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COLLEGE OF NURSING

In Partial Fulfillment of the

Requirements of the Subject
NCM 106 Related Learning Experience
2nd Rotation: Case Scenario 5 Cervical Cancer

Submitted to:
Mr. Victor Degamo

Submitted by:
Catherine Batobalonos
Asterlyn Coniendo
Algeia Demetillo
Niñ a Marie Lopez
 A Case of Cervical Cancer
A 34 year old woman, G3P3, presented to a secondary-level hospital with abnormal vaginal bleeding for two months. She had
been on Depo-Provera contraception for 10 years. She defaulted on her last dose as she suspected that it was the cause of her
abnormal bleeding. She had no prior cervical screening but a pap smear taken when she started bleeding showed high-grade
squamous intraepithelial lesion (HSIL).

PAST MEDICAL-SURGICAL HISTORY:

She had no chronic medical problems and her only surgical history was excision of a right upper arm lipoma. She had no
smoking history. On gynaecological examination, a fungating exophytic tumor replacing the cervix was seen and a punch
biopsy was taken. Her hemoglobin count was 5.2 grams per decilitre (g/dl); she was transfused five units of packed red blood
cells and referred to your unit.

ASSESSMENT:

On arrival to your unit, she had an elevated diastolic blood pressure of 133/106, tachycardia of 135 beats per minute and a
temperature of 36.6 degrees celcius. Her chest was clear and on cardiovascular examination she had no gallop rhythm or
murmurs. Her abdomen was soft and non-tender. On vaginal and recatal examination, she had a 6 x 8 cm exophytic fungating
tumor replacing the cervix, which was confined to the upper two-thirds of the vagina with bilateral pelvic sidewall
involvement.

She had normocytic hypochromic anemia of 7.7 g/dl with normal renal and liver function tests. Her syphilis and HIV screening
test were negative. Chest X-ray and cytoscopy did not show any metastases or bladder invasion respectively. Abdominal
imaging via ultrasound scan showed a normal liver and she had no hydroureteronephrosis. The punch biopsy result showed
moderately differentiated cervical squamous cell carcinoma. She was clinically staged as FIGO stage IIIB. She consented to
treatment with pelvic radiotherapy, which was the recommendation of the oncologist. Prior to starting her treatment, she had
been admitted twice with severe anemia, transfused a total of six units of packed red blood cells (excluding the five units she
received from the referral hospital), she completed her treatment on November 14, 2019.

Two months after completion of her radiation treatment, the patient presented with a shoulder abscess on the right arm, for
which she had incision and drainage. Enterobacter cloacae complex, sensitive to ciprofloxacin, was isolated from the wound
and she received appropriate treatment. However, three months after rhe incision and drainage the wound had not healed and
this prompted a biopsy. The results confirmed metastatic squamous cell carcinoma of cervical origin.

GENERAL SURVEY:

Patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right shoulder-unchanged since
the other day, facial grimace noted, on O2 inhalation at 2-4 liters per minute prn, pale conjunctiva noted, dry skin noted,
hooked with PNSS 1L at 40 gtts/min, reported 10 kg weight loss, complains of easy fatigability and poor appetite. Reports
vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T: 37.6 degrees celcius, P: 84bpm, RR: 31cpm,
BP: 90/60 mmHg.

Guide Questions ( Case Scenario 4-Cervical Cancer)

1. Discuss what is Pap Smear? (Procedure and possible complications)

 Pap Smear is also called Pap test, it is a procedure to test for cervical cancer in women.
  Pap smear involves collecting cells from your cervix – the lower, narrow end of your uterus that’s at the top of
your vagina.
 Detectiing cervical cancer early with a Pap Smear gives you a greater chance at a cure.
 A pap smear can also detect changes in your cervical cells that suggest cancer may develop in the future.
Detecting these abnormal cells early with a pap smear is your first step in halting the possible develoment of
cervical cancer.

Why is Pap smear done?

 The pap smear is usually done in conjunction with a pelvic exam. In women older than age 30, the pap test may
be combined with a test for human papillomavirus – a common sexuallty transmitted infection that can cause
cervical cancer.

How often is pap smear should be repeated?

 Doctors generally recommend repeating pap testing every three years for women ages 21 to 65.
 Women age 30 and older can consider pap testing every five years if the procedure is combined with testing for
HPV.
 If you have certain risk factors, your doctor may recommend more frequent pap smears regardless of your age.
These risk factors include:
 A diagnosis of cervical cancer or a pap smear that showed precancerous cells
 Exposure to diethylstilbestrol (DES) before birth
 HIV infection
  Weakend immune system due to organ transplant, chemotherapy or chronic corticosteroid use
 A history of smoking

How you prepare:

 To ensure that your Pap smear is most effective, follow these tips prior to your test:
 Secure patient’s consent
 The test must be adequately explained and understood by the patient before a written, and
informed consent is obtained.
 Obtain the patient’s health history
 These include parity, date of last menstrual period, surgical status, contraceptive use,
history of vaginal bleeding, history of previous pap smears and history of radiation or
chemotherapy.
 Ask lists of the patient’s current medications
 If a patient is taking a vaginal antibiotic, the pap smear is delayed for one month after the
treatment has benn completed.
 Avoid intercourse, douching, or using any vaginal medicines or spermicidal foams, creams or
jellies for two dats before having a pap smear, as these may wash away or obscure abnormal cells.

