SURIGAO EDUCATION CENTER

Km. 2, 8400 Surigao City, Philippines

CERVICAL CANCER (STAGE III)

A CASE PRESENTATION
Presented to:

THE FACULTY OF THE COLLEGE OF ALLIED MEDICAL SCIENCES NURSING DEPARTMENT SURIGAO EDUCATION CENTER

In Fulfillment of the Requirements for the Degree BACHELOR OF SCIENCE IN NURSING LEVEL 3

Presented by: ACERO, Julie Ferlyn O. COSTINIANO, Daryll Richmond J. ELIMANCO, Christine P. FLORES, Maria Lourdes N. FUENTES, Syhra D. NISHIHARA, Margie C. PAQUEO, Michael M. REPUTANA, Jane A. SURIGAO, Mielyn B. TELLO, Vida T.

MARCH 2012

ACKNOWLEDGMENT

As the presentors of this group case presentation, with deep appreciation and heartfelt gratitude, we would like to acknowledge the following people who have supported us and made this study a successful one: To our parents who morally and financially supported us. For their encouragement and understanding why were always late in coming home. To our clinical instructors who undoubtedly imparted their knowledge and shown their support to us. To all staff of Caraga Regional Hospital in OB-Gyne Ward, who gave us the permit to copy all the information necessary for this educational output to be completed from the patients chart. To the patient and patients family who never ceased to answer whatever questions we have raised. And most especially, to our Heavenly Father for giving us all the blessings, strength, wisdom and enlightenment that we are able to complete all the information needed. Indeed, this case study has definitely enhanced and advanced our knowledge in our chosen career.

THE PRESENTORS

CASE CONTENTS

TITLE
ACKNOWLEDGMENT INTRODUCTION REVIEW OF RELATED LITERATURE PATIENTS HEALTH HISTORY PHYSICAL ASSESSMENT 12 CRANIAL NERVES ASSESSMENT REVIEW OF SYSTEM LABORATORY EXAMINATIONS HUMAN ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY (NARRATIVE FORM) PATHOPHYSIOLOGY (SCHEMATIC DIAGRAM) DRUG STUDY NURSING CARE PLAN DISCHARGE PLAN DEFINITION OF TERMS APPENDICES A. DOCTOR(S) ORDER B. INTRAVENOUS FLUID SHEET C. FAMILY GENOGRAM D. MORTALITY RATE OF CERVICAL CA IN SURIGAO CITY BIBLIOGRAPHY/REFERENCES

PAGE

INTRODUCTION Activating oxygen can produce compounds called radicals that put oxidative stress on cells. Such stress could ultimately lead to cancer and other diseases. John Simon

According to the Filipino cancer registry annual report, cervical cancer is the second most common malignancy and is the most common cause of cancer-related mortality among Filipino women. Although considered as a preventable disease, the burden of cervical cancer in the Philippines remains to be moderately high, where the cost of nationwide organized cytology screening has been a significant limitation. In a country where existing health infrastructure is not sufficiently developed to support cytology-based screening program, the use of alternative screening modalities, such as visual inspection of the cervix aided by acetic acid (VIA) with or without magnification, is currently under evaluation. In addition, prophylactic Human Papillomavirus (HPV) vaccination for the prevention of infection and related disease is being considered as an additional cervical cancer control strategy. Cervical cancer is the term for a malignant neoplasm arising from cells originating in the cervix uteri. One of the most common symptoms of cervical cancer is abnormal vaginal bleeding, but in some cases there may be no obvious symptoms until the cancer has progressed to an advanced stage. Treatment usually consists of surgery (including local excision) in early stages, and chemotherapy and/or radiotherapy in more advanced stages of the disease. Patient CE, 48 years old, a resident of Banahaw Sabang 3, Surigao City was admitted at Caraga Regional Hospital for complaints of vaginal bleeding on January 16, 2012, 7:10 pm. She was diagnosed with Stage 3 Cervical Cancer. There were an estimated 530 000 cases of cervical cancer and 275 000 deaths from the disease in 2008. It is the third most common female cancer ranking after breast (1.38 million cases) and colorectal cancer (0.57 million cases). The incidence of cervical cancer varies widely among countries with world age-standardized rates ranging from <1 to >50 per 100 000. Cervical cancer is the leading cause of cancer-related death among women in Eastern, Western and Middle Africa; Central America; South-Central Asia and Melanesia. The highest incidence rate is observed in Guinea, with 6.5% of women developing cervical cancer before the age of 75

years. India is the country with the highest disease frequency with 134 000 cases and 73 000 deaths. Cervical cancer, more than the other major cancers, affects women <45 years. Worldwide, more than 238,000 women die each year from cervical cancer; over 80 % these women live in developing countries (2). In the Philippines, cancer ranks third among the leading causes of morbidity and mortality. Cervical cancer is the 2nd most common type of cancer in women, next only to breast cancer. The incidence of cervical cancer in the Philippines has remained unchanged since 1980, with an overall survival rate of 51.7 %, or about 10 per 100,000 women dying from the disease over 5 years. In 2005, an estimated 7,277 new cases and 3,807 deaths will occur (3) in that country. About two-thirds of cervical cancer cases in the Philippines are diagnosed at an advanced stage; owing to inadequate radiotherapy facilities in the country, mortality is high. The lack of knowledge and information about Cervical Cancer is one of the reasons why we chose this case. Not many Filipino women know about the disease, that it is preventable and can be cured when detected at the onset. We strongly believe that this case study will be very helpful in our career someday as future registered nurses.

