31

4. Evaluation Phase Utilizing the same Assessment tool for the final evaluation of level of adaptation. Final results as follows. Table 10. Final Assessment of Mrs. F
Assessment Parameters A. PHYSIOLOGICAL FACTORS 1. Oxygenation 2. Nutrition 3. Elimination 4. Activities of Daily Living 5. Rest and Sleep Sub Total B. PSYCHOLOGICAL FACTORS Sub Total C. SOCIO-CULTURAL FACTORS 1. Interpersonal Relationship 2. Community Resources Sub Total D. SPIRITUAL FACTORS Sub Total E. DEVELOPMENTAL FACTORS Sub Total TOTAL No. of Items 3 5 2 2 3 15 5 5 2 1 3 3 3 3 3 29 Perfect Score 12 20 8 8 12 60 20 20 8 4 12 12 12 12 12 116 Clients Score 10 16 7 6 9 48 15 15 7 4 11 10 10 9 9 93 Mean Score 3.33 3.2 3.5 3 3 3.2 3 3 3.5 4 3.67 3.33 3.33 3 3 3.21 Description High High High Average Average High Average High High High High Average High

Table 7 shows the level of adaptation of Mrs. F.. in the final assessment and described as High with a mean score of 3.21. It indicates an increased level of adaptation in all the assessment areas after the nursing interventions were carried out thru the utilization of Neumans System Model.
3.21 Scale 0 1 2 3 4

LOW

BELOW AVERAGE

AVERAGE

HIGH

Figure 5. The Evaluative Scale for the Level of Adaptation Based on the Final Assessment of Mrs. F.

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Table 11. Comparative Result of Initial and Final Assessment

Assessment Parameters A. PHYSIOLOGICAL FACTORS 1. Oxygenation 2. Nutrition 3. Elimination 4. Activities of Daily Living 5. Rest and Sleep Sub Total B. PSYCHOLOGICAL FACTORS Sub Total C. SOCIO-CULTURAL FACTORS 1. Interpersonal Relationship 2. Community Resources Sub Total D. SPIRITUAL FACTORS Sub Total E. DEVELOPMENTAL FACTORS Sub Total TOTAL Perfect Score 12 20 8 8 12 60 20 20 8 4 12 12 12 12 12 116 INITIAL Client Initial Score Mean 8 10 5 3 6 32 12 12 5 4 9 8 8 7 7 68 2.67 2 2.5 1.5 2 2.13 2.4 2.4 2.5 4 3 2.67 2.67 2.3 2.3 2.34 FINAL Client Final Score Mean 10 16 7 6 9 48 15 15 7 4 11 10 10 9 9 93 3.33 3.2 3.5 3 3 3.2 3 3 3.5 4 3.67 3.33 3.33 3 3 3.21 Mean Score Difference 0.66 1.20 1.00 1.50 1.00 1.07 0.60 1.00 0 0.67 0.66 0.70 0.87

Table 8 shows the comparison in the initial and final assessment of client. Data reveals an increase in the mean scores in all of the assessment areas with a mean difference of 0.87 as shown on the scale below. Scale 0 4 1 2 3

LOW HIGH

BELOW AVERAGE
2.34 2

AVERAGE
3.21

Figure 6. The Evaluative Scale of the level of adaptation based on the initial and final assessment of Mrs. F.

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Findings

Utilizing Betty Neumans

Model as a guide and means to determine the level of

adaptation of Mrs. F, findings shows a remarkable increase in the overall mean scores from 2.34 (Average) to 3.21 (High). Results reveal that there is a significant increase in the Level of Adaptation of Mrs. F. with a mean difference of 0.87. With the very active participation of the client and the family in the care management, it is more likely that the patient will have a more positive outlook and will be able to manage his own care.

Conclusion

Based on the findings of the initial and final assessment, it is therefore concluded that utilizing Neumans System Model has been effective in the care of client with oncologic disorder (nasopharyngeal carcinoma). Having established rapport with the client, the nurse and the client himself, were able to fully assess the condition and find solution to address the needs of the client. Furthermore thru the utilization of Neumans System Model assisted him to a higher level of adaptation.