 Empty the bladder

 Pap smear involves the insertion of the speculum into the vagina and could press down the
lower abdomen.
 Try not to schedule a pap smear during your menstrual period. It’s best to avoid this time of your
cycle, if possible.
What you can expect during the pap smear:

 A pap smear is performed in your doctor’s office and takes only a few minutes.
 You may be asked to undress completely or only from the waist down.
 You’ll lie down on your back on an exam table with your knees bent. Your heels rest in supports called
stirrups.
 Your doctor will gently insert an instrument called speculum inyo your vagina.
 The speculum holds the walls of your vagina apart so that your doctor can easily see your cervix.
 Inserting the speculum may cause a sensation of pressure in your pelvic area.
 Then your doctor will take samples of your cervical cells using a soft brush and a flat scraping device
called a spatula, this usually doesn’t hurt.
o Collection technique using the conventional collection
 The specimen from the bursh and spatula is wiped on the slide and fixed immediately by
immersing the slide in equal parts of 95% ethanol or by using a spary fixative.
o Collection technique using the thinprep collection
 The brush and spatula are immediately immersed in a thinprep solution with a swirling
motion to release the material. The brush and spatula are then removed from the solution
and the botle lid is replaced and secured.

After the Pap Smear:

  After your pap smear you can go about your day without restrictions. Depending on the type of pap testing
you’re undergoing, your doctor transfers the cell sample collected from your cervic into a contianer holding a
special liquid to preserve the sample ( liquid-based pap test) or onto a glass slide (conventional pap smear).
 The samples are transferred to a laboratory where they’re examined under a microscope to look for
characterisitcs in the cells that indicate cancer or a precancerous condition.
 Ask your doctor about when you can expect the results of your test.

Possible complications after pap smear:

 Pelvic discomfort or pain

 Most women do not experience pain after a pap smear. In certain cases, however, you may feel slught
sensations of pelvic discomfort, pressure or pain while your doctor removes cervical cells. Such
complications are temporary and typically resolve as soon as the pap smear is completed.
 Cramping
 Mild abdominal cramping can occur as a possible complication of a pa smear. You may experience
cramping during or immediately after a pap smear. This possible complication of a pap smear is
temporary and typically subsides shortly after treatment.
 Vaginal bleeding
 Scraping cells from the cervix can irritate or inflame this region of your reproductive tract. Consequently,
you can experience vaginal bleeding after a pap smear. Vahinal bleeding is typicaaly mild and subsuides
within a day of the pap smear. You may notice that your normal vaginal secretions appear unusually pink
or contain small amounts of blood. If you experience persistent or profuse vaginal bleeding after having a
pap spear, contact your doctor.

Results of pap smear:

  Normal Result
 If only normal cervical cells were discovered during your pap smear, you’re said to have a negative result.
You won’t need any further treatment or testing unitl you’re due for your next pap smear and pelvic
exam.
 Abnormal Result
 If abnormal or unusual cells were discovered during your pap smear, you’re said to have a positive result.
A positive result doesn’t mean you have a cervical cancer. What a positive reuslt means depends on the
type of cells discovered in your test.

