Capitol University

College of Nursing

Papillary Carcinoma of the Thyroid

(A case study of RLE7,ThFS, group 12)

In partial fulfillment of the requirements

Of RLE 7-2nd semester, SY 2009-2010

Presented by:

Gaid, Paulo

Jangaw, Wilbur

Japos, Leizel

Jose, Yumi

Kiamco, Paula Christy

Labininay, Marigold

Lagamon, Robina Joyce

Langam, Ronald

Layam, Gerome

Leones, Japhet

Lequigan, katrene

Presented to:

Ryan Ruiz, R.N.

February 2009

Table of Contents

Introduction……………………………………………………………………………..

Client’s Profile………………………………………………………………………….

Socio-demographic data……………………………………………………..

Vital Signs……………………………………………………………………..

Physical Assessment………………………………………………………...

Anatomy and Physiology…………………………………………………………….

Pathophysiology………………………………………………………………………

Laboratory Tests and Results……………………………………………………...

Nursing Care Plans………………………………………………………………….

Drug Studies…………………………………………………………………………

Discharge Planning…………………………………………………………………

Learning Experiences………………………………………………………………

References…………………………………………………………………………..

Introduction

Having heard such a very rare case wherein even up to the present times

experts have not yet discovered an all cure for the disease condition really

challenges the group to pursue a case study of such.

Cancer, specifically papillary carcinoma of the thyroid, is one of which

effective medical treatment is not really established, perhaps, that which would really

save the life of the patient even when diagnosed at the very late stage.

Papillary carcinoma, by definition, is a relatively common well-differentiated

thyroid cancer. It must be considered a variant of papillary thyroid carcinoma (mixed

form). It typically arises as an irregular, solid or cystic mass that arises from

otherwise normal thyroid tissue (http://www.google.com).

Thyroid cancer is a cancer that starts in the thyroid gland. Papillary

carcinomas typically grow very slowly. Usually they develop in only one lobe of

thyroid gland, but sometimes they occur in both lobes. Even though they grow

slowly, papillary carcinoma often spread to the lymph nodes in the neck. Both most

of the time, this can be successfully treated and is rarely fatal. Despite its well-

differentiated characteristics, papillary carcinoma may be overtly or minimally

invasive. In fact, these tumors may spread easily to other organs. Papillary tumors

have a propensity to invade lymphatic but are less likely to invade blood vessels.

Tumors that invade or extend beyond the thyroid capsule have a worse prognosis

because of an high local recurrence rate (http://www.yahoo.com).

This is closely related to the activation of trk and rets proto-oncogenes, both

acting by amplifying and rearranging mechanisms. The trk proto-oncogene codes for

tyrosine kinase receptors; the ret shows a paracentric inversion of chromosome 10

and 11 in 30% of the cases. However, the ret proto-oncogene is over expressed

some molecules that physiologically regulate the growth of the thyrocytes, such as

interleukin-1 and interleukin-8, or other cytokines(ie, insulin like growth factor-1

transforming growth factor -beta, epidermal growth factor) could play a role in the

pathogene's of this cancer.(htt://www.wikipedia.com)

Thyroid cancers are more often found in patients with a history of low-or-high-

dose external irradiation. Papillary tumors of the thyroid are the most common form

of thyroid cancer to result from exposure to radiation. Accounts for 85% of thyroid

cancers due to radiation exposure.

It occurs more frequently in women and presents in the 30-40 year age group

and it may also occur in children. 5%-10% of these are malignant and men have a

higher risk, even it is not common to them, of a nodule being malignant.

This case study has come to realization with the primordial aim of

understanding the disease condition in order to formulate plans of effective nursing

interventions that would help bring back the patient to the normal health status in a

gradual stage. Nursing care has been rendered to patient for one-duty shift. Hence,

evaluation of the effectivity and efficiency of such nursing interventions was not well

established.

Client’s Profile

Socio-demographic Data

Patient X is a 75-year-old, female, a Filipino citizen, from Layawan, Oroqueta City. She is religiously affiliated to Mormons religious group. She is a widow left with 9 children. Her primary language is Cebuano and is a high school graduate. She is a chronic smoker and started to smoke during her early 20’s for about 1/2 pack of cigarettes per day. She also has inherited diabetes mellitus from both sides of her parents who had a history of the disease.