Recommendation Having cancer or other disease condition bring about stress to an individual and its family, it may be physiologically, psychologically, social, spiritual and developmental. And Neumans System Model is based on individuals relationship to stress, the reaction to it and adaptation to stress. Based on the result, it is then recommended the use of Neuman System Model in the care of client with cancer. It is also recommended to use the theory on other disease condition since it is applicable to a variety of nursing practice settings involving individuals, families, groups and communities.

34

Bibliography
Books Doenges, Marilyn et al. (2006) Nursing Care Plans: Guidelines for Individualizing Client Care across Life Span, 7th Edition Johnson, Marion et al. (2006), NANDA, NOC and NIC Linkages Kozier, et al. (2004), Fundamentals of Nursing: Concepts, Processes and Practices, 7th Edition

Smeltzer and Bare (2007), Brunner & Suddarths Textbook of Medical-Surgical Nursing 10th edition Spark and Taylor (2005), Nursing Diagnosis Reference Manual, Sixth Edition

Electronic

Brennan

(2006),

Nasopharyngeal

Carcinoma,

Retrieved

from

http://www.nature.com/bjc/journal/v102/n9/full/6605640a.html Fawcett (2007), Overview of Nurse Theorists. Neumans System Model, Retrieved from http://www4.desales.edu/~sey0/neuman.html National Cancer Institute (2006), Nasopharyngeal Carcinoma, Retrieved from http://www.cancer.gov/cancertopics/pdq/treatment/nasopharyngeal/HealthProfessional/pa ge1

Paulino, et. al. (2007), Nasopharyngeal Cancer Clinical Presentation, Retrieved from http://emedicine.medscape.com/article/988165-clinical#a0218 Reyes, et. al. (2008), Neumans System Model, Retrieved from http://nursingtheories.blogspot.com/2008/07/betty-neumans.html

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Western Mindanao State University COLLEGE OF NURSING Master in Nursing Program Zamboanga City August 01, 2011 Livia A. Sana, MD Hospital Director Western Mindanao Medical Center Zamboanga City Thru: Dolores B. Pacatang, R.N Chief Nurse Dear Maam: I am a student of Master in Nursing at Western Mindanao State University. I am currently taking up Intensive Practicum. And for my course requirement, I am to conduct a case study of medical-surgical cases. In connection to this, I would like to get a patient from Intensive Care Unit for 10-days nursing care. I would also like to check the chart for other pertinent data. Rest assured all data I gather will be treated as confidential and be discussed for educational purposes only. I am hoping for your kind consideration and favorable response. Very truly yours, John Waller S. Buhian, R.N. Noted by: SARAH S. TAUPAN, R.N., M.N. Course Professor MSN 202 VICENTA T. ESCOBAR, M.N., M.A.N. Chairperson, Graduate School CN GLORIA G. FLORENDO, R.N., M.N. PhD Dean, College of Nursing

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B. Gordons 11 Functional Health Pattern

1. Health Perception Health Management Pattern It was 4 months ago that the patient noticed a mass on her right neck. Then she went to two specialists for consultation. She also went to Davao for check-up. When she knew about the result of the biopsy, she was depressed and decided to made follow-up to a specialist for treatment. Accordingly, they have no family history of cancer. She is a heavy smoker back then. She can consume at least 5 sticks per day and she thinks this is the reason why she had cancer. She has also asthma.

2. Nutritional Metabolic Pattern She weighs 35 kgs, slim, but accordingly back then she already have the same body built. She loss her appetite to food since the appearance of the neck mass. She doesnt eat a lot. She has difficulty of swallowing. She doesnt take any vitamins or nutritional supplements.

3. Elimination Pattern Accordingly, she doesnt have problem in urinating. She is catheterize for accurate measurement of input and output. At present she doesnt move bowel everyday, sometimes its after two days.

37

4. Activity Exercise Pattern Accordingly, she doesnt do exercise. . Her daily routine activities back then is sleeping, preparing meals, eating, and watching TV. At present, she is advised on complete bed rest without toilet privileges. She looks so weak.

