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THE CLINICAL CARITAS PROCESSES IN CARING FOR A PATIENT WITH MALIGNANT LYMPHOMA

A Clinical Paper Presented to The Faculty of the College of Nursing Graduate School Cebu Normal University

In Partial Fulfillment of the Requirements for the Degree Master in Nursing Major In Medical-Surgical Nursing

John Andro D. Banga May 2012 APPROVAL SHEET

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This clinical paper entitled The Clinical Caritas Processes in Caring for a Patient with Malignant Lymphoma prepared and submitted by John Andro D. Banga in partial fulfillment of the requirements for the degree MASTER IN NURSING with the field of specialization MEDICAL-SURGICAL NURSING,

has been examined and is recommended for acceptance and approval for ORAL EXAMINATION. JEZYL T. CEMPRON, R.N., M.N. Professor, College of Nursing Adviser THE TECHNICAL PANEL

DAISY R. PALOMPON, R.N., M.A.N., Ph.D. Dean, College of Nursing- Graduate School Chairman

ANTONIETA G. OBIEDO, R.N., M.N. Professor, College of Nursing Member

JEZYL T. CEMPRON, R.N., M.N. Professor, College of Nursing Adviser

Accepted and Approved for ORAL EXAMINATION.

DAISY R. PALOMPON, R.N., M.A.N., Ph.D. Dean, College of Nursing- Graduate School Cebu Normal University PANEL OF ORAL EXAMINERS

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Approved by the Committee on Oral Examination with a grade of PASSED.

DAISY R. PALOMPON, R.N., M.A.N., Ph.D. Dean, College of Nursing- Graduate School Chairman

ANTONIETA G. OBIEDO, R.N., M.N. Professor, College of Nursing Member

JEZYL T. CEMPRON, R.N., M.N. Professor, College of Nursing Adviser

ACCEPTED AND APPROVED in partial fulfillment of the requirements for the degree MASTER IN NURSING with the field of specialization MEDICALSURGICAL NURSING.

DAISY R. PALOMPON, R.N., M.A.N., Ph.D. Dean, College of Nursing- Graduate School Cebu Normal University

Acknowledgement I would like to express my deepest and most sincere gratitude to the following persons who have shared their valuable time and support, and for

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giving me inspiration and guidance, which made possible the completion of the study: Our God Almighty, who is the sources of all graces and who continually blesses me with the gift of knowledge, wisdom, and skill in fulfilling this goal, My parents, who are always there for me with their unending love and for continuously offering prayers for my success, My girlfriend, Jofeillyn P. Tumakay, for your love and unwavering support and faith in me, My adviser, Miss Jezyl T. Cempron, for her expertise, guidance and for properly motivating me in all the phases of this study: Thank you for the opportunity to work under your guidance, The Hospital Administrators, Medical Directors and Nursing Service Staff of the Vicente Sotto Memorial Medical Center: Thank you for facilitating and giving me the opportunity to conduct my study in your institution, My patient and his brother, for their time spent, theier cooperation and patience in answering the questions which form the very essence of the output of this study, The CNU librarians, for their assistance, support, and kindness in helping me find the resources needed in this study, My co-faculty members and friends, for all the prayers , enlightenment and encouragement in every aspect leading to the completion of this study, Thank you. The Researcher

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I would like to dedicate this study to everyone who has ever experienced the challenge of working with cancer patients and their families.

ABSTRACT Title: Clinical Caritas Processes in Caring for a Patient with Malignant Lymphoma Author: School: John Andro D. Banga, R.N. Cebu Normal University College of Nursing- Graduate Studies Degree: Master in Nursing

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Major in Medical-Surgical Nursing Adviser: Year Completed: Miss Jezyl T. Cempron, R.N., M.N. 2012

This study utilized Clinical Caritas in Caring for a Patient with Malignant Lymphoma. The case study research design was used. Data gathering was done in Ward 3B (Pay Ward) of the Vicente Sotto Memorial Medical Center. The patient was assessed using a researcher-made assessment tool based on Jean Watsons ordering of needs combined with Gordons Functional Health Pattern and physical assessment. The researcher collected the data through interviews, direct observation, and physical assessment. The researcher completed fifty hours of exposure in Ward 3B (Pay Ward) last July 5-10, 2011. The ordering of needs was utilized in the assessment of the patient. After thorough assessment, the following nursing problems were identified: Under Biophysical needs, ineffective airway clearance and hyperthermia. Chronic pain, impaired physical mobility, and activity intolerance were under Psychophysical needs. Psychosocial needs included impaired skin integrity and self care deficit. Lastly, the intrapersonal-interpersonal needs which included situational low self esteem. Nursing care plans were then formulated and clinical caritas was applied. Finally, evaluation was done after providing holistic nursing care. Watsons theory helped the nurse provide care to this type of patient in a way that the nurse instills faith and hope and all the carative factors despite his condition, uplifts dignity and recognize that there are humans who still need love and genuine care.

Table of Contents Title Page Approval Sheet ---------------------------------------------------------------------------Panel of Oral Examiners Acknowledgement -----------------------------------------------------------------------Dedication ---------------------------------------------------------------------------------Abstract -------------------------------------------------------------------------------------Chapter 1 Introduction Background and Rationale of the Study --------------------------------Theoretical and Conceptual Framework --------------------------------Statement of the Problem --------------------------------------------------Significance of the Study ---------------------------------------------------Research Methodology ----------------------------------------------1 2 -8 8 Page -ii iii iv v vi

------- 9 -9 10 10 11

Research Design --------------------------------------------------------- ---Research Locale -------------------------------------------------------------Research Instrument --------------------------------------------------------Data Gathering Procedure -------------------------------------------------2 Results and Discussion Clinical Profile of the Patient ----------------------------------------------Biophysical --------------------------------------------------------------------Psychophysical --------------------------------------------------------------Psychosocial ------------------------------------------------------------------

- 12 13 --18 - 18

Intrapersonal-Interpersonal ------------------------------------------------- 19
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Psychopathophysiology ------------------------------------------------------ 20 Identified Patient Needs ------------------------------------------------------ 23 Documentation of Clinical Caritas Processes ------------------------24 3 Conclusions and Recommendations Conclusions --------------------------------------------------------------------- 38 Recommendations ------------------------------------------------------------ 38 Bibliography ---------------------------------------------------------------------------------- 40 Appendices ----------------------------------------------------------------------------------- 42 A. Transmittal Letter ------------------------------------------------------------------------ 43 B. Adviser Designation -------------------------------------------------------------------- 44 C. Daily Time Record ---------------------------------------------------------------------- 45 D. Assessment Tool ------------------------------------------------------------------------ 46 E. Anatomy and Physiology -------------------------------------------------------------- 51 F. Pharmacologic Management --------------------------------------------------------- 55 G. Diagnostic and Laboratory Results -------------------------------------------------63 H. Nurses' Notes ---------------------------------------------------------------------------- 65 I. Documentation ---------------------------------------------------------------------------- 71 J. Curriculum Vitae ------------------------------------------------------------------------- 72

List of Figures Figure Title Page

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Schematic Diagram Using the Nursing Process of Jean Watson

Schematic Diagram of the Psychopathophysiology of Malignant Lymphoma

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Lymph Nodes

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i List of Tables Table 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Title Carative Factors and Clinical Caritas Processes Summary of the Identified Nursing Problems Ineffective Airway Clearance Hyperthermia Altered Nutrition: Less than Body Requirements Risk for Infection Chronic Pain Impaired Physical Mobility Activity Intolerance Impaired Skin Integrity Self Care Deficit Situational Low Self Esteem Risk for Spiritual Distress Hematology Clinical Chemistry Immunology Report Inefffective Airway Clearance Hyperthermia Activity Intolerance Chronic Pain Self Care Deficit Impaired Physical Mobility Page 4 23 24 25 26 27 29 30 31 33 34 35 37 63 64 64 65 66 67 68 69 70

Chapter 1 Introduction Background and Rationale of the Study The lymphatic system flows toward the bloodstream. It returns fluid from the body tissues to the blood. When a body part becomes swollen, the lymph vessels collect the excess fluid and carry it to the veins through the lymphatic system. This process is detrimental because water, proteins, and other molecules continuously leak out of tiny blood capillaries into the surrounding body tissues. This lymph fluid has to be drained, so it then returns to the blood stream via the lymphatic vessels (Hargrove-Huttel, 2005). Malignant lymphomas are cancerous tumors of lymphoid tissue. They are characterized by lymphocyte proliferation and progressive, painless enlargement of the lymph node. In general, malignant lymphomas arise from transformed cells of the lymphatic system. Within several weeks or months, the lymphomas in the lymph nodes spread from there via the blood and lymphatic vessels to the entire body. They can affect almost all organs of the body. If untreated, lymphomas will be fatal in most cases. Most patients with lymphomas are characterized by lymph node swellings (Burke, Lemon & Mohn-Brown, 2003). The malignant lymphomas rank third, comprising 9.0% of all cancers. These usually involve the lymph nodes but may at times arise from other organs rich in lymphoid tissue. They cause swelling of lymph nodes in the neck, chest axilla and groin. They may also be present as generalized weakness and fever (Department of Health, 2006).

From 2004-2008, the median age at diagnosis for lymphoma was 38 years. The age-adjusted incidence rate was 2.8 per 100,000 men and women per year. It is estimated that 8,490 men and women (4,670 men and 3,820 women) will be diagnosed with, and 1,320 men and women will die of malignant lymphoma in 2010. Approximately 12.3% were diagnosed under age 20; 31.5% between 20 and 34; 15.8% between 35 and 44; 12.5% between 45 and 54; 9.7% between 55 and 64; 8.5% between 65 and 74; 7.2% between 75 and 84; and 2.3% 85+ years of age (World Health Organization, 2010). The researcher intends to use Jean Watsons Theory of Caring, specifically the Clinical Caritas Processes to provide holistic and humane care to the patient with malignant lymphoma who needs palliative and supportive care. Watson defined nursing as a human science of persons and human healthillness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions. Integration of the Clinical Caritas Processes in nursing care is utilized when all the medical and surgical interventions fail. In this connection, the nurse can offer emotional support by simply being with the patient so that the patient would feel that he is cared for, given assistance with his basic needs, and endowed with a helping-trust relationship in order for him to have a sense of self worth. Theoretical-Conceptual Framework This study is anchored on the Clinical Caritas Processes of Jean Watsons Theory of Caring. She adopts a view of the human being as: .. a valued person in and of him or herself to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional

integrated self. He, human, is viewed as greater than and different from, the sum of his or her parts (Watson, 2001). The theory of caring and nursing has existed in every society. A caring attitude is not transmitted from generation to generation. It is transmitted by the culture of the profession as a unique way of coping with the environment. Nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health. It focuses on health promotion and the treatment of disease. The Theory of Caring states that holistic health care is central to the practice of caring in nursing. It defines nursing as a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions (Watson, 1997). The theory of Jean Watson has seven assumptions for the science of caring in nursing. It asserts that caring can be effectively demonstrated and practiced only interpersonally. Second, caring consists of carative factors that result in the satisfaction of certain human needs. Third, effective caring promotes health and individual or family growth. Fourth, caring responses accept the person not only as he or she is now but as what he or she may become. Fifth, a caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time. Sixth, caring is more healthogenic than curing. The practice of caring integrates biophysical knowledge with knowledge of human behavior to generate or promote health and to provide ministrations to those who are ill. Lastly, the practice of caring is central to nursing. (Watson, 2001)

In addition to the seven assumptions, it describes ten "Caritas Processes". Originally, the "Carative Factors," these define essential "core values": Table 1: Carative Factors and Clinical Caritas Processes (Watson, 2001)
Carative Factors 1. Humanistic altruistic values. 2. Instilling/enabling faith & hope. 3. Cultivation of sensitivity to ones self and others. 4. Development of helpingtrusting, human caring relationship. 5. Promotion and acceptance of expression of positive and negative feelings. Caritas Processes Practicing loving-kindness & equanimity for self and other. Being authentically present to/enabling/sustaining/honoring deep belief system and subjective world of self/other. Cultivating of ones own spiritual practices; deepening self-awareness, going beyond ego self. Developing and sustaining a helping-trusting, authentic caring relationship.

Being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for. 6. Systematic use of scientific Creatively using presence of self and all ways of knowing/ (creative) problem solving multiple ways of being/doing as part of the caring process; caring process. engaging in the artistry of caring-healing practices. 7. Promotion of transpersonal Engaging in genuine teaching-learning experiences that teaching-learning. attend to the whole person, their meaning; attempting to stay within the others frame of reference. 8. Provision for a supportive, Creating healing environment at all levels (physical, nonprotective, and/or corrective physical, subtle environment of energy and mental, social, spiritual consciousness whereby wholeness, beauty, comfort, environment. dignity and peace are potentiated. 9. Assistance with gratification of Assisting with basic needs, with an intentional, caring human needs. consciousness of touching and working with embodied spirit of individual, honoring unity of Being; allowing for spiritual emergence. 10. Allowance for existential- Opening and attending to spiritual-mysterious, unknown phenomenological spiritual existential dimensions of life-death; attending to soul care dimensions. for self and one- being- cared- for.