REVIEW OF RELATED LITERATURE

The function of the cervix is to allow flow of menstrual blood from the uterus into the vagina, and direct the sperms into the uterus during intercourse. The opening of the cervical canal is normally very narrow. However under the influence of the body hormones and the pressure from the fetal head, this opening widens to about 4 inches (10 cm.) during labor, to allow the birth of a baby. If the opening is loose, as observed in some women, it can lead to miscarriages during pregnancy.

DEFINITION Cervical cancer is the term for a malignant neoplasm arising from cells originating in the cervix uteri. One of the most common symptoms of cervical cancer is abnormal vaginal bleeding, but in some cases there may be no obvious symptoms until the cancer has progressed to an advanced stage. Cancer screening using the Pap smear can identify precancerous and potentially precancerous changes in cervical cells and tissue. Treatment of high-grade changes can prevent the development of cancer in many victims. In developed countries, the widespread use of cervical screening programs has reduced the incidence of invasive cervical cancer by 50% or more.

RISK FACTORS Exposure to human papillomavirus Multiple sex partners Early age at first intercourse Sex with a promiscuous partner History of sexually transmitted diseases Family history of cervical cancer Low socioeconomic status Smoking and exposure to secondhand smoke Multiple pregnancies or early childbearing Long-term contraceptive use

CAUSES The causes for cervical cancer are not clearly understood, however, Human Papilloma Virus (HPV) infection is strongly associated with it. An infection of the Human Immunodeficiency Virus (HIV) increases the susceptibility to develop cervical carcinoma. Other risk factors: Age: Cervical cancer affects mostly the middle-aged, and is seen rarely in women below 15years. Smoking: Cigarette smoking women are at twice the risk of developing cervical cancer in comparison to non-smokers. Race: Certain races and ethnic groups like African- American, Hispanics and Native Americans are genetically predisposed to develop cervical cancer. Promiscuity: Having multiple sex- partners or having a partner, who is promiscuous, increases the chances of developing cervical cancer. STD: A history of a sexually- transmitted disease makes a woman susceptible to develop cervical cancer. Reproductive History: Having seven or more number of full- term pregnancies predisposes a woman to develop cervical cancer. Oral Contraceptives: Long -term use of oral contraceptives makes a woman more prone to develop cervical cancer.

SIGNS AND SYMPTOMS Early cervical cancers usually don't cause symptoms. When the cancer grows larger, women may notice one or more of these symptoms: Abnormal vaginal bleeding Bleeding that occurs between regular menstrual periods Bleeding after sexual intercourse, douching, or a pelvic exam Menstrual periods that last longer and are heavier than before Bleeding after going through menopause Increased vaginal discharge Pelvic pain Pain during sex

Infections or other health problems may also cause these symptoms. Only a doctor can tell for sure. A woman with any of these symptoms should tell her doctor so that problems can be diagnosed and treated as early as possible.

DETECTION AND DIAGNOSIS Doctors recommend that women help reduce their risk of cervical cancer by having regular Pap tests. A Pap test (sometimes called Pap smear or cervical smear) is a simple test used to look at cervical cells. Pap tests can find cervical cancer or abnormal cells that can lead to cervical cancer. Finding and treating abnormal cells can prevent most cervical cancer. Also, the Pap test can help find cancer early, when treatment is more likely to be effective. For most women, the Pap test is not painful. It's done in a doctor's office or clinic during a pelvic exam. The doctor or nurse scrapes a sample of cells from the cervix. A lab checks the cells under a microscope for cell changes. Most often, abnormal cells found by a Pap test are not cancerous. The same sample of cells may be tested for HPV infection. If you have abnormal Pap or HPV test results, your doctor will suggest other tests to make a diagnosis: Colposcopy: The doctor uses a colposcope to look at the cervix. The colposcope combines a bright light with a magnifying lens to make tissue easier to see. It is not inserted into the vagina. A colposcopy is usually done in the doctor's office or clinic. Biopsy: Most women have tissue removed in the doctor's office with local anesthesia. A pathologist checks the tissue under a microscope for abnormal cells. Punch Biopsy: The doctor uses a sharp tool to pinch off small samples of cervical tissue. LEEP: The doctor uses an electric wire loop to slice off a thin, round piece of cervical tissue. Conization: The doctor removes a cone-shaped sample of tissue. A conization, or cone biopsy, lets the pathologist see if abnormal cells are in the tissue beneath the surface of the cervix. The doctor may do this test in the hospital under general anesthesia. Removing tissue from the cervix may cause some bleeding or other discharge. The area usually heals quickly. Some women also feel some pain similar to menstrual cramps. Your doctor can suggest medicine that will help relieve your pain.