5. Sleep Rest Pattern She looks so weak. She currently has problem with sleeping and complained of not feeling well rested. She doesnt have any medication to promote sleep.

6. Cognitive Perceptual Pattern She doesnt have any sensory deficits. She is conscious and coherent and participates actively in the interaction. He doesnt experience any changes in memory lately. Her chest ain is already resolving after giving medication, pain scale of 4/10.

7. Self- Perception Self Concept Pattern She doesnt get mad easily. When she was diagnosed to have an illness, she got really depressed. Right now she is anxious about what will happen to her.

8. Role Relationship Pattern They are six in the family. Her three children already got married and have their own family. Her one son is her companion at home. His husband is assigned in Davao and went home every month. They have close family ties. They talk a lot and usually share a lot of interests. When they have problems, they talk about it and weigh options to solve the problem. She is the

38

housewife of the family. She doesnt have any problem with his children. When her husband and children learned about her illness, they got depressed also.

9. Sexuality Reproductive Pattern She has 4 children with no history of abortion, she doesnt experience any sexual problem. She doesnt have any problem with his children.

10. Coping Stress Tolerance Pattern In times of crisis, the entire family is talking about it. Her family is always at her side presently, taking care of her.

11. Value Belief Pattern Her family is the most valuable thing in her life now. Religion is also important to her because it really helps him during times of crisis. She clings to God.

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C. Table 12. Laboratory Work-ups

Date August 08, 2011 Procedure Hematology >Hemoglobin >Hematocrit 0.40 0.54 >White Blood Cells 4.5 11.0 10^3/uL Differential Count > Segmenters 0.50 0.70 >Lymphocytes 0.20 0.40 >Eosinophils 0.01 0.05 >Platelet 150 350 10^3/uL >Protime 10.2 13.2 >% Activity 83 100 >INR 0.85 1.10 Clinical Chemistry >FBS 3.90 6.40 >Uric Acid 214 488 >Creatinine 80 115 >BUN 2.80 7.20 >Cholesterol 0.00 5.20 >HDL 0.00 0.91 >LDL 0.00 0.34 8.9 649 126 6.9 2.5 0.5 1.5 >It reflects reduced renal perfusion from decreased cardiac output. 227 15.8 51.5 1.43 0.04 0.06 > Decrease with Immunosuppression. stress and 0.90 >Immunosuppression. 11.56 0.42 >Acute infection and bone marrow suppression. Normal 135 g/L 180 g/L Result 146 g/L Interpretation/Analysis

>Increases with infections.

40

>Triglyceride 0.00 2.30 >Sodium 135 145 > Potasium 3.50 5.30 >Troponin T Negative Positive 4.2 110 >Decreased sodium level indicate fluid excess and can be caused by heart failure. >After myocardial injury, elevated serum troponin Tcan be detected within 3 to 4 hours. these earlyand prolonged elevationsmake very early diagnosis of MI possible. 0.1

>Chest X-Ray APL The heart is normal in size and configuration. Lung fields are clear. Trachea is not narrowed. Cardiomegaly with pulmonaru congestion / edema PTB Minimal Atheromatous Aorta

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D. Table 13. Treatment (Medication)

Generic Asprin Dosage/Fre quency 80 mg, 1 tab OD PO PC meals Classificat ion Anticoagul ant, Antiplatele ts, Fibrinolyti cs Indication Prophylaxis of thromboembo lic disorders, MI, transient ischemic attacks and stroke Treatment of primary hypercholeste rolemia, heterozygous familial hypercholeste rolemia Prevention of atheroscleroti c events in peripheral arterial disease, or within 35 days of MI or within 6 months of ischemic stroke Treatment of acute deep vein thrombosis, pulmonary embolism, unstable angina, acute coronary syndrome, Treatment of edema associated with CHF, cirrhosis of the liver ad Contraindi cation Gastric and duodenal ulcers. hemorrhagi c diathesis Side effects Gastric hemorrhage, hypersensitivity thrombocytopeni a Nursing Responsibility Advise patient to take drug with food, milk, antacid or large glass of water to reduce unpleasant GI reactions Advise patient to watch for small round red pinprick spots, bleeding gums, and signs of GI bleeding Assess patient for underlying causes for hypercholesterolemia and obtain baseline lipid profile. Warn patient to avoid alcohol. advise patient that drug can be taken at any time of the day, without regards to meals Advise patient to refrain from activities in which trauma and bleeding may occur Notify prescriber if unusual bleeding or bruising occurs. Take the medication after meals Monitor blood counts within 2 weeks of stopping treatment