2. Based on the case, list down and discuss the different diagnostic test/laboratory test use for Cervical Cancer?
 Pap Smear
 Pap Smear is also called Pap test, it is a procedure to test for cervical cancer in women.
 Result: Patients result showed high-grade squamous intraepithelial lesion (HSIL).
 Gynecological Examination
 Procedures aimed at assessing the health of a woman’s reproductive system.
 The general examination usually makes use of a speculum for a view of the vagina and cervix.
 Patient’s result: Fungating exophytic tumor replacing the cervic was seen.
 Punch Biopsy
 A procedure in which a small round piece of tissue about the size of a pencil eraser is removed using a sharp,
hollow, circular instrument that is used to cut into a lesion on the skin. The instrument is turned clockwise
and counterclockwise to cut down 4 millimeters to the layer of fatty tissue below the dermis.
 The tissue is then checked under a microscope for signs of disease.
 A punch biopsy may be used to check for certain types of cancer including skin, vulvar, and cervical cancer.
 It may also be used to check for certain skin conditions and changes that may lead to cancer.
 Patient’s result showed moderately differentiated cervical squamous cell carcinoma.
 Vaginal and Rectal Examination
  A digital rectal exam (DRE) is a test for both men and women. It allows a doctor to check the lower rectum,
pelivs and lower belly for cancer and other health problems including:
 Prostate cancer in men
 Blood in the stool or an abnormal mass in the anus or rectum
 Uterine or ovarian cancer in women along with a vaginal examination
What will happen during the procedure?
o The doctor will usually ask you to lie on your back on an exam table and put your feet in raised
stirrups. He or she may ask you to relax and take a deep breath before gently inserting a lubricated,
gloved finger into your rectum. The goal is to feel the reproductive organs and the bowel. The doctor
may also feel for abnormalities in the internal organs by applying pressure on the lower abdomen or
pelvic area with the other hand.
 Patient’s result: she had a 6 x 8 cm exophytic fungating tumor replacing the cervix, which was confined to the
upper two thirds of the vagina with bilateral pelvic sidewall involvement.
 Chest X-ray
 The most commonly performed diagnostic x-ray examination. A chest x-ray produces images of the heart,
lungs, airways, blood vessels and the bones of the spne and chest.
 Patients result: Clear
 Renal Function Test
 Test for renal function, identifying presence of renal disease and monitoring the reponse of kidney to
treatment. Ad determining the progression of renal disease.
 Patients result: Normal
 Liver Function Test
 Liver function test are blood test that measures different enzymes, proteins and other substances made by
the liver. These test checks the overall health of your liver.
 Patients result: Normal
 Syphilis Screening Test
  Are used to screen for and diagnose syphilis.
 Syphilis is one of the most common STD. it is a bacterial infection spread through vaginal, oral or and sex
with an infected person.
 Patients result: negative
 HIV Screening Test
 HIV test shows whether you are infected with HIV. HIV is a virys that attacks amd destroys cells in the
immune system. These cells protect your body against disease causing germs, such as bacteria and viruses.
 Patients result: negative
 Cytoscopy
 Is aprocedure that allows your doctor to examine the linig of your bladder and the tube that carries urine out
of your body (urethra).
 A hollow tube(cystoscope) equopped with a lens is inserted into your urethra slowly advanced into your
bladder.
 Patients result: did not show any metastases or bladder invasion respectively
 Abdominal Imaging Via Ultrasound
 Is a medical test that uses high frequency sound waves to capture live images from the inside of your body. It
is also known as sonography.
 Patients result: showd a normal liver and she had no hydroureteronephrosis
 Complete Blood Count
 A complete blood count (CBC) is a blood test used to evaluate your overall health and detect a wide range of
disorders, including anemia, infection and leukemia. A complete blood count test measures several
components and features of your blood, including: Red blood cells, which carry oxygen.
 Patients result: hemoglobin of 5.2 grams per deciliter
3. What are the signs and symptoms of cervical CA (book based) and what were the signs and symptoms manifested by
the patient based on the case?
 Signs and Symptoms (book based)
 Thin watery vaginal dischagre often noticed after intercourse or douching
  Symptoms such as discharge, irregular bleeding, pain, bleeding after sexual intercourse occur, the disease
may be advanced
 Advanced cervical cancer
 The vaginal discharge gradually increases and becomes watery and finally dark and foul
smelling from necrosis and infection of the tumor.
 The bleeding which occurs at irregular intervals between periods(metrorrhagia) or after
menopause may be slight (just enough to spot the undergarments) and occurs usually after
mild trauma or pressure(e.g intercourse, douching, or bearing down during defecation).
 Leg pain
 Dysuria
 Rectal bleeding
 Edema of the extremities
 Fatigue
 Weight loss
 Loss of appetite
 Nerves in the region may be affected producing excruciating pain in the back and legs that
is relieved only by large doses of opoid analgesics
 Extreme emaciation and anemia
 Fever due to secondary infection, anscess in the ulcerating mass and by fistula formation
 Signs and Symptoms (based on the case)
 Abnormal bleeding for two months
 Normocytic hypochromic anemia 7.7 g/dl
 Severe anemia
 Shoulder abscess on the right arm
 Fever 36.7 degrees celcius
 Reported 10 kg weight loss
  Easy fatigability
 Poor appetite
 Vaginal bleeding consuming 5-10 pads per day
4. What are the etiologic factors or risk factors in the development of cervical CA (book based) and what are the identified
risk factor based on the case?
 Etiologic factors book based
 Sexual activity
o Multiple sex partners
o Early age at first coitus
 Sex with uncircumcised males
 Sexual contact with males whose partners have had cervical cancer
 Early childbearing
 Exposure to human papillomavirus types 17 and 18
 HIV infection and other causes of ummunodeficiency
 Smoking and exposure to secondhand smoke
 Exposure to diethylstilbestrol (DES) in utero
 Family history of cervical cancer
 Low socioeconmomic status (maybe related to early marriage and early childbearing)
 Nutritional deficiencies (folate, beta-carotene, and vitamin c levels are lower in women with cervical
cancer than women without it)
 Chronic cervical infection
 Overweight status
 Long term use of hormonal contraceptives

 Etiologic factors based on the case

 Nutritional deficiencies (anemia)
  Maybe ealry age at first coitus
 Maybe early childbearing
 Maybe low socioeconomic status
 Long term use of hormonal contraceptives

5. Discuss the staging of cervical CA.

The FIGO stages are further categorized as follows:

Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded)
Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion ≤5 mm and largest
IA
extension ≤7 mm
IA1 Measured stromal invasion of ≤3.0 mm in depth and extension of ≤7.0 mm
IA2 Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of not >7.0 mm
IB Clinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than stage IA
IB1 Clinically visible lesion ≤4.0 cm in greatest dimension
IB2 Clinically visible lesion >4.0 cm in greatest dimension
Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina
IIA Without parametrial invasion
IIA1 Clinically visible lesion ≤4.0 cm in greatest dimension
IIA2 Clinically visible lesion >4 cm in greatest dimension
IIB With obvious parametrial invasion
The tumor extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis
Stage III
or non-functioning kidney
IIIA Tumor involves lower third of the vagina, with no extension to the pelvic wall
IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney
The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder
Stage IV
or rectum. A bullous edema, as such, does not permit a case to be allotted to Stage IV
IVA Spread of the growth to adjacent organs
IVB Spread to distant organs
6. Discuss the different surgical procedure/technique/approach for cervical CA.
 Cryosurgery
  It uses a gas called liquid nitrogen to freeze the abnormal cancer cells on your cervix. An “ice ball” forms, and
the bad cells die. You can go home after the procedure. You may have a watery discharge for a few weeks.
 Cryosurgery is typically used during stage 0, which means the physician has found abnormal cells only on the
surface of your cervix.

 Laser Surgery
 This is usually reserved for stage 0 cervical cancer. It uses a laser beam to burn off the cancer cells on your cervix.
They may also cut a small piece of tissue to examine in a lab. They’ll numb your cervix so you won’t have
any pain.

 Conization
 They do this before they recommend chemotherapy or radiation. If you want to be able to have kids later, it may
be the only treatment they recommend.
 It uses a surgical or laser knife to remove a cone-shaped piece of tissue from your cervix. They may also use a thin
wire heated by electricity. This is called the loop electrosurgical excision procedure, or LEEP. They’ll look at your
tissue sample under a microscope. If the edges of the cone have cancer cells, some of the cancer may have been
left behind. Your physician may then recommend chemo or radiation.

 Hysterectomy
 The physician removes your uterus and cervix. Your other reproductive organs -- your ovaries and fallopian
tubes -- are left in place, unless there’s a medical reason they should be removed, too.

There are different ways to do a hysterectomy:

 Abdominal hysterectomy: The uterus is removed through a surgical incision in the front of the
abdomen.
 Vaginal hysterectomy: The uterus is removed through the vagina.
  Laparoscopic hysterectomy: The uterus is removed using laparoscopy.
 Robotic-assisted surgery: In this approach, the laparoscopy is done with special tools attached to
robotic arms that are controlled by the doctor to help perform precise surgery.

 Radical Hysterectomy
 The physician removes your uterus and the tissues next to it. They’ll also remove about 1 inch of the vagina next
to your cervix. And, they may take some of the lymph nodes from your pelvic area. These are pockets of immune
system tissue that are about the size of a pea. He’ll leave your ovaries and fallopian tubes, unless it’s medically
necessary to take them, too.

 Trachelectomy
 The physician removes your cervix and the top part of your vagina, but they leave your uterus intact.
They place a stitch, or a band, where your cervix had been. This opening leads to your uterus.
 They may also remove the lymph nodes near your cervix or uterus. They’ll perform this surgery either through
your vagina or through a cut in your abdomen.

 Pelvic Exenteration
 If you’ve had cervical cancer that came back, this may suggest as a surgical option. They’ll remove your cervix, uterus,
and surrounding organs and tissues. They’ll also remove nearby lymph nodes. And, depending on where the cancer
has spread, they may take your bladder, vagina, rectum, and part of your colon.
12. Based on your current general survey, formulate an FDAR ( ate least 3 of the problems you have identified).

F- Fluid Volume Deficit

D - Patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right shoulder-
unchanged since the other day, facial grimace noted, on O2 inhalation at 2-4 liters per minute prn, pale conjunctiva
noted, dry skin noted, hooked with PNSS 1L at 40 gtts/min, reported 10 kg weight loss, complains of easy fatigability
and poor appetite. Reports vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T: 37.6
degrees celcius, P: 84bpm, RR: 31cpm, BP: 90/60 mmHg.

A - Assessed general health status, vital signs taken and recorded, raised side rails, maintained IVF flow rate and
checked patency, monitored and check skin turgor, assessed and monitored amount and color of urine, encouraged the
patient to drink prescribed water intake, provided comfortable environment, provided adequate rest period,
emphasized the relevance of maintaining proper nutrition and hydration, encouraged patient to verbalize feelings and
needs, encouraged SO to attend patients needs, assessed any unusualities.

R - Seen patient lying on bed on a comfortable position, absence of dry skin, patient verbalizes comfort with vital signs
of T: 37.0 degrees Celsius, P: 90bpm, R: 24cpm, BP: 100/80 mmHg, SPO2: 99%.

F – Fatigue
D - Patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right shoulder-
unchanged since the other day, facial grimace noted, on O2 inhalation at 2-4 liters per minute prn, pale conjunctiva
noted, dry skin noted, hooked with PNSS 1L at 40 gtts/min, reported 10 kg weight loss, complains of easy fatigability
and poor appetite. Reports vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T: 37.6
degrees celcius, P: 84bpm, RR: 31cpm, BP: 90/60 mmHg.