STAGING If the biopsy shows that you have cancer, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. Staging is a careful attempt to find out whether the tumor has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body. Cervical cancer spreads most often to nearby tissues in the pelvis, lymph nodes, or the lungs. It may also spread to the liver or bones. When cancer spreads from its original place to another part of the body, the new tumor has the same kind of cancer cells and the same name as the original tumor. For example, if cervical cancer spreads to the lungs, the cancer cells in the lungs are actually cervical cancer cells. The disease is metastatic cervical cancer, not lung cancer. For that reason, it's treated as cervical cancer, not lung cancer. Doctors call the new tumor "distant" or metastatic disease. Your doctor will do a pelvic exam, feel for swollen lymph nodes, and may remove additional tissue. To learn the extent of disease, the doctor may order some of the following tests: Chest X-rays: X-rays often can show whether cancer has spread to the lungs. CT Scan: An x-ray machine linked to a computer takes a series of detailed pictures of your organs. A tumor in the liver, lungs, or elsewhere in the body can show up on the CT scan. You may receive contrast material by injection in your arm or hand, by mouth, or by enema. The contrast material makes abnormal areas easier to see. MRI: A powerful magnet linked to a computer is used to make detailed pictures of your pelvis and abdomen. The doctor can view these pictures on a monitor and can print them on film. An MRI can show whether cancer has spread. Sometimes contrast material makes abnormal areas show up more clearly on the picture. PET Scan: You receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in your body. Cancer cells use sugar faster than normal cells and areas with cancer look brighter on the pictures.

SCREENING FOR CANCER The acronym CAUTION US according to American Cancer Society provides a systemic way of remembering the cancer warning signals. As health workers, it is our responsibility to inform as many people of these warning signals. These aspects should be included in the client assessment.

Change in bowel or bladder habits.

o Changes in stream/flow of urine or its color and amount. o Changes in the caliber and color of stools. o Presence of blood in stools. o Difficulty in urination and defecation.

A sore that does not heal.

o Skin irritations are usually self-limiting. It changes in the skin and underlying muscles take time to heal, it is recommended to have it examined.

Unusual bleeding or discharge.

o Unusual discharges in the breast, for non-breast feeding women.

Thickening or lump in the breast or elsewhere.

o Skin and underlying tissues should normally be smooth to touch. Unusual lumps/bukol or thickening need to be examined closely.

Indigestion and difficulty in swallowing.

o This could be explored further by interviewing the client to assess for associated events.

Obvious change in wart or mole.

o Warts or moles are circumscribed cutaneous discolorations to skin elevations that should not increase in size, nor ulcerate.

Nagging cough or hoarseness in voice.

o Evaluate for symptoms related for persistent cough and its quality.

Unexplained anemia.
o Monitoring the hemoglobin levels of suspected client is important.

Sudden weight loss.

o Awareness and monitoring of changes in body weight is a common warning sign.

STAGES OF CERVICAL CANCER The stage is based on where cancer is found. These are the stages of invasive cervical cancer: Stage I: The tumor has invaded the cervix beneath the top layer of cells. Cancer cells are found only in the cervix. Stage II: The tumor extends to the upper part of the vagina. It may extend beyond the cervix into nearby tissues toward the pelvic wall (the lining of the part of the body between the hips). The tumor does not invade the lower third of the vagina or the pelvic wall. Stage III: The tumor extends to the lower part of the vagina. It may also have invaded the pelvic wall. If the tumor blocks the flow of urine, one or both kidneys may not be working well. Stage IV: The tumor invades the bladder or rectum. Or the cancer has spread to other parts of the body. Recurrent cancer: The cancer was treated, but has returned after a period of time during which it could not be detected. The cancer may show up again in the cervix or in other parts of the body.

INCIDENCE & MORTALITY From 2004-2008, the median age at diagnosis for cancer of the cervix uteri was 48 years of age. Approximately 0.2% was diagnosed under age 20; 14.3% between 20 and 34; 25.8% between 35 and 44; 23.9% between 45 and 54; 16.4% between 55 and 64; 10.6% between 65 and 74; 6.4% between 75 and 84; and 2.5% 85+ years of age. The age-adjusted incidence rate was 8.1 per 100,000 women per year. These rates are based on cases diagnosed in 2004-2008 from 17 SEER geographic areas. Incidence Rates by Race Race/Ethnicity Female All Races 8.1 per 100,000 women White 8.0 per 100,000 women Black 10.0 per 100,000 women Asian/Pacific Islander 7.3 per 100,000 women American Indian/Alaska Native 7.8 per 100,000 women

Hispanic

12.2 per 100,000 women

NUMBERS TO REMEMBER (ABS-CBN News) 8 - A Filipina dies of cervical cancer every 8 minutes. 30 - Number of years that the incidence rate/mortality rates for cervical cancer has not changed. 2/3 - Most of the time, there is late diagnosis among patients. 1 1/2 -Years since Cervical Cancer Prevention Program (CECAP) was formed in the Philippines. 89 - Number of trained Single Visit Approach (SVA) providers. 14 - Number of clinical trainers. 73 - Number of trained barangay health workers for SVA. 90 - Number of barangay health researchers for SVA. 10,337 - Total number of Filipinas screened as of July 2008. 235 - Women who tested positive, treated and referred to secondary level of treatment after VIA. 7,277 - Number of cervical cancer cases in the Philippines as of 2005 (though according to Almaria, this is underestimated and is not representative of the whole population

since survey was only done in Rizal, Cebu and Davao.) 30 - Women who have become sexually active should have themselves checked up by their obstetrician-gynecologist every 2-3 years before 30 and every year after 30. 500 - Number of kilometers that Team David's Salon will go through from Vigan, Ilocos Sur to Olongapo, Zambales as part of CECAP's cervical cancer information campaign in Luzon from Sept. 13-17, 2008

PROGNOSIS A patients prognosis for cervical cancer depends on the stage of the cancer, the type of cervical cancer, and the size of the tumor.