According to the theory, the nursing process contains the same steps as the scientific research process. They both try to solve a problem. Both provide a framework for decision making. The assessment phase involves observation, identification and review of the problem; and use of applicable knowledge in literature. It also includes conceptual knowledge for the formulation and

conceptualization of framework. It includes the formulation of hypothesis, and defining variables that will be examined in solving the problem. In Watsons book entitled Nursing the Philosophy and Science of Caring, the second half of the book is about helping people gratify their human needs. These are classified into two; the lower order needs which include biophysical needs and psychophysical needs and the higher order needs which include psychosocial needs and intrapersonal-interpersonal needs. A need is defined generally as a prerequisite of a person to relieve distress and improve his wellbeing (Watson, 1999). The lower order needs consist of the biophysical needs and the psychopyhsical needs. The biophysical needs include the need for food and fluid, elimination, and ventilation. These are also commonly called the survival needs as they are essential to sustain life. Next is the psychophysical needs. These are the need for activity-inactivity and the need for sexuality. This subdivision is also referred to as functional needs. When these needs are met, it is believed to increase the quality of living. The higher order needs consist of psychosocial needs. These are the need for achievement and affiliation, referred to as integrative needs. Reaching these needs can bring out the human potential, maturity, and satisfaction towards others. The second is intrapersonal-interpersonal needs. This is the need for selfactualization or growth-seeking needs. All the higher order needs are long-term goals the nurse must attempt to reach. The planning phase helps to determine how variables would be examined or measured; it includes a conceptual approach or design for problem solving. It

determines what data would be collected and how, and on whom. In the intervention phase, the use of clinical caritas processes was emphasized in the implementation of the plan. It included the collection of data. The last phase in Jean Watson's nursing process is evaluation. This is the analysis of the data as well as the examination of the effects of interventions based on the data. It includes the interpretation of the results, the degree to which a positive outcome has occurred, and whether the result can be generalized. It may also generate additional hypothesis or may even lead to the generation of a nursing theory (Watson, 2001).

Jean Watsons Theory of Human Caring

Patient with Malignant Lymphoma

Assessment

Lower Order Needs Biophysical Needs Psychophysical Needs Higher Order Needs Psychosocial Needs Intra-Interpersonal Needs

Planning

Intervention Clinical Caritas Processes

Evaluation

Figure 1: Schematic Diagram of the Theoretical-Conceptual Framework of Jean Watsons Human Theory of Caring Statement of the Problem This study aimed to utilize Jean Watsons Theory of Caring Clinical Caritas Processes in the care of a patient with malignant lymphoma. Specifically, it sought to answer the following questions: 1. What are the assessment findings of the patient based on the following ordering of needs: 1.1 Lower Order Needs 1.1.1 Biophysical needs

1.1.2 Psychophysical needs 1.2 Higher Order Needs 1.2.1 Psychosocial needs 1.2.2 Intrapersonal-Interpersonal needs 2. What is the psychopathophysiology of malignant lymphoma? 3. What are the identified nursing problems? 4. What Clinical Caritas Processes were implemented in the nursing care of the patient? 5. What are the evaluations observed? Significance of the Study Patients with malignant lymphoma and their families. The study will be beneficial to cancer patients, especially the case presented in this study, since it enhances the nursing care provided because of the integration of Jean Watsons theory. The nursing interventions that were provided involved the humanistic aspect of nursing care. In this way, the patient would be able to feel as a human person who needs to be cared for in a way that his totality as a person is respected and accepted. Nurse Practitioners. This case study will provide staff nurses with information on the clinical caritas processes of Jean Watsons theory and help them understand its nature and application to clinical nursing practice. This will serve as an example on how to utilize the theory in providing caring relationships to the patients that they are serving. Nurse Educators.The study would also serve as a guide to clinical nursing intructors in making teaching plans and instructional materials. It is

important that they will be able to integrate caring with clinical nursing practice when teaching the student nurses because this will serve as a foundation for the student nurses to become caring professionals when they soon will be caring for patients in the future. Future Researchers. The study will serve as a reference and guide to future nurse researchers who are interested in using Jean Watsons Theory of Caring in their research and case studies. Research Methodology Research Design The researcher used a qualitative approach, by conducting a case study. A case study is an intensive analysis of an individual stressing human needs relative to the context to explain a complex phenomenon. In this study, it focused on the utilization of clinical caritas processes in the care of the patient with malignant lymphoma. Research Locale The researcher conducted the study in the Vicente Sotto Memorial Medical Center, a government-owned, 800-bed capacity tertiary hospital located on B. Rodriguez Street, Cebu City. The hospital has its own laboratory, blood bank, radiology and imaging departments for X-ray and computed tomography (CT) scan services, renal department, intensive care unit (neonatal, pedia, & adult), operating room, post-anesthesia care unit, cardiac catheterizaton laboratory, delivery room, pharmacy, out-patient department, physical

rehabilitation department, trauma center, cancer clinic, and the 12 different hospital wards each classified according to specialization.

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The researcher was assigned at Ward 3B, (Pay Ward) of the Vicente Sotto Memorial Medical Center (VSMMC) which had 10 patient rooms, five of which are semiprivate that can accommodate three patients each. The other five rooms are private with single beds and are fully airconditioned with television sets and restrooms. This ward also has a separate room for post-kidney transplant patients. Various patients with medical and surgical conditions, mostly members of PhilHealth, were served. Research Instrument This study utilized a researcher-made patient assessment tool based on the clinical caritas processes of Jean Watson combined with Gordons Functional Health Patterns and Physical Assessment. It is categorized according to Watsons Order of Needs. Under the Lower Order Needs are the Biophysical needs which include general information, health history, and physical assessment, and the Psychosocial Needs which utilized the Gordon Functional Health Patterns, specifically the Activity-Exercise pattern and Sexuality-Sexual Pattern. Under the Higher Order Needs are the Psychosocial needs which

comprise the stress, relationships, and role functioning and the last Order of Needs is the Intrapersonal- Interpersonal Needs which focus on the need for selfactualization. Data Gathering Procedures After enrolling in the intensive practicum program, the formulation and approval of the concept paper followed. After the approval of the title, the researcher proceeded with the acquisition of the request letter from the Graduate School office for submission to the respective adviser and to the chief nurse of

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the Vicente Sotto Memorial Medical Center for approval to conduct an Intensive Practicum in the said medical institution. During the actual practicum at the hospital, orientation was done involving the physical set-up of the hospital as well as the staff nurses and personnel assigned in the ward, after which the researcher identified the patient based on the inclusion and exclusion criteria of the study. After the patient had been identified, assessment was performed using the physical assessment tool. Then planning was formulated and interventions were rendered to the patient based on the clinical caritas processes of Jean Watson. Thorough evaluation was done by the researcher in order to determine the level of care rendered. The researcher completed fifty hours of exposure in Ward 3B (Pay Ward). Inclusive dates of clinical exposure were from July 5-10, 2011.

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Chapter 2 Results and Discussion This chapter features the data collected in the assessment of the patient utilizing the physical assessment, identified nursing problems, plan of care, and nursing actions based on Watsons Ordering of Needs with the utilization of Clinical Caritas, and the Self Acceptance Assessment tool. Patients Profile This is a case of Mr. N.T., male, single, 44 years old, Filipino, Roman Catholic, born last October 11, 1966 in Cebu City, Cebu. Patient was admitted last May 31, 2011 at 3:10pm for complaints of generalized body malaise, anorexia, and vomiting. Patient was brought to Ward 3B (Pay Ward) on the same day and was placed in Room 002. Patient was admitted to the Vicente Sotto Memorial Medical Center (VSMMC) for more than a month. A year prior to admission, patient verbalized that he fell out of a tree. He noted the swelling of his right foot without any presence of an open wound. He went to St. Vincent Hospital and was diagnosed as having malignant masses around his right leg. He was diagnosed with Malignant Lymphoma Diffuse B-Cell, status post Chemotherapy for 7 times. Last January 29, 2011 he was admitted at Perpetual Succour Hospital (PSH) for almost a month for his chemotherapy sessions. Three weeks prior to admission, the patient was admitted again at Perpetual Succour Hospital due to generalized body malaise, anorexia, and
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vomiting. Due to financial constraints, the patients family opted to transfer him to the Vicente Sotto Memorial Medical Center (VSMMC) for continuity of medical care. When he was eighteen years old, he had meningitis and was admitted at the Cebu Doctors University Hospital (CDUH). He was treated by the medical professionals; however, his speech and writing skills were impaired. He could only utter incomprehensible sounds as a result of his previous disease condition. He also has difficulty in writing because of decreased muscular coordination due to meningitis. He has no known allergies to food and drugs. He is non-asthmatic, has no history of cardiac illness, is non-diabetic and non-hypertensive. He was diagnosed with Rheumatoid Arthritis and had undergone pharmacologic management with corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs). Biophysical Profile The patient was seen lying in bed, in supine, moderate high back rest position, was awake, coherent, responsive and afebrile. He has a Glasgow Coma Scale of 15 (E = 4, V = 5, M = 6). He has a nasogastric tube, French 16, in place and clamped. The patient is hooked to oxygen inhalation of 2 liters per minute via nasal cannula. With ongoing intravenous fluid at the right arm, Plain Normal Saline Solution (PNSS) 1 Liter at 30 drops per minute, is infusing well, nonphlebitic and non-infiltrated. On inspection, the patients head is normocephalic, the face is symmetric, hair color is black and dull. There are no gross structural deformities. Upon

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palpation, hair texture is rough and dry but resilient, with presence of moderate amounts of dandruff flakes on scalp. No presence of edema, tenderness and bruises noted on scalp and face. The eyes are symmetric, globes are protruded, no signs of scaling, secretions and erythema on the lid margins are noted and there is no periorbital edema. The sclera is white in color, palpebral conjuctiva is pale pink in color and moist. Pupillary size is 2 millimeters for both eyes, both are brisk in reaction, demonstrate accommodation and are isocoric. Vision is adequate, patient is neither farsighted nor nearsighted. The ears are symmetric and in line with the inner canthus of the eye. There is no presence of edema, bruises and tenderness on palpation. Hearing is adequate and the patient was able to hear a whispered voice at a distance of 2-3 feet away. On inspection, the chest is normal and symmetric in expansion. Anterolateral diameter is larger than the posterior-anterior diameter. No signs of edema, hematoma and bruises are noted. Fine crackles are heard on

auscultation on both lower lung fields. However, the patient is bradypneic at a rate of 10-11 cyles per minute. There is also presence of dyspnea and productive cough with moderate amount of yellowish, sticky mucus secretions. The apical pulse is regular in rhythm and has a rate of 68 beats per minute. There is no chest pain noted. Nail beds are pale, but there is no clubbing. Capillary refill time is three seconds. The patients abdomen is symmetric, soft and non-tender. Prior to admission, he was on full oral diet at home. Oral fluid intake at home was usually

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six (6) glasses per day. His mouth and tongue are moist but oral mucous membranes are pale pink in color. There is evident anorexia due to his medical condition. The patient has no dentures or tooth cavities present. Prior to his multiple hospital admissions for the treatment of his condition, the patient verbalized that he had a regular dietary food intake like scrambled eggs and hotdog with hot soup in the morning or sometimes bread and hot chocolate. In the afternoon he had vegetables, chicken, and meat, and in the evening he usually ate the same as his lunch. The patient usually ate 1 cups of rice, 1-2 pieces of chicken or meat, and a bowl of soup. He had no restrictions or preferences with his dietary intake and he did not experience any difficulty in eating, swallowing and chewing. The food that the patient normally eats could no longer be possible due to his illness. Weight loss was manifested by the patient. He had a total weight loss of five kilograms, from a weight of 60 kilograms down to 55 kilograms. During admission, the patient had a nasogastric tube(NGT) which served as passage way of his food, water, and medications. This was done since the patient had a decreased appetite and had difficulty in swallowing. In the hospital, he was on blenderized feeding to meet his caloric requirements. His diet specification is as follows: 1,200 kilocalories in 1,000 ml in 6 divided feedings, composed of 35 percent proteins of high biologic value, 55 percent carbohydrates and 10 percent fats plus one egg white every other feeding. Prior to his diagnosis of malignant lymphoma, the patient defecated three times a week with a normal consistency of stool. The amount of stool was moderate and was brown in color. In the hospital, he defecated at least once a