A – Assessed general health status, vital signs taken and recorded, raised side rails, maintained IVF flow rate and
checked patency, educated energy conservation techniques, instructed the client about medications that may stimulate
RBC production in the bone marrow, provided supplemental oxygen therapy as needed, anticipated the need for the
transfusion of packed RBCs, assisted the client in developing a schedule for daily activity and rest, stressed the
importance of frequent rest periods, encouraged patient to verbalize feelings and needs, assessed for any unusualities.

R – Seen patient lying on bed, patient verbalizes reduction of fatigue as evidenced by reports of increased energy and
ability to perform desired activites with a vital signs of T: 37.0 degrees Celsius, P: 90bpm, R: 24cpm, BP: 100/80 mmHg,
SPO2: 99%.

F – Risk for infection

D - Patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right shoulder-
unchanged since the other day, facial grimace noted, on O2 inhalation at 2-4 liters per minute prn, pale conjunctiva
noted, dry skin noted, hooked with PNSS 1L at 40 gtts/min, reported 10 kg weight loss, complains of easy fatigability
and poor appetite. Reports vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T: 37.6
degrees celcius, P: 84bpm, RR: 31cpm, BP: 90/60 mmHg.
A – Assessed general health status, vital signs taken and recorded, raised side rails, monitored IVF flow and checked
patency, instructed the client to report signs and symtomps of infection immediately, anticipated the need for
antibiotic, antiviral and antifungal therapy, taught the client and visitors the proper hand washing, informed the client
the importance of changing wound dressing, assissted in changing wound dressing, encouraged the client to verbalize
feelings and needs, assessed any unusualities.

R – Seen client lying on bed with newly changed wound dressing, patient verbalized the importance of changing wound
dressing and seen patient absence of signs and symptoms of infection.

F – Fatigue

D – Pt is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right shoulder-unchanged
since the other day,  facial grimace noted, on O2 inhalation at 2-4L/min prn, pale conjunctiva noted, dry skin noted,
hooked with PNSS 1L at 40gtts/min, reported 10kg  weight loss, complains of easy fatigability & poor appetite. Reports
vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T-37.6 degrees Celsius, P-84bpm, RR-
31cpm, BP-90/60mmHg.

A – assessed general health status, encouraged active ROM exercises, assist with activities and provide to promote
relief, sleep and relaxation, monitored vital signs assisted patient on changing position, kept watch for any unusualities.

R – seen patient sleeping comfortably.

F – altered comfort

D – Pt is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right shoulder-unchanged
since the other day,  facial grimace noted, on O2 inhalation at 2-4L/min prn, pale conjunctiva noted, dry skin noted,
hooked with PNSS 1L at 40gtts/min, reported 10kg  weight loss, complains of easy fatigability & poor appetite. Reports
vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T-37.6 degrees Celsius, P-84bpm, RR-
31cpm, BP-90/60mmHg.

A – assessed general health status, taken and monitored vital signs, provided comfort measures, assisted in doing active
and passive range of motion exercises, instructed SO to arrange the things properly at bedside, assisted with ADLs,
assessed for any unusualities.

R – seen patient lying on bed sleeping comfortably and displayed relaxed behavior.

F – imbalance nutrition: less than body requirements

D – Pt is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right shoulder-unchanged
since the other day,  facial grimace noted, on O2 inhalation at 2-4L/min prn, pale conjunctiva noted, dry skin noted,
hooked with PNSS 1L at 40gtts/min, reported 10kg  weight loss, complains of easy fatigability & poor appetite. Reports
vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T-37.6 degrees Celsius, P-84bpm, RR-
31cpm, BP-90/60mmHg.

A – Monitored and recorded vital signs, assessed general health status, monitored and recorded height and weight,
encouraged mouth care before meals, monitored dietary intake, encouraged intake of fruit juices, carbonated
beverages, assessed for any unusualities.

R – patient gain at required weight.

F – Risk for infection

D - Received patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right
shoulder-unchanged since the other day,  facial grimace noted, on O2 inhalation at 2-4L/min prn, pale conjunctiva
noted, dry skin noted, hooked with PNSS 1L at 40gtts/min, reported 10kg  weight loss, complains of easy fatigability &
poor appetite. Reports vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T-37.6 degrees
Celsius, P-84bpm, RR- 31cpm, BP-90/60mmHg.

A - Assessed patients general status & needs, Provided bedside care and comfort measures, Provided clean and well
ventilated environment, Monitored and recorded vital signs and I&O, Regulated IV fluid at desired rate, Assist degree of
pain, Assist airway patency, Provided O2 inhalation as ordered, Educated the importance of wound care, Educated the
pt and SO the importance of hand washing in preventing infection, Advised patient to use loose clothing o promote
comfort, Teach pt and SO what are signs of infection to report; Fever, swelling, heat, pain, erythema or changes in
respiratory or mental status, Educate patient to avoid eating raw meat or fish

R - Patient able to verbalized the importance of good hygiene and enumerated the possible known signs of infection.

