I. Diagnostic / Laboratory with normal results and abnormal results with implication

Rectal Mass BiopsyProcedureDatePurposeNormalResultsImplication

1. Rectal Mass Biopsy8 February 2015A rectal biopsy is used to determine the cause of abnormal growths found during anoscopy, sigmoidoscopy, or other tests. It can also be used to confirm the diagnosis of amyloidosis.The anus and rectum appear normal in size, color, and shape. There should be no evidence of bleeding, polyps, hemorrhoids, or other abnormalities. No problems are seen when the biopsy tissue is examined under a microscope.Positive for adenocarcinoma well to moderately differentiatedThis test is a common way to confirm amyloidosis. It also determines the specific causes of abnormal conditions of the rectum, such as colitis. Other findings could include: Abscesses, Colorectal polyps, Infection, Inflammation and Tumors

Nursing Interventions Define and explain the test State the specific purpose of the test Explain the procedure Discuss test preparation, procedure, and posttest careBilirubinProcedureDatePurposeNormalResultsImplication

2. Bilirubin18 February 2015Testing for bilirubin in the blood is therefore a good test of measuring damage to your liver.ALP IFCC Gen.2: 32-144Alanine Aminotrans liquid: 10-36Aspartate Aminotrans liquid: 10-30Bilirubin Total Gen.3: 3.4-17Bilirubin dir Gen.2: 0-3.4Indirect Bilirubin: -ALP IFCC Gen.2: 76.6

Alanine Aminotrans liquid: 17.9Aspartate Aminotrans liquid: 29.8Bilirubin Total Gen.3: 20.0

Bilirubin dir Gen.2: 11.6Indirect Bilirubin: 8.4Reasons for high bilirubin levels could be that more blood cells are being destroyed than normal. This is called hemolysis.

Nursing Intervention: A blood sample is needed. Inform patient on how this is done. Instruct patient not to eat or drink for at least 4 hours before the test. The patient's health care provider may instruct you to stop taking drugs that affect the test.

HematologyProcedureDatePurposeNormalResultsImplication

3. Hematology18 February 2015This test is used to evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characters, State of hydration and dehydration, Polycythemia, to manage chemotherapy decisions.Complete Blood CountHgb: 120-160Hct: 0.37-0.43RBC: 4.0-5.4WBC: 4.0-10

DifferentialSegmenters: 0.55-0.65Lymphocytes: 0.25-0.35Eosinophils: 0.02-0.04Monocytes: 0.03-0.06Basophils: 0.00-0.01

Atypical CellsMCV:80-100MCH: 26-32Mchc:32-36RDW: 11-15Platelet count: 130-400Prothrombin Time:10.6-13.6sClotting Time: 2-7mBleeding Time: 2-4mComplete Blood CountHgb: 150

Hct: 0.43RBC: 5.8WBC:20.01

DifferentialSegmenters: 0.90Lymphocytes: 0.07Eosinophils: 0.0Monocytes: 0.03Basophils: 0.0

Atypical CellsMCV:73MCH:25.6MCHC:35RDW:20.71Platelet count: 277

Prothrombin Time: -

Clotting Time: -Bleeding Time: -High RBC could point to an underlying medical condition, such as polycythemia vera or heart disease.WBC higher than normal may have an infection or inflammation.An increased percentage of segmenters and lymphocytes may be due to chronic bacterial infection

Nursing Intervention: Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured. Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values. Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of lipidemia. Apply manual pressure and dressings over puncture site on removal of dinner. Monitor the puncture site for oozing or hematoma formation. Instruct to resume normal activities and diet.Arterial Blood GasProcedureDatePurposeNormalResultsImplication

