268

Measures the average concentration of Hgb in RBCs. Low MCHC levels can mean anemia (which C.M. has due to her blood analysis results) due to lack of iron, the body is unable to absorb enough iron due to conditions like Crohn’s or celiac disease, long menstrual cycles, or peptic ulcers. Normal MCHC levels are: 33.4-35.5g/dL.

(Gotter, 2019)

Measures the amount of red blood cells one has in their body. RBCs has hemoglobin that helps carry oxygen. “How much oxygen your body tissues get depends on how many RBCs you have and how well they work” (UCSF Health, 2018).

A normal RBC count for women is about 4.2-6.1cells/mcL. Low RBC level in the blood can be due to bleeding, bone marrow failure, overhydration, malnutrition, overhydration or pregnancy.

For patient C.M., her low RBC level may be due to anemia, bone marrow failure due to her cervical cancer, and lack of erythropoietin (hormone deficiency) as her kidneys are also failing.

(UCSF Health, 2018)

R E S U L T S

RBC 2.1

HGB 64

HCT 0.21

MCHC 308

Measures the amount of hemoglobin (Hgb) in the blood. The function of Hgb is that it helps carry oxygen from the lung, to the rest of the body. Lower levels of Hgb could indicate a blood disorder, such as anemia. Patient C.M. is unable to eat the required amount of nutrition in her body which could mean that her diet is low in iron or minerals, hence the low levels of Hgb (MedlinePlus, 2020).

Normal range of Hgb in women: 12.0-15.5g/dcL.

Because she has cervical cancer, there is abnormal growth of cells in the cervix which can often cause bleeding and iron deficiency (Jewell, 2019).

“Measures how much of the blood is made up of RBCs” (MedlinePlus, 2020). Abnormal levels of hematocrit (HCT) can mean a blood disorder, dehydration, or some other underlying medical condition. HCT blood tests can help determine blood disorders such as anemia (low RBCs) or polycythemia vera (high RBCs). Normal range of HCT for women: 34.9%-44.5% (Nall, 2018).

Blood

Analysis

(American Cancer Society, 2020)

Anemia

LABS

This is when one does not have enough healthy RBCs in the blood or the blood has lower than normal hemoglobin levels. Hemoglobin helps carry oxygen to different cells in the body. Anemia is usually a side effect in cancer. Chemotherapy or radiation can also cause anemia, as well as other major organ problems such as a severe heart, lung, kidney, or liver disease.

Symptoms include: tachycardia, tachypnea, shortness of breath, lightheadedness, angina, edema in the hands or feet, or fatigue. Diagnoses include a complete blood count or CBC, a bone marrow exam, or further blood tests to check iron, vitamin B12 and folate levels.

Treatment of anemia is important for cancer patients such as C.M. as it can delay cancer treatment. Most common type of treatment for anemia is iron therapy, a RBC transfusion, medications, or erythropoiesis-stimulating agents.

268 Concept Map

Reason for Admittance:

Abdominal Pain

ER

The glomerular filtration rate tells us how well our kidneys are functioning. It estimates the amount of blood passing through the glomeruli per minute. It can be estimated using creatinine blood levels. Normal GFR levels range from 90-120mL/min. A low level of eGFR for more than 3 months can be a sign of chronic kidney disease.

R E S U L T S

Urea: a normal waste product found in the blood.

This comes from breaking down the proteins found in the foods you eat as well as from body metabolism. The kidneys are in charge of filtering this out from the blood with the normal range being, 7-20mg/dL. Abnormal values like the patient’s (50.9mg/dL) can indicate that the kidneys are not working well enough to filter it out from the blood and is also a sign of kidney failure.

Normal use of muscle cells produces creatinine as a waste product in the blood. A normal functioning kidney allows the excretion of creatinine in the urine. Normal creatinine levels for women: <1.2mg/dL. An abnormal lab value of creatinine can tell us whether or not the kidneys are working well. The patient has an increased level of creatinine which tells us that the kidneys are losing their ability to filter blood. This along with other lab values, can indicate kidney failure.

(National Kidney Foundation, 2017)

Urea 50.9

eGFR 31

Creatinine 168

Objective

Data

Urinalysis

Kidney Failure

Krizia Pantony

Kidney Failure

Is when the kidneys are damaged and are unable to filter out waste products and extra water from the body. It also lowers red blood cell production as well as imparis blood pressure regulation. Having kidney failure means the kidneys have lost 90% of its function. Causes of kidney failure can be from trauma or from other diseases such as hypertension and diabetes. Chemotherapy and radiation can also damage the kidneys. Chemo treatments that are toxic to kidneys are called nephrotoxic.

Signs and symptoms of kidney failure include: nausea, fatigue, weight loss, edema in feet or ankles, anorexia, trouble sleeping, itching and anemia.