Atorvastati n

40 mg, 1 tab OD PO at HS

Dyslipidae mic Agent

Clopidogre l

75 mg 1 tab OD PO PC meals

Anticoagul ant, Antiplatele ts, Fibrinolyti cs

Active liver disease, persistent elevation of serum transiminas e, pregnancy, lactation Hematopoet ic disorder, hemorrhaog c diathesis, GI ulcers, acute cerebral hemorrhage , or severe liver dysfunction Clinically significant bleeding, acute bacterial endocarditis , IM administrati on Anuria, hepatic coma and electrolyte imbalance

headache, Face edema, fever, malaise, abdominal pain,.

GI disturbances and skin rashes. Blood dyscrasia. hepatitis and cholestatic jaundice

Fundapari nox

2.5 mg SQ OD

Thromboly tics

Anemia, bleeding, purpura, edema

Give by SC injection only,

never IM

Tell patient to report signs and

symptoms of bleeding

Regularly monitoring CBC,

platelet count, creatinine level and stool occult blood test

Furosemid e

20mg, IVT q12

Diuretics

Tinnitus, nausea and vomiting, weakness, dizziness, muscle cramps, GI disturbance and

Monitor fluid intake and

output and electrolyte, BUN and carbon dioxide levels Watch out for signs of hypokalemia, such as

42

renal diseas

dry mouth

weakness and cramps

Advise patient to immediately

report ringing in ears, severe abdominal pain or sore throat or fever, these may indicate toxicity

Lsctulose

30 cc, OD at HS

Laxatives

Treatment of constipation and hepatic encephalopat hy

Low galactose diet, intestinal obstruction

Abdominal discomfort associated with flarulence and cramps

To minimize sweet taste,

dilute with water or fruit juice reduce GI disturbance. For constipation and production of soft stools: preferably taken in one time during breakfast instruct not to take other laxatives during lactulose therapy necessary in Asian and patient with hepaticimpairment Must be given before meals hazardous activity if he gets dizzy

Maybe taken with meals to

Omeprazol e 40 mg, IVT OD Antacid and Antiulcera nt Treatment of dyspepsia, duodenal ulcer, gastric ulcer, reflux esophagitis, and in control of acid secretions in pathological hypersecretor y conditions Treatment of systemic and local bacterial infctions caused by susceptible organisms. Urinary tract and lower respirator tract infections. Chronic hepatic disease Headache, diarrhea, abdominal pain, nausea, dizziness, vomiting, rash,

Dosage adjustment may be Caution patient to avoid

Piperacilli n + Tazobacta m

4.5 gms, IVT q8

Penicillins

Hypersensit ivity to penicillins, cephalospor ins

Diarrhea, nausea and vomting, rash, leucopenia, thrombocytopeni a, pruritus, urticaria, fever, injection site reaction

Assess for history of allergy to clindamycin, history of asthma or other allergies; hepatic or renal dysfunction; lactation; history of regional enteritis or ulcerative colitis; history of antibiotic associated colitis. Explain to the patient the importance of taking the full prescribed course of antibiotic therapy. Stress not to stop therapy without informing the prescribing physician. Instruct patient to report severe or watery diarrhea, abdominal pain, inflamed mouth or vagina, skin rashes or any other reactions noticed after starting drug therapy.

