pancreatic mass

Pancreatic Pancreatic Head massHead mass

INTRODUCTIONINTRODUCTION

• ““It is a weariness disease It is a weariness disease to preserve health by to to preserve health by to strict a regimen.” Our strict a regimen.” Our body is the mirror of body is the mirror of whatever lifestyle we whatever lifestyle we have. It is the one who have. It is the one who suffers on what we put suffers on what we put inside.inside.

• Patient with pancreatic head mass Patient with pancreatic head mass develop acute recurrent pancreatitis in develop acute recurrent pancreatitis in childhood, which usually progresses to childhood, which usually progresses to chronic pancreatitis and pancreatic chronic pancreatitis and pancreatic cancer in early adulthood. A consistent cancer in early adulthood. A consistent association has been demonstrated association has been demonstrated between cigarette smoking and excessive between cigarette smoking and excessive alcohol drinking for the development of alcohol drinking for the development of pancreatic cancer. Hereditary pancreatic cancer. Hereditary pancreatitis is a genetic disease caused pancreatitis is a genetic disease caused by a mutation of a cationic trypsinogen by a mutation of a cationic trypsinogen gene. it is more common on male than in gene. it is more common on male than in female because of lifestyle.female because of lifestyle.

• Sixty percent of pancreatic cancers Sixty percent of pancreatic cancers develop in the pancreatic head; 40% develop in the pancreatic head; 40% develop in the body and tail. The major develop in the body and tail. The major symptoms include abdominal pain, symptoms include abdominal pain, anorexia, weight loss, and jaundice. The anorexia, weight loss, and jaundice. The pain is located in the epigastrium and pain is located in the epigastrium and has a quality characterized as deep and has a quality characterized as deep and boring. The pain may be intermittent or boring. The pain may be intermittent or constant, and is progressive. Painless constant, and is progressive. Painless jaundice indicates a potentially jaundice indicates a potentially resectable lesion located in the resectable lesion located in the pancreatic head. A predominance of pancreatic head. A predominance of abdominal pain suggests neural plexus abdominal pain suggests neural plexus involvement, location in the tail, involvement, location in the tail, unresectability, and a poor prognosis. unresectability, and a poor prognosis.

• The only potentially curative The only potentially curative therapy for pancreatic cancer is therapy for pancreatic cancer is surgical resection. The standard surgical resection. The standard operation for adenocarcinoma in the operation for adenocarcinoma in the pancreatic head or uncinate process pancreatic head or uncinate process is the pancreaticoduodenectomy, or is the pancreaticoduodenectomy, or "Whipple operation." The Whipple "Whipple operation." The Whipple operation involves resection of the operation involves resection of the pancreatic head, duodenum, pancreatic head, duodenum, common bile duct, distal stomach, common bile duct, distal stomach, and gallbladder.and gallbladder.

• Pancreatic head mass has been Pancreatic head mass has been a common disease in people a common disease in people unhealthy lifestyle. I want to unhealthy lifestyle. I want to know more about this case and know more about this case and enhanced my knowledge about enhanced my knowledge about it. I want to be familiar about it. I want to be familiar about this case so that I can this case so that I can implement appropriated implement appropriated nursing actions to improve the nursing actions to improve the condition of my client.condition of my client.

OBJECTIVESOBJECTIVES

• General ObjectivesGeneral Objectives

• To gain knowledge on the certain disease To gain knowledge on the certain disease ( Pancreatic Head Mass) aimed at as a ( Pancreatic Head Mass) aimed at as a part of our course competency, also to part of our course competency, also to provide us complete learning experience provide us complete learning experience that would help us understand and that would help us understand and increase the capability in meeting the increase the capability in meeting the case as student nurses. To enhance the case as student nurses. To enhance the nurses skills and to develop nurses nurses skills and to develop nurses attitude towards caring and attitude towards caring and communicating to patient with Pancreatic communicating to patient with Pancreatic Head Mass.Head Mass.

• Specific ObjectivesSpecific Objectives

• To know information about To know information about pancreatic head mass.pancreatic head mass.

• To know the signs and symptoms To know the signs and symptoms of pancreatic head mass. of pancreatic head mass.

• To determine the complications To determine the complications that caused by the disease.that caused by the disease.

• To enumerate the risk factors To enumerate the risk factors that may cause by Pancreatic that may cause by Pancreatic head mass and the organs that head mass and the organs that are affected.are affected.

• To be knowledgeable enough To be knowledgeable enough with regards to the tests and with regards to the tests and treatment of the disease.treatment of the disease.

• To provide nursing care plan To provide nursing care plan to help patient recover.to help patient recover.

• To evaluate level of patient’s To evaluate level of patient’s recovery.recovery.

• To think of nursing plans To think of nursing plans when the client is discharged.when the client is discharged.

PATIENT’S PATIENT’S PROFILEPROFILE

• Name: Patient XName: Patient X• Age: 55 yrs. oldAge: 55 yrs. old• Gender: MaleGender: Male• Civil Status: SingleCivil Status: Single• Birthday: April 23, 1953Birthday: April 23, 1953• Birthplace: Santol, Tanauan BatangasBirthplace: Santol, Tanauan Batangas• Nationality: FilipinoNationality: Filipino• Religion: Roman CatholicReligion: Roman Catholic• Chief Complaint: Abdominal PainChief Complaint: Abdominal Pain• Date of Admission: June 29, 2008Date of Admission: June 29, 2008• Date of Operation: July 4, 2008Date of Operation: July 4, 2008• Attending Physician: Dr. Arellano, Attending Physician: Dr. Arellano,

Gonzales, Reyes, IlaganGonzales, Reyes, Ilagan

CLINICAL APPRAISALCLINICAL APPRAISAL

• A. Past Health HistoryA. Past Health History• Patient X was born in their Patient X was born in their

house with normal delivery. He received house with normal delivery. He received all the vaccine for his immunization all the vaccine for his immunization since he was a child. This is his first since he was a child. This is his first time to be hospitalized for the reason of time to be hospitalized for the reason of abdominal pain. He usually uses abdominal pain. He usually uses analgesics for pain which can be bought analgesics for pain which can be bought in any store of their barangay. He never in any store of their barangay. He never experienced any vehicular accidents experienced any vehicular accidents because their place is far from the city because their place is far from the city and only few vehicles are seen in their and only few vehicles are seen in their place.place.

• B. Family HistoryB. Family History• The family of Patient The family of Patient

X has a history of tumor. His X has a history of tumor. His mother died because of mother died because of tumor in a part of tumor in a part of gastrointestinal area. His gastrointestinal area. His other relatives also have other relatives also have cases of tumors. cases of tumors.

• C. Personal HistoryC. Personal History• Patient X is fond of Patient X is fond of

drinking alcohol. He drinks drinking alcohol. He drinks alcohol 3-4 times in a week. As alcohol 3-4 times in a week. As his form of work, he plants his form of work, he plants vegetables in their backyard. He vegetables in their backyard. He usually sleeps at 9 pm and usually sleeps at 9 pm and wakes up at 6 in the morning. wakes up at 6 in the morning. Watching TV is his form of Watching TV is his form of relaxation.relaxation.

• D. Social HistoryD. Social History• Patient X reached Patient X reached

Grade 4, he works as a Grade 4, he works as a farmer in their place, farmer in their place, Santol, Tanauan Batangas Santol, Tanauan Batangas with a monthly income of with a monthly income of 1000 pesos. He lives with 1000 pesos. He lives with his two sisters in his his two sisters in his mother’s house.mother’s house.

• E. E. Psychologic HistoryPsychologic History• Patient X experienced Patient X experienced

his major stressor while he was his major stressor while he was resting after work 3 months ago. resting after work 3 months ago. He made an eye to eye contact He made an eye to eye contact when communicating but find it when communicating but find it hard to verbalize words because hard to verbalize words because of his condition. Despite if that, of his condition. Despite if that, he still can sleep and rests well.he still can sleep and rests well.

• F. History of Present IllnessF. History of Present Illness• 3 months ago, Patient 3 months ago, Patient

X experienced abdominal pain X experienced abdominal pain associated with jaundice and associated with jaundice and weight loss. He is first seen in weight loss. He is first seen in the private hospital for check-the private hospital for check-up and referred to Batangas up and referred to Batangas Regional Hospital. He was Regional Hospital. He was admitted last June 29 and had admitted last June 29 and had his surgery last July 4, 2008.his surgery last July 4, 2008.

PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT

SKINSKIN• InspectionInspection

• > slightly yellowish in color> slightly yellowish in color

• > Abnormal; may indicate high > Abnormal; may indicate high level of bilirubin in the blood.level of bilirubin in the blood.

• PalpationPalpation

• > temperature within > temperature within normal rangenormal range

• NormalNormal

HEADHEAD

• InspectionInspection

• >Symmetrical in shape>Symmetrical in shape

• > Normal> Normal

HAIRHAIR

• InspectionInspection

• > without infestation of lice> without infestation of lice• >combined black and white hair>combined black and white hair• > with normal > with normal

• > Normal> Normal

SCALPSCALP

• InspectionInspection

• > absence of abrasion> absence of abrasion

• > Normal> Normal

EYESEYES

• EYE BROWSEYE BROWS• InspectionInspection

• > symmetrically aligned> symmetrically aligned

• > Normal> Normal

• EYE LASHESEYE LASHES• InspectionInspection

• > with normal > with normal distributiondistribution

• > Normal> Normal

• PUPILPUPIL

• InspectionInspection

• > constricts to penlight> constricts to penlight

• > Normal> Normal

• CONJUNCTIVACONJUNCTIVA

• InspectionInspection

• > slightly yellowish in color> slightly yellowish in color

• > Abnormal: may indicate high > Abnormal: may indicate high bilirubin level in the bloodbilirubin level in the blood

EARSEARS

• AURICLEAURICLE• InspectionInspection

• > Symmetrically aligned> Symmetrically aligned

• > Normal> Normal

• EAR CANALEAR CANAL

• InspectionInspection

• > Symmetrically aligned> Symmetrically aligned

• > Normal> Normal

NOSENOSE

• InspectionInspection• > Presence of NGT> Presence of NGT

• >Abnormal; may indicate >Abnormal; may indicate NPONPO

LIPSLIPS

• InspectionInspection

• > slightly dry> slightly dry

• > Abnormal: may indicate > Abnormal: may indicate low fluid intake through low fluid intake through mouthmouth

TEETHTEETH

• InspectionInspection

• > presence of dental cavities> presence of dental cavities

• > Abnormal: may indicate > Abnormal: may indicate poor oral hygiene.poor oral hygiene.

TONGUETONGUE

• InspectionInspection

• > positioned centrally> positioned centrally

• > Normal> Normal

TONSILTONSIL

• InspectionInspection

• > positioned centrally> positioned centrally

• > Normal> Normal

LYMPH NODESLYMPH NODES

• PalpationPalpation

• > not palpable> not palpable

• > Normal> Normal

SHOULDERSHOULDER

• InspectionInspection

• >level shoulder>level shoulder

• > Normal> Normal

CHESTCHEST

• InspectionInspection

• > Symmetrical chest > Symmetrical chest expansionexpansion

• > Normal> Normal

ABDOMENABDOMEN

• InspectionInspection

• > Presence of sutured wound > Presence of sutured wound and Jackson Prattand Jackson Pratt

• > Abnormal; may indicate > Abnormal; may indicate undergone operationundergone operation

UPPER EXTREMITIESUPPER EXTREMITIES

• HANDSHANDS

• InspectionInspection

• > thin to touch> thin to touch

• > Normal> Normal

NAILSNAILS

• InspectionInspection• > convex curvature> convex curvature• > Normal> Normal• > slightly dirty> slightly dirty• > Abnormal; may indicate > Abnormal; may indicate

poor personal hygienepoor personal hygiene

LOWER EXTREMITIESLOWER EXTREMITIES

• Inspection/ palpationInspection/ palpation

• > no edema> no edema

• > Normal> Normal

• Summary:Summary:• Almost all the body parts in Almost all the body parts in

physical assessment are normal physical assessment are normal expect from some abnormalities expect from some abnormalities such as yellowish discoloration in such as yellowish discoloration in the skin and conjunctiva, slightly the skin and conjunctiva, slightly dry lips, presence of dental cavities, dry lips, presence of dental cavities, presence of nasogastric tube, presence of nasogastric tube, presence of sutured wound and presence of sutured wound and Jackson Pratt in the stomach and Jackson Pratt in the stomach and slightly dirty nails.slightly dirty nails.

ANATOMY AND ANATOMY AND PHYSIOLOGYPHYSIOLOGY

• The pancreas is located The pancreas is located retroperitoneal, posterior to the stomach retroperitoneal, posterior to the stomach in the inferior part of the left quadrant. It in the inferior part of the left quadrant. It has a head near the midline of the body has a head near the midline of the body and a tail that extends to the left where and a tail that extends to the left where it touches the spleen. It is a complex it touches the spleen. It is a complex organ composed of both endocrine and organ composed of both endocrine and exocrine tissues that perform several exocrine tissues that perform several functions. The endocrine part of the functions. The endocrine part of the pancreas consist of pancreatic islets. pancreas consist of pancreatic islets. The islet cells produce insulin and The islet cells produce insulin and glucagon, which are very important in glucagon, which are very important in controlling blood levels of nutrients such controlling blood levels of nutrients such as glucose and amino acids.as glucose and amino acids.

• The exocrine part of the pancreas The exocrine part of the pancreas is a compound acinar gland . The is a compound acinar gland . The acini produce digestive enzymes. acini produce digestive enzymes. Clusters of acini are connected by Clusters of acini are connected by small ducts, which join to form small ducts, which join to form larger ducts, and a larger ducts larger ducts, and a larger ducts join to form pancreatic duct. The join to form pancreatic duct. The pancreatic duct joins the common pancreatic duct joins the common bile duct and empties into the bile duct and empties into the duodenum.duodenum.

• Function of the PancreasFunction of the Pancreas

• The exocrine secretions of the The exocrine secretions of the pancreas include HCOpancreas include HCO33, which , which neutralize the acidic chyme that neutralize the acidic chyme that enters the small intestine from the enters the small intestine from the stomach. The increased pH stomach. The increased pH resulting from the secretion of resulting from the secretion of HCOHCO33 stops pepsin digestion but stops pepsin digestion but provides the proper environment provides the proper environment for the function of pancreatic for the function of pancreatic enzymes.enzymes.

• The major proteolytic enzymes The major proteolytic enzymes are trypsin, chymotrypsin and are trypsin, chymotrypsin and carboxypeptidase. These carboxypeptidase. These enzymes continue the protein enzymes continue the protein digestion that started in the digestion that started in the stomach and pancreatic stomach and pancreatic amylase continues the amylase continues the polysaccharide digestion that polysaccharide digestion that begun in the oral cavity. begun in the oral cavity.

PATHOPHYSIOLOGPATHOPHYSIOLOGYY

• Pancreatic cancer can arise Pancreatic cancer can arise from both the exocrine and from both the exocrine and endocrine portions of the endocrine portions of the pancreas. Of pancreatic pancreas. Of pancreatic tumors, 95% develop from the tumors, 95% develop from the exocrine portion of the exocrine portion of the pancreas, including ductal pancreas, including ductal epithelium, acinar cells, epithelium, acinar cells, connective tissue, and connective tissue, and lymphatic tissue. lymphatic tissue.

• Approximately, 75% of all Approximately, 75% of all pancreatic carcinomas occur within pancreatic carcinomas occur within the head or neck of the pancreas. the head or neck of the pancreas. 15-20% occur in the body of the 15-20% occur in the body of the pancreas and 5-10% occur in the pancreas and 5-10% occur in the tail. Typically, pancreatic cancer tail. Typically, pancreatic cancer first metastasizes to regional lymph first metastasizes to regional lymph nodes, then to the liver and less nodes, then to the liver and less commonly to the lungs. It can also commonly to the lungs. It can also directly invade surrounding visceral directly invade surrounding visceral organs such as the duodenum, organs such as the duodenum, stomach and colon.stomach and colon.

• As in other organs, chronic As in other organs, chronic inflammation is a predisposing inflammation is a predisposing factor in the development of factor in the development of pancreatic cancer. Patients pancreatic cancer. Patients with chronic pancreatitis from with chronic pancreatitis from alcohol, especially those with alcohol, especially those with familial forms, have much familial forms, have much higher incidence and an higher incidence and an earlier age of onset on earlier age of onset on pancreatic carcinoma.pancreatic carcinoma.

PANCREAS

Head Body TailExocrine Endocrine

Pancreatic Cancer Formed

Regional Lymph Nodes

Liver

Lungs

DuodenumStomach

colon

Ductal epithelium

Acinar Cells

Connective Tissue

Lymphatic Tissue

NURSING CARE PLANNURSING CARE PLAN

ASSESSMENTASSESSMENT

• S> “ Malala pa ang ubo S> “ Malala pa ang ubo ko,” as verbalized by ko,” as verbalized by the patient.the patient.

• O > presence of productive O > presence of productive cough.cough.

• > difficulty vocalizing.> difficulty vocalizing.• > excessive sputum> excessive sputum• > RR= 28 bpm> RR= 28 bpm• > restless> restless• > weak > weak

NURSING DIAGNOSIS NURSING DIAGNOSIS

• > Ineffective airway > Ineffective airway clearance related to clearance related to presence of secretions in presence of secretions in the bronchi. the bronchi.

SCIENTIFIC EXPLANATIONSCIENTIFIC EXPLANATION • > Pulmonary complications following > Pulmonary complications following

surgery are associated with significant surgery are associated with significant morbidity and have been shown to morbidity and have been shown to increase the length of hospitalization. increase the length of hospitalization. Efforts have been focused on the Efforts have been focused on the minimization of postoperative risk minimization of postoperative risk factors, such as prolonged bed rest factors, such as prolonged bed rest and inadequate pain control, and on and inadequate pain control, and on the routine use of incentive the routine use of incentive spirometryspirometry..

PLANNINGPLANNING

• > After 3 hours of > After 3 hours of nursing intervention, the nursing intervention, the client will be able to client will be able to maintain better airway maintain better airway patency.patency.

INTERVENTION INTERVENTION

RATIONALERATIONALE• > Monitored > Monitored

respiration and respiration and breath sounds, breath sounds, noting rate and noting rate and sound. sound. ( tachypnea, ( tachypnea, stridor, crackels stridor, crackels and wheezes).and wheezes).

• > Positioned head > Positioned head appropriate for appropriate for age/ condition.age/ condition.

• >To note the >To note the inactive inactive respiratory respiratory distress and/ or distress and/ or accumulation of accumulation of secretions.secretions.

• > To open or > To open or maintain open maintain open airway in at-rest airway in at-rest or compromised or compromised individual.individual.

• > Elevated head > Elevated head of the bed and of the bed and changed position changed position every 2 hours.every 2 hours.

• > Encouraged > Encouraged deep breathing deep breathing and coughing and coughing exercises.exercises.

• >To take >To take advantage of advantage of gravity decreasing gravity decreasing pressure on the pressure on the diaphragm and diaphragm and enhancing enhancing drainage of/ drainage of/ ventilation to ventilation to different lung different lung segments.segments.

• > To maximize > To maximize effort.effort.

• > Observe signs > Observe signs and symptoms of and symptoms of infection infection (increased (increased dyspnea with dyspnea with onset of fever, onset of fever, change in change in sputum color, sputum color, amount or amount or character.)character.)

• > Performed > Performed bronchial tapping bronchial tapping

• > To identify infectious > To identify infectious process/ promote process/ promote timely intervention.timely intervention.

• > To enhance the > To enhance the client’s capability to client’s capability to expectorate expectorate secretions. secretions.

EVALUATION EVALUATION

• The client maintained The client maintained better airway patency and better airway patency and expectorated secretions expectorated secretions readily.readily.

ASSESMENTASSESMENT

• S> “Nilalagnat ako.” as S> “Nilalagnat ako.” as verbalized by the patient.verbalized by the patient.

• O> temperature= 39 O> temperature= 39 degrees Celsiusdegrees Celsius

• > warm to touch> warm to touch• >RR= 29 bpm>RR= 29 bpm• > weak> weak• > restless> restless

NURSING DIAGNOSISNURSING DIAGNOSIS

• Increased in body Increased in body temperature related to temperature related to tissue trauma secondary tissue trauma secondary to removal of IV.to removal of IV.

SCIENTIFIC EXPLANATIONSCIENTIFIC EXPLANATION

• Fever is a common, fast and easy Fever is a common, fast and easy measurable sign of inflammation measurable sign of inflammation and infection. An increase in body and infection. An increase in body temperature often coincides with temperature often coincides with the liberation of microbiological the liberation of microbiological products or live bacteria into the products or live bacteria into the circulation. During sepsis, circulation. During sepsis, hyperthermia may also occur. hyperthermia may also occur.

PLANNINGPLANNING

• After 2 hours of nursing After 2 hours of nursing interventions, the client's interventions, the client's temperature will decrease temperature will decrease from 39 degrees Celsius to from 39 degrees Celsius to 38 degrees Celsius.38 degrees Celsius.

INTERVENTION RATIONALEINTERVENTION RATIONALE

• > Monitored > Monitored vital signs.vital signs.

• > Monitored all > Monitored all sources of fluid sources of fluid loss such as loss such as urine, vomiting urine, vomiting and diarrhea.and diarrhea.

• > To have a > To have a guide for guide for nursing actions nursing actions to be taken.to be taken.

• > Potentiates > Potentiates fluid and fluid and electrolytes electrolytes losses.losses.

• > Noted > Noted absence/ absence/ presence of presence of sweating as sweating as body attempts body attempts to increase to increase heat loss by heat loss by evaporation, evaporation, conduction and conduction and diffusion.diffusion.

• >Evaporation is >Evaporation is decreased by decreased by environmental environmental factors as high factors as high humidity and high humidity and high ambient ambient temperature, as temperature, as well as body well as body factors producing factors producing loss of ability to loss of ability to sweat or sweat sweat or sweat glands glands dysfunction.dysfunction.

• > Performed > Performed tepid sponge tepid sponge bath.bath.

• > Maintained > Maintained bed rest.bed rest.

• > Heat loss by > Heat loss by evaporation evaporation and and conduction.conduction.

• >To reduce >To reduce metabolic metabolic demands/oxydemands/oxygen gen consumption.consumption.

EVALUATIONEVALUATION

• > Body temperature > Body temperature decreased form 39 decreased form 39 degrees Celsius to 38 degrees Celsius to 38 degrees Celsius.degrees Celsius.

ASSESSMENTASSESSMENT

• S> “ Medyo sumasakit S> “ Medyo sumasakit ang tahi ko,” as ang tahi ko,” as verbalized by the patient.verbalized by the patient.

• O> limited mobilityO> limited mobility• > facial grimace> facial grimace• > PR= 88 bpm> PR= 88 bpm• > BP= 140/90 mmHg> BP= 140/90 mmHg• > with sutured wound on > with sutured wound on

hypogastric region.hypogastric region.• > Pain Scale= 6 out of 10.> Pain Scale= 6 out of 10.

NURSING DIAGNOSISNURSING DIAGNOSIS

•Pain related to Pain related to tissue trauma tissue trauma secondary to secondary to operation.operation.

SCIENTIFIC EXPLANATIONSCIENTIFIC EXPLANATION

• Unpleasant sensory from actual Unpleasant sensory from actual or potential tissue damage; or potential tissue damage; sudden or slow onset of any sudden or slow onset of any intensity from mild to severe. intensity from mild to severe. Pain is a signal that something is Pain is a signal that something is wrong. It is due to infection and wrong. It is due to infection and increased number of white blood increased number of white blood cells on the sight of incision to cells on the sight of incision to fight microorganisms that will fight microorganisms that will enter on the sutured wound and enter on the sutured wound and prevent sepsis.prevent sepsis.

INTERVENTION INTERVENTION RATIONALERATIONALE

• > Monitored vital > Monitored vital signs.signs.

• > Observed non > Observed non verbal cues/ pain verbal cues/ pain behaviors and behaviors and other objective other objective defining defining characteristics.characteristics.

• > To have a guide > To have a guide for nursing actions for nursing actions to be taken. to be taken.

• > Observations > Observations may/may not be may/may not be congruent with congruent with verbal reports or verbal reports or maybe only maybe only indicator present indicator present when client is when client is unable to unable to verbalize. verbalize.

• > Provided comfort > Provided comfort measures (therapeutic measures (therapeutic touch, repositioning, touch, repositioning, use of heat/cold use of heat/cold packs), quite packs), quite environment and calm environment and calm activities.activities.

• > Encouraged use of > Encouraged use of relaxation techniques relaxation techniques such as focused such as focused breathing and imaging. breathing and imaging.

• > To promote non > To promote non pharmacological pharmacological pain pain management.management.

• > To distract > To distract attention and attention and reduce tension.reduce tension.

EVALUATIONEVALUATION

• The pain decreased to The pain decreased to a tolerable level a tolerable level allowing the patient to allowing the patient to mobilize wit minimal mobilize wit minimal assistance.assistance.

DRUG STUDYDRUG STUDY

NAME OF THE DRUG NAME OF THE DRUG

• Generic Name: Generic Name: • UnasynUnasyn

• Brand Name: Brand Name: • Ampicilin Sodium and Sulbactam Ampicilin Sodium and Sulbactam

Sodium Sodium

CLASSIFICATION ON CLASSIFICATION ON ACTIONACTION

• Inhibits cell wall Inhibits cell wall synthesis during synthesis during bacterial multiplication. bacterial multiplication.

INDICATIONS INDICATIONS

• Intra-abdominal, Intra-abdominal, gynecologic, and skin gynecologic, and skin structure infections structure infections caused by susceptible caused by susceptible strains. strains.

CONTRAINDICATIONS CONTRAINDICATIONS • Contraindicated to patients Contraindicated to patients

hypersensitive to drug or other hypersensitive to drug or other penicillin.penicillin.

• Use cautiously in patients with other Use cautiously in patients with other drug allergies ( especially to drug allergies ( especially to cephalosporins) because of possible cephalosporins) because of possible cross-sensitivity, and in those with cross-sensitivity, and in those with mononucleiosis because of high risk mononucleiosis because of high risk of maculopapular rash. of maculopapular rash.

ADVERSE REACTION ADVERSE REACTION

• CV: thrombophlebitis, vein irritationCV: thrombophlebitis, vein irritation• GI: diarrhea, Nausea, GI: diarrhea, Nausea,

pseudomembranous colitis,vomiting, pseudomembranous colitis,vomiting, stomatitis, gastritis, black hairy tongue, stomatitis, gastritis, black hairy tongue, enterocolitis.enterocolitis.

• HEMATOLOGIC: agranulocytosis, HEMATOLOGIC: agranulocytosis, leucopenia, anemia, eosinophilia.leucopenia, anemia, eosinophilia.

• SKIN: pain at injection site.SKIN: pain at injection site.• OTHER: hypersensitivity OTHER: hypersensitivity

reaction,anaphylaxis,overgrowth of non reaction,anaphylaxis,overgrowth of non susceptible organisms. susceptible organisms.

NURSING RESPONSIBILITY NURSING RESPONSIBILITY

• Ask patient about allergic Ask patient about allergic reactions to penicillin. Obtain reactions to penicillin. Obtain specimen of culture and specimen of culture and sensitivity test.sensitivity test.

• In patient with impaired renal In patient with impaired renal function, decrease dosage.function, decrease dosage.

• In children, don’t use I.M. route.In children, don’t use I.M. route.

• Monitor liver function test results Monitor liver function test results during therapy, especially in during therapy, especially in patients with impaired liver patients with impaired liver function.function.

• If large doses are given or if If large doses are given or if therapy is prolonged, bacterial therapy is prolonged, bacterial and fungal superinfectiton may and fungal superinfectiton may occur, especially in elderly, occur, especially in elderly, debilitated or debilitated or immunosuppresssed patient. immunosuppresssed patient.

MONITORING MONITORING PARAMETERS PARAMETERS

• May increase alkaline May increase alkaline phosphatase, bilirubin, phosphatase, bilirubin, creatinine and LDH levels.creatinine and LDH levels.

• May increase eosinophil count. May increase eosinophil count. May decrease granulocyte, May decrease granulocyte, platelet and WBC count.platelet and WBC count.

• May alter results of urine May alter results of urine glucose tests that use glucose tests that use cupric sulfate, such as cupric sulfate, such as Benedict reagent and Benedict reagent and clinitest.clinitest.

NAME OF DRUGS NAME OF DRUGS

• Generic Name:Generic Name:• CaptorilCaptoril• Brand Name:Brand Name:• CapotenCapoten

CLASSIFICATION ON CLASSIFICATION ON ACTIONACTION

• > Inhibits ACE, preventing > Inhibits ACE, preventing conversion of angiotensin I to conversion of angiotensin I to angiotensin II, a potent angiotensin II, a potent vasoconstrictor. Less angiotensin II vasoconstrictor. Less angiotensin II decreases peripheral arterial decreases peripheral arterial resistance, decreasing aldosterone resistance, decreasing aldosterone secretions, which reduces sodium secretions, which reduces sodium and water retention and lowers and water retention and lowers blood pressure. blood pressure.

INDICATIONSINDICATIONS

• > Hypertension> Hypertension• > Diabetic nephropathy> Diabetic nephropathy• > Heart failure> Heart failure• > left ventricular > left ventricular

dysfunction after acute MI.dysfunction after acute MI.

CONTRAINDICATIONS CONTRAINDICATIONS • > Contraindicated in patients > Contraindicated in patients

hypersensitive to drug or other ACE hypersensitive to drug or other ACE inhibitors.inhibitors.

• > Use cautiously in patients with > Use cautiously in patients with impaired renal function or serious impaired renal function or serious autoimmune disease, especially systemic autoimmune disease, especially systemic lupus erythematous, and in those who lupus erythematous, and in those who have been exposed to other drug that have been exposed to other drug that affect WBC counts or immune response. affect WBC counts or immune response.

ADVERSE REACTION ADVERSE REACTION

• CNS: dizziness, fainting, CNS: dizziness, fainting, headache, fatigue, fever.headache, fatigue, fever.

• CV: tachycardia, hypotensionCV: tachycardia, hypotension• GI: abdominal pain, anorexia, GI: abdominal pain, anorexia,

constipation, dry mouth, constipation, dry mouth, nausea and vomiting.nausea and vomiting.

• METABOLIC: hyperkalemiaMETABOLIC: hyperkalemia• RESPIRATORY: dry, non RESPIRATORY: dry, non

productive cough.productive cough.• OTHER: angioedema OTHER: angioedema

NURSING NURSING RESPONSIBILITYRESPONSIBILITY

• > Monitor patients BP and PR > Monitor patients BP and PR frequently.frequently.

• > Elderly patients may be > Elderly patients may be more sensitive to drug’s more sensitive to drug’s hypotensive effects.hypotensive effects.

• > Assess patient for signs of > Assess patient for signs of angioedema.angioedema.

• > Drug causes more > Drug causes more frequent occurrence of frequent occurrence of cough, compared with other cough, compared with other ACE inhibitors.ACE inhibitors.

• > Don’t confuse Captopril > Don’t confuse Captopril with Capitrol. with Capitrol.

MONITORING MONITORING PARAMETERS PARAMETERS

• > May increase alkaline > May increase alkaline phosphatase, bilirubin and phosphatase, bilirubin and potassium levels. May decrease potassium levels. May decrease hemoglobin level and hematocrit.hemoglobin level and hematocrit.

• > May decrease granulocyte, > May decrease granulocyte, platelet, RBC and WBC counts.platelet, RBC and WBC counts.

• > May decrease granulocyte, > May decrease granulocyte, platelet, RBC and WBC counts platelet, RBC and WBC counts

NAME OF DRUGS NAME OF DRUGS

• Generic Name:Generic Name:• MetronidazoleMetronidazole• Brand Name: Brand Name: • FlagylFlagyl

CLASSIFICATION OF CLASSIFICATION OF ACTION ACTION

• > Direct-acting trichomonacide and > Direct-acting trichomonacide and amebicide that works inside and amebicide that works inside and outside the intestines. It’s thought outside the intestines. It’s thought to enter the cells of to enter the cells of microorganisms that contain microorganisms that contain nitroreductase, forming unstable nitroreductase, forming unstable compounds that bind to DNA and compounds that bind to DNA and inhibit synthesis causing cell death. inhibit synthesis causing cell death.

INDICATIONS INDICATIONS

• > Amebic Liver abscess> Amebic Liver abscess• > Intestinal amebiasis> Intestinal amebiasis• >Trichomoniasis>Trichomoniasis• > Refractory trichomoniasis> Refractory trichomoniasis

• > Bacterial infections caused > Bacterial infections caused by anaerobic organisms.by anaerobic organisms.

• >To prevent postoperative >To prevent postoperative infection in contaminated and infection in contaminated and potentially contaminated potentially contaminated colorectal surgery. colorectal surgery.

• > Bacterial Vaginosis> Bacterial Vaginosis

CONTRAINDICATIONSCONTRAINDICATIONS

• > Contraindicated in patients > Contraindicated in patients hypersensitive to drug or other hypersensitive to drug or other nitroimidazole derivatives.nitroimidazole derivatives.

• > Use cautiously in patients > Use cautiously in patients with history of CNS disorder, or with history of CNS disorder, or retinal and visual field changes.retinal and visual field changes.

• > Use cautiously in patients > Use cautiously in patients who take hepatotoxic drugs who take hepatotoxic drugs or have hepatic disease or or have hepatic disease or alcoholism. alcoholism.

ADVERSE REACTION ADVERSE REACTION

• CNS: headache, fever, CNS: headache, fever, dizziness, incoordination, dizziness, incoordination, confusion, irritability, confusion, irritability, depression, weakness, insomia.depression, weakness, insomia.

• CV: edema, flushing, CV: edema, flushing, • EENT: rhinitis, sinusitis, EENT: rhinitis, sinusitis,

pharyngitispharyngitis

• GI: nausea, abdominal pain, GI: nausea, abdominal pain, stomatitis, vomiting, diarrhea, stomatitis, vomiting, diarrhea, constipation, dry mouth.constipation, dry mouth.

• GU: darkened urine, polyuriaGU: darkened urine, polyuria• OTHER: decreased libido, OTHER: decreased libido,

overgrowth of non susceptible overgrowth of non susceptible organism. organism.

NURSING RESPONSIBILITY NURSING RESPONSIBILITY

• > Monitor liver function test results > Monitor liver function test results carefully in elderly patients.carefully in elderly patients.

• > Observe patient for edema, > Observe patient for edema, especially if he’s receiving especially if he’s receiving corticosteroids,corticosteroids,

• > Record number and character of > Record number and character of stools when drug is used to treat stools when drug is used to treat amebiasis. amebiasis.

MONITORING MONITORING PARAMETERS PARAMETERS

• > May decrease WBC and > May decrease WBC and neutrophil counts.neutrophil counts.

• > May falsely decrease > May falsely decrease triglycerides and triglycerides and aminotransferase levels. aminotransferase levels.

PROGNOSISPROGNOSIS

• Some patients with Some patients with Pancreatic head mass Pancreatic head mass that is resectable ( can that is resectable ( can be surgically removed) be surgically removed) are cured. However, cure are cured. However, cure rates are significantly rates are significantly less than 50%. less than 50%.

• In our case study, the patient In our case study, the patient experienced early signs and symptoms experienced early signs and symptoms of abdominal pain associated with of abdominal pain associated with jaundice and weight loss. When he was jaundice and weight loss. When he was admitted in the hospital, he also admitted in the hospital, he also experienced vomiting. He underwent experienced vomiting. He underwent hematology and ultrasound for whole hematology and ultrasound for whole abdomen and left hemithorax. He also abdomen and left hemithorax. He also underwent biopsy of the pancreas and underwent biopsy of the pancreas and operation of gastrojejunostomy. The operation of gastrojejunostomy. The improvement of his condition was seen improvement of his condition was seen several days after the operation. several days after the operation.

• His condition was improved but not enough for His condition was improved but not enough for him to be discharge in the hospital. He is still not him to be discharge in the hospital. He is still not allowed to eat or drink anything through mouth. allowed to eat or drink anything through mouth. He still have nasogastric tube where he takes his He still have nasogastric tube where he takes his medications, and a Jackson Pratt connected to medications, and a Jackson Pratt connected to his area where body fluids are build. But his area where body fluids are build. But because of immeasurable support of his sister because of immeasurable support of his sister and other relatives, our patient still fights and and other relatives, our patient still fights and show signs that he will be well soon.show signs that he will be well soon.

DISCHARGED DISCHARGED PLANNINGPLANNING

• MM > > Instruct the client to take his medication Instruct the client to take his medication such as Captopril, Metronidazole, such as Captopril, Metronidazole, Cefoxitin and Esomeprazole. Cefoxitin and Esomeprazole.

• >Reinforce importance of medication >Reinforce importance of medication compliance to patient and his relatives: it’s compliance to patient and his relatives: it’s time, route, dosage, frequency and duration.time, route, dosage, frequency and duration.

• >Advice to report unusual >Advice to report unusual manifestations and side effects of drug to manifestations and side effects of drug to physician.physician.

MEDICATIONMEDICATION

EE > Instruct the patients relative to > Instruct the patients relative to provide calm and non stressful provide calm and non stressful environment.environment.> Provide environment with normal room > Provide environment with normal room and body temperature.and body temperature.> Maintain clean and safe environment.> Maintain clean and safe environment.> Encourage patient to have mild exercise.> Encourage patient to have mild exercise.

ENVIRONMENT/EXERCISEENVIRONMENT/EXERCISE

TT> Teach patient how to > Teach patient how to manage pain regarding his manage pain regarding his sutured wound.sutured wound.

TREATMENTTREATMENT

HH> > Explain to patient’s relative regarding Explain to patient’s relative regarding disease and its manifestations.disease and its manifestations.

          >Discuss possible complications of >Discuss possible complications of disease and its signs and symptoms.disease and its signs and symptoms.

      >Instruct the client to have proper >Instruct the client to have proper hygiene.hygiene.

HEALTH HEALTH TEACHING/HYGIENETEACHING/HYGIENE

>Discuss the importance of >Discuss the importance of proper personal hygiene.proper personal hygiene.

          > Encourage the patient to do > Encourage the patient to do proper hand washing before and proper hand washing before and after eating and whenever it is after eating and whenever it is necessary.necessary.

OO> > Inform relatives and patient Inform relatives and patient regarding the importance of regarding the importance of compliance on follow up.compliance on follow up.

OUT PATIENT FOLLOW OUT PATIENT FOLLOW UPUP

DD> > Encourage the patient to increase fluid intake and Encourage the patient to increase fluid intake and eat nutritious foods such as fruits and vegetables.eat nutritious foods such as fruits and vegetables.

> Instruct the patient to avoid salty and fatty foods.> Instruct the patient to avoid salty and fatty foods.

> Instruct the patient to avoid smoking and > Instruct the patient to avoid smoking and alcoholic beverages.alcoholic beverages.

DIETDIET

S S > Encourage patient’s relative > Encourage patient’s relative to seek spiritual support.to seek spiritual support.> Encourage the patient to hold > Encourage the patient to hold his faith in God.his faith in God.

SPIRITUALSPIRITUAL

BIBLIOGRAPHYBIBLIOGRAPHY

• Kozier, Barbara, Fundamentals of Nursing, 7Kozier, Barbara, Fundamentals of Nursing, 7 thth Edition, Gentzler Company, 2002Edition, Gentzler Company, 2002

• Brunner and Suddarth’s Textbook of Medical-Brunner and Suddarth’s Textbook of Medical-surgical Nursing, 11surgical Nursing, 11thth Edition , Volume I. Edition , Volume I.

• Doenges, Marilyn G., Nurses Pocket Guide, 10Doenges, Marilyn G., Nurses Pocket Guide, 10 thth Edition, Stamper Company., 2003Edition, Stamper Company., 2003

• Brener, Toby E., Nursing 2007 Drug Handbook Brener, Toby E., Nursing 2007 Drug Handbook 2727thth Edition, Little John Company., 2007 Edition, Little John Company., 2007

• Internet:Internet:• http://www.google.com.phhttp://www.google.com.ph• http://www.yahoo.comhttp://www.yahoo.com