125321274 peritoneal-carcinomatosis-grand-case-study

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ASCITES SECONDARY TO PERITONEAL TUBERCULOSIS,
RULE OUT PERITONEAL CARCINOMATOSIS
____________________
A Case Study Presented to the
College of Health Sciences Faculty
Notre Dame University
Cotabato City
____________________
In Partial Fulfillment of the

Requirements for the Degree of
BACHELOR OF SCIENCE IN NURSING
By
Alim, Suharto U.
Ambolodto, Sandra Mae A.
Cadungog, Evelyn Claire O.
Gorospe, Irish Kate A.
Rubi, Beverly Joy A.
Sero, Valerie P.
Sumampao, Diamond M.
Suyom, Jessieden E.
December 13, 2012
Ascites Secondary to Peritoneal ii
ACKNOWLEDGEMENT
This case study would not have been provided, done and studied if not for the
support of the people who unselfishly contributed their time, knowledge, skills, and
effort. With grateful heart and minds, the group would like to extend their gratitude to the
following:
The Almighty Father, source of strength, wisdom, and knowledge for giving them
hope and enlightenment, which they need to accomplish these study.
Their beloved parents, for providing them financial assistance that made possible
the compilation of their study and for inspiring, and giving them enough strength, and
courage in pursuing their study.

Lyreyann A. Cordero, RN for assisting and guiding the group in their case study
and checking their case written output.
The Cotabato Regional and Medical Center and staff of medicine ward for the
trust and time, thus, giving us enough time to gather relevant data to our patient and the
staff of emergency department for supervising us upon duty hours and assisted us on the
delivery of quality nursing service.
To our client and her family, for their trust, willing participation, and allowing the
group to render appropriate nursing service and conduct an interview, assessment and
study on her disease process.
To Maureen Laurice T. Cases, RN, their adviser for critiquing and checking their
work, sharing her expertise, comments, and suggestions which added to the group’s
knowledge improved the study.
Ascites Secondary to Peritoneal iii
TABLE OF CONTENTS
Page
TITLE PAGE ...................................................................................................................... i
ACKNOWLEDGEMENT..............................................................................................
CHAPTER I INTRODUCTION
Overview of the Case........................................................
Incidence........................................................................
Rationale for Choosing the Case..........................................
CHAPTER II OBJECTIVES
General Objective..........................................................
Specific Objectives.................................................................
CHAPTER III PATIENT’S HISTORY.............................................................
i
ii
1
1
2
3
3
4
7
7
11
13

CHAPTER IV PHYSICAL ASSESSMENT...............................................................
General Physical Survey.................................................
Focus Assessment.............................................................
CHAPTER V REVIEW OF ANATOMY & PHYSIOLOGY............................
CHAPTER VI PATHOPHYSIOLOGY ………………..………………………
Narrative Discussion.........................................................
Schematic Diagram............................................................
CHAPTER VII COURSE IN THE HOSPITAL …………………………………
CHAPTER VIII NURSING CARE PLAN ……………………………….……..
CHAPTER IX DRUG STUDY…………………….……………………………
CHAPTER X LABORATORY STUDY...........…………………………………
CHAPTER XI PROGNOSIS …………………………………………………..
CHAPTER XII DISCHARGE SUMMARY PLAN …………………………..….
CHAPTER XIII BIBLIOGRAPHY ……………………………………………...
CHAPTER I
INTRODUCTION
Peritoneal carcinomatosis (PC) is a type of secondary cancer that affects the lining
of the abdominal cavity, called the peritoneum. It occurs when cancer metastasizes from
another part of the body and implants into the lining. Peritoneal carcinomatosis most
commonly follows severe or untreated pancreas, ovarian, stomach, and colon cancer.
Symptoms can vary, but many people experience extreme fatigue and abdominal pain.
Quick, aggressive treatment in the form of medications and surgery is vital in preventing
fatal complications (Jeffress, 2012). Tumor growth on intestinal surfaces and associated

fluid accumulation eventually result in bowel obstruction and incapacitating levels of
ascites, which profoundly affect the quality of life for affected patients. Recently,
population-based studies have revealed that PC occurs relatively frequently among
patients with colorectal cancer (CRC). Risk factors for developing PC have been
identified: right-sided tumor, advanced T-stage, advanced N-stage, poor differentiation
grade, and younger age at diagnosis (Klaver et. al, 2012). Peritoneal carcinomatosis
represents a devastating form of cancer progression with a very poor prognosis
(Kusamura et. al, 2010).
In Germany, 66,000 new cases are diagnosed every year. Up to 25% of those
patients develop a peritoneal carcinomatosis (Sugarbaker et. al, 2007). Cytoreductive
surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are playing an
ever increasing role in the treatment of peritoneal carcinomatosis (Austin et. al, 2012).
Ascites Secondary to Peritoneal 2
Although survival benefit of this procedure has been reported in numerous literatures,
this treatment is still not widely accepted worldwide because of the necessity of long
learning curves for application of these techniques and high postoperative mortality and
morbidity rates (Mizumoto, 2012). Most patients with this condition will not live much
longer than two years without treatment. The shortest time they usually survive is only
six months. According to the peritoneal carcinomatosis survival rate statistics, 17% of the
patients who received treatment died after surgery (Peritoneal Health, 2010). The most
common cause of peritoneal carcinomatosis in women is ovarian cancer. Two-thirds of
women with ovarian cancer present with abdominal dissemination of disease, the

standard management of which comprises surgical debulking followed by chemotherapy
(Johnson, 1993).
The researchers chose this case because they wanted to know more about this type
of cancer since this case has long been considered a fatal clinical entity, rarely seen and
treated palliatively, thus it will help and add additional learning’s from what they had
already learned from their past concept, thus, this study will help them give appropriate
health teachings for their future clients with the same cancer called peritoneal
carcinomatosis.
CHAPTER II
OBJECTIVES
General Objective:
This case study aims to understand the disease process of Peritoneal
Carcinomatosis and to learn about its aftermath in the human body; thereby helping us,
the student nurses to be guided on how to deal with clients with the said condition,
especially the implementation of nursing care.

Specifically, the study aims to:
1. Organize patient’s data to establish good background information.
2. Review the health history.
3. Understand the definition of Peritoneal Carcinomatosis.
4. Determine the signs & symptoms and complications manifested by the patient.
5. Discuss the normal functioning of the Gastrointestinal System.
6. Present the pathophysiological basis of the disease.
7. Study the different laboratory and diagnostic tests.
8. Understand the significance of specific medications given to the patient.
9. Formulate and prioritize different nursing care plans.
10. Impart appropriate health teachings to the patient and as well as to the family.
11. Discuss discharge plan and prognosis for the continuity of care.
12. Assist future researches that they may use the output as basis for further research.
CHAPTER III
PATIENT’S HISTORY
NAME: Ms. Bella
AGE: 23 years old
SEX: Female
CIVIL STATUS: Single
NATIONALITY: Filipino
ADDRESS: RH 4, Cotabato City

DATE OF BIRTH: November 30, 1989
RELIGION: Roman Catholic
OCCUPATION: Housewife
_____________________________________________________________________________________
DATE/TIME OF ADMISSION: December 5, 2012 / 11:10 am
PREVIOUS ADMISSION: November 22-30, 2012
ATTENDING PHYSICIAN: Nelson P. Gilapay, MD
ADMITTING V/S: T: 36.5°C HR: 98bpm
RR: 25 bpm BP: 120/90 mmHg
Ht: 5’1 Wt: 42 kg
CHIEF COMPLAINT: Abdominal distention
ADMITTING DIAGNOSIS: Ascites secondary to Peritoneal
Tuberculosis, rule out Peritoneal
Carcinomatosis
Past Illness History
Long before, the patient was living a simple and happy life. She experienced
childhood illness such as German measles during her fourth grade. She loves chicken so
much and does not necessarily do exercise.
She formerly worked as a clerk. Years passed by, this young lady turns into a
lovely maiden, August 2012; she was admitted and delivered her first child, a baby girl,
via Normal Spontaneous Vaginal Delivery at Cotabato Regional and Medical Center. She
claimed to have regular prenatal visit in the same institution. She had no extraordinary
qualms during her pregnancy.

Two months after her delivery, she noticed to have constipation for few days and
took one dose of laxative (Dulcolax). However, constipation persists and abdominal
distention was observed by her and her family. Despite of these manifestations, they did
not immediately seek any medical attention. One month prior to admission, patient
consulted a private physician and requested for abdominal CT scan but failed to comply.
Last November 22, 2012, she was admitted with chief complaints of constipation
and abdominal distention. She was diagnosed with peritoneal carcinomatosis. She was
then discharged last November 30, 2012, with take home medications of Furosemide
40mg 1 tablet once a day, Spironolactone 25mg 1 tablet for twice a day, Vitamin B
complex + Folic acid + Ferrous sulfate 1 capsule twice daily, and Vitamin C (Poten cee)
1 tablet twice a day, Ciprofloxacin 500mg 1 tablet twice daily, and Domperidone 1 tablet
three times a day, and was encouraged to increase fiber in the diet.
Present Illness History
She was supposed to come back for follow up checkup on December 5, 2012 but
a day before her follow up checkup, she was hurriedly brought to the same hospital due
to progressive abdominal distention and difficulty of breathing, and was admitted.
Family History
On the client’s mother side, she claimed a positive history of hypertension, and
her uncle died a year ago from liver cirrhosis, but no idea about the health history on her
father side.