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week, with moderate amounts of yellow to brown stool of a semisolid to watery consistency. The patient verbalized that he had a normal voiding pattern at

home, with four to six voiding times and amounts of about one and a half cup per voiding. Urine color was from light yellow to amber and the patient did not experience any pain before, during and after urination. During his hospital stay he voided about six to nine times per day into his diaper. The urine color was concentrated yellow to orange without any pain upon and after urination. The general skin appearance was pale but with elastic skin turgor especially on the upper part of the body. However, there was evident Grade I pitting edema on the posterior portion of his lower right leg and foot. On the lateral portion of his right foot, there was an open wound measuring approximately five (5) centimeters x four (4) centimeters which was reddish and moist. Some parts of its edges showed signs of necrosis. There was also serosanguinous and purulent drainage from the wound. He had no bedsores upon inspection. The patient has been bedridden since October of last year after he fell from a tree and his lower right leg and right foot swelled. He currently needs assistance in eating, dressing, grooming, toileting, bathing, transferring and in walking due to his condition. He uses a wheelchair for transport since he is having generalized body weakness and has an unsteady gait because of the swelling in his right leg and foot. Inspection showed that the patients genitals are normal; no lesions and gross deformities are present. There is a moderate amount of pubic hair and no nits are present. The scrotal sac color is darker compared to other parts of the

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body. Upon palpation, there is no edema or tenderness. The right testes is slightly larger than the left. He verbalizes complaints of dull, throbbing pain in his lower extremities especially in the wound in his right foot. His pain score is five out of 10 on the numeric rating scale. The pain is usually made worse by pressure, movement, positioning, and dressing changes. Prior to the diagnosis of his condition, the patient stated that his normal sleeping time was around eight oclock in the evening and he woke up at five oclock in the morning. He religiously took a nap in the afternoon at around one oclock up to three oclock. The patient did not experience any difficulty falling asleep at night especially if he had a soft pillow between his legs. During admission, there was a change in sleeping pattern as verbalized by the patient. He had an abnormal sleeping pattern due to recurrent productive cough, pain on his right foot, and difficulty in breathing.

Psychophysical Profile Prior to his diagnosis of malignant lymphoma, the patient managed a small convenience store. He had an impaired speech and writing, due to his previous illness, but he was able to take care of himself with regards to bathing, grooming, toileting, and even ambulating. He exercised everyday especially his speech and hand writing skills. The patient had been unemployed since graduation from college.

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During admission, the patients significant other performed a passive range of motion exercises to exercise his muscles and joints. He was turned to his side every two hours and needed assistance in sitting up in bed with oxygen at two liters/minute. The patient complained of difficulty in breathing, especially when exerting effort. Before his diagnosed illness, the patient had never been with a woman and never got the chance to love due to the onset of his illness when he was eighteen years old. During admission, he verbalized that the only true love that he got was the love of his family. His family was very supportive not only financially but also physically, mentally, and spiritually. Psychosocial Profile Prior to his diagnosis of malignant lymphoma, the patient already had difficulty in speaking and writing. Neither glasses nor hearing aid was used. During admission, the patient used a sheet of paper with the letters of the alphabet as his mode of communication. Prior to admission, the patient was dependent on his older sister and brother who supported him all through these years. He was unemployed. When he had problems, he usually asked for help from his older brother. During admission, the patient was very dependent on his older brother and sister. He could not fight stress without them. Prior to admission, the patient used Bisaya and English as his spoken languages. He expressed him self through speaking with gestures. He was living all alone in Moalboal. He sought help from his older brother who lives in Cebu City. He was the middle child of five siblings. His older sister had a lending

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business and his brother worked at the University of San Jose Recoletos. His two younger sisters were married with kids. The patient was a graduate of Bachelor of Science in Accountancy but was not able to take up the licensure exam. Despite the fact that he had meningitis when he was eighteen years old, still he was able to continue his study. Intrapersonal-Interpersonal Profile Prior to his multiple hospitalizations for the treatment of his condition, the patient described his health as fair. According to the patient, hospitalization was one way of treating illness by following the prescribed treatment. During admission, the patient verbalized his health as poor. He had body malaise, weight loss, and poor self care. Prior to his multiple hospitalizations for the treatment of his condition, the patient was concerned about his speaking and writing skills. He added that it was very important especially when dealing with others. During admission, the patient was concerned about his hair loss, lowered immune system, and the wound in his right foot. He described himself as disabled and incapable of doing things the way they were. The patient is a Roman Catholic and believes in Almighty God. He verbalized the importance of faith in God, hope, and love. During admission, the patients faith strengthened and he prayed that he would be cured of his illness. Psychopathophysiology of Malignant Lymphoma According to Smeltzer (2004), the exact etiology of malignant lymphoma is still unknown. There are risk factors such as having a family history of cancer, a history of meningitis and rheumatoid arthritis, which contribute to the

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development of the disease. The growth of malignant lymphoma is also affected through exposure to precipitating factors such as chemicals, radiation and viruses. There is mutation of the proto-oncogenes and/or disruption of the tumor suppressor genes in the body which causes cell transformation. Cellular transformation can cause release of cytokines which cause accumulation of inflammatory cells; the transformed cell also causes release of growth factors which are responsible for the proliferation of malignant and non-malignant lymph cells. The increase of malignant and non-malignant lymph cells causes a catabolic effect of the tumor on the bodys metabolism and selective trapping of nutrients by rapidly growing tumor cells. These tumor cells secrete calaetin which act on the satiety center in the hypothalamus. In response to this the macrophage cells secrete the tumor necrosis factor (TNF) which can also affect the bodys satiety center and suppress the release of lipoprotein lipase which is responsible for fatty acids not released from lipoproteins. These processes contribute to cachexia, body weakness and unintentional weight loss of ten (10) percent. The tumor necrosis factor also causes the release of endogenous pyrogens that act on the thermoregulation center in the hypothalamus which is the cause of fever and night sweats (Timby & Smith, 2005). The proliferation of the malignant and non-malignant lymph cells causes skeletal involvement which results in bone pain and suppression of

hematopoeisis. Suppression of hematopoeisis results in decreased white blood cells, red blood cells and platelets which in turn cause anemia. There is also impaired T-lymphocyte function which leads to increased susceptibility to

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opportunistic infections. This increased susceptibility to infections is often manifested by febrile episodes. The presence of pus and discoloration around the wound area is a result of the infectious process brought about by poor hygiene and the presence of IV line. (Black & Hawks, 2005).

Agent: Unknown

Patient with Malignant Lymphoma Susceptible Host: Middle age Environment: Exposure to History of Cancer, Meningitis precipitating factors (virus) and Rheumatoid Arthritis

Mutation of proto-oncogenes/disruption of tumor suppressor genes Cell transformation Transformed cell release growth factors Proliferation of malignant and non-malignant lymph cells

Catabolic effect of tumor on body metabolism and selective trapping of nutrients by rapidly growing tumor cells Cachexia, weakness, unintentional wt. loss (10 %)

Acts on hypothalamus Macrophages secrete TNF Fever, night sweats

Skeletal involvement Suppression of hematopoeisis Decreased WBC, RBC, platelets Anemia Impaired Tlymphocyte function Increased susceptibility to opportunistic infections Fever, presence of pus and discoloration around the wound area

Pallor, body malaise, & immunosuppression

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Figure 2. Schematic Diagram of the Psychopathophysiology of Malignant Lymphoma.

Identified Patient Needs The table below shows all the nursing problems presented as nursing diagnoses grouped according to the ordering of needs. Table 2. Summary of the Identified Nursing Problems
Component Nursing Problems a. Ineffective airway clearance related to presence of excessive mucus secretions at the tracheobronchial tree b. Hyperthermia related to increased metabolic rate due to illness 1. Biophysical Needs c. Altered nutrition less than body requirements related to consequences of chemotherapy and surgery as evidenced by altered taste sensation d. Risk for infection related to inadequate secondary defenses (immunosuppresion) as a result of chemotherapy 2.Psychophysical NeedsNeeds a. Chronic pain related to chronic stimulation of nerve endings on the right leg and foot due to malignant and inflammatory process secondary to disease process b. Impaired physical mobility related to limitations in movement, discomfort and decreased physical strength

LOWER ORDER NEEDS

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c. Activity intolerance related to imbalance between oxygen supply and demand d. Impaired skin integrity related to disruption of skin and underlying tissues and altered skin turgor (presence of edema) at the right lower leg and foot 3. Psychosocial NeedsNeeds HIGHER ORDER NEEDS a. Self care deficit (Eating, Grooming, Toileting) related to generalized body weakness and discomfort on the lower right leg a. Situational low self esteem related to functional impairments and loss of health status b. Risk for spiritual distress related to ovewhelming fear of impending death.

4. Intrapersonal-....Interpe rsonal ..........Needs

Documentation of Clinical Caritas Processes Biophysical Needs Table 3. Ineffective Airway Clearance
Nursing Diagnosis: Ineffective airway clearance related to presence of excessive mucus secretions at the tracheobronchial tree Subjective cues: cge ako ubo as verbalized by the patient Objective cues: received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; recurrent productive cough noted, characterized by yellowish mucus secretions. Plan of Care Nursing Interventions Rationale Clinical Caritas After 8 hours of Monitored respiratory Tachypnea, use of Practice of lovingsystematic nursing rate, rhythm, depth; accessory muscles, kindness and intervention, the note presence of presence of cyanosis, equanimity within patient will be able to pallor/cyanosis. and changes in sputum context of caring maintain a patent suggest developing consciousness. airway and respiratory secretions will be distress/pulmonary Being authentically readily expectorated. edema (Sandra, 2005). present in enabling and sustaining the deep Auscultated lungs, Airway obstruction/ belief system and noting stridor, Respiratory distress subjective life world of wheezing/crackles, can occur very quickly self and one-being diminished breath or may be delayed cared for. sounds. (Sandra, 2005). Developing and Elevated head of bed. Promotes optimal lung sustaining a helpingexpansion/respiratory trusting, authentic function (Sandra, caring relationship. 2005).

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Nurses should engage in genuine teachinglearning experience that will attend to the curiosity of being and meaning attempting to stay within the others frame of reference. Nurses should create a healing environment at all levels (physical as well as non-physical, subtle environment of energy and consciousness, whereby it can potentiate wholeness, beauty, comfort, dignity and peace. Assistance in the basic needs of patient.

Encouraged coughing/deepbreathing exercises and frequent position changes. Suctioned necessary) extreme maintaining technique. (if with care, sterile

Promotes lung expansion, mobilization and drainage of secretions (Sandra, 2005). Helps to maintain clear airway, but should be done cautiously because of mucosal edema and inflammation. Sterile technique reduces risk of infection (Sandra, 2005). Increasing hoarseness/decreased ability to swallow suggests increasing tracheal edema and may indicate need for prompt intubation (Sandra, 2005). Oxygen corrects hypoxemia/acidosis. Humidity decreases drying of respiratory tract and reduces viscosity of sputum (Sandra, 2005). Baseline is essential for further assessment of respiratory status and as a guide to treatment (Sandra, 2005). Chest physiotherapy drains dependent areas of the lung, while incentive spirometry may be done to improve lung expansion, thereby promoting respiratory function and reducing atelectasis (Sandra, 2005).

Promoted voice rest but assessed ability to speak and/or swallow oral secretions periodically.

Administered humidified oxygen via appropriate mode, e.g. nasal cannula.

Monitored/Graphed pulse oximetry.

Provided/Assisted with chest physiotherapy and incentive spirometry.

Evaluation: After 4 hours of nursing interventions, the patient will be able to maintain airway patency and expectorate secretions.

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Table 4. Hyperthermia
Nursing Diagnosis: Hyperthermia related to increased metabolic rate due to illness Subjective cues: Init ko as verbalized by the patient. Objective cues: received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; warm to touch, flushed skin noted, with body temperature of 38.4 degrees Centigrade. Plan of Care Nursing Interventions Rationale Clinical Caritas After 1 hour of Monitored patient Room Practice of lovingsystematic nursing temperature. temperature/number of kindness and intervention, the blankets should be equanimity within patient will be able altered to maintain context of caring to demonstrate near-normal body consciousness. temperature within temperature (Sandra, normal range. 2005). Being authentically present in enabling and Monitored May help reduce fever sustaining the deep environmental (Sandra, 2005). belief system and temperature; limited or subjective life world of added linens as self and one-being indicated. cared for. Provided supplemental oxygen. To offset increased oxygen demands and consumption (Sandra, 2005). To support circulating volume and tissue perfusion (Sandra, 2005). Used to reduce fever by its central action on the hypothalamus (Sandra, 2005). Nurses should engage in genuine teachinglearning experience that will attend to the curiosity of being and meaning attempting to stay within the others frame of reference.