Three years ago, patient X has started consultation from a doctor for complaints of swollen mass palpated in the neck and choking sensation everytime she eats. However, the mass has increased in size for the past few months and on January 20, 2010 she was diagnosed with papillary carcinoma on both lobes of the thyroid. Then on January 22, 2010 she underwent thyroidectomy and tracheostomy.

Patient X’s age is 75 years old. Her mobility status is limited due to her age. She requires special nutritional needs appropriate for her age – low fat especially low saturated fats, low in sodium and sugar. She also needs to eat vegetables and fruits.

Vital Signs

Temperature: 36.1 degrees Celcius Respiratory Rate: 11 cpm

Pulse Rate: 59 bpm Blood Pressure: 100/70 mmHg

Physical Assessment

This portion of the case study will present the deviation from the abnormal findings

of the physical assessment presented in a cephalo-caudal approach. These data are

then considered in the making of the nursing care plan.

Head

Aspect of Consideration Findings

Hair Dry Hair

Nose

Aspect of Consideration Findings

Mucosa Pale

Others With Nasogastric Tube in placed

Mouth

Aspect of Consideration Findings

Lips Pallor

Mucosa Pallor

Teeth Missing teeth with dentures

Gums Pallor

Neck

Aspect of Consideration Findings

Neck With tracheostomy Decreased range of motion

Skin

Aspect of Consideration Findings

General color Pallor

Texture Rough

Moisture Dry

Others Lesions and cracks between

toes

With edema in lower extremities

Respiratory

Aspect of Consideration Findings

Breathing Pattern > Bradypnea and use of accessory

muscles

> Wheezes and ronchi upon

auscultation

Cough Productive cough with light

green sputum

Abdomen

Aspect of Consideration Findings

General With striae

Bowel sounds Hypoactive

Elimination Pattern

Aspect of Consideration Findings

Usual bowel Pattern 3 -4 times a week, with light-

yellow colored stool

Bowel sounds Hypoactive

Others: LBM February 1, 2010

Activities of Daily Living /Mobility Status

0- Total independence 3- Assist with device and person

1- Assist with device 4- Total dependence

2- Assist with person

Feeding: 3 Meal Preparation: 4 Bed Mobility: 2

Bathing: 4 Cleaning: 4 Chair /toilet transfer: 4

Dressing; 4 Laundry: 4 Ambulation: 3

Grooming: 2 Toileting: 4 ROM: 3

Cognitive – Perceptual Pattern

Aspect of Consideration Findings

Appropriate behavior/ communication Unable to communicate verbally

due to tracheostomy tube

Emotional state Worried,anxious, restless,

irritable

Anatomy and Physiology

The thyroid gland is a

butterfly-shape organ and is

composed of two cone-like lobes or

wings, lobus dexter (right lobe) and

lobus sinister (left lobe), and is also

connected with the isthmus. The

organ is situated on the anterior side

of the neck, lying against and around

the larynx and trachea, reaching

posteriorly the oesophagus and

carotid sheath. It starts cranially at

the oblique line on the thyroid

cartilage (just below the laryngeal

prominence or Adam's apple) and extends inferiorly to the fifth or sixth tracheal ring.

It is difficult to demarcate the gland's upper and lower border with vertebral levels

because it moves position in relation to these during swallowing.

The thyroid gland is covered by a fibrous sheath, the capsula glandulae

thyroidea, composed of an internal and external layer. The external layer is

anteriorly continuous with the lamina pretrachealis fasciae cervicalis and

posteriorolaterally continuous with the carotid sheath. The gland is covered

anteriorly with infrahyoid muscles and laterally with the sternocleidomastoid muscle.

On the posterior side, the gland is fixed to the cricoid and tracheal cartilage and

cricopharyngeus muscle by a thickening of the fascia to form the posterior

suspensory ligament of Berry. In variable extent, Lalouette's Pyramid, a pyramidal

extension of the thyroid lobe, is present at the most anterior side of the lobe. In this

region, the recurrent laryngeal nerve and the inferior thyroid artery pass next to or in

the ligament and tubercle. Between the two layers of the capsule and on the

posterior side of the lobes there are on each side two parathyroid glands.

The thyroid isthmus is variable in presence and size, and can encompass a

cranially extending pyramid lobe (lobus pyramidalis or processus pyramidalis),

remnant of the thyroglossal duct. The thyroid is one of the larger endocrine glands,

weighing 2-3 grams in neonates and 18-60 grams in adults, and is increased in

pregnancy.