Dialysis (hemodialysis or peritoneal dialysis) and kidney transplant are the only two treatments for kidney failure.

O2 1.5L

(National Kidney Foundation, 2020)

HR 60

RESP 18

(American Cancer Society, 2020)

Vitals

BP 125/78

Blood Transfusion (November 13)

TEMP 37.0

SPO2 95%

RBCs are given to patients with severe iron-deficiency such as C.M. Even though it will not correct the patient’s iron deficiency, the transfusions are given in order to replace the lack of RBCs in their body.

This procedure is a rapid way in helping treat the symptoms of anemia but is only a temporary relief.

Social Determinants of Health

Caucasian

NKA

O2 1L

BP 117/60

Smoker,

1 pack a day

RESP 16

47 years old

Vitals

HR 75

Has a needle phobia; most of her medications are thorugh her PICC line

SPO2 96 %

TEMP 36.8

Has a positive outlook on life, patient states:

"Life has been a little hard the past few years. But I'm glad to have my husband, sometimes I don't feel like I'm sick at all."

Female

ondansetron

hydromorphone

octreotide

Patient is on this due to her nausea and vomiting.

• An antiemetic.
• It is for prevention and treatment of nausea and vomiting.
• Blocks serotonin effects at selective antagonist sites located in vagal nerve terminals and the chemoreceptor triggering in the CNS.

Patient is on this for pain management of her abdominal pain due to bowel obstruction.

• An opioid analgesic.
• It is for moderate-to-severe pain and can be used alone or with other nonopioid analgesics.
• For patients who need around the clock management for ongoing pain.
• It binds to opiate receptors in the central nervous system, where it alters the perception of and response to painful stimuli.

Patient is experiencing diarrhea due to her cervical cancer. A partial bowel obstruction can also cause diarrhea.

• For mild, acute, or chronic diarrhea or for patients with certain cancers that cause diarrhea.
• It copies the actions of naturally occurring somatostatin (inhibits GI, endocrine, exocrine, pancreatic, and pituitary secretions).

(Kluwer, 2017)

Unable to pass flatus, was also nauseous and vomiting

Individuals with low immune systems can have a hard time trying to get rid of an HPV infection (oncogenic HPV types) and this may eventually turn normal cells into abnormal cells, and then cancer. HPV infections usually do not cause any significant symptoms or health problems and almost 90% of infections clear on their own within two years. But problems arise when the virus stays and the infection does not get better. This can then cause genital warts as well as recurrent respiratory papillomatosis, or throat warts. Most cancers that are caused by the HPV infection do not show any symptoms until the cancer has progressively grown.

Since most infections clear on their own, there is no treat specifically for the infection itself. But routine HPV and cervical cancer screenings can help identify health problems that arise from HPV infections.

(Gabbey, 2020)

Human Papillomavirus (HPV)

PPN

sodium bicarbonate

For the patient's GERD.

• An antacid, used to relieve heartburn and acid indigestion.
• Increases plasma bicarbonate levels, where it raises pH solution to fight clinical manifestations of acidosis.

Bowel Obstruction

This is when the small intestine or colon is blocked either fully or partially, preventing food, fluids or gas to pass through the way it should.

The function of the small intestine is it receives digested food from the stomach and absorbs the nutrients the body needs. The rest of that is then transported into the large intestine, where it absorbs further nutrients and fluids that were passed through.

Causes are usually due to tumours that have formed and is blocking the intestine, tissues or adhesions that form after a surgery is done to the small or large intestine, medications often affect the GI tract (narcotics, laxatives, chemo drugs), or sometimes fecal impaction occur (this is when a large and dry stool is built up due to constipation.

Patient is unable to meet her nutritional needs through oral or enteral feedings, hence why she needs parental nutrition.

• The need for PPN depends on the patient’s diagnosis, their medical history or their prognosis.
• This is often prescribed to patients who are unable to absorb nutrients through their GI tract for more than 10 days.

HPV is a sexually transmitted disease, where it is part of more than 200 related viruses.

• It falls into two groups: low and high risk.
• C.M. has the high risk HPV where it can cause several types of cancer. The two that are responsible for most cancers caused by HPV are called HPV16 and HPV18.
• Most HPV infections can be easily fought off by your immune system. But if a high-risk HPV infection keeps recurring, that can lead to cell changes. If left undiagnosed, it may eventually become cancer.
• Transmission is through vaginal intercourse, anal sex, oral sex, or other skin-to-skin contact.
• HPV can be prevented by getting a vaccine where it can provide protection for new HPV infections.

