V. MEDICAL MANAGEMENT a.

DIAGNOSTIC AND LABORATORY PROCEDURES HEMATOLOGY DIAGNOSTIC AND LABORATORY PROCEDURES Hemoglobin DATE ORDERED/ DATE RESULTS DO: 11-29-12 DR: 11-29-12 DO: 12-04-12 DR: 12-04-12 DO: 11-29-12 DR: 11-29-12 DO: 12-04-12 DR: 12-04-12 DO: 11-29-12 DR: 11-29-12 GENERAL DESCRIPTION INDICATION OR PURPOSE RESULTS NORMAL VALUES ANALYSIS AND INTERPRETATIO N Decreased hemoglobin count it indicates that the patient has anemia.

Hematocrit

It is used to measure the amount of hemoglobin found in the deciliter of blood. It is usually part of a complete blood count. Hematocrit measure the percentage by volume of packed RBCs in a whole blood sample

Measures the severity of anemia or polycythemia and to monitor response to therapy.

100 g/dl

M: 125 175 g/dl F: 115-155 g/dl

91 g/dl

To aid diagnosis of polycythemia, anemia, or abnormal states of hydration

0.30 %

M: 0.400.52 % F: 0.380.48 %

0.28 %

Decreased hematocrit levels indicate that the patient has infiltration of RBC in the alveoli.

WBC

One of the cell the body makes to help fight infection

Helps in diagnosing infection and inflammation as well as

14.2

510 x 10 /L

The result reveals above normal range of leukocytes count which can signify

DO: 12-04-12 DR: 12-04-12

determine the need for further tests.

11.9

presence of infection.

RBC

DO: 11-29-12 DR: 11-29-12 DO: 12-04-12 DR: 12-04-12

The blood cells that carry oxygen. Red cells contain hemoglobin and it is the hemoglobin which permits them to transport oxygen (and carbon dioxide) Lymphocytes are small white blood cell that play an role in the bodys immune response that is, in the bodys fight against germs and diseases.

Helps assess the bloods oxygen-carrying capacity and can be useful in diagnosing anemia or protein deficiency and dehydration

3.50

M:4.56.3x10 /L F:4.25.4x10 /L

RBCs are in their abnormal limits because Oxygen transportation is impaired.

3.39

Lymphocytes

DO: 11-29-12 DR: 11-29-12 DO: 12-04-12 DR: 12-04-12

Determine if there is enough cell that produces antibodies and other chemicals responsible for destroying microorganisms; contributes to allergic reactions, graft rejection, tumor control, and

0.17

0.20-35

Decreased lymphocytes in blood causes a condition known as lymphocytopenia. The result is within the normal range.

0.20

regulation of the immune system Platelet DO: 11-29-12 DR: 11-29-12 DO: 12-04-12 DR: 12-04-12 A platelet count is a diagnostic test that determines the number of platelets in the patient's blood and determines the ability of patients blood to clot normally Is an enzyme that catalyzes the creatinine metabolic pathway in muscle cells and brain tissue. CK reflects normal tissue catabolism, increased serum levels indicate trauma to cells. To assist in the diagnosis of bleeding disorders and to monitor patients who are being treated for any disease 469 150-400 X 10 /L An increased count can result from hemorrhage

Creatinine

DO: 11-30-12 DR: 11-30-12

To monitor the patients response to treatment and determine whether the acute phase is declining. To monitor the wound healing process of internal incisions.

1.5 mg/dl

M: 0.8- 1.2 mg/dl F: 0.6 0.9 mg/dl

Elevated levels generally indicate renal disease that has seriously damaged of the nephrons.

Nursing Responsibilities:

Prior Check the doctors order Explain the purpose of the test and what to expect. Inform the patient that the examination requires blood specimen to be withdrawn Explain that minimal pain will be felt upon withdrawal of blood specimen Inform the client that fluid and food restriction is not required. Fill up the laboratory request form properly and send it to the laboratory technician before the collection of sample.

During Instruct patient to stay still in the extraction of blood Apply sterile technique in the extraction of blood Use of the distal vein of the arm first Use patients non dominant hand whenever possible Completely fill the collection tube and invert or gently several times to thoroughly mix the sample and the anticoagulant.

After Check laboratory results and report abnormal findings to the physician. Apply pressure on the venipuncture site until bleeding stop Send specimen to the laboratory right away with proper label Document procedure and response of the patient Apply warm soaks if hematoma develops at the site of blood extraction.

FLUID AND ELECTROLYTES DIAGNOSTIC DATE AND ORDERED/ LABORATORY DATE PROCEDURES RESULTS Sodium DO: 11-29-12 DR: 11-29-12 GENERAL DESCRIPTION INDICATION OR PURPOSE RESULTS NORMAL VALUES ANALYSIS AND INTERPRETATION

The sodium test measures the amount of sodium in relation to the amount of water in the body. The potassium test measures serum levels of potassium, the major intracellular cation.

Potassium

DO: 11-29-12 DR: 11-29-12 DO: 12-01-12 DR: 12-01-12 DO: 12-02-12 DR: 12-02-12 DO: 12-03-12

To evaluate fluid-electrolyte and acid-base balance and related neuromuscular, renal and adrenal functions To monitor renal function, acid-base balance, and glucose metabolism

136.7

135-145 mmo/L

The sodium is within normal level indicating that urine formation of fluid level in intravascular area is in normal.

1.6

3.5 5.5 mmo/L

1.68

1.93

2.10

DR: 12-03-12 DO: 12-04-12 DR: 12-04-12 DO: 12-05-12 DR: 12-05-12 2.39

2.89

Nursing Responsibilities: Prior After Apply pressure to the puncture site Evaluate patient with increased or decreased potassium level for arrhythmias. Attach results to the chart as soon as they are available. Explain the procedure and its purpose Inform that there is no fluid and food restrictions Assess during history which may interfere the results.

During Adhere to standard precautions

URINALYSIS DIAGNOSTIC DATE AND ORDERED/ LABORATORY DATE PROCEDURES RESULTS Urinalysis DO: 11-29-12 DR: 11-29-12

GENERAL DESCRIPTION

INDICATION OR PURPOSE To determine the presence of glucose in the urine. This also evaluates color, odor, and opacity.

RESULTS

NORMAL VALUES

ANALYSIS AND INTERPRETATION

Urinalysis evaluates and determines specific gravity and pH, detects and measures protein and glucose and examine sediment for blood cells and crystals.

Color: Yellow

Straw to dark yellow

Appearance: Turbid Reaction: 6.0 Specific Gravity: 1.005 Albumin Sugar: +1 Sugar: Negative Pus Cells: 2530 Red Cells: 0.1 Epithelial cells: few Bacteria: Few

Clear 4.5 7.5 1.005 1.035

Mucus Threads: Many DO: 12-04-12 DR: 12-04-12 Color: Light yellow Appearance: Slightly turbid Specific Gravity: 1.005 Albumin Sugar: +1 Sugar: Negative Pus Cells: 5.8 Red Cells: 0.2 Epithelial cells: few Straw to dark yellow

Clear 1.005 1.035

Nursing Responsibilities Prior

Gather all materials needed for the collection of urine and properly label specifically the patients specimen cup Explain the procedure to the patient Explain the importance of the procedure and the results because its her right to know why is the procedure needed and for her to be more compliant Both the nurse and the patient should wash their hands before and after the collection Provide privacy while the urine is being collected Instruct patient how to catch a midstream specimen of urine Inform the patient that no pain will be felt, and that no needle will be used.

During Provide privacy Reassure the patient that the nurse is just outside (the bathroom) waiting for the patient.

After After collection of the urine, arrange for prompt transport of it to the laboratory. Document procedure and patients response Assist the patient on her bed

b. Intravenous Fluids

Medical Management

Date Ordered

General Description

Indication or Purpose

Clients response to treatment

D5LRS 1L x 20-21 gtts/min

11-29-12 11-30-12 12-01-12 12-02-12

Hypertonic solutions are those that have an effective osmolarity greater than the body fluids. This pulls the fluid into the vascular by osmosis resulting in an increase vascular volume. It raises

This Intravenous Fluid is indicated for treatment of persons needing extra calories who cannot tolerate fluid overload and for the treatment of shock.

The patient maintained hydration status and was able to comply with all of her medication regimens.

intravascular osmotic pressure and provides fluid, electrolytes and calories for energy. PNSS 11-29-12 12-01-12 12-02-12 12-03-12 12-04-12 NURSING RESPONSIBILITIES (FOR IVF) Before 1. Verify the physicians order indicating the type of solution, the amount to be administered, the rate of flow of the infusion and any allergies. 2. Explain the procedure and prepare the client 3. Assess clients VS for baseline data, skin turgor, bleeding tendencies, disease or injury to the extremities, status of vein to determine the appropriate puncture site. A solution that contains It was given to patient fewer dissolved particles (such as salt and other electrolytes) than is found in normal cells and blood. for potassium chloride incorporation.

During

1. Wash hands before proceeding with the procedure. 2. Open and prepare infusion set and proceed with the procedures. 3. Select the venipuncture site. Put on clean gloves and clean the venipuncture site before inserting the catheter and initiating infusion. Tape the catheter properly. 4. Ensure appropriate infusion flow.

After 1. Apply a medication label on the solution if a medication is added. 2. Document relevant data. 3. Monitor clients response. Check infusions at least every 2 hours to ensure that the indicated milliliters per hour have infused and that IV patency is maintained.

c. Drug Study c.1. Ranitidine Route of Admin. Dosage and freq. of Administration

Name of Drug Generic Name Brand Name

Date Ordered Date Performed Date Changed

Indication(s) Or Purposes Client Response to Treatment

G.N: Ranitidine

DO: Nov.29, 2012

1 amp IV every 8 hours

Ranitidine is used to treat conditions linked to stomach acid, e.g.

The patients abdominal pain decrease

DP: Nov.29-Dec.02, 2012 B.N:

gastritis, stomach and duodenal ulcers (peptic ulcer disease), heartburn, and oesophagitis. Also it is

Zantac

used to treat abdominal pain which is caused by too much acid in the stomach (Mosby, 2002)

Nursing Responsibility for Ranitidine:

Antacids should be taken one hour before or one hour after ranitidine, as they inhibit the effectiveness.

c.2. Ceftriaxone

Name of Drug Generic Name Brand Name

Date Ordered Date Performed Date Changed

Route of Admin. Dosage and freq. of Administration

Indication(s) Or Purposes Client Response to Treatment

G.N: Ceftriaxone DO: Nov.29, 2012

1 gm IV every 12 hours

It is used for treatment of serious infections of the lower respiratory tracts.

The patient did not experience any side effects such as nausea and vomiting and the medication reduced the patients complain of pain from 9/10 to 6/10.

B.N: Rocephin

DP: Nov.29-Dec.02, 2012

Nursing Responsibility for Ceftriaxone: Assess patients previous sensitivity reaction to penicillin or cephalosphorins Assess for allergic reaction

c.3 Paracetamol Name of Drug Generic Name Brand Name Date Ordered Date Performed Date Changed Route of Admin. Dosage and freq. of Administration Indication(s) Or Purposes Client Response to Treatment

G.N: Acetaminophen

DO: Nov.29, 2012

1 amp IV every 4 hours PRN T >37.8C

Inhibits the synthesis of prostagalandins that may serve as mediators of pain and fever

The patient manifested a decreased in body temperature after the administration of the drug.

B.N: Paracetamol

Nursing Responsibility for Paracetamol: Monitor vital signs of patient regularly. Monitor for any possible adverse reactions

c.4. Metoclopramide Name of Drug

Date Ordered

Route of Admin.

Indication(s)

Client Response to

Generic Name Brand Name

Date Performed Date Changed

Dosage and freq. of Administration

Or Purposes

Treatment

G.N: Metoclopramide

DO: Nov.29, 2012

1 amp IV every 8 hours PRN for VM

Prevention of postoperative nausea and vomiting. Treatment of postsurgical and gastric stasis (Mosby, 2002)

The patient didnt experience nausea and vomiting after patients surgery

B.N: Plasil

Nursing Responsibility for Metoclopramide: Administer to 1 hour before meal for better absorption.

c4. Kalium Durule

Name of Drug Generic Name Brand Name

Date Ordered Date Performed Date Changed

Route of Admin. Dosage and freq. of Administration

Indication(s) Or Purposes Client Response to Treatment

G.N: Kalium Durule

DO: Nov.30, 2012

2 tab TID

Prevention and correction of potassium deficiency

The patient experience increase in potassium

DP: Nov.30, 2012

Nursing Responsibility for Kalium Durule: Arrange for serial serum potassium before and during therapy Administer oral drug after meals or with food and a full glass of water to decrease GI upset.

Name of Drug Generic Name Brand Name

Date Ordered Date Performed Date Changed

Route of Admin. Dosage and freq. of Administration

Indication(s) Or Purposes Client Response to Treatment

G.N: Ferrous Sulfate + Folic Acid

DO: Dec.03, 2012

1 cap OD

Ferrous sulfate and folic acid is used to treat iron deficiency anemia (a lack of red blood cells caused by having too little iron in the body).

Nursing Responsibility for FeSO4: Administer ferrous sulfate and folic acid on an empty stomach, at least 1 hour before or 2 hours after a meal. Avoid taking antacids or antibiotics within 2 hours before or after taking ferrous sulfate and folic acid.

Name of Drug Generic Name Brand Name

Date Ordered Date Performed Date Changed

Route of Admin. Dosage and freq. of Administration

Indication(s) Or Purposes Client Response to Treatment

G.N: Omeprazole

DO: Dec.03, 2012

40mg 1 cap OD

Short term treatment of active duodenal ulcer

Decreases the amount of acid produced in the stomach.

BN: Losec

Nursing Responsibility for Omeprazole: Administer before meals.

Name of Drug Generic Name Brand Name

Date Ordered Date Performed Date Changed

Route of Admin. Dosage and freq. of Administration

Indication(s) Or Purposes Client Response to Treatment

G.N: Potassium Chloride

DO: Nov.29, 2012

10 mEqs x 2 hours for 3 cycles

Treatment of hypokalemia

The patients potassium level increased.

Dec.01,2012

10 mEqs x 1 hour for 4 cycles

10 mEqs x 1 hour for Dec.05, 2012 6 cycles

Nursing Responsibility for Omeprazole:

NURSING RESPONSIBILITIES FOR DRUG ADMINISTRATION (GENERAL)

Before Check doctors order. Check the bottle label/medication three times before giving the drug. Before giving drug, ask patient about allergic reactions to penicillin. A negative history of penicillin allergy is no guarantee against future allergic reactions. Obtain specimen for culture and sensitivity before initiating therapy. First dose may be given before receiving results.

During Explain the purpose of the drug. Administer Drug as order Assess patients condition

After Check Vital Signs after giving medication

Instruct patient to inform any adverse reaction that may occur Instruct patient not to take any medications aside from the doctors order. d. DIET

Date ordered Type of diet Date performed Type of diet wherein Diet as Tolerated client can eat any food that she can already tolerate to eat. Indicated to bring back the patients normal diet and to absorb nutrients that she needs to regain and restore energy and nourishment. General description Indications or purpose

Clients response

Patient gained strength and tolerated the diet.

Nursing Responsibilities for DAT DIET

Before

Explain the purpose of the diet to the patient. Inform the patient about possible complications if the order is not performed Verify doctors order

During Observe patients tolerance to the diet. Ensure that the client is receiving adequate nutrition

After Stress to the patient the importance of the following prescribed diet to prevent further aggravation of patients condition. Document e. ACTIVITY

TYPE OF ACTIVITY

DATE ORDERED DATE PERFORMED

GENERAL DESCRIPTION

INDICATIONS OR PURPOSE

CLIENTS RESPONSE

Bed Rest

The patient should be on bed to decrease oxygen demand and

To conserve energy. To promote recovery and to provide rest

The patient was able to avoid any stressful activities

the patient has the privilege to go to the toilet.

and prevent fatigability

Ambulation

Pt. performed ADLs, maintain good body alignment and carry out active ROM exercises

To be able to move and strengthen the muscles.

Pt. was able performed her ADLs like walking

Nursing Responsibilities for Activities Check the physicians order for ambulation Identify the patient before exercise Explain to the patient the need for that activity Help the client to comply and participate on the activity Assist patient during activity Promote quiet environment to comply and participate with the activity

ASSESSMENT S>

NURSING DIAGNOSIS Hyperthermi

SCIENTIFIC EXPLANATIO N In response to

PLANNING

After 6

NURSING INTERVENTIO N Monitor vital

RATIONAL E To maintain

EVALUATIO N

a O> Patient looks pale and weak in appearance Skin warm to touch Restlessness Febrile, T: 38C

infection, inflammatory mediators and neutrophils are activated which will travel to the infected area via increased blood flow and chemotaxis. WBCs, particularly neutrophils, migrate into the site to perform phagocytosis. Neutrophils immediately die after performing their function, and release pyrogens. Pyrogens stimulate fever by increasing heat production and conservation. Fever stimulates

hours of effective nursing interventions , the patients temperature will decrease within its normal range.

signs

baseline data for effective managemen t To treat underlying causes

Administer antipyretic as ordered

immune system activity and kills microorganism s

ASSESSMENT S> O>

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING After

NURSING INTERVENTION

RATIONALE

EVALUATION

VI. DAILY PATIENTS RECORD/EVALUATION DAYS NURSING PROBLEMS VITAL SIGNS ADMISSION Premature uterine contraction BP-100/70 T-36.8 PR-80 RR-20 FHT-140 DAY 1 DAY 2 DAY 3 DISCHARGE Mild UTI BP-110/70 T- 36.8 PR-90 RR-20 FHT- 159

BP-100/70 T-36.8 PR-80 RR-20 FHT-144

BP-100/70 T-36.1C PR-89Bpm RR-18bpm FHT- 135-152

BP-100/60 T-36.5 PR- 85 RR-23 FHT- 139-160

LABORATORY PROCEDURES

IVF,NGT

Hemoglobin Hematocrit RBC WBC Platelet Lymphocytes Blood typing D5LRS

CBC,U/A PC

Sodium potassium

Pelvic ultrasound

MGH

D5LRS MgSo4

DRUGS

DIET

Soft diet

with Foley catheter Pelvic ultrasound D5LRS Ferrous sulfate Magnesium Cefuroxime sulfate Cefuroxime D/C of cephalexin NPO/soft diet NPO

Pelvic ultrasound D5LRS

Referred ultrasound IVF consumed CEFUROXIME ISOXILAN

NPO

SOFT DIET MGH

VII.

SUMMARRY OF FINDINGS

The patient was diagnosed of Gastric Adenocarcinoma which is commonly known as Gastric Cancer. Gastric Adenocarcinoma is one type of Stomach Cancer that happens when a malignant tumor grew in the stomach lining of the person affected. Carcinoma is the most common type of Stomach Cancer and it starts in the glandular tissue of the stomach. Patient was ordered to take some diagnostic procedures such as Hemoglobin, Hematocrit, WBC Count, Neutrophil Count, Lymphocytes, Monocytes, Eosinophils, Platelet (Hematology), ABO Typing, Creatinine Kinase, BUN, Sodium, Potassium and Urinalysis. The patient was given an Intravenous Fluid of D5LRS 1L and D5W 500 ml.

These fluids were given to the patient to maintain hydration. Aside from Intravenous Fluids, the patient was also given medications that can help in the treatment of patients condition. He was given Ranitidine, Tramadol and Cefazolin which were ordered by the Doctor. The patient was able to take the prescribed medications and able to cooperate with the Nurse. Nothing Per Orem Diet was also prescribed to the patient for he is unable to take foods, beverages and medications orally. Surgical Procedures was also performed to the patient such as Explored Laparotomy which is a method of abdominal exploration in order for the physician to examine the abdominal organs. Other procedures that were administered/performed includes Blood Transfusion which is needed for the patient in order to change blood loss due to Surgery/Operation. Epidural Anesthesia and Jejunostomy feeding were also given/performed/administered to the patient.