CHAPTER IV
PHYSICAL ASSESSMENT
Appearance and Behavior
1. Age, Sex, and Race -23 years old, Female, Asian
2. Body Build -Ectomorphic; emaciated
3. Posture and Gait -Coordinated movement when sitting and
walking with difficulty.
4. Hygiene and Grooming -Slightly clean and neat, unfixed hair,

untrimmed nails
5. Dress -Appropriate for age, place and climate
6. Odor of the body and breath -Slight foul smell noted on body and breath
7. Signs of distress -Mild respiratory distress
8. Apparent state of health -Use accessory muscles when breathing,
anxious, pain scale of 6/10.
9. Attitude -Cooperative with treatment
10. Affect and mood -Cooperative with treatment, expresses
feelings regarding her condition
11. Speech -Understandable, moderate pace, clear tone
12. Thought Process -Conscious, oriented, coherent, follows
direction
Skin
Fair skin. Has smooth skin texture, no presence of wounds. Hair is well
distributed on both parts of the body, nails are untrimmed. Skin returns back after 3-4
seconds when doing skin turgor; warm to touch.
Head
Skull is oval, smooth skull contour, uniform consistency, no tenderness palpated,
absence of nodule or mass with symmetrical facial features and movements.
Eyes

Eyebrows are evenly distributed, symmetrically aligned, equal movements of the
eye; eyelashes are equally distributed, curved and slightly outward. Eyelids skin is intact,
closes symmetrically, bilateral blinking, bulbar conjunctiva is clear with tiny vessel, and
palpebral conjunctiva is pink with no discharge. Sclera appears moist.
Ears
Ears are symmetrical, color same as face, firm and not tender; Pinna coils after it
folded. Presence of mass, lesions, lacerations, bruises, swelling was not seen upon
inspection. No unusual discharge noted.
Mouth
Slightly dry lips, yellowish teeth, pale gums, no swelling noted; Tongue is pink in
color, no lesions, no tenderness, no palpable nodules, uvula is position on midline of soft
palate. Tonsils are not inflamed, slight halitosis noted upon assessment.
Nose
Nose is symmetrical and straight, without nasal discharge, uniform in color, not
tender, no lesions; nasal septum is intact and located in the midline. External surface of
the patient’s nose is smooth and oily.
Neck
Patient can move his neck freely without any difficulty. No lesions, masses,
deformities noted upon inspection. No neck vein enlargement.
Chest/Lungs

Chest and lung expansion symmetry are equal, with mild respiratory distress,
intercostals spaces are equal but labored; respiratory, rhythm and depth are even,
respiratory rate of 25 breaths/min, evident use of accessory muscles when breathing.
Abdomen
Patient’s abdomen is distended. Abdominal girth is 93 cm. Scars noted on her
right lower quadrant of the abdomen due to paracentesis, and left lower quadrant of the
abdomen due to biopsy procedure. Have palpable masses at all quadrants of the abdomen.
Genito-urinary
Has regular urination. No indwelling catheter present.
Upper extremities
Patient’s upper limbs, shoulders and arms were symmetrical but thin. No
deformities and swelling noted. No tenderness on the bones of the wrists and fingers and
no structural deviations.
Lower extremities
Patient’s lower limbs are symmetrical but thin. No deformities and swelling
noted.

FOCUS ASSESSMENT
Abdominal Assessment
A. INSPECTION
1. Skin
Color of the abdomen is same with other parts of the body; smooth and
shiny in texture with visible veins observed.
2. Umbilicus

Flat, centrally located at the midline; pale in color.
3. Contour
Distended and round in contour.
4. Symmetry
Abdomen is symmetrical upon inspection.
5. Enlarged organs
No enlarged organs based on diagnostic tests.
6. Peristalsis
No peristalsis noted upon inspection.
7. Pulsation
No pulsation noted upon observation.
B. AUSCULTATION
1. Bowel sounds
Hypoactive bowel sounds heard in all four quadrants upon auscultation.
C. PERCUSSION
1. Entire Abdomen
Dullness noted in all quadrants of the abdomen.
D. PALPATION
1. Measure Abdominal Girth
93cm
E. Special Maneuvers

1. Assess for possible ascites
Has visible veins observed upon inspection; ascites noted.
2. Testing for shifting dullness
Positive for shifting dullness, dullness of percussion shifts as patient was
turned from side to side.
3. Testing for fluid wave
Positive fluid wave transmitted from one abdominal wall side to the other
side upon placing a hand on one side of the abdomen, then pressing the opposite
side of the abdomen with the other hand, shifting the fluid.
CHAPTER V
REVIEW OF ANATOMY & PHYSIOLOGY
The Abdomen and the Gastrointestinal System

The abdomen (commonly called the belly) is the body space between the thorax
(chest) and pelvis. The diaphragm forms the upper surface of the abdomen. At the level
of the pelvic bones, the abdomen ends and the pelvis begin.
The abdomen contains all the digestive organs, including the stomach, small and
large intestines, pancreas, liver, and gallbladder. These organs are held together loosely
by connecting tissues (mesentery) that allow them to expand and to slide against each
other. The abdomen also contains the kidneys and spleen. Many important blood vessels
travel through the abdomen, including the aorta, inferior vena cava, and dozens of their
smaller branches. In the front, the abdomen is protected by a thin, tough layer of tissue
called fascia. In front of the fascia are the abdominal muscles and skin. In the rear of the
abdomen are the back muscles.
Abdominal organs
 Digestive tract: Stomach, small intestine, large intestine with cecum and appendix
 Accessory organs of the digestive tract: Liver, gallbladder and pancreas
 Urinary system: Kidneys and ureters - but technically located in retroperitoneum -
outside peritoneal membrane
 Other organs: Spleen

Introduction to the gastrointestinal system
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from
the oral cavity, where food enters the mouth, continuing through the pharynx,
oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There
are various accessory organs that assist the tract by secreting enzymes to help break down
food into its component nutrients. Thus the salivary glands, liver, pancreas and gall
bladder have important functions. Food is propelled along the length of the GIT by
peristaltic movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break food down into
nutrients, which can be absorbed into the body to provide energy. First food must be
ingested into the mouth to be mechanically processed and moistened. Secondly, digestion
occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates
are chemically broken down into their basic building blocks. Smaller molecules are then
absorbed across the epithelium of the small intestine and subsequently enter the
circulation. The large intestine plays a key role in reabsorbing excess water. Finally,
undigested material and secreted waste products are excreted from the body via
defecation (passing of faeces).
The Peritoneum
The peritoneum is the serous membrane that forms the lining of the abdominal
cavity or the coelom—it covers most of the intra-abdominal (or coelomic) organs -
in amniotes and some invertebrates (annelids, for instance). It is composed of a layer

of mesothelium supported by a thin layer of connective tissue. The peritoneum both
supports the abdominal organs and serves as a conduit for their blood and lymph vessels
and nerves.
The abdominal cavity (the space bounded by the vertebrae, abdominal
muscles, diaphragm and pelvic floor) should not be confused with the intraperitoneal
space (located within the abdominal cavity, but wrapped in peritoneum). The structures
within the intraperitoneal space are called "intraperitoneal" (e.g. the stomach), the
structures in the abdominal cavity that are located behind the intraperitoneal space are
called "retroperitoneal" (e.g. the kidneys), and those structures below the intraperitoneal
space are called "subperitoneal" or "infraperitoneal" (e.g. ththe bladder).
The peritoneal membrane is a semi-permeable membrane that lines the abdominal
wall (parietal peritoneum) and covers the abdominal organs (visceral peritoneum). The
membrane is a closed sac in males. The fallopian tubes and ovaries open into the
peritoneal cavity in females. The size of the membrane approximates the body surface
area (1-2 m2). There are about 100 cc of transudate that is contained in the cavity in
normal individuals.
A. Blood Supply
The parietal peritoneum derives its blood supply from the arteries in the
abdominal wall. This blood drains into the systemic circulation. The visceral
peritoneum is supplied by blood from the mesenteric and celiac arteries which
drain into the portal vein.
B. Lymphatics
Subdiaphragmatic lymphatics are responsible for 80% of the drainage

from the peritoneal cavity. The drainage is then absorbed into the venous
circulation through the right lymph duct and the left thoracic lymph duct. A
balance of solutes and fluid in the interstitial tissue is maintained by absorption of
fluid from the peritoneal cavity. The average lymphatic rate of absorption in the
PD patient is 0.5-1.0 ml/min. Factors that affect the rate of absorption are
respiratory rate, posture, and intra-abdominal pressure.
Layers
Although they ultimately form one continuous sheet, two types or layers of
peritoneum and a potential space between them are referenced:
 The outer layer, called the parietal peritoneum, is attached to the abdominal wall.
 The inner layer, the visceral peritoneum, is wrapped around the internal organs
that are located inside the intraperitoneal space.
 The potential space between these two layers is the peritoneal cavity; it is filled
with a small amount (about 50 mL) of slippery serous fluid that allows the two
layers to slide freely over each other.
 The term mesentery is often used to refer to a double layer of visceral peritoneum.
There are often blood vessels, nerves, and other structures between these layers.
Subdivisions
There are two main regions of the peritoneum, connected by the epiploic
foramen (also known as the omental foramen or foramen of winslow):

 The greater sac (or general cavity of the abdomen), represented in red in the
diagrams above.
 The lesser sac (or omental bursa), represented in blue. The lesser sac is divided
into two "omenta":
- The lesser omentum (or gastrohepatic) is attached to the lesser curvature of
the stomach and the liver.
- The greater omentum (or gastrocolic) hangs from the greater curve of the
stomach and loops down in front of the intestines before curving back
upwards to attach to the transverse colon. In effect it is draped in front of the
intestines like an apron and may serve as an insulating or protective layer.
The mesentery is the part of the peritoneum through which most abdominal organs are
attached to the abdominal wall and supplied with blood and lymph vessels and nerves.
CHAPTER VI
PATHOPHYSIOLOGY
Narrative Explanation:
Peritoneal Carcinomatosis is a broad description in which multiple tumors
develop in, and line the peritoneal abdominal cavity and linings.
This description is used in conjunction with cancers and conditions of appendix,

colon, gall bladder, ovaries, mesothelioma, pancreas, Pseudomyxoma Peritonei, rectal,
sarcomas, small bowel, and stomach. When tumor develops from the peritoneum, it is
referred to as Primary Peritoneal Surface Malignancy. Occasionally, a tumor far from
the abdomen or a bone cancer can result in peritoneal carcinomatosis after cancerous
cells invade lymph nodes and the bloodstream.
Symptoms of Peritoneal Carcinomatosis may initially be detected by appearing
on as a diffused thickening of the peritoneum on a CT scan. The appearance of ascites
refers to the accumulation of fluid within the peritoneal cavity and may occur for a
variety of conditions including post operative inflammation or to cancer. The most
common symptoms of peritoneal carcinomatosis include acute or chronic aches,cramps,
bloating, and full-body fatigue. Many symptoms are caused when excess fluid
accumulates in the abdominal cavity, a direct consequence of nearby tumor activity.
Other problems such as breathing difficulties, digestive problems, and chest pains may be
present as well, depending on the extent and location of the original cancer.
Schematic Diagram:
Predisposing Factors
 Age (23 yrs. old)
 Gender (Female)
 Heredity
Precipitating Factors
 Environmental conditions
 Lifestyle
 Other health conditions
Damage to DNA in cell nucleus
Cell death
Cell Cycle Alteration
Carcinogenesis

Imbalance between
production and
absorption of fluid
Increased production and proliferation of enzymes and hormones
Tumor implants
compress the bowel
by their volume
New and rapid growth
Ascites (Abdominal
distention: Girth-93cm)
Bowel
obstruction
Compression and elevation
of the diaphragm
DOB
Pain
Damaged to surrounding
tissues and nerve
compression as tumor grows
Dissemination from the primary tumor
Invasion in the GIT
Paracentesis
Mechanical
effects:
Systemic
effects:
Cachexia
(muscle wasting)
Body cannot
synthesize amino
acids
Altered protein
metabolism
Weight loss
(From 50 kg to 42 kg)
Palpable
masses on the
abdomen

CHAPTER VII
COURSE IN THE HOSPITAL
DATE &
TIME
SIDE NOTES ORDERS RATIONALE
Peritoneal
Carcinomatosis

December
5, 2012
11:10 am
Problem:
Ascites
secondary to
Peritoneal TB,
r/o Peritoneal
carcinomatosis
 Admit with consent
under the service of
green team.
 Monitor vital signs
every hour and record.
 Small frequent
feedings.
 MIO every 4 hours and
record.
 IVF: D5LR 1L @ KVO
(microset)
 Laboratory:
 CBC, BT
 AFB peritoneal
fluid
 Medications:
 Ceftriaxone 1mg
IVTT every 12
hours ANST
-Admission for referral of
care.
-For close monitoring and
to watch out for any
unsualities.
-To prevent gastrointestinal
reflux.
-Provides information
about fluid status,
circulating volume and
replacement needs.
-Replacement therapy; to
support fluids and
electrolytes in the body.
-To use as baseline
information in comparison
to next repeated laboratory
exams.
-A screening test to
provide information about
the cellular components of
the patient’s blood; to
determine presence of any
abnormalities or disorders.
-Acid- fast bacilli, to
identify pathogenic
organisms present in the
peritoneal fluid, as well as,
to identify the
antimicrobial therapy that
is best suited for the
particular micobacteria
identified.
-An antibiotic
Cephalosphorin, for
treatment of susceptible

December
5, 2012
5:00 pm
(-) obstruction
seen
Surgical notes;
Thank you for
the referral seen
and examined
A/P
carcinomatosis
vs. PTB
 Ranitidine 50mg
IVTT every 8 hours
 Metoclopramide
10mg IVTT every 8
hours PRN for
vomiting
 Multivitamins +
Amino acid 1
capsule once a day
 For paracentesis, secure
consent
 Continue medication
management
 Refer
 For:
 CEA
 TSH
 FT4
infection.
-An H2 receptor
antagonist, used to
decrease gastric secretion.
-An antiemetic, for
management of nausea and
vomiting associated with
various GI disorders.
-To prevent low levels of
vitamins, folic acid, and
amino acids in the body.
-Secure consent, because
the procedure to be done is
an invasive procedure.
-Carcinoembryonic
antigen, a test performed
when cancer is suspected
but not yet diagnosed and
especially when doctor
suspects that cancer has
metastasized.
-Thyroid stimulating
hormonetest, is a test that
measures the amount of
thyroid stimulating
hormone in the blood.
-FT4, a test used to
determine if the thyroid
gland is functioning
properly; aids in
diagnosing
hyperthyroidism or

9:30 pm
December
6, 2012
12:00 mn
7:00 am
5:00 pm
December
7, 2012
8:00 am
(-) DOB,
Conscious,
coherent
(-) BM for 3
days
(+) thirsty
 For CA-19-9
 Weight patient
 For serum Na, K, Ca
 For abdominal x-ray,
supine upright
 For PPD
 For chest x-ray PA
 For UR provided
paracentesis
 Paracentesis done, no
backflow
 Will repeat
paracentesis tomorrow
 IVF to follow:D5LR
1L at 20 gtts/min
hypothyroidism.
-A screening test for
cancer; (main use: tumor
marker)
-Initial losses or gains
reflect changes in
hydration but sustained
losses suggest nutritional
deficit.
-To assess levels
-An imaging test to
visualize the organs and
structures inside the
abdomen.
-PPD (purified protein
derivative), test used to
diagnose tuberculosis.
-An imaging study to help
determine and reveal if
there are any extensive
pathologic processes
present in the patient’s
lung or any associated ribs
fracture.
-A procedure to take out
fluid that has collected in
the peritoneal cavity.
support fluids and

December
7, 2012
December
8, 2012
1:45pm
9:40pm
Paracentesis
failed
(-) BM
(-) DOB
(+) dyspnea
 Multivitamins +
minerals (supplement)
1 vial OD x 12 hours
 Biopsy done
 Dressing done of
punctured sites; send
slides and specimens.
 For cell block and
cytology
 Lactulose 30cc TID
 Still for paracentesis
 Management for
diagnostic laparotomy
 Refer back to surgery
 O2 intubation at
4L/min via nasal
cannula
 High back rest
 Tramadol drip:
tramadol 100 mg 1amp
+ D5W 500cc x 24
hours
 Refer for any
-To supplement the diet
with additional vitamins
and minerals
-Biopsy is a medical test
that involves removal of
tissue in order to examine
it for a type disease.
-To promote healing of the
punctured site and prevent
infection; For laboratory
analysis.
-A diagnostic test used to
look for cancers and
precancerous changes. It
may also be used to look
for viral infections in cells.
-For treatment of
constipation.
-Will repeat paracentesis
because the first attempt
failed.
- A test to visualize the
organs and structures
within the abdomen.
-To supply oxygen to the
patient.
-To enhance lung
expansion and ventilation.
- A narcotic-like pain
reliever used to treat
moderate to severe pain.

December
9, 2012
9:00am
December
10, 2012
8:00am
9:00am
(+) DOB
(+) abdominal
distenetion and
pain
(+) abdominal
distention
(-) tenderness,
organomegaly
(+) fluid wave
(+) abdominal
distention
unusualities
 Patient’s relative
appraised of patient’s
Condition
 Standby intubation set
 VS q hour to include
O2 saturation
 For close watch
 IVF TF: D5LR 1L @
20 gtts/ min
 Monitor VS q hourly
 Family appraised of
patient’s condition
 Continue supportive
care
 Refer if with problem
 Still for referral to
surgery
 O2 @ 3L/min
 For repeat paracentesis
tomorrow
 For general liquids
 Thank you for referral
-To inform the family
about the patient’s
condition.
-As preparation for a
certain procedure.
-To carefully monitor the
patient’s condition.
-To carefully monitor the
patient and for immediate
referral for any
unusualities.
support fluids and
-To provide oxygen and
support ventilation.
-To provide the body
nutrition in liquid form,
also to prepare for
diagnostic procedure and
severe illness.

December
11, 2012
7:00 am
(-) DOB
(-) Chest pain
(+ )Distended
abdomen
(+) Fluid wave
 Patient seen and
examined
 History reviewed
 For referral to service
consultant
 Refer
 IVF TF: PNSS 1L @
20 gtts/min
 Albumin 25% 50cc+
furosemide 20mg x 2
hours q12hours
 To start once
paracentesis done
 IVF TF: D5LR 1L at
20 gtts/min
 Suggest paracentesis
today
 For serum electrolytes
 Refer
 Rounds with Dr.
Tolentino
 Plan for diagnostic
laparoscopy once
decided
 Refer once with
-For further assessment and
to contain information,
thus, help diagnose the
patient’s condition.
-An isotonic solution; used
to support fluids and
-Albumin and Furosemide
therapy helps improve fluid
balance in the body by
dieresis.
support fluids and
-A procedure to take out
fluid that has collected in
the peritoneal cavity.
-A laboratory test to
determine the electrolytes
level in the body.
-To know if patient agreed

consent
 Refer accordingly
with the planned diagnostic
procedure.

CHAPTER VIII
NURSING CARE PLAN # 1
HRP NSG.
Dx
AMB PATHO-
PHYSIOLOGY
CLIENT
OUTCOME
NURSING
INTERVENTIONS
RATIONALE EVALUATION
E
X
C
H
A
N
G
I
N
G
Ineffective
breathing
pattern r/t
decreased
lung
compliance
secondary to
ascites
(Dec.7,
2012)
Subjective:
-“Medyo
nahihirapan
akong
huminga,
malaki kasi
tong tiyan ko”,
as verbalized.
Objective:
-RR: 25 bpm
-Nasalflaring
noted
-DOB noted
-Uses
accessory
muscles
-Abdominal
distention
noted due to
ascites
-Abdominal
girth of 93 cm
The accumulation of
fluid may cause
breathing difficulties
by compressing the
diaphragm.
A person with
ascites has a
swollen, rounded
stomach. The skin
on the abdomen is
tight. The size of the
abdomen is related
to the amount of
fluid present.
Ascites may extend
as far as the chest
cavity. The presence
of the fluid adds
pressure to the lungs
and may cause the
individual to
experience difficulty
breathing.
Within the shift,
patient will breathe
with minimal
difficulty as
evidenced by not
using accessory
muscle and RR
within normal
range.
1. Monitor vital signs.
2. Place on semi-
fowler’s position with
arms supported with
pillows.
3. Maintain calm
attitude while dealing
with client and to
significant others.
4. Encourage adequate
rest and sleep periods
between activities.
5. Instructed to avoid
overeating/ gas-
forming foods.
-To watch out for
abnormalities, assess
condition.
-To relieve pressure on
the diaphragm.
-To limit the level of
anxiety.
-To limit fatigue and
preserve energy.
-They can cause
abdominal distention,
thus, will aggravate
difficulty of breathing.
Goal not met,
patient’s
respiratory rate
was 27 bpm,
evident use of her
accessory muscles
when breathing.

HRP NSG.
Dx
AMB PATHO-
PHYSIOLOGY
CLIENT
OUTCOME
NURSING
INTERVENTIONS
E
X
C
H
A
N
G
I
N
G
Deficient
fluid
volume
r/t active
fluid
volume
loss
(ascites:
third
spacing)
(Dec.7,
2012)
Subjective:
“Kadalasan
talaga gusto
kong
tubig.”
Objective:
-Abdominal
distention
(ascites)
- Muscle
weakness
-Poor skin
turgor
Ascites is the
accumulation
of fluid in the
peritoneal
cavity. Third
spacing occurs
when too much
fluid moves
from the
intravascular to
interstitial
space causing
a reduced
blood volume
in intravascular
space.
Within the
shift, the
patient will
able to
maintain fluid
volume at a
functional
level as
evidenced by
individually
adequate
urinary output
with normal
specific
gravity, stable
vital signs,
moist mucous
membranes,
good skin
turgor and
prompt
capillary refill.
1. Note possible condition that
may create a fluid volume deficit
such as fluid restriction,
vomiting or use of diuretics.
2. Monitor vital signs, noting
low blood pressure—severe
hypotension, rapid heartbeat,
and thready peripheral pulses.
3. Compare usual and current
weight.
4. Measure abdominal girth.
5. Instruct the client to avoid
foods very high in sodium
content.
6. Monitor Intake and output
accurately.
7. Instruct patient to avoid drinks
containing caffeine e.g.
beverages and coffee.
8. Change position frequently.
-Help identify and
prevent further fluid
deprivation.
-Changes in vital signs
are associated with fluid
volume loss and/or
hypovolemia.
-To note for any
significant fluid gain or
loss.
-To note for the extent of
fluid retention in the
abdomen.
-To avoid excessive
water retention and
further fluid shifting
(ascites).
-To note for significant
fluid loss and gain.
-To reduce effects of
diuresis.
-To reduce pressure on
fragile skin and tissues.
Goal partially
met. The
patient was
able to
maintain fluid
volume at a
functional
level as
evidenced by
good vital sign,
but skin turgor
was still poor
(3-4 sec).

HRP NSG.
Dx
AMB PATHO-
PHYSIOLOGY
CLIENT
OUTCOME
NURSING
INTERVENTONS
F
E
E
L
I
N
G
Acute pain r/t
abdominal
fullness
secondary to
ascites
(Dec.8,2012)
Subjective:
“Masakit
ang
tiyan ko
ngayon” as
verbalized
-pain scale
of 6/10
Objective:
-pale and
weak
looking
-with
limited
movements
noted
-facial
grimace
noted
-diaphoresis
noted
Pain is a highly
subjective state in
which a variety
of unpleasant
sensations and a
wide range of
distressing
factors may be
experienced by
the sufferer. Pain
may be a
symptom of
injury or illness.
Pain may also
arise from
emotional,
psychological,
cultural, or
spiritual distress.
Within the
shift, client
will report
pain is
relieved or
controlled
and
demonstrate
use of
relaxation
skills and
diversional
activities.
1. Allow patient to verbalize
pain.
2. Provide non-pharmacologic
comfort measures such as
repositioning, back rub and
diversional activities such as
listening to music and
conversing about pleasant
things.
3. Encourage use of stress
management skills or
complementary therapies such
as guided imagery and
therapeutic touch.
4. Observe or monitor signs
and symptoms associated with
pain, such as BP,HR, temp.,
color and moisture of skin,
restlessness,and ability to
focus.
5. Provide rest periods to
facilitate comfort, sleep, and
relaxation.
-Pain is subjective that can
only be felt by the person
affected.
-Promotes relaxation and
helps refocus attention.
-Enables patient to
participate actively in
nondrug treatment of pain
and enhances sense of
control.
- Some people deny the
experience of pain when it is
present. Attention to
associated signs may help
the nurse in evaluating pain.
- Pain may result in fatigue,
which may result in
exaggerated pain and
exhaustion.
Goal met, client
appears calm
and relaxed,
pain was
decreased from
6/10 to 3/10;
verbalized,
“Medyo hindi
na masakit
ngayon”.

HRP NSG.
Dx
AMB PATHO-
PHYSIOLOGY
CLIENT
OUTCOME
NURSING
INTERVENTIONS
E
X
C
H
A
N
G
I
N
G
Altered
bowel
elimination:
Constipation
r/t decreased
motility of
GI tract
(Dec. 8,
2012)
Subjective:
-“Hindi parin
ako
nakakabawas
simula ng
naadmit ako”
as verbalized.
-Reports
decreased
frequency of
bowel
movement
Objective:
-Abdominal
distention
noted due to
ascites
-Abdominal
girth of 93 cm
-Limited fluid
intake of
1000mL
-Inadequate
fiber intake due
to loss of
appetite
Constipation is a
condition
characterized by
infrequent or
hard bowel
movements, or
having difficulty
passing bowel
movements.
Also known as
irregularity,
Constipation can
include pain
when having a
bowel
movement, an
inability to “go”
after trying for
more than ten
minutes or
having no bowel
movement after
more than three
days.
Within the
shift, patient
will be able to
establish or
regain an
elimination
pattern as
evidenced by
bowel
movement
with at least
normal
consistency,
thus,
participate and
understand the
appropriate
interventions
or solutions in
order to
relieve self
from
constipation.
INDEPENDENT:
1. Auscultate abdomen for
presence and location of
bowel sounds and its
characteristics.
2. Note color, odor, consistency,
amount, and frequency of
previous stool.
3. Identify factors (eg.
Medications, bedrest, diet)
that may cause or contribute
to constipation.
4. Encourage on high fiber
foods, and suggest warm
stimulating fluids.
5. Encourage on light exercises
as tolerated.
DEPENDENT:
6. Administer laxative or stool
softeners as ordered.
-This reflects the bowel
activity.
-This provides baseline
comparison, promotes
recognition of changes.
-Assessing causative
factor is an essential first
step in teaching and
planning for improved
bowel elimination.
-To improve consistency
of stool and facilitate
passage.
-Influences bowel
elimination by improving
muscle tone and
stimulating peristalsis.
-May be necessary to
gently stimulate
peristalsis/ stool
evacuation.
Goal not met,
patient was still
unable to regain
her bowel
movement.

HRP NSG.
Dx
AMB PATHO-
PHYSIOLOGY
CLIENT
OUTCOME
NURSING
INTERVENTIONS
E
X
C
H
A
N
G
I
N
G
Imbalanced
nutrition less
than body
requirements
related to
feeling of
being full and
mal-
absorption
(Dec.11,
2012)
Subjective:
“Hanggang
apat na
kutsara lang
kaya kong
kainin kasi
feeling ko
wala ng
mapaglagyan
pagkain sa
tyan ko” as
verbalized.
Objective:
-Weakness
noted
-Poor muscle
tone
-Decreased
subcutaneous
fat/ muscle
mass
The client
perceived that
there is no space in
her stomach that’s
why she didn’t take
lots of food. Her
nutritional needs
was very high due
to poor eating
habits. She seems
to have poor
nutritional status.
Within 8 hours of
nursing
interventions the
client will be able to
regain weight and
verbalize
understanding of
causative factors
when known and
necessary
inteventions
 Assess weight, age,
body build,
strength, activity/
rest level
 Auscultate bowel
sounds. Note
characteristics of
stool.
 Weigh weekly and
document results.
 Encourage to
verbalize feelings
and concerns
 Discuss eating
habits including
food preferences,
intolerance,
aversions
 Determine
psychological
factors
-Use as comparative
baseline
-To identify if bowel
movement is present
for peristalsis
-To monitor
effectiveness of dietary
plan
-To know the real
concern/ feeling of the
client.
-To appeal to client
likes/ desires.
-To assess body image
and congruency with
reality
Goal partially met,
the client’s
nutritional status
enhances as
evidenced by
verbalization of
“Medyo naging
okay na ako
ngayon, may lakas
na ako” and
having an energy
during the conduct
of assessment and
during or within
the activity period.

HRP NSG.
Dx
AMB PATHO-
PHYSIOLOGY
CLIENT
OUTCOME
NURSING
INTERVENTIONS
F
E
E
L
I
N
G
Mild anxiety
related to
threat/
changes in
health status
secondary to
peritoneal
tuberculosis
(Dec.8, 2012)
Subjective:
“Kinakabahan
ako sa
kalagayan ko
ngayon”, as
verbalized.
Objective:
- -Awake with
blank stare
- -Focus on self
- Pale and
weak looking
-Limited
movements
noted
-Diaphoresis
noted
Mild anxiety speaks
for itself. Basically
your body's natural
warning system telling
you to go on alert
when there is no actual
cause for alarm.Even
though mild anxiety is
slighter in terms of
effects, it still can be a
heavy baggage
especially if it occurs
more often than you
think. On the case of
our client she was
anxious about her
current condition, if
there will be a good
prognosis or not.
Those suffering from
mild anxiety will
usually only suffer
from the physical and
mental symptoms.
Within the
shift, client
will be able
to appear
relaxed and
report
anxiety is
reduced to a
manageable
level.
1. Explore client’s
feelings.
2. Allow/ encourage
client to speak
openly about fears
and concerns.
3. Establish a
therapeutic
relationship,
conveying empathy
and unconditional
positive regard
4. Acknowledge
anxiety or fear. Do
not deny or reassure
that everything will
be alright
5. Monitor and record
vital signs.
-To know what/ how
does client really feels.
-To let him express
what are those he
think that makes him
worry.
-To let patient feel that
he’s not alone and to
avoid the contagious
effect or transmission
of anxiety.
-Not to let client
assure herself and
blame anyone if
something happen.
-To identify physical
responses associated
with both medical and
emotional conditions.
Goal met, client
was able to
expressed
feelings and
concerns;
appears relaxed
and verbalized,
“Mas okay sa
ngayon kesa
kanina”.

HRP NSG.
Dx
AMB PATHO-
PHYSIOLOGY
CLIENT
OUTCOME
NURSING
INTERVENTIONS
F
E
E
L
I
N
G
Anticipatory
grieving
related to
perceived
potential
death
(Dec.11,
2012)
Subjective:
“Malala na
daw tong
sakit ko”,
as
verbalized.
Objective:
-Weakness
noted
-
Alterations
in sleep
pattern
Grieving is an
intellectual and
emotional
responses and
behaviors by
which the
individual and
family work
through the
process of
modifying self
concept based on
the perception of
potential loss.
Since patient’s
illness has a poor
prognosis, and
chance of
survival is
minimal, it is
normal that the
patient and
family mourn.
Within the
shift, the
client will be
able to
identify and
express
feelings
appropriately.
1. Establish rapport to the client.
2. Provide open, nonjudgmental
environment. Use therapeutic
communication skills.
3. Encourage verbalization of
thoughts/concerns and accept
expressions of sadness,anger,
rejection. Acknowledge
normality of these feelings.
4. Reinforce teaching regarding
disease process and treatments
and provide information as
requested/
appropriate about dying. Be
honest; do not give false hope
while providing emotional
support.
5. Identify positive aspects of
the situation.
-To establish trust and
cooperation to the client.
- Promotes and encourages
realistic dialogue about
feelings and concerns.
- Patient may feel supported
in expression of feelings by
the understanding that deep
and often conflicting
emotions are normal and
experienced by others in this
difficult situation.
- Patient/SO benefit from
factual information.
Individuals may ask direct
questions about death, and
honest answers promote trust
and provide reassurance that
correct information will be
given.
-Possibility of remission and
slow progression of disease
and/or new therapies can
offer hope for the future.
Goal met, client
and family were
able to verbalize
understanding of
the dying process
and feelings of
being supported in
grief work.

HRP NSG.
Dx
AMB PATHO-
PHYSIOLOGY
CLIENT
OUTCOME
NURSING
INTERVENTIONS
M
O
V
I
N
G
Self-care
deficit r/t
lack of
motivation
in
performing
good
hygiene.
(Dec.7,
2012)
Subjective:
“Hindi ko na
magawang
maligo at mag-
ayos ng katawan
ko dahil sa sakit
ko”, as
verbalized.
Objective:
-discomfort
noted
-dry skin
-slight
unpleasant body
odor noted
Self-care deficit is
described as an
impaired ability
to perform
complete feeding,
bathing/ hygiene,
dressing and
grooming or
toileting
activities.
Since the patient
has weakness, it’s
hard for her to
move and do
daily activities
that’s why self-
care is often
depleted.
Within the shift,
the client will
be able to
cooperate in the
practice of good
and proper
hygiene.
1. Establish rapport to
the client.
2. Encourage to
verbalize feelings and
concerns.
3. Assist on adaptation
to accomplish
activities of daily
living.
4. Provide
communication among
those who are
involved in caring for
assisting the client.
5. Allow sufficient
time for the client to
accomplish task to
fullest extent of
ability.
-To establish trust
and cooperation to
the client.
-To discover barriers
to participation.
-To encourage client
and build on
successes.
-Enhances
coordination and
continuity of care.
-To enhance client’s
capabilities and
promote
independence.
Goal met, client
and family were
able to participate
in promoting good
hygiene to the
patient by giving
him a bed bath.

CHAPTER IX
DRUG STUDY # 1
GEN.
NAME
BRAND
NAME
DRUG
CLASS
MODE OF
ACTION
INDICATION
CONTRA-
INDICATION
ACTUAL
DOSE
USUAL
DOSE
SIDE
EFFECTS
NURSING
RESPONSIBILITIES
C
E
F
T
R
I
A
X
O
N
E
R
O
C
E
P
H
I
N
C
E
P
H
A
L
O
S
P
O
R
I
N
Inhibits
bacterial
wall
synthesis,
thus,
promoting
osmotic
instability
which
eventually
leads to
bacterial
cell death.
-Used to treat
infection
caused by
staphyloco-
ccus,
streptococcus,
E.coli, and
other
susceptible
microorganis
m. Skin to
skin structure
infection and
biliary tract
infection.
Contra-
indicated for
patients who
have known
hypersensitive
to cephalos-
porins and
any of its
components.
Ceftriaxone
1gm q12
ANST ( )
Ceftriaxone
1-2 gms
once a day
Signs of
allergy: skin
rashes, fever.
Hematologic:
leukopenia,
reversible
thrombo-
penia
Digestive:
nausea,
vomiting,
anorexia,
diarrhea
1. Observe the 10R’s of
administering drugs
(RIGHT: client,
medication, dosage,
route, time,
documentation, health
education, to refuse,
assessment, evaluation).
2. Assess patient’s previous
sensitivity reaction to
cephalosporins.
3. Monitor for signs of
allergic reaction.
4. Monitor vital signs before
and after giving the drug
esp. HR,RR,BP. Report
changes.
5. Explain that the patient
may experience the
following side effects:
nausea, diarrhea.
6. Encourage patient to
report for signs of
abnormalities.

DRUG STUDY # 2
GEN.
NAME
BRAND
NAME
DRUG
CLASS
MODE OF
ACTION
INDICATION
CONTRA-
INDICATION
ACTUAL
DOSE
USUAL
DOSE
SIDE
EFFECTS
NURSING
RESPONSIBILITIES
R
A
N
I
T
I
D
I
N
E
Z
A
N
T
A
C
Histamine
(H2)
receptor
antagonist
Inhibits the
action of
histamine at
H2 receptors
of the parietal
cells of the
stomach,
inhibiting
basal gastric
acid secretion
that
stimulates by
food, insulin,
histamine,
cholinergic
agonist,
gastrin, and
pentagastrin.
-Short-term
treatment of
active duodenal
ulcer; treatment
of gastro-
esophageal
reflux disease;
short-term
treatment of
active, benign
gastric ulcer;
treatment of
pathologic GI
hypersecretory
conditions
(postoperative
hypersecretion)
; heartburn.
-Contra-
indicated with
allergy to
ranitidine.
Use cautiously
with impaired
renal
or hepatic
function.
Ranitidine
50mg
IVTT q8
Ranitidine
25-50mg
IV twice or
thrice daily
CNS:
Headache,
malaise,
dizziness
CV:
Tachycardia,
bradycardia
GI:
Constipation,
diarrhea,
abdominal
pain,
hepatitis
Hematologic:
Leukopenia,
granulocytop
enia,
thrombocyto
penia,pancyt
openia
Local: Pain at
IV site,
phlebitis
administering drugs (RIGHT:
client, medication, dosage,
route, time, documentation,
health education, to refuse,
assessment,evaluation).
2. Monitor vital signs and watch
out for abnormalities such as
tachycardia or bradycardia.
3. Monitor intake and output.
4. Explain to hat she may
experience the following side
effects: headache,malaise.
5. Check laboratory results for
abnormalities and refer to the
physician.
6. Check the insertion site for
phlebitis.
7. Encourage to report
immediately for any signs of
abnormalities.

DRUG STUDY # 3
GEN.
NAME
BRAND
NAME
DRUG
CLAS
S
MODE OF ACTION INDICATION
CONTRA-
INDICATION
ACTUAL
DOSE
USUAL
DOSE
SIDE
EFFECTS
NURSING
RESPONSIBILITIES
M
E
T
O
C
L
O
P
R
O
M
I
D
E
P
L
A
S
I
L
Anti-
emetic
It binds to dopamine D2
receptors where it is a
receptor antagonist, and is
also a mixed 5-HT3 receptor
antagonist/ 5-HT4 receptor
agonist. The antiemetic
action of metoclopramide is
due to its antagonist activity
at D2 receptors in the chemo-
receptor trigger zone (CTZ)
in the CNS—this action
prevents nausea and
vomiting triggered by most
stimuli. At higher doses, 5-
HT3 antagonist activity may
also contribute to the
antiemetic effect. The
gastroprokinetic activity of
metoclopramide is mediated
by muscarinic activity, D2
receptor antagonist activity
and 5-HT4 receptor agonist
activity. The gastro-
prokinetic effect itself may
also contribute to the
antiemetic effect.
-Disturbances
of GI motility
-For nausea
andvomiting
-Contra-
indicated witha
llergy to
metoclopramid
e;
GI hemorrhage;
Mechanical
obstruction
or perforation;
fluid overload,
and renal
impairment
Metoclo-
promide
10mg
IVTT q8
PRN for
vomiting
Metoclo-
promide
1amp IV
q 6-8°
CNS:
restlessness,
drowsiness,
fatigue,
insomnia,
dizziness,
anxiety
CV:
transient
hypertension
GI: nausea
and diarrhea
administering drugs
(RIGHT: client,
medication, dosage,
route, time,
2. Check history: allergy
to metoclopramide, GI
hemorrhage, mechanical
obstruction
or perforation.
3. Monitor BP carefully
during IV
administration.
4. Monitor intake and
output.
5. Tell patient that she
may experience the said
side effects:drowsiness,
nausea,dizziness.

DRUG STUDY # 4
GEN.
NAME
BRAND
NAME
DRUG
CLASS
MODE OF
ACTION
INDICATION
CONTRA-
INDICATION
ACTUAL
DOSE
USUAL
DOSE
SIDE
EFFECTS
NURSING
RESPONSIBILITIES
M
U
L
T
I
V
I
T
A
M
I
N
S
+
A
M
I
N
O
A
C
I
D
S
N
U
T
R
I
W
E
L
L
Multi-
vitamins
and
supple-
ments
Multivitamin is
a combination
of many
different
vitamins that
are normally
found in foods
and other
natural
sources.Many
act as
coenzymes or
catalysts in
numerous
metabolic
processes. It
also works by
providing extra
vitamins, folic
acid, and amino
acids to the
body when you
need more than
what you get in
your diet.
Treating or
preventing
low levels of
vitamins, folic
acid, and
amino acids in
the body.
-Contra-
indicated if
you are
allergic to any
ingredient in
multivitamins
with folic
acid/amino
acids and if
you have high
blood levels of
arginine
(argininemia).
Multi-
vitamins +
Amino
acids 1cap
OD
Multi-
vitamins
1cap daily
Allergic
reactions:
Rash, hives,
itching,
difficulty
breathing,
tightness in
the chest,
swelling of
the mouth,
face,lips, or
tongue
2. Take multivitamins with folic
acid/amino acids by mouth
with or without food. If
stomach upset occurs, take
with food to reduce stomach
irritation.
3. Take multivitamins with folic
acid/amino acids with a full
glass of water (8 oz/240 mL).
4. Explain that she may
experience the following side
effects: rash,difficulty
breathing.
abnormalities.

DRUG STUDY # 5
GEN.
NAME
BRAND
NAME
DRUG
CLASS
MODE OF
ACTION
INDICATION CONTRA-
INDICATION
ACTUAL
DOSE
USUAL
DOSE
SIDE
EFFECTS
NURSING
RESPONSIBILITIES
M
U
L
T
I
V
I
T
A
M
I
N
S
+
M
I
N
E
R
A
L
S
S
U
P
P
L
E
M
E
N
T
S
Multi-
vitamins
and
supple-
ments
Multivitamin
and minerals
are used to
provide
vitamins and
minerals that
are not taken
in through
the diet.
Multivitamin
and minerals
works by
treating
vitamin or
mineral
deficiencies
caused by
illness, pregn
ancy, poor
nutrition,
digestive
disorders,
certain
medications,
and many
other
conditions.
Dietary
supplement
for the
treatment and
prevention of
vitamin and
mineral
deficiencies.
-Contra-
indicated if
you are
allergic to any
ingredient in
multivitamins
and minerals
and any of its
components.
Multi-
vitamins +
Minerals
(Supplements)
1 vial OD x
12hours
Multi-
vitamins +
Minerals 1
vial once or
twice a day
Less
serious side
effects:
upset
stomach,
headache,
unusual or
unpleasant
taste in
your mouth
Allergic
reaction:
Hives,
difficulty
breathing,
swelling of
your face,
lips,
tongue, or
throat.
1. Remember the 10R’s of
administering drugs
(RIGHT: client, medication,
dosage, route, time,
2. Monitor for manifestations
of hypersensitivity
appearance promptly.
3. Do not take this medication
with milk, other dairy
products, calcium
supplements, or antacids that
contain calcium. Calcium
may make it harder for your
body to absorb certain
ingredients of
the multivitamin.
4. Check for nutritional
deficiencies.
abnormalities.

DRUG STUDY # 6
GEN.
NAME
BRAND
NAME
DRUG
CLASS
MODE OF
ACTION
INDICATION
CONTRA-
INDICATION
ACTUAL
DOSE
USUAL
DOSE
SIDE
EFFECTS
NURSING
RESPONSIBILITIES
L
A
C
T
U
L
O
S
E
L
I
L
A
C
Laxative
Ammoni
a
reduction
drug
Metabolism of
lactulose by
bacteria results in
reduced colonic
pH which
stimulates
peristalsis &
decreases stool
transit time. In
turn, decreased
water reabsorption
from the feces
further facilitates
the passage of
soft, well-formed
stools. Increased
osmotic pressure
of fecalmaterial
secondary to an
increase in colonic
organic acids
results in accum.
of fluid from
surrounding
tissues, helping to
soften stool mass.
Treatment of
constipation.
Prevention
and treatment
of portal-
systemic
encephalo-
pathy
-Contra-
indicated to
patients with
allergy to
lactulose,
low-
galactose
diet.
-Use
cautiously
with
diabetes,
pregnancy
and lactation.
Lactulose
30cc TID
Lactulose
30cc
syrup
OD HS
GI:
Transient
flatulence,
distention,
intestinal
cramps,
belching,
diarrhea,
nausea
Other:
Acid-base
imbalance
administering drugs
(RIGHT: client,
medication, dosage, route,
time, documentation,
2. Instruct that this drug may
be taken with fruit juice or
milk to increase
palatability.
3. Do abdominal examination,
check bowel sounds, and
serum electrolyte levels.
4. Do not administer if patient
has already pass out stool
especially if stool is liquid.
6. Tell patient that she may
experience these side
effects: flatulence, intestinal
cramps, nausea)
7. Report if unusualities occur.

DRUG STUDY # 7
GEN.
NAME
BRAND
NAME
DRUG
CLASS
MODE OF
ACTION
INDICATION
CONTRA-
INDICATION
ACTUAL
DOSE
USUAL
DOSE
SIDE
EFFECTS
NURSING
RESPONSIBILITIES
T
R
A
M
A
D
O
L
T
R
A
M
A
L
Analgesic,
opioid
analgesic
Binds to –
opiate
receptors in
the CNS
causing
inhibition
of ascending
pain pathway
s, altering the
perception
of and
response
to pain; also
inhibits the
reuptake of
norepinephri
ne and
serotonin,
which also
modifies the
ascending
pain pathway
.
Moderate to
severe acute or
chronic pain
and in painful
diagnostic or
therapeutic
measures.
Hypersensi-
tivity to
tramadol,
opioids, or any
component of
the
formulation;
opioid-
dependent
patients; acute
intoxication
with alcohol,
hypnotics,
centrally-
acting
analgesics,
opioids, or
psychotropic
drugs.
Tramadol
drip:
tramadol
100 mg
1amp +
D5W
500cc x
24 hours
Tramadol
50 - 100
mg IV
every
4 - 6 hours
●Dizziness
●Nausea
●Drowsiness
●Dry mouth
●Constipation
●Headache
●Sweating
●Vomiting
●Itching
●Rash
●Atelectasis
2. Assess type,location, and
intensity of pain before and
2-3 hr (peak) after
administration.
3. Assess BP & RR before and
periodically during
administration.
4. Assess bowelfunction
routinely.
5. Encourage patient to cough
and breathe deeply every 2 hr
to prevent atelactasis and
pneumonia.
6. Instruct client to report any
adverse reaction to
the physician or nurse.

DRUG STUDY # 8
GEN.
NAME
BRAND
NAME
DRUG
CLASS
MODE OF
ACTION
INDICATION
CONTRA-
INDICATION
ACTUAL
DOSE
USUAL
DOSE
SIDE
EFFECTS
NURSING
RESPONSIBILITIES
A
L
B
U
M
I
N
A
L
B
U
M
I
N
A
R
Plasma
expanders
Blood
derivatives
Provides
increase in
intravascular
oncotic
pressure and
causes
mobilization
of fluids from
interstitial
into
intravascular
space.
For plasma
volume
expansion and
maintenance of
cardiac output
in the treatment
of certain types
of shock or
impending
shock; may be
useful for burn,
ARDS,
peritonitis, and
ascites.
Unless the
condition
responsible for
hypoproteinemi
a can be
corrected,
albumin can
only provide
symptomatic
relief of
supportive
treatment.
-Contra-
indicated with
allergy to
albumin and
any of its
components,
with severe
anemia and
Albumin
25% 50cc
+ furose-
mide
20mg x 2
hours
q12hours
Albumin
25% vials:
2-3 ml/
minute
maximum
 Fever
 Chills
 Flushing
 Hives,
 Skin Rash
 Itching
 Headache
 Nausea
 Breathing
Difficulty
 Rapid
Heart Rate
2. Monitor vital signs and
watch out for abnormalities.
4. Explain to the parents that
he may experience the
following side effects:
fever,chills, nausea.
5. Check laboratory results for
abnormalities and refer to
the physician.
6. Watch out for symptoms of
overdose, such as:
hypervolemia, CHF,
pulmonary edema.
abnormalities.

DRUG STUDY # 9
GEN.
NAME
BRAND
NAME
DRUG
CLASS
MODE OF
ACTION
INDICATION
CONTRA-
INDICATION
ACTUAL
DOSE
USUAL
DOSE
SIDE
EFFECTS
NURSING
RESPONSIBILITIES
F
U
R
O
S
E
M
I
D
E
L
A
S
I
X
Loop
Diuretic
Inhibits
sodium &
chloride
reabsorptio
n at the
proximal
tubules,
distal
tubules and
ascending
loop of
henle
leading to
excretion
of water
together
with
sodium,
chloride
and
potassium.
-Treatment of
fluid
accumulation
such as ascites,
edema
associated with
CHF,hepatic
cirrhosis, renal
disease.
- Hypersen-
sitivity to
furosemide,
sulfonylureas, or
any other drugs.
-
Contraindicated
in patients with
anuria,
hyponatremia
or hypovolemia.
Albumin
25% 50cc
+ furose-
mide
20mg x 2
hours
q12hours
Furosemide
20-40mg
IV
everyday
of one to
two times a
day
●Low blood
pressure
●Dehydration
and electrolyte
depletion
●Orthostatic
HPN
●Pruritus
●Vertigo
●Dizziness
●Fever
●Nausea
●Vomiting
●Constipation
●Oral and
gastric
irritation
●Diarrhea
●Increased
blood sugar
and uric acid
levels may also
occur.
administering drugs
(RIGHT: client,
medication, dosage,
route, time,
2. Check the BP first before
administration.
3. Monitor Intake and
Output of the patient.
4. Explain that she may
experience these side
effects:dizziness, nausea.
5. Instruct client to report
any signs of side effects.

CHAPTER X
LABORATORY STUDY # 1
DETERMINATION ACTUAL VALUE NORMAL VALUE SIGNIFICANCE/INTERPRETATION NURSING RESPONSIBILTY
HEMATOLOGY
(December 5, 2012)
● WBC
● RBC
● HGB
 HCT
 PLT
 MCV
 MCH
 MCHC
17.2 x 109
/ L
4.51 x 1012
/L
118 g/L
0.38
957 x 109
/L
84.0 fL
26 pg
340g/L
4.0-10.0 x 109
/ L
4.50-5.4 x 1012
/L
115-155 g/L
0.36-0.47
100-300 x 109
/L
86-100 fL
26-31 pg
310-375 g/L
 Increased; indicative of impending
infection or inflammation in the body due to
disease process.
 Normal; good oxygenation in the blood,
may decrease because of disease process.
 Normal; good circulation of oxygen in the
blood.
 Normal;there is good hydration status in
the patient’s body; good oxygen supply.
 Increased; or thrombocytosis, may result
from iron deficiency anemia or
inflammatory disorders.
 Decreased; MCV measures the ratio of
hematocrit to RBC count. May indicate iron
deficiency anemia
 Normal; MCH gives the hemoglobin to
RBC ratio.
 Normal: MCHC measures the ratio of
hemoglobin weight to hematocrit.
 Explain the procedure &
purpose of performing the
procedure, and that is to
determine infection & its
severity because of the
disease. This test is very
important as baseline data.
 Tell patient as well as watcher
that the test requires a blood
sample and explain who will
perform the venipuncture.
 Give health teachings on
patient’s diet and medication
that may contribute to the
result of the test.
 Based on the result, instruct
patient to eat nutritious foods
especially rich in vitamins,
minerals and iron, such as
fish, vegetables, and fruits.
 Advise to have adequate rest
and sleep periods.

 RDW
Differential Count
 Neutrophils
 Lymphocytes
 Monocytes
 Eosinophils
 Basophils
12.1 %
80 %
10 %
9.0 %
1.0 %
0 %
11.6-13.7 %
40-70 %
19-42 %
3.0-9.0 %
2.0-8.0 %
0-5.0 %
 Normal; RDW determines the measurement
of RBCs.
 Increased; may indicate infection,
inflammatory processes during physical
stress,or with tissue necrosis.
 Decreased; may signal infection in the body
and/or anemia.
 Normal; may increase because of illness
disease.
 Decreased; signals infection because of
illness.
 Normal; aids in determining specific
conditions.
 Stress out the importance of
taking multivitamins as
prescribed by the physician.
 Educate about the importance
of medications and treatment
regimen.
 Note for any abnormalities on
findings and refer the results
to the physician.

DETERMINANTS ACTUAL
VALUE
NORMAL
VALUE
SIGNIFICANCE/ INTERPRETATION NURSING
INTERVENTIONS
CLINICAL CHEMISTRY
(November 23, 2012)
 Creatinine
 SGPT/ALT
 SGOT/AST
 ALP
(Alkaline phosphatase)
 Total Protein
73.4 umol/L
333.4 nKat/L
383.4 nKat/L
1300.3 nKat/L
62 g/L
53-97 mmol/L
0-517 nKat/L
0-517 nKat/L
700-1630
nKat/L
64-83 g/L
Normal; indicates that the kidneys are able to
properly remove all creatinine. May increase if
dehydrated or took certain medications.
Normal; indicates that liver and kidneys are
functioning well. Low levels of ALT are normally
found in the blood. But when the liver is damaged or
diseased, it releases ALT into the bloodstream, which
makes ALT levels go up. Most increases in ALT
levels are caused by liver damage.
Normal; indicates no liver damage. High levels may
indicate severe MI, severe infectious mononucleosis
or alcoholic cirrhosis. Low levels indicate hemolytic
anemia, metastatic hepatic tumors or fatty liver.
Normal;indicates no liver or bone disease. ALP test
measures the amount of alkaline phosphatase
released from the tissues into the blood and is a
marker of the hepatobilary system function.
Moderate increase indicates acute biliary obstruction.
Low levels are linked to hypophosphatasia and
protein or magnesium deficiency.
Decreased;may be indicative of certain diseases such
as GI disease, protein deficiency, neoplastic disease,
malnutrition or malabsorption.
 Explain the procedure & purpose
of performing the procedure, and
that is to help diagnose the
occurrence of disease and if there
are complications, to test
effectiveness of medications and
find treatments for the disease.
 Explain the procedure to the
client that the medical
technician will get sample of her
blood for testing.
 Give health teachings on
patient’s diet and medication that
may contribute to the result of
the test.
 Instruct patient to eat nutritious
foods especially rich in vitamins,
minerals and proteins, such as
fish, vegetables, and fruits. Also,
instruct to eat nutritious food that
helps in cleansing the kidney.
 Strictly monitor the intake and
output.

 Albumin
 Globulin
 A/G Ratio
33 g/L
29 g/L
1.1
35-52 g/L
20-35 g/L
1.7-2.2
Decreased; may indicate that not enough protein is
being absorbed in the body, may also reflect diseases
such as malnutrition or ascites.
Normal;Globulin carries essential metals through the
bloodstream and carries them to the various parts of
the body and helps the body to fight infections.
Globulin proteins include enzymes, antibodies and
more than 500 other proteins. High levels indicate
tuberculosis. Low levels indicate GI disease,
malnutrition, or malabsorption.
Decreased;A low A/Gratio reflects overproduction
of globulins, due to chronic infections, liver and
kidney disease,fatty necrotic liver, rheumatoid
arthritis, leukemia, increased amount of nonspecific
protein, and autoimmunity disorders. On the other
hand, a high A/G ratio suggests under production of
immunoglobulin; this is seen in genetic deficiencies
and in cases of nephrosis, liver dysfunction, acute
hemolytic anemia, and hypogammaglobulinemia /
agammaglobulinemia.
 Advise to have adequate rest and
sleep periods.
 Stress out the importance of
taking multivitamin and
supplements as prescribed by the
physician.
 Note for any unusualities on
findings and refer the results to
the physician.

DETERMINANTS ACTUAL
VALUE
NORMAL
VALUE
INTERPRETATION / SIGNIFICANCE NURSING
RESPONSIBILITY
URINALYSIS
(November 23, 2012)
 Color
 Albumin
 Sugar
 Transparency
 pH
 Specific Gravity
 Pus Cells
 RBC
Yellow
(+)
(-)
Cloudy
Acidic
1.025
0-2/hpf
0-2/hpf
Pale yellow to
amber
None or 0-
8mg/dL
None or
0.08mml/L
(0-25mg/dL)
Clear to
slightly hazy
Acidic
1.003-1.060
Females: None
or 5-10/hpf
None or 0-
5/hpf
Normal; color may change due to diet and drugs.
Abnormal; an increase in urinary albumin excretion is indicative
of increased permeability of the filters of the kidney called,
glomerulus which due caused by some kidney damage.
Normal; normally, glucose is not present in the urine because it
is reabsorbed from the renal tubules.
Abnormal; cloudy urine may be caused by crystal deposits,
white cells, epithelial cells or fat globules.
Normal; pH measures how acidic or alkaline the urine is.
Sometimes urine pH is affected by certain treatments.
Normal; this checks the amount of substance in the urine. When
you drink lots of fluid your specific gravity becomes low. When
you are dehydrated your specific gravity becomes high.
Normal; there should be no yeast cells and bacteria or parasites
in the urine, if present; it means that there is infection.
Normal; normally, there is no blood in the urine. One of the
common causes of RBC in the urine is infection or inflammation
of the urinary tract itself (cystitis).
1. Instruct patient to void
into a clean, dry
container.
2. Sterile disposable
container should be used
always.
3. Cover all specimens
tightly, label properly and
send immediately to the
laboratory.
4. Observe standard
precaution when handling
the specimen.
5. Avoid the specimen to be
exposed to extreme
temperature such as
sunlight or heat.
6. The specimen should be
preserved if not to send to
laboratory to have
accurate results.

 Amorphous Urates
 Epithelial Cells
111
11
None
None to few
Increased; Amorphous Urates indicates uric acid crystals in the
urine. Higher than acceptable levels of uric acid crystals in urine
can be caused by gout, cardiovascular disease, diabetes, uric acid
stone, urolithiasis, and metabolic syndrome.
Increased; may suggest inflammation within the bladder, but
they may also originate from the skin and could be contaminated.
Sometimes, it is normal not to have any epithelial cells present in
a urine sample or to have occasional numbers of any of the three
cell types. Large numbers of squamous cells may indicate
contamination of the urine specimen, but large numbers of either
the transitional or renal tubular cells may indicate a serious
disease process.
7. Note for any unusualities
on findings and refer the
results to the physician.

DETERMINANTS ACTUAL
VALUE
NORMAL
VALUE
INTERPRETATION / SIGNIFICANCE NURSING RESPONSIBILITY
PERITONEAL
FLUID ANALYSIS
(November 26, 2012)
 Glucose
 Lactate
dehydrogenase
 Total protein
 Albumin
 Globulin
7.40 mmol/L
2025 U/L
6.6
4.20 g/dL
2.40g/dL
4.2-6.2 mmol/L
36-229.1 U/L
7.3-21.1 g/dL
< 1.1 g/dL
2.4-4.5 g/dL
Increased; may indicate tuberculosis and/or
malignancy; could be low in malignant ascites
Increased; Elevated levels of LDH and changes in the
ratio of the LDH isoenzymes usually indicate some type
of tissue damage. LDH levels typically will rise as the
cellular destruction begins, peak after some time period,
and then begin to fall.
Decreased; may be indicative of a symptom of a disease,
infection or an underlying condition. When there is
inadequate protein intake, the body begins to breakdown
muscle to obtain enough amino acids for the synthesis of
serum albumin.
Increased; to distinguish exudates and transudates.
Values above 1.1 g/dL are considered evidence of a
transudate.
Normal; Globulins are proteins that include gamma
globulins (antibodies) and a variety of enzymes and
carrier/transport proteins. Low globulin levels signify a
type of protein deficiency; high levels mean chronic
infections.
 Explain the procedure &
purpose of performing the
procedure, and that is to help
distinguish between types of
peritoneal fluid and help
diagnose the cause of fluid
accumulation (ascites).
 Explain that in this procedure,
a local anesthetic is applied to
the area of operation and then a
catheter is routed from the skin
into the peritoneal cavity. As
soon as this is done, the
peritoneal fluid will start to
flow out.
 Monitor vital signs prior to the
procedure.
 Advise to empty the bladder
first before the procedure
becausethis is a lengthy test.
 Note for any unusualities on
findings and refer the results to
the physician.

DETERMINANTS ACTUAL
VALUE
NORMAL
VALUE
SIGNIFICANCE/
INTERPRETATION NURSINGINTERVENTION
Immunology
CA 12-5
(November 28,
2012)
127 U/ml 0.35 U/ml Increased: indicates that the
cancer antigen is increased in
colon, upper gastrointestinal
(GI), ovarian, and other
gynaecologic cancers:
pregnancy, peritonitis.
 Explain the procedure and the purpose of
performing such procedure, and that is to
determine infection because of the disease, that
this test is very important as baseline data.
 Tell patient as well as watcher that the test
requires a blood sample and explain who will
perform the venipuncture.
 Give health teachings on patient’s diet that may
contribute to the result of the test.
 Based on the result, instruct the patient to eat
nutritious foods especially rich in iron, such as
fish, vegetables, and fruits.
 Advise to have adequate rest and sleep periods.
 Stress out the importance of taking
multivitamins as prescribed by the physician.

DETERMINANTS ACTUAL
VALUE
NORMAL
VALUE
SIGNIFICANCE/
Immunology
(December 6, 2012)
 Free T4
 TSH
 CEA
(Carcinoembryonic
Antigen)
0.95
4.08
531.12
0.58-1.64
ug/dl
0.34-5.60
µU/ml
0-3 ng/ul
Normal; indicates that thyroid hormone feedback
system is functioning well. This test was done to
evaluate thyroid function. The free T4 test is a newer
test that is not affected by protein levels. Since free T4
is the active form of thyroxine, the free T4 test is
thought by many to be a more accurate reflection of
thyroid hormone function.
Normal; indicates normal functioning of the thyroid.
T4 will be ordered along with a TSH to give a more
complete evaluation of the adequacy of the thyroid
hormone feedback system. These tests are usually
ordered when a person has symptoms of hyper or
hypothyroidism.
Increased; can indicate possible cancerous activity.
Increased CEA levels may also indicate some non-
cancer-related conditions, such as some forms of
inflammation, cirrhosis, and peptic ulcer. A CEA test
is ordered when the patient’s symptoms suggest the
possibility of cancer. CEA is an embryonic protein
which could be secreted in adult as well, if there is any
abnormality in protein producing organs, especially
liver, but similar protein can also be secreted if there is
a presence of cancer.
 Explain the procedure and the purpose of
performing such procedure, and that is to
evaluate thyroid function, determine
possibility of cancer,diagnosis of certain
illness or to monitor the effectiveness of
treatment.
 Tell patient as well as watcher that the test
requires a blood sample and explain who
will perform the venipuncture.
 Give health teachings on patient’s diet that
may contribute to the result of the test.
 Educate on the importance of strict
compliance to medication and treatment
regimen.
 Advise to have adequate rest and sleep
periods.
 Advise to eat nutritious foods necessary to
improve health and to hasten recovery.

DETERMINANTS ACTUAL
VALUE
NORMAL
VALUE
SIGNIFICANCE/
Electrolytes
(December 11, 2012)
 Serum Na
 Serum K
 Serum Ca
126.6
3.91
1.02
135-148
mmol/L
3.5-5.3
mmol/L
1.13-1.32
mmol/L
Decreased; indicates an electrolyte disturbance in which
the sodium concentration in the serum is lower than normal.
Sodium is the dominant extraellular cation and cannot freely
cross the cell membrane. Hyponatremia is most often a
complication of other medical illnesses in which excess
water accumulates in the body at a higher rate than can be
excreted (for example in congestive heart failure, syndrome
of inappropriate antidiuretic hormone, SIADH or
polydipsia.
Normal; Potassium testing is frequently ordered, along with
other electrolytes. The most common cause of hyperkalemia
is kidney disease, but many drugs can decrease potassium
excretion from the body and result in this condition.
Hypokalemia can occur if someone has diarrhea and
vomiting or if is sweating excessively. Potassium can be lost
through the kidneys in urine; in rare cases,potassium may
be low because someone is not getting enough in their diet.
Decreased; indicates an electrolyte imbalance.
Hypocalcaemia either occurs as a result of too much
calcium loss or insufficient calcium intake through food.
Early symptoms of low serum calcium include frequent
muscle cramps and joint pains. In addition to this, inability
to perform tiresome activities, fatigue, brittle nails, and
yellowness of teeth also occur as a result of abnormally low
level of calcium in the blood stream.
 Explain the procedure and the purpose
of performing such procedure, and that
is to determine electrolyte imbalance
in the body due to disease process
 Tell patient as well as watcher that the
test requires a blood sample and
explain who will perform the
venipuncture.
 Because of electrolyte imbalance,
initial treatment consists of slow
correction of the hyponatremia via
fluid restriction.
 To restore calcium to a normal level,
advise patient to eat calcium-rich foods
or calcium supplements on a regular
basis or as prescribed.
 Advise to eat nutritious foods
necessary to improve health and to
hasten recovery.

DIAGNOSTIC TESTS
 ABDOMINAL ULTRASOUND (November 23, 2012)
The liver is normal in size and echopattern. The intrahepatic ducts are not dilated. There are no focal mass lesions
seen.
The gallbladder is distended. There are no intraluminal stones seen. Wall is not thickened. The common duct is not
dilated.
The pancreas and spleen are normal in size and echopattern. There are no solid nor fluid-filled mass lesions seen.
The right kidney measures 11.0 x 3.4 cms while the left measures 10.0 x 4.2 cms. The cortical echoes exhibit normal
echogenicity and show good distinction of its corticomedullary junctions. The pelvocalyceal systems are intact. No ectasia
norlithiasis seen. There are no focal renal mass lesions detected.
The uterus is not dilated. The urinary bladder is distended without intravesical lithiasis seen.
The uterus is normal in size with an intact endometrium. No abnormal uterine/adnexal mass seen.
Fluid collection is seen in the peritoneal cavity. There are omental cakes and thickening of the peritoneal lining.
Impression: Omental cake / Peritoneal thickening, consider peritoneal carcinomatosis vs. peritoneal tuberculosis
Massive ascites
Normal sonogram of the liver, gallbladder, pancreas, spleen, kidneys, urinary bladder and uterus.

 ABDOMINAL CTSCAN (November 27, 2012)
Multiple plain & contrast enhanced axial CT images of the whole abdomen show the following findings:
The liver, gallbladder, pancreas, spleen and adrenals are normal. There are no enhancing mass lesions seen. The
intrahepatic and pancreatic ducts are not dilated.
Both kidneys exhibit good excretory functions. No ectasia, masses nor lithiasis seen.
The ureters and urinary bladder are opacified and maintains its normal course and configurations.
There are distended fluid-filled intestinal loops seen. However, no evident intraluminal masses are seen. There are
thickening noted in the peritoneal lining seen in the left.
Fluid density is seen in the abdominal cavity, with the uterus and ovaries floats within. There are no septations noted.
There are no enlarged intra abdominal / retroperitoneal nodes seen.
The mesentery, vascular and osseus structures are unremarkable.
Impression: Ascites with thickened peritoneal lining, left possibilities of inflammatory (Tuberculosis) vs.
Carcinomatosis are considered.

 TRANSVAGINAL – TRANSABDOMINAL ULTRASOUND (November 29, 2012)
The uterus is anteverted with smooth contour and homogenous echopattern measuring 5.5 x 2.3 x 3.3 cm (The cervix
measures 2.6 x 19 x 1.3 cm with homogenous stoma and distinct endocervical canal).
The endometrium is hyperechoic measuring 0.2 cm thick with intact subendometrial halo.
The right ovary measures 3.0 x 1.7 x 1.8 cm.
The left ovary measures 2.5 x 1.8 x 1.8 cm.
There’s massive anechoic free fluid in the cul de sac.
The omentum is converted into a heterogenous mass measuring 18 x 10 cm.
Impression: Normal uterus
Thin endometrium
Normal ovaries
Consider GI pathology

 CHEST AP (December 10, 2012):
There are no active lung infiltrates seen
Heart is not enlarged
Diaphragm is elevated
Bony thorax is unremarkable
Impression: Elevated Diaphragm
 MISCELLANEOUS REPORT (November 25, 2012):
Specimen Submitted: Peritoneal Fluid
Final Report: No growth after 48 hours incubation
Gram Stain: No organism seen
AFB: None found

CHAPTER XI
PROGNOSIS
CRITERIA
VERY
GOOD
(5)
GOOD
(4)
FAIR
(3)
POOR
(2)
VERY
POOR
(1)
JUSTIFICATION
Severity/
Nature of
disease
Ms. Bella’s disease is
difficult to treat and is
fatal. Onset of disease is
rapidly progressive and for
now, only supportive care
can be rendered.
Financial
Status
Though they are able to
comply and provide
financial support
minimally, they are now
referred to service
consultant because of
heavy expenses.
Family
Support
The family of the patient’s
partner supports her most
of the time. Her parents
seldom visit her and buy
for her medicines.
Patient factor
The patient is cooperative
and participative to
treatment regimen, though
weak and sometimes
irritable.
Availability &
accessibility
of appropriate
treatment
Most of the appropriate
treatment and resources are
available.

Respective Numerical Values:
Very Good= 5 Good = 4 Fair = 3 Poor = 2 Very Poor=1
Standard Rating:
Very Good = 4.20 – 5.00
Good = 3.41 – 4.20
Fair = 2.61 – 3.40
Poor = 1.81 – 2.60
Very Poor = 1.0 – 1.80
Formula:
Rate x Frequency
No. of Criteria
Computaion:
Very Good: 5 x 0 = 0
Good: 4 x 1 = 4
Fair: 3 x 2 = 6
Poor: 2 x 1 = 2
Very Poor: 1 x 1 = 1
13 ÷ 5 criteria = 2.60 or POOR
General Prognosis:
Based on the criteria, Ms. Bella has poor prognosis with a result of 2.60. Specifically,
she has scores of zero (0) in very good; two (1) in good; two (2) in fair; one (1) in poor and
one (1) in very poor.

In general, the client has a poor prognosis due to the onset, severity and
progression of the disease and complications secondary to her health problems.
Peritoneal carcinomatosis represents a devastating form of cancer progression
with a very poor prognosis. It is the most common terminal feature of abdominal
cancers. peritoneal cancer can be hard to detect in the early stages. That's because its
symptoms are vague and hard to pinpoint. When clear symptoms do occur, the disease
has often progressed. Care at this time is focused on relieving symptoms and quality of
life issues post-treatment.

CHAPTER XII
DISCHARGE SUMMARY PLAN
I. MEDICATION
Instruct patient and watcher to administer the prescribed medications on a right
dose, frequency and time.
RATIONALE: To meet the therapeutic effect of the drug and prevent over
dosage of the medication.
 Explain the purpose of the medication.
RATIONALE: This will provide information to both the client and the parent
as to why the patient needs to take the prescribed medication.
 Explain the indication and possible side effects brought by each of the drug.
RATIONALE: This will give awareness on both the patient and the watcher
to prevent panic when side effects are experienced by the client.
 Instruct the client and watcher that when adverse effect occurs and if there are
any unusualities consult the physician immediately.
RATIONALE: To prevent any complications and give appropriate
interventions
II. EXERCISE
 Encourage client not to do strenuous activities and limit activities within own
capacity as possible.
RATIONALE: Activities that require great muscle strength should be
avoided to prevent injury and fatigue.

III. TREATMENT
 Instruct to maintain the prescribed medication as regularly as ordered by the
physician.
RATIONALE: To have a pace of supportive care.
 Let the patient and family know that they should maintain a conducive, peaceful,
and non-stressful environment.
RATIONALE: To promote relaxation and good palliative care.
 Explain to the client and family the need for heightened quality of life until her
last days.
RATIONALE: To make the client and family aware that the care does not
end in the hospital and that their participation is a must in the continuation of
care.
IV. HYGIENE
 Encourage the client to observe proper hygiene like taking a bath everyday,
hand washing before and after performing activities especially when having
meals and brushing of teeth every after meal.
RATIONALE: Hygiene promotes comfort and cleanliness to the client
and it also increases the sense of wellness.
V. OUT PATIENT FOLLOW-UP
 If possible, instruct the patient to follow physician’s order on when to consult
for checkup.
RATIONALE: To enable the physician to evaluate patient’s condition.

 Advise the family to supervise the patient properly.
RATIONALE: To take note for any unusualities and can be referred
immediately.
VI. DIET
 Inform the family that the patient must receive adequate & proper nutrition
(especially high fiber diet). Eat fruits and green leafy vegetables.
RATIONALE: To modify patient’s diet and prevent further complication.
VII. SEXUAL ACTIVITY
 Instruct patient that sexual intercourse is not recommended.
RATIONALE: Care is focused on supportive and emotional care.

CHAPTER XIII
BIBLIOGRAPHY
Austin, F., Mavanur, A., Sathaiah, M., Steel, J., Lenzner, D., Ramalingam, L., Holtzman,
M., Ahrendt, S., Pingpank, J., Zeh, H., Bartlett, D., & Choudry, H. (2012).
Peritoneal Carcinomatosis. Retrieved December 11, 2012 from,
http://pmppals.org/peritoneal-carcinomatosis.html
Brunner, L. S. &Suddarth’s D.S. (2008). Medical-Surgical Nursing 11th& 12th edition,
Volume 1 & 2.
Doenges, M., Moorhouse, M., &Murr A. (2002). Nursing Care Plans: Guidelines for
Individualizing patient care 6th edition.
Gould, B. (2007). Pathophysiology for the Health Professionals 3rd edition.
Gulanick, M., Klopp, A., Galanes, S., Gradishar, D., &Puzas, M. (1994). Nursing Care
Plan 3rd edition.
Hoofnagle JH. Peritoneal Carcinomatosis. In: Goldman L, Ausiello D, eds. Cecil
Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 151.
Jeffress, D. (2012). What Is Peritoneal Carcinomatosis?
Retrieved December 10, 2012 from,
http://www.wisegeek.com/what-is-peritoneal-carcinomatosis.htm
Johnson, RJ.(1993). Radiology in the management of ovarian cancer.
http://radiology.rsna.org/content/221/1/173.full
Karch, A. (2007). Lippincott’s Nursing Drug Guide.
Kusamura, S., Baratti, D., Zaffaroni, N., Villa, R., Laterza, B., Balestra, MR., & Deraco,
M. (2010). Pathophysiology and biology of peritoneal carcinomatosis.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999153/
McCann, J. (2004). Handbook of Diseases 3rd edition.

Mizumoto, A., Canbay, E., Hirano, M., Takao, N., Matsuda, T., Ichinose, M., &
Yonemura, Y. (2012). Gastroenterology Research and Practice Volume 2012
http://www.hindawi.com/journals/grp/2012/836425/
Peritoneal Health Guide (2010). Peritoneal Carcinomatosis Survival Rate.
http://peritoneal-health.info/peritoneal-carcinomatosis-survival-rate/
Sugarbaker, PH., Esquivel, J., & Sticca, R., (2007). Cytoreductive surgery and
hyperthermic intraperitoneal chemotherapy in the management of peritoneal
surface malignancies of colonic origin:a consensus statement.
http://www.ncbi.nlm.nih.gov/pubmed/17072675
Electronic resources:
http://bestpractice.bmj.com/bestpractice/monograph/750/basics/pathophysiology.
http://www.medicinenet.com/peritonealtuberculosis /page4.htm
http://www.streetdirectory.com/travel_guide/111734/medical_conditions/
peritoneal carcinomatosis _a_ in_history.html
http://www.who.int/mediacentre/factsheets/fs328/en/index.html - WHO 2012
http://www.ehow.com/list_6329814_signs-symptoms-peritoneal-
carcinomatosis.html
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