PREVENTION Two tests can help prevent cervical cancer 1. The Pap test (or Pap smear) looks for precancers, cell changes on the cervix that may become cervical cancer if they are not treated appropriately. The Pap test is recommended for all women. 2. The Human Papillomavirus (HPV) test looks for the virus that can cause these cell changes. Talk with your doctor, nurse, or other health care professional about whether the HPV test is right for you. The most important thing you can do to help prevent cervical cancer is to have regular screening tests. If you are 30 or older, and your screening tests are normal, your chance of getting cervical cancer in the next few years is very low. For that reason, your doctor may tell you that you will not need another screening test for up to three years. But you should still go to the doctor regularly for a check-up that may include a pelvic exam. It also is important for you to continue getting a Pap test regularlyeven if you think you are too old to have a child, or are not having sex anymore. If you are older than 65 and have had normal Pap test results for several years, or if you have had your cervix removed (during an operation called a hysterectomy), your doctor may tell you it is okay to stop getting regular Pap tests.

TREATMENT If cervical cancer is diagnosed at an early stage, it's usually possible to treat it using surgery. In some cases, it's possible to leave the womb in place, but sometimes it will need to be removed. The surgical procedure that is used to remove the womb is known as a hysterectomy. Radiotherapy is an alternative to surgery for some women with early stage cervical cancer. More advanced cases of cervical cancer are usually treated using a combination of chemotherapy and radiotherapy. Radiotherapy can also cause infertility as a side effect. HPV vaccination In 2008, a national vaccination programme was launched to vaccinate girls against HPV 16 and HPV 18. The vaccine is most effective if it's given a few years before a girl becomes sexually active, so it's given to girls between the ages of 12 and 13.

There are two types of HPV vaccination: Cervarix - which only provides protection against cervical cancer Gardasil - which provides protection against cervical cancer and genital warts The NHS vaccination programme currently only offers the cervarix vaccine. The gardasil vaccine is only available privately at a cost of around 250 to 300 for the recommended threedose course.

COMPLICATIONS Cervical cancer can occur in one of two ways: As a side effect of treatment The result of advanced cervical cancer o Side Effects Early Menopause - if your ovaries are surgically removed, or if they're damaged during treatment with radiotherapy, it will trigger an early menopause (if you haven't already had it). Most women experience the menopause in their early fifties. The menopause is caused when your ovaries stop producing the hormones, estrogen and progesterone. This leads to the following symptoms: you no longer have monthly periods or your periods become much more irregular hot flushes vaginal dryness loss of sex drive mood changes stress incontinence - leaking urine when you cough or sneeze night sweats thinning of the bones, which can lead to brittle bones (osteoporosis) These symptoms can be relieved by taking a number of medications that stimulate the production of estrogen and progesterone. This treatment is known as hormone replacement therapy (HRT).

Narrowing of the Vagina - Radiotherapy to treat cervical cancer can often cause your vagina to become narrower. This can make having sex painful or difficult. There are two main treatment options if you have a narrowed vagina. o The first is to apply hormonal cream to your vagina. This should increase moisture within your vagina and make having sex easier. o The second is to use a vaginal dilator, which is a tampon shaped device that's made out of plastic. You insert it into your vagina and it is designed to help make your vagina suppler. It is usually recommended that you insert the dilator for five to 10 minutes at a time on a regular basis during the day, over the course of six to 12 months.

Many women find discussing the use of a vaginal dilator embarrassing, but it's a standard and well-recognized treatment for narrowing of the vagina. Your specialist cancer nurse or radiographers in the radiotherapy department should be able to give you more information and advice. You may find that the more times you have sex, the less painful it becomes. However, it may be several months before you feel emotionally ready to be intimate with a sexual partner. Lymphoedema - If the lymph nodes in your pelvis are removed, it can sometimes disrupt the normal workings of your lymphatic system. One of the functions of the lymphatic system is to drain away excess fluid from the bodys tissue. A disruption can cause a build-up of fluid in the tissue. This can lead to certain body parts becoming swollen, usually the arms and legs. This is known as lymphoedema. There are a number of exercises and massage techniques that can reduce the swelling. Wearing specially designed bandages and compression garments can also help. Emotional Impact - The emotional impact of living with cervical cancer can be significant. Many people report experiencing a rollercoaster effect. For example, you may feel down when you receive a