The thyroid is supplied with arterial blood from the superior thyroid artery, a

branch of the external carotid artery, and the inferior thyroid artery, a branch of the

thyrocervical trunk, and sometimes by the thyroid ima artery, branching directly from

the brachiocephalic trunk. The venous blood is drained via superior thyroid veins,

draining in the internal jugular vein, and via inferior thyroid veins, draining via the

plexus thyroideus impar in the left brachiocephalic vein.

Lymphatic drainage passes frequently the lateral deep cervical lymph nodes and

the pre- and parathracheal lymph nodes. The gland is supplied by sympathetic nerve

input from the superior cervical ganglion and the cervicothoracic ganglion of the

sympathetic trunk, and by parasympathetic nerve input from the superior laryngeal

nerve and the recurrent laryngeal nerve.

Physiology

The primary function of the thyroid is production of the hormones thyroxine

(T4), triiodothyronine (T3), and calcitonin. Up to 80% of the T4 is converted to T3 by

peripheral organs such as the liver, kidney and spleen. T3 is about ten times more

active than T4.

T3 and T4 production and action

The system of the thyroid hormones T3 and

T4.

Thyroxine (T4) is synthesised by the

follicular cells from free tyrosine and on the

tyrosine residues of the protein called

thyroglobulin (Tg). Iodine is captured with

the "iodine trap" by the hydrogen peroxide

generated by the enzyme thyroid

peroxidase (TPO) and linked to the 3' and

5' sites of the benzene ring of the tyrosine residues on Tg, and on free tyrosine.

Upon stimulation by the thyroid-stimulating hormone (TSH), the follicular cells

reabsorb Tg and proteolytically cleave the iodinated tyrosines from Tg, forming T4

and T3 (in T3, one iodine atom is absent compared to T4), and releasing them into

the blood. Deiodinase enzymes convert T4 to T3. Thyroid hormone that is secreted

from the gland is about 90% T4 and about 10% T3.

Cells of the brain are a major target for the thyroid hormones T3 and T4.

Thyroid hormones play a particularly crucial role in brain maturation during fetal

development. A transport protein that seems to be important for T4 transport across

the blood-brain barrier (OATP1C1) has been identified. A second transport protein

(MCT8) is important for T3 transport across brain cell membranes.

Non-genomic actions of T4 are those that are not initiated by liganding of the

hormone to intranuclear thyroid receptor. These may begin at the plasma membrane

or within cytoplasm. Plasma membrane-initiated actions begin at a receptor on the

integrin alphaV beta3 that activates ERK1/2. This binding culminates in local

membrane actions on ion transport systems such as the Na(+)/H(+) exchanger or

complex cellular events including cell proliferation. These integrins are concentrated

on cells of the vasculature and on some types of tumor cells, which in part explains

the proangiogenic effects of iodothyronines and proliferative actions of thyroid

hormone on some cancers including gliomas. T4 also acts on the mitochondrial

genome via imported isoforms of nuclear thyroid receptors to affect several

mitochondrial transcription factors. Regulation of actin polymerization by T4 is critical

to cell migration in neurons and glial cells and is important to brain development.

T3 can activate phosphatidylinositol 3-kinase by a mechanism that may be

cytoplasmic in origin or may begin at integrin alpha V beta3.

In the blood, T4 and T3 are partially bound to thyroxine-binding globulin,

transthyretin, and albumin. Only a very small fraction of the circulating hormone is

free (unbound) - T4 0.03% and T3 0.3%. Only the free fraction has hormonal activity.

As with the steroid hormones and retinoic acid, thyroid hormones cross the cell

membrane and bind to intracellular receptors (α1, α2, β1 and β2), which act alone, in

pairs or together with the retinoid X-receptor as transcription factors to modulate

DNA transcription [1] .

T3 and T4 regulation

The production of thyroxine and triiodothyronine is regulated by thyroid-

stimulating hormone (TSH), released by the anterior pituitary. The thyroid and

thyrotropes form a negative feedback loop: TSH production is suppressed when the

T4 levels are high, and vice versa. The TSH production itself is modulated by

thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus and

secreted at an increased rate in situations such as cold (in which an accelerated

metabolism would generate more heat). TSH production is blunted by somatostatin

(SRIH), rising levels of glucocorticoids and sex hormones (estrogen and

testosterone), and excessively high blood iodide concentration.