Increased fluid intake to replace fluids and electrolytes. Provided tepid sponge baths; avoided use of alcohol.

Nurses should create a healing environment at all levels (physical as well as non-physical, subtle environment of energy and Administered Used to reduce fever consciousness, whereby antipyretics, e.g. (Sandra, 2005). it can potentiate the acetaminophen. wholeness, beauty, comfort, dignity and peace. Evaluation: After 1 hour of nursing interventions, the patient will be able to maintain core temperature within normal range.

Table 5. Altered Nutrition: Less than Body Requirements

Nursing Diagnosis: Altered nutrition less than body requirements related to consequences of chemotherapy, radiation, and surgery as evidenced by altered taste sensation. Subjective cues: dli au ko ganahan mokaon as verbalized by the patient. Objective cues: received patient lying in bed with PNSS iL regulated @ 20 gtts/minute infusing well @ right arm; hair loss noted, unable to utter words/inability to speak clearly; patient used pen and paper to communicate; hesitant to share his lived experiences noted; decreased social interaction observed. Plan of Care Nursing Interventions Rationale Clinical Caritas

26
After 2-3 days of nursing intervention, the patient will be able to recognize changes in selfconcept in an accurate manner without negating self-esteem. Monitored daily food intake and kept food dietary as indicated. Assessed patient for pallor, and weight gain or loss. Identifies nutritional strengths/ deficiencies (Huttel, 2005). Helps in identification of protein-calorie malnutrition, especially when weight measurements are less than normal (Huttel, 2005). Can trigger nausea/vomiting response (Huttel, 2005). Practice of kindness equanimity context of consciousness. lovingand within caring

Controlled environmental factors (e.g. strong odors or noise). Avoided over sweet, fatty, or spicy foods. Encouraged use of relaxation techniques, visualization and guided imagery.

Being authentically present in enabling and sustaining the deep belief system and subjective life world of self and one-being cared for. Developing and sustaining a helpingtrusting, authentic caring relationship. Nurses should engage in genuine teachinglearning experience that will attend to the curiosity of being and meaning attempting to stay within the others frame of reference. Nurses should create a healing environment at all levels (physical as well as non-physical, subtle environment of energy and consciousness, whereby it can potentiate wholeness, beauty, comfort, dignity and peace.

May prevent onset or reduce severity of nausea, decrease anorexia, and enable patient to increase intake (Huttel, 2005). To meet nutritional needs of the patient (Huttel, 2005). To avoid abdominal cramps or discomfort (Huttel, 2005).

Maintained nasogastric tube feeding for enteric feeding as prescribed. Made sure that blenderized feeding was warm before administering it.

Assistance in the basic needs of patient. Evaluation: After 3 days of nursing interventions, patient was able to participate in specific interventions to stimulate appetite/increase dietary intake.

Table 6. Risk for Infection

Nursing Diagnosis: Risk for infection related to inadequate secondary defenses (immunosuppresion) as a result of chemotherapy Subjective cues: not applicable; this is a risk nursing diagnosis Objective cues: received patient lying in bed with PNSS iL regulated @ 20 gtts/minute infusing well @ right arm; weakness noted, unable to utter words/inability to speak clearly, patient used pen and paper to communicate, pitting pedal edema with +1 grade noted, weakness of the lower extremities noted. Patient underwent several chemotherapy sessions. Plan of Care Nursing Interventions Rationale Clinical Caritas After 2-3 days of Promoted good hand- Protects patient from Practice of loving-

27
nursing intervention, the patient will be able to demonstrate techniques, lifestyle changes to promote safe environment. washing procedures. Limited visitors who may have infections. Placed in reverse isolation as indicated. Emphasized hygiene. personal sources of infection, such as visitors and staff who may have URI (Timby & Smith, 2005). Limits potential sources of infection (Timby & Smith, 2005). Temperature elevation may occur because of various factors, e.g. chemotherapy, disease process, or infection (Timby & Smith, 2005). Reduces pressure and irritation to tissues and may prevent skin breakdown which is potential site for bacterial growth (Timby & Smith, 2005). Limits fatigue, yet encourages sufficient movement to prevent stasis complications, e.g., pneumonia, decubitus, and thrombus formation (Timby & Smith, 2005). Development of stomatitis increases risk of infection (Timby & Smith, 2005). Stressed importance of good oral hygiene. Reduces risk of contamination, limits portal of entry for infectious agents (Timby & Smith, 2005). Monitoring status of myelosuppression is important for preventing further complications e.g. infection, anemia, or hemorrhage (Timby & Smith, 2005). May be used to treat identified infection or given prophylactically in kindness equanimity context of consciousness. and within caring

Monitored vital signs especially the temperature.

Being authentically present in enabling and sustaining the deep belief system and subjective life world of self and one being cared for. Developing and sustaining a helpingtrusting, authentic caring relationship. Nurses should engage in genuine teachinglearning experience that will attend to the curiosity of being and meaning attempting to stay within the others frame of reference. Nurses should create a healing environment at all levels (physical as well as non-physical, subtle environment of energy and consciousness, whereby it can potentiate wholeness, beauty, comfort, dignity and peace. Assistance in the basic needs of patient.

Repositioned frequently; kept linens dry.

Promoted adequate rest/exercise periods.

Avoided/limited invasive procedures. Adhered to aseptic techniques.

Monitored CBC with differential WBC and granulocyte and platelet count as indicated.

28
immunocompromised Administered patient (Timby & antibiotics (Tazocin) as Smith, 2005). prescribed. Evaluation: After 3 days of nursing interventions, the patient was able to participate in interventions to prevent/reduce risk for infection.

Psychophysical Needs Table 7. Chronic Pain

Nursing Diagnosis: Chronic pain related to chronic stimulation of nerve endings at the lower right foot Subjective cues: Sakit tiil as verbalized by the patient. Objective cues: Received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; facial grimaces noted; guarded movements observed; with pain score of 5 ( 0 as the lowest and 10 as the highest). Plan of Care Nursing Interventions Rationale Clinical Caritas After 2 hours of Determined pain Information provides Practice of lovingsystematic nursing history, e.g. location of baseline data to kindness and intervention, the pain, frequency, evaluate need for equanimity within patient will be able duration, and intensity effectiveness of context of caring to report maximal (0-10 scale), and relief interventions consciousness. pain relief/control. measures used. (Doenges, M. et al, 2008). Being authentically present in enabling and Provided basic comfort Promotes relaxation sustaining the deep measures and helps refocus belief system and (repositioning, attention (Doenges, M. subjective life world of backrub) and et al, 2008). self and one being cared diversional activities for. (e.g. music, television). Developing and Enables patient to sustaining a helpingEncouraged use of participate actively in trusting, authentic caring stress management nondrug treatment of relationship. skills (e.g. relaxation pain and enhances techniques, sense of control Nurses should engage visualization, guided (Doenges, M. et al, in genuine teachingimagery), laughter, 2008). learning experience that music, and therapeutic will attend to the touch. curiosity of being and Goal is maximum pain meaning attempting to Evaluated pain control (Doenges, M. stay within the others relief/control at regular et al, 2008). frame of reference. intervals. Adjusted medication regimen as Nurses should create a necessary. healing environment at An organized plan all levels (physical as Developed beginning with the well as non-physical, individualized pain simplest dosage subtle environment of management plan with schedules and least energy and the patient and invasive modalities consciousness, whereby physician. improves chance for it can potentiate

29
pain control (Doenges, M. et al, 2008). wholeness, beauty, comfort, dignity and peace.

Useful for mild to Administered moderate pain Assistance in the basic analgesics as indicated (Doenges, M. et al, needs of patient. (e.g. Tramadol). 2008). Evaluation: After 2 hours of nursing intervention, the patient verbalized methods that caused alleviation of pain and facial grimacing has decreased.

Table 8. Impaired Physical Mobility

Nursing Diagnosis: Impaired physical mobility related to limitations in movement, discomfort and decreased physical strength Subjective cues: Lisud lihok as verbalized by the patient. Objective cues: received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; guarded movements observed; unable to move from side to side and needed assistance; body malaise noted. Plan of Care Nursing Interventions Rationale Clinical Caritas After 2-3 days of Maintained proper Promotes functional Practice of lovingsystematic nursing body alignment with positioning of kindness and intervention, the supports or splints. extremities and equanimity within patient will be able prevents contractures, context of caring to verbalize and which are more likely consciousness. demonstrate over joints (Doenges, willingness to M. et al, 2008). Being authentically participate in present in enabling and activities and Noted circulation, Edema may sustaining the deep verbalize proper motion, and sensation compromise circulation belief system and exercises of the of digits frequently. to extremities subjective life world of lower leg. potentiating tissue self and one being cared necrosis/development for. of contractures (Doenges, M. et al, Developing and 2008). sustaining a helpingtrusting, authentic caring Prevents progressive relationship. Performed ROM tightening scar tissue exercise consistently, and contractures; Nurses should engage initially passive, then enhances maintenance in genuine teachingactive. of muscle/joint learning experience that functioning and will attend to the reduces loss of curiosity of being and calcium from the bone meaning attempting to (Doenges, M. et al, stay within the others 2008). frame of reference. Promotes safe ambulation (Doenges, M. et al, 2008). Enables family/SO to be active in patient care and provides Nurses should create a healing environment at all levels (physical as well as non-physical, subtle environment of energy and consciousness, whereby it can potentiate

Instructed and assisted with mobility aids, e.g. wheelchair as appropriate. Encouraged family/SO

30
support and assistance with ROM exercises. more constant/consistent therapy (Doenges, M. et al, 2008). wholeness, beauty, comfort, dignity and peace. Assistance in the basic needs of patient. Evaluation: After 2-3 days of nursing intervention, the goal was met through demonstrating proper exercises for the lower extremities and he also did activities of daily living without discomfort.

Table 9. Activity Intolerance

Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by weakness and fatigue. Subjective cues: Kapoy as verbalized by the patient. Objective cues: Received patient lying in bed with PNSS iL regulated @ 20 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; weakness noted, unable to tolerate/perform on the ADL. Plan of Care Nursing Interventions Rationale Clinical Caritas After 4 hours of Assessed patients Influences choice of Being authentically systematic nursing ability to perform interventions/ needed present in enabling and intervention, the normal tasks, noting assistance (Timby & sustaining the deep patient will be able reports of weakness, Smith, 2005). belief system and to participate fatigue, and difficulty subjective life world of willingly in the accomplishing tasks. self and one being cared activities and for. increase activity Monitored BP, pulse, Cardiopulmonary tolerance (including respirations during and manifestations result Creative use of self. ADLs). after activity. from attempts by the heart and lungs to Nurses should engage bring adequate amount in genuine teachingof oxygen to the learning experience that tissues (Timby & will attend to the Smith, 2005). curiosity of being and meaning attempting to Encouraged bed rest, Enhances rest to lower stay within the others quiet atmosphere. bodys oxygen frame of reference. requirements and reduces strain on the Nurses should create a heart and lungs (Timby healing environment at & Smith, 2005). all levels (physical as well as non-physical, Enhances lung subtle environment of Elevated head of the expansion to maximize energy and bed as tolerated. oxygenation for cellular consciousness, whereby uptake (Timby & it can potentiate Smith, 2005). wholeness, beauty, comfort, dignity and Postural hypotension peace. or cerebral hypoxia may cause dizziness, Assistance in the basic Encouraged patient to fainting, and increased needs of patient. change position slowly risk of injury (Timby & and monitored him for Smith, 2005). dizziness. While help may be

31
necessary, self-esteem is enhanced when patient does some things for self (Timby & Smith, 2005). Identifies deficiencies in RBC components affecting oxygen transport, and treatment needs (Doenges, 2004). Maximizing oxygen transport to tissues improves ability to function (Timby & Smith, 2005). This is to prevent aspiration (Timby & Smith, 2005).

Provided assistance with activities/ambulation as necessary.

Monitored laboratory studies, e.g. HB/Hct and RBC count.

Provided supplemental oxygen as indicated.

Administered blenderized feeding via NGT as ordered. Evaluation: After 4 hours of nursing intervention, the goal was met, the patient demonstrated increase in activity tolerance and participated willingly in necessary or desired activities.