(Thomas, 2020)

Medications

(Kluwer, 2017)

Access to Health Services

C.M. was first diagnosed 4 years ago after visiting her family doctor in Delburne, Alberta. She complained of heavy menstrual bleeding and pain after sexual intercourse. C.M. and her husband felt like she would be better off seeking medical treatment here in Red Deer as they had close friends residing in the city in case they needed a place to stay. They have also had better experiences with the staff here in Red Deer during past hospital stays. I believe that because of this easy access to health services despite living about half an hour away, this increased her likelihood of getting treatment for her cervical cancer which increases a positive prognosis in her case.

(National Cancer Institute, 2020)

acetaminophen

"Prayers are what gets me through the day sometimes."

Used to attend mass every Sunday

For pain management, used in conjunction with hydromorphone.

• A nonopioid analgesic.
• For mild pain or for fever.
• Stops synthesis of prostaglandins that acts as mediators of pain and fever, mainly in the central nervous system.

Gastroesophageal Reflux Disease

Symptoms often include: abdominal pain and cramps, distention of the abdomen, nausea, dry mouth, constipation, diarrhea as loose stool may pass through the impaction, or not being able to pass flatus.

Diagnosis can be done through X-rays, a colonoscopy, or a CT scan.

There are many treatment options for a bowel obstruction. Sometimes resting the bowel is the best approach where the patient is NPO for a few days and is given IV fluids to avoid electrolyte imbalance or dehydration. Other options include initiating an NG tube insertion in order to help relieve abdominal swelling and vomiting, medication such as IV antibiotics can also help and prevent peritonitis (inflammation of the peritoneum). Peritonitis happens when the contents in the bowel leaks into the peritoneal cavity. Surgery is also an option but it is left as a last resort if the problem cannot be managed by using the alternative options mentioned above.

(Canadian Cancer Society, n.d.)

C.M.

Spirituality

(Kluwer, 2017)

Alert & orientated x3

Grew up Catholic

Also known as acid reflux, is when gastric acid in the stomach goes back up to the esophagus.

• The most common symptom of GERD is heartburn.
• The lower esophageal sphincter or LES weakens or relaxes too long in an individual with GERD, hence why acid content travels back up.
• Lifestyle issues that cause GERD are obesity, overeating, smoking or alcohol use.

Acute Care

Abdomen semi-firm, with mass left of umbilicus

Wheezes on expiration

(Cedars Sinai, n.d.)

Patient has dry and pale skin

Physcical Assessment

Hysterectomy

Hypoactive bowel sounds x4 quadrants

Subjective Data

Likes trying new recipes

Reads thriller books in her past time

A surgical procedure where the uterus is removed.

• This ends menstruation as well as the chances of pregnancy.
• Various reasons why this procedure is performed.
• It can be due to abnormal vaginal bleeding, a severe endometriosis (tissue from the uterus starts forming outside), or uterine prolapse (uterus muscle starts to weaken, and “drops” into the vaginal canal).
• Patient C.M. was suppose to have this procedure done 4 years ago, but a tumour was found.

Mental Health

NG Tube in left nostril, IV running PPN on PICC line lcoated on right upper arm

Diagnosis:

Cervical Cancer with Partial Bowel Obstruction

Radial pulses equal bilaterally with regular rhythm, S1 and S2 ausculatted

Spends time with her grandchildren

(Cleveland Clinic, 2018)

Loves to knit

Nasogastric

Tube

Placement

3 sons

8 grandchildren

ANATOMY

Social Supports

NG tube allows access to the stomach and its content. NG tubes allow drainage of gastric contents, stomach decompression, get specimens from the gastric contents, or serve as a passageway into the GI tract. Patient C.M. was admitted due to her bowel obstruction which the NG tube can help treat. NG tubes can also help treat gastric immobility, as well as be used for enteral feedings.

(University of Ottawa, n.d.)

CERVIX

UTERUS

Husband of 10 years

2 daughters

• The cervix is considered the neck of the uterus that extends into the vagina.
• This firm structure is made up of glands and muscular tissue that softens and is easily bent when under the influence of hormones when a woman is pregnant.
• The protective mucus the glandular tissue provides are manipulated during a woman’s menstrual cycle or when pregnant.
• The cervix is also supplied with blood from the uterine artery. This is often where a significant amount of blood is lost during pregnancy.
• The os, or also known as the opening of the cervix, forms a path between the vagina and the uterus. The uterine opening is called the “internal os”, while the vaginal opening is called “external os”. The endocervical canal is the space between the two.
• It has two types of cells: glandular cells, which lines the endocervical canal, and the squamous cells, which lines the ectocervix (outer part of the cervix) and the vagina.
• The endocervical canal is also where menstrual discharge and sperm entrance occur.

• Located between the bladder and the rectum is a thick and muscular organ called the uterus.
• It is divided into three parts: the fundus, the cervix, and the body of the uterus.
• The uterus is supported by ligaments called the broad ligaments, and its wall is made up of three layers.
• They are the perimetrium, myometrium, and the endometrium.