An additional hormone produced by the thyroid contributes to the regulation of

blood calcium levels. Parafollicular cells produce calcitonin in response to

hypercalcemia. Calcitonin stimulates movement of calcium into bone, in opposition

to the effects of parathyroid hormone (PTH). However, calcitonin seems far less

essential than PTH, as calcium metabolism remains clinically normal after removal

of the thyroid (thyroidectomy), but not the parathyroids.

Significance of iodine

In areas of the world where iodine is lacking in the diet, the thyroid gland can

be considerably enlarged, resulting in the enlarged thyroid glands of endemic goitre.

In this situation, women with severe iodine deficiency can give birth to infants with

thyroid hormone deficiency, who will have physical growth and development

problems. Brain development can be severely impaired. This is a condition called

endemic cretinism, and it is one cause of congenital hypothyroidism. Newborn

children in many developed countries are now routinely tested for congenital

hypothyroidism as part of newborn screening. Children with congenital

hypothyroidism are treated by supplementation with levothyroxine, which enables

them to grow and develop normally.

Thyroxine is critical to the regulation of metabolism and growth throughout the

animal kingdom. Among amphibians, for example, administering a thyroid-blocking

agent such as propylthiouracil (PTU) can prevent tadpoles from metamorphosing

into frogs; in contrast, administering thyroxine will trigger metamorphosis.

Because the thyroid concentrates this element, it also concentrates various

radioactive isotopes of iodine produced by nuclear fission. In the event of large

accidental releases of such material into the environment, the uptake of radioactive

iodine isotopes by the thyroid can, in theory, be blocked by saturating the uptake

mechanism with a large surplus of non-radioactive iodine, taken in the form of

potassium iodide tablets. While biological researchers making compounds labelled

with iodine isotopes do this,November 2009 in the wider world such preventive

measures are usually not stockpiled before an accident, nor are they distributed

adequately afterward. One consequence of the Chernobyl disaster was an increase

in thyroid cancers in children in the years following the accident.

The use of iodised salt is an efficient way to add iodine to the diet. It has

eliminated endemic cretinism in most developed countries, and some governments

have made the iodination of flour, cooking oil or salt mandatory. Potassium iodide

and sodium iodide are typically used forms of supplemental iodine.

As with most substances, either too much or too little can cause problems.

Recent studies on some populations are showing that excess iodine intake could

cause an inceased prevelence of autoimmune thyroid disease resulting in

permanent hypothyroidism. Some governments are reviewing the quantity of iodine

added to salt using local salt consumption data.

Predisposing Factors: (Please refer to Fig A)

Precipitating Factors: (Please refer to Fig B)

Papillary carcinoma develops in the thyroid

Tumors grows slowly

Tumor cells becomes invasive

Goes to invading into the lymphatic

Though Uncommon Distant spread of cancer cells may occur

Compromise other organs major function

May invade other organs

Cancer may become Systemic

Surgery:

Removal of the thyroid

If treated:

SurgeryChemotherapyRadiotherapy

Destruction of cancer cells:

ChemotherapyRadiotherapy

Abnormal Growth of mass in the right

breast

If not treated

May spread to other organs and thyroids greatly impede swallowing.

Pathologic Report: Positive for Cancer Cells

DEATH

Cancer Cells Destroyed

Etiologic Factors Actual Rationale

Age: Thyroid carcinoma is common in person at all ages with mean age of 49 years old.

Patient X is an elderly, most likely she is more prone on having thyroid cancer age75 years old.

Elderly person tend to be more at risk on developing thyroid cancer

Gender: Recent studies found out that the female-to-male ratio is almost 3:1 related in patients’ age which older than 45 years.

Patient X’s gender is female

Women are three times more prone to develop cancer than men.

Lifestyle: cigarette smoking mostly increase the risk of developing thyroid disorders/cancer

Patient X has been smoking for more than 30 years

Foreign studies found out that smoking greatly increase the risk of developing thyroid disorders. One component of tobacco smoke is cyanide, which is converted to thiocyanate, which acts as an anti-thyroid agent, directly inhibiting iodide uptake and hormone synthesis.

Predisposing Factors (figure A.)

Precipitating Factors (figure B.)

