbal

communication, with slurred

speech in a low tone voice

-GCS score of 11/15 (Moderate

brain injury):

Eye = 4, eye opens

spontaneously

Verbal = 2, incomprehensible

Motor= 5, localizes to pain

Cranial Nerves

(not assessed due to patient’s

limited response and tolerance)

REPRODUCTIVE SYSTEM

(not assessed due to wearing of

diaper)

---SAME---

Additional: unconscious, unresponsive

to any command

-GCS score of 3/15 (severe brain

injury):

Eye = 1, no eye opening

Verbal= 1, no verbal response

Motor= 1, no motor response

--SAME—

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Diagnostic Imaging Studies

Taken on April 13, 2011

CHEST X-RAY (PA)

This is to visualize the physical structure of the lungs to rule out

abnormalities, specifically consolidation on the lung parenchyma.

Result:

Massive right sided hydrothorax noted. Hidden pulmonary mass cannot be

ruled out

Interpretation:

This result shows that there is the passage of ascites from the

peritoneal to the pleural cavity through small diaphragmatic defects.

Patients with advanced cirrhosis and portal hypertension have abnormal

extracellular fluid volume regulation that in most cases results in

accumulation of fluid, typically in the abdominal cavity (ascites) or

lower extremities (edema). The negative intrathoracic pressure

generated during inspiration favors the passage of fluid from the

intra-abdominal to the pleural space.

April 13, 2011

ULTRASOUND – WHOLE ABDOMEN

- The liver is enlarged with multiple echogenic masses seen in

the right lobe. Minimal free fluid noted in the hepatic

recess.

- The pancreas, spleen, and kidneys are sonographically normal

- The gallbladder and urinary bladder with normal wall thickness

and echofree

- The uterus and ovaries are technically difficult to imague due

to bowel gas

Remarks:

1. Solid hepatic masses. Consider primary new growths

2. Non-visualization of uterus and ovaries due to bowel gas.

-Suggest: Transvaginal or transrectal ultrasound for better

visualization

3. The other visualized organs are sonographically

unremarkable

Interpretation:

Cancer starts with damage to DNA (a nucleic acid that contains the

genetic instructions used in the development and functioning of all

12

http://en.wikipedia.org/wiki/Genetics

http://en.wikipedia.org/wiki/Nucleic_acid

known living organisms ). This damage causes changes in these

instructions. Liver cancer also occurs as metastatic cancer, which

happens when tumors from other parts of the body spread (metastasize)

to the liver. In the liver cancer, some cells begin to grow

abnormally. One result is that cells may begin to grow out of control

and eventually form a tumor/mass of malignant cells.

Laboratory Examinations

April 12, 2011

Hepatitis B surface antigen (HBsAG) - Protein that is present on the

surface of the virus; will be present in the blood with acute and

chronic HBV infections

Often used to screen for and detect HBV infections; earliest indicator

of acute hepatitis B and frequently identifies infected people before

symptoms appear; undetectable in the blood during the recovery period;

it is the primary way of identifying those with chronic infections.

Result:

Reactive

Interpretation:

This result shows that patient is positive for hepatitis B. Hepatitis

B virus has three antigens for which there are commonly-used tests -

the surface antigen (HBsAg), the core antigen (HBcAg) and the e

antigen (HBeAg). Markers found in the blood can confirm hepatitis B

infection and differentiate acute from chronic infection. These

markers are substances produced by the hepatitis B virus (antigens)

and antibodies produced by the immune system to fight the virus.

TUBE METHOD: FORWARD AND REVERSE TYPING RH TYPING

Anti-A Anti-B Anti-D Known A Known B

0 4+ 4+ 2+ 0

Type B+

April 12, 2011, 12:50 am

RANDOM BLOOD SUGAR TEST

Random blood sugar (RBS) measures blood glucose regardless of when the

person last ate. Several random measurements may be taken throughout

the day. Random testing is useful because glucose levels in healthy

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http://en.wikipedia.org/wiki/Organism

people do not vary widely throughout the day. Blood glucose levels

that vary widely may mean a problem. This test is also called a casual

blood glucose test.

Result Normal Range

RBS 76 mg/dl 45-130 mg/dl

April 12, 2011, 2:08 am

Complete Blood Count

The CBC is used as a broad screening test to check for such disorders

as anemia, infection, and many other diseases. It is actually a panel

of tests that examines different parts of the blood

Results Normal Range Remark

Hemoglobin 12.4 g% 12-14 g% Normal

Hematocrit 40.4 vol% 37-44 vol% Normal

WBC Count 6.600 T/cumm 5-10 T/cumm Normal

Differential Count:

Neutrophil Seg 78% 55-60% Increased

Lymphocytes 17% 20-35% Decreased

Monocytes 4% 1-6% Normal

Eosinophils 1% 1-4% Normal

Basophils - 0-0.5% Normal

Platelet Count 188,000 150-400 T/cumm Normal

Interpretation:

A high neutrophil count can be caused by cancer spreading in the body.

Cancer is a group of diseases in which symptoms are due to an abnormal

and excessive growth of cells in one of the body organs or tissues. A

cell is the smallest, most basic unit of life, that is capable of

existing by itself. Abnormal values of the differential count suggest

infection or may be altered process of cellular differentiation.

April 13, 2011, 2:02 am

ELECTROLYTES

The electrolyte panel is frequently ordered as part of a routine

physical, either by itself or as components of a basic metabolic

panel or comprehensive metabolic panel. It is used to screen for an

electrolyte or acid-base imbalance and to monitor the effect of

treatment on a known imbalance that is affecting bodily organ

function. Since electrolyte and acid-base imbalances can be present

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http://www.labtestsonline.org/understanding/conditions/anemia.html

with a wide variety of acute and chronic illnesses, the electrolyte

panel is frequently ordered for hospitalized patients and those who

come to the emergency room.

Sodium 140.6 mmol/L 135-148 mmol/L

Potassium 3.44 mmol/L 3.5-5.3 mmol/L

April, 14, 2011 - 9:51:45 am

BLOOD CHEMISTRY - SERUM

Assays Results Normal Range Details

BUN 61 mg/dl 11-36 mg/dl High

Creatinine 1.08 mg/dl 0.57-0.9 mg/dl High

Uric Acid 7,2 mg/dl 2.5-6.8 mg/dl High

Cholesterol 202 mg/dl 0-200 mg/dl High

Triglycerides 61 mg/dl 0-250 mg/dl Normal

Chol-HDL 9 mg/dl 45-65 mg/dl Low

Chol-LDL 181 mg/dl 0-150 mg/dl High

SGPT 96 U/L 0-36 U/L High

Interpretation: most results are high which indicate dysfunctional

liver, probably liver failure. Liver fails to do its normal functions

properly.

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CHAPTER III

LITERATURE REVIEW

Normal Anatomy and Physiology

Cells make up the smallest level of a living organism such as

yourself and other living things. The cellular level of an organism is

where the metabolic processes occur that keep the organism alive. That

is why the cell is called the fundamental unit of life. Cells are sacs

of fluid surrounded by membranes. Inside the fluid float chemicals and

organelles. An organism contains parts that are smaller than a cell,

but the cell is the smallest part of the organism that retains

characteristics of the entire organism. For example, a cell can take

in fuel, convert it to energy, and eliminate wastes, just like the

organism as a whole can. But, the structures inside the cell cannot

perform these functions on their own, so the cell is considered the

lowest level. Therefore, cells not only make up living things; they

are living things. The most important characteristic of a cell is that

it can reproduce by dividing. If cells did not reproduce, you or any

other living thing would not continue to live. Cell division is the

process by which cells duplicate and replace themselves.

The cell-division cycle is a vital process by which a single-

celled egg develops into a mature organism, as well as the process by

which hair, skin, blood cells, and some internal organs are renewed.

Cell Division:

Interphase Time between

divisions

Protein synthesis

carried out

Chromatin present

Nucleolus present

DNA replicated

towards division

time

Prophase Chromatin thickens

into chromosomes

Nuclear membrane

disintegrates

Centriole pairs

move to opposite

ends of the cell

Spindle fibers

begin to form

Metaphase Guided by the

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spindle fibers, the

chromosome pairs

line up along the

center of the

spindle structure

Anaphase The chromosome

pairs (sisters)

begin to pull apart

Once separated,

they are called

daughter

chromosomes

Due to pull, many

chromosomes bend

Groove in plasma

membrane present

Telophase Chromosomes return

to chromatin

Spindle

disintegrates

Nuclear membrane

takes shape again

Centrioles

replicate

Membrane continues

to pinch inward

(in plant cells a

new cell wall is

laid)

When the process is complete, each cell will have the same genetic

material that the original cell had before replication. Each of the

daughter cells is also identical to each other. Note that once

telophase is complete, the cell returns to interphase.

In either case it is the completion of the cell cycle that produces

new organisms, a process that can go on throughout life by forming a

group of cells to form a tissue that composed an organ, which

comprises a system just like the respiratory system, Gastrointestinal

system, that are responsible in maintaining homeostasis.

Cell Differentiation

17

Within the bone marrow there is a pluripotent stem cell. This stem

cell is the “Mother Cell” or the originator of all blood cells. It has

the ability to self-renew and create progenitor stem cell lines. They

are naturally limited in number.

By reviewing the diagram, you can see that all cells come from the

stem cell. An attack on the stem cell can theoretically affect all of

them similarly.

THE RESPIRATORY SYSTEM

The respiratory system is a group of organs and tissues that help you

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breathe. The main parts of this system are the airways, the lungs and

linked blood vessels, and the muscles that enable breathing.

Respiratory system is divided into two tracts: upper respiratory tract

(nose, pharynx, larynx, and trachea), and lower respiratory tract

(bronchus, bronchioles, and alveoli).

The Pathway

Air enters the nostrils

passes through the nasopharynx,

the oral pharynx

through the glottis

into the trachea

into the right and left bronchi, which branches and rebranches

into

bronchioles, each of which terminates in a cluster of

alveoli

LUNGS

The lungs are the body's major organs of respiration. The two

vital parts that make up the lungs are located on each side of the

chest within the rib cage. They are separated by the heart and other

contents of the mediastinum. The top, or apex, of each lung extends

into the lowest part of the neck, just above the level of the first

rib. The bottom, or base, of each lung extends down to the diaphragm,

which is the major breathing-associated muscle that separates the

chest from the abdominal cavity.

Each lung is divided into upper and lower lobes. The right lung is

larger and heavier than the left lung, which is somewhat smaller in

size because of the position of the heart. The root connects the lungs

to the heart and the trachea (windpipe). Each root is made up of a

main stem bronchus (large air passage connecting the windpipe to the

right or left lungs), pulmonary artery (major artery that brings

oxygen-poor blood back to the right or left lungs), pulmonary vein

(major vein receiving oxygen-rich blood from the lobes of the right or

left lungs), the bronchial arteries and veins, as well as nerves and

lymphatic vessels. A clear, thin, shiny covering known as pleura,

which covers the lungs. The inner, visceral layer of the pleura is

attached to the lungs and the outer, parietal layer is attached to the

chest wall. The trachea splits into right and left main stem bronchi.

These are the major air passages from the trachea to the lungs and are

similar to the trachea in tissue composition. The tracheobronchial

tree conducts, humidifies, and heats air that is breathed in, or

inspired. At its endpoints, the tracheobronchial tree connects with

19

the blood vessels. The lining of the tracheobronchial tree is composed

of columnar epithelium (column-shaped surface cells) and glands that

produce mucus and serous (clear plasma) fluid. The cilia (hair-like

projections on columnar epithelium) move in a constant, beating motion

to cleanse the airways of foreign bodies and infectious organisms. A

watery "mucous blanket" - a gel-like liquid - covers and is moved by

the cilia and aids the lungs' self-cleaning. Coughing triggers a high-

speed flow of air that mobilizes the mucous blanket. The sputum

produced by such mobilization contains mucus, nasal secretions, and

saliva. The essential tissue of the lung—lung parenchyma—is made up of

clusters of spongy air sacs called lobules. Each lobule contains about

2,200 alveoli (air sacs and ducts) and have connective tissue

coverings are called segmental bronchi. The smallest subdivisions, and

do not have connective tissue coverings, are called bronchioles. The

final branches of the bronchioles are called terminal bronchioles. The

bronchioles end in irregular, swollen projections known as alveolar

ducts (terminal branches composed of special gas-exchanging tissue)

and alveolar sacs (blind passages of alveolar ducts).

The alveolar sacs are tiny, thin-walled, cup-shaped structures are

lined with a detergent-like substance known as surfactant, which

reduces surface tension and prevents them from collapsing during

breathing.

Functions of the Respiratory System

Providing large area for gas exchange between air and circulating

blood.

Moving air to and from the gas-exchange surfaces of the lungs.

Protecting the respiratory surfaces from dehydration and

temperature changes and defending against invading pathogens.

Producing sounds permitting speech, singing, and non-verbal

auditory communication.

Providing olfactory sensations to the central nervous system for

the sense of smell.

How the Lungs Work

The lungs expand upon inhalation, or inspiration, and fill with air.

They then return to their resting volume and push air out upon

exhalation, or expiration. These two movements make up the process of

breathing, or respiration.

The respiratory system contains several structures. When you breathe,

the lungs facilitate this process:

1. Air comes in through the mouth and/or nose, and travels down

through the trachea, or "windpipe." This air travels down the

trachea into two bronchi, one leading to each lung. The bronchi

20

then subdivide into smaller tubes called bronchioles. The air

finally fills the alveoli, which are the small air sacs at the

ends of the bronchioles.

2. In the alveoli, the lungs facilitate the exchange of oxygen and

carbon dioxide to and from the blood. Adult lungs have hundreds

of alveoli, which increase the lungs' surface area and speed this

process. Oxygen travels across the membranes of the alveoli and

into the blood in the tiny capillaries surrounding them.

3. Oxygen molecules bind to hemoglobin in the blood and are carried

throughout the body. This oxygenated blood can then be pumped to

the body by the heart.

4. The blood also carries the waste product carbon dioxide back to

the lungs, where it is transferred into the alveoli in the lungs

to be expelled through exhalation.

The Lungs' Protections

Several lung parts and functions act as protective mechanisms to

keep out irritants and foreign particles. The hairs and mucus in the

nose prevent foreign particles from entering the respiratory system.

The breathing tubes in the lungs secrete mucus, which also helps

protect the lungs from foreign particles. This mucus is naturally

pushed up toward the epiglottis, where is passed into the esophagus

and swallowed.

Mechanisms of breathing

To take a breath in, the external intercostal muscles contract,

moving the ribcage up and out. The diaphragm moves down at the same

time, creating negative pressure within the thorax. The lungs are held

to the thoracic wall by the pleural membranes, and so expand outwards

as well. This creates negative pressure within the lungs, and so air

rushes in through the upper and lower airways.

Expiration is mainly due to the natural elasticity of the lungs, which

tend to collapse if they are not held against the thoracic wall. This

is the mechanism behind lung collapse if there is air in the pleural

space (pneumothorax).

Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form

very narrow terminal bronchioles, which terminate in the alveoli.

There are many millions of alveoli in each lung, and these are the

areas responsible for gaseous exchange, presenting a massive surface

area for exchange to occur over.

Each alveolus is very closely associated with a network of capillaries

containing deoxygenated blood from the pulmonary artery. The capillary

and alveolar walls are very thin, allowing rapid exchange of gases by

21

passive diffusion along concentration gradients.

CO2 moves into the alveolus as the concentration is much lower in the

alveolus than in the blood, and O2 moves out of the alveolus as the

continuous flow of blood through the capillaries prevents saturation

of the blood with O2 and allows maximal transfer across the membrane.

THE LIVER

The liver fills the right and center of the upper abdominal

cavity just below the diaphragm. It has a larger right lobe and a

smaller left lobe.

The blood supply of the liver differs from that of other organs.

The liver receives oxygenated blood by way of the hepatic artery. By

way of the portal vein, blood from the abdominal digestive organs and

the spleen is brought to the liver before being returned to the heart.

This special pathway is called hepatic portal circulation and permits

the liver to regulate blood levels of nutrients or to remove

potentially toxic substances such as alcohol from the blood before

the blood circulates to the rest of the body.

The only digestive function of the liver is the production of

bile by the hepatocytes (liver cells). Bile flows through small bile

ducts, converges into larger ones, and leaves the liver by way of the

common hepatic duct. The common hepatic duct joins the cystic duct of

the gallbladder to form the common bile duct, which carries bile

to the duodenum.

Bile is mostly water and bile salts. Its excretory function is to

carry bilirubin and excess cholesterol to the intestines for

elimination in feces. The digestive function of bile is accomplished

via bile salts, which emulsify fats in the small intestine.

Emulsification is a type of mechanical digestion in which large fat

globules are broken into smaller globules but are not chemically

changed. Production of bile is stimulated by the hormone secretin,

which is produced by the duodenum when acidic chyme enters the small

intestine.

22

Functions of the Liver

The liver is involved in a great variety of metabolic functions,

most of which involve the synthesis of specific enzymes. For the sake

of simplicity, these functions may be grouped into categories.

CARBOHYDRATE METABOLISM. The liver regulates the blood glucose level

by storing excess glucose as glycogen and changing glycogen back to

glucose when the blood glucose level is low. The liver also changes

other monosaccharides such as fructose and galactose to glucose, which

is more readily used by cells for energy production.

AMINO ACID METABOLISM. The liver regulates the blood levels of amino

acids based on tissue needs for protein synthesis. Of the 20 amino

acids needed for the production of human proteins, the liver is able

to synthesize 12, called the nonessential amino acids, by the process

of transamination. The other eight amino acids, which the liver cannot

synthesize, are called the essential amino acids. Essential amino

acids are required in the diet.

Excess amino acids (those not needed for protein synthesis)

undergo the process of deamination in the liver; the amino group is

removed and the remaining carbon chain is converted to a simple

carbohydrate that is used for energy production or converted to fat

for energy storage. The amino groups are converted to urea, a

nitrogenous waste product that is removed from the blood by the

kidneys and excreted

in urine.

LIPID METABOLISM. The liver forms lipoproteins for the transport of

lipids in the blood to other tissues. The liver also synthesizes

cholesterol and excretes excess cholesterol into bile to be eliminated

23

in feces.

The liver is also the main site of the process called beta

oxidation, in which fatty acid molecules are split into twocarbon

acetyl groups. These acetyl groups may be used by the liver to produce

energy, or they may be combined to form ketones to be transported to

other cells for energy production.

SYNTHESIS OF PLASMA PROTEINS. The liver synthesizes albumin, clotting

factors, and globulins. Albumin, the most abundant plasma protein,

helps maintain blood volume by pulling tissue fluid into capillaries.

Clotting factors produced by the liver include prothrombin and

fibrinogen, which circulate in the blood until needed for chemical

clotting. The globulins synthesized by the liver become part

of lipoproteins or act as carriers for other molecules in the

blood.

PHAGOCYTOSIS BY KUPFFER CELLS. The fixed macrophages of the liver are

called Kupffer cells (or stellate reticuloendothelial cells). They

phagocytize worn blood cells and pathogens that circulate through the

liver. Many of the bacteria that enter the liver come from the colon,

after being absorbed along with water. Portal circulation brings this

blood to the liver before entering circulation throughout the

remainder of the body. These bacteria are normal flora of the colon

but would be harmful elsewhere.

FORMATION OF BILIRUBIN. The fixed macrophages of the liver phagocytize

worn red blood cells (RBCs) and form bilirubin from the heme portion

of their hemoglobin. The liver also removes from the blood the

bilirubin formed in the spleen and red bone marrow and excretes it

into bile to be eliminated in feces.

STORAGE. The liver stores the minerals iron and copper; the fat-

soluble vitamins A, D, E, and K; and the water soluble vitamin B12.

DETOXIFICATION. The liver synthesizes enzymes that alter harmful

substances to less harmful ones. Alcohol and medications are examples

of potentially toxic chemicals. The liver also converts ammonia from

the colon bacteria to urea, a less toxic substance.

ACTIVATION OF VITAMIN D. The skin, kidneys, and liver each perform a

different role in providing the body with activated vitamin D.

24

Theoretical Background

Primary Liver Cancer

Primary liver cancer develops from the benign tumors. It is the most

common type of cancer. Most of the growths in the liver such as

hemangiomas, focal nodular hyperplasia, hepatic adenomas are usually

benign, that is, non-cancerous. Chronic kidney disease, hepatitis B or

C, some toxins, viral infections of the liver can cause primary liver

cancer. It is further divided into three types.

Hepatocellular Carcinoma or Hepatoma

Cholangiocarcinomas or Bile Duct Cancer

Angiosarcomas and Hemangiosarcoma

Hepatocellular carcinoma is the most common primary liver cancer. it

is an uncontrolled growth of hepatocyte cells in the liver results in

hepatocellular carcinoma. About 80% of people with primary liver

cancer have cirrhosis of the liver. Hepatitis C infection is

responsible for about 50% to 60% of all liver cancers, and hepatitis B

is responsible for approximately 20%.

Metastatic carcinoma or the liver is more common than primary

carcinoma. The liver is a common site of metastatic growth because of

its high rate of blood flow and extensive capillary network. Cancer

cells in other parts of the body are commonly carried to the liver via

the portal circulation.

Cancer cells cause the liver to be enlarged and misshapen. Hemorrhage

and necrosis in the liver are common. Lesions may be singular or

numerous and nodular or diffusely spread over the entire liver. Some

tumors infiltrate into other organs such as the gallbladder or into

the peritoneum or diaphragm. Primary liver tumors commonly metastasize

to the lung.

Secondary Liver Cancer

Secondary cancer is caused by the spread of cancerous cells, which are

located outside the liver. It can spread from gastrointestinal organs

like stomach, pancreas and colon, as the blood flows from these organs

to the liver or it can also spread through the lymphatic

system. Secondary liver cancer is also called as metastatic cancer. In

most of the cases, it is a result of primary liver cancer. It can be a

result of advanced breast cancer, colorectal cancer, lung cancer,

kidney cancer or some other types of cancers.

25

http://www.buzzle.com/articles/cancer/

http://www.buzzle.com/articles/secondary-liver-cancer-symptoms-and-treatment.html

Risk Factors for Liver Cancer

The exact cause of primary liver cancer is still unknown. In adults,

however, certain factors are known to place some individuals at higher

risk of developing liver cancer. These factors include:

Gender. The male/female ratio for hepatoma is 4:1.

Age over 60 years.

Environmental exposure to carcinogens (cancer causing

substances). Examples of environmental carcinogens are aflatoxin,

substance produced by a mold that grows on rice and peanuts;

thorium dioxide, used at one time as a contrast dye for x rays of

the liver; and vinyl chloride, used in manufacturing plastics.

Use of oral estrogens for contraception (birth control).

Hereditary hemochromatosis. Hemochromatosis is a disorder

characterized by abnormally high levels of iron storage in the

body. It often progresses to cirrhosis.

Cirrhosis. Hepatomas appear to be a frequent complication of

cirrhosis of the liver. Between 30-70% of hepatoma patients also

have cirrhosis. It is estimated that a patient with cirrhosis has

40 times the chance of developing a hepatoma than a person with a

healthy liver. Cirrhosis usually results from alcohol abuse or

chronic viral hepatitis.

Exposure to hepatitis B (HBV) or hepatitis C (HBC) viruses. In

Africa and most of Asia, exposure to hepatitis B is an important

factor; in Japan and some Western countries, exposure to

hepatitis C is associated with a higher risk of developing liver

cancer. In the United States, nearly 25% of patients with liver

cancer have evidence of HBV infection. Hepatitis B and C are

commonly found among intravenous drug abusers.

Clinical Manifestations

It is difficult to diagnose and differentiate liver cancer from

cirrhosis in its early stages because of their similar clinical

manifestations (e.g., hepatomegaly, splenomegaly, jaundice, weight

loss, peripheral edema, ascites, portal hypertension). Other common

manifestations of liver cancer include dull abdominal pain in the

epigastric or right upper quadrant region, anorexia, nausea and

vomiting, increased abdominal girth. Patients frequently have

pulmonary emboli.

Underlined words signify the clinical manifestations exhibited by

the patient

26

Medical Management

Administer oxygen inhalation at 2-4 LPM via nasal cannula

Chemotherapy

o Chemotherapy is used for patients with hepatocellular cancer

who are not likely to benefit from other procedures (e.g.,

surgery, transplantation, ablation). A variety of

chemotherapeutic agents (e.g., 5-fluoracil [5-FU] and

leucovorin) administered either systemically or regionally

have been used to treat liver cancer. Sorafenib (Nexavar), a

targeted therapy, is used to treat metastatic liver cancer.

It inhibits tyrosine kinases, some of which are involved in

promoting new blood vessel growth to tumors.

Surgical Management

Radiofrequency Ablation Treatment

o A thin needle is inserted through the skin and into the core

of the tumor. Then electrical energy is used to create heat

in a specific location for a limited amount of time. The end

result is destruction of tumor cells. This procedure can be

done percutaneously, laparoscopically, or through an open

incision. This therapy, although not ideal for all patients,

can be used both for tumors (<5cm in size) that are

considered resectable and for palliative purposes.

Complications are not common but can include infection,

bleeding, dysrhythmias, and skin burn.

Chemoembolization

o A catheter is placed in the arteries to the tumor and an

embolic agent is administered, often mixed with a

chemotherapeutic agent(s). the embolic agent reduces the

blood supply, thus allowing greater exposure of liver cells

to the chemotherapy drugs.

Nursing Management

Give analgesics as ordered and encourage the patient to identify

care measures that promote comfort.

Provide patient with a sodium, fluid, and protein restricted diet

and that prohibits alcohol.

Elevate the patient’s legs to increase venous return and decrease

edema.

27

Monitor and treat fever.

Provide meticulous skin care.

Turn the patient to sides frequently and keep bed linens from

wrinkles to prevent pressure ulcers.

Provide comprehensive care and emotional assistance towards the

patient and to the significant others as well.

Monitor the patient for fluid retention and ascites.

Monitor respiratory function.

Explain the treatments to the patient and his family, including

adverse reactions the patient may experience.

CHAPTER IV

CASE ANALYSIS AND INTERVENTIONS

28

Pathophysiology:

(prolongation)

29

EtiologyPrecipitating: Predisposing:-nutrition -age -familial hx of liver problem -HBV

Injury to liver

Inflammation (hepatitis) Healing, scarring

Constant necrosis & proliferation cycle

Chronic liver disease

Proliferation arrest, stellate cell

activation

Extensive scarring

Liver cirrhosisDisorganized

nodular regeneration

Obstructs biliary, vascular channels

Increased pressure in mesenteric tributaries of portal vein

Increased hydrostatic

pressure

Fluid shifts out of vessels

Decreases intravascular vol

Less bld supply to renal system

Hepatorenal syndrome

*inc. uric acid*inc. creatinine*BUN

Obstructive jaundice

Obx of bile

canali-culi

bilirubin not

conju-gated & excreted

Inc. urobili-nogen

*dark urine

Bile duct obx

Conju-gated

bilirubin enters

bld stream,

reabsorption of bile

*light colored

stool*pruritus

Blood bypasses liver

+ ammonia in bld reaches

brain

HEPATIC ENCEPHALO-

PATHY*coma

*asterixis

Portal hypertension

Disten-tion of

collateral veins,

radiates to

abdomen*caput medusa

Backflow of blood*edema on lower

extre-mities, grade 2

Moderate genomic instability, acted by HBV DNA

Protooncogenes mutate into oncogenes

Severe genomic instability

(cancer cell)HEPATOCELLULAR

CARCINOMARapid growth of primary tumor

Formation of blood vessels w/in the tumor

itself(tumor angiogenesis)

Some segments of tumor detach from

primary tumor

Releases metalloproteinase

enzyme

Releases metalloproteinase

enzyme

Basement membrane of blood vessels are

destroyed

Metastatic tumor cell penetrates into the

blood vessel, enters the blood circulation

Blood from liver goes to right atrium of the heart, to pulmonary

arteryto lungs for oxygenation

Metastatic tumor cells arrest in the capillary

bedsAdhere to capillary

basement membraneGain entrance into the

lung parenchyma

Immunologic surveillance of macrophages:-phagocytosis

-processing of target cells

-release of cytokines

Immunologic escape mechanisms of cancer

cells:-suppression of factors-weak surface antigens

-immune system’s tolerance to tumor

antigens-suppression of

immune response-blocking antibodies

Tumor cell proliferation & angiogenesis LUNG METASTASIS Pathologic changes

Nonspecific inflammatory changes w/ hypersecretion of

mucusDisruption of thoracic

ductLymphatic fluid leak

into pleural spaceHYDROTHORAX

Reactive hyper-

plasia of basal cells

Metaplasia of

epithelium to stratified squamous

cellsHYPERTROPHY

Legend:Italics - manifestationsArrows – Disease ProcessALL CAPS - Complications

Medical Management

1. Intravenous fluid therapy

> Giving of substances directly into a vein; the administration of a

balanced electrolyte solution into the venous circulation; the

administration / introduction of fluids directly into the vein. Aside

from iv hydrates the patient, IV also maintain & replace body stores

of water, electrolytes, vitamins, proteins, fats & calories of the

patient. It also restores the volume of blood components as well

as providing avenue for the administration of medication.

For the patient:

> D5NM @ KVO

>Hypertonic solution draws fluid from the ICF causing cells to shrink

and ECF to expand. It initially increases osmolarity causing the fluid

to be pulled from the interstitial & intracellular compartments into

the blood vessel (intravascular space). It is indicated to regulate

urine output, stabilize blood pressure and reduce risk of edema. It is

also given to patients with fluid loss, hyponatremia and anemia.

Nursing considerations:

· Check for signs of IV infiltration.

· Regulate and monitor the flow rate. It should be in the right

amount.

· In giving IV medications, it should be slowly administrated to

lessen the pain in administering especially those antibiotics.

· IV fluids should be slowly administrated to prevent overload.

· Check the sodium levels of the patient.

2. Antibiotic therapy

> A drug used to treat infections caused by bacteria and other

microorganisms. An antibiotic was a substance produced by one

microorganism that selectively inhibits the growth of another.

Antibiotics are also known as antibacterials. Bacteria are tiny

organisms that can sometimes cause illness to humans. There are many

types of antibiotic, these includes macrolydes, cephalosporin,

fluoroquinolone, penicillin, tetracycline, and macrolyde.

Nursing considerations:

· Check for hypersensitivity of the drug.

· Check for allergies.

· Consider the 5 rights of medication before administering it.

30

· Monitor the patient for adverse reactions.

· Instruct the patient to report any unusual symptoms immediately.

3. Oxygen therapy

> The administration of oxygen as a therapeutic modality. It is

prescribed by the physician, who specifies the concentration, method

of delivery, and liter flow per minute. It alleviates tiredness and

decreases shortness of breath of the patient.

>the 02 that the patient had is via nasal cannula/ nasal prongs

regulated at 2-4L/min.

>It is the most inexpensive device used to administer oxygen. It

doesn’t interfere with the client’s ability to talk.

Nursing Considerations:

· Place cautionary signs reading “No Smoking: Oxygen in use” on the

clients door, at the foot or head of the bed, and on the oxygen

equipment.

· Check the nasal catheter if it’s working properly with your hand.

· Assess skin, breathing pattern, chest movement, and Lung sounds

to check the effectivity of the therapy.

· Regulate the flow rate as prescribed.

· Monitor V/S to note any signs of distress.

Pharmacologic Management

Generic Name: Allopurinol

Brand Name: Zyloprim

Therapeutic Classification: Antigout drug

Indication: Management of patients with malignancies that result in

elevations of serum and urinary uric acid

Dosage: 100 mg 1 tablet OD

Drug Action: Inhibits the enzyme responsible for the conversion of

purines to uric acid with a decrease in serum and

sometimes in urinary uric acid levels, relieving the

signs and symptoms of gout

Side Effects and Adverse Reactions: Headache, drowsiness,

nausea, vomiting, diarrhea

Nursing Responsibilities:

Administer drug following meals

Arrange for regular medical follow-up and blood tests

Generic Name: Ciprofloxacin

Brand Name: Ciloxan

31

Therapeutic Classification: Antibacterial, Fluoroquinolone

Indication: For the treatment of lower respiratory tract infection

Dosage: 200mg IVTT every 8 hours

Drug Action: Bactericidal; interferes with DNA replication in

susceptible bacteria preventing cell reproduction

Side Effects and Adverse Reactions: Headache, dizziness, nausea,

vomiting, diarrhea


Arrange for culture and sensitivity tests before beginning

therapy

Continue therapy for 2 days after signs and symptoms of infection

are gone

Ensure that patient is well hydrated

Encourage patient to complete full course of therapy

Generic Name: Furosemide

Brand Name: Lasix

Therapeutic Classification: Loop Diuretic

Indication: Edema associated with hepatocellular carcinoma

Dosage: 20 mg IVTT every 12 hours

Drug Action: Inhibits reabsorption of sodium and chloride from the

proximal and distal tubules and ascending limb of the

loop of Henle, leading to a sodium-rich diuresis

Side Effects and Adverse Reactions: Dizziness, vertigo, paresthesias,

xanthopsia, weakness, orthostatic

hypotension, thrombophlebitis,

photosensitivity, rash, pruritus,

urticaria, nausea, anorexia,

vomiting, oral and gastric

irritation, leukopenia, anemia,

constipation, diarrhea, urinary

bladder spasm, thrombocytopenia,

muscle cramps and muscle spasms


Administer with food or milk to prevent GI upset

Give early in the day so that increased urination will not

disturb sleep

Measure and record weight to monitor fluid changes

Arrange to monitor serum electrolytes, hydration, liver and renal

function

32

Arrange for potassium-rich diet of supplemental potassium as

needed

Generic Name: Omeprazole

Brand Name: Zegerid

Therapeutic Classification: Antisecretory Drug, Proton Pump Inhibitor

Indication: Reduction of risk of upper GI bleeding in critically ill

patients

Dosage: 40 mg IVTT OD

Drug Action: Gastric acid-pump inhibitor: Suppresses gastric acid

secretion by specific inhibition of the hydrogen-

potassium ATPase enzyme system at the secretory surface

of the gastric parietal cells; blocks the final step of

acid production

Side Effects and Adverse Reactions: Headache, dizziness, diarrhea,

abdominal pain, nausea and

vomiting, URI symptoms


Administer before meals

Administer antacids with, if needed

Instruct patient to report severe headache, worsening of

symptoms, fevers, chills

33

34

NURSING CARE MANAGEMENTNURSING CARE PLAN (PRIORITY NO. 1)

SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS

SCIENTIFIC ANALYSIS

PLANNING INTERVENTIONS RATIONALE EVALUATION

Patient whispered “Tabangi ko ninyo, lisud na kaayo iginhawa.”

-RR= 28 cpm, deep and labored-Jaw jutting and nasal flaring noted-Poor capillary refill of 4 seconds-Pallor noted on conjunctivae and fingernails -Labored breathing with use of accessory muscles (intercostal and abdominal muscles) noted-Diminished peripheral sounds noted on right lung field when auscultated-Decreased sensorium observed- Chest x-ray result showed a massive right sided hydrothorax -GCS of 11/15, moderate brain injury

Impaired gas exchange related to ventilation perfusion imbalance secondary to massive right sided hydrothorax

Definition:Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveoli-capillary membrane

Source:Nurse’s Pocket Guide, 11th edition by Doenges, M., Moorhouse M.F., & Murr, A.

According to Lewis, Heitkemper, Dirksen, O’Brien,and Butcher, hydrothorax/pleural effusion is a collection of fluid in the pleural space, secondary to altered hydrostatic or oncotic pressure. With this increased volume of fluid in the pleural space, one can conclude that there will be a decreased movement of the chest wall, thus causing dyspnea and impaired gas exchange. Moreover, it has been mentioned that hydrothorax is not a disease in itself, but rather, a manifestation of a serious disease, which, in the case of our patient, is hepatoma, or hepatocellular carcinoma. A large effusion (hepatic hydrothorax) occasionally appears during the course of the

Immediate Goal- That after 15-30 minutes:-Patient/SO will be able to verbalize understanding of causative factors and appropriate interventions related to gas exchange

Short-term goals- That after two hours, the patient will demonstrate improved ventilation and oxygenation as manifested by:-respiratory rate returning to normal or near normal range (12-20 cpm)-decreased use of accessory muscles-improved capillary refill (1-3 seconds)- reduced jaw jutting and nasal flaring-pinkish mucous

Independent:-Take vital signs of the patient especially respiratory rate and heart rate.

- Assess level of consciousness and mentation changes with use of Glascow coma scale.

-Elevate head of bed to semi-fowler or high fowler’s position.

- Encourage frequent position changes.

- Encourage adequate rest and limit activities to within client tolerance.

-Evaluate pulse oximetry to determine

- To provide a baseline data for comparison of patient’s health status.

- Poor brain oxygenation can reduce patient’s sensory ability. A decline to below 50% oxygen in brain is considered to be indicative of cerebral ischemia.

- By gravity, the diaphragm is freed from the enlarged liver and provides enough space for the lungs to expand and receive oxygen.

- Promotes optimal chest expansion and drainage of secretions.

- Helps limit oxygen needs and consumption.

- The body ideally should receive at least 95% of oxygen.

That after 2 hours, the patient had a remarkable decrease in perfusion as manifested by:-respiratory rate 29 cpm, deep and labored-constant use of accessory muscles-poor capillary refill of 4 seconds-jaw jutting and nasal flaring noted-pale mucous membranes and fingernails noted-diminished breath sounds noted- reduced Glasgow coma scale to 3/15, severe brain injury-patient is unresponsive to speech and painful stimuli

35

disease. The fluid in the pleural space is believed to be derived from ascitic fluid that may accompany hepatic cirrhosis. Although the exact mechanism is somewhat controversial, it appears that the ascitic fluid is transported directly into the pleural space. A therapeutic thoracentesis, usually accompanied by a paracentesis, these interventions may not be successful. Management of hepatic hydrothorax remains a clinical challenge.

Source:Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.

membranes and fingernails-clearer breath sounds when auscultated

Long-Term Goal-That after 1 week:-Patient will maintain optimal gas exchange.

oxygenation.

- Ensure availability of proper emergency equipment including ET/trach set and suction machines.

Dependent:- Administer medications as indicated.

Collaborative:-Assist with thoracentesis.

Below it would pose problem on brain’s vital functions.

- Intubation ensures that oxygen is delivered straight to lung alveoli, improving perfusion. Suctioning helps remove secretions that may block lung ventilation

- Inhaled and systemic glucocorticosteroids, bronchodilators. To treat underlying conditions.

-Thoracentesis is a procedure to remove fluid from the space between the lungs and chest wall.

36

NURSING CARE PLAN (PRIORITY NO. 2)

SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS

SCIENTIFIC ANALYSIS


“Tabangi ko ninyo, lisud na kaayo iginhawa,” as verbalized by the patient

-RR= 22 cpm, deep and labored-nasal flaring noted-Poor capillary refill of 4 seconds-Pallor noted on conjunctivae and fingernails -Labored breathing with use of accessory muscles (intercostal and abdominal muscles) noted-muscle strength of 0 on both lower extremities, no palpable muscular contraction (paralysis)-GCS of 11/15, moderate brain injury-asterixis noted on both arms and hands

Functional Level Classification:Level IV-dyspnea and fatigue at rest

Activity intolerance related to generalized weakness secondary to hepatic encephalopathy

Definition:Insufficient physiological or psychological energy to endure or complete required or desired daily activities


“Hepatic encephalopathy is a neuropsychiatric manifestation of liver damage. It is considered a terminal complication in liver disease. It can occur in any condition in which liver damage causes ammonia to enter the systemic circulation without liver detoxification” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2008). This disease is basically a disorder of protein metabolism and excretion. The main pathogenic agents appear to be nitrogenous ammonia and aromatic amino acids. The ammonia normally goes to the

Immediate goal-That after 15-30 minutes:-Patient/SO will identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible

Short-term goal- that after 1 hour:-Patient will use identified techniques to help enhance patient’s activity tolerance

Long-term goals-that after 1 week:-Patient will participate willingly in necessary/ desired activities-Patient will report measurable increase in activity

Independent:-Note presence of factors contributing to fatigue (e.g., cancer)

-Adjust intensity level of activities

-increase exercise/ activity levels gradually

-Plan care to carefully balance rest periods with activities

-Provide positive atmosphere, while acknowledging difficulty of the situation for the client

-promote comfort measures and provide for relief of pain

-Instruct

-Fatigue affects both the client’s actual and perceived ability to participate in activities

-to prevent overexertion

-to conserve energy

-to reduce fatigue

-to help minimize frustration and rechannel energy

-to enhance ability to participate in activities

-there may be a

After 8 hours, patient has been able to:-increase RR from 22 cpm to 28 cpm-demonstrate deep and labored breathing still-reduce GCS from 11/15 (moderate brain injury) to 3/15 (severe brain injury)-demonstrate a muscle strength of O in both upper and lower extremities

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liver via portal circulation and is converted to urea, which is then excreted by the kidneys. When the liver is unable to convert ammonia to urea, large quantities of ammonia remain in the systemic circulation. The ammonia crosses the blood-brain barrier and produces neurologic toxic manifestations. Clinical manifestations of encephalopathy include changes in neurologic & mental responsiveness (ranging from sleep disturbance, to lethargy, to deep coma), slow and deep respirations, slow and slurred speech, hyperactive reflexes, and asterixix (flapping tremors).

Source:Medical-Surgical

tolerance-patient will be able to demonstrate a decrease in physiological signs of intolerance

client/SO in monitoring response to activity

-Plan for progressive increase of activity level

-Encourage client to maintain positive attitude (e.g., suggest use of relaxation techniques)

Dependent:-Provide O2

therapy

need to alter activity level

-both activity tolerance and health status may improve with progressive training

-to enhance sense of well-being

-to help patient relieve from dyspnea and fatigue

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Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.

39

NURSING CARE PLAN (PRIORITY NO. 3)SUBJECTIVE OBJECTIVE NURSING

DIAGNOSISSCIENTIFIC ANALYSIS

PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME

“Init na siya kayo. Murag nagpatol na gani siya kay nikalit ug puti ang mata unya nanggahi napaakan ang dila,” as verbalized by the significant other.

-T= 38. 9 °C-RR= 28 cpm, tachypneic-patient is hot to touch-diaphoresis noted-seizure/convulsion occurence

Hyperthermia related to infectious process

Definition:Body temperature elevated above normal range


“Infection is a primary cause of death in the patient with cancer.The usual sites of infection include the lungs, the GU system, mouth, rectum, peritoneal cavity, and blood. Infection occurs as a result of the ulceration and necrosis of a tumor, compression of vital organs by the tumor, and neutropenia caused by the disease process or the treatment of cancer. Patients who have a temperature of 38°C or higher should be reported immediately. Assessment most often includes signs and symptoms of fever, determination of

Immediate Goal-That after 15-30 minutes, patient/SO will be able to:-identify underlying cause/ contributive factors, and importance of treatment

Short-Term Goals-That after 8 hours, patient will demonstrate the ff:-T= 36.5-37.5° C-Skin cool to touch-No reccurence of seizure/ convulsion

-SO demonstrates behavior to monitor and promote normothermia.

Long-Term Goals-That after 1 week, patient will be able to:-maintain core temperature within normal range-be free of

Independent:-Monitor core temperature.

-Assess neurological response, noting level of consciousness and orientation.

-Apply tepid sponge bath

- apply local ice packs especially in the groin and axillae

-maintain bedrest

Independent:-provide supplemental oxygen

-administer antibiotics as ordered

Collaborative:-provide high-

- To evaluate effects/degree of hypothermia.

- High fever can cause seizures predisposing patients to further seizure related injuries.

-promote heat loss by evaporation.

- this promote heat loss in areas of high blood flow

-to reduce metabolic demands/oxygen consumption

-to offset increased oxygen demands and consumption

-to treat infection

-to meet

That after 8 hours, the patient is afebrile as evidenced by:-T= 37.1°C-Diaphoresis noted-Skin is slightly cool to touch-No recurrence of fever-SO verbalized, “Di gyud to magsalig lang sa tambal. Kinahanglan na mag spongebath para dali manaog ang hilanat.”

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possible etiology, and CBC.”


seizure activity-demonstrate behaviors to monitor and promote normothermia-be free of complications such as is irreversible brain damage and acute renal failure

calorie diet, tube feedings, and parenteral nutrition

-administer replacement fluids and electrolytes

increased metabolic needs

-to support circulating volume and tissue perfusion



PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME

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“Nigamay gyud pag-ayo si mama sa la pa siya nagreklamo unya karon nahospital siya, maluoy na mi maglantaw sa iyahang lawas,” as verbalized by SO

“Di naman gyud siya mukaon, mao to gipatubuhan nalang sa doctor para didto nalang iagi tanan iyahang pagkaon,” as verbalized by SO

-patient appears very weak to chew and swallow-emaciated-pale and dry mucous membrane observed-noted weakness of the muscles required for mastication

Imbalanced nutrition: less than body requirements related to loss of appetite and inability to absorb nutrients secondary to Hepatoma

Definition:Intake of nutrients insufficient to meet metabolic needs


“A person’s appetite to ingest food is a significant factor in how much food is eaten. An appetite center is located in the hypothalamus. It is directly/indirectly stimulated by hypoglycaemia, an empty stomach, decrease in body temperature, and input from higher brain centers.” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2008) The hormone ghrelin released from the stomach mucosa plays a role in appetite stimulation. Leptin, another hormone, is involved in appetite suppression. Thus, “appetite may be inhibited by stomach distention, illness (especially accompanied by fever), hyperglycemia, and n/v.” (Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L., 2008)

Immediate Goal- That after 15-30 minutes, patient/SO will:-verbalize understanding of some factors causing malnutrition

Short-Term Goals- That after 8 hours, patient will demonstrate the ff:-Pinkish and moist mucous membrane-Reduce respiratory rate-Regain strength and muscle tone to perform basic ADLs

Long-Term Goals- That after 4 weeks, patient will be able to:-Demonstrate behaviors/ lifestyle changes to maintain appropriate weight-Display normalization of laboratory values and be free of signs of malnutrition

Independent:-Determine client’s ability to chew, swallow and taste food.

- Assess drug interactions and use of laxatives and diuretics.

- Assess weight and muscle mass, and laboratory test such as amino acid profile, BUN, liver function and electrolytes.

- Note age, body build, strength, activity/rest level.

-provide NGT feeding properly

-provide adequate fluid intake

Dependent: - Assist in inserting nasogastric tubes to deliver osteorized feeding.

-This can affect ingestion and digestion of food nutrients.

-This may affect appetite, food intake and absorption.

- This provides baseline parameters

- Helps determine nutritional needs.

-to aid in the proper digestion and absorption of nutrients in the body

-to prevent dehydration

- NGT can ensure that nutrients reach to gastric organs and more ready for absorption.

At the end of our care, the patient will be able to:-decrease creatinine, BUN, and uric acid levels to within normal range-increase HDL levels to within normal range- develop pinkish and moist mucous membranes-increase in muscle tone

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Source: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition, 2008, by Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.

- Assist in administering parenteral D5NM. Watch for overinfusion.

Collaborative:-provide a soft diet composed of less than 1,600 calories and low protein, as ordered

- Multiple and balanced intravenous solutions helps correct electrolyte deficiency.

-to aid in decreasing BUN, creatinine, and uric acid levels and to provide the patient with adequate energy needed for the body’s good functioning




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“Ayaw ko ninyo pasagdai. Tabangi ko ninyo pag-ampo. Dili na nako kaya. Iampo ko day,” as verbalized by patient

“Muanhi man to si Father unya para ampuan siya kay nagrequest man siya kanako,” as verbalized by SO

-patient is sulken-weak-crying observed

Death anxiety related to uncertainty about the existence of higher power and life after death.

Definition:Vague, uneasy feeling of discomofort or dread generated by perceptions of a real or imagined threat to one’s existence.


Death is defined by Lewis, Heitkemper, Dirksen, O’Brien,& Bucher, as “the irreversible cessation of circulatory and respiratory function or the irreversible cessation of all functions of the entire brain, including the brainstem.” Today, as a result of the increasing number of persons with chronic diseases, terminal illness and dying have received greater attention. Most individuals will have a long period of serious illness before dying, with the onset of months/years before death. For example, approximately half of all patients diagnosed with cancer will die from their disease within a

Immediate Goal- That after 15 to 30 minutes, patient will:-verbalize feelings of sadness, guilt and fear

Short-Term Goal- That after 2 hours hours, patient will:-formulate a plan dealing with individual concerns and eventualities of dying as appropriate

Long-Term Goals- That after 3 days, patient and SO will:-look toward/plan for the future one day at a time-be able to readily say goodbye to each other

Independent:-Ascertain current knowledge of situation to identify misconceptions, lack of information and other pertinent issues.

-Provide open and trusting relationship

-Provide calm, peaceful setting and privacy as appropriate

-Assist the client in engaging spiritual activities and experience prayer and meditation

-Refer to therapists and spiritual advisers.

-The concept of higher power in the afterlife provides comfort and strength to the dying person.

-Genuine rapport can help the patient express her feelings to the nurse about the unknown.

-This promotes relaxation and ability to deal with the situation.

-This reduces feelings of guilt allowing the person to move forward toward resolution.

-To help with the grief work.

At the end of our care, the S/O verbalized,“Dinhi na si Father. Gi-ampuan na siya. Nagpasalamat ra pud mi na nahumana ang pag-ampo para makapreparar siya sa kamatayon.”

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few years. However, the time from diagnosis of a terminal illness to death varies considerably depending on the patient’s diagnosis and extent of disease. Most patients and families struggle with a terminal diagnosis and the realization that there is no cure. The patient and the family feel overwhelmed, powerless, fatigued, and fearful. With this, both the patient and the significant others may experience death anxiety. For the Catholics, however, they believe in eternal life after death. “Yes, we are fully confident, and we would rather be away from these earthly bodies,

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for then we will be at home with the Lord.” (2 Corinthians 5:8 ) This biblical quote may offer much comfort for those Catholics “who have the faith as that of a mustard seed” (Matthew 17:20)


The New American Bible: The New Catholic Translation (1987), by Heenan, J.C.