F – Ineffective tissue perfusion

D - Received patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right
shoulder-unchanged since the other day,  facial grimace noted, on O2 inhalation at 2-4L/min prn, pale conjunctiva
noted, dry skin noted, hooked with PNSS 1L at 40gtts/min, reported 10kg  weight loss, complains of easy fatigability &
poor appetite. Reports vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T-37.6 degrees
Celsius, P-84bpm, RR- 31cpm, BP-90/60mmHg.

A - Assessed patient general status, Performed bedside care and provided patient comfort, Monitored and recorded
vital signs, I & O and O2 saturation, Advised patient to use loose clothing o promote comfort, Provide clean and well
ventilated environment, Encourage adequate rest, Assess capillary refill time, Provide 02 inhalation Assess skin color
and mucous membranes, Monitor blood pressure, Assess degree of pain, Assess airway patency, Initiate IV fluid as
prescribed, Elevate HOB at 30 degrees, Instructed patient to report any unsualities, Advised to take the medication
religiously as prescribed

R - Patient maintains tissue perfusion and blood pressure within normal range.

F – Fatigue

D -Received patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right
shoulder-unchanged since the other day,  facial grimace noted, on O2 inhalation at 2-4L/min prn, pale conjunctiva
noted, dry skin noted, hooked with PNSS 1L at 40gtts/min, reported 10kg  weight loss, complains of easy fatigability &
poor appetite. Reports vaginal bleeding consuming 5-10 pads per day. The vital signs are as follows; T-37.6 degrees
Celsius, P-84bpm, RR- 31cpm, BP-90/60mmHg.

A -Assessed patient general statu, Monitored and recorded vital signs and I&0, Regulated IV fluid at desired rate and
encouraged fluid intake, Encouraged rest period assist sleep and rest pattern, Assist for proper positioning in bed,
Provide clean and well ventilated environment, Encourage use of relaxation techniques, Emphasized the importance of
healthy diet like adequate protein and calorie, Intake to increase tolerance of ADL, Encouraged to cooperate in course
of medication as prescribe by physician.

R - Patient ambulate and performed ADLs

 8. Make a comprehensive drugs study of the drugs given to the patient based on the case ( Depo-provera, Ciprofloxacin).

DRUG STUDY

Name of Classification Mechanism Indication Contraindication Adverse Reaction Nursing

Drug of Action Responsibilities
Generic Name: Therapeutic Inhibits the Abnormal Contraindicated in CNS:  depression, CVA, BEFORE
Depo-provera classification:  secretion of uterine bleeding pregnant women, fatigue,insomnia, Assess history of
Amen, Curretab, Cycrin. Hormone, gonadotropins from hormonal patients hypersensitive to dizziness, headache hypersensitivity
Progestin which, in turn, imbalance drug, and patients with reaction to
Brand Name: prevents follicular active or previous CV: thrombophlebitis, pu progestins. For
Medroxyprogesterone maturation and Contraception in thromboembolic lmonary pretreatment client
acetate Functional ovulation and women.  disorders, cerebral embolism, edema, throm arrange the periodic
classification:  results in vascular disease, boembolism. history, general
ORAL ROUTE Antineoplastic, endometrial Secondary apoplexy, breast cancer, status and vital signs
MINIMUM DOSE contraceptive Agent thinning. These amenorrhea undiagnosed abnormal EENT: exophthalmos,
2.5 mg actions produce vaginal bleeding, missed diplopia. Discontinue
MAXIMUM DOSE Pregnancy risk its contraceptive Endometrial or abortion, or hepatic medication and
10 mg category X effect. renal carcinoma dysfunction. Tablets are GU: breakthrough consult physician if
(adjunct) contraindicated in bleeding, dysmenorrhea, sudden, partial, or
IV ROUTE patients with liver amenorrhea, cervical complete loss of
Minimum Dose Reduction of dysfunction or known or erosion, abnormal vision occurs; if
150 mg/ml endometrial suspected malignant secretions papilledema or
hyperplasia in disease of the genital retinal vascular
Maximum Dose postmenopausal organs. HEPATIC: cholestatic lesions are present,
400 mg/ml women   Use cautiously in jaundice, severe hepatic discontinue drug.
patients with diabetes dysfunction
Oral:  Paraphilia in mellitus, seizures, Metabolic: changes in Review test result, it
Gen- Medroxy (CAN), men migraines, cardiac or weight, anorexia may increase liver
Novo-Medrone (CAN), renal disease, asthma, or function test values
Prover depression. SKIN: rash, pain, and cause abnormal
induration, sterile thyroid function test
Parenteral:  abscesses, acne, pruritus, results
Depo-Provera, Depo- melasma, alopecia,
subQ Provera 104 hirsutism. Shake suspension
vigorously just
Others breast tenderness, before use to ensure
enlargement, or secretion, complete suspension
incomplete abortion, of drug.
hormone-dependent
carcinoma DURING
Use parenteral form
only for I.M.
administration. Inject
deep into large
muscle mass,
preferably the gluteal
muscle.

Monitor patient for

development of
sterile abscesses.

 Monitor serum
glucose level in
diabetic patient.
Monitor Blood
pressure during
treatment

AFTER
Advise patient to
report chest pain,
difficulty breathing,
or leg pain.

Educate client that

this drug should not
be taken during
pregnancy due to
risk of serious fetal
abnormalities

Instruct patient about

 signs of
CVA.

Instruct patient to
report adverse all
reaction.

Name of Classification Mechanism Indication Contraindication Adverse Reaction Nursing

Drug of Action Responsibilities
Generic Name: Therapeutic Inhibits bacterial Ciprofloxacin is used Ciprofloxacin is CNS: Headache, Before:
Ciprofloxacin, cipro Classification: DNA synthesis by to treat infections of contraindicated in dizziness, ataxia, Assess vital signs history
Fluoroquinolone/qui inhibiting DNA the skin, lungs, persons with a history hallucination, of hypersensitivity to
Brand Name: nolones gyrase enzyme. airways, bones, and of hypersensitivity to elevated ICP, Ciprofloxacin or
Quinosyn joints caused by ciprofloxacin, any agitation, dizziness, Quinolones.
susceptible bacteria. member of the insomnia,
DOSE Ciprofloxacin is also quinolone class of nightmares, paranoia, Administer on an empty
MAXIMUM Funtional frequently used to antimicrobial agents, or tremor. stomach 1 hr before or 2
DOSE: Classification: treat urinary any of the product hr after meals, with a full
400mg Antibacterial/ anti- infections caused by components. CV: arrhythmias, glass of water. Products
MINIMUM DOSE infective bacteria such as E. angina. or foods containing
Frequency: coli. Effective in calcium, magnesium,
BID Pregnancy Category treating infectious RESPI: difficulty aluminum, iron, or zinc
ROUTE: C diarrheas caused by Contraindicated for the breathing, cough should not be ingested
IV E. coli, treatment of certain for 4 hr before and 2 hr
ORAL Campylobacter sexually transmitted EENT: dry eye, eye after administration
jejuni, and Shigella diseases by some pain, photosensitivity
bacteria. experts due to bacterial
During:
resistance. DERM:
Monitor bowel function.
Avoid exposure to photosensitivity,
Diarrhea, abdominal
strong sunlight or sun rash, hives, skin
cramping, fever, and
lamps during treatment. itching, peeling and
bloody stools should be
blistering
reported to health care
professional promptly as
GI: nausea, vomiting
a sign of
diarrhea, dry mouth,
pseudomembranous
abdominal pain,
colitis.
hepatotoxicity

GU: vaginitis,
vaginal itching, renal
failure
Monitor laboratory
Other: fever, rash, results May causeqserum
hypersensitivity AST, ALT, LDH,
bilirubin, and alkaline
phosphatase. May also
causeqorpserum glucose.

May cause dizziness and

drowsiness. Caution
patient to avoid driving
or other activities
requiring alertness until
response to medication is
known.

Do not drink or eat a lot

of caffeine-containing
products such as coffee,
tea, energy drinks, cola,
or chocolate.
Ciprofloxacin may
increase nervousness,
sleeplessness, heart
pounding, and anxiety
caused by caffeine.

Tell patient that

Ciprofloxacin can cause
side effects that may
impair his thinking or
reactions. Tell patient to
be careful if he plans to
drive or do anything that
requires him to be awake
and alert.

After
◙ Instruct patient to avoid
taking antacids, vitamin
or mineral supplements,
within 6 hours before or 2
hours after you take
ciprofloxacin. These other
medicines can make
ciprofloxacin much less
effective when taken at
the same time.

Inform patient that

Ciprofloxacin may cause
swelling or tearing of a
tendon (the fiber that
connects bones to
muscles in the body),
especially in the
Achilles' tendon of the
heel. These effects may
be more likely to occur if
you are over 60, if you
take an oral steroid
medication, or if you
have had a kidney, heart,
or lung transplant.
Do not take the
medication in larger
amounts, or take it for
longer than
recommended by your
doctor

Instruct patient to stop

taking ciprofloxacin and
call the doctor at once if
he has sudden pain,
swelling, tenderness,
stiffness, or movement
problems in any of your
joints. Also instruct
patient to rest his joint
until he receive medical
care or instructions.
11. Formulate a teaching plan based on the case.

HEALTH TEACHING

Topic: Wound Care Infection Prevention

General Objectives: After 1 hour of SN-Patient teaching-learning activities, the patient will be able to acquire adequate knowledge, skills
and attitude towards wound care, prevention of infection and ways to progressive wound healing.

Specific Learning content Teaching learning Time Allotment Resources Evaluation

Objectives Objectives Parameters

After 30-45 DEFINITION:  One on one  5mins  Visual aids After 45 minutes of
minutes of SN- Infection is the process of discussion  Word-boards comprehensive
PT interaction, invasion and multiplication  Pamphlets nurse- client family
the pt will be of microorganisms such as  Explain using  hand-outs
 10mins interaction the
able to: bacteria, viruses and chart, graphs  Pictures/flashcar client- family will be
parasites that are not film slides. ds
normally present within the able to elaborate and
 CHN bag
body. Prevention is the answer questions
 Virtual
action taken to decrease the  10mins related to wound
Presentation
chance of getting a disease care, infection
or condition.  Health prevention toward
teaching  5mins progressive wound
1. Importance of healing.
1. State the preventing infection:
a. To prevent  Group
importance  5mins
of organisms from discussion
 preventing invading the
infection body  Self instruction  5mins
b. Prevent further
damage to
organs or tissues  Evaluation
c. To progress to a  5mins
better health
condition and
remain
uninjured.

2. Ways to decrease risk of

infection:
a. Frequent
handwashing
b. Change dressing
2. Enumerate frequently
ways to c. Frequent
prevent or changing of
decrease clothes
risk of d. Prevent dressing
infection from becoming
moist.

3. Importance of wound
care to progressive
wound healing
a. Reduces risk of
infection
b. Strengthen first
line defenses
c. To help decrease
3. State the or control pain
importance sensation
of wound
care to
 facilitate
faster
healing

4. Interventions that
can help
progressive
wound healing

a. Frequent changing of
4.Cite dressing
b. Use of sterile dressing
interventions
c. Diet rich in protein
that can help d. Encourage rest periods
progressive e. Ingestion of vitamin
wound healing supplements to aid in
wound healing
f. Avoid applying
pressure, or touching
the wound

5. Allow patient to
verbalize feelings,
questions, or concerns
regarding the topic.
5.Show positive
attitude towards
health topic
Sources: World Health Organization, Center of Disease Control and prevention, Department of Health Philippines ( 2020)

FDAR
FOCUS Risk for Infection
DATA Received patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at right
shoulder-unchanged since the other day,  facial grimace noted, on O2 inhalation at 2-4L/min prn, pale
conjunctiva noted, dry skin noted, hooked with PNSS 1L at 40gtts/min, reported 10kg  weight loss, complains
of easy fatigability & poor appetite. Reports vaginal bleeding consuming 5-10 pads per day. The vital signs are
as follows; T-37.6 degrees Celsius, P-84bpm, RR- 31cpm, BP-90/60mmHg.
ACTION o Assessed patients general status & for possible signs of infection
o Provided bedside care and comfort measures
o Provided clean and well ventilated environment
o Monitored and recorded vital signs and I&O
o Regulated IV fluid at desired rate
 o Assist degree of pain
o Assist airway patency
o Provided O2 inhalation as ordered
o Educated the importance of wound care
o Educated the pt and SO the importance of hand washing in preventing infection
o Advised patient to use loose clothing o promote comfort
o Teach pt and SO what are signs of infection to report; Fever, swelling, heat, pain, erythema or
changes in respiratory or mental status
o Educate patient to avoid eating raw meat or fish

RESPONSE Patient able to verbalized the importance of good hygiene and enumerated the possible known signs of
infection.

FOCUS Ineffective tissue perfusion

DATA
Received patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at
right shoulder-unchanged since the other day,  facial grimace noted, on O2 inhalation at 2-4L/min prn,
pale conjunctiva noted, dry skin noted, hooked with PNSS 1L at 40gtts/min, reported 10kg  weight
loss, complains of easy fatigability & poor appetite. Reports vaginal bleeding consuming 5-10 pads per
day. The vital signs are as follows; T-37.6 degrees Celsius, P-84bpm, RR- 31cpm, BP-90/60mmHg.

ACTION o Assessed patient general condition blood pressure and perfusion

o Performed bedside care and provided patient comfort
o Monitored and recorded vital signs, I & O and O2 saturation
o Advised patient to use loose clothing o promote comfort
o Provide clean and well ventilated environment
o Encourage adequate rest
o Assess capillary refill time
 o Provide 02 inhalation
o Assess skin color and mucous membranes
o Monitor blood pressure
o Assess degree of pain
o Assess airway patency
o Initiate IV fluid as prescribed
o Elevate HOB at 30 degrees
o Instructed patient to report any unsualities
o Advised to take the medication religiously as prescribed

RESPONSE Patient maintains tissue perfusion and blood pressure within normal range.

FOCUS FATIGUE
DATA Received patient is lying on bed, on semi-fowlers position, pallor noted, with intact wound dressing at
right shoulder-unchanged since the other day,  facial grimace noted, on O2 inhalation at 2-4L/min prn,
pale conjunctiva noted, dry skin noted, hooked with PNSS 1L at 40gtts/min, reported 10kg  weight loss,
complains of easy fatigability & poor appetite. Reports vaginal bleeding consuming 5-10 pads per day.
The vital signs are as follows; T-37.6 degrees Celsius, P-84bpm, RR- 31cpm, BP-90/60mmHg.
ACTION o Assessed patient general condition
o Monitored and recorded vital signs and I&0
o Regulated IV fluid at desired rate and encouraged fluid intake
o Encouraged rest period assist sleep and rest pattern
o Assessed skin integrity for dryness, pallor and cyanosis
o Administered 02 inhalation as desired rate
o Assist for proper positioning in bed
o Provide clean and well ventilated environment
o Encourage use of relaxation techniques
o Emphasized the importance of healthy diet like adequate protein and calorie
o Intake to increase tolerance of ADL
o Encouraged to cooperate in course of medication as prescribe by physician.
RESPONSE Patient ambulate and performed ADLs