Etiologic Factors Actual Rationale

Developing abnormal buildup of mass in the front upper neck.

Patient X experience an enlargement of her neck and difficulty in swallowing

3 months prior to admission patient X experience chocking when swallowing food even in small amount and notices build up of mass in the neck.

Laboratory and Tests Results

Microbiology Gram Stain Report

February 5, 2010

Result: No microorganism seen

Polymorphonuclear cells: Moderate

Epithelial cells: Few

Interpretation:

Neutrophils or polymorphonuclear cells (Polys) fight bacterial infections. They normally account for 55% to 70% of WBCs. If you have a very low count, you could get a bacterial infection. This condition is called neutropenia. Advanced HIV disease can cause neutropenia. So can some medications including ganciclovir, a drug used to treat cytomegalovirus and the anti-HIV drug.

Clinical Chemistry

February 4, 2010

Ionized Calcium

Result: 0.91 mmol/L

Reference range: 1.12 – 1.32 mmol/L

Interpretation:

Ionized calcium is vitally important in blood coagulation, nerve conduction, neuromuscular transmission and in muscle contraction. Decreased ionized calcium (hypocalcemia) often results in cramps (tetany), reduced cardiac stroke work and depressed left ventricular function. Prolonged hypocalcemia may result in bone demineralization (osteoporosis) which can lead to spontaneous fractures.

January 25, 2010

Final Pathological Report:

Papillary Carcinoma, both lobes

Fibro-collagenous Tissue, Specimen B

Gross and Microscopic Description:

Received two specimens:

a. A specimen consists of the thyroid gland the left and right lobes measure 10.2 x 7.5 x 4 and 6.8 x 7 x 3 cm. The isthmus measure 3 x 0.2 cm. Cut sections of the left and right lobe show ill defined fan mass, 8 x 4.7 and 3.2 x 1.8 cm, surrounded by meats and fan parenchyma.

b. Specimen consists of an irregular strip of grayish white rubbery tissue fragment measuring 0.3 cm. Black all.

Microscopic Description:

Microsections of both lobes show thyroid tissues. There are solid sheets tumor cells, round to avoid with nuclear clearing. Fibrous tissues separate sheets of tumor cells.

Microsection of specimen b show fibro-collagenous tissues. There is no evidence of malignancy.

Interpretation:

Papillary carcinoma: About 8 of 10 thyroid cancers are papillary carcinomas (also called papillary cancers or papillary adenocarcinomas). Papillary carcinomas typically grow very slowly. Usually they develop in only one lobe of the thyroid gland, but sometimes they occur in both lobes. Even though they grow slowly, papillary carcinomas often spread to the lymph nodes in the neck. But most of the time, this can be successfully treated and is rarely fatal.

Several different variants (subtypes) of papillary carcinoma can be recognized under the microscope. Of these, the follicular variant (also calledmixed papillary-follicular variant) occurs most often. The usual form of papillary carcinoma and the follicular variant have the same outlook for survival (prognosis), and treatment is the same for both. Other variants of papillary carcinoma (columnar, tall cell, diffuse sclerosis) are not as common and tend to grow and spread more quickly

HEMOGLUCOTEST

Normal Values: Before Meals: 90-130 mg/dl

After Meals: less than 180 mg/dl

Results

January 27, 2010 227 mg/dl

January 31, 2010 243 mg/dl

February 2, 2010 104 mg /dl----------7:50 pm

February 4, 2010 183 mg /dl ----------7:30 pm

February 4, 2010 107 mg/dl ----------11:30 am

February 5, 2010 231 mg/dl

Interpretation:

Healthy blood sugar level ranges

Blood sugar levels over 200 mg/dL (mg/dL = milligrams of glucose per deciliter of blood) or under 60 mg/dL are considered unhealthy. High blood sugar levels (above 200 mg/dL) may be a sign of inadequate levels of insulin, caused by diabetes medication, overeating, lack of exercise, or other factors. Low blood sugar levels (below 60 mg/dL) may be a caused by taking too much insulin, skipping or postponing a meal, over-exercising, excessive alcohol consumption, or other factors.

The following are the most common symptoms of hyperglycemia (high blood sugar). However, each individual may experience symptoms differently. Symptoms may include rapid weight loss, feeling sick, thirst, vomiting, fatigue, blurred vision and fainting. The following are the most common symptoms of hypoglycemia (low blood sugar). However, each individual may experience symptoms differently. Symptoms may include: hunger, fatigue and shakiness.