4. Arterial Blood Gas18 February 2015An arterial blood gas (ABG) analysis can tell you about a patient's oxygenation, acid-base balance, pulmonary function, and metabolic status. This indispensable tool helps you assess and monitor critically ill patients in giving care to them.pH: 7.35-45pCO2: 35-45pO2: 80-100O2sat:95-97

pH: 7.41pCO2: 28.8pO2: 70.2O2sat: 94.5

Decreased PCO2 may indicate Hyperventilation, Hypoxia, and Anxiety.Decreased PO2 levels are associated with: Decreased oxygen levels in the inhaled air, Anemia, Heart decompensationCOPD, and Hypoventilation

Nursing Intervention: Explain the arterial blood gas analysis evaluates how well the lungs are delivering the oxygen to the blood and eliminating carbon dioxide. Tell the patient that the test requires a blood sample. Explain to the patient, who will perform the arterial puncture, when it will occur, and where the puncture site will be; radial, brachial, or femoral artery. Inform the patient that he may not need to restrict food and fluids. Instruct the patient to breathe normally during the test, and warn him that he may experience a brief cramping or throbbing pain at the puncture site.Chemistry TestProcedureDatePurposeNormalResultsImplication

5. Chemistry Test18 February 2015Blood chemistry testing is defined simply as identifying the numerous chemical substances found in the blood. The analysis of these substances will provide clues to the functioning of the major body systems.Sodium: 135-148mmol/LPotassium: 3.6-5.2mmol/LSodium: 141.6 mmol/LPotassium: 2.9mmol/LLow potassium levels (hypokalemia) can cause weakness as cellular processes are affected. Dehydration, diarrhea, excessive sweating (hyperhidrosis) and laxative abuse are common causes of low potassium levels.

Nursing Intervention: Define and explain the test State the specific purpose of the test Explain the procedure Discuss test preparation, procedure, and posttest careCreatinine and BUNProcedureDatePurposeNormalResultsImplication

6. Creatinine and BUN18 February 2015A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys and liver are working. A BUN test measures the amount of urea nitrogen that's in your blood.Albumin Gen.2: 35-50Crea Jaffe Gen.2 Comp: 44-80Calcium Gen.2: 2.20-2.75Magnesium: 0.60-1.10Urea/Bun liquid: 2.78-7.64Albumin Gen.2: 25.23Crea Jaffe Gen.2 Comp: 66.6Calcium Gen.2: 2.06

Magnesium: 0.61Urea/Bun liquid: 5.16Poor nutritional state - you haven't been eating enough protein, or you may be losing protein, usually during a period of illness and Renal (kidney) dysfunction - your kidneys may not work well due to any number of conditions. Low calcium levels may be cause by Vitamin D deficiency, chronic renal failure and magnesium deficiency

Nursing Intervention Tell the patient that the BUN test is used to evaluate kidney function. Inform the patient that he need not to restrict food and fluids, but should avoid diet high in meat. Use alcohol to remove the iodine from the venipuncture site. Monitor the venipuncture site for bleeding and signs of infection.

II. Related Medical Treatment (Operations) Operation Performed / Procedure: Anterior Resection Hartmann's procedureHartmanns ProcedureThis is an operation to remove part of the sigmoid colon and/ or the rectum. It is most usually performed for patients with a bowel cancer or diverticular disease.It is often performed in an emergency situation where there is a blockage of the bowel, a perforation of the bowel or of if there is a lot of infection (abscess) around the bowel.What does the operation involve? Whilst this operation can be performed as a laparoscopic (keyhole) procedure because it is usually performed as an emergency an open technique is often preferred. During the operation the diseased part of the sigmoid colon and/ or rectum is removed. This involves taking away the blood vessels and lymph nodes to this part of the bowel. If the surgeon doesnt feel that it is safe to rejoin the bowel, because of infection, obstruction or perforation, the end of the colon is brought to the surface on the left side of the abdomen to create a colostomy. The rectum that is left behind is usually closed off with staples or sutures and left inside the abdomen. Forming a colostomy and leaving the other end of the bowel inside is known as Hartmanns operation or procedure. The operation time may vary for this type of surgery but is usually around 3 hours. The piece of bowel that is removed is sent to the pathology department where the pathologist carefully examines it. The results are usually available within two weeks of the operation.What are the risks? There are risks associated with any abdominal operation. Pre-operative assessment of heart and lung conditions are made, as well as any coexisting medical conditions. During the hospital admission patients wear stockings and are given a regular tiny injections to prevent thrombosis (blood clots). Bleeding if very rare in this type of surgery, blood is always available if a transfusion is required. Wound infections can occur in any form of intestinal surgery, open or laparoscopic. Wound infections rarely cause serious problems but may require treatment with antibiotics. Sometimes the bowel may take longer than normal to start working, this is known as ileus. Patients may develop abdominal distension and vomiting. If this happens the surgeon will normally recommend a period of bowel rest with continued intravenous fluids and sometimes a tube passed via the nose to the stomach (nasogastric tube). When the bowel doesnt start working properly, there may be a kink, twist or an adhesion causing a blockage. This is known as obstruction. Patients may develop colicky abdominal pains, abdominal distension and vomiting. If this happens the surgeon will normally recommend a period of bowel rest with continued intravenous fluids and sometimes a tube passed via the nose to the stomach (nasogastric tube). In most cases the obstruction settles spontaneously occasionally an operation is required to relieve the blockage. There are important nerves in the pelvis and whilst the surgeon will make every effort to avoid damaging these it is recognised that they can sometimes be involved in this type of surgery. These nerves are important as they control erections and ejaculation in men and influence bladder emptying in men and women. The effects may improve with time but sometimes these can be permanent. Patients who have had radiotherapy are at higher risk of pelvic nerve dysfunction after surgery.What happens after the operation?After the operation patients will have an intravenous drip, which is normally in place for 24 hours, or until, a normal fluid intake is resumed.A catheter (tube inserted to drain the bladder) is normally kept in place for 48- 72hours.Occasionally an abdominal drain is used (small tube passing through the abdominal wall). This is normally removed after a few days.An epidural is often used in keyhole and open surgery to provide pain relief after the operation and is usually continued at least until the next day. Your anaesthetist will be able to discuss this with you before the operation.Patients are allowed to eat and drink as soon as they feel able after the operation (usually the same day).Patients are encouraged to mobilise as soon as possible after the operation.Hospital stay is usually 5-7 days for keyhole surgery and 7-10 days for open surgery although this may vary.Following discharge from hospital, patients are encouraged to keep mobile. They should avoid heavy lifting or increased physical activities for about 6 weeks. Patients can normally resume driving after about 4-6 weeks but this may vary.A follow up consultation is usually arranged after about two weeks. Patients can always be seen sooner if there are problems.In many cases the colostomy can be reversed. This involves another operation when the surgeon takes away the colostomy and rejoins this to the end of the bowel that has been left inside. The surgeon will discuss this at follow up. Normally patients are advised to wait at least 3 months, so they are fully recovered, before undergoing a reversal.

III. Gordons AssessmentHealth perception / Health ManagementThe client knows the importance of compliance with medication regimen, use of health promotion activities such as regular exercises, and annual check-ups.

Nutritional- Metabolic Condition of skin, teeth, hair, and nails are normal in accord to her age. Patient is older and had less flexibility and less appropriate functioning of body mechanics.

EliminationThere are already changes in bowel habits, noted to have poor bowel movements and voiding pattern due to distention and lack of nutritional balances such as fluids and electrolytes.

Activity - ExercisePatient can perform limited and little exercises and was encouraged to ambulate and do deep breathing exercises, back in her home when shes still feeling well she can still perform other little chores in the house such as sweeping the floor, cleaning the windows, and washing the dishes.

Cognitive - PerceptualIn regards to patients senses, everything is still sharp, she can see well in her age, can smell things and can tell what it is with eye closed, pain perception is normal, cognitive functions such as language, memory and decision making is good.

Sleep - RestLately the patient would describe difficulty of breathing thus having lacks of sleep because of disturbing discomforts of the patients condition.

Self- Perception / Self -conceptPatient Maddie had a strong will for herself. She wanted to continue living for her love ones. She sees herself as an important member of a family or a friend. She was confident that she can still do a lot of things in the future.

Role - RelationshipEven if patient Maddie is living with her sons, she tend to keep her role as a good mother and grandmother to her children and grandchildren and wishes to work hard with them and for them.

Coping / Stress ToleranceShe had her own ways of managing her stress. She doesnt want being such a burden and would fulfill her roles in continuing of her living.

Value / BeliefPatient Maddie is a catholic and she believes that God had already planned all of her tomorrows and wishes to live as far as she could fighting her illness.

IV. Drug StudyName of DrugDate OrderedRoute, dosage, and frequency of administrationMechanism of action and General classificationIndications or PurposesClients response to med w/ actual s/e

1. Amikacin February 18, 2015500mg OD to complete 5daysBactericidal: inhibits protein synthesis in susceptible strains of gram-negative bacteria, and the functional integrity of bacterial cell membrane appears to be disrupted, causing cell death.Short-term treatment of serious infections caused by susceptible strains of Pseudomonas species, E. coli, indole-positive Proteus species, Providencia species, Klebsiella, Enterobacter, and Serratia species, Acinetobacter speciesPatient treatment of Amikacin therapy had been effective.

Nursing Interventions: Arrange for culture and sensitivity testing of infected area before treatment. Monitor duration of treatment: usually 7---10 d. If clinical response does not occur within 3---5 d, stop therapy. Prolonged treatment leads to increased risk of toxicity. If drug is used longer than 10 d, monitor auditory and renal function daily. Give IM dosage by deep injection. Ensure that patient is well hydrated before and during therapy. The following side effects may occur: ringing in the ears, headache, dizziness (reversible; safety measures may need to be taken if severe); nausea, vomiting, loss of appetite (small frequent meals, frequent mouth care may help). Report pain at injection site, severe headache, dizziness, loss of hearing, changes in urine pattern, difficulty breathing, rash or skin lesions.

2. Pipta2 February 18, 20154.5g TIV q6

Nursing intervention:

3. Metronidazole February 16, 2015500mg TIV q8Bactericidal: Inhibits DNA synthesis in specific (obligate) anaerobes, causing cell death; antiprotozoal-trichomonacidal, amebicidal: Biochemical mechanism of action is not known.Acute infection with susceptible anaerobic bacteriaPatients response to treatment is good.

Nursing Interventions: Take full course of drug therapy; take the drug with food if GI upset occurs. Do not drink alcohol (beverages or preparations containing alcohol, cough syrups); severe reactions may occur. Your urine may appear dark; this is expected. Refrain from sexual intercourse during treatment for trichomoniasis unless partner wears a condom. Apply the topical preparation by cleansing the area and then rubbing a thin film into the affected area. Avoid contact with the eyes. Cosmetics may be applied to the area after application. You may experience these side effects: Dry mouth with strange metallic taste (frequent mouth care, sucking sugarless candies may help); nausea, vomiting, diarrhea (eat frequent small meals). Report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills.

4. Combivent NebulizationFebruary 17, 2015 Q8Anti-inflammatory effect; local administration into nasal passages maximizes beneficial effects on these tissues, while decreasing the likelihood of adverse effects from systemic absorption.Treatment of mild to moderate active Crohn's disease involving the ileum or ascending colonThere is management of symptoms of seasonal or perennial allergies

Nursing Interventions: Do not use more often than prescribed; do not stop without consulting your health care provider. It may take several days to achieve good effects; do not stop if effects are not immediate. Use decongestant nose drops first if nasal passages are blocked. Prime unit before use for Pulmicort Turbuhaler; rinse mouth after each use. Store Respules upright, protect from light; discard open envelopes after 2 wk; gently shake before use. You may experience these side effects: Local irritation (use your device correctly), dry mouth (suck sugarless lozenges). Report sore mouth, sore throat, worsening of symptoms, severe sneezing, exposure to chickenpox or measles, eye infections.

5.N-acetylcysteine February 18, 2015200mg in 250cc H2O TIDMucolytic activity: splits links in the mucoproteins contained in respiratory mucus secretions, decreasing the viscosity of the mucus Antidote to acetaminophen hepatotoxicity: protects liver cells by maintaining cell function and detoxifying acetaminophen metabolitesMucolytic adjuvant therapy for abnormal, viscid, or inspissated mucus secretions in acute and chronic bronchopulmonary disease (emphysema with bronchitis, asthmatic bronchitis, tuberculosis, pneumonia), in pulmonary complications of cystic fibrosis, and in tracheostomy care; pulmonary complications associated with surgery, anesthesia, post-traumatic chest conditions; diagnostic bronchial studiesPatient's response to treatmnt, mucus secretions were prevented and lessen.

Nursing Intervention: Dilute the 20% acetylcysteine solution with either Normal Saline or Sterile Water for Injection; use the 10% solution undiluted. Refrigerate unused, undiluted solution, and use within 96 h. Drug solution in the opened bottle may change color, but this does not alter safety or efficacy. Administer the following drugs separately, because they are incompatible with acetylcysteine solutions: tetracyclines, erythromycin lactobionate, amphotericin B, iodized oil chymotrypsin, trypsin, hydrogen peroxide. Use water to remove residual drug solution on the patient's face after administration by face mask. Inform patient that nebulization may produce an initial disagreeable odor, but it will soon disappear. Monitor nebulizer for buildup of drug from evaporation; dilute with Sterile Water for Injection to prevent concentrate from impeding nebulization and drug delivery. Establish routine for pulmonary toilet; have suction equipment on standby.

6. IrbesartanFebruary 19, 2015150mg, 1tab OD AMSelectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the renin-angiotensin system as well as the release of aldosterone, leading to decreased BP.Treatment of hypertension as monotherapy or in combination with other antihypertensivePatient's hypertension is controlled and managed with the treatment.

Nursing Intervention: Alert surgeon and mark patient's chart with notice that irbesartan is being taken. The blockage of the renin-angiotensin system following surgery can produce problems. Hypotension may be reversed with volume expansion. Monitor patient closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volume (excessive perspiration, dehydration, vomiting, diarrhea); excessive hypotension can occur.Take this drug without regard to meals. Do not stop taking this drug without consulting your health care provider. You may experience these side effects: Dizziness (more likely to occur in any situation where you may be fluid depleted [extreme heat, exertion]; avoid driving or performing hazardous tasks); headache (medications may be available to help); nausea, vomiting, diarrhea (proper nutrition is important; consult with your dietitian); symptoms of URI, cough (do not self-medicate; consult with your nurse or physician if this becomes uncomfortable). Report fever, chills, dizziness

7. OlanzapineFebruary 18, 20155mg OD HSMechanism of action not fully understood; blocks dopamine receptors in the brain, depresses the RAS; blocks serotonin receptor sites; anticholinergic, antihistaminic (H1), and alpha-adrenergic blocking activity may contribute to some of its therapeutic (and adverse) actions; produces fewer extrapyramidal effects than most antipsychotics.Treatment of schizophrenia

Patient's manifestation of mental illness, irritability and anxiety had been managed

Nursing Intervention: Take this drug exactly as prescribed; do not change dose without consulting your physician. Peel back foil on blister pack of disintegrating tablets; do not push through foil; use dry hands to remove tablet, place entire tablet in mouth. This drug cannot be taken during pregnancy. If you think you are pregnant or wish to become pregnant, contact your health care provider. You may experience these side effects: Drowsiness, dizziness, sedation, seizures (avoid driving, operating machinery, or performing tasks that require concentration); dizziness, faintness on arising (change positions slowly, use caution); increased salivation (if bothersome, contact your health care provider); constipation (consult with your health care provider for appropriate relief measures); fast heart rate (rest and take your time if this occurs). Report lethargy, weakness, fever, sore throat, malaise, mouth ulcers, and flulike symptoms.

8. FluoxetineFebruary 18, 201520mg OD AMActs as an antidepressant by inhibiting CNS neuronal uptake of serotonin; blocks uptake of serotonin with little effect on norepinephrine; little affinity for muscarinic, histaminergic, and alpha1-adrenergic receptors.Treatment of depression; most effective in patients with major depressive disorderPatient's irritability and anxiety had been managed treatment had been effective.

Nursing Intervention: Arrange for lower or less frequent doses in elderly patients and patients with hepatic or renal impairment. WARNING: Establish suicide precautions for severely depressed patients. Limit quantity of capsules dispensed. Administer drug in the morning. If dose of > 20 mg/day is needed, administer in divided doses. Monitor patient for response to therapy for up to 4 wk before increasing dose. Switch to once a week therapy by starting weekly dose 7 days after last 20 mg/day dose. If response is not satisfactory, reconsider daily dosing. It may take up to 46 wk before the full effect occurs. Take in the morning (or in divided doses if necessary). If you are taking the once weekly capsule, mark calendar with reminders of drug day.

9. AmlodipineFebruary 19, 20155mg 1tab OD PMInhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmembrane calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse, depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to decreased cardiac work, decreased cardiac oxygen consumption, and in patients with vasospastic (Prinzmetal's) angina, increased delivery of oxygen to cardiac cells. Angina pectoris due to coronary artery spasm (Prinzmetal's variant angina) Chronic stable angina, alone or in combination with other agents Essential hypertension, alone or in combination with other antihypertensivesPatient's hypertension and arhythmias had been managed with the treatment.

Nursing Intervention: WARNING: Monitor patient carefully (BP, cardiac rhythm, and output) while adjusting drug to therapeutic dose; use special caution if patient has CHF. Monitor BP very carefully if patient is also on nitrates. Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy. Administer drug without regard to meals. Take with meals if upset stomach occurs. You may experience these side effects: Nausea, vomiting (eat frequent small meals); headache (adjust lighting, noise, and temperature; medication may be ordered). Report irregular heartbeat, shortness of breath, swelling of the hands or feet, pronounced dizziness, constipation.

10. Kalium DuruleFebruary 19, 20151tab TIDPrincipal intracellular cation of most body tissues, participates in a number of physiologic processes--maintaining intracellular tonicity, transmission of nerve impulses, contraction of cardiac, skeletal, and smooth muscle, maintenance of normal renal function; also plays a role in carbohydrate metabolism and various enzymatic reactions.Prevention and correction of potassium deficiency; when associated with alkalosis, use potassium chloride; when associated with acidosis, use potassium acetate, bicarbonate, citrate, or gluconateTreatment of cardiac arrhythmias due to cardiac glycosides (IV)Patient's cardiac arrhytmias had been treated and patient responds well in accords to correction of potassium

Nursing Intervention: Arrange for serial serum potassium levels before and during therapy. Administer liquid form to any patient with delayed GI emptying. Administer oral drug after meals or with food and a full glass of water to decrease GI upset. Caution patient not to chew or crush tablets; have patient swallow tablet whole. Mix or dissolve oral liquids, soluble powders, and effervescent tablets completely in 3---8 oz of cold water, juice, or other suitable beverage, and have patient drink it slowly. Arrange for further dilution or dose reduction if GI effects are severe. Agitate prepared IV solution to prevent "layering" of potassium; do not add potassium to an IV bottle in the hanging position. Monitor IV injection sites regularly for necrosis, tissue sloughing, phlebitis. Monitor cardiac rhythm carefully during IV administration. Caution patient that expended wax matrix capsules will be found in the stool. Caution patient not to use salt substitutes.