INTRODUCTION

Acute Biologic Crisis is a condition that may result to patient mortality if left
unattended in a brief period of time. Condition that warrants immediate attention
for the reversal of disease process and prevention of further morbidity and
mortality.
Hepatic Hemangiomas are the most common type of benign
(noncancerous) tumor in or on the liver. The tumor is comprised of a network of
blood vessels, the cells that line those blood vessels (endothelial cells), and the
hepatic artery, which acts as a primary fuel supply for the mass. Other names for
this tumor include cavernous or capillary hepatic hemangioma.
Hemorrhoids are swollen veins in the lowest part of your rectum and anus.
Sometimes the walls of these blood vessels stretch so thin that the veins bulge
and get irritated, especially when you poop. Internal hemorrhoids are far enough
inside the rectum that you can't usually see or feel them. They don't generally
hurt because you have few pain-sensing nerves there. Bleeding may be the only
sign of them. External hemorrhoids are under the skin around the anus, where
there are many more pain-sensing nerves, so they tend to hurt as well as bleed.
According to the National Center for Biotechnology Information, U.S.
National Library of Medicine, Hemorrhoid disease is the fourth leading outpatient
gastrointestinal diagnosis, accounting for 3.3 million ambulatory care visits in the
United States. Self-reported incidence of hemorrhoids in the United States is 10
million per year, corresponding to 4.4% of the population. Both genders report
peak incidence from age 45 to 65 years. Notably, Caucasians are affected more
frequently than African.
According to the latest WHO data published in 2017 Liver Disease Deaths
in Philippines reached 8,401 or 1.36% of total deaths. The age adjusted Death
Rate is 11.32 per 100,000 of population ranks Philippines #119 in the world.

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Our patient B.A, 69 years old female was admitted to San Pedro Hospital
due to Painful of Hemorrhoids/ Abdominal pain and was diagnosed with Mixed
hemorrhoids t/c Hepatic hemangioma. We have chosen her as our subject for
case study since her diagnosis is not that easily to be cared for and it is in line to
our current concept Acute Biologic Crisis rotation.

The nursing implication of this case study in the nursing education is that it
will enhance more our knowledge to what the disease really is and to what extent
it could. It will help us to acquire more information base on the disease process
of the client and the accompanying signs and symptoms that go with it. In the
nursing practice, applying those learnings in real life situation would provide us,
student nurses, the necessary skills to be utilized in the service of patients and
helps us to become competent nurses in the future. Finally, in nursing research,
we believe that this case study can be of great help to the nursing community,
where it can be used as additional reference by student nurses in the future.

GENERAL OBJECTIVES:

That after the 3 weeks of clinical exposure at Intensive Care Unit in San Pedro
Hospital, the students of BSN-4D Group 3 Subgroup 1, will enhanced our
knowledge, skills and attitude towards the care to our client and also to present a
case study related to the present concept.

SPECIFIC OBJECTIVES:

To achieve our general objectives of this case study, we formulated the following
specific objectives:

a. Relay the biographical data of our client;

b. review the developmental task of the client's age level;
c. describe the physical assessment of the client;
d. define the disease;
e. review the anatomy and physiology of the system involved;
f. determine the etiology of cervical cancer;
g. identify the symptomatology of the said disease;

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h. examine the schematic diagram of the disease;
i. report the laboratory finding of the client;
j. discuss the drugs given to the client;
k. relate the nursing theory to our client's case;
l. formulate a nursing care plan;
m. discuss the discharge plans for the client;
n. cite books and internet websites used as a reliable source of all the
information; and
o. Present the case study in a comprehensive manner

INITIAL DATA BASE

Biographical Data Clinical Data
Name: A. A. B. Chief Complaint: Painful of
Gender: Female Hemorrhoids/ Abdominal pain
Age: 69 years old Date of Admission: 11/05/18
Birthdate: 09/09/1949 Admitting Diagnosis: Mixed
Place of Birth: Cebu City Hemorrhoids to consider Hepatic
Occupation: Retired Social Worker in Hemangioma r/o Malignancies
the Church Attending Physician: Dr. Alexander
School Attainment: 1st year College Lim
Nationality: Filipino
Address: San Jose Village, Sasa
Davao City
Socio-economic Status: Dependent
on their son; (Income: 50,00php)

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Family Health History

Maternal Side Paternal Side

From the genogram above it shows that the paternal and maternal side of
the client doesn’t know about anything that causes their deaths, but to the
siblings of the client there is history of liver cirrhosis and tuberculosis which is
considered as hereditary disease. Other than that both sides do not have any
known diseases.

Past Health History

Client A.B. has no vices. Sometimes she likes to walk and usually joins zumba
lessons in their barangay once a week. The Client likes to eat vegetables and
fish. Her snacks are bread, biscuits, fish cracker and chicharon, and also she
likes to drink a lot of water. If the client will go to bed, she will bring 1 liter of
water. The client takes over the counter medicines every time she had fever, flu
and colds. She has no history of any allergy. Her maintenance is sambong, once
a day. The client’s first hospitalization was on 2014; this was the time she was
diagnosed of kidney stones. The client was treated at brokenshire hospital with
the use of laser technology, the patient was diagnosed of hemorrhoids but there

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was no treatment done, and also with hyperthyroidism. The patient took
carbimazole, once a day but stopped few years ago. 1 year ago, the patient had
onset of abdominal pain with a pain scale of 5-6/10 and still there’s no treatment
nor consultation done. Last August, the patient was diagnosed with hepatic
hemangioma through CT scan. On November 5, 2018, the client was admitted to
San Pedro Hospital due to a chief complaint of abdominal pain.

History of Present Illness

3 weeks ago prior to admission, the patient felt severe abdominal pain at
the flank and gluteal area with a pain scale of 10/10 lasting for 10 seconds. The
patient was relieved when her husband massaged her and if not relieved, she
took mefemamic acid 500mg. On November 5, 2018, at 10am, the patient had
onset of dyspnea and abdominal pain. Therefore, the family decided to rush the
patient for admission.

DEVELOPMENTAL TASK
ERIK ERIKSON’S PSYCHOSOCIAL THEORY OF DEVELOPMENT

Stage Crisis Justification

Maturity Ego Integrity During this time, It is during

65yrs Old- Death Vs this time that we contemplate our
Despair accomplishments and can
develop integrity if we see
ourselves as leading a successful
life
Ego Integrity means fully
accepting oneself and coming to
terms with the death. Accepting
responsibility for your life and
being able to undo the past and

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achieve satisfaction with self is
essential.
Despair means complete loss
or absence of hope.
MET
Her daughter thinks that her
mother have the sense of
fulfillment knowing that she have
done something significant during
her younger years like having a
good and Godly oriented family
and having a professional
children. She can feel that her
mother is contented, because she
believe that her mother have lived
her life to the fullest by
successfully having a successful
children by means of having their
stable jobs.

ROBERT HAVIGHURST’S DEVELOPMENTAL TASK

Task Met/Unmet Justification

Adjusting to deteriorating Met Client is adjusting to
health and physical deteriorating health
strength by means of
willingness to take all
means just to be
cured.
Adjusting to retirement Met Because she lived
contented and happy

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after she retired as a
social worker in the
church
Meeting social and civil Met Our client is an active
obligations member in their
church which is the
Jehovah’s witness.
She serves in their
church by leading
their meetings.
Adjusting to death or loss of Unmet Because her spouse
spouse is still alive

PHYSICAL ASSESSMENT
Our physical assessment was done on November 20, 2018 @ 8am in the
ICU department, cubicle number 2. The result are as follows:

I. General Survey

Our client is a 69-year-old female with an endomorph body built. She

approximately weighs at 50 kilograms. She is intubated and attached to the
mechanical ventilator with the set-up of: respiratory rate of 12, FiO2 of 40%, tidal
volume of 500, and AC mode. She has a distended abdomen and has an
abdominal girth of 93 cm. A nasogastric tube was also attached to the client’s left
nostril with distal end open to drain to beside bottle; the drainage was greenish in
color and was slightly foul smelling. She also has a post op dressing in her
abdomen; dressing is soiled because of some discharges but it is intact. The
client is slightly jaundiced and the skin is dry and warm to touch. There is also a
grade 1 edema noted on the client’s upper and lower extremities. The client also
has a urinary catheter attached to a urobag draining light to dark colored urine

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and was also wearing diapers, clean and not soiled. The vital signs of the client
are as follows:

Vital Sign Result Normal range Interpretation

Temperature 37.7 C 36.5-37.5 C Slightly above normal
Cardiac rate 119 60-100 bpm Above normal;
Tachycardia
Respiratory rate 21 16-20 cpm Slightly above normal
Pulse rate 110 60-100 bpm Above normal
Blood pressure 100/70 120/80 – 140/90 Normal
mmHg
SpO2 96 98-100% Slightly below normal

II. Skin

The skin of the client is dry and slightly jaundiced, skin turgor is good and
the capillary refill time is 2-3 seconds. There are also slight hematomas noted on
several areas of both arms due to blood extraction. A post op dressing was also
noted on client’s abdomen; the dressing is dry, clean, and intact. The nails are
clean but not trimmed. There are no other unusualities noted upon assessment.

III. Head

Our client’s head is normocephalic. There were no lesions or depressions

noted upon assessment. Scalp is dry and there was no scaling noted. Hair is
fine, smooth, and black in color. Facial movements such as raising of the
eyebrows are symmetrical upon assessment.

IV. Eyes

The client has an icteric sclera. There is also presence of arcus senilis in
both eyes brought about by aging. Pupillary reaction is brisk and pupillary size is
2 upon assessment. Consensual reflex is also observed in the client upon

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assessment. Eyebrows are aligned and eye lashes are curled outward. No
unusualites noted upon further assessment.

V. Ears

Equal in size, position is in line with the outer canthus of the eyes. Pinna is
normoset and symmetrical. No disharges or clogged matter noted upon
inspection. Client can substantially hear from a close distance and is cooperative
upon request during bed side care.

VI. Nose

Client’s nose is not deviated and there are no purulent discharges noted
upon assessment. Nasal mucosa is moist and pink; right nostril is patent and the
left nostril has a nasogastric tube inserted to it. Distal end of the nasogastric tube
is open to drain to bedside bottle draining greenish and slightly foul smelling
gastric content. There were no lesions noted upon inspection and no further
unusualities found upon assessment.

VII. Mouth and Pharynx

Client’s lips are dry and chapped with noticeable peeling. There is also a
endotracheal tube inserted to the mouth of the client with a size of 7.5 and with a
level of 19. There is noticeable accumulation of saliva in the mouth with a sticky
consistency and slightly yellowish in color. Suctioning was done to the client;
aspirate was sticky and clear amounting to 100 cc. Mucosa is pinkish and moist
upon inspection. There are also some cavities noted on client’s teeth and there
was also a slight yellowing discoloration. The uvula is not deviated and the
mucosa is pinkish upon inspection. And gag reflex was present; this was
evaluated during suctioning on the endotracheal tube of the patient. There are no
further unusualities noted upon assessment.

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VIII. Neck

There are no abnormalities noted upon assessment of the client’s neck.

Client can move her neck from side to side but in a slow manner. Lymph nodes
are not swollen or enlarged during palpation.

IX. Thorax and Breasts

The client’s thorax is symmetrical in shape and there are no depressions

or any abnormalities noted upon assessment. Upon auscultation, client has
noticeable bibasal crackles upon auscultation. Also, client’s respirations are non
labored due to the attachment to the mechanical ventilator. Weaning was also
started with 5 minutes of in-line neb every hour. Unfortunately, the client was not
able to tolerate the first 5 minutes of weaning hence, it was hold. Client’s breasts,
upon assessment, was free from any lesions. Nipple and areola were clean and
dry and there are no purulent discharges noted. There are no further unusulities
noted upon assessment.

X. Heart

The client has a strong and distinct apical heart beat with no extra heard
sounds noted. Peripheral pulses of the client are also strong except for the
femoral pulse which is weak upon assessment. There are no other abnormalities
noted upon assessment.

XI. Abdomen

The abdomen of our client is round, soft, and distended. There is a post
op dressing in the client’s abdomen; the dressing is soiled but intact. There is a
noticeable fluid retention of the client exhibiting ascites with an abdominal girth of
93 cm upon assessment. The bowel sounds of the client are hypoactive during
auscultation of each quadrant ranging from 2-3 bowel sounds/quadrant.
Percussion and palpation was not done to the client because it was
contraindicated and may result to gastrointestinal bleeding.

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XII. Extremities

The client can move her extremities despite the development of a grade 1
pitting edema both in her arms and legs. There are also noticeable hematomas in
both of her arms due to blood extractions and there is also noticeable swelling in
both hands brought about by IV insertions. Other than that, there are no
abnormalities noted upon assessment.

XIII. Genitalia

There are no abnormalities in the client’s genitalia besides from the

development of a hematoma in the client’s right labia. There was no known
cause on what could have resulted to the said hematoma.

DEFINITION OF DIAGNOSIS
Mixed Hemorrhoids

Hemorrhoids are abnormally enlarged anal cushions containing

arteriovenous anastomosis, traditionally described as occurring in the 3, 7 and 11
o’clock positions. (Chugh, A., Singh, R., & Agarwal, P. (2015). Management of
hemorrhoids (6th ed., Vol. 25). Indian Journal of Clinical Practice.)

Hemorrhoids are “varicosities of the veins of the hemorrhoidal plexus,

often complicated by inflammation, thrombosis, and bleeding”. (Gami, B. (2015).
HEMORRHOIDS – A COMMON AILMENT AMONG ADULTS, CAUSES &
TREATMENT: A REVIEW (Vol. 3). Pharmaceutical Biotechnology lab, Ipcowala
Santram Institute of Biotechnology & Emerging Sciences, Dharmaj 388430,
Gujarat India.)

Hemorrhoids are “vascular cushions, consisting of thick submucosa

containing both venous and arterial blood vessels”. (Timby, B. K., & Smith, N. E.
(n.d.). Introductory medical-surgical nursing (8th ed.). Lippincott williams and
wilkins.)

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Hepatic Hemangioma

Hepatic hemangiomas are benign tumors of the liver consisting of clusters

of blood-filled cavities, lined by endothelial cells, fed by the hepatic artery.
(Balaban, D. V. (2015). Hepatic hemangioma review. Journal of medicine and
life.)

Hemangiomas are noncancerous liver tumors composed of a mass of

abnormal blood vessels. They are the most common benign primary tumors of
the liver. (Unal, E., Acar, A., Canbak, T., & Tulan, H. (2016). Liver Hemangiomas:
A Wide Range of Management from Observation to Hepatic Transplantation.
Journal of family medicine and community health.)

Hemangiomas are common focal liver lesions, usually detected in the

work up of asymptomatic patients. (S. florim, C. maciel, A.T. almeida, & F.A
costa. (n.d.). Hepatic hemangiomas: Typical and atypical imaging findings,
pitfalls and differential diagnosis. doi:10.1594/ecr2017/C-1754)

ANATOMY AND PHYSIOLOGY

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Weighing in at around 3 pounds, the liver is the body’s second largest
organ; only the skin is larger and heavier. The liver performs many essential
functions related to digestion, metabolism, immunity, and the storage of nutrients
within the body. These functions make the liver a vital organ without which the
tissues of the body would quickly die from lack of energy and nutrients.
Fortunately, the liver has an incredible capacity for regeneration of dead or
damaged tissues; it is capable of growing as quickly as a cancerous tumor to
restore its normal size and function.

The liver is a roughly triangular organ that extends across the entire
abdominal cavity just inferior to the diaphragm. Most of the liver’s mass is located
on the right side of the body where it descends inferiorly toward the right kidney.
The liver is made of very soft, pinkish-brown tissues encapsulated by a
connective tissue capsule. This capsule is further covered and reinforced by the
peritoneum of the abdominal cavity, which protects the liver and holds it in place
within the abdomen.

The peritoneum connects the liver in 4 locations: the coronary ligament,

the left and right triangular ligaments, and the falciform ligament. These
connections are not true ligaments in the anatomical sense; rather, they are
condensed regions of peritoneal membrane that support the liver.

The wide coronary ligament connects the central superior portion of the liver
to the diaphragm.

Located on the lateral borders of the left and right lobes, respectively,
the left and right triangular ligaments connect the superior ends of the liver to
the diaphragm.

The falciform ligament runs inferiorly from the diaphragm across the
anterior edge of the liver to its inferior border. At the inferior end of the liver,
the falciform ligament forms the round ligament (ligamentum teres) of the liver

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and connects the liver to the umbilicus. The round ligament is a remnant of
the umbilical vein that carries blood into the body during fetal development.

The liver consists of 4 distinct lobes — the left, right, caudate, and quadrate
lobes.

The left and right lobes are the largest lobes and are separated by the
falciform ligament. The right lobe is about 5 to 6 times larger than the tapered
left lobe.

The small caudate lobe extends from the posterior side of the right
lobe and wraps around the inferior vena cava.

The small quadrate lobe is inferior to the caudate lobe and extends
from the posterior side of the right lobe and wraps around the gallbladder.

Bile Ducts

The tubes that carry bile through the liver and gallbladder are known as
bile ducts and form a branched structure known as the biliary tree. Bile produced
by liver cells drains into microscopic canals known as bile canaliculi. The
countless bile canaliculi join together into many larger bile ducts found
throughout the liver.

These bile ducts next join to form the larger left and right hepatic ducts,
which carry bile from the left and right lobes of the liver. Those two hepatic ducts
join to form the common hepatic duct that drains all bile away from the liver. The
common hepatic duct finally joins with the cystic duct from the gallbladder to form
the common bile duct, carrying bile to the duodenum of the small intestine. Most
of the bile produced by the liver is pushed back up the cystic duct by peristalsis
to arrive in the gallbladder for storage, until it is needed for digestion.

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Blood Vessels
The blood supply of the liver is unique among all organs of the body due
to the hepatic portal vein system. Blood traveling to
the spleen, stomach, pancreas, gallbladder, and intestines passes through
capillaries in these organs and is collected into the hepatic portal vein. The
hepatic portal vein then delivers this blood to the tissues of the liver where the
contents of the blood are divided up into smaller vessels and processed before
being passed on to the rest of the body. Blood leaving the tissues of the liver
collects into the hepatic veins that lead to the vena cava and return to the heart.
The liver also has its own system of arteries and arterioles that provide
oxygenated blood to its tissues just like any other organ

Lobules

The internal structure of the liver is made of around 100,000 small

hexagonal functional units known as lobules. Each lobule consists of a central
vein surrounded by 6 hepatic portal veins and 6 hepatic arteries. These blood
vessels are connected by many capillary-like tubes called sinusoids, which
extend from the portal veins and arteries to meet the central vein like spokes on
a wheel.

Each sinusoid passes through liver tissue containing 2 main cell types: Kupffer
cells and hepatocytes.

 Kupffer cells are a type of macrophage that capture and break down
old, worn out red blood cells passing through the sinusoids.
 Hepatocytes are cuboidal epithelial cells that line the sinusoids and
make up the majority of cells in the liver. Hepatocytes perform most of the
liver’s functions — metabolism, storage, digestion, and bile production.
Tiny bile collection vessels known as bile canaliculi run parallel to the
sinusoids on the other side of the hepatocytes and drain into the bile ducts
of the liver.

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Physiology of the Liver

Digestion

The liver plays an active role in the process of digestion through the
production of bile. Bile is a mixture of water, bile salts, cholesterol, and the
pigment bilirubin. Hepatocytes in the liver produce bile, which then passes
through the bile ducts to be stored in the gallbladder. When food containing fats
reaches the duodenum, the cells of the duodenum release the hormone
cholecystokinin to stimulate the gallbladder to release bile. Bile travels through
the bile ducts and is released into the duodenum where it emulsifies large
masses of fat. The emulsification of fats by bile turns the large clumps of fat into
smaller pieces that have more surface area and are therefore easier for the body
to digest.

Bilirubin present in bile is a product of the liver’s digestion of worn out red
blood cells. Kupffer cells in the liver catch and destroy old, worn out red blood
cells and pass their components on to hepatocytes. Hepatocytes metabolize
hemoglobin, the red oxygen-carrying pigment of red blood cells, into the
components heme and globin. Globin protein is further broken down and used as
an energy source for the body. The iron-containing heme group cannot be
recycled by the body and is converted into the pigment bilirubin and added to bile
to be excreted from the body. Bilirubin gives bile its distinctive greenish color.
Intestinal bacteria further convert bilirubin into the brown pigment stercobilin,
which gives feces their brown color.

Metabolism
The hepatocytes of the liver are tasked with many of the important
metabolic jobs that support the cells of the body. Because all of the blood leaving
the digestive system passes through the hepatic portal vein, the liver is
responsible for metabolizing carbohydrate, lipids, and proteins into biologically
useful materials.

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Our digestive system breaks down carbohydrates into the monosaccharide
glucose, which cells use as a primary energy source. Blood entering the liver
through the hepatic portal vein is extremely rich in glucose from digested food.
Hepatocytes absorb much of this glucose and store it as the macromolecule
glycogen, a branched polysaccharide that allows the hepatocytes to pack away
large amounts of glucose and quickly release glucose between meals. The
absorption and release of glucose by the hepatocytes helps to maintain
homeostasis and protects the rest of the body from dangerous spikes and drops
in the blood glucose level.

Fatty acids in the blood passing through the liver are absorbed by
hepatocytes and metabolized to produce energy in the form of ATP. Glycerol,
another lipid component, is converted into glucose by hepatocytes through the
process of gluconeogenesis. Hepatocytes can also produce lipids like
cholesterol, phospholipids, and lipoproteins that are used by other cells
throughout the body. Much of the cholesterol produced by hepatocytes gets
excreted from the body as a component of bile.

Dietary proteins are broken down into their component amino acids by the
digestive system before being passed on to the hepatic portal vein. Amino acids
entering the liver require metabolic processing before they can be used as an
energy source. Hepatocytes first remove the amine groups of the amino acids
and convert them into ammonia and eventually urea. Urea is less toxic than
ammonia and can be excreted in urine as a waste product of digestion. The
remaining parts of the amino acids can be broken down into ATP or converted
into new glucose molecules through the process of gluconeogenesis.

Detoxification
As blood from the digestive organs passes through the hepatic portal
circulation, the hepatocytes of the liver monitor the contents of the blood and
remove many potentially toxic substances before they can reach the rest of the
body. Enzymes in hepatocytes metabolize many of these toxins such as alcohol

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and drugs into their inactive metabolites. And in order to keep hormone levels
within homeostatic limits, the liver also metabolizes and removes from circulation
hormones produced by the body’s own glands.
Storage
The liver provides storage of many essential nutrients, vitamins, and
minerals obtained from blood passing through the hepatic portal system. Glucose
is transported into hepatocytes under the influence of the hormone insulin and
stored as the polysaccharide glycogen. Hepatocytes also absorb and store fatty
acids from digested triglycerides. The storage of these nutrients allows the liver
to maintain the homeostasis of blood glucose. Our liver also stores vitamins and
minerals - such as vitamins A, D, E, K, and B12, and the minerals iron and
copper - in order to provide a constant supply of these essential substances to
the tissues of the body.
Unfortunately, one common hereditary disorder called hemochromatosis
causes the liver to store too much iron, potentially leading to liver disease.
Modern DNA health testing can help you find out if you are genetically at higher
risk of acquiring this condition or others like Gaucher disease and alpha-1
antitrypsin deficiency, all of which increase your risk of developing liver disease.
Production
The liver is responsible for the production of several vital protein
components of blood plasma: prothrombin, fibrinogen, and albumins.
Prothrombin and fibrinogen proteins are coagulation factors involved in the
formation of blood clots. Albumins are proteins that maintain the isotonic
environment of the blood so that cells of the body do not gain or lose water in the
presence of body fluids.
Immunity
The liver functions as an organ of the immune system through the function
of the Kupffer cells that line the sinusoids. Kupffer cells are a type of fixed
macrophage that form part of the mononuclear phagocyte system along with
macrophages in the spleen and lymph nodes. Kupffer cells play an important role
by capturing and digesting bacteria, fungi, parasites, worn-out blood cells, and

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cellular debris. The large volume of blood passing through the hepatic portal
system and the liver allows Kupffer cells to clean large volumes of blood very
quickly.

SYMPTOMATOLOGY
Symptoms Present/Not Rationale Justification
Present
Pain in the right,  It is where the liver is It is present in our client
upper quadrant located. Ruptured because her hemangioma
of the abdomen tumor causes pain has ruptured which then
and bleeding inside cause pain and bleeding
the abdomen. inside the abdomen.
Nausea and X When liver is It is not present in our client
vomiting enlarged, it pushes
the stomach therefore
giving the feeling of
nausea and vomiting
Feeling a sense X An enlarged liver It is not present in our client
of fullness pushes on the
despite eating stomach and creates
only a small a feeling of fullness.
portion of food
An enlarged liver X Mass will form in the Our client’s liver is enlarged
liver which will then with a heterogenous mass
increase in size later measuring 16.0cm x 10.8 x
on. 12.3cm.

ETIOLOGY
Predisposing Factors

Factors Present/Not Justification

Present
Age X Those between ages 30 and 50 are also at a higher risk
for a liver hemangioma.

Gender ✓ Women are more likely to be diagnosed with a liver

hemangioma than men are.

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Hormone X May increase the risk or increase the size and
replacement discontinuing contraceptive regimen can lead to lesion
therapy regression.

Precipitating Factors

Factors Present/Not Present Justification

Pregnancy ✓ Women who have been pregnant are
more likely to be diagnosed with a liver
hemangioma than women who have
never been pregnant. It's believed the
hormone estrogen, which rises during
pregnancy, may play a role in liver
hemangioma growth.

SCHEMATIC DIAGRAM

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NARRATIVE
A liver hemangioma is a benign lump in the liver. These lumps consist of
blood vessels and are usually harmless. There are certain causes of liver
hemangioma and one of the precipitating factors is the pregnancy. And the
predisposing factors are age, gender, and hormone replacement therapy. With
these factors present, there will be an alteration in the cell components leading to
dysplasia. In dysplasia, the cells look abnormal under a microscope but are not
cancer – that is why hepatic hemangioma is benign and is not cancerous. There
will then be an alteration in the gene that controls apoptosis leading to
proliferation of cells. Since there is now an increased number of cells, the blood
vessels will swell then there will be a formation of huge vascular spaces. The
blood will now go through a cavern with endothelial cells scattered all throughout
which then leads to a formation of a mass in the liver. If it is treated immediately
through medications and surgery, there will be a good prognosis. But if it is not
treated immediately, the tumor will increase in size. There will be a compression
of neighboring organs which will then increase the intra-abdominal pressure
leading to rupture of the liver. There will be a severe blood loss which will
decrease the oxygen supply at the cellular level and cause hypovolemic shock,
leading to death.

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DIAGNOSTICS
BLOOD CHEMISTRY

DATE TEST RESULT NORMAL RANGE & INTERPRETATION NURSING INTERVENTION

DEFINITION
11/05/2018 Creatinine 108.3 53-115 umol/L The patient’s 1. Explain the procedure to the
creatinine level is patient and its purpose.
Creatinine is a within normal range. 2. Inform the patient to
chemical waste temporarily stop taking
molecule that is medications that can alter the
generated from test results.
muscle metabolism. 3. Inform the patient that there
Abnormally high will be a slight discomfort due
levels of creatinine to needle insertion.
warn of possible 4. Observe sterile technique
malfunction or failure during the procedure.
of the kidneys. 5. Ensure correct labeling,
SGOT/AST 62.00 15-41 U/L The patient’s storage and transportation of
SGOT/AST result is the specimen.
SGOT is a blood test above normal range 6. Explain to the patient that
which measures one which indicates the there might be a hematoma at

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of two liver enzymes possibility of a liver the puncture site after blood
which is aspartate problem. extraction.
aminotransferase. An 7. Apply cold compress to the
SGOT test evaluates puncture site if the hematoma
how much of liver is large.
enzyme is in the 8. Monitor test results.
blood. High AST 9. Do medical hand washing.
result may indicate 10. Inform the patient that he/she
liver problem. can continue taking the
withheld medicines after the
procedure.
SGPT/ALT 24.00 14-54 U/L The SGPT/ALT of the
patient is within
SGPT is a blood test normal range.
which measures one
of two liver enzymes
which is alanine
aminotransferase. An
SGPT test evaluates
how much of liver

23
enzyme is in the
blood. High ALT
result may indicate
liver problem.
Total 22.16 6.8-34.2 umol/L The total bilirubin of
Bilirubin the patient is within
A bilirubin test normal range.
measures the amount
of bilirubin in the
blood. High levels of
bilirubin is a sign that
either the red blood
cells are breaking
down at an unusual
rate or that the liver
isn’t breaking down
waste properly and
clearing the bilirubin
from the blood.

24
Direct 5.24 1.7-8.6 umol/L The direct bilirubin of
Bilirubin the patient is within
Conjugated or direct normal range.
bilirubin travels from
the liver into the small
intestine. A very small
amount passes into
the kidneys and is
excreted in the urine.
Conjugated bilirubin
can increase when
the liver is able to
process bilirubin but
is not able to pass the
conjugated bilirubin to
the bile for removal.
This test is usually
done to look for liver
problems such as
hepatitis or blockages

25
such as gallstones.
High levels of direct
bilirubin indicates that
there might be a liver
problem, hepatitis or
gallstones.
Indirect 16.92 0.0-19.0 umol/L The indirect bilirubin of
Bilirubin the patient is within
Indirect bilirubin or normal range.
unconjugated bilirubin
is the difference
between total and
direct bilirubin.
Unconjugated
bilirubin may be
increased when there
is an unusual amount
of RBC destruction
(hemolysis) or when

26
the liver is unable to
process bilirubin.
Total Protein 57.14 65-81 g/L

The total protein test

measures the total
amount of two
classes of protein in
the blood which are
albumin and globulin.
Elevated total protein
may indicate
inflammation or
infections while low
total protein levels
may indicate
bleeding, liver
disorder, kidney
disorder, malnutrition,
malabsorption,

27
conditions, extensive
burns,
agammaglobulinemia,
inflammatory
conditions and
delayed post-surgery
recovery.
Albumin 25.30 35-50 g/L The albumin level of
the patient is below
This test measures normal range.
the amount of the
protein albumin in the
blood. The liver
makes albumin and
this carries
substances such as
hormones, medicines,
and enzymes
throughout the body.
This test can help

28
diagnose, evaluate,
and watch kidney and
liver conditions. When
the kidneys begin to
fail, albumin starts to
leak into the urine.
This causes a low
albumin level in the
blood.
Globulin 31.84 15-35 g/L The globulin level of
the patient is within
Globulins are group normal range.
of proteins in the
blood. They are made
in the liver by the
immune system.
Globulins play an
important role in liver
function, blood
clotting, and fighting

29
infection. Low
globulin levels can be
a sign of liver or
kidney disease. High
levels may indicate
infection,
inflammatory disease
or immune disorders.
A/G Ratio 0.79 1.2-2.2 The A/G ratio of the
patient is below
Albumin/Globulin ratio normal range.
measures the amount
of protein in the
blood. Low A/G ratio
may indicate an
autoimmune disorder,
kidney disease or
cirrhosis or a tumor in
the bone marrow.
High A/G ratio may

30
indicate liver, kidney
or intestinal disease.
It can also indicate
low thyroid activity
and leukemia.
Sodium 133.8 136-144 mmol/L The sodium levels of
the patient is below
This measures the normal range.
amount of sodium
present in the blood.
A blood sodium lower
than the normal level
is called
hyponatremia which
can cause damage to
the cells. A blood
sodium higher than
the normal level is
called hypernatremia.
This can cause

31
elevation in the blood
pressure.
Potassium 4.3 3.6-5.1 mmol/L The potassium level of
the patient is within
This measures the normal range.
amount of potassium
present in the blood.
Potassium is an
electrolyte that’s
essential for proper
muscle and nerve
function. Low
potassium level is
called hypokalemia
while high potassium
level is called
hyperkalemia.
Hyperkalemia can
lead to changes in

32
the rhythm of the
heart.
Total 2.02 2.23-2.58 mmol/L The total calcium level
Calcium of the patient is below
This measures the normal range.
amount of free and
bound calcium in the
blood. Free calcium is
not attached to
anything in the body
while bound calcium
is attached to albumin
or other substances
in the blood. High
levels of calcium in
the blood is called
hypercalcemia which
is usually a result of
overactive
parathyroid glands.

33
Low calcium level is
called hypocalcemia
which indicates a
problem in the
parathyroid gland,
improper diet, kidney
disorders or the
effects of certain
drugs.
Alkaline 111.0 38-126 U/L The patient’s alkaline
Phosphatase phosphatase is within
This measure the normal range.
amount of the
enzyme in the blood.
Elevated levels of
alkaline phosphatase
may indicate biliary
obstruction, bone
conditions,
osteoblastic bone

34
tumors, osteomalacia,
liver disease,
hyperparathyroidism,
leukemia, lymphoma,
paget’s disease,
rickets and
sarcoidosis. Low
levels of alkaline
phosphatase may
indicate
hypophosphatasia,
malnutrition, protein
deficiency and Wilson
disease.

35
DATE TEST RESULT NORMAL RANGE & INTERPRETATION NURSING
DEFINITION INTERVENTION
11/06/2018 FBS 5.1 4.4-6.4 mmol/L The patient’s fasting blood 1. Explain the procedure
sugar is normal. to the patient and its
Fasting blood sugar is the purpose.
amount of glucose in the 2. Inform the patient to
blood without food intake. A temporarily stop taking
fasting blood sugar level less medications that can
than 5.6 mmol/L is normal. A alter the test results.
fasting blood sugar level from 3. Inform the patient that
5.6 to 6.9 mmol/L is there will be a slight
considered prediabetes. If it's discomfort due to
7 mmol/L or higher on two needle insertion.
separate tests, the patient 4. Observe sterile
has diabetes. technique during the
Total 3.6 0-5.2 mmol/L The total cholesterol of the procedure.
Cholesterol patient is within normal range. 5. Ensure correct
Total cholesterol is the total labeling, storage and
amount of cholesterol in the transportation of the
blood. specimen.

36
Triglycerides 0.9 0-1.68 mmol/L The triglycerides of the patient 6. Explain to the patient
Triglycerides are the calories is within normal range. that there might be a
not needed by the body hematoma at the
which were converted and puncture site after
stored in the fat cells of the blood extraction.
body. People with high 7. Apply cold compress to
triglycerides often have a the puncture site if the
high total cholesterol level, hematoma is large.
including a high LDL (bad) 8. Monitor test results.
cholesterol level and a low 9. Do medical hand
HDL (good) cholesterol level. washing.
Many people with heart Inform the patient that
disease or diabetes also he/she can continue
have high triglyceride levels. taking the withheld
HDL 0.6 1.03-1.55 mmol/L The patient’s HDL cholesterol medicines after the
Cholesterol is below normal range which procedure.
People with high triglycerides increases her risk of
usually also have lower levels developing a heart disease.
of the good kind of
cholesterol, or HDL. Having a

37
low HDL increases the risk of
developing heart disease.
LDL 2.82 3.36-4.14 mmol/L The LDL of the patient is low
Cholesterol Low density lipoproteins are which is good for the patient
also known as the bad since it reduces the risk of
cholesterol. This is stroke and heart attacks.
considered bad since it
becomes part of plaque
which can cause an
obstruction in the arteries and
it increases the risk of stroke
and heart attacks.

38
DATE TEST RESULT NORMAL RANGE INTERPRETATION NURSING
& DEFINITION INTERVENTION
11/21/2018 Sodium 149.9 136-144 mmol/L The patient’s 11. Explain the
sodium level is procedure to
This measures the within normal the patient and
amount of sodium range. its purpose.
present in the 12. Inform the
blood. A blood patient to
sodium lower than temporarily
the normal level is stop taking
called medications
hyponatremia that can alter
which can cause the test
damage to the results.
cells. A blood 13. Inform the
sodium higher than patient that
the normal level is there will be a
called slight
hypernatremia. discomfort due
This can cause

39
elevation in the to needle
blood pressure. insertion.
14. Observe
sterile
Potassium 3.6 3.6-5.1 mmol/L The patient’s technique
potassium level is during the
This measures the within normal procedure.
amount of range. 15. Ensure correct
potassium present labeling,
in the blood. storage and
Potassium is an transportation
electrolyte that’s of the
essential for specimen.
proper muscle and 16. Explain to the
nerve function. patient that
Low potassium there might be
level is called a hematoma
hypokalemia while at the
high potassium puncture site
level is called

40
hyperkalemia. after blood
Hyperkalemia can extraction.
lead to changes in 17. Apply cold
the rhythm of the compress to
heart. the puncture
site if the
Total Calcium 2.00 2.23-2.58 mmol/L The patient’s total hematoma is
calcium is below large.
This measures the normal range. 18. Monitor test
amount of free and results.
bound calcium in 19. Do medical
the blood. Free hand washing.
calcium is not 20. Inform the
attached to patient that
anything in the he/she can
body while bound continue
calcium is attached taking the
to albumin or other withheld
substances in the medicines
blood. High levels

41
of calcium in the after the
blood is called procedure.
hypercalcemia
which is usually a
result of overactive
parathyroid glands.
Low calcium level
is called
hypocalcemia
which indicates a
problem in the
parathyroid gland,
improper diet,
kidney disorders or
the effects of
certain drugs.

Magnesium 0.80 0.74-1.03 mmol/L The patient’s

magnesium level is

42
This is to measure within normal
the amount of range.
magnesium in the
blood. An elevated
level of
magnesium is
referred to as
hypermagnesemia.
Hypermagnesemia
occurs when the
process that keeps
the levels of
magnesium in the
body at normal
levels does not
work properly..
When the kidneys
do not work
properly, they are
unable to get rid of

43
excess
magnesium and
this makes the
person more
susceptible to a
build-up of the
mineral in the
blood.

DATE TEST RESULT NORMAL INTERPRETATION NURSING

RANGE & INTERVENTIONS
DEFINTION
11/24/18 Albumin 23.88 35-50 g/L The albumin level 1. Explain the
of the patient is procedure to
This test below the normal the patient and
measures the range. its purpose.
amount of the 2. Inform the
protein albumin in patient to

44
the blood. The temporarily
liver makes stop taking
albumin and this medications
carries that can alter
substances such the test
as hormones, results.
medicines, and 3. Inform the
enzymes patient that
throughout the there will be a
body. This test slight
can help discomfort due
diagnose, to needle
evaluate, and insertion.
watch kidney and 4. Observe sterile
liver conditions. technique
When the kidneys during the
begin to fail, procedure.
albumin starts to 5. Ensure correct
leak into the labeling,
urine. This storage and

45
causes a low transportation
albumin level in of the
the blood. specimen.
6. Explain to the
patient that
there might be
a hematoma at
the puncture
site after blood
extraction.
7. Apply cold
compress to
the puncture
site if the
hematoma is
large.
8. Monitor test
results.
9. Do medical
hand washing.

46
Inform the patient
that he/she can
continue taking
the withheld
medicines after
the procedure.

DATE TEST RESULT NORMAL RANGE & INTERPRETATION NURSING

DEFINTION INTERVENTION
11/19/18 SGOT/AST 58.00 15-41 U/L The patient’s 1. Explain the
SGOT/AST is procedure to
SGOT is a blood test above normal the patient
which measures one range. and its
of two liver enzymes purpose.
which is aspartate 2. Inform the
aminotransferase. patient to
An SGOT test temporarily
evaluates how much stop taking
of liver enzyme is in medications
the blood. High AST that can alter

47
result may indicate the test
liver problem. results.
3. Inform the
patient that
SGPT/ALT 30.00 14-54 U/L The patient’s there will be a
SGOT/ALT is slight
SGPT is a blood test within normal discomfort due
which measures one range. to needle
of two liver enzymes insertion.
which is alanine 4. Observe
aminotransferase. sterile
An SGPT test technique
evaluates how much during the
of liver enzyme is in procedure.
the blood. High ALT 5. Ensure correct
result may indicate labeling,
liver problem. storage and
transportation
of the
Total Bilirubin 126.96 6.8-34.2 umol/L specimen.