Propan with Iron

1 cap OD

Appetite Enhancer

For all types of anorexia specifically in conditions

Primary hemochrom atosis

Mild drowsiness and occasional GI discomfort

Teach patient healthy dietary

habits

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Salbutamo l + Ipratropiu m

1 neb q4

Antiasthma tic and COPD preparation

associated with irritability, body weakness and easy fatigability. Fe deficiency anemia and malnutrition management of reversible bronchospas m associated with obstructive airway disease Prevention of attacks of angina pectoris. Supplementar y treatment for CHF.,

Transderm Nitro patch

5mg. 1 patch OD

AntiAnginal

Hypertrophi c obstriuctive cardiomyop athy. Hisory of hypersensiti vity to soya lecithin Acute circulatory failure, increased intracranial pressure, myocardial insufficienc y due to obstruction Pregnancy and Lactation

Fine tremor of skeletal muscle, palpitations, headache, dizziness, nervousness, dryness of mouth Nausea and vomiting, application site reactions, postural hypotension, flushing, dizziness

Warn patient about risk of

.Gastric discomfort, nausea, headache, vertigo

Trimetazid ine

35 mg, I tab BID PO

AntiAnginal Drugs

Treatment of ischemic heart disease, angina pectoris, sequelae of infarction

paradoxical bronchospasm and to stop drug immediately of it occurs. It may cause dryness of mouth, offer water after nebulization watch out for tachycardia Closely monitor vital signs particularly blood pressure. Excessive hypotension may worsen MI Transdermal forms can be applied to any nonhairy part of the skin except distal parts of the arms or legs Drug may cause headaches, Treat headache with aspirin or acetaminophen Take immediately after meals

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Table 14: Comparison of Initial and Final Assessment

INITIAL ASSESSMENT PARAMETERS A. PHYSIOLOGICAL FACTORS A. Oxygenation Manifests normal vital signs: Respiratory Rate (16-20 breaths/min) with normal breath sound and effortless breathing. Pulse Rate (60-100 beats/min). Blood Pressure (100-120/60 -80 mmHg). B. Nutrition 1. Adheres to soft, low salt, low fat diet 2. Eat regularly at least three times a day. 3. Drinks sufficient amount of water (1,500cc) of water daily. 4. Takes nutritional supplements like multivitamins. 5. Exhibits ideal body weight for height and age. C. Elimination 1. Defecates soft formed stool daily. 2. Voids approximately 5 8 times daily (800-1000cc) without any difficulty. D. Activities of Daily Living 1. Performs activities of daily living independently. 2. Performs active and passive exercises E. Rest and Sleep 1. Sleeps at least 6-8 hours at night without interruption. 2. Takes adequate amount of rest at daytime. 3. Feels rested and ready for daily activities after sleep. B. PSYCHOLOGICAL FACTORS 1. Expresses concerns about the nature of disease. 2. Inquires about the nature of disease. 3. Expresses contentment in life. 4. Feels that life is worth living. 5. Enjoys normal day to day activities C. SOCIO-CULTURAL FACTORS A. Interpersonal Relationship 1. Demonstrates good interpersonal relationship with wife and children 2. Mingles with relatives and friends. B. Community Resources Utilizes health facilities (like health center, hospital) appropriately for care needs. D. SPIRITUAL FACTORS 1. Expresses faith in God 2. Devotes regular worship time. 3. Expresses gratification with compatibility of spiritual belief and daily living. E. DEVELOPMENTAL FACTORS 1. Works with sense of accomplishment. 2. Shows ability to work with dedication. 3. Demonstrates ability to make decisions in given situation. TOTAL FINAL

2 3 3 2 2 2 2 2 2 3 2 1 2 2 2 3 3 2 2 2

3 4 3 3 3 3 4 3 3 4 3 3 3 3 3 3 3 3 3 3

3 2 4 3 3 2 2 3 2 79

4 3 4 4 3 3 3 3 3 96

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Table 15. Likert Scale for Categorizing NANDA, Nursing Outcome Classification and Nursing Intervention Classification

Scoring Indicators are rated by the use of the following scale: 1 = Extremely Compromised 2 = Substantially Compromised 3 = Moderately Compromised 4 = Mildly Compromised 5 = Not Compromised Category =

Computation

Total Score of Indicators Total Number of Indicators