Creatinine

Normal range: 0.6 - 1.2 mg/dL

Sodium

Normal range: 135 - 145 mEq/L

BUN

Normal range: 5 – 35

Potassium

Normal range: 3.5 - 5.0 mEq/L

Decrease in serum potassium is seen usually in states characterized by excess K+ loss, such as in vomiting, diarrhea, villous adenoma of the colorectum, certain renal tubular defects, hypercorticoidism, etc. Redistribution hypokalemia is seen in glucose/insulin therapy, alkalosis (where serum K+ is lost into cells and into urine), and familial periodic paralysis. Drugs causing hypokalemia include amphotericin, carbenicillin, carbenoxolone, corticosteroids, diuretics, licorice, salicylates, and ticarcillin.

Drug Study

Generic Name: atorvastatin calcium

Brand Name: Lipitor

Classification: Antilipemics

Dosage: 40 mg

Route: PO

Frequency: OD @ HS

Indications and dosages:

- Adjunct to diet to reduce LDL and total cholesterol, apolipoprotein B and triglyceride levels in patients with primary hypercholesterolemia and mixed dyslipidemia; primary dysbetelipoproteinemia that doesn’t respond adequately to diet; adjunct to diet for elevated triglyceride levels.

- Alone or as adjunct to lipid-lowering treatments such as LDL apheresis in patients with homozygous familial hypercholesterolemia.

Mechanism action:

- Inhibits 3-hydroxy-3-methyglutaryl coenzyme A (HMG-CoA) reductase, which is an early (and rate-limiting) step in cholesterol biosynthesis.

Adverse reactions:

CNS: headache, asthenia, insomia.

EENT: rhinitis, pharyngitis, sinusitis.

GI: abdominal pain, dyspepsia, flatulence, nausea, constipation, diarrhea.

GU: urinary tract infection.

Musculoskeletal: arthritis, myalgia.

Respiratory: bronchitis.

Other: infection, peripheral edema.

Contraindications:

- Contraindicated in patients hypersensitive to drug and in those with active liver disease or unexplained persistent elevations of transaminase levels. Also contraindicated in pregnant and breast-feeding women and in women of childbearing potential.

Nursing Responsibilities:

- Remember 10 rights of drug administration

- Drug should be withheld or discontinued in patients at risk for renal failure, in serious, acute conditions that suggest myopathy, and severe acute infection, hypotension and uncontrolled seizures.

- Start drug therapy only after diet and other nonpharmacologic treatments prove ineffective. Patient should follow a standard low-cholesterol diet before and during therapy.

- Drug maybe given as a single dose at any time of the day, with or without food.

- Warn patient to avoid alcohol.

- Advise patient that drug can be taken at any time of the day, without regard to meals.

Generic name: budesonide

Brand name: Pulmicort turbuhaler

Classification: Respiratory tract drugs

Dosage: ½ neb

Route: via tracheostomy

Frequency: tid

Indications and Dosages:

-Prophylactic therapy in maintenance treatment of asthma.

Action:

- Anti-inflammatory corticosteroid that exhibits potent glucocorticoid activity and weak mineralocorticoid activity. Have a wide range of inhibitory activity against such cell types as mast cells and macrophages and mediator involved in allergic and non-allergic inflammation.

Adverse Reactions:

CNS: headache, asthenia, insomia.

EENT: rhinitis, pharyngitis, sinusitis.

GI: oral candidiasis, dyspepsia, nausea, dry mouth, taste perversion, vomiting and abdominal pain.

Metabolic: weight gain

Respiratory: increased cough, bronchospasm.

Musculoskeletal: back pain, fractures, myalgia.

Other: flu-like symptoms, fever, hypersensitivity reactions.

Contraindications:

- Contraindicated in patients hypersensitive to drug and in those with status asthmaticus or other acute asthma episodes.

Nursing Responsibilities:

- Remember 10 rights of drug administration.

- If bronchospasm occurs after using budesonide, stop therapy and treat with bronchodilator

- Improve lung function has been observed within 24 hours of starting budesonide treatment, although maximum benefit may not achieved for 1 – 2 weeks or longer.

- In rare cases, inhaled corticosteroids have been linked to increased intraocular pressure and cataract development. If local irritation occurs, drug may be discontinued.