Table 10. Impaired Skin Integrity

Nursing Diagnosis: Impaired Skin Integrity related to disruption of skin and underlying tissues and altered skin turgor (presence of edema) at the right lower leg and foot Subjective cues: No verbal cues. Objective cues: Received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; pitting pedal edema with +1 grade noted, weakness of the lower extremities noted. Plan of Care Nursing Interventions Rationale Clinical Caritas After 3 days of Reinforced initial Protects wound from Practice of lovingnursing intervention, dressing/change as mechanical injury and kindness and the patient will be indicated. Used strict contamination. equanimity within able to display aseptic techniques. Prevents accumulation context of caring improvement in of fluids that may cause consciousness. wound healing. excoriation (Doenges, M. et al, 2008). Being authentically present in enabling and Reduces risk of skin sustaining the deep Gently removed tape trauma and disruption belief system and (in direction of hair of wound (Doenges, M. subjective life world of growth) and dressings et al, 2008). self and one being when changing. cared for. Early recognition of Inspected wound delayed Developing and regularly; noting healing/developing sustaining a helpingcharacteristics and complications may trusting, authentic integrity. prevent a more serious caring relationship. situation (Doenges, M. et al, 2008). Nurses should engage

32
in genuine teachinglearning experience that will attend to the curiosity of being and meaning attempting to stay within the others frame of reference. Assistance in the basic needs of patient.

Assessed amount and characteristics of drainage.

Decreasing drainage suggests evolution of healing process (Doenges, M. et al, 2008). Promotes venous return and limits edema formation. Note: Elevation in presence of venous insufficiency may be detrimental (Doenges, M. et al, 2008). Prevents contamination of wound (Doenges, M. et al, 2008). Aids in drying wound and facilitates healing processes (Doenges, M. et al, 2008). Reduces skin contaminants; aids in removal of exudates (Doenges, M. et al, 2008). Removes infectious exudates/necrotic tissue to promote healing (Doenges, M. et al, 2008).

Elevated wound area as appropriate.

Cautioned patient not to touch the wound.

Left wound open to air as soon as possible. Cleansed skin surface with dilute hydrogen peroxide, or running water. Irrigated assisted debridement needed. wound; with as

Vacuum dressing may be used to hasten healing in large, Monitored and draining wound/fistula, maintained specialty to increase patient dressings, e.g. guava comfort, and to reduce decoction frequency of dressing changes (Doenges, M. et al, 2008). Evaluation: After 3 days of nursing intervention, the patient was able to display improvement of wound healing as evidenced by several wounds which had dried up and minimized purulent discharge.

Psychosocial Needs Table 11. Self Care Deficit

Nursing Diagnosis: Self care deficit(eating, grooming, toileting) related to generalized body

33
weakness and discomfort on the lower right leg Subjective cues: No verbal cues Objective cues: Received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; body odor noted; poor hygiene noted; unable to take a bath for a month; dry skin noted, long fingernails noted. Plan of Care Nursing Interventions Rationale Clinical Caritas After 1 hour of Involved patient in Enhances sense of Practice of lovingnursing intervention, formulation of plan of control and aids in kindness and the patient will be care at level of ability. cooperation and equanimity within able to maintain development of context of caring good hygiene and independence consciousness. cooperate in the (Doenges, M. et al, procedure of proper 2008). Being authentically grooming. present in enabling and Encouraged self care. Doing for oneself sustaining the deep enhances feeling of belief system and self-worth. Failure can subjective life world of produce self and one being cared discouragement and for. depression (Doenges, M. et al, 2008). Developing and sustaining a helpingProvided and Modesty may lead to trusting, authentic caring promoted privacy, reluctance to relationship. including during participate in care or bathing/showering. perform activities in the Nurses should engage presence of others in genuine teaching(Doenges, M. et al, learning experience that 2008). will attend to the curiosity of being and Encouraged/Assisted Reduces risk of gum meaning attempting to with routine disease/tooth loss; stay within the others mouth/teeth care daily. promotes proper fitting frame of reference. of dentures (Doenges, M. et al, 2008). Nurses should create a healing environment at all levels (physical as well as non-physical, subtle environment of energy and consciousness, whereby it can potentiate wholeness, beauty, comfort, dignity and peace. Assistance in the basic needs of patient. Evaluation: After 1 hour of nursing intervention, the goal was met, the patient was able to maintain good hygiene and participate in the procedure of proper grooming.

Intra-Interpersonal Needs Table 12. Situational Low Self Esteem

Nursing Diagnosis: Situational low self esteem related to functional impairments and loss of

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health status Subjective cues: niubos ako pagtan-aw ako kaugalingon as verbalized by the patient. Objective cues: Received patient lying in bed with PNSS iL regulated @ 20 gtts/minute infusing well @ right arm; hair loss noted, unable to utter words/inability to speak clearly; patient used pen and paper to communicate; hesitant to share his lived experiences noted; decreased social interaction observed. Plan of Care Nursing Interventions Rationale Clinical Caritas After 2-3 days of Discussed with Aids in defining Practice of lovingnursing intervention, patient/SO how the concerns to begin kindness and the patient will be diagnosis and problem-solving equanimity within able to recognize treatment were process (Huttel, 2005). context of caring changes into self- affecting the patients consciousness. concept in accurate personallife/home and manner without work activities. Being authentically negating selfpresent in enabling and esteem. Reviewed anticipated Anticipatory guidance sustaining the deep side effects associated can help patient/SO belief system and with a particular begin the process of subjective life world of treatment, including adaptation to new state self and one being cared possible effects on and to prepare for side for. sexual activity and effects (Huttel, 2005). sense of Developing and attractiveness/desirabil sustaining a helpingity, e.g., alopecia, trusting, authentic caring disfiguring surgery. relationship. Told the patient that not all side effects Nurses should engage occur, and others may in genuine teachingbe learning experience that minimized/controlled. will attend to the May help reduce curiosity of being and Encouraged discussion problems that interfere meaning attempting to on problem-solving with acceptance of stay within the others concerns. treatment or stimulate frame of reference. progression of disease (Huttel, 2005). Nurses should create a healing environment at Acknowledged Validates reality of all levels (physical as difficulties patient may patients feelings and well as non-physical, be experiencing. Give gives permission to subtle environment of information that take whatever energy and counseling is often measures are consciousness, whereby necessary and necessary to cope with it can potentiate important in the what is happening wholeness, beauty, adaptation process. (Huttel, 2005). comfort, dignity and peace. Evaluated support Helps with planning for structures available to care while hospitalized Assistance in the basic and used by as well as after needs of patient. patient/SO. discharge (Huttel, 2005). Provided emotional support for patient/SO during diagnostic tests and treatment phase. Although some patients adapt/adjust to cancer effects or side effects of therapy, many need additional support during this

35
period (Huttel, 2005). Used touch during interactions, if acceptable to patient, and maintained eye contact. Affirmation of individuality and acceptance is important in reducing patients feelings of insecurity and self doubt (Huttel, 2005).

Evaluation: After 3 days of nursing intervention, the patient incorporated changes in self-concept in an accurate manner.

Table 13. Risk for Spiritual Distress

Nursing Diagnosis: Risk for spiritual distress related to ovewhelming fear of impending death. Subjective cues: Naay mga panahon nga daw hapit ko mawad-an og pagsalig sa Ginoo, as verbalized by the patient. Objective cues: Received patient lying in bed with PNSS iL regulated @ 20 gtts/minute infusing well @ right arm; lack of interest in any religious events observed, weakness noted, reluctant to share feelings with others regarding his spiritual distress, unable to utter words/inability to speak clearly, patient used pen and paper to communicate, weakness of the lower extremities noted. Plan of Care Nursing Interventions Rationale Clinical Caritas After 2-3 days of Communicated Client may view anger Practice of lovingnursing intervention, willingness to listen to at God and a religious kindness and the patient will be the clients feelings leader as a forbidden equanimity within able to verbalize regarding spiritual topic and may be context of caring acceptance of self distress. reluctant to initiate consciousness. as being worthy. discussion of spiritual conflicts (Lippincott Being authentically Williams & Wilkins, present in enabling and 2004). sustaining the deep belief system and Suggested contact with Other contacts may subjective life world of another spiritual help client to move self and one being cared support person, such toward a new spiritual for. as the hospital understanding chaplain. (Lippincott Williams & Developing and Wilkins, 2004). sustaining a helpingtrusting, authentic caring Explored client desires The client may value relationship. to engage in a religious prayer and spiritual practice or ritual and rituals highly Nurses should engage accommodate his or (Lippincott Williams & in genuine teachingher request to the Wilkins, 2004). learning experience that extent possible. will attend to the curiosity of being and Offered to pray with This can help to meet meaning attempting to him or her or to read clients spiritual needs stay within the others from a religious text. (Lippincott Williams & frame of reference. Wilkins, 2004). Nurses should create a healing environment at all levels (physical as well as non-physical, subtle environment of

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energy and consciousness, whereby it can potentiate wholeness, beauty, comfort, dignity and peace. Assistance in the basic needs of patient. Evaluation: After 3 days of nursing intervention, the patient was able to express feelings regarding beliefs.

Chapter 3 Conclusion and Recommendations Conclusion After going through this case study, the researcher concludes that caring is integral to nursing, especially in dealing with cancer patients who need palliative and supportive care. The theory encompasses many aspects of the human being in providing nursing care by utilizing the Clinical Caritas which are the core ideas of the theory. It covers the totality of the patient and uplifts the dignity of the patient by recognizing and accepting him as a unique individual with unique needs, patterning the nursing interventions according to his needs and instilling care by using the Clinical Caritas in every intervention rendered. Recommendations The researcher recommends the application of the Clinical Caritas of Jean Watson in the clinical practice especially in caring for patients who require

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palliative and supportive care. The researcher recommends integration of the theory in the curriculum to the students as it would inculcate values and help them develop the caring attitude which is essential when they will be dealing with patients. This could be used as a tool for reference since the application of Clinical Caritas of Jean Watsons Theory of Caring is not limited to these patients but the researcher would recommend the use patients. Bibliography Books Black, J. & Hawks, J. H.2005. Medical-surgical nursing: clinical management for positive outcomes. 7th Edition. Elsevier Saunders LTD. Independence Square West, Philadelphia. Burke K, et al.2003.Medical surgical nursing Education,Inc. care.New Jersey.Pearson of Clinical Caritas for a wide variety of

Carpenito-Moyet, Lynda Juall.2004.Nursing care plans & documentation: nursing diagnoses and collaborative problems.4th Edition.Lippincott Williams & Wilkins, 530 Walnut Street, Philadelphia PA 19106. Doenges, Marilynn E., et al.1997.Nursing care plans guidelines for individualzing patient care. F. A. Davis Company.Philadelphia. Doenges, Marillyn E., et al.2002.Nursing care plans.6th Edition.F.A. Davis Company.Philadelphia. Doenges, Marilynn E., et al.2004.Nurses pocket guide.9th Edition. F.A. Davis Company.Philadelphia. Hodgson, B. Et al. 2006.Saunders nursing drug handbook. Tampa, Florida. Elsevier Saunders. Luckmann, J.1997.Saunders manual of nursing care.Philadelphia.W.B. Saunders Company.

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Ray A. Hargrove-Huttel.2005.Medical-surgical nursing.4th Edition.Lippincott & Williams.Philadelphia. Rizzo, Donald C.2006.Fundamentals of anatomy and physiology.2nd Edition. Thompson Delmar Learning Corporation, % Maxwell Clifton Park, NY 12065. Sandra, Nettina.2005.Manual of nursing practice. 8th Edition.Lippincott Williams & Wilkins.Philadelphia. Smeltzer, Suzanne C.2004.Textbook of medical-surgical nursing.10thEdition. Lippincott Williams and Wilkins, 530 Walnut Street, Philadelphia PA 19106. Timby, Barbara K. & Smith, Nancy E.2005. Introductory medical-surgical nursing.8th Edition.J.B. Lippincott Company.New York.page 518. Internet Sources Basa G, et al.1977.Cancer epidemiology in the philippines.Retrieved on September 20, 2011 @ 8pm.http://seer.cancer.gov/ statfacts/html/hodg.html Cancerbackup. 2003.The lymphatic system.Retrieved on October 1, 2011 @ 11pm.http://www.newworldencyclopedia.org/entry/Lymphatic_system N. Piller and M.O. OConner, P.T. Hill.2002.Lymphatic system in the lymphoedema handbook. Retrieved on October 1, 2011 @ 11pm.http://www .lymphnotes.com/article.php/id/151/

Paula Ford-Martin.2005.Malignant lymphoma. Retrieved on September 20, 2011 @ 9pm.http://www.healthline.com/ galecontent/malignant-lymphoma Journals Glasera & Hsuab.Hodgkin's Disease in Asians: Incidence Patterns and Risk Factors in Population-Based Data.July 2001 Ohshima, et al. The world health organization classification of malignant lymphoma: incidence and clinical prognosis in HTLV-1-endemic area of Fukuoka.January 2002 Unpublished Materials Basubas, C. G. 2010.Watsons theory of human caring in the care of a patient with acute lymphocytic leukemia.Cebu City,Cebu Normal University Homecillo, C. 2009.Watsons theory in the care of a patient with diabetes mellitus type 2.Cebu City,Cebu Normal University

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Appendix

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Appendix A Transmital Letter