48
The patient’s total 6. Explain to the
A bilirubin test bilirubin is above patient that
measures the normal range. there might be
amount of bilirubin in a hematoma
the blood. High at the
levels of bilirubin is a puncture site
sign that either the after blood
red blood cells are extraction.
breaking down at an 7. Apply cold
unusual rate or that compress to
the liver isn’t the puncture
breaking down site if the
waste properly and hematoma is
clearing the bilirubin large.
from the blood. 8. Monitor test
results.
Direct Bilirubin 74.82 1.7-8.5 umol/L 9. Do medical
The patient’s direct hand washing.
Conjugated or direct bilirubin is above 10. Inform the
bilirubin travels from normal range. patient that

49
the liver into the he/she can
small intestine. A continue
very small amount taking the
passes into the withheld
kidneys and is medicines
excreted in the after the
urine. Conjugated procedure.
bilirubin can
increase when the
liver is able to
process bilirubin but
is not able to pass
the conjugated
bilirubin to the bile
for removal. This test
is usually done to
look for liver
problems such as
hepatitis or
blockages such as

50
gallstones. High
levels of direct
bilirubin indicates
that there might be a
liver problem,
hepatitis or
gallstones.

Indirect Bilirubin 52.14 0.0-19.0 umol/L

The patient’s
Indirect bilirubin or indirect bilirubin is
unconjugated above normal
bilirubin is the range.
difference between
total and direct
bilirubin.
Unconjugated
bilirubin may be
increased when
there is an unusual

51
amount of RBC
destruction
(hemolysis) or when
the liver is unable to
process bilirubin.

Alkaline 139.00 38-126 U/L

Phosphatase This measure the The patient’s
amount of the alkaline
enzyme in the blood. phosphatase is
Elevated levels of above normal
alkaline range.
phosphatase may
indicate biliary
obstruction, bone
conditions,
osteoblastic bone
tumors,
osteomalacia, liver

52
disease,
hyperparathyroidism,
leukemia,
lymphoma, paget’s
disease, rickets and
sarcoidosis. Low
levels of alkaline
phosphatase may
indicate
hypophosphatasia,
malnutrition, protein
deficiency and
Wilson disease.

53
DATE TEST RESULT NORMAL INTERPRETATION NURSING
RANGE & INTERVENTIONS
DEFINITION
11/19/18 Potassium 3.3 3.6-5.1 mmol/L The patient’s 1. Explain the
potassium level is procedure to
This measures below normal the patient and
the amount of range. its purpose.
potassium 2. Inform the
present in the patient to
blood. Potassium temporarily
is an electrolyte stop taking
that’s essential medications
for proper muscle that can alter
and nerve the test
function. Low results.
potassium level is 3. Inform the
called patient that
hypokalemia there will be a
while high slight
potassium level is discomfort due

54
called to needle
hyperkalemia. insertion.
Hyperkalemia can 4. Observe sterile
lead to changes technique
in the rhythm of during the
the heart. procedure.
5. Ensure correct
labeling,
storage and
transportation
of the
specimen.
6. Explain to the
patient that
there might be
a hematoma at
the puncture
site after blood
extraction.

55
7. Apply cold
compress to
the puncture
site if the
hematoma is
large.
8. Monitor test
results.
9. Do medical
hand washing.
10. Inform the
patient that
he/she can
continue taking
the withheld
medicines
after the
procedure.

56
DATE TEST RESULT NORMAL RANGE & INTERPRETATION NURSING
DEFINITION INTERVENTION
11/14/18 Total Protein 53.94 65-81 g/L The patient’s total 1. Explain the
protein level is procedure to
The total protein test below the normal the patient
measures the total range. and its
amount of two purpose.
classes of protein in 2. Inform the
the blood which are patient to
albumin and globulin. temporarily
Elevated total protein stop taking
may indicate medications
inflammation or that can alter
infections while low the test
total protein levels results.
may indicate 3. Inform the
bleeding, liver patient that
disorder, kidney there will be a
disorder, malnutrition, slight
malabsorption, discomfort due

57
conditions, extensive to needle
burns, insertion.
agammaglobulinemia, 4. Observe
inflammatory sterile
conditions and technique
delayed post-surgery during the
recovery. procedure.
5. Ensure correct
Albumin 36.98 35-50 g/L The patient’s labeling,
albumin level is storage and
This test measures within normal transportation
the amount of the range. of the
protein albumin in the specimen.
blood. The liver 6. Explain to the
makes albumin and patient that
this carries there might be
substances such as a hematoma
hormones, medicines, at the
and enzymes puncture site
throughout the body.

58
This test can help after blood
diagnose, evaluate, extraction.
and watch kidney and 7. Apply cold
liver conditions. When compress to
the kidneys begin to the puncture
fail, albumin starts to site if the
leak into the urine. hematoma is
This causes a low large.
albumin level in the 8. Monitor test
blood. results.
9. Do medical
Globulin 16.96 15-35 g/L The patient’s hand washing.
globulin level is 10. Inform the
Globulins are group within normal patient that
of proteins in the range. he/she can
blood. They are made continue
in the liver by the taking the
immune system. withheld
Globulins play an medicines
important role in liver

59
function, blood after the
clotting, and fighting procedure.
infection. Low
globulin levels can be
a sign of liver or
kidney disease. High
levels may indicate
infection,
inflammatory disease
or immune disorders.

A/G Ratio 2.18 1.2-2.2 The A/G Ratio of

the patient is above
Albumin/Globulin ratio the normal range.
measures the amount
of protein in the
blood. Low A/G ratio
may indicate an
autoimmune disorder,

60
kidney disease or
cirrhosis or a tumor in
the bone marrow.
High A/G ratio may
indicate liver, kidney
or intestinal disease.
It can also indicate
low thyroid activity
and leukemia.

Magnesium 1.03 0.70-1.00 mmol/L The patient’s

magnesium level is
This is to measure above normal
the amount of range.
magnesium in the
blood. An elevated
level of magnesium is
referred to as
hypermagnesemia.
Hypermagnesemia

61
occurs when the
process that keeps
the levels of
magnesium in the
body at normal levels
does not work
properly.. When the
kidneys do not work
properly, they are
unable to get rid of
excess magnesium
and this makes the
person more
susceptible to a build-
up of the mineral in
the blood.

62
DATE TEST RESULT NORMAL INTERPRETATION NURSING
RANGE & INTERVENTION
DEFINITION
11/12/18 Sodium 137.7 136-144 mmol/L Within normal 1. Explain the
range procedure to
the patient and
Potassium 4.3 3.6-5.1 mmol/L Within normal its purpose.
range 2. Inform the
patient to
Total Calcium 1.80 2.23-2.58 mmol/L Below normal temporarily
range stop taking
medications
Magnesium 0.73 0.74-1.03 mmol/L Below normal that can alter
range the test
results.
3. Inform the
patient that
there will be a
slight
discomfort due

63
to needle
insertion.
4. Observe
sterile
technique
during the
procedure.
5. Ensure correct
labeling,
storage and
transportation
of the
specimen.
6. Explain to the
patient that
there might be
a hematoma at
the puncture
site after blood
extraction.

64
7. Apply cold
compress to
the puncture
site if the
hematoma is
large.
8. Monitor test
results.
9. Do medical
hand washing.
10. Inform the
patient that
he/she can
continue
taking the
withheld
medicines
after the
procedure.

65
DATE TEST RESULT NORMAL INTERPRETATION NURSING
RANGE & INTERVENTION
DEFINITION
11/21/18 Amylase 46.00 30.0-110.0 U/L The amylase level 1. Explain the
of the patient is procedure to
This measures within normal the patient
the amount of range. and its
amylase in the purpose.
blood or urine. 2. Inform the
Amylase is an patient to
enzyme, or temporarily
special protein, stop taking
that helps digest medications
food. High levels that can alter
of amylase may the test
indicate acute results.
pancreatitis, 3. Inform the
blockage in the patient that
pancreas or there will be a
pancreatic slight

66
cancer. A low discomfort due
amylase may to needle
indicate chronic insertion.
pancreatitis, liver 4. Observe
disease or cystic sterile
fibrosis. technique
during the
The lipase level of
Lipase 282.00 23.0-300.0 U/L procedure.
the patient is within
normal range. 5. Ensure correct
This measures labeling,
the amount of storage and
lipase in the transportation
body. Lipase is of the
secreted by the specimen.
pancreas in the 6. Explain to the
digestive tract to patient that
help break down there might be
fats. If there is a hematoma
elevated lipase at the
level, there might puncture site

67
be a blockage in after blood
the pancreas extraction.
which prevents 7. Apply cold
the release of compress to
lipase to the the puncture
intestinal tract. If site if the
there is low lipase hematoma is
level, it may large.
indicate the 8. Monitor test
presence of results.
cystic fibrosis or 9. Do medical
chronic hand washing.
pancreatitis. 10. Inform the
patient that
he/she can
continue
taking the
withheld
medicines

68
after the
procedure.

DATE TEST RESULT NORMAL INTERPRETATION NURSING

RANGE & INTERVENTION
DEFINITION
11/22/18 Creatinine 93.8 53-115 umol/L The patient’s 1. Explain the
creatinine level is procedure to
Creatinine is a within normal the patient
chemical waste range. and its
molecule that is purpose.
generated from 2. Inform the
muscle patient to
metabolism. temporarily
Abnormally high stop taking
levels of medications
creatinine warn of that can alter
possible the test
malfunction or results.

69
failure of the 3. Inform the
kidneys. patient that
there will be a
slight
discomfort due
to needle
insertion.
4. Observe
sterile
technique
during the
procedure.
5. Ensure correct
labeling,
storage and
transportation
of the
specimen.
6. Explain to the
patient that

70
there might be
a hematoma
at the
puncture site
after blood
extraction.
7. Apply cold
compress to
the puncture
site if the
hematoma is
large.
8. Monitor test
results.
9. Do medical
hand washing.
10. Inform the
patient that
he/she can
continue

71
taking the
withheld
medicines
after the
procedure.

DATE TEST RESULT NORMAL INTERPRETATION NURSING

RANGE & INTERVENTION
DEFINITION
11/16/18 Ammonia 85.00 11-32 umol/L The ammonia level 1. Explain the
of the patient is procedure to
This test checks above normal the patient
the level of range. and its
ammonia in the purpose.
blood. Ammonia 2. Inform the
is a chemical patient to
made by a temporarily
bacteria in the stop taking
intestines and the medications
body’s cells while that can alter

72
the it process the test
protein. High results.
levels of 3. Inform the
ammonia may patient that
indicate that the there will be a
patient has liver slight
disease or reye’s discomfort due
syndrome. A low to needle
level of ammonia insertion.
may indicate that 4. Observe
the kidneys aren’t sterile
removing waste technique
as they should. during the
procedure.
5. Ensure correct
labeling,
storage and
transportation
of the
specimen.

73
6. Explain to the
patient that
there might be
a hematoma
at the
puncture site
after blood
extraction.
7. Apply cold
compress to
the puncture
site if the
hematoma is
large.
8. Monitor test
results.
9. Do medical
hand washing.
10. Inform the
patient that

74
he/she can
continue
taking the
withheld
medicines
after the
procedure.

DATE TEST RESULT INTERPRETATION NURSING

INTERVENTION
11/19/18 Chest PA Left ventricular The left ventricle of 1. Explain the
cardiomegaly with the heart is enlarged. procedure and its
pulmonary congestion There is fluid inside purpose to the
the pulmonary cavity patient.
which causes the 2. Change patient’s
congestion. clothes into
patient’s gown.
Intercurrent Intercurrent means 3. Remove all metals
pneumonia that a disease and jewelries.
considered. intervenes during the

75
course of another 4. Inform the patient
disease. Pneumonia that there will be
is an inflammatory no discomfort
condition of the lung upon the
affecting the alveoli. procedure.
5. Assist patient to
Bilateral pleural A pleural effusion is a the xray
effusion buildup of fluid in the department.
pleural space, an 6. Return patient’s
area between the belongings after
layers of tissue that the procedure.
line the lungs and the 7. Assist the patient
chest cavity. back to his/her
room.
Atherosclerotic aorta There is hardening 8. Monitor laboratory
and narrowing of the results.
aorta which affects 9. Compare past and
the blood flow in the present result.
body. 10. Make patient
comfortable.

76
DATE TEST RESULT NORMAL RANGE & INTERPRETATION NURSING
DEFINITION INTERVENTIONS
11/24/18 Hemoglobin 98 120-160 g/L The patient’s 11. Explain the
haemoglobin level is procedure to the
Haemoglobin is a red low. patient and its
protein responsible for purpose.
transporting oxygen in 12. Inform the patient to
the blood. Low temporarily stop
haemoglobin count is taking medications
known as anemia that can alter the test
which means that there results.
is not enough red 13. Inform the patient
blood cells in the body. that there will be a
A high haemoglobin slight discomfort due
count is known as to needle insertion.
polycythemia which 14. Observe sterile
means that there is too technique during the
many red blood cells in procedure.
the body.

77
15. Ensure correct
labeling, storage and
transportation of the
Red Blood Cell 3.40 specimen.
The patient’s RBC count 16. Explain to the patient
is low. that there might be a
hematoma at the
4.0-5.0 puncture site after
blood extraction.
Red blood cells carry 17. Apply cold compress
oxygen throughout the to the puncture site if
body. They also the hematoma is
remove carbon dioxide large.
in the body and 18. Monitor test results.
transports it to the 19. Do medical hand
lungs for exhalation. washing.
High RBC may indicate 20. Inform the patient
erythrocytosis and this that he/she can
may be due to continue taking the
smoking, congenital

78
heart disease, withheld medicines
dehydration, renal cell after the procedure.
carcinoma, pulmonary
fibrosis or
polycythemia vera.
MCH 28.9 Low RBC count may
indicate anemia, bone The MCH level of the
marrow failure, patient is within normal
erythropoietin range.
deficiency, hemolysis,
internal or external
bleeding, leukemia,
malnutrition, multiple
myeloma, nutritional
deficiencies,
pregnancy or thyroid
disorders.

28-33 pg

79
Mean corpuscular
haemoglobin refer to
the average amount of
hemoglobin found in
the red blood cells in
MCV 93.2 the body. Low MCH
may indicate that there The MCV level is
is not enough normal.
haemoglobin in the
blood. High MCH may
indicate macrocytic
anemia. This occurs
when the blood cells
are too big which can
result to not having
enough vitamin B12 or
folic acid. Liver
diseases, overactive
thyroid, drinking
MCHC 31.0 alcohol regulary may

80
cause high MCH
levels. The MCHC is low.

82-98 fl
Mean corpuscular
volume is the average
volume of red cells in a
specimen. MCV is
elevated or decreased
in accordance with
average red cell size;
ie, low MCV indicates
microcytic (small
average RBC size),
normal MCV indicates
normocytic (normal
average RBC size),
and high MCV
indicates macrocytic

81
(large average RBC
size).

White Blood Cell 25.3 33-36 g/L

The mean corpuscular
hemoglobin The WBC is above the
concentration (MCHC) normal range.
is the average
concentration of
Neutrophil 76 hemoglobin in the red
blood cells. The most
common cause of low The neutrophil count is
MCHC is anemia. above the normal range.
Hypochromic
microcytic anemia
commonly results in
low MCHC. This
condition means the
Lymphocyte 10 red blood cells are
smaller than usual and

82
have a decreased level The lymphocyte is
of hemoglobin. A high below normal range.
MCHC value is often
present in conditions
Monocyte 10 where hemoglobin is
more concentrated
within the red blood The monocyte is above
cells. It can also occur normal range.
in conditions where red
blood cells are fragile
or destroyed, leading
to hemoglobin being
present outside of the
red blood cells.

Eosinophil 3 4.8-10.8
It is also leucocytes
which are the cells of The eosinophil is within
immune system that normal range.
are involved in

83
protecting the body
against infection.

40-70 %
Basophil 1 A type of immune cell
that is one of the first
cell types to travel to The basophil is within
the site of an infection. normal range.
Neutrophils help fight
infection by ingesting
microorganisms and
releasing enzymes that
kill the
microorganisms.
Hematocrit 0.32
19-48 % The haematocrit is
below normal range.
Lymphocytes is a type
of white blood cell that

84
is part of the immune
system.

3-9 %

Platelet Count 214.00 Monocytes are a type

of white blood cell that The platelet count is
fight certain infections within normal range.
and help other white
blood cells remove
dead or damaged
tissues, destroy cancer
cells, and regulate
immunity against
foreign substances.

2-8 %

Eosinophils are a type

of white blood cell that

85
play an important role
in the body's response
to allergic reactions,
asthma, and infection
with parasites.

0-0.5 %

Basophils is a type of
white blood cell that
protect the body
against disease and
infections by eating
some types of bacteria,
foreign substances and
other cells.

0.37-0.45 %

86
Hematocrit is the
proportion, by volume,
of the blood that
consists of red blood
cells.The test for
hematocrit measures
the volume of cells as
a percentage of the
total volume of cells
and plasma in whole
blood

150-400

It is also known as
thrombocytes, a cell
that plasy a key role in
blood clotting. They are
small blood
components who’s

87
function is to stop
bleeding, sticking to
the lining of blood
vessels

DATE TEST RESULT NORMAL RANGE & NURSING INTERVENTIONS

DEFINITION
11/22/18 Hemoglobin 107 120-160 g/L 1. Explain the procedure to the patient and
Red Blood Cell 3.69 4.0-5.0 its purpose.
MCH 29.0 28-33 pg 2. Inform the patient to temporarily stop
MCV 91.0 82-98 fl taking medications that can alter the test
MCHC 31.9 33-36 g/L results.
White Blood Cell 26.3 4.8-10.8 3. Inform the patient that there will be a slight
Neutrophil 75 40-70 % discomfort due to needle insertion.
Lymphocyte 9 19-48 % 4. Observe sterile technique during the
Monocyte 10 3-9 % procedure.
Eosinophil 5 2-8 % 5. Ensure correct labeling, storage and
Basophil 1 0-0.5 % transportation of the specimen.
Hematocrit 0.34 0.37-0.45 %
Platelet Count 172.00 150-400

88
6. Explain to the patient that there might be a
hematoma at the puncture site after blood
extraction.
7. Apply cold compress to the puncture site if
the hematoma is large.
8. Monitor test results.
9. Do medical hand washing.
10. Inform the patient that he/she can continue
taking the withheld medicines after the
procedure.

DATE TEST RESULT NORMAL RANGE & NURSING INTERVENTIONS

DEFINITION
11/05/18 Hemoglobin 67 120-160 g/L 1. Explain the procedure to the patient and
Red Blood Cell 2.50 4.0-5.0 its purpose.
MCH 27.0 28-33 pg 2. Inform the patient to temporarily stop
MCV 85.0 82-98 fl taking medications that can alter the test
MCHC 31.8 33-36 g/L results.
White Blood Cell 10.3 4.8-10.8 3. Inform the patient that there will be a slight
Neutrophil 69 40-70 % discomfort due to needle insertion.

89
Lymphocyte 17 19-48 % 4. Observe sterile technique during the
Monocyte 9 3-9 % procedure.
Eosinophil 4 2-8 % 5. Ensure correct labeling, storage and
Basophil 1 0-0.5 % transportation of the specimen.
Hematocrit 0.21 0.37-0.45 % 6. Explain to the patient that there might be a
Platelet Count 165.00 150-400 hematoma at the puncture site after blood
extraction.
7. Apply cold compress to the puncture site if
the hematoma is large.
8. Monitor test results.
9. Do medical hand washing.
10. Inform the patient that he/she can continue
taking the withheld medicines after the
procedure.