Generic name: calcitriol

Brand name: Rocaltrol

Classification: Parathyroid like drugs

Dosage: .25 mg

Route: PO

Frequency: bid

Mechanism of action:

- Vitamin D analogue that stimulates calcium absorption from the GI tract and promotes movement of calcium from bone to blood.

Indications:

- hypocalcemia in patients undergoing long term dialysis.

- hypoparathyroidism, pseudohypoparathyroidism

- management of secondary hyperparathyroidism and resulting metabolic bone disease in predialysis patient.

Adverse reactions:

- none reported

Contraindications:

- Contraindicated in patients with hypercalcemia or vit. D toxicity. Withhold all preparations containing vit. D.

Nursing responsibilities:

- Use cautiously in patients receiving cardiac glycosides and in those with hyperparathyroidism.

- Protect drug from direct light.

- Tell patient to immediately report symptoms of vit. D intoxication: weakness, nausea, vomiting, dry mouth, constipation, muscle or bone pain, or metallic taste.

- Instruct patient to adhere to diet and calcium supplementation and to avoid unapproved OTC drugs and magnesium containing antacids.

Generic name: albumin 25%

Brand name: Albutein 25%

Classification: Blood derivatives or hematologic drugs

Dosage: 100 ml

Route: IVTT

Frequency: od

Mechanism of action:

- Albumin 25% provides intravascular oncotic pressure in a 5:1 ratio, causing a fluid shift from interstitial spaces to the circulation and slightly increasing plasma protein level.

Indications:

- hypovolemic shock

- hypoproteinemia

- hyperbilirubinemia

Adverse reactions:

- CNS: headache

- CV: vascular overload after rapid infusion, hypotension, tachycardia

- GI: increase salivation, nausea, vomiting

- Musculoskeletal: back pain,

- Respiratory: dyspnea, pulmonary edema

- Skin: urticaria, rash

- Others: chills, fever

Contraindications:

- Contraindicated in patient hypersensitive to drug and in those with severe anemia or cardiac failure.

Nursing responsibilities:

- Remember 10 rights of drug administration.

- Use with extreme caution in patients with hypertension, and pulmonary edema.

- Monitor vital signs carefully.

- Monitor fluid intake and output.

- Follow storage instructions on bottle freezing may cause bottle to break.

- Tell patient to report adverse reactions promptly

Generic name: methyprednisolone sodium

Brand name: Solu-Medrol

Classification: Hormonal drugs

Dosage: 50mg

Route: IVTT

Frequency: TID

Mechanism of action:

- Not clearly defined. Decreases inflammation, mainly by stabilizing leukocyte lysosomal membrane; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism.

Indications:

- severe inflammation or immunosuppression- shock

Adverse reactions:

CNS: insomnia, seizure, headache

CV: hypertension, edema, thrombophlebitis, heart failure, cardiac arrest, circulatory collapse after rapid use of large IV doses

EENT: cataracts, glaucoma

GI: peptic ulceration, GI irritation, nausea, vomiting

Metabolic: hypocalcemia, hypokalimia, hyperglycemia

Musculoskeletal: muscle weakness, osteoporosis

Skin: delayed wound healing, various skin eruptions

After abrupt withdrawal: rebound inflammation, fatigue, weakness, dizziness, lethargy, depression, dyspnea, orthostatic hypotension, hypoglycemia.

After prolonged use, sudden withdrawal maybe fatal.

Contraindications:

- contraindicated in patient hypersensitive to drug or its ingredients and in those with systemic fungal infection; also contraindicated in premature infants

Nursing responsibilities:

- Remember 10 rights of drug administration.- Determine whether patient is sensitive to other corticosteroid.- For better results and less toxicity, give once or daily dose in the morning.- Give oral dose with food when possible.- Watch for depression or psychotic episodes especially in high dose therapy.- Unless contraindicated, give low-sodium diet that’s high in potassium and

protein.- Gradually reduce dosage after long term therapy.- Tell patient not to stop drug abruptly or without prescriber’s consent.

Generic name: meropenem trihydrate

Brand name: Meronem

Classification: Anti-bacterial

Dosage: 500mg

Route: IVTT

Frequency: QID

Mechanism of action:

- Exerts its bactericidal action by interfering with vital bacterial cell wall synthesis. The ease with which it penetrates bactericidal cells, its high level of stability to all serine B-lactamase and its marked affinity for the penicillin binding proteins explain the potent bactericidal activity against broad spectrum of aerobia and anaerobic bacteria.