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Appendix B Adviser Designation

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Appendix C Daily Time Record

43

Appendix D Assessment Tool I. Gordons Functional Health Pattern Biophysical Profile A. Elimination Pattern B. Nutritional-Metabolic Pattern C. Sleep-Rest Pattern Psychophysical Profile A. Activity-Exercise Pattern B. Sexuality-Reproductive Pattern Psychosocial Profile A. Cognitive-Perceptual Pattern B. Coping-Stress Tolerance Pattern C. Role-Relationship Pattern Intrapersonal-Interpersonal Profile A. Health Perception-Health Management Pattern B. Self Perception-Self Concept Pattern C. Value-Belief Pattern II. Physical Assessment
Assessment Tool ADMISSION DATA Date: __________Time: __________

44 Patients Name: ___________________________________Date of Birth:___________ (Family) (First Name) (Middle Name) Address: _____________________________ Age: ____ Sex: ____ Room No.:________Height: _______cms. Weight: ________kgs. T:_____ P:______ R: ______ BP: _______ PRESENCE OF PAIN? YES ______ NO ______ Pain Score: _________ Condition on Arrival: ___Conscious ___Drowsy ___Unconscious How Admitted ___Ambulatory ___Wheelchair ___Stretcher ___Carried Accompanied by whom/relation: ____________________________________________ Attending Physician(s): ___________________________________________________ Admitting Diagnosis/Impression: _____________________________________________________________________ ______________________________________________________________________

ALLERGIES: ___ No known allergies ___ Unknown ___ Medications (specify):___________________ ___ Food (specify): ________________________ ___ Non-drug/Non-food:____________________

MEDICAL HISTORY: Check those that apply. ___Heart Disease ___Arthritis ___Asthma ___Kidney Disease ___Deaf ___Hepatitis ___Legally Blind ___HPN ___COPD ___Stroke ___Seizure ___SLE FAMILY HISTORY: ___Heart Disease ___Kidney Disease ___Legally Blind ___Stroke ___Arthritis ___Allergy ___HPN ___Seizure ___Asthma ___Hepatitis ___COPD ___SLE

___Emphysema ___Pneumonia ___PTB ___Mental Disorder ___Emphysema ___Blood Disorder ___PTB ___Mental Disorder

___Diabetes ___Cancer ___Others ___NONE ___Diabetes ___Cancer ___Others ___NON

PHYSICAL ASSESSMENT/ GORDONS FUNCTIONAL HEALTH PATTERN ASSESSMENT Biophysical Profile 1. Elimination Pattern Bowel a. Problem of:

___Diarrhea ___Constipation ___Irregular BM (specify) ________________________ ___None b. Change in color: ___No ___Yes (specify)_________________________ c. Presence of incontinence ___No ___Yes d. Presence of: ___Colostomy ___Ileostomy ___None e. Last Bowel Movement: (date) __________________ Urinary a. Appearance ___Clear ___Cloudy ___Others (specify) ______________

45 b. Change in color ___No ___Yes (specify)____________________________ c. Presence of ___Nocturia ___Frequency ___Dysuria ___Incontinence ___None ___Others (specify) __________ d. Adaptive aids ___Diapers/Pads Condom Catheter ___None Catheter type: ___Indwelling ___Indwelling ___Suprapubic Remarks: ______________________________________________________________________

2. Nutritional-Metabolic Pattern a. Type of Diet (at home): ___Full ___Soft ___Liquid ___other (specify)_____ b. Nutritional Approach: ___oral (hospital) ___Enteral (Specify type): ___NGT ___Ostomy Size Date last change:________________ Parenteral (Specify type): ___CVC ___PIC Weight: ___Gain, (How much?) ______kg ___Loss, (How much?) ______kg ___No change c. Diet Restriction ___None ___With (specify) ______________________ d. Fluid Restriction ___None ___With (specify) _______________________ Fluid Intake (amount/day): ____________________________ e. Oral Cavity Mouth/Tongue ___Moist ___Dry ___Coated ___Lesions Teeth ___Own ___Dentures (U/L) ___Others: __________ f. Presence of ___Nausea ___Anorexia ___Vomiting ___None ___Abnormal Blood sugar level: ___high ___low

3. Sleep-Rest Pattern a. Sleep Problem: ___Trouble falling asleep ___Early AM waking ___Sleep apnea ___No problem b. Do you feel rested after sleeping? ___Yes ___No c. Home Exercise Program: ___Yes ___No Comments: ______________________________________________________________________ Psychophysical Profile 4. Activity-Exercise Pattern a. Mobility Aids: ___Cane ___Walker ___Wheelchair ___Others_________ b. Range of Motion ___Full ___Impaired c. Balance and Gait: ___Steady ___Unsteady d. Edema: Location: ___________________________ Grade: ______________ Characteristic: _____________________________________________ Edema: Location: ___________________________ Grade: ______________ Characteristic: _____________________________________________ e. Upper Extremities:___Equal ___Strong Weakness/Paralysis:___Right ___Left Radial Pulses: ___Absent ___Weak ___Fair ___Strong f. Lower Extremities:___Equal ___Strong Weakness/Paralysis:___Right ___Left Pedal Pulses: ___Absent ___Weak ___Fair ___Strong

46 Remarks ______________________________________________________________________

5. Sexuality-Reproductive Pattern Male a. Testicular self-exam: ___No ___Yes Describe findings: ______________________________________________ b.Any concerns? (Optional) __________________________________________ c. Sexual dysfunction medications and other pertinent information: ______________________________________ Remarks ______________________________________________________________________

Psychosocial Profile 6. Cognitive-Perceptual Pattern a. Mental Status: ___Alert ___Coherent ___Responsive ___Confused ___Agitated ___Anxious ___Incoherent ___Unresponsive ___Depressed ___Others b. Cognition: ___No Problems ___Recent memory changes ___Difficulty Learning ___Developmentally Impaired ___Others:___________________________ Oriented to: ___Time ___Person ___Place ___No to all c. Hearing ___Adequate ___Minimal Difficulty ___Impaired ___Highly Impaired ___Hearing Aid d. Vision: ___Adequate ___Impaired ___Highly Impaired ___Severely Impaired Visual Apparatuses: ___Glasses ___Contact Lenses ___Magnifying Lens e. Speech: ___Normal ___Slurred ___Aphasic ___Speech Impaired ___Non-communicative f. Patient Understands English: ___Yes ___No Remarks ______________________________________________________________________ 7. Coping-Stress Tolerance Pattern a. Making Decisions: ___alone ___with assistance b. What do you like about yourself? c. Stress: ___Problem-solving ___Eat ___Sleep ___seek help ___others (specify) ________________________________________ d. What would you like to change in your life? ___________________________ 8. Role Relationship Pattern a. Nationality: ________________________ b. Marital Status: ___Married ___Single ___Separated ___Widowed ___Divorced c. Educational Attainment: ___None ___Elementary ___HS ___College d. Suspected Abuse or Neglect: (Refer to physicians assessment) e. Family: ___Lives ___Lives with ________________________ f. Occupation: ___________________________________________

47 ___Full Time ___Part Time ___Retired ___Others g. Emotional Status: ___cooperative ___anxious __depressed ___end of life

Intrapersonal-Interpersonal Profile 9. Health Perception-Health Management Pattern a. Substance Use ___None ___Unknown b. Tobacco ___No ___Yes If yes, form of tobacco_____________ Last Use_________ Years Used_________ Amount per day__________ c. Drugs ___No ___Yes Last Use ________ Years Used________ Amount/Frequency_________ d. Alcohol ___No ___Yes Last use ________ Years Used_________ Amount per day___________ Do you ever drink more than you want? ____No ___Yes

10. Self Perception-Self Concept Pattern a. What are you most concerned about? ___disease ___family ___Others (specify) __________________________________ b. What are your present health goals? ___becoming ill ___getting better ___maintaining health ___Others (specify) ______________ c. To what do you attribute the following? ___becoming ill ___getting better ___maintaining health ___Others (specify) ______________

11. Value-Belief Pattern a. Religion(s) __________________________ b. Religious restriction(s) ______________________________ Comments: _______________________________________________________

Appendix E Anatomy and Physiology Introduction

48

The lymphatic system is intimately associated with the blood and the cardiovascular system. Both systems transport vital fluids throughout the body and both have a system of vessels that transport these fluids. The lymphatic system transports a fluid called lymph through special vessels called lymph capillaries and lymphatics. The lymph eventually gets returned to the blood from where it originated. In addition to fluid control, our lymphatic system is essential in helping us control and destroy a large number of microorganisms that can invade our bodies and cause disease and even death. The lymphatic system consists of the lymph, lymph vessels, lymph nodes, and four organs. The organs are the tonsils, the spleen, the thymu gland, and peyers patches (D. Rizzo, 2006). Functions of the Lymphatic System The lymphatic system works in close cooperation with other body systems to perform these important functions. The lymphatic system aids the immune system in destroying pathogens and filtering waste so that the lymph can be safely returned to the circulatory system. It removes excess fluid, waste, debris, dead blood cells, pathogens, cancer cells, and toxins from these cells and the tissue spaces between them. The lymphatic system also works with the circulatory system to deliver nutrients, oxygen, and hormones from the blood to the cells that make up the tissues of the body. In lymphedema affected tissues, the lymph is unable to drain properly. Instead, within these swollen tissues, the protein-rich lymph becomes stagnant. When bacteria enter this fluid through a break in the skin, they thrive on this protein-rich fluid. It is for this reason that lymphedema affected tissues are prone to infections (Timby & Smith, 2005).

49

Figure 3: Lymph Nodes Lymphatic Circulation Fluid in blood vessels experiences osmotic as well as hydrostatic pressures. The former favors absorption into the vessel while the latter favors net filtration of fluids, mainly plasma, into the interstitial space. When filtration is favored, plasma leaks out of the vessel and into the surrounding tissues. From there, it enters the lymphatic system through the process of diffusion. Through the use of fibers, the walls of the lymph capillaries are joined to the connective tissues nearby and are held open. Consequently, large gaps between the cells are formed, which allow fluid, interstitial proteins, and other matter such as bacteria to flow into the lymph capillary (D. Rizzo, 2006).

The Origin of Lymph Lymph originates as plasma, which is the fluid portion of blood. The arterial blood that flows out of the heart slows as it moves through a capillary bed (see figure above). This slowing allows some plasma to leave the arterioles and flow into the tissues where it becomes tissue fluid. Also known as extracellular

50

fluid, this is fluid that flows between the cells but is not found within the cells. This fluid delivers nutrients, oxygen, and hormones to the cells. As this fluid leaves the cells, it takes with it cellular waste products and protein cells. Approximately 90 percent of this tissue fluid flows into the venules. Here it enters the venous circulation as plasma and continues in the circulatory system. The remaining 10 percent of the fluid that is left behind is now known as lymph (Timby & Smith, 2005). Lymphatic Capillaries In order to leave the tissues, the lymph must enter the lymphatic system through specialized lymphatic capillaries. Approximately 70 percent of these are superficial capillaries that are located near, or just under, the skin. The remaining 30 percent, which are known as deep lymphatic capillaries, surround most of the bodys organs. Lymphatic capillaries begin as blind-ended tubes that are only a single cell in thickness. These cells are arranged in a slightly overlapping pattern, much like the shingles on a roof. Each of these individual cells is fastened to nearby tissues by an anchoring filament (D. Rizzo, 2006).

Lymphatic Vessels The lymphatic capillaries gradually join together to form a mesh-like network of tubes that are located deeper in the body. As they become larger, these structures are known as lymphatic vessels. Deeper within the body the lymphatic vessels become progressively larger and are located near major veins.

51

Like veins, lymphatic vessels, which are known as lymphangions, have one-way valves to prevent any backward flow. Each angion is a segment created by the space between two sets of valves. Smooth muscles in the walls of the lymphatic vessels cause the angions to contract sequentially to aid the flow of lymph toward the thoracic region. Because of their shape, these vessels are previously referred to as a string of pearls (Timby & Smith, 2005). Lymph Nodes There are between 600-700 lymph nodes present in the average human body. It is the role of these node to filter the lymph before it can be returned to the circulatory system. Although these nodes can increase or decrease in size throughout life, any nodes that has been damaged or destroyed, does not regenerate. Lymph nodes, glandular tissue along the lymphatic network, are clustered in the axilla, groin, neck, @ large vessels of the thorax, and abdomen. Lymphatic ducts, through which lymph flows, connect the nodes. The nodes contain both T and B lymphocytes (released from the bone marrow but do not reach the thymus gland) in the smaller nodules of each lymph node (Timby & Smith, 2005).