2 siblings

Lives in Delburne, Alberta with her husband and 3 dogs. Both C.M. and her husband own a farm.

Social Supports and Coping Skills

While caring for this patient, I have found out that she has a good social support system that she can rely on when going through a hard time. Her sons help out in their farm back in Delburne when her and her husband has to drive to Red Deer for her appointment with her oncologist. She also listed a few hobbies she likes to do in her spare time, or when faced with stress. Her favourite thing would have to be knitting scarves and mittens for her grandchildren especially in the winter time. The one day I took care of her, she had her wool and knitting supplies by the side of her bed and was in the process of making a blanket. Her husband is also constantly by her side during the two days I was in charge of her care. Even after working late on their farm, C.M. mentioned that her husband would still try his best to visit her even if it was just for half an hour (since visitor hours are done by 8pm). Because of her positive outlook on life despite her prognosis, I believe that C.M. has a reliable and strong social support system as well as strong coping skills when faced through hardships.

From a Polish background, her great grandparents migrated to Canada back in 1945.

PATHOPHYSIOLOGY

Culture

Where does cervical cancer start?

It starts in the cells lining the cervix.

The cervix has two parts and is covered in two different types of cells:

• Endocervix: the opening of the cervix, leading into the uterus, is covered in glandular cells
• Exocervix: the outer part of the cervix is covered in squamous cells.

This is the area where doctors look at during a speculum exam.

The transformation zone is the area where these two cells mentioned above meet. This is also where most of the abnormal cell growth happens.

For patient C.M., her cervical cancer is adenocarcinoma. This means that it developed from glandular cells, the mucus producing gland in the endocervix.

• glandular cells are involved in producing cervical mucus as well as the menstrual cycle.

(American Cancer Society, 2020)

Can speak a little bit of Polish, patient states "it's been a while since I've spoken the language and I haven't been back since I was a kid."

(Candian Cancer Society, n.d.)

Diagnosis usually starts if a routine pap test result is abnormal. A physical exam is then done while the physician asks if you have any symptoms related to cervical cancer. A HPV test is also required if cervical cancer is suspected as cervical cancers often arise due to recurring HPV infections. A biopsy is also done in order to check for cancer cells present in the tissues or cells in the cervix.

X-rays, CBC, endoscopy are a few of the other options for diagnosing cervical cancer.

Treatment usually depends on the stage, the patient’s age, their overall health, if they are of childbearing age and want to get pregnant, as well as the patient's preference. Radiation, chemotherapy and surgery are the most common ways to treat cervical cancer.

#3

#1

Gender

For my patient C.M., gender plays a vital role in her prognosis as according to the World Health Organization (n.d.), cervical cancer is the fourth most common cancer in women. C.M. is also 47 years old and a smoker who smokes one pack a day. This puts her at higher chances of getting cervical cancer, as “most cases of cervical cancer occur in women younger than 50 years of age” (Canadian Cancer Society, n.d.). Tobacco used has also been found in the cervical mucus of women who smoke. Research shows that tobacco substances may play a role in damaging the DNA cells found in the cervix, contributing to the development of cervical cancer. Smokers also have a relatively weaker immune system compared to a non-smoker, making their immune system less effective in fighting off infections (American Cancer Society, 2020). She also had her first child when she was 20 years old, which is also a risk factor for cervical cancer. The American Cancer Society states that “women who were younger than 20 years when they had their first full-term pregnancy are more likely to get cervical cancer in life”, compared to those who waited.

Short: The nurse will educate the patient on how to prevent future urinary tract infections, often caused by cervical cancer and its treatment.

• Educate the patient to limit their caffeine intake, make sure to drink enough fluids (preferably 2.5L), and to try to urinate every 3 to 4 hours. (Healthwise Staff, 2019)

Long: The patient will not experience any UTI for at least 4 months after discharge.

#2

Short: The nurse will educate the patient on how to recognize signs and symptoms of anemia as well as care instructions once she is discharged.

• Symptoms include loss of energy, difficulty concentrating, pale skin, shortness of breath, dizziness, and heart palpitations. (Brown, 2020)
• Care instructions include: incorporating steamed vegetables in their diet to keep their iron content, take medications as prescribed, drinking plenty of fluids, including iron-rich foods such as red meat, raisins, whole-grain bread, poultry and eggs. (Healthwise Staff, 2019)

Long: The patient is able to recognize the signs and symptoms of anemia as well as incorporate the care instructions the nurse has listed on the day she was discharged.

Short: The nurse will suggest support groups relevant and appropriate to the patient in order to help reduce tension and stress, plus help curb the potential feeling of loneliness if the patient’s prognosis gets worse.

Long: The patient will have a chosen support group and will attend at least once a week or when is able to.