DATE TEST RESULT NORMAL RANGE & NURSING INTERVENTIONS

DEFINITION
11/13/18 Hemoglobin 102 120-160 g/L 1. Explain the procedure to the patient and
Red Blood Cell 3.43 4.0-5.0 its purpose.
MCH 29.8 28-33 pg

90
MCV 91.2 82-98 fl 2. Inform the patient to temporarily stop
MCHC 32.6 33-36 g/L taking medications that can alter the test
White Blood Cell 15.7 4.8-10.8 results.
Neutrophil 81 40-70 % 3. Inform the patient that there will be a slight
Lymphocyte 7 19-48 % discomfort due to needle insertion.
Monocyte 9 3-9 % 4. Observe sterile technique during the
Eosinophil 2 2-8 % procedure.
Basophil 1 0-0.5 % 5. Ensure correct labeling, storage and
Hematocrit 0.31 0.37-0.45 % transportation of the specimen.
Platelet Count 114.00 150-400 6. Explain to the patient that there might be a
hematoma at the puncture site after blood
extraction.
7. Apply cold compress to the puncture site if
the hematoma is large.
8. Monitor test results.
9. Do medical hand washing.
10. Inform the patient that he/she can continue
taking the withheld medicines after the
procedure.

91
DATE TEST RESULT DEFINITION NURSING INTERVENTION
11/06/18 Protime Control 13.9 A prothrombine 1. Explain the procedure to the patient and
time measures its purpose.
the number of 2. Inform the patient to temporarily stop
seconds it takes taking medications that can alter the
for a clot to form test results.
in a person's 3. Inform the patient that there will be a
sample of blood slight discomfort due to needle
after substances insertion.
(reagents) are 4. Observe sterile technique during the
added. procedure.
5. Ensure correct labeling, storage and
Protime 16.4 The PT is often transportation of the specimen.
performed with a 6. Explain to the patient that there might
partial be a hematoma at the puncture site
thromboplastin after blood extraction.
time and together 7. Apply cold compress to the puncture
they assess the site if the hematoma is large.
amount and 8. Monitor test results.
function of 9. Do medical hand washing.

92
proteins called Inform the patient that he/she can continue
coagulation taking the withheld medicines after the
factors that are procedure.
an important part
of proper blood
clot formation.

INR 1.209 The INR provides

a standardised
method of
reporting the
effects of an oral
anticoagulant
such as warfarin
on blood clotting.

% Activity 71.6 A pooled normal

plasma (arbitrarily
assigned 100%
activity) was

93
progressively
diluted with saline
and tested for the
PT.

APTT Control 30.4 Activated partial

thromboplastin
time (aPTT or
APTT) is a
medical test that
characterizes
blood
coagulation. They
add a substance
to test the speed
of the blood to
clot faster.

APTT 31.1

94
Activated partial
thromboplastin
time (aPTT or
APTT) is a
medical test that
characterizes
blood
coagulation.

DATE TEST RESULT NURSING INTERVENTION

11/06/18 Protime Control 13.9 1. Explain the procedure to the patient and its purpose.
Protime 16.6 2. Inform the patient to temporarily stop taking medications
INR 1.226 that can alter the test results.
% Activity 70 3. Inform the patient that there will be a slight discomfort due
APTT Control 29.3 to needle insertion.
APTT 24.2 4. Observe sterile technique during the procedure.
5. Ensure correct labeling, storage and transportation of the
specimen.
6. Explain to the patient that there might be a hematoma at the
puncture site after blood extraction.

95
7. Apply cold compress to the puncture site if the hematoma is
large.
8. Monitor test results.
9. Do medical hand washing.
10. Inform the patient that he/she can continue taking the
withheld medicines after the procedure.

DATE TEST RESULT NURSING INTERVENTION

11/19/18 Protime Control 13.9 1. Explain the procedure to the patient and its purpose.
Protime 16.6 2. Inform the patient to temporarily stop taking medications
INR 1.226 that can alter the test results.
% Activity 70.1 3. Inform the patient that there will be a slight discomfort due
APTT Control 28.9 to needle insertion.
APTT 25.3 4. Observe sterile technique during the procedure.
5. Ensure correct labeling, storage and transportation of the
specimen.
6. Explain to the patient that there might be a hematoma at the
puncture site after blood extraction.
7. Apply cold compress to the puncture site if the hematoma is
large.

96
8. Monitor test results.
9. Do medical hand washing.
10. Inform the patient that he/she can continue taking the
withheld medicines after the procedure.

DATE TEST RESULT DEFINITION NURSING

INTERVENTION
11/13/18 ClottingTime 3 mins and 45 secs Clotting time is the 1. Explain the
time required for a procedure to the
sample of blood to patient and its
coagulate in vitro purpose.
under standard 2. Inform the patient
conditions. to temporarily stop
taking medications
Bleeding Time 2 minutes Bleeding time is a that can alter the
laboratory test to test results.
assess platelet 3. Inform the patient
function and the that there will be a

97
body’s ability to form slight discomfort
a clot. due to needle
insertion.
4. Observe sterile
technique during
the procedure.
5. Ensure correct
labeling, storage
and transportation
of the specimen.
6. Explain to the
patient that there
might be a
hematoma at the
puncture site after
blood extraction.
7. Apply cold
compress to the
puncture site if the

98
hematoma is
large.
8. Monitor test
results.
9. Do medical hand
washing.
10. Inform the patient
that he/she can
continue taking
the withheld
medicines after
the procedure.

DATE TEST RESULT DEFINITION NURSING

INTERVENTION
11/23/18 CT Scan of the Whole Multiple hepatic Hepatic 1. Explain the
Abdomen cavernous hemangiomas (also procedure and its
hemangiomas referred to as purpose to the
cavernous patient.
hemangiomas

99
because of the 2. Obtain informed
cavernous vascular consent.
space seen 3. Review past and
histologically) are the present health
most common benign history.
mesenchymal hepatic 4. Instruct to have
tumors. nothing per mouth
after midnight.
5. Change patient’s
Minimal ascites Ascites refers to clothes into
abnormal patient’s gown.
accumulation fluid in 6. Inform patient that
the abdominal there will be no
(peritoneal) cavity. discomfort felt
during the
Nephrolithiasis and Nephrolithiasis procedure.
renal cortical cysts, (kidney stones) is a 7. Instruct patient not
left disease affecting the to move during the
urinary tract. Kidney procedure.
stones are small

100
deposits that build up 8. Remove all metals
in the kidneys, made and jewelries.
of calcium, phosphate 9. Assist patient to
and other the CT scan
components of foods. department.
Renal cysts are sacs 10. Do medical hand
of fluid that form in washing after the
the kidneys. procedure.

Aorto-iliac Aortoiliac occlusive

arteriosclerosis disease is the
blockage of the aorta,
the main blood vessel
in your body, or the
iliac arteries. The iliac
arteries are the
branches that your
aorta divides into
around the level of
the belly button to

101
provide blood to your
legs and the organs in
your pelvis. This
blockage is typically
caused by a buildup
of plaque within the
walls of your blood
vessels.

Senile-osteoporosis
Senile osteoporosis
with thoracolumbar
the bone density is
spondylosis
reduced due to aging
bones and calcium
deficiency this leads
to deterioration of
bone structure.
Spondylosis refers to
degenerative changes
in the spine such
as bone spurs and

102
degenerating
intervertebral discs
between the
vertebrae.

Pleural effusion is the

Incidental note of: build-up of excess
Bilateral pleural fluid between the
effusion with passive layers of the pleura
atelectasis of both outside the lungs.
lower lobes Relaxation or passive
atelectasis results
when a pleural
effusion or a
pneumothorax
eliminates contact
between the parietal
and visceral pleurae.

103
Arteriosclerosis is the
hardening and the
Aortic and coronary narrowing of the
arteriosclerosis arteries.

A severe and
generalized edema
Thoracoabdominal with widespread
soft tissue edema subcutaneous tissue
(anasarca) swelling.

DATE TEST RESULT NORMAL RANGE INTERPRETATION NURSING

& DEFINITION INTERVENTION
11/24/18 PH 7.49 7.35-7.45 Above normal range 1. Explain the
Tells how acidic or procedure to
alkaline a the patient
substance is. and its
purpose.
PCO2 23.2 35-45 mmHg Below normal range

104
PCO2 (partial 2. Inform the
pressure of carbon patient to
dioxide) reflects the temporarily
the amount of stop taking
carbon dioxide gas medications
dissolved in the that can alter
blood. the test
results.
PO2 90 80-100 mmHg Within normal range 3. Inform the
PO2 (partial patient that
pressure of oxygen) there will be a
reflects the amount slight
of oxygen gas discomfort due
dissolved in the to needle
blood. insertion.
4. Observe
HCO3 17.8 21-28 mmol/L Below normal range sterile
It is the amount of technique
bicarbonate present during the
in the blood. procedure.

105
5. Ensure correct
TCO2 18.5 23-30 mmol/L Below normal range labeling,
TCO2 is a measure storage and
of carbon dioxide transportation
which exists in of the
several states specimen.
6. Explain to the
BE -4 (-2)-(+2) mmol/L Below normal range patient that
The amount of acid there might be
required to restore a hematoma
a litre of blood to its at the
normal pH at a puncture site
PaCO2 of 40 after blood
mmHg. extraction.
7. Apply cold
95-100 % compress to
O2 Sat 98.7 Oxygen saturation Within normal range the puncture
is the fraction of site if the
oxygen-saturated hematoma is
hemoglobin relative large.

106
to total hemoglobin 8. Monitor test
(unsaturated + results.
saturated) in the 9. Do medical
blood. hand washing.
10. Inform the
patient that
he/she can
continue
taking the
withheld
medicines
after the
procedure.

DATE TEST RESULT NORMAL RANGE NURSING INTERVENTION

& DEFINITION
11/13/18 PH 7.49 7.35-7.45 1. Explain the procedure to the patient and its
PCO2 25.2 35-45 mmHg purpose.
PO2 72.9 80-100 mmHg 2. Inform the patient to temporarily stop taking
HCO3 19.4 21-28 mmol/L medications that can alter the test results.

107
TCO2 20.2 23-30 mmol/L 3. Inform the patient that there will be a slight
BE -3.9 (-2)-(+2) mmol/L discomfort due to needle insertion.
O2 Sat 96.0 95-100% 4. Observe sterile technique during the procedure.
5. Ensure correct labeling, storage and
transportation of the specimen.
6. Explain to the patient that there might be a
hematoma at the puncture site after blood
extraction.
7. Apply cold compress to the puncture site if the
hematoma is large.
8. Monitor test results.
9. Do medical hand washing.
10. Inform the patient that he/she can continue
taking the withheld medicines after the
procedure.

DATE TEST RESULT NORMAL RANGE NURSING INTERVENTION

& DEFINITION
11/12/18 PH 7.50 7.35-7.45 1. Explain the procedure to the patient and its
PCO2 20.9 35-45 mmHg purpose.

108
PO2 133 80-100 mmHg 2. Inform the patient to temporarily stop taking
HCO3 16.2 21-28 mmol/L medications that can alter the test results.
TCO2 16.9 23-30 mmol/L 3. Inform the patient that there will be a slight
BE -5.3 (-2)-(+2) mmol/L discomfort due to needle insertion.
O2 Sat 99.7 95-101% 4. Observe sterile technique during the procedure.
5. Ensure correct labeling, storage and
transportation of the specimen.
6. Explain to the patient that there might be a
hematoma at the puncture site after blood
extraction.
7. Apply cold compress to the puncture site if the
hematoma is large.
8. Monitor test results.
9. Do medical hand washing.
10. Inform the patient that he/she can continue
taking the withheld medicines after the
procedure.

109
DATE TEST RESULT NORMAL RANGE NURSING INTERVENTION
& DEFINITION
Oct 15, 2018 PH 7.47 7.35-7.45 1. Explain the procedure to the patient and its
PCO2 33.1 35-45 mmHg purpose.
PO2 106.6 80-100 mmHg 2. Inform the patient to temporarily stop taking
HCO3 24.2 21-28 mmol/L medications that can alter the test results.
TCO2 25.2 23-30 mmol/L 3. Inform the patient that there will be a slight
BE 0.6 (-2)-(+2) mmol/L discomfort due to needle insertion.
O2 Sat 98.5 95-102% 4. Observe sterile technique during the procedure.
5. Ensure correct labeling, storage and
transportation of the specimen.
6. Explain to the patient that there might be a
hematoma at the puncture site after blood
extraction.
7. Apply cold compress to the puncture site if the
hematoma is large.
8. Monitor test results.
9. Do medical hand washing.

110
10. Inform the patient that he/she can continue
taking the withheld medicines after the
procedure.

DATE TEST RESULT NORMAL RANGE NURSING INTERVENTION

& DEFINITION
11/14/18 PH 7.54 7.35-7.45 1. Explain the procedure to the patient and its
PCO2 21.2 35-45 mmHg purpose.
PO2 61.2 80-100 mmHg 2. Inform the patient to temporarily stop taking
HCO3 18.5 21-28 mmol/L medications that can alter the test results.
TCO2 19.1 23-30 mmol/L 3. Inform the patient that there will be a slight
BE -3.9 (-2)-(+2) mmol/L discomfort due to needle insertion.
O2 Sat 94.6 95-103% 4. Observe sterile technique during the procedure.
5. Ensure correct labeling, storage and
transportation of the specimen.
6. Explain to the patient that there might be a
hematoma at the puncture site after blood
extraction.
7. Apply cold compress to the puncture site if the
hematoma is large.

111
8. Monitor test results.
9. Do medical hand washing.
10. Inform the patient that he/she can continue
taking the withheld medicines after the
procedure.

DATE TEST RESULT NORMAL RANGE NURSING INTERVENTION

& DEFINITION
11/14/18 PH 7.63 7.35-7.45 1. Explain the procedure to the patient and its
PCO2 17.3 35-45 mmHg purpose.
PO2 65.9 80-100 mmHg 2. Inform the patient to temporarily stop taking
HCO3 18.3 21-28 mmol/L medications that can alter the test results.
TCO2 18.8 23-30 mmol/L 3. Inform the patient that there will be a slight
BE -2.7 (-2)-(+2) mmol/L discomfort due to needle insertion.
O2 Sat 96.6 95-104% 4. Observe sterile technique during the procedure.
5. Ensure correct labeling, storage and
transportation of the specimen.
6. Explain to the patient that there might be a
hematoma at the puncture site after blood
extraction.

112
7. Apply cold compress to the puncture site if the
hematoma is large.
8. Monitor test results.
9. Do medical hand washing.
10. Inform the patient that he/she can continue
taking the withheld medicines after the
procedure.

DATE TEST RESULT NORMAL INTERPRETATION NURSING

RANGE & INTERVENTION
DEFINTION
11/06/18 Color Light yellow Normal urine Normal urine color. 1. Identify the
color ranges from patient.
pale yellow to 2. Explain the
deep amber. Dark purpose and
or orange urine the procedure
may indicate liver to the patient.
malfunctioning. 3. Review past
Pale or colorless and present
urine indicates health history.

113
that there is too 4. Provide
much fluid intake. patient with
container
Transparency Clear Freshly voided Normal urine 5. Instruct to
urine is clear and transparency wash the
transparent. genitals first
Cloudy urine may before saving
be caused by urine.
crystals, deposits, 6. Instruct to do
white cells, red mid stream
cells, epithelial catch.
cells or fat 7. Instruct the
globules. patient to
wash the
Reaction 7.5 A urine pH level The urine pH is genital after
test is a test that acidic. urinating.
analyzes the 8. Ensure proper
acidity or labeling of the
alkalinity of a specimen.
urine sample.

114
9. Immediately
Specific Gravity 1.010 A urine specific deliver the
gravity test specimen to
compares the the lab.
density of urine to 10. Monitor
the density of urinalysis
water. This can result.
help determine
how well the
kidneys are
diluting the urine.
Urine that’s too
concentrated
could mean that
the kidneys aren’t
functioning
properly or that
there is not
enough fluid
intake. Urine that

115
isn’t concentrated
enough can
indicate diabetes
insipidus which
causes thirst and
the excretion of
large amounts of
diluted urine.

0-17 /UL

WBC 19 Higher levels of The WBC is high

leukocytes in the
bloodstream may
indicate an
infection.

0-11 /UL

116
A high count of
RBC 5 red blood cells in The RBC is within
the urine can normal range
indicate infection,
trauma, tumors,
or kidney stones.

0-17 /UL

Epithelial cells

Epithelial Cells 4 from the bladder The epithelial cells

and external is within normal
urethra are range
normally present
in the urine in
small amounts.
However, the
amount of
epithelial cells in
the urine
increases when

117
someone has a
urinary tract
infection or some
other cause of
inflammation.

0-1 /UL

Urinary casts are

Casts 0 tiny tube-shaped The cast is within

particles that can normal range
be found when
urine is examined
under the
microscope.

0-278 /UL

High levels of
bacteria in urine

118
Bacteria 11 indicates urinary The bacteria is
tract infection. within normal range

The glucose urine

test measures the
amount of sugar
(glucose) in a
Glucose - urine sample. The There is no glucose
presence of present in the urine
glucose in the
urine is called
glycosuria or
glucosuria.

Healthy kidneys
do not allow a
significant
amount of protein
to pass through

Protein - their filters. But

filters damaged

119
by kidney disease There is no protein
may let proteins present in the
such as albumin urine.
leak from the
blood into the
urine. Proteinuria
can also be a
result of
overproduction of
proteins by the
body.

120
POSSIBLE LABORATORY TESTS

Thoracentesis

Thoracentesis is a procedure in which a needle is inserted into the pleural

space between the lungs and the chest wall. This procedure is done to remove
excess fluid, known as a pleural effusion, from the pleural space to help you
breathe easier.

This is applicable for our patient since she has pulmonary congestion
which makes breathing for our patient difficult.

Angiography

Angiography is a test that uses dye and special x -rays to show the insides
of arteries and can reveal whether plaque is blocking the arteries and how severe
the plaque is.

Since our patient has atherosclerosis and arteriosclerosis, it is important

for us to know how severe is the plaque build-up in the arteries of our patient.

Ultrasound of the thorax

This non-invasive test can help tell the difference between atelectasis,
hardening and swelling of a lung due to fluid in the air sacs (lung consolidation),
and pleural effusion.

This is applicable to our patient since she has passive atelectasis and
pleural effusion.