52

Appendix F Pharmacologic Management

NAME OF NAME OF DRUG DRUG GENERIC NAME: GENERIC Dexamethasone NAME: Lactulose BRAND NAME: Decadron BRAND NAME: Duphalac INDICATION/R OUTES/ DOSE: INDICATION/R OUTES/ DOSE: PO/IM/IV: Adults, Elderly: PO: Adults, 0.75-9mg/ day Elderly: 15-30ml divided doses (10-20mg)/day q6-12h. up to 60ml Children: 0.08(40g)/day. 0.3mg/kg/day in Children: doses 7.5ml divided (5g)/day after q6-12h. breakfast. FREQUENCY: T.I.D

MECHANISM OF MECHANISM OF ACTION ACTION Inhibits accumulation of inflammatory cells at Hyperosmotic Retains ammonia in inflammation sites, laxative, Ammonia phagocytosis, colon (decreases Detoxicant lysosomal enzyme serum ammonia release, and synthesis concentration), and/or release of producing osmotic mediators of effect. inflammation. Therapeutic Effect: Therapeutic increased Effect: Promotes Prevents/supresses cell peristalsis, bowel and tissue (expelling immune evacuation reactions, inflammatory ammonia from colon). process.

CLASSIFICATION CLASSIFICATION Corticosteroid

INDICATION INDICATION Treatment of chronic Treatment inflammatory of conditions, constipation, allergic, prevention of neoplastic, portal systemic autoimmune encephalopathy diseases; (including management hepatic cerebral coma). of edema, septic shock; adjuvant antiemetic in treatment of chemotherapyinduced emesis.

CONTAINDICATION CONTAINDICATION Active untreated infections; viral, fungal, Those on tuberculosis, galactosediseases free diet, abdominal of the eye. pain, nausea, vomiting, appendicitis. Cautions: Respiratory tuberculosis, untreated Cautions: Diabetes systemic infections, Mellitus ocular herpes simplex, hyperthyroidism, cirrhosis, ulcerative colitis

Saunders Nursing Drug Handbook, 2006 Saunders Nursing Drug Handbook, 2006

SIDE/ ADVERSE NURSING SIDE/ ADVERSE NURSING EFFECTS RESPONSIBILITIES EFFECTS RESPONSIBILITIES Frequent: Cough, Baseline Assessment Occasional: Baseline Assessment dry mouth, Question for hypersensitivity Abdominal Assess condition before hoarseness, to therapy the and any of corticosteroids. cramping, assess throat irritation. Obtain baseline for height, flatulence, regularly thereafter to increased thirst, weight, BP, serum glucose, monitor drugs Occasional: abdominal effectiveness electrolytes. discomfort Intervention/Evaluation Localized fungal Encourage adequate infection (thrush) Intervention/Evaluation fluid Rare: Nausea, Monitor I&O, daily weight. intake.. Assess bowel vomiting sounds for Rare: Increased Assess for edema.peristalsis. Evaluate Monitor daily bowel activity, bronchospasm, food tolerance and record stool consistency; bowel esophageal activity.ofReport Hyperacidity Adverse Effect: time evacuation. Assess candidiasis. Diarrhea indicates promtly. Check vital signs at for abdominal disturbances. overdosage. Long least 2 times/day. electrolytes Monitor serum Be alert to Adverse Effect: term use may rsult infection: sore throat, fever. in patients exposed to in laxative Monitor serum frequent, or prolonged, electrolytes, Muscle wasting, dependence, excessive use of Monitor for hypercalcemia, chronic medication. osteoporosis, Assess constipation, loss hypokalemia. spontaneous of normal bowel emotional status,Teachingto Patient/Family ability fractures, sleep. function. Evacuation occurs in 24-48 cataracts, peptic hours of initial dose. ulcer, CHF. Institute measures to Patient/Family Teaching Do promote defecation; not change dose/schedule or increase stop taking fluid drug. intake, Notify exercise, high-fiber diet. physician of fever, sore throat, muscle aches, sudden weight gain/edema. Severe stress may require increased dosage.

52

53

NAME OF DRUG

CLASSIFICATION

MECHANISM OF ACTION

INDICATION

CONTAINDICATION

SIDE/ ADVERSE EFFECTS

NURSING RESPONSIBILITIES

54
GENERIC NAME: Ibandronate BRAND NAME: Boniva INDICATION/R OUTES/ DOSE: PO: Elderly: daily Adults, 2.5mg Calcium Regulator Binds to bone hydroxyapatite (part of the mineral matrix of bone), inhibits osteoclast activity. Therapeutic Effect: Reduces rate of bone turnover/resorption, resulting in net gain in bone mass. Treatment/ Prevention of osteoporosis in postmenopaus sal women. Hypersensitivity to other biphosphonates (etidronate, tiludronate), uncorrected hypocalcemia, inability to stand or sit upright for at least 60 minutes, severe renal impairment (creatinine clearance less than 30ml/min.). Caution: GI diseases, dysphagia, esophagitis, gastritis, ulcer, mild to moderate renal impairment. Frequent: Back pain, Dyspepsia (epigastric distress, heartburn), peripheral discomfort, diarrhea, headache, myalgia. Occasional: Dizziness, arthralgia, asthenia (lack of strength, energy) Adverse Effect: Upper respiratory infection occurs occasionally. Overdose results in hypocalcemia, hypophosphat emia. Baseline Assessment Hypocalcemia, Vitamin D deficiency must be corrected prior to beginning therapy. Obtain laboratory baselines, esp. Serum electrolytes, renal function. Obtain results of bone density study. Intervention/Evaluation Monitor electrolytes, esp. Serum calcium, alkaline phosphate levels. Patient/Family Teaching Instruct patient that expected benefits occur only when medication is taken with full glass (6-8 oz) of plain water, first thing in the morning and at least 60 min prior to first food, beverage, medication of the day. Do not lie down for at least 60 min after taking medication. Consider weight-bearing exercises, modify behavioral factors ( cigarette smoking and alcohol consumption).

Saunders Nursing Drug Handbook, 2006

NAME OF

CLASSIFICATION

MECHANISM OF

INDICATION

CONTAINDICATION

SIDE/

NURSING

55
ADVERSE EFFECTS Frequent: Drowsiness, dizziness, muscular weakness, hypotension, dry mouth/nose/ lips, urinary retention, thickening of bronchial secretions. Occasional: Epigastric distress, flushing, visual or hearing disturbances, paresthesia, diaphoresis, chills. Adverse Effect:Hypersensitivity reaction may occur.

DRUG GENERIC NAME: Diphenhydramin e Hydrochloride BRAND NAME: Benadryl INDICATION/R OUTES/ DOSE: PO/IM/IV: Adults Elderly: 25-50 mg q4h. Maximum: 400mg/day. Children: 5 mg/kg/day in divided doses q6-q8h. Maximum: 300 mg/day. Antiemetic, Anticholinergic, Antihistamine.

ACTION Competes with histamine at histamine receptor sites. Inhibits central acetylcholine. Therapeutic Effect: Results in anticholinergic, antipruritic, antitussive, antiemetic effects. Produces antidyskinetic, sedative effect. Treatment of allergic reactions, Parkinsonism; prevention/ treatment of nausea, vomiting, vertigo due to motion sickness; antitussive; short-term management of insomnia. Topical form used for relief of pruritus, insect bites, skin irritations. Acute exacerbation of asthma, those receiving MAOIs. Cautions: Narrow-angle glaucoma, peptic ulcer, prostatic hypertrophy, pyloro-duodena or bladder neck obstruction, asthma, COPD, increased intraoculzr pressure, cardiovascular disease, hyperthyroidism, hypertension, seizure disorders.

RESPONSIBILITIES Baseline Assessment If patient is having acute allergic reaction, obtain history of recent ingested foods, drugs, environmental exposure. Monitor rate, depth, rhythm, type of respiration, quality/rate of pulse. Assess lung sounds for rhonchi, wheezing, rales. Intervention/Evaluation Monitor BP, esp. in elderly (increased risk for hypotension). Monitor children closely for paradoxical reaction. Patient/Family Teaching Tolerance to antihistamine effect generally does not occur; tolerance to sedative effect may occur. Avoid tasks that require alertness, motor skills until response to drug is established. Dry mouth, drowsiness, diziness may be an expected response of drug. Avoid alcohol NURSING RESPONSIBILITIES

Saunders Nursing Drug Handbook, 2006 NAME OF DRUG MECHANISM OF ACTION

CLASSIFICATION

INDICATION

CONTAINDICATION

SIDE/ ADVERSE EFFECTS

56
GENERIC NAME: Azithromycin BRAND NAME: Zithromax INDICATION/R OUTES/ DOSE: IV: Adults 500 mg/ day followed by oral therapy. Antibiotic Binds to ribosomal receptor sites of susceptible organisms. Therapeutic Inhibits systhesis. Effect: protein Treatment of mild to moderate infections of upper respiratory tract (pharyngitis, tonsilitis), lower respiratory tract (acute bacterial exacerbation, COPD, pneumonia). Hypersensitivity to azithromycin, erythromycin, any macrolide antibiotic. Cautions: Renal/Hepatic Impairment. Occasional: Nausea, vomiting, diarrhea, abdominal pain. Rare: Headache, dizziness, alergic reaction. Baseline Assesssment Question for history of hepatitis, allergies to azithromycin, erythromycins. Intervention/Evaluation Check for GI discomfort, nausea, vomiting. Determine pattern of bowel activity and stool consistency. Assess for hepatic toxicity: malaise, fever, abdominal pain. Evaluate for superinfection: genital/anal pruritus, sore mouth or tongue, moderate to severe diarrhea. Patient/Family Teaching Continue therapy for full length of treatment. Dose should be evenly spaced. Take oral medication with 8 oz water at least 1 hr before or 2 hrs after food.

Saunders Nursing Drug Handbook, 2006

NAME OF

CLASSIFICATION

MECHANISM OF

INDICATION

CONTAINDICATION

SIDE/

NURSING

57
ADVERSE EFFECTS Frequent: Dizziness/verti go, nausea, constipation, headache, somnolence. Occasional: Vomiting, pruritus, diaphoresis, dry mouth, diarrhea. Adverse Effect: Overdosage results in respiratory depression, seizures. Renal/Hepatic impairement.

DRUG GENERIC NAME: Tramadol Hydrochloride BRAND NAME: Ultram INDICATION/R OUTES/ DOSE: PO: Adults, Elderly: 50-100 mg q4-6h. Maximum 75 years or younger: 400 mg/day. Maximum older than 75 years: 300 mg/day. Non-narcotic analgesic

ACTION Binds to opiate receptors and inhibits reuptake of norepinephrine and serotonin. Therapeutic effect: Reduces intensity of pain stimuli incoming from sensory nerve endings, altering pain perception and emotional response to pain. Management of moderate to moderately severe pain. Acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids, psychotropic drugs. Extreme Caution: CNS depression, anoxia, advanced hepatic cirrhosis, epilepsy, respiratory depression, acute alcoholism, shock. Caution: Sensitivity to opioids, increased intracranial pressure, hepatic/renal impairment, acute abdominal conditions.

RESPONSIBILITIES Baseline Assessment Assess onset, type, location, duration of pain. Effect of medication is reduced if full pain recurs before next dose. Assess drug history. Intervention/Evaluation Monitor pulse, BP. Assist with ambulation if dizziness, vertigo occurs. Palpate bladder for urinary retention. Monitor pattern of daily bowel activity/ stool consistency. Sips of tepid water may relieve dry mouth. Patient/Family Teaching Avoid alcohol, OTC medications. May cause drowsiness, dizziness, blurred vision. Avoid tasks requiring alertness, motor skills until response to drug is established. Informed physician if severe constipation, difficulty in breathing, and seizures arise.

Saunders Nursing Drug Handbook, 2006

58
SIDE/ ADVERSE EFFECTS Frequent: nausea and vomiting, mild to severe bone pain, alopecia, diarrhea, fever, and fatigue. Occasional: Anorexia, dyspnea, headache, cough, skin rash. Adverse Effect: Chronic administration occasionally produces chronic neutropenia, spleenomegaly . arrhythmias occur rarely, thrombocytope nia, and MI.

NAME OF DRUG GENERIC NAME: Filgrastim BRAND NAME: Neupogen INDICATION/R OUTES/ DOSE: Alert: Begin at least 24 hours after the last dose of chemotherapy; diiscontinue at least 24 hours before next dose of chemotherapy. Subcutaneous/I V: Adults, Elderly: initially 5mcg/kg/day. May increase by 5 mcg/kg for each chemotherapy cycle.

CLASSIFICATION Granulocyte colony-stimulating factor (GCSF)

MECHANISM OF ACTION Stimulates production, maturation, activation of neutrophils. Therapeutic Effect: Activates neutrophil to increase their migration and cytotoxicity.

INDICATION Decrease infection incidence in patients with malignancies receiving myelosuppress ive therapy associated with severe neutropenia, fever.