Indications:

- Lower respiratory tract infections- Urinary tract infections including complicated infections- Intraabdominal infections- Septicemia- Meningitis

Adverse reactions:

CNS: Seizures, headache

GI: Diarrhea, vomiting, constipation, glossitis

GU: Presence of RBC in urine

Respiratory: Apnea, dyspnea

Skin: Rash, pruritus

Contraindications:

- Contraindicated in patients who have demonstrated hypersensitivity to its product.

Nursing responsibilities:

- Remember 10 rights of drug administration.

- Use cautiously in elder patient and in those with history of seizure disorders or impaired renal functions.

- Stop drug and notify prescriber if an allergic reactions occurs.

- Monitor patient for signs and symptoms of infection.

- Monitor patient’s balance and weight carefully.

- Instruct patient to report adverse reactions.

Discharge Plan

Medication

> Strict compliance to the drug regimen should be emphasized

> Emphasis to take home medication consistently following the right drugs, dosage,

timing & frequency, and route.

Exercise

> It is best to start the exercise program slowly until you get stronger, also find a

suitable exercise program to suit your condition.

> Exercise is important this makes your heart stronger, lowers blood pressure, and

help keep your body healthy.

> Maintaining a regular exercise will help facilitate adequate blood flow for

nourishing different parts of the body.

Treatment

> Have a regular check-up with your physician regarding with your condition for any

continuing treatment and medications.

Health Teachings

> Emphasis on personal hygiene to promote comfort and prevent infection.

> Do regular exercises, eat right food, and take medications to enhance recovery

and healing as indicated by the physician.

Out Patient

> Regular check-up for monitoring of development and if there are presence of

complication.

Diet

> Consult a nutritionist for a proper diet program.

Tips:

> Eat nutritious and healthy food, to avoid constipation. Eat foods such as oatmeal,

whole-grain breads and cereals, fruits and vegetables.

> If certain food gives the client cramps or diarrhea do not include the food in the

diet, try the food again in few weeks by taking small portions then gradually increase

the portion size.

> Eat slowly and do not use straw when drinking.

> Drink at least 8-10 glasses of water a day; limit the amount of soda, tea and

coffee.

Spirituality

>Tell the patient/client to pray for God, for him nothing is impossible. Ask for inner

strength to carry his trials

Learning Experiences

In doing the case study, the essence of team effort and patience were always

their. Everything we have done entails patience, knowledge and skills in doing each

task correctly. We have learned a lot about proper nursing interventions, rendering

care to our patients, regarding the disease conditions, manifestations and a lot more.

One should also need to analyze all the significant data to know the relationship of

other data. We have also learned time-management in doing our individual task.

While in the other hand, our experience in CUMC – Station 2 was honestly

tiring but a promising experience indeed. It was fortunate to have a good relationship

with our group mates, hospital staffs and to our beloved clinical instructor as well.

What happened in this rotation was a lot of new ideas, new terms and topics that we

have not tackled from previous rotations. The hospital itself also imposes on what is

the ideal thing to do for the student nurse to follow; and as soon as we become

registered nurses, we will be able to follow the proper principle that a nurse must

follow. Although this rotation was a bit toxic, this will help each one of us to become

a lot better. We admit we have committed a couple of mistakes, but what is more

important is what you learned from your mistakes.

We would like to thank, our ever grateful, God Almighty, thank you so much

for giving the group strength to handle each situation confidently. To our dear CI,

Mr. Ryan C. Ruiz, R.N., thank you for being effective in the field. As a clinical

instructor, he emphasized the values of professionalism, respect and patience. To

our beloved parents who have shown support and understanding in all activities.

And to the Hospital Staffs who help and guide us for this rotation.

 

References

http://www.virtualcancercentre.com/diseases.asp?did=556&page=3

http://emedicine.medscape.com/article/281237-overview

http://www.dartmouth.edu/~humananatomy/part_6/chapter_36.html

http://www.fascrs.org/physicians/education/core_subjects/2003/

anatomy_colon_rectum_anus/

http://chestofbooks.com/health/anatomy/Human-Body-Construction/Blood-

Vessels.html