121
MEDICAL MANAGEMENT
THERAPEUTICS

Date Order Rationale

11/5/18 - IVF: PLR 1L fast drip to Used because it has little to no
300cc then regulate @ effect on the tissues and Make
120cc/hr the person feel hydrated
preventing hypovolemic shock or
hypotension.
- Labs: CBC now w/ PT, APT The labs are used as a baseline
U/A now w/ FBS so that the management will be
Serum elec now accurate to the patient’s need.
ECG 12L now
HGT now
SGPT, SGOT, TB, B1, B2
now
Serum Crea now
TPAG and Chest x-ray now
11/6/18 - Please secure 4 units of supplying oxygen to cells and
PRBC of pt’s blood type cross tissues. providing essential
match to run for 4 hrs w/ 2hrs nutrients to cells, such as amino
interval acids, fatty acids, and glucose.
- Add 1 banana per meal removing waste materials, such
- Please transfuse 2 units of as carbon dioxide, urea, and
PRBC after crossmatch lactic acid. protecting the body
w/4hrs interval to run for 4 hrs/ from infection and foreign bodies
unit through the white blood cells.
- Prepare CBC 6hrs after 2nd So that the temperature of the
BT patient will not be increase,
- Give purosemide 20mg IVTT prevent from fever.
every post BT
- Hot Sitz bath pt. 15-20mins
TID
- For USD of whole abdomen
tom.
- AFP-Hold
- Give paracetamol 500mg tab
now then RTC q 4hrs,
paracetamol PRN for fever
11/7/18 - Give Unasyn 1.5gm IVTT q - Ampicillin and sulbactam are
8hrs penicillin antibiotics that fight
- For Triphsic CT scan of bacteria. Ampicillin and
upper abdomen today sulbactam is a combination
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- Add 2 egg whites per meal medicine used to treat many
Radiology Notes: different types of infections
- Castor oil 60cc P.O 7pm caused by bacteria.
tonight
- Increase OFI, 1glass q
30mins if w/o fluid restrictions
- NPO 12mn until after the
procedure
- Bisacodyl 10mg 2
supp/rectum @6am tom.
- Please ensure IV line
patency prior to procedure
11/8/18 - Refer if persistence of - so that the doctor’s will do
vomiting something to prevent vomiting if
- Refer to Dr. Bangoy for the patient is still vomit.
evaluation
11/9/18 - Follow up referral to Dr. - supplying oxygen to cells and
Bangoy tissues. providing essential
- Pls transfuse blood to run for nutrients to cells, such as amino
4hrs then repeat CBC after acids, fatty acids, and glucose.
6hrs removing waste materials, such
as carbon dioxide, urea, and
lactic acid. protecting the body
from infection and foreign bodies
through the white blood cells.
11/10/18 - Limit abdomen palpation - because if you palpate the
patients abdomen you don’t
know what will happen.
11/11/18 - Serum elec now Oxygen is used by people in the
HGT now respiration (breathing) process.
ECG 12L now Tanks of oxygen are used in
- O2@2L/min medicine to treat people with
- For STAT abdominal USD breathing problems.
- STAT CP evaluation refer to
Dr. M.Lim
- CBR w/o BRP
- NPO temporarily
- Pls secure 5 units PRBC of
pt’s blood type and
crossmatch 2 units for
possible OR use
- Transfuse 2 units once
available to run for 4hrs
- Increase IVF rate to 140cc/hr
- Start KCL 40meqs + 1L
PNSS to run @ 100cc/hr

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KCL drip x 2cycles regulate
after 2nd cycle
- Repeat CBC now
- Refer to Dr. Magnaye for co-
mgt
- Insert foley catheter attached
to urobag Fr.16
- Give transamic acid 1gram
IV now 500mg q 6 IVTT
- Schedule pt. for STAT
EXLAP
- Pls secure another 2 units of
PRBC do not crossmatch
- Secure 4units FFP and 4
units of 4 units of PH
concentrate
- Pls transfuse PH 1 hr prior to
OR
- Pls transfuse and
crossmatch all available blood
- Start MgSO4 drip 500g
MgSO4 + 20cc PNSS slow
push now
- Start calglue drip 1:1 10cc
10% cal + 10cc PNSS
- Fast drip 3 units PRBC one
after another
- Incorporate 2gm MgSO4 in
present PNSS to run 140cc/hr
11/12/18 Post OP Orders: - for closely monitoring
- To ICU - supplying oxygen to cells and
VS q 15 x 1 hr then q hourly tissues. providing essential
NPO nutrients to cells, such as amino
Hook to mech vent: acids, fatty acids, and glucose.
VT- 500, AC mode, RR- 16, removing waste materials, such
FIO2- 100% as carbon dioxide, urea, and
IVF: Cumulative 140cc/hr: lactic acid. protecting the body
PLR 1L@ KVO rate from infection and foreign bodies
MgSO4 drip @50cc/hr to C/D through the white blood cells.
Tramadol drip @ 20cc/hr - to know if the patient is
PNSS 1LL @KVO rate dehydrated or overhydrated.
Meds: Unasyn 1.5g IVTT q8 - so that the patient will not have
Tramadol drip 300mg in bedsore
PNSS 500cc @ 20cc/hr - In a catheter embolization
Transamic acid 500mg IVTT procedure, medications or
q6 synthetic materials called

124
Preudix infusion: 200meq embolic agents are placed
(2ml) + 48cc PNSS @ 3cc/hr through a catheter into a blood
BP precautions maintain BP vessel to prevent blood flow to
>100mmHg the area.
Transfuse current blood to run
in 1 hr
Transfuse 2nd unit FFP after
blood to run in 1hr
Repeat cbc + serum elec 6hrs
after BT
I&O monitoring q hourly
Moderate high back rest
Keep pt. thermo regulated
Decrease RR to 14
Decrease FIO2 to 60%
Relay CBC, include Mg in
repeat labs
After BT, resume PNSS 1L
@ 100cc/hr, incorporate
40meqs KCL to run @
100cc/hr
- Start TPN 1,400 KCAL in
24hrs
- Please secure additional 5
units of PRBC do not
crossmatch yet
- For repeat CBC at 10am
- Bedsore precautions
- Absolutely no abdominal
palpation or percussion
- Schedule for STAT
Embolization at spmc secure
another 3 units of PRBC now
will schedule @ 4pm
- Insert NGT Fr. 14 and open
to drain, clear with surgery
- Change foley catheter to Fr.
20
- Clear for STAT embolization
- Start Vit K 10mg IVTT now
11/13/18 -Start TPN 1400KCAL IN -Oxygen is used by people in the
24hrs respiration (breathing) process.
- Open NGT to drain- H20 Tanks of oxygen are used in
50cc gavage/lavage medicine to treat people with
- Increase O2 inhalation to breathing problems.
4L/min via nasal cannula

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- Measure abdominal girth @ - to sure that the abdomen of the
9pm patient did not enlarged.
- IVF TF: PNSS + 2 vials
albumin 20% + furosemide
60mg @ same rate
11/14/18 - Open NGT to drain - Omeprazole is used to treat
- Omeprazole 40mg IVTT OD certain stomach and esophagus
1st dose now problems (such as acid reflux,
- Furosemide 40mg IVTT now ulcers). It works by decreasing
- Decrease albumin to the amount of acid your stomach
120cc/hr makes. It relieves symptoms
- Secure 2 units platelet such as heartburn, difficulty
concentrate (stand by) swallowing, and persistent
- Incorporate 40meqs of KCL cough.
to albumin and cocktail @
same rate
11/15/18 Post OP Orders: -for closely monitoring
- To ICU - to know if the patient is
VS q 15 x 1 hr then q hourly dehydrated or overhydrated.
NPO - so that the patient will not have
IVF: Left hand: PNSS 1L side bedsore
drip FWB 1 to run for 4hrs,
PNSS 1L + 2 vials albumin
20% + 60 meq KCL + 40mg
furosemide @120cc/hr
- PLR 1L side drip: prudix
infusion @ 3cc/hr, PLR 1L
side drip: kabina 1,400KCAL
@ 80 cc/hr
- Right arm: PNSS 500cc side
drip: tramadol 300mg @
20cc/hr
- cumulative IV rate of
200cc/hr then decrease to
KVO rate during BT
- I&O monitoring q hourly
- Moderate high back rest
- Keep pt. thermoregulated
-Hook to mech vent w/ same
set up
- Additional meds: Nalbuphen
5mg IVTT q 6PRN
- Para IV 500mg IV infusion
@ 4pm x 1 dose (HOLD)
- Open NGT to drain
- Diazepam 5mg IVTT now

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- D5W 1amp IVTT
- Measure abdominal girth
now
11/16/18 - Maintain on NPO - so that the pt’s lip will not be
- IVF 180 cc/hr, cycle kabiven dry
- May wet lips - so that the pt. will exercise that
- Start weaning w/ inline beb she can breathe on her own.
FIO2 40%, 15mins q hrly x 2
cycle the 30 mins 2 hrly x 2
cycles
- Start lactulose enema 300cc
+ 700 cc PNSS retain for
60mins then TID
- Hold weaning for now
- Resume meds per NGT
11/17/18 - Instill 100 cc of PNSS per - Vitamin K is used to treat and
NGT prevent low levels of certain
- Albumin decrease to 60cc/hr substances (blood clotting
- Increase instill to 150cc factors) that your body naturally
every 3hrs produces. These substances
- Vit K decrease to 1 amp IV help your blood to thicken and
OD stop bleeding normally
11/19/18 - Change foley cath Fr. 16 - so that the pt. will exercise that
- Facilitate Chest X-Ray she can breathe on her own.
- C/D TPN - Suction may be used to clear
- Start exercise weaning w/ the airway of blood, saliva,
inline neb FIO2 40% 10 mins vomit, or other secretions so that
q hrly until 9pm inform if a patient may breathe.
tolerated Suctioning can prevent
- Suction secreations pulmonary aspiration, which can
- Hook back to MV for now lead to lung infections.
11/20/18 - Resume OF feeding 100cc - for the patient not to feel
to consume in 2hrs every 3hrs hungry.
- increase weaning to 10mins - so that the pt. will exercise that
q hrly she can breathe on her own.
11/21/18 transfer 1unit FWB after - so that the pt. will exercise that
proper cross matching to run she can breathe on her own.
for 4hrs
resume weaning 15mins q
hourly
transfer iv site right
hold ngt feeding
(+) BM; abd girth 93-103cm
NGT aspirate 15cc
monitor pvc’s, frequent
maintain on npo

127
ngt open to drain
refer to dr. roa for co-mgt
refer to dr. magnaye for gastro
eval
serum __
for triphasic ct scan
maintain ivf cumulative at 130
HOLD triphasic CT scan
for CT scan of WA with
contrast
refer
11/22/18 do CXR upright sitting today - Whenever possible the patient
along with ct scan of WA should be imaged in an upright
PA position. AP views are less
useful and should be reserved
for very ill patients who cannot
stand erect.
11/24/18 start feeding with Ensure - protein concentrate, whey
today @ 9am protein concentrate, and/or soy
cont present mgt protein isolate are used to
will update AP provide high quality protein.
for change of dry dressing
11/25/18 increase Ensure feeding to - protein concentrate, whey
100cc (1:2 dilution) q 3hrs protein concentrate, and/or soy
daily dressing protein isolate are used to
provide high quality protein
- so that there will be no
infection

11/26/18 Hold weaning for today - so that the pt. rest

11/2718 For change Foley catheter - need to change the foley cath
today because if they do not change it
Include 2 eggs in feeding per there is a possible for entry of
NGT infection
Suggest to decrease
cumulative rate to 80cc/hr

128
DRUG STUDY
Generic Name Vitamin D/ Calcium Carbonate

Brand name Caltrate Plus

Classification Antianemics

Mechanism of Caltrate plus provides a concentrated form of calcium,

Action formulated for optimal absorption.
Vitamin D helps in the absorption of calcium
Magnesium is necessary for strong teeth and bones
Date ordered 11/05/18

Ordered Dose 1tab BID

Indication Prevention and treatment of osteoporosis
Contraindication Hypersensitivity to Calcium and patients with renal
insufficiency
Side effects abdominal pain, constipation, diarrhea, eructation, flatulence,
nausea, vomiting
Adverse effects hypercalcemia, hypercalcuria and nephrolithiasis

Drug Interaction Calcium carbonate can decrease the absorption of other

drugs. Some examples of affected drugs
include tetracyclineantibiotics (such
as doxycycline, minocycline),
Nursing Withhold drug and notify physician immediately if
Responsibilities bronchospasms occur following its use.
Monitor cardiovascular status; report tachycardia.
Monitor liver enzymes periodically with long-term therapy.

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Generic Name: Diosmin + Hesperidin
Brand Name: Daflon
Classification: Venotonic and vasculoprotective

Mechanism of Action: It increases venous tone and increases resistance in

small vessels.
Date ordered: 11/5/18
Ordered Dose: 2 tabs tid
Indication: Venous circulation disorders (swollen legs, pain, nocturnal cramps)
& symptoms due to acute hemorrhoidal attack.
Contraindication: Allergies to the drug
Side Effects: Stomach upset, vomiting.
Adverse Effects: Signs of an allergic reaction, like rash; hives; itching; red,
swollen, blistered, or peeling skin with or without fever; wheezing; tightness in
the chest or throat; trouble breathing, swallowing, or talking; unusual
hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
Nursing Responsibilities:
1. Observe the 10 rights in giving medications
2. Monitor vital signs especially blood pressure
3. Report episodes of vomiting; take into account the amount, consistency, and
the odor of the vomitus.
4. Assess for rashes and any signs of allergic reaction
5. Document pertinent findings and report unusualities immediately.

Generic Name: Policresulen cinc Hcl

Brand Name: Faktu Ointment
Classification: Anti-hemorrhoids

Mechanism of Action: Inhibits the growth of bacteria; providing relief from

hemorrhoids pain; reducing the pain.
Date ordered: 11/5/18
Ordered Dose: apply on anal; od

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Indication: Hemorrhoids pain, Hemorrhoid pain, Hemorrhoids, Piles
pain, Piles itching, Pain, Infection, Eczema, Infections, Pruritus and other
conditions.
Contraindication: Allergic reactions to the drug, not to be used in the eyes,
and not taken by mouth; menstrual period.
Side Effects: Burning or itching
Adverse Effects: Mild pain/stinging may occur if the rectal tissue is raw
or bleeding.
Drug Interaction: Some drugs if given with faktu can increase heart rate and
blood pressure such as MAOIs and antihypertensive drugs.
Nursing Responsibilities:
1. Observe the 10 rights in giving medications
2. Assess for rashes in the sight of application; this may be a sign of allergic
reaction
3. Assist patient with sitz bath and strictly comply with duration of the bath as
ordered
4. Report any signs of bleeding
5. Document pertinent findings and report to physician any unusualities.

Generic Name: Ampicillin Sulbactam

Brand Name: Unasyn
Classification: Antibiotic; Penicillin

Mechanism of Action: Bacterial action against sensitive organisms; inhibits

synthesis of bacterial cell wall, causing cell death
Date ordered: 11/7/18
Ordered Dose: 1.5 gm ivtt anst q8
Indication: Treatment of infections caused by susceptible strains of bacteria
and gram-positive organisms
Contraindication: Allergies to penicillins, cephalosporins; use cautiously with
renal disorders.
Side Effects: Glossitis, stomatitis, gastritis, nausea, vomiting, diarrhea
Adverse Effects: Heart failure, nephritis, superinfections, hallucinations,
seizures
Drug Interaction: Increase effect with probenecid; increased risk for rash with
allopurinol; increased bleeding effect with heparin, oral coagulants.
Nursing Responsibilities:
1. Observe the 10 rights in giving medications

131
2. Determine allergies to the medications through skin testing
3. Observe for any development of rashes, itching, and other signs of
hypersensitivity.
4. Monitor clotting time results; this is a precautionary measure for bleeding
5. Document findings and report to physician immediately for development of
any complication

Generic Name: Castor oil

Brand Name: Emulsoil
Classification: Laxative

Mechanism of Action: It decreases fluid absorption and increases secretion

in the small intestine and colon. Castor oil also decreases the activity of the
circular smooth muscle which is believed to produce an increase in intestinal
transit. The mechanism by which castor oil produces its effect on the gut could
involve inhibition of Na +, K +-ATPase, activation of adenylate cyclase,
stimulation of prostaglandins and nitric oxide biosynthesis. Castor oil changes
the intestinal permeability and causes histological abnormalities, but these
alterations are not essential for the laxative effect. Platelet activating factor
(PAF) is most likely one of the mediators of castor-oil induced damage, while
nitric oxide has a protective role possibly by reducing PAF biosynthesis.
Date ordered: 11/7/18
Ordered Dose: 60 cc
Indication: Short term relief of constipation; to prevent straining; to evacuate
the bowel for diagnostic procedures; to remove ingested poisons from the
lower GI tract.
Contraindication: Allergy to the drug, third trimester of pregnancy, and acute
abdominal pain
Side Effects: Weakness and dizziness
Adverse Effects: Excessive bowel activity, perianal irritation, abdominal
cramps, cathartic dependence.
Drug Interaction: Has certain interactions with antacids, neomycin, and other
laxatives.
Nursing Responsibilities:
1. Observe the 10 rights in giving medications
2. Provide safety precautions as the drug can cause the patient dizziness and
weakness
3. Observe for signs of allergic reaction

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4. Report persistent and excessive bowel activity after the administration of the
drug
5. Report any unusualities to the physician to prevent further complications

Generic Name Senna Glycoside

Brand name Senokot Forte

Classification Laxatives

Mechanism of Contains sennosides which acts as a stimulant laxative. It

Action works by irritating and stimulating intestinal cells, producing
contractions in intestines, water influx to the intestines and
bowel movement.
Date ordered 11/9/18

Ordered Dose 1tab OD hs

Indication For the relief and control of constipation in the elderly, during
pregnancy and puerperium
Contraindication Patients with an acute surgical abdomen.

Side effects Rectal bleeding, poor bowel function, kidney

inflammation, signs of an allergic reaction (may include
hives, rash, itching, chest tightness, or swelling of the face,
lips, tongue, or throat)
Adverse effects Gastrointestinal Disorders: Uncommon: Feces discoloration,
nausea, rectal hemorrhage, vomiting. Immune System
Disorders: Uncommon: Urticaria. Very Rare: Anaphylactic or
anaphylactoid reaction. Renal and Urinary Disorders:
Uncommon: Chromaturia. Skin and Subcutaneous Tissue
Disorders: Uncommon: Erythematous rash, maculopapular
rash, perianal irritation. Reversible pigmentation of the colon,
melanosis coli, may also result from prolonged use of senna
containing preparations.
Drug Interaction No known drug interactions.
Nursing 1) Be aware that drug may alter urine and feces color;
Responsibilities yellowish brown (acid), reddish brown (alkaline).
2) Continued use may lead to dependence.
3) Consult physician if constipation persists.

133
4) Reduce dose in patients who experience considerable
abdominal cramping.
5) Monitor Intake and output

Generic Name Tranexamic Acid

Brand Name Tranexan

Classification Haemostatics
Mechanism of Tranexamic acid is an antifibrinolytic agent that competitively
action inhibits breakdown of fibrin clots. It blocks binding of
plasminogen and plasmin to fibrin, thereby preventing
haemostatic plug dissolution.
Date Ordered 11/12/18
Ordered Dose 500 mg IV q6
Indication Short-term management of haemorrhage
Renal Impairment

Contraindication History of or active thromboembolic disease. History

of convulsions. Severe renal impairment.

Side Effects Diarrhoea, nausea, vomiting, disturbances in colour vision,

giddiness, hypotension (after rapid IV inj), thromboembolic
events.

Adverse Effects CNS: Dizziness, malaise, headache,

seizures. CV: Faintness, orthostatic hypotension;
dysrhythmias; thrombophlebitis, thromboses. Special
Senses: Tinnitus, nasal congestion. Conjunctival
erythema. GI: Nausea, vomiting, cramps, diarrhea,
anorexia. Urogenital:Diuresis, dysuria, urinary frequency,
oliguria, reddish-brown urine (myoglobinuria), acute renal
failure. Prolonged menstruation with cramping. Skin: Rash.
Drug Interaction Potentially Fatal: Increased risk of thrombus formation with
estrogens

Nursing  Check IV site at frequent intervals for extravasation.

Responsibilities

134
 Observe for signs of thrombophlebitis. Change site
immediately if extravasation or thrombophlebitis
occurs
 Monitor & report S&S of myopathy: muscle weakness,
myalgia, diaphoresis, fever, reddish-brown urine
(myoglobinuria), oliguria, as well as thrombotic
complications: arm or leg pain, tenderness or
swelling, Homan's sign, prominence of superficial
veins, chest pain, breathlessness, dyspnea. Drug
should be discontinued promptly.
 Monitor vital signs
 Monitor Intake and urine output.
 Lab tests: with prolonged therapy, monitor creatine
phosphokinase activity and urinalyses for early
detection of myopathy.
 Report difficulty urinating or reddish-brown urine.
 Report arm or leg pain, chest pain, or difficulty
breathing.

Generic Name: Cefoxitin Sodium

Brand Name: Monowel
Classification: Cephalosporins

Mechanism of Action: Bind to bacterial cell wall membrane causing cell

death.
Date ordered: 11/13/18
Ordered Dose: 1gm ivtt q8 anst
Indication: Used for the treatment, control, prevention, & improvement of the
following diseases, conditions and symptoms bacterial infections before, during
or after certain surgeries
Contraindication: allergies to monowel, blood clotting problems, bowel
problems, andbreast feeding
Side Effects: Diarrhea, nausea, vomiting
Adverse Effects:
Drug Interaction: Gentamycin and heparin may cause the drug to not work
properly and increase the risk of its side effects
Nursing Responsibilities:
1. Observe the 10 rights in giving medications
2. Determine allergies to the medications through skin testing
3. Observe for sign of superinfection and notify physician immediately

135
4. Avoid alcohol-containing medications while on therapy
5. Document any pertinent finding and report to physician as necessary.

Generic Name Omeprazole

Brand name Omepron

Classification Proton pump inhibitor

Mechanism of Is a selective and irreversible proton pump inhibitor. It

Action suppresses stomach acid secretion by specific inhibition of
the ATP system found at the secretory surface of gastric
parietal cells.
Date ordered 11/14/18

Ordered Dose 40 mg IVTT OD

Indication Short-term treatment of active duodenal ulcer,
gastroesophageal reflux disease (GERD), including erosive
esophagitis and symptomatic GERD; long term treatment of
pathologic hypersecretory conditions (e.g. Zollinger-Ellison
syndrome, multiple endocrine adenomas, systemic multiple
endocrine adenomas, systemic mastocytosis); to maintain
healing of erosive esophagitis; i
Contraindication Hypersensitivity to the drug

Side effects Headache, stomach pain, nausea, diarrhea.

Adverse effects Seizures, tremors, muscle weakness, dizziness,

Drug Interaction Ampicilin esters, azole anti-fungals, iron derivatives

Nursing Assess other medications patient may be taking for
Responsibilities effectiveness and interactions (especially those dependent
on cytochrome P450 metabolism or those dependent on acid
environment for absorption).
Monitor therapeutic effectiveness and adverse reactions at
beginning of therapy and periodically throughout therapy.
Assess GI system: bowel sounds every 8hours, abdomen for
pain and swelling, appetite loss.

136
Monitor hepatic enzymes: AST, ALT, increased alkaline
phosphatase during treatment.
Assess knowledge/teach appropriate use of this medication,
interventions to reduce side effects, and adverse symptoms
to report.
Assessment & Drug Effects
Lab tests: Monitor urinalysis for hematuria and proteinuria.
Periodic liver function tests with prolonged use.

Generic Name: Piperacillin/Tazobactam

Brand Name: Tazocin
Classification: Penicillin

Mechanism of Action: Piperacillin works by weakening the cell walls

of bacteria. It allows holes to appear in the cell walls, which kills off the
bacteria causing the infection. Certain bacteria are resistant to penicillin -
type antibiotics, because they have developed the ability to produce
defensive chemicals called beta-lactamases. These interfere with the
structure of penicillin-type antibiotics and stop them from working.
Tazobactam is a type of medicine called a beta-lactamase inhibitor. It stops
the bacteria from inactivating the piperacillin, which increases the range of
bacteria that the piperacillin can kill.
Date ordered: 11/15/18
Ordered Dose: 4.5gms ivtt q8 anst
Indication: Treat serious bacterial infections such
as pneumonia, septicaemia (blood poisoning), peritonitis, complicated skin
infections and complicated urinary tract infections. It's also used to treat
bacterial infections in people with a low white blood cell count
(neutropenia).
Contraindication: Tazocin is not suitable for people who have ever had an
allergic reaction to a penicillin or cephalosporin-type antibiotic. Make sure
your doctor knows if you've ever had an allergic reaction to an antibiotic, or
if you have a history of any other allergies.
Side Effects: Diarrhea, thrush, nausea, vomiting, constipation, indigestion,
stomach ache, rashes or itching, headache, and insomnia.
Adverse Effects: Inflammation of the bowel (colitis); problems with
your blood cells; kidney or liver inflammation.
Drug Interaction: It has an interaction with contraceptives which will reduce
the effects of preventing pregnancy; if given with anticoagulants, may increase
the anti-blood clotting effects of warfarin; if given with vaccines, the vaccine will
be less effective; and if given with methotrexate, it may decrease the excretion

137
of methotrexate in the body which may lead to the increased risk of its side
effects.
Nursing Responsibilities:
1. Observe the 10 rights in giving medications
2. Determine allergies to the medications through skin testing
3. Observe for any development of rashes, itching, and other signs of
hypersensitivity.
4. Monitor Liver function test results; report immediately if low or high results
are noted
5. Document findings and report to physician immediately for development of
any complication

Generic Name Bisacodyl

Brand Name Dulcolax

Classification Gastrointestinal agent, Stimulant Laxative
Mechanism of Expands intestinal fluid volume by increasing epithelial
action permeability.

Date Ordered 11/16/18

Ordered Dose 2 supp
Indication Temporary relief of acute constipation and for evacuation of
colon before surgery, proctoscopic, sigmoidoscopic, and
radiologic examinations. Also used to cleanse colon before
delivery and to relieve constipation in patients with spinal
cord damage.

Contraindication Acute surgical abdomen, nausea, vomiting, abdominal

cramps, intestinal obstruction, fecal impaction; use of rectal
suppository in presence of anal or rectal fissures, ulcerated
hemorrhoids, proctitis.

Side Effects Systemic effects not reported. Mild cramping, nausea,

diarrhea, fluid and electrolyte disturbances (especially
potassium and calcium).

Adverse Effects persistent nausea/vomiting/diarrhea, muscle

cramps/weakness, irregular heartbeat, dizziness, fainting,

138
decreased urination, mental/mood changes (such as
confusion).

Drug Interaction ANTACIDS will cause early dissolution of enteric coated

tablets, resulting in abdominal cramping.

Nursing  Evaluate periodically patient's need for continued use

Responsibilities of drug; bisacodyl usually produces 1 or 2 soft formed
stools daily.
 Monitor patients receiving concomitant
anticoagulants. Indiscriminate use of laxatives results
in decreased absorption of vitamin K.

 Add high-fiber foods slowly to regular diet to avoid

gas and diarrhea. Adequate fluid intake includes at
least 6–8 glasses/d.

Generic Name Vitamin K

Brand name Mephyton

Classification Haemostatics

Mechanism of Phytomenadione (vitamin K1), a naturally occurring

Action compound, promotes hepatic synthesis of clotting factors (II,
VII, IX, X) and of coagulation inhibitors (protein C and S). It
is used to prevent and treat haemorrhages related to vitamin
K deficiency.

Date ordered 11/17/18

Ordered Dose 1 amp OD

Indication Treating and preventing bleeding problems in people with low
levels of the blood clotting protein prothrombin.

 Hereditary hypoprothrombinemia,
Contraindication
 Overanticoagulation due to heparins

Side effects  Taste changes (SC, IM, or IV use)

 Flushing (SC, IM, or IV use)

139
 Injection site hematoma
 Injection site pain

Adverse effects Hypersensitivity or anaphylaxis-like reaction: facial flushing,

cramp-like pains, convulsive movements, chills, fever,
diaphoresis, weakness, dizziness, shock, cardiac arrest.
CNS: Headache (after oral dose), brain damage, death.
GI: Gastric upset.
Hematologic: Paradoxic hypoprothrombinemia (patients with
severe liver disease), severe hemolytic anemia.
Metabolic: Hyperbilirubinemia, kernicterus.
Respiratory: Bronchospasm, dyspnea, sensation of chest
constriction, respiratory arrest.
Skin: Pain at injection site, hematoma, and nodule formation,
erythematous skin eruptions (with repeated injection


Drug Interaction vitamin K + warfarin

caution advised, use for therapeutic advantage to reverse

over-anticoagulation: combo may decr. INR, anticoagulant
efficacy, delay re-anticoagulation (antagonistic effects)

vitamin K + cholestyramine

give oral fat-soluble vitamins >1h before or >4-6h after bile

acid binding resin doses: combo may cause fat-soluble
vitamin malabsorption (absorption decreased)

Nursing Observe 10 patients rights

Responsibilities Give solution immediately after dilution at a rate not to
exceed 1 mg/min.
Monitor patient constantly. Severe reactions, including
fatalities, have occurred during and immediately after IV
injection.

Maintain consistency in diet and avoid significant increases

in daily intake of vitamin K–rich foods when drug regimen is
stabilized. Know sources rich in vitamin K: Asparagus,
broccoli, cabbage, lettuce, turnip greens, pork or beef liver,
green tea, spinach, watercress, and tomatoes.

Monitor Vital Signs

140
Inform the patient that there will be changes in his/her taste

Report if there is unusualities

Generic Name Meropenem

Brand name Meronem

Classification broad-spectrum carbapenem antibiotic

Mechanism of Meropenem is a synthetic carbapenem β-lactam antibiotic

Action that exerts its bactericidal activity by inhibiting bacterial cell
wall synthesis in gm+ve and gm-ve bacteria through binding
to several penicillin-binding proteins (PBPs).

Date ordered 11/18/18

Ordered Dose 1gm IV q8

Indication Intra-abdominal infections,
Skin and skin structure infection,

Contraindication Hypersensitivity to meropenem, other carbapenems. History

of anaphylactic reaction to β-lactams (e.g. penicillins,
cephalosporins).

Side effects  headache;

 nausea, vomiting, diarrhea;
 anemia;
 skin rash; or
 swelling or irritation where the medicine was injected.

Adverse effects GI effects (e.g. diarrhoea, nausea, vomiting, constipation),

local reactions (e.g. pain and inflammation at inj site,

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phlebitis or thrombophlebitis), disturbances in LFTs, positive
direct or indirect Coombs' test, Stevens-Johnson syndrome,
toxic epidermal necrolysis, thrombocythaemia, headache,
haemolytic anaemia, rash, pruritus, sepsis, apnoea, shock,
glossitis, and oral candidiasis. Rarely, convulsions.
Drug Interaction Increased plasma concentration w/ probenecid. May
decrease plasma levels of valproic acid thus, increasing the
risk of seizures.

Nursing  Observe Patients Rights

Responsibilities  Monitor Vital Signs
 Determine history of hypersensitivity reactions to
other beta-lactams, cephalosporins, penicillins, or
other drugs.
 Discontinue drug and immediately report S&S of
hypersensitivity (see Appendix F).
 Report S&S of superinfection or pseudomembranous
colitis (see Appendix F).
 Monitor for seizures especially in older adults and
those with renal insufficiency.
 Learn S&S of hypersensitivity, superinfection, and
pseudomembranous colitis; report any of these to
physician promptly.


Generic Name Carvedilol

Brand name Coreg

Classification Alpha and Beta blockers

Mechanism of Carvedilol is a non selective β-adrenergic blocking agent

Action which causes vasodilation by blocking the activity α-1
receptors. It exerts antihypertensive effect partly by reducing
total peripheral resistance and vasodilation.

Date ordered 11/18/18

Ordered Dose 25 mg ½ tab q12

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Indication Hypertension, Heart Failure, Left ventricular dysfunction post
myocardial infarction, Angina pectoris

Contraindication
Bronchial asthma or related bronchospastic conditions. AV
block 2nd and 3rd degree. Sick sinus syndrome or severe
bradycardia. Cardiogenic shock. NYHA class IV heart failure.
COPD w/ bronchial obstruction. Metabolic acidosis. Severe
peripheral arterial circulatory disturbances. Severe hepatic
impairment.

Side effects Dizziness, lightheadedness, drowsiness, diarrhea, impotence,

or tiredness may occur.
Adverse effects Bradycardia, syncope, dizziness, headache, fatigue,
asthenia, arthralgia, urinary incontinence, interstitial
pneumonitis, generalised oedema, diarrhoea, nausea,
vomiting, hyperglycaemia, wt gain, cough, abnormal vision,
increased BUN and nonprotein nitrogen (NPN).

Drug Interaction Decreased serum levels w/ rifampicin. Combination w/ Ca

channel blockers (e.g. verapamil and diltiazem) can lead to
bradycardia and myocardial depression. Potentiates insulin-
induced hypoglycaemic action. May increase hypoglycaemic
effects of antidiabetic agents. Increased risk of bradycardia
w/ digoxin.

Nursing
Responsibilities
 Observe Patients rights
 Monitor for therapeutic effectiveness which is
indicated by lessening of S&S of CHF and improved
BP control.
 Lab tests: Monitor liver function tests periodically; at
first sign of hepatic toxicity stop drug and notify
physician.
 Monitor for worsening of symptoms in patients with
PVD.
 Monitor digoxin levels with concurrent use; plasma
digoxin concentration may increase.
 Do not abruptly discontinue taking this drug.
 You may experience dizziness or faintness, as a risk
of orthostatic hypotension.
 Avoid abrupt repositioning
 Maintain Safety Precautions

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Generic Name Orphenadrine citrate &, Paracetamol

Brand Name Norgesic Forte

Classification Muscle Relaxants, Analgesic, Antipyretic
Mechanism of Orphenadrine citrate is a skeletal muscle relaxant. It acts in
action the central nervous system to produce muscle relaxant
effects. Paracetamol is used to treat or prevent pain and
reduce fever.

Date Ordered 11/18/18

Ordered Dose 1 tab q8
Indication Symptomatic relief of mild to moderate pain of acute
musculoskeletal disorders.

Contraindication Because of the mild anticholinergic effect of orphenadrine,

Norgesic or Norgesic Forte should not be used in patients
with glaucoma, pyloric or duodenal obstruction, achalasia,
prostatic hypertrophy or obstructions at the bladder neck.
Norgesic or Norgesic Forte is also contraindicated in patients
with myasthenia gravis and in patients known to be sensitive
to aspirin or caffeine.

Side Effects  Abdominal or stomach cramps, pain, or discomfort

(mild to moderate)
 dryness of mouth
 heartburn or indigestion
 nausea or vomiting (mild)

Adverse Effects  Abdominal or stomach pain, cramping, or burning

(severe)
 bloody or black, tarry stools
 decreased urination
 eye pain

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 fainting
 fast or pounding heartbeat
 shortness of breath, troubled breathing, tightness in
chest, or wheezing
 skin rash, hives, itching, or redness
 sores, ulcers, or white spots on lips or in mouth
 swollen and/or painful glands
 unusual bleeding or bruising
 unusual tiredness or weakness
 vomiting of blood or material that looks like coffee
grounds

Drug Interaction Orphenadrine: Phenothiazines & other antimuscarinic drugs.

Paracetamol: Alcohol or other CNS depressants.
Anticoagulant. Increased gastric emptying w/
metoclopramide.

Nursing Observe Patients Rights

Responsibilities
 Observe Patients Rights
 Lab tests: Periodic blood, urine, and liver function
studies with prolonged therapy.
 Report complaints of mouth dryness, urinary
hesitancy or retention, headache, tremors, GI
problems, palpitation, or rapid pulse to physician.
Dosage reduction or drug withdrawal is indicated.
 Monitor elimination patterns. Older adults are
particularly sensitive to anticholinergic effects (urinary
hesitancy, constipation); closely observe
 Relieve mouth dryness by frequent rinsing with clear
tepid water,

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Generic Name KCL Potassium Chloride

Brand name Kalium Durule

Classification Electrolytic and water balance agent; Replacement solution

Mechanism of Principal intracellular cation; essential for maintenace of

Action intraccellular isotonicity, transimmion of nerve impulses,
contraction of cardiac, skeletal and smooth muscles,
maintenence of normal kidney function and for enzyme
activity. Plays a prominent role in both formation and
correction of imbalances in acide-base metabolism
Date ordered 11/19/18

Ordered Dose 1tab TID pc

Indication mineral supplement used to treat or prevent low amounts
ofpotassium in the blood
Contraindication Severe renal impairment; severe hemolytic reactions;
untreated Addison’s disease; crush syndrome; early
postoperative oliguria (except during GI drainage); adynamic
ileus; acute dehydration; heat cramps, hyperkalemia,
patients receiving potassium-sparing diuretics, digitalis
intoxication with AV conduction disturbance.
Side effects mild nausea or upset stomach;
mild or occasional diarrhea;
slight tingling in your hands or feet

Adverse effects GI:Nausea, vomiting, diarrhea, abdominal distension.

BodyWhole:Pain, mental confusion, irritability, listlessness,
paresthesias of extremities, muscle weakness and
heaviness of limbs, difficulty in swallowing, flaccid paralysis.
Urogenital:Oliguria, anuria.
Hematologic:Hyperkalemia.
Respiratory:Respiratory distress.
Drug Interaction Angiotensin-converting enzyme (ACE) inhibitors, such as
captopril (Capoten), enalapril (Vasotec), and lisinopril

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(Prinivil, Zestril) Angiotensin-receptor blockers (ARB), such
as losartan (Cozaar), diovan (Valsartan), or irbesartan
(Avapro) Diuretic drugs (often called "water pills")
Nursing 1) Monitor I&O ratio and pattern in patients receiving the
Responsibilities parenteral drug. If oliguria occurs, stop infusion promptly and
notify physician.
2) Monitor for and report signs of GI ulceration (esophageal
or epigastric pain or hematemesis).
3) Monitor patients receiving parenteral potassium closely
with cardiac monitor. Irregular heartbeat is usually the
earliest clinical indication of hyperkalemia.
4) Monitor cardiac rate
5) Notify physician of persistent vomiting because losses of
potassium can occur.
6) Report continuing signs of potassium deficit to physician:
Weakness, fatigue, polyuria, polydipsia

Generic Name: Lactulose

Brand Name: Constulose
Classification: Laxative

Mechanism of Action: The drug passes unchanged into the colon where
bacteria break it down into organic acids that increase the osmotic pressure in
the colon and slightly acidify the colonic contents, resulting in an increase in
stool water content, stool softening, laxative action.
Date ordered: 11/19/18
Ordered Dose: 30 cc od hs
Indication: Treatment of constipation; prevention and treatment of portal-
systemic encephalopathy
Contraindication: Allergy to lactulose, low-galactose diet; use cautiously with
diabetes, pregnancy, and lactation.
Side Effects: Diarrhea, nausea, acid-base imbalance, and electrolyte
imbalance
Adverse Effects: Transient flatulence, distention, intestinal cramps, and
belching
Drug Interaction: Has certain interactions with antacids, neomycin, and other
laxatives.
Nursing Responsibilities:
1. Assess for Allergy to lactulose, low-galactose diet, diabetes, lactation.
2. Do not freeze laxative form. Extremely dark or cloudy syrup may be unsafe;
do not use.

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3. Give laxative syrup orally with fruit juice, water or milk to increase
palatability.
4. Monitor for adverse drug effects.
5. Report diarrhea, severe belching, abdominal fullness.
6. Do not administer other laxatives while using lactulose.
7. Monitor serum ammonia levels.
8. The following side effects may occur: abdominal fullness, flatulence,
belching.
9. Assure ready access to bathroom; bowel movements will be increased to 2-
3 per day.

Generic Name: Calcium gluconate

Brand Name: Cal-G
Classification: Antacid; Electrolyte

Mechanism of Action: Plays a role in normal cardiac function, renal function,

respiration, blood coagulation, and cell membrane and capillary permeability.
Calcium also regulates the release and the storage of neurotransmitters and
hormones, the uptake and binding of amino acids, absorption of vitamin b12,
and gastric secretions
Date ordered: 11/19/18
Ordered Dose:
Indication: Calcium deficiencies; magnesium sulfate toxicity
Contraindication: Allergy to calcium, renal calculi, hypercalcemia, ventricular
fibrillation during cardiac resuscitation and patients with the risk of existing
digitalis toxicity.
Side Effects: Bradycardia, peripheral vasodilation, local burning, hypotension,
nausea, vomiting, constipation, and rebound hyperacidity
Adverse Effects: Severe necrosis and sloughing and abscess formation
Drug Interaction: Decreased serum levels of oral tetracyclines, oral
fluoroquinolones, salicylates, iron salts with oral calcium salts; antagonism of
effects of verapamil with calcium.
Nursing Responsibilities:
1. Assess for cutaneous burning sensations and peripheral vasodilation, with
moderate fall in BP, during direct IV injection.
2. Monitor ECG during IV administration to detect evidence of hypercalcemia:
decreased QT interval associated with inverted T wave.
3. Observe IV site closely. Extravasation may result in tissue irritation and
necrosis.
4. Monitor for hypocalcemia and hypercalcemia

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5. Determine levels of calcium and phosphorus (tend to vary inversely) and
magnesium frequently, during sustained therapy. Deficiencies in other ions,
particularly magnesium, frequently coexist with calcium ion depletion.

Generic Name

Acetaminophen
Brand name Paracetamol

Classification Analgesic, Antipyretic

Mechanism of Paracetamol is an analgesic and antipyretic. Its mechanism

Action of action is believed to include inhibition of prostaglandin
synthesis, primarily within the central nervous system.
Date ordered 11/19/18

Ordered Dose 300 mg IV q4 PRN

Indication Treatment of mild-to-moderate pain and fever
(analgesic/antipyretic)
Contraindication Contraindicated in patients with known hypersensitivity to
paracetamol, or any other components of the formulation.
Side effects Endocrine & metabolic: May increase chloride, uric acid,
glucose; may decrease sodium, bicarbonate, calcium

Hematologic: Anemia, blood dyscrasias (neutropenia,

pancytopenia, leukopenia) Hepatic: Bilirubin increased,
alkaline phosphatase increased Renal: Ammonia
increased, nephrotoxicity with chronic overdose, analgesic
nephropathy Miscellaneous: Hypersensitivity reactions (rare)
Adverse effects Thrombocytopaenia, anaphylaxis, cutaneous hypersensitivity
reactions including skin rashes, angioedema and Stevens-
Johnson syndrome, bronchospasm in patients sensitive to
aspirin and other NSAIDs, hepatic dysfunction.
Drug Interaction The anticoagulant effect of warfarin and other coumarins
may be enhanced by prolonged regular daily use of
paracetamol with increased risk of bleeding;

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Nursing 10 Patients right
Responsibilities Should not be taken with any other paracetamol containing
product
Monitor if there is hypersensitivity of the drug
Refer if there is any signs of hypersensitivity
Assess if there is fever or pain: type of pain, location,
intensity, duration and temperature

Generic Metoclopramide
Name

Brand Placil
Name
Classificati Antiemetics
on
Mechanis Metoclopramide blocks dopamine receptors and in higher doses,
m of it also blocks serotonin receptors in chemoreceptor trigger zone of
action the CNS. It enhances the response to acetylcholine of tissue in
upper GI tract causing enhanced motility and accelerated gastric
emptying w/o stimulating gastric, biliary, or pancreatic secretions.

Date 11/19/18
Ordered
Ordered 1amp now
Dose
Indication Prophylaxis of chemotherapy-induced nausea and vomiting
Intubation of the small intestine, Premedication for radiologic
examination of the upper gastrointestinal tract

Contraindi Sensitivity or intolerance to metoclopramide; allergy to sulfiting

cation agents; history of seizure disorders; concurrent use of drugs that
can cause extrapyramidal symptoms; pheochromocytoma;
mechanical GI obstruction or perforation; ileus; history of breast
cancer; pregnancy (category B), lactation, children <6 y, infants,
and neonates.

Side Drowsiness, dizziness, tiredness, trouble sleeping,

Effects agitation, headache, and diarrheamay occur.

Adverse mental/mood changes (such as anxiety, confusion, depression,

Effects thoughts of suicide), decreased sexual ability, inability to keep

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still/need to pace, muscle spasms/uncontrolled muscle movements
(such as twisting neck, arching back), Parkinson-like symptoms
(such as shaking, slowed/difficult movement, mask-like facial
expression

Drug Alcohol and other CNS DEPRESSANTS add to

Interaction sedation; ANTICHOLINERGICS, OPIATE ANALGESICS may
antagonize effect on GI motility; PHENOTHIAZINES may
potentiate extrapyramidal symptoms; may decrease absorption
of acetaminophen, aspirin,atovaquone, diazepam, digoxin, lithi
um, tetracycline; may antagonize the effects
of amantadine, bromocriptine, levodopa, pergolide, ropinirole,
pramipexole; may cause increase in extrapyramidal and dystonic
reactions
with PHENOTHIAZINES, THIOXANTHENES, droperidol, haloper
idol, loxapine, metyrosine; may prolong neuromuscular blocking
effects of succinylcholine.

Nursing  Report immediately the onset of restlessness, involuntary

Responsib movements, facial grimacing, rigidity, or tremors.
ilities Extrapyramidal symptoms are most likely to occur in
children, young adults, and the older adult and with high-
dose treatment of vomiting associated with cancer
chemotherapy. Symptoms can take months to regress.
 Be aware that during early treatment period, serum
aldosterone may be elevated; after prolonged
administration periods, it returns to pretreatment level.
 Lab tests: Periodic serum electrolyte.
 Monitor for possible hypernatremia and hypokalemia (see
Appendix F), especially if patient has CHF or cirrhosis.
 Adverse reactions associated with increased serum
prolactin concentration (galactorrhea, menstrual disorders,
gynecomastia) usually disappear within a few weeks or
months after drug treatment is stopped.

Generic Name: Silymarin

Brand Name: Mitodex
Classification: Hepatic protectors,
cholalogues & cholelitholytics

Mechanism of Action: Carnitine orotate represents functional histological

restoration effect to injured hepatocytes and also acts as lipotropic factor to

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fatty liver. It promotes α-oxidation of normal fatty acids and metabolism in
hepatocytic mitochondria; Therefore, Mitodex is indicated for mitochondrial
dysfunctions, hepatitis, hepatic cirrhosis, fatty liver, hepatic intoxication,
alcoholic liver dysfunction.
Date ordered: 11/20/18
Ordered Dose: 2 vials
Indication: Treatment of mitochondrial dysfunctions. Acute and chronic
hepatitis, fatty liver, hepatic cirrhosis, hepatic intoxication by drug or chemical
substances
Contraindication: Allergies to Mitodex
Side Effects: Diarrhea, itching, somnolence, paresthesia
Adverse Effects: Low serum folic acid, pulmonary edema, congestive heart
failure
Drug Interaction: If drug is given with alcohol, caffeine, carbamazepine,
chloramphenicol, cholestyramine, colchicine, dipyridamole, epoetin, glucose,
and levodopa, there is an increase risk that the drug will not work properly and
there will be an exaggeration of its side effects.
Nursing Responsibilities:
1. Observe the 10 rights in giving medications
2. Monitor serum folic acid from time to time
3. Assess for development of pulmonary crackles
4. Monitor vital signs especially blood pressure and heart rate
5. Report unusualities immediately to the physician

Generic Name Linezolid

Brand name Zyvox

Classification Antibacterial

Mechanism of The drug works by inhibiting the initiation of bacterial protein

Action synthesis.

Date ordered 11/21/18

Ordered Dose 600 mg IVTT q12

Indication Used for the treatment of infections caused by multi-resistant
bacteria including streptococcus and methicillin-resistant
Staphylococcus aureus (MRSA).

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Contraindication ZYVOX formulations are contraindicated for use in patients
who have known hypersensitivity to linezolid or any of the
other product components.

Side effects  Diarrhea

 Vomiting
 Headache
 Nausea
 Anemia
 Thrombocytopenia
 Rash
 HTN

Adverse effects Superinfection

 C. difficile-assoc. diarrhea
 Anemia
 Leukopenia
 Pancytopenia
 Thrombocytopenia
 Lactic acidosis
 Peripheral neuropathy
 Optic neuropathy
 Vision loss
 Serotonin syndrome
 Anaphylaxis
 Angioedema
 Stevens-Johnson syndrome
 Toxic epidermal necrolysis
 Skin rxn, severe
 Seizures

Drug Interaction Do not use linezolid if you have taken an MAO inhibitor in
the past 14 days. A dangerous drug interaction could occur.
MAO inhibitors include isocarboxazid, methylene blue
injection, phenelzine, rasagiline, selegiline, and
tranylcypromine.

Nursing Observe patients rights

Responsibilities Monitor I and O
Advise to avoid food rich in tyramine
Assess signs of hypersensitivity to the drug
Report any unusualities
Provide Safety Precautions
Monitor Vital Signs
Encourage to increase oral fluid intake

153
Generic Name Tramadol

Brand Name Ultram

Classification Analgesics (Opioid)
Mechanism of It is a centrally acting synthetic opioid analgesic. Although its
action mode of action is not completely understood, from animal
tests, at least two complementary mechanisms appear
applicable: binding of parent and M1 metabolite to μ-opioid
receptors and weak inhibition of reuptake of norepinephrine
and serotonin.

Date Ordered 11/23/18

Ordered Dose 50 mg IV q8 PRN
Indication This medication is used to help relieve moderate to moderately
severe pain. Tramadol is similar to opioid (narcotic) analgesics.
It works in the brain to change how your body feels and
responds to pain

Contraindication  severe asthma or breathing problems;

 a blockage in your stomach or intestines;
 if you have recently used alcohol, sedatives,
tranquilizers, or narcotic medications; or
 if you have used an MAO inhibitor in the past 14 days
(such as isocarboxazid, linezolid, methylene blue
injection, phenelzine, rasagiline, selegiline, or
tranylcypromine).

Side Effects Nausea, vomiting, constipation, lightheadedness, dizziness,

drowsiness, or headache may occur. Some of these side
effects may decrease after you have been using
this medication for a while.
Adverse Effects pruritus, agitation, anxiety, diarrhea, hallucination,tremor,
and diaphoresis.

Drug Interaction Taking MAO inhibitors with this medicationmay cause a

serious (possibly fatal) drug interaction. Avoid taking MAO
inhibitors (isocarboxazid, linezolid, methylene blue,
moclobemide, phenelzine, procarbazine, rasagiline,
safinamide, selegiline, tranylcypromine)

Nursing Observe Patients Rights

Responsibilities Stop taking all other around-the-clock narcotic pain
medications when you start taking tramadol.

154
 Assess for level of pain relief and administer prn dose
as needed but not to exceed the recommended total
daily dose.
 Monitor vital signs and assess for orthostatic
hypotension or signs of CNS depression.
 Discontinue drug and notify physician if S&S of
hypersensitivity occur.
 Assess bowel and bladder function; report urinary
frequency or retention.
 Use seizure precautions for patients who have a
history of seizures or who are concurrently using
drugs that lower the seizure threshold.
 Monitor ambulation and take appropriate safety
precautions.

Generic Name Furosemide

Brand name Lasix

Classification Loop Diuretics

Mechanism of Inhibits reabsorption of sodium and chloride form the

Action proximal and distal tubules and ascending limb of the loop of
henle, leading to a sodium rich diuresis
Date ordered 11/27/17

Ordered Dose 20 mg IVTT q12

Indication Hypertension. Edema associated with heart failure, cirrhosis,
renal disease
Contraindication Contraindicated with allergy to furosemide, sulfonamides;
allergy to tatrazone, anuria, severe renal failure, hepatic
coma, pregnancy, lactation
Side effects Thirst, increase urination, muscle cramps, itching or rash,
weakness,
dizziness, spinning sensation, diarrhea, stomach pain, and
constipation

155
Adverse effects Irreversable hearing loss, tinnitus, orthostatic hypotension,
volume depletion, cardiac arrhythmias, thrombophlebitis,
jaundice, leukopenia, anemia, muscle cramps
Drug Interaction Increased risk of cardiac arrhythmias with digitalis
glycosides, increased risk of ototoxicity with aminoglycoside
antibiotic, decreased absorption of furosemide with
phenytoin, may reduce effect of insulin or oral anti-diabetics
Nursing 1. Monitor vital signs before giving drug.
Responsibilities 2. Monitor intake and output
3. Monitor serum electrolytes
4. Encourage to eat foods rich in potassium such as banana
5. Avoid sudden changes in position

Generic Name: Compound amino acids

Brand Name: Moriamin Forte
Classification: Vitamins

Mechanism of Action: Works by providing nutritional requirements of the

body to maintain physiological balance; promoting protein synthesis and
wound healing.
Date ordered: 11/27/18
Ordered Dose: 2 caps tid
Indication: Nutritional deficiency, malnutrition, and component for parenteral
nutrition.
Contraindication: Allergies, pre-existing diseases, and current health
conditions such as pregnancy
Side Effects: Metabolic imbalances, allergic manifestations, idiosyncratic
reactions, and hyperammonemia
Adverse Effects: Gastrointestinal intolerance, high nitrogen levels in the
blood, aluminum poisoning, and coma.
Drug Interaction: The drug has an interaction with levodopa which causes
decrease effectivity of the drug and the increased risk of its side effects.
Nursing Responsibilities:
1. Observe the 10 rights in giving medications.
2. Assess patient for signs of vitamin deficiency before and periodically
throughout therapy.
3. Assess nutritional status through 24 h diet recall.
4. Determine frequency of consumption of vitamin rich foods.
5. Observe for the development of side effects

156
Generic Name: Spironolactone
Brand Name: Aldactone
Classification: Potassium-sparing diuretic

Mechanism of Action: Completely blocks the effects of aldosterone in the

renal tubule, causing the loss of sodium and water and retention of potassium.
Date ordered: 11/27/18
Ordered Dose: 50 mg 1 tab od
Indication: Adjunctive therapy to edema associated with heart failure,
nephrotic syndrome, and hepatic cirrhosis; treatment of hypokalemia or
prevention of hypokalemia in patients that are high risk in developing it and
also with patients who have cardiac arrhythmias.
Contraindication: Allergy to spironolactone, hyperkalemia, renal disease,
anuria, amiloride or triamterene use.
Side Effects: Dizziness, headache, drowsiness, rash, cramping, diarrhea, and
deepening of voice, hirsutism, and gynecomastia.
Adverse Effects: Agranulocytosis, fatigue, ataxia, confusion, urticaria, dry
mouth, thirst, vomiting, impotence, irregular menses, amenorrhea,
postmenopausal bleeding, hyperkalemia, and hyponatremia.
Drug Interaction: Increase hyperkalemia with potassium supplements, ACE
inhibitors, and diets rich in potassium; decreased diuretic effect with
salicylates; decreased prothrombinemic effect of anticoagulants; increase
hypotensive effect with diuretics and other hypotensive drugs, especially
ganglionic blockers.
Nursing Responsibilities:
1. Observe the 10 rights in giving medications
2. Strictly monitor for the I & O of the patient
3. Monitor for serum potassium levels
4. Monitor vital signs especially heart rate and blood pressure
5. Document findings and report unusualities right away to the physician

157
NURSING THEORY

THEORY OF COMFORT by Katharine Kolcaba

The Theory of Comfort considers patients to be individuals, families,

institutions, or communities in need of health care. The environment is any
aspect of the patient, family, or
institutional surroundings that can be
manipulated by a nurse or loved one in
order to enhance comfort. Health is
considered to be optimal functioning in
the patient, as defined by the patient,
group, family, or community.
In the model, nursing is described as
the process of assessing the patient's comfort needs, developing and
implementing appropriate nursing care plans, and evaluating the patient's
comfort after the care plans have been carried out. Nursing includes the
intentional assessment of comfort needs, the design of comfort measures to
address those needs, and the reassessment of comfort levels after
implementation. Assessment can be objective, such as the observation of wound
healing, or subjective, such as asking the patient if he or she is comfortable.

In our case, the patient has Hepatic Hemangioma. That is why Theory of
Comfort is the most applicable one to our patient because this theory is
composed of three forms: relief, ease, and transcendence. If specific comfort
needs of a patient are met, the patient experiences comfort in the sense of relief.

158
HELPING ART OF CLINICAL NURSING by Ernestine Wiedenbach
Ernestine Wiedenbach views nursing as the art of nurturing or caring for
someone in a motherly fashion. In
order for nurses to fulfill the nurse's
helping role, we should be able to
identify patients' need for help
through observing behavior
consistent or inconsistent with their
comfort, exploring the meaning of their behavior, determining the cause of their
discomfort or incapability and determining whether they can resolve their problems
or have a need for help.

In our case, the patient has Hepatic Hemangioma. With this, we need to be
observant enough for us to identify what the client might need especially with
understanding facial expressions, actions and discomforts. Once the patient’s
need for help is identified, the nurse can then administer the help needed and
validate that the need for help was met. As nurses, we should be able to gain
mastery of the practice of identifying a patients’ need for help through observation
of presenting behaviors and symptoms. In providing care, we should exercise
sound judgment through deliberative, practiced and educated recognition of
symptoms. Also, we need to remember that the patient's perception of the situation
is an important consideration to the nurse when providing competent care.

159
NURSING CARE PLANS

DATE/ CUES NEED NSG DIAGNOSIS OBJECTIVE OF INTERVENTIONS EVALUATION

TIME CARE
Novem N Altered That within 30 Independent: November 20, 2018 @
ber 20, OBJECTIVE: U thermoregulation: minutes of care, 9AM
2018 T hyperthermia r/t the patient’s fever1. Perform TSB. GOAL MET AS
@ 8am - Temperature of R increase of pyrogens in will be alleviated R. Through conduction, EVIDENCED BY:
37.7 C (N: 36.5- I the body as evidenced by: the heat is alleviated from
37.5 C) T the body to the tepid
BP- 100/70 (N: I Rationale: temperature of the A. Temperature of
120/80 – 140/90 O a.) Temperat sponge bath. 37.2 (N:36.5-
N Pyrogens are released ure within 37.5’C)
mmHg)
A by the body that normal 2. Monitor temperature
CR-119 (N: 60-100
L increases body range every 10 minutes. B. Absence of chills
bpm) temperature. They are (36.5- R: To detect further
PR-110 (N: 60-100 A being triggred as an 37.5’C) development of the John Gel Alcarlo A.
bpm) N immunologic response b.) Absence temperature. Panal
RR-21 (N: 16-20 D system whenever there of chills
cpm) is presence of bacteria. 3. Place gooselamp at
M bedside.
-fever and chills E Nurseslabs. (2018). R. The chills will be
T Hyperthermia – Nursing alleviated from the heat of
Medications: A Diagnosis & Care Plan. the gooselamp.
B Retrieved at
-Paracetamol O https://nurseslabs.com/ 4. Let patient take liberal
300mg IV q4 L hyperthermia amount of fluid
I R. To hydrate the body
C hence regulating the
thermoregulation of the
body.

160
Dependent:

5. Administer
Paracetamol as ordered
R. Paracetamol is an
antipyretic that lowers
body temperature.

Gulanick, M., Myers, J.

(2014). Nursing care
plans: Diagnoses,
interventions, and
outcomes.
Philadelphia, PA.
Elsevier Mosby.

DATE CUES NEED NURSING OBJECTIVE OF NURSING EVALUATION

DIAGNOSIS CARE INTERVENTIONS
TIME
N S: N Fluid volume excess r/t That within my 2- 1.) Monitor VS especially HR November 21, 2018 @
reduced ability of the day span of and BP 2pm
O U body to pull fluids into nursing care, my R: Water retention can
V O: T the circulatory system patient will have cause the patient to have “Goal Partially Met”
reduced fluid episodes of hypertension
E -(+) Bibasal R volume level as and tachycardia. That after my 2-day
Crackles evidence by: span of nursing care,
Rationale:

161
M -Abdominal I Oncotic pressure is the 2.) Monitor intake and output my patient had
girth of 93 cm one responsible for a.) Urine output is closely. reduced fluid volume
B T pulling fluids into the greater than or R: Dehydration may be the levels as evidenced
- soft, round, circulatory system. equal to 30 cc/hr; result of fluid shifting even if by:
E and distended I
This pressure is oral intake is adequate.
R abdomen O exerted by proteins, b.) decrease a.) Urine output of 45-
-(+) edema on N namely albumin. This abdominal girth of 3.) Administer diuretics as 70 cc/hr;
right and left pressure tends to pull 2-3 cm; prescribed.
20 extremities; A fluids into the blood R: Diuretic aids in the b.) Abdominal girth of
grade 1 vessels resulting to a c.) maintain excretion of excess body 104 cm;
L
more balanced ratio of cardiac rate within fluids.
2 -with post op plasma is to RBC. If normal range (60- c.) cardiac rate of 105
dressing on this pressure fails to 100 bpm); and 4.) Review CxR reports. bpm; and
0 abdomen (s/p - pull fluids into the R: X-ray studies show d.) minimal bibasal
exlap; s/p blood vessels, it will d.) absence of cloudy white lung fields as crackles noted upon
1
cholecystecto stay in the interstitial bibasal crackles. interstitial edema auscultation,
8 my) M spaces of the body accumulates.
-with foley causing edema and in 5.) Assess for changes in
E
catheter (Fr. some cases in the respiratory pattern and
@ 14) attached T peritoneal cavity presence of crackles. Christian Andre C.
to urobag causing ascites which R: These signs are caused Catacutan, St.N
A will result into fluid by accumulation of fluids in
draining dark
8 am yellow colored B volume excess in the the lungs. BSN 4D-Grp 3
urine. client.
O 6.) Assess urine output in
-VS of: response to diuretic therapy.
L
(Reference: Johnson, R: Mediations are given IV
HR: 119 bpm
I J. (2004). Brunner and because there are times that
RR: 21 cpm suddarth’s textbook of that excess fluid volume in
C
medical surgical the abdomen may interfere

162
Bp: 100/70 nursing. Lippincott with the absorption of oral
mmHg Williams & Wilkins. diuretic medication.
P
10th edition)
-NVS of: 7.) Assess for bounding
A
RLS of 1 peripheral pulses.
T R: This assessment is an
GCS of 11 indication of fluid overload.
T
-(-) labored
E 8.) Reposition the client
respirations
every 2 hours.
R
-PNSSiL + 2 R: Repositioning prevents
vials Albumin N fluids to accumulate on
80% + 60 mg dependent areas.
Furosemide +
60 mEqs KCl 9.) Place the patient in a
@ 40cc/hr semi-fowler’s/ high fowler’s
position.
-Blood
R: Raising the head of the
Chemistry
bed provides comfort and
Hgb: 102 facilitates breathing.
(120-160 g/L)
(Reference: Doenges, M.,
RBC: 3.48 Moorhouse, M., and Murr, A.
(4.0-5.0 (2016). Nurse’s pocket
10^12/L) guide. F.A. DAVIS
MCHC: 32.0 COMPANY, Philadelphia,
(33-36 g/L) Pennsylvania)

Hct: 0.32
(0.37-0.45)

163
-Albumin as
of November
24, 2018:
23.88 (35-50)
-Liver
function test:
(11/19/18):
SGOT/AST:
58 (15-41
U/L)
SGPT/ALT:
30 (0-35 U/L)
Total Bilirubin:
126.96 (6.8-
34.2 umol/L)
Direct
Bilirubin:
74.82 (1.7-8.6
umol/L)
Indirect
Bilirubin:
52.14 (0-19
umol/L)
Alkaline
Phosphatase:
139 U/L)

164
-USD of
Whole
Abdomen
(11/11/18):
-Large
Cavernous
Hemangioma,
right hepatic
lobe
-staghorn
calculi, left
-bilateral renal
cortical cysts
-CxR
(11/19/18):
-Impression:
left ventricular
cardiomegaly
with
pulmonary
congestion;
bilateral
pleural
effusion
-Total Intake:
(11/19/18)

165
IVFs: 1.220
cc
Others: 105
cc
-Total
Output: 575
cc
-Retention:
(+) 750 cc
-Total intake:
(11/20/18)
IVFs: 1,275
cc
Others: 130
cc
-Total
output: 435
cc
-Retention:
(+) 970 cc
-Endotracheal
tube attached
to mechanical
ventilator with

166
the following
set-up:
FiO2: 40%
RR:12
Mode: AC
VT: 500
-Diagnosis:
Mixed
hemorrhoids
t/c hepatic
hemangioma
r/o
malignancies

DATE/ CUES NEE NSG OBJECTIVE OF INTERVENTIONS EVALUATION

TIME D DIAGNOSIS CARE
11 OBJECTIVE A Decreased That within 3 days of 1. Note skin color, November 27, 2018 @
/ : C cardiac output r/t nursing care, the temperature, and 9AM
20 T enlargement of patient will moisture. GOAL PARTIALLY MET
/ Vital signs: I the left ventricle experience an R. Cold, clammy, AS EVIDENCED BY:
2018 Temperatur V as evidenced by improved cardiac and pale skin is
@ e: 37.7 C I secondary to

167
8am (N: 36.5- T increased cardiac output as evidenced compensatory B. Cardiac rate is within
37.5 C) Y rate by: increase in normal range (70
BP: 100/70 sympathetic bpm. N: 60-
(N: 120/80 – A Rationale: nervous system 100bpm);
140/90 N An enlarged heart c.) Cardiac rate stimulation and low
mmHg) D can be caused by within normal cardiac output and C. cardiac output is still
CR: 119 conditions that range; oxygen not within normal
(N: 60-100 E cause your heart d.) Cardiac output desaturation. range
bpm) X to pump harder within normal 2. Assess heart rate (2800/1000=2.8L);
PR: 110 E than usual or that range; and and blood pressure. and
(N: 60-100 R damage your e.) Blood pressure R. Most patients
bpm) C heart muscle. within normal have compensatory D. blood pressure is not

RR: 21 I Sometimes the range. tachycardia and within normal range

(N: 16-20 S heart enlarges significantly low (130/90. N: 120/80 –

cpm) E and becomes blood pressure in 140/90 mmHg)

weak for response to reduced

-cardiac P unknown cardiac output.
output: A reasons. As this 3. Record urine Kristel Shanen S.

T thickening and output. Determine Crame

T stiffening of heart

168
Stroke E muscle how often the
volume x R progresses, your patient urinates.
cardiac rate N heart may R. The renal system
enlarge to try to counterbalances low
Stroke pump more blood BP by retaining
volume= to your body. Due water. Oliguria is a
systolic- to the increased classic sign of
diastolic in size of the left decreased renal
100-70=30 ventricle, it is perfusion.
unable to give out 4. Check symptoms
CO= more blood to the for chest pain.
30x119= body. R. Low cardiac
3,570/1000= output can further
3.57L Source: Enlarged decrease
(N: 4-8L) heart. (2017, myocardial
November 17). perfusion, resulting
-laboratory Retrieved from in chest pain.
results: https://www.mayo 5. If chest pain is
clinic.org/disease present, have
s- patient lie down and

169
Aorto-iliac conditions/enlarg monitor cardiac
arteriosclero ed- rhythm.
sis heart/symptoms- R. These actions
Aortic and causes/syc- can increase
coronary 20355436 oxygen delivery to
arteriosclero the coronary
sis arteries and improve
Left patient prognosis.
ventricular 6. Examine
cardiomegal laboratory data,
y especially arterial
Atheroscler blood gases and
otic aorta electrolytes,
including potassium.
R. Patient may be
receiving cardiac
glycosides and the
potential for toxicity
is greater with
hypokalemia;

170
hypokalemia is
common in heart
patients because of
diuretic use.
7. Monitor
laboratory tests
such as complete
blood count, sodium
level, and serum
creatinine.
R. Routine blood
work can provide
insight into the
etiology of heart
failure and extent of
decompensation.

Source: Decreased
Cardiac Output –
Nursing Diagnosis &

171
Care Plan. (2017,
September 23).
Retrieved from
https://nurseslabs.c
om/decreased-
cardiac-
output/#nursing-
interventions

172
Date/ Cues Need Nursing Diagnosis Objective Of Care Nursing Interventions Evaluation
time
N Objective: N Impaired Skin Integrity That within 1 week 1) Assist for change November 28,
O Post U related to surgical incision span of care the of dressing. Use 2018
V operative T as evidenced by post patient will maintain strict Aseptic
E dressing on R operative dressing on the intact skin integrity technique “GOAL
M Abdomen I abdomen as evidenced by r) to prevent infection PARTIALLY MET”
B T 2) Assist amount and
E Thoracoabdo I a)Display timely characteristics of That within 1 week
R minal soft O Rationale: wound healing drainage span of care the
tissue edema N During an open without r) Decreasing patient maintain
2 (Anasarca) A cholecystectomy your complications drainage suggests intact skin integrity
0 L surgeon makes a 6-inch evolution of healing as evidenced by:
Minimal (15-centimeter) incision in b)Display intact skin process and
2 Ascites & your abdomen below your free of signs of presence of bloody or a)The dressing is
0 ribs on your right side. The pressure or odoriferous exudate Dry and intact
1 abdominal M muscle and tissue are pulled breakdown suggest
8 girth of 93 cm
E back to reveal your liver and complications b)No signs of
T gallbladder. Your surgeon c)Demonstrate 3) Inspect the incision pressure or
Post A then removes the behaviors that regularly, noting breakdown on the
Exlaparotomy B gallbladder. reduce tension on characteristics and skin
Post O suture line integrity
Cholecystect L Reference: Retrieved from r) Early Recognition c)Reduced tension
omy I https://www.mayoclinic.org/t of delayed healing or on the suture line.
C ests- developing
procedures/cholecystectomy complications may
P /about/pac-20384818 prevent more serious Zamantha Angel
A complications P. Araneta
T 4) Splint abdominal
T incisions with pillow
E

173
R during coughing and
N movement
r) Equalized pressure
on the wound,
minimizing the risk of
dehiscence
5) Caution client not
to touch the incision
r) Prevent
contamination of area
5) Assist in changing
position
r) improve circulation,
muscle tone and joint
motion
6)Limit intake of
water
r) to reduce edema

174
DATE & CUES NEED NURSING DIAGNOSIS GOAL OF CARE INTERVENTIONS
TIME
Objective: A Impaired physical Within patient’s 1. Monitor Vital Signs
N - (+) Edema on both C mobility r/t decreased stay, patient will be R: To identify physical
O upper and lower T muscle strength. able to maintain as responses associated with
V extremities I much mobility and both medical and emotional
E - Limited Range of V Rationale: functional conditions.
M Motion I Muscle weakness independence as
B - Requires help to T happens when your full possible as 2. assist patient to do active
E chang position in Y effort doesn't produce a evidence by: ROM exercises on the
R bed - normal muscle lower extremities.
20 - Lying on bed, E contraction or a.) Demonstrate R: to improve muscle
, awake,coherent, & X movement. If the brain some measures to strength and joint
2 responsive E decreases neural increase mobility; mobility.
0 - Slow movement R activity contributes to
1 - Difficulty in turning C deterioration of b.) demonstrate 3. Used side rails of bed.
8 I musculoskeletal health some of use R: To prevent the patient
S the muscles will loss of adaptive devices to from possible fall or
E muscular mass, accident that might.

175
@ flexibility and strength increase mobility;
8 P then the density and and 4. Provided an adequate
AM A strength of the bones rest periods as well as
T decreases and to the c.) uses of safety comfort and safety
T joints loss of cartilage measures to measures to the patient.
E and stiffening of minimize potential R: To prevent further
R ligaments and tendons for injury. stress,fatigue and injury.
N reduces joint mobility.
Reference: 5. Provide comfort
Videbeck, S. (2011). measures such as a
Psychiatric-Mental
calm/quiet environment
Health Nursing. (5th
ed.). Philadelphia: R: To assist in the
Lippincott Williams &
relaxation of the patient
Wilkins.

6. Provide foam or flotation

mattress, water or air
mattress or kinetic
therapy bed, as
necessary.

176
R: Provide foam or
flotation mattress, water
or air mattress or kinetic
therapy bed, as
necessary.

7. Promote and facilitate

early ambulation when
possible. Aid with each
initial change: dangling
legs, sitting in chair,
ambulation.
R: These movements
keep the patient as
functionally working as
possible. Early mobility
increases self-esteem
about reacquiring
independence and

177
reduces the chance that
debilitation will transpire.

8. Provide the patient of

rest periods in between
activities. Consider
energy-saving
techniques.
R: Rest periods are
essential to conserve
energy. The patient must
learn and accept his her
limitations.
References:
Doenges, M; Moorhouse, M.F;
Murr, A. (2016). Nurse’s Pocket
Guide 14th edition. F.A. DAVIS
COMPANY: Philadelphia,
Pennsylvania.

178
Townsend, M.C. & Morgan, K.I.
(2017). Essentials of Psychiatric
Mental Health Nursing:
Concepts of Care in Evidence-
Based Practice. (8th ed.).
Philadelphia: F.A. Davis Co.

179
Date & Cues Need Nursing Diagnosis Objective of Implementation Evaluation
Time Care
N OBJECTIVE: N Risk for aspiration That within my 1. Assess level of November 20, 2018
O - NGT Fr.16 U r/t nasogastric tube 7 hour span of consciousness. @ 3pm
V - Feeding of T feeding nursing care, R: The primary risk factor of
E 1,600 R patient will not aspiration is decreased level After my 7 hour
M - With I R: Aspiration is one show any of consciousness. span of nursing
B endotrache T of the most signs of 2. Monitor respiratory rate, care, patient did not
E al I common aspiration as depth, and effort. Note any show any signs of
R tracheosto O complications in evidenced by: signs of aspiration such as aspiration as
my N enterally fed dyspnea, cough, cyanosis, evidenced by:
20 A patients. The a. maintains a wheezing, or fever.
L source of aspiration patent airway R: Signs of aspiration a. maintained patent
2 is due to the with normal should be identified as soon airway with normal
0 H accumulation of breath sounds as possible to prevent breath sounds
1 E secretions in the b. absence of further aspiration and to b. absence of
8 A pharynx of reflux coughing initiate treatment that can be coughing
L gastric contents life-saving.
@ T from the stomach 3. Check placement before
H into the pharynx. feeding, using tube
8am There is evidence markings, x-ray study (most
P in the literature accurate), pH of gastric
A showing that the fluid, and color of aspirate
T presence of a as guides.
T nasogastric feeding R: A displaced tube may
E tube is associated erroneously deliver tube
R with colonization feeding into the airway.
N and aspiration of Chest x-ray verification of
pharyngeal accurate tube placement is
secretions and most reliable. Gastric
gastric contents aspirate is usually green,

180
leading to a high brown, clear, or colorless,
incidence of Gram- with a pH between 1 and 5.
negative 4. Check residuals before
pneumonia in feeding, or every 4 hours if
patients on enteral feeding is continuous. Hold
nutrition. However, feedings if amount of
other aspects may residuals is large, and notify
be equally the physician.
important and R: Large amounts of
should also be residuals indicate delayed
considered when gastric emptying and can
evaluating a patient cause distention of the
suspected of stomach, leading to reflux
having aspiration emesis. The amount of
and aspiration residuals may vary
pneumonia. The depending on the volume
mechanisms and rate of infusion;
responsible for however, the evaluation can
aspiration in be unreliable. Feedings are
patients bearing a often held if residual volume
nasogastric feeding is greater than 50% of the
tube are (1). loss of amount to be delivered in 1
anatomical integrity hour.
of the upper and 5. Keep head of bed
lower esophageal elevated when feeding and
sphincters, (2). for at least a half hour
increase in the afterward.
frequency of R: Maintaining a sitting
transient lower position after meals may
esophageal help decrease aspiration
sphincter pneumonia in the elderly.

181
relaxations, and Denise Adrienne L.
(3). desensitization Moreno, StN
of the
pharyngoglottal
adduction reflex.

Reference:
Gomes, G. (2003).
The nasogastric
feeding tube as a
risk factor for
aspiration and
aspiration
pneumonia.
Retrieved from
https://www.ncbi.nl
m.nih.gov/pubmed/
12690267 on
November 4, 2018

182
DISCHARGE PLANNING
Medications

 Instruct the watcher to comply the medications for client.

 Observe the proper timing in giving of medications.
 Inform the watcher about the common side effects of the medications
given to the client.
 If antibiotics are given, inform the watcher that the course of the therapy
should be strictly followed until it is completed not until signs and
symptoms are absent.

Exercise

 Encourage the client to do range of motion exercises as tolerated.

 Instruct the client to turn to her sides as tolerated.
 Do deep breathing exercises 10 times for at least twice a day.

Treatment

 Instruct to continue the prescribed treatment by the doctor such as

medications, diet, and activities.

Hygiene

 Instruct the watcher to perform bed bath to the client.

 Instruct watcher to assist client in doing bathroom privileges.
 Perform oral hygiene everyday to stimulate appetite.

Out patient

 Instruct the watcher to comply with the doctor’s order on when to come
back for follow up check-up.
 If unusualities are noted days after discharge, consult physician
immediately to
 Prevent further complications.

183
Diet

 Inform the watcher about the diet of the client; on what she must avoid
and what she must take in.
 Also provide a list of certain foods that the client should avoid for further
compliance.

PROGNOSIS
According to our research, hepatic hemangioma has an excellent prognosis
for it is a benign tumor and therefore is noncancerous. And in the case of our
patient, although her hemangioma has ruptured, she immediately underwent
surgery. And with this, she has a good prognosis for she immediately complied
with the suggested surgery by the doctor and the medications needed. Her
family is emotionally, financially, and even spiritually supportive to her. They
make sure that they are able to visit her in a day. The patient is financially
supported by her daughter who is in abroad and is also financially stable so she
has no problem with the hospital finances.

184
REFERENCES
Balaban, D. V. (2015). Hepatic hemangioma review. Journal of medicine and life
Chugh, A., Singh, R., & Agarwal, P. (2015). Management of hemorrhoids (6th
ed., Vol. 25). Indian Journal of Clinical Practice
Decreased Cardiac Output – Nursing Diagnosis & Care Plan. (2017, September
23). Retrieved from https://nurseslabs.com/decreased-cardiac-
output/#nursing-interventions

Doenges, M., Moorhouse, M., and Murr, A. (2016). Nurse’s pocket guide. F.A. DAVIS
COMPANY, Philadelphia, Pennsylvania

Doenges, M; Moorhouse, M.F; Murr, A. (2016). Nurse’s Pocket Guide 14 th

edition. F.A. DAVIS COMPANY: Philadelphia, Pennsylvania.

Gami, B. (2015). HEMORRHOIDS – A COMMON AILMENT AMONG ADULTS,

CAUSES & TREATMENT: A REVIEW (Vol. 3). Pharmaceutical
Biotechnology lab, Ipcowala Santram Institute of Biotechnology &
Emerging Sciences, Dharmaj 388430, Gujarat India
Gomes, G. (2003). The nasogastric feeding tube as a risk factor for aspiration
and aspiration pneumonia. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/12690267 on November 4, 2018

Gulanick, M., Myers, J. (2014). Nursing care plans: Diagnoses, interventions, and
outcomes. Philadelphia, PA. Elsevier Mosby.
Hodgson, B., et. al. (2014). Nursing drug handbook. St. Louis Missouri. Saunders
Johnson, J. (2004). Brunner and suddarth’s textbook of medical surgical nursing.
Lippincott Williams & Wilkins. 10 th edition
Kluwer, W. (2015). Nursing drug handbook. Philadelphia

Migaly, J. (2018). Review of Hemorrhoid Disease: Presentation and

Management. Retrieved at
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Mims Philippines (2017). Retrieved from http://www.mims.com/philippines/

drug/information

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Retrieved from https://www.mayoclinic.org/tests-
procedures/cholecystectomy/about/pac-20384818

S. florim, C. maciel, A.T. almeida, & F.A costa. (n.d.). Hepatic hemangiomas:
Typical and atypical imaging findings, pitfalls and differential diagnosis.
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Skidmore-Roth, L. (2012). Mosby’s 2012 nursing drug handbook reference. St. Louis
Missouri. Elsevier

Source: Enlarged heart. (2017, November 17). Retrieved from

https://www.mayoclinic.org/diseases-conditions/enlarged-heart/symptoms-
causes/syc-20355436

Timby, B. K., & Smith, N. E. (n.d.). Introductory medical-surgical nursing (8th

ed.). Lippincott williams and wilkins
Townsend, M.C. & Morgan, K.I. (2017). Essentials of Psychiatric Mental Health
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Philadelphia: F.A. Davis Co.

Unal, E., Acar, A., Canbak, T., & Tulan, H. (2016). Liver Hemangiomas: A Wide
Range of Management from Observation to Hepatic Transplantation.
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Videbeck, S. (2011). Psychiatric-Mental Health Nursing. (5th ed.). Philadelphia:
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World Life Expectancy. (2018). Liver Disease in Philippines. Retrieved at

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186