CONTAINDICATION Hypersensitivity to E. coli- derived proteins, 24 hours before or after cytotoxic chemotherapy, use in other drugs that may result in lowered platelet count. Cautions: Malignancy with myeloid characteristics due to a GCSFs potential to act as a growth factor; gout, psoriasis, preexisting cardiac conditions.

NURSING RESPONSIBILITIES Baseline Assessment CBC, platelet count (differential) should be obtained prior to therapy initiation and twice a week thereafter. Intervention/Evaluation In septic patients, be alert to adult respiratory distress syndrome. Closely monitor those with preexisting cardiac conditions. Monitor BP (transient decrease in BP may occur), temperature, CBC with differential, platelet count, Hct, serum uric acid, hepatic function tests. Patient/Family Teaching Inform physician of fever, chills, severe bone pain, chest pain, palpitations.

Saunders Nursing Drug Handbook, 2006

NAME OF DRUG

CLASSIFICATION

MECHANISM OF ACTION

INDICATION

CONTAINDICATION

SIDE/ ADVERSE EFFECTS

NURSING RESPONSIBILITIES

59
GENERIC NAME: Silver Sulfadiazine BRAND NAME: Flamazine INDICATION/R OUTES/ DOSE: Topical: Adults, Elderly, Children: Apply 1-2 times a day. Burn Preparation Acts on cell wall/cell membrane in concentration; selectively toxic in bacteria. Therapeutic Effect: Produces bactericidal effect. Prevention, treatment of infection in second and third degree burns; protecting against conversion from partial to full-thickness wounds (infection causing extended tissue destruction) None known. Cautions: Renal/Hepatic Impairment. Frequent: burning feeling at treatment site. Occasional: Brown/gray skin discoloration, rash itching. Rare: Increased sensitivity skin sunlight. Saunders Nursing Drug Handbook, 2006 Baseline Assesssment Determine initial CBC, serum renal/hepatic function test results. Intervention/Evaluation Monitor serum electrolytes, urinalysis, renal function, CBC if burns are extensive, therapy prolonged. Patient/Family Teaching For external use only, may discolor skin.

of to

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Appendix G Laboratory Results Table 14. Hematology

Complete Blood Count WBC count Hemoglobin Hematocrit MCV MCH RBC count MCHC RDW MPV Platelet count Neutrophil Lymphocytes Monocytes Eosonophil Basophil Results 1.40 93 .28 94.00 31.30 2.98 332 13.60 9.50 165 48 46 01 01 0 Reference (4.8-10.8)10^g/L (140-180)g/L (.42-.52) L/L (80-94)fl (27-31) pg (4.70-6.10) 10^12L (330-370) g/L (11-16) fl (7.2-11.1) fl (150-400) 10^9/L (40-74)% (19-48)% (3-9)% (0-7) (0-2) Erythrocytopenia Significance Leukopenia Erythrocytopenia Hemodilution

Date/Time Rendered: 07/06/11 (11:47am) Date/Time Received: 07/06/11 (15:09pm)

Table 15. Clinical Chemistry

Blood Chemistry Results Reference Significance 60

61 Sodium Potassium Chloride Creatinine Albumin Iron 2.90 3.0 (3.5-5.0) g/dl (9.5-29.9) umol/L 134.4 2.33 106.5 1.74 (135-148) mmol/L (3.50-5.30) mmol/L (98-107) mmol/L (0.9-1.3) mg/dl Impairment of kidney function Hypoalbuminemia Low iron content in the body, low production of healthy RBCs. Iron is necessary for the synthesis of hemoglobin, the oxygen-binding content of red blood cells. Hypercalcemia Hypokalemia

Ionized Calcium

1.7

(0.9-1.4) mmol/L

Date/Time Rendered: 07/03/11 (14:22am) Date/Time Received: 07/03/11 (14:22pm)

Table 16. Immunology Report

Tumor Marker Ferritin Result 2304 Reference (30-400) ng/ml Significance Hemochromatosis

Date/Time Rendered: 06/27/11 (17:52pm) Date/Time Received: 06/27/11 (18:22pm)

Electrocardiogram Taken last June 24, 2011 Impression: Sinus Rhythm with Non Specific ST segment elevation

Appendix H Nurses Notes Table 17. Inefffective Airway Clearance

62 Nurses Progress Notes Date and Time July 5, 2011 F Focus D Data A Action R Response 2 PM 10 PM Ineffective Airway Clearance related to presence of excessive mucus secretions at the tracheobronchial tree D - received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; recurrent productive cough noted characterized with yellowish mucus secretions; with O2 inhalation via nasal pronged regulated @ 2 L/min.; with NGT for feeding, weakness noted; swelling and redness on the right feet noted; deep shallow breathing with slight use of accessory muscles noted; with the following vital signs of T= 36.6'C P= 75 beats/minute R= 15 breaths/minute, BP= 110/80 mm/Hg. A - Assessed patient's condition, monitored and recorded vital signs, encouraged patient to increase fluid intake, bedside and environmental care done, regulated O2 at desired level of 2-3 L/min. to maintain adequate airways and improve respiratory function and gas exchange, positioned patient in a semi- fowler's position to help proper lung expansion, turned patient every 2 hours to take advantage of gravity decreasing pressure on the diaphragm and to help facilitate ventilation of different lung segments, encouraged to have adequate rest, instructed him on the proper deep breathing technique such as purse-lip breathing, encouraged him to limit activities to level of respiratory tolerance. R - Patient was able to demonstrate techniques and verbalized understandings on the interventions rendered, still for continuous nursing care.

2 PM

10 PM

Table 18. Hyperthermia

Nurses Progress Notes

63

Date and Time July 6, 2011 2 PM

F Focus

D Data A Action R Response 2 PM 10 PM

10 PM

Hyperthermia related to D - "Init ko", as verbalized by the patient, increased metabolic rate received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right due to illness arm; unable to utter words; patient used pen and paper to communicate; warm to touch, flushed skin noted, with body temperature of 38.4 degrees Centigrade; with O2 inhalation via nasal pronged regulated @ 2 L/min., with NGT for feeding; with the following vital signs of T= 38.4 degrees Celcius P= 75 beats/minute R= 15 breaths/minute, BP= 110/80 mm/Hg. A - Assessed patient's condition, monitored and recorded vital signs, encouraged patient to increase fluid intake, performed tepid sponge bath, administered antipyritic medication as ordered, bedside and environmental care done, regulated O2 at desired level of 2 L/min. to maintain adequate airways and improve respiratory function and gas exchange, positioned patient in a semi- fowler's position to help proper lung expansion. R - Patient was able to demonstrate techniques and verbalized understandings on the interventions rendered, still with shallow breathing, still for continuous nursing care.

Table 19. Activity Intolerance

Nurses Progress Notes Date and Time July 7, F Focus D Data A Action R Response 2 PM 10 PM

64 2011 2 PM Activity Intolerance related to imbalance between oxygen supply and demand D - Kapoy as verbalized by the patient. received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; weakness noted; unable to tolerate/perform on the ADL., with nasogastric tube, with O2inhalation, with edema on the right foot noted; with the following vital signs of T= 37.1'C P= 80 beats per minute, R= 13= breaths per minute BP= 120/80 mm/Hg. A - Assessed patient's health status, monitored and recorded vital signs, measured and recorded intake and output, encouraged expressions of feeling resulting from condition, assisted with activities, ensured safety and comfort, imparted health teaching about proper hygiene, encouraged patient for maximal activity within ability, assisted in teaching and demonstrating appropriate safety measures, instructed significant other not to leave patient unattended, provided bed rest. R - Patient participated willingly in necessary or desired activities.

10 PM

Table 20. Chronic Pain

Nurses Progress Notes Date and Time July 8, 2011 F Focus D Data A Action R Response 2 PM 10 PM

65 Chronic Pain related to chronic stimulation of nerve endings on the right leg and foot due to malignant and inflammatory process secondary to disease process D - Sakit tiil as verbalized by the patient; received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; facial grimace noted; guarded movements observed; with pain score of 5 ( 0 as the lowest and 10 as the highest).; with NGT for feeding, guarded movement noted; with the following Vital Signs of T= 37.4'C, P= 85 bpm, R= 21 cpm, BP= 120/80 mm/Hg. A - Assessed pts condition, environmental and bedside care done, monitored & recorded V/S, regulated IVF at desired rate, encouraged patient to do diversional activities such as reading newspaper, encouraged pt to do relaxation techniques such as doing deep breathing, encouraged pt to verbalize intensity of pain, administered pain medication as ordered. R - Seen patient lying comfortably in bed with the pain score decreased from 5 down to 2 ( 0 as the lowest and 10 as the highest).

2 PM

10 PM

Table 21. Self Care Deficit

Nurses Progress Notes Date and Time July 9, 2011 Self care deficit (eating, F Focus D Data A Action R Response 2 PM 10 PM D -received patient lying in bed with PNSS iL

66 2 PM grooming, toileting) related to generalized body weakness and discomfort on the lower right leg
regulated @ 30 gtts/minute infusing well @ right arm; unable to utter words; patient used pen and paper to communicate; body odor noted; poor hygiene noted; unable to take a bath for a month dry skin noted; long fingernails noted.scaly skin noted; thin hair noted; hair loss noted; dandruff on hair and eyebrows noted; dry lips noted; poor skin turgor noted; with the following vital signs T- 37.4 Degrees Celcius, P- 69 beats/minute, R-15 breaths/minute, BP120/80mm/Hg.

10 PM

A - Assessed pt.s condition, monitored and recorded vital signs, assisted patient to take a bath and encouraged him to take a bath every day, environmental care done and stressed the importance of clean environment, applied lotion on pt.s skin for promoting good skin care, instructed pt. to do strict hand washing, instructed visitors to do reverse isolation, kept patients skin clean and dry, done strict asepsis in every procedure, provided wellbalanced diet, increased fluid intake, instructed patients SO to assist pt. in any procedure, utilized wheelchair in transporting the patient, provided long rest periods, used soft mattress/ soft foam and reposition pt. every two hours. R - Patients condition has improved. He appears neat and clean. Still for continuous nursing care for maintenance of proper hygiene.

Table 22. Impaired Physical Mobility

Nurses Progress Notes Date and Time July 10, 2011 2 PM Impaired physical mobility related to F Focus D Data A Action R Response 2 PM 10 PM D -received patient lying in bed with PNSS iL regulated @ 30 gtts/minute infusing well @ right

67 limitations in movement, discomfort and decreased physical strength

arm; unable to utter words; patient used pen and paper to communicate; guarded movements observed; unable to move from side to side and needed assistance; body malaise noted; limited range of motion noted; scaly skin noted; with O2 inhalation via nasal pronged regulated @ 2 liters per minute; and with NGT for feeding; with the following vital signs of T= 37.4'C, P= 79 bpm, R= 16 cpm, BP= 120/80 mm/Hg.

10 PM

A - Assessed pt.s condition, monitored and recorded vital signs, performed bedside care, measured and recorded intake and output, determined/assessed degree of immobility in relation to functional level scale, instructed patient on use of side rails, overhead trapeze and roller pads, instructed him to have regular skin care, provided comfort measures for the safety of the patient, assisted patient to do passive ROM exercise on the lower extremities, assisted or have significant others reposition patent on regular schedule as ordered by the physician, encouraged patients significant others involvement in decision making as much as possible, involved significant other in care, assisted them to learn ways of managing problems of immobility, administered analgesics as ordered. R - Patient was able to verbalize understanding about the interventions imparted as evidenced by doing exercise for the lower extremities.

Appendix I Documentation

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The researcher and the panel members

Appendix J Curriculum Vitae

JOHN ANDRO D. BANGA

128- Puente, Carmen, Cebu Philippines 6000

69 PERSONAL BACKGROUND
Profession Date of Birth Place of Birth Religion Mother Father : Registered Nurse : January 31, 1988 : Cogon East, Carmen, Cebu Roman Catholic : Cristina D. Banga : Edwin P. Banga

EDUCATIONAL BACKGROUND
COLLEGE : Degree : SECONDARY : Southwestern University Villa Aznar Urgello St. Cebu, Philippines Bachelor of Science in Nursing (BSN) Graduated: March 2008 Carmen National High School Cogon West, Carmen Cebu Graduated: April 2004 Puente Elementary School Puente, Carmen, Cebu Graduated: March 2000

PRIMARY

PROFESSIONAL EXAMINATION
Passed the Philippine Nurses Licensure Examination Cebu City, Philippines November 2008

WORK EXPERIENCE
Clinical Instructor Colegio de San Antonio de Padua Guinsay, Danao City July 01, 2010 - Present

PROFESSIONAL ORGANIZATIONS
Member Philippine Nurses Association (PNA)

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