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PROGRESS NOTES

DATE PROBLEM MEDICAL/SURGICAL INTERVENTION

NURSING INTERVENTION

OUTCOME

April 12, 2011

-dyspnea -O2 inhalation ordered at 2-4 LPM-CBC taken

-place a “no smoking” sign in the room

-dyspnea was relieved

April 13, 2011

-dyspnea

-grade 2 bipedal pitting edema on both lower extremities

-body weakness

-continued O2 inhalation at 2-4 LPM

-Chest X-ray done-Prescribed diet: CHON, soft diet -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered-electrolyte levels assessed (Na and K)

-NGT inserted; prescribed diet: 1600 cal, Osteorized Feeding

-place a “no smoking” sign in the room -Elevate the patient’s legs to increase venous return and decrease edema-keep bed linens from wrinkles

-give health teachings and demonstrate to patient/SO about importance of ROM exercises


-edema not relieved, patient complained of decreased sensorium on lower extremities

-patient tried to remove NGT and complained of discomfort upon feeding

April 14, 2011

-dyspnea

-grade 2 bipedal pitting edema on both lower extremitiesNoted

-body weakness

-blood chemistry done-continued O2 inhalation at 2-4 LPM

-Prescribed diet: CHON-Furosemide (Lasix) 20 mg IVTT every 12 hours ordered

-prescribed diet: 1600 cal, Osteorized Feeding


-keep bed linens from wrinkles-turn patient to sides

-give health teachings and demonstrate to patient/SO about importance of ROM exercises


-edema not relieved, reports of pain on lower extremities

-patient tried to remove NGT and complained of discomfort upon feeding

April 15, 2011

-dyspnea

-grade 2 bipedal pitting edema on both lower extremities

-body


-Prescribed diet:

CHON, soft diet -Furosemide (Lasix) 20 mg IVTT every 12 hours ordered-electrolyte levels assessed (Na and K)


-Elevate the patient’s legs to increase venous return and decrease edema-encourage SO to help patient turn to sides regularly-give health teachings and

-dyspnea was treated

-edema not relieved, patient complained of decreased sensorium and pain on lower extremities

-patient

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weakness -prescribed diet: 1600 cal, Osteorized Feeding

demonstrate to patient/SO about importance of ROM exercises

tried to remove NGT and complained of discomfort upon feeding

April 16, 2011

-dyspnea

-grade 2 bipedal pitting edema on both lower extremitiesnoted

-Fever of 38.9°C

-body weakness, 0 muscle strength


-Prescribed diet:

CHON-Furosemide (Lasix) 20 mg IVTT every 12 hours ordered

-prescribed diet: 1600 cal, Osteorized Feeding

-place a “no smoking” sign in the room-encouraged to turn to sides-provide health teachings to SO regarding meticulous skin care

-health teachings given regarding proper application of TBS

-instruct SO to provide passive proper ROM exercises regularly

-dyspnea was treated

-edema not relieved, reports of pain on lower extremities

-fever was treated

-muscle strength still O

DISCHARGE PLAN

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MEDICATIONS:

Generic Name: Allopurinol

Therapeutic Classification: Antigout drug

Indication: Management of patients with malignancies that result

in elevations of serum and urinary uric acid

Dosage: 100 mg 1 tablet OD

Drug Action: Inhibits the enzyme responsible for the conversion

of purines to uric acid with a decrease in serum and

sometimes in urinary uric acid levels, relieving the

signs and symptoms of gout

Side Effects and Adverse Reactions: Headache, drowsiness, nausea,

vomiting, diarrhea

Client Teaching: Administer following meals

Generic Name: Ciprofloxacin

Therapeutic Classification: Antibacterial, Fluoroquinolone

Indication: For the treatment of lower respiratory tract

infection

Dosage: 500 mg 1 tablet every 8 hours, via NGT

Drug Action: Bactericidal; interferes with DNA replication in

susceptible bacteria preventing cell reproduction

Side Effects and Adverse Reactions: Headache, dizziness, nausea,

vomiting, diarrhea

Client Teachings:

o Continue therapy for 2 days after signs and symptoms of

infection are gone

o Ensure that patient is well hydrated

o Encourage patient to complete full course of therapy

Generic Name: Furosemide

Therapeutic Classification: Loop Diuretic

Indication: Edema associated with hepatocellular carcinoma

Dosage: 20 mg tablet every 12 hours

Drug Action: Inhibits reabsorption of sodium and chloride from

the proximal and distal tubules and ascending limb

of the loop of Henle, leading to a sodium-rich

diuresis

Side Effects and Adverse Reactions: Dizziness, vertigo,

paresthesias, weakness, orthostatic hypotension

Photosensitivity, pruritus, urticaria, nausea,

vomiting, anorexia, constipation, diarrhea

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Client Teachings:

o Administer with food or milk to prevent GI upset

o Give early in the day so that increased urination will not

disturb sleep

o Arrange for potassium-rich diet of supplemental potassium as

needed

Generic Name: Omeprazole

Therapeutic Classification: Antisecretory Drug, Proton Pump

Inhibitor

Indication: Reduction of risk of upper GI bleeding in critically

ill patients

Dosage: 40 mg tablet OD

Drug Action: Gastric acid-pump inhibitor: Suppresses gastric acid

secretion by specific inhibition of the hydrogen-

potassium ATPase enzyme system at the secretory surface

of the gastric parietal cells; blocks the final step of

acid production

Side Effects and Adverse Reactions: Headache, dizziness,

diarrhea, abdominal pain, nausea and vomiting

Client Teachings:

o Administer before meals

o Administer antacids with, if needed

o Instruct patient to report severe headache, worsening of

symptoms, fevers, chills

EXERCISE:

Avoid strenuous exercises.

Turn patient to sides regularly to prevent the development of

pressure ulcers.

Maintain bed rest. However, patient must be encouraged to do

exercises which she can tolerate. Teach the significant others

how to help patient perform passive ROM.

HEALTH TEACHINGS:

Instruct SO(s) to support patient in maintaining hygiene and good

grooming. They must know how to properly support the patient upon

dressing, toileting, and other basic activities. Meticulous skin

care must be provided.

Elevate both feet to promote venous return and to decrease edema.

Keep bed linens free from wrinkles to avoid pressure ulcer

development

50

Instruct SO to constantly monitor fever and teach SO how to

properly apply tepid sponge bath

Explain the disease process, causative factors, signs and symptom

and treatment to the patient and significant others.

Follow the prescribed dosage of the medication, how many times it

should be taken, and the route of the medication.

Return for follow up care and evaluation

Encourage patient to take the prescribed medications every day.

Teach client on avoiding stress or stress control and its

importance.

Teach patient to follow prescribed diet strictly.

Teach SO how to feed the patient via NGT and how to prepare

osteurized food.

Encourage patient to have regular check up or when signs and

symptoms re-occur.

Encourage patient to communicate with the health care provider

regarding his condition and therapy.

Counseling or a support group can help in emotional condition

Avoid strenuous activity, heavy lifting and vigorous exercise

Teach patient to avoid alcoholic beverages

Encourage family to help the patient cope with his recent

condition.

Teach non-pharmacological techniques ( massage, music therapy,

guided imagery and relaxation )

OUT-PATIENT:

Contact physician for the following problems:

Any unanswered questions and emotional support needs.

Fever more than 40°C or chills

Allergic or other reactions to medication(s)

Anxiety, depression, trouble sleeping

Change in bowel or bladder habits.

Indigestion or difficulty in swallowing.

DIET:

Eat a balanced, sodium-restricted diet of no more than 2,000 mg

or 2 g of sodium a day.

1600 calories must be consumed per day

Limit proteins and fluid intake.

SPIRITUAL CARE:

Encourage patient and significant others to pray together and to

offer special prayers with the intention of asking enough

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