diagnosis, but feel up when removal of the cancer has been confirmed. Then you may feel down again as you try to come to terms with the after effects of your treatment. This type of emotional disruption can sometimes trigger depression. Signs that you may be depressed include: o feeling down or hopeless during the past month o no longer taking pleasure in the things that you enjoy o Contact your GP for advice if you think that you may be depressed. There are a range of effective treatments for depression, including antidepressant medication and talking therapies, such as cognitive behavioral therapy (CBT). You may also find Jo's Cervical Cancer Trust website a useful resource. It's the UKs only charity dedicated to women who are affected by cervical cancer. There may also be local support groups in your area for women affected by cancer. Your specialist cancer nurse should be able to provide contact details. o Advanced Cervical Cancer Some of the complications that can occur in cases of advanced cervical cancer are discussed below. Pain - If the cancer spreads into your nerve endings, bones or muscles it can often cause severe pain. However, a number of effective painkilling medications can usually be used. Depending on the levels of pain, they can range from paracetamol and the non-steroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, to more powerful opiate-based painkillers, such as codeine and morphine. Kidney Failure - Your kidneys remove waste material from your blood. The waste is passed out of your body in urine through tubes called the ureters. Kidney function can be monitored by a simple blood test called serum creatinine level. Severe cases of hydronephrosis can cause the kidneys to become scarred, which can lead to loss of most or all of the kidney's functions. This is known as kidney failure. Kidney failure can cause a wide range of symptoms, including:

o tiredness o swollen ankles, feet or hands (due to water retention) o shortness of breath o feeling sick o blood in your urine (haematuria) Treatment options for kidney failure that's associated with cervical cancer include draining urine out of the kidneys using a tube that's inserted through the skin and into each kidney (percutaneous nephrostomy). Another option is to widen each of the ureters by placing a small metal tube called a stent inside them. Blood Clots - Cervical cancer, like any other cancer, can make the blood more sticky and make it more prone to form clots. Bed rest after surgery and chemotherapy can also increase the risk of developing a clot. Advanced cervical cancer can spread to your blood vessels directly, which can also increase your risk of developing a blood clot. A type of blood clot known as deep venous thrombosis (DVT) can occur in cases of cervical cancer. DVT is a blood clot that develops in one of the deep veins in the body, usually in the leg. Symptoms of a DVT include: o pain, swelling and tenderness in one of your legs (usually your calf) o a heavy ache in the affected area o warm skin in the area of the clot o redness of your skin, particularly at the back of your leg, below the knee Bleeding - If the cancer spreads into your vagina, bowel or bladder, it can cause significant damage, resulting in bleeding. Bleeding can occur in your vagina, rectum (back passage), or you may pass blood when you urinate. Minor bleeding can often be treated using a medication called tranexamic acid, which encourages the blood to clot and stop the bleeding. Major bleeding can be treated using a

combination of medications that are designed to lower blood pressure. This should help to stem the flow of blood. Fistula - A fistula is an uncommon but distressing complication that occurs in around 1 in 50 cases of advanced cervical cancer. A fistula is an abnormal channel that develops between two sections of the body. In most cases involving cervical cancer, the fistula develops between the bladder and the vagina. This can lead to a persistent discharge of fluid from the vagina. Vaginal Discharge - Another uncommon but distressing complication of advanced cervical cancer is an unpleasant smelling discharge from your vagina. The discharge can occur for a number of reasons, such as the breakdown of tissue, the leakage of bladder or bowel contents out of the vagina, or a bacterial infection of the vagina. Treatment options for vaginal discharge include an anti-bacterial gel called

metronidazole, and wearing clothing that contains charcoal. Charcoal is a chemical compound that's very effective in absorbing unpleasant smells.

ARTICLE # 1: HPV Vaccines (Gardasil) Now Pushed Onto Boys in Canada Thursday, February 02, 2012 by: Ethan A. Huff, staff writer

(NaturalNews) There is still a whole lot of money to be made from pushing human papillomavirus (HPV) vaccines on young people around the world. But in order to accomplish this, the market for the vaccines, which include Merck & Co.'s Gardasil and GlaxoSmithKline's Cervarix, must be expanded to include males as well as females, which is what is currently taking place in Canada. CBC News reports that Canada's National Advisory Committee on Immunization (NACI) has now recommended that HPV vaccines be administered to boys between the ages of nine and 26. The announcement comes just months after a U.S. Centers for Disease Control and Prevention (CDC) committee also recommended that boys get jabbed with the HPV vaccine, despite the fact that nearly 25,000 children have had serious adverse events as a result of the vaccine, and more than 100 have died (http://sanevax.org/). Since Canada has a universal healthcare system, provinces and territories that adopt the new recommendations will be required to fund the vaccines, which have never been proven safe or effective in girls, let alone boys. Even the NACI report itself admits that "there are no studies that directly demonstrate that HPV vaccination of males will result in less sexual transmission of vaccine-related HPV types from males to females in reduced incidence of cervical cancer" (http://www.lifesitenews.com). Even so, vaccinating boys against HPV somehow still makes sense to Dr. Franziska Baltzer, a spokesman from the Canadian Association of Adolescent Health and head of adolescent medicine at Montreal Children's Hospital, who believes that boys as young as nine "contribute to the spread of HPV," a virus that many experts still say causes cervical cancer. Boys do not have a cervix, of course, which is why drug companies have had to convince government health authorities that boys are carriers of HPV. But keep in mind that HPV has never even been proven to be a cause of cervical cancer, which means vaccinating anyone against HPV is completely pointless in the first place (http://www.naturalnews.com). Neither Gardasil nor Cervarix has ever been proven to prevent HPV, either. The U.S. Food and Drug Administration (FDA) actually admitted in reports back in 2003 that HPV is not scientifically linked to causing cervical cancer. In fact, the Gardasil vaccine was found to be

responsible for actually causing a nearly 50 percent increase in precancerous lesions in women (http://www.naturalnews.com/022404.html).

ARTICLE # 2: Cancer Incidence and Survival in Metro Manila and Rizal Province, Philippines

Department of Surgery, Philippine General Hospital, University of the Philippines Manila, 2Philippine Cancer Society-Manila Cancer Registry, 3Department of Health-Rizal Cancer Registry, Manila, 4Research and Biotechnology Division, Bioinformatics Department, St Lukes Medical Center, Quezon City, 5Department of Obstetrics and Gynecology, Philippine General Hospital, University of the Philippines Manila, 6College of Public Health, University of the Philippines Manila, Manila, Philippines and 7Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland Received July 15, 2009; accepted February 26, 2010. The database of two population-based cancer registries (Philippine Cancer Society Manila Cancer Registry and Department of Health-Rizal Cancer Registry) was used to generate age standardized incidence rates of cancer during 19802002. Five-year relative survival rates were obtained for incident cases from 1993 to 2002 using a period analysis method. Overall incidence had increased in both males and females. Among males, lung cancer was the leading cancer and reached a peak in 198892. Colorectal and prostate cancers showed rising trends and became more common than liver cancer, with stable incidence over time. Stomach cancer incidence fell steeply. Among females, there was a steady increase in incidence of breast cancer. There was a slight decrease in the incidence of the second common cancer, cervical cancer, and colorectal cancer became equally common. Lung cancer incidence in females also reached a peak by 19982002 and then slightly decreased. Oral cavity cancer decreased strongly in the last period. In general, survival rates among Philippine residents were one-third lower than among Filipino-Americans and Whites in the USA especially in cancer sites wherein effective early detection methods may be available such as breast, cervix, colorectal and thyroid cancers.

PATIENTS HEALTH HISTORY

A. Biographic Data Name of Patient: Age: Sex: Date of Birth: Place of Birth: Address: Religion: Nationality: Civil Status: Occupation: Educational Attainment: Weight: Height: Mrs. CE 48 years old Female November 21, 1963 Surigao City Banahaw, Sabang 3, Surigao City Catholic Filipino Married Housewife, worked as a factory worker Elementary Graduate 45 kgs. 51

B. Admission Data Name of Hospital: Case Number: Ward Service: Date of Admission: Time of Admission: Mode of Admission: Date of Discharge: Time of Discharge: Admitting Physician: Attending Physician: Date and Time of clinical encounter: Caraga Regional Hospital 62652-2012 OB-Gyne Ward January 16, 2012 7:10 pm Stretcher February 27, 2012 1:30 pm Dr. Comelon Dr. Mantilla January 17, 2012

C. Vital Signs upon Admission Temperature: Heart rate: Respiratory rate: Blood Pressure: 37.1 C 84 bpm 60 cpm 120/80 mmHg

D. Vital Signs upon Assessment Temperature: Heart rate: Respiratory rate: Blood Pressure: 36.3 C 80 bpm 25 cpm 100/70 mmHg

E. Chief Complaint (+) Vaginal Bleeding

F. Sources of Information The primary source of information is the patient. The secondary source of data is the patients chart.

G. Admitting Impression Cervical CA

H. Final Diagnosis Stage 3 Cervical CA

HISTORY OF PRESENT ILLNESS

Three (3) days prior to admission, the patient claimed that while riding in a tricycle she had a heavy vaginal bleeding and pain at abdominopelvic area (pain scale 8/10). But she refused to be brought to the hospital upon thinking of financial inadequacy. She went home, took a rest and prayed that the bleeding would subside. Two (2) days prior to admission, she stated that the bleeding was no longer that heavy so she went to work and did her usual daily routine. In the afternoon, the bleeding ceased fortunately. A day prior to admission, Mrs. CE experienced weakness and dizziness while at work but she ignored it. An hour prior to admission, she experienced heavy vaginal bleeding again that made her jeans so stained and wet. Grabe jud kabasa ang ako pantalon kay nibulwak ako dugo, as verbalized by Mrs. CE. So accompanied by her co-worker, she was rushed to Caraga Regional Hospital.

PAST HEALTH HISTORY

A. Childhood Illness The patient had some instances of fever, cough and common colds during her childhood days. She had chicken pox at the age of 17 yrs. old and had not taken any medication.

B. Childhood Immunization Mrs. CE claimed that she was not immunized for it was not yet available during her time.

C. History of Hospitalization The patients 1st hospitalization was last 1991 at Caraga Regional Hospital when she undergone surgery because of her ectopic pregnancy. She added that she cannot remember the exact month and date of that hospitalization and who performed the operation. Her 2nd hospitalization was on 1992 when she had her 3rd pregnancy, a pregnancy called vernacularly as kyawa, wherein she continuously had her daily scanty menstruation until such time that she

delivered the baby. But unfortunately her baby died an hour after the delivery .The patients 3 rd hospitalization was on September 11, 2011 because of heavy vaginal bleeding. Her attending physician was Dr. Mantilla and she stayed at the hospital for 5 days. On November 30, 2011 she was hospitalized again because of vaginal bleeding. It was her 4th hospitalization wherein she was submitted for an ultrasound with a negative result. On December 03, 2011, the date of her discharge, the bleeding occurred again so the physician decided to submit her for a biopsy exam (to determine of metastasis) thus postponed her way home. On December 16, 2011, she was diagnosed to have a cervical cancer through the biopsy result. Her attending physician advised her for a second opinion so she went to Manila and undergone biopsy for the second time at Jose P. Reyes Hospital. Her 5th hospitalization was on December 23, 2011, the diagnosis was stage III cervical cancer. She went back to Surigao after her discharge and was hospitalized again on January 16, 2012 as her 6th hospitalization. Last February 17, 2012 was her 7th hospitalization and was transfused of 3 Packed Red Blood Cells. Supposedly, the patient will undergo an operation but due to some reasons the physician advised that chemotherapy and radiation therapy would be the best intervention for her condition. Unfortunately Mrs. CE is not financially stable for the said therapy so she was discharged last February 27, 2012.

D. Surgical History The patient stated that she undergone surgery for ectopic pregnancy year 1991.

E. Accidents and Injuries The patient stated that she had no history of accident and injury

F. Allergies She claimed that she had no allergies.

G. Obstetric History The patient claimed that her first menarche occurred when she was 18 years old. Her menstruation takes 1 week regularly and she can consume 2 sanitary pads per day. She claimed that she never experienced dysmenorrheal during her menstruation. Mrs. CE admitted that she

had her first sexual intercourse at the age of 24 years old with her live-in partner. She claimed that she used natural method of family planning (calendar method). Her first pregnancy was last 1989 and delivered the baby normally (NSVD). Her second pregnancy resulted to ectopic pregnancy so she undergone surgery during that time. The patients 3rd pregnancy was the one termed kyawa or medically termed as anencephaly (no posterior skull), as verbalized by the patient. Her 4th and 5th pregnancy was delivered normally (NSVD).After her separation with her live-in partner, she got married last 1998 and blessed with 2 children both NSVD. She has 5 living children in all. She also claimed that during the time she experienced heavy vaginal bleeding, she can consume 2 adult diapers per day and the color of her discharges is reddish and has a foul odor. She viewed sex as normal activity between two individuals who love each other. The patient added that although she doesnt experience pain during sexual intercourse, she and her husband agreed not to have sexual activity anymore because of her illness. She never had any screening tests like Pap smear.

FAMILY HEALTH HISTORY The patient claimed that she doesnt know about the causes of her grandparents death both paternal and maternal side. Some of her relatives are alcoholics. This includes her father who died of suicide while drunk at the age of 69 years old. Her mother died of aneurysm at the age of 62 years old. Her third cousin (paternal side) died of cervical cancer. Another cousin is suffering from breast cancer until now. Her elder sister is suffering from hypertension. (Refer to Appendix C page 76).

LIFESTYLE

Personal Habits Early in the morning as she wakes up after performing self grooming, she drinks cup of coffee while doing some household chores. She used to drink alcoholic beverages but stopped at the age of 24 years old.

Diet Before Hospitalization The patient claimed that she eats 3 times a day. She is fond of eating dried salted fish buyad, bagoong and canned goods (tinapa). She drinks one glass of water every meal and can consume more than one liter of water in a day. Her normal breakfast consist of half cup of cooked rice, fish and vegetables. She has no special diet and no known food allergies. During Hospitalization She still eats 3 times a day. Her diet is as tolerated. She eats anything of what are being provided by the hospital.

Sleep and Rest Pattern Before Hospitalization The patient normally sleeps at 7:00 pm but oftentimes had a hard time to get a good sleep. She usually wakes up at 4:00 am. Watching TV is her form of relaxation. During Hospitalization The patient stated that she usually sleeps at 10:00 pm and wakes up at around 3:00 am because of the noisy environment and due to continuity of care provided such as taking of vital signs and administration of drugs.

Elimination Pattern Before Hospitalization Mrs. C voids yellow colored urine 6 times a day with an amount which she estimated as, pareha kahamok sa 8oz na botilya ng coke as verbalized by the patient and claimed that she had not experienced any difficulties in urination. She also claimed that she usually defecates once every 3 days with brown, formed or semi-solid stool. During Hospitalization During confinement still she urinates 6 times in a day with yellow colored urine but having a foul odor. She defecates once in a week with brown, formed or semi-solid stool.

Activities of Daily Living (ADL) Before Hospitalization The patient had no difficulties in performing the basic activities such as grooming, locomotion and performing household chores. During Hospitalization The patient still performed few of the basic activities specifically grooming, dressing and toileting but had difficulty in doing her household chores such as washing soiled clothes.

Recreation/ Hobbies Mrs. CE during weekend just spent her time cleaning the house, doing the household chores and watch television. She included too, that sewing is also helpful to divert her attention.

SOCIAL DATA

Family Relationship/Friendship Mrs. CE has a good relationship with her family. She is a good wife and mother to her children. Talking to the family especially to her husband is the most effective way of taking away unpleasant feelings.

Ethnic Affiliation The patient claimed that she believes in quack doctor (albularyos) but she prefers to seek medical care.

Educational History Mrs. CE claimed that she is an elementary graduate and wasnt able to continue due to financial problem.

Occupational History Mrs. CE worked as a factory worker (exporting sea foods company) before she was being diagnosed of cervical cancer.

Socio-Economic Status Mrs. CE is a Philhealth member and depends on her husbands income (250 per day).

PSYCHOLOGICAL DATA She stated that her major stressor aside from her condition is the feud between her husband and her stubborn son. She always pray every day and asks for guidance from God. She has the ability to verbalize appropriate emotions and uses non verbal communications such as eye movements, gestures and interacts clearly during an interview.

GROWTH AND DEVELOPMENT In the growth and development, our patient belongs to the middle aged adults. The individuals characteristics shows lifestyle changes due other changes; physical development, psychosocial development, spiritual development and health problems.

Physical Changes Of The Middle Aged Adults Appearance Hair begins to thin and gray hair appears. Skin turgor and moisture decrease, subcutaneous fat decreases, and wrinkling occur. Fatty tissue is distributed, resulting in fat deposits in the in the abdominal area. Musculoskeletal system Skeletal muscle bulk decreases at about age 60. Thinning of the intervertebal discs a decrease in height of about 1 inch. Muscle growth continues in proportion to use. Cardiovascular system Sensory perception Blood vessels lose elasticity and become thicker Visual acuity declines. Auditory acuity for high sounds decreases particularly in men. Taste sensation also diminished Metabolism Gastrointestinal system Metabolism slows, resulting in weight gain. Gradual decreases in tone of large intestine may predispose the individual to constipate. Urinary system Nephron units are lost during this time and glomerular filtration rate decreases. Sexuality Hormonal changes takes places, menopause

PHYSICAL ASSESSMENT

Date of Clinical Assessment: January 17, 2012 and January 20, 2012

General Survey Assessed/received patient lying on bed, awake, conscious, responsive, and coherent with an ongoing IVF of 1L D5LR at 700 cc level running at 20 gtts/min with + amino acid + ampules infusing well at left metacarpal vein with the following vital signs: Temperature: Heart rate: Respiratory rate: Blood Pressure: 36.3 C 80 bpm 25 cpm 100/70 mmHg

Patients GTPAL: G7 T5 P1 A1 L5

Skin Presence of bruise noted (in the left knee). Pallor noted. Cool and clammy to touch. Good skin turgor in both upper and lower extremities; the skin returns to its previous state immediately after being tented.

Hair Hair is black and is evenly distributed. Silky and smooth hair. No areas of hair loss noted. Dandruff on scalp noted. Thick hair strands.

Nails Trimmed dirty nails. Convex shaped; with a nail plate angle of about 160 degrees. Smooth in texture. Intact epidermal lining around the nails. Capillary Refill Test less than 3 seconds.

Skull and Face Rounded (normocephalic and symmetrical with frontal, parietal and occipital prominences). Head size is appropriate to body size. No nodules or masses upon palpation.

Eyes and Vision Eyebrows and eyelashes are evenly distributed. Eyelids are intact. Sclera appears white. Pale conjunctiva. No discharges and discoloration noted. Blink reflex intact. Able to read words at a distance of 18-20 inches. (+) Pupils Equal Round and Reactive to Light Accommodation (PERRLA).

Ears and Hearing Ears are symmetrical in size and in line with the outer canthus of the eyes. Color of ears is the same with the facial skin. No discharges and foul odor noted upon inspection. Pinna and ear canal are clean. Auricles are firm and recoil to previous state when folded. No nodules or masses noted upon palpation. Able to hear whispered words and ticking of watch at a distance of 10cm.

Nose and Sinuses Symmetric and straight. No watery discharges. Air moves freely as the client breathes through nares. The patient has good sense of smelling, can smell the scent of an orange fruit. Not tenderness, masses and pain noted upon palpation. No oxygen inhalation attached.

Oropharynx (Mouth and Throat) Dry and pale lips noted upon inspection. Incomplete teeth noted. Tongue is able to move freely and able to swallow foods. Tonsils are pink in color and smooth upon inspection. No dentures upon inspection. Gums are not inflamed. Good oral hygiene.

Neck Jugular vein is not visible. Muscles are equal in size with the head centered. Coordinated muscle movement with no discomfort. Head flexes over 45. Lymph nodes are not palpable.

Cardiovascular and Peripheral System Skin color of palm of the hand and feet is pale. Pale nail beds upon inspection. Symmetric pulse volumes, full pulsations of peripheral pulses. Heart rate is 80 beats per minute. Blood Pressure is 100/70mmHg. (Vital signs taken during the time of assessment on January 17, 2012 @ 10:00 am).

Respiratory System Chest is symmetric. Skin and chest wall are intact and has uniform temperature. No tenderness and masses noted upon palpation. Normal breath and effortless respiration noted. No wheezing and crackles sound upon auscultation. Full and symmetric chest wall expansion.

Breasts and Axillae Breasts are symmetrical in size; color is the same as with the abdomen. Both nipples are symmetrical in size. No discharges noted. No tenderness, masses, and nodules noted upon palpation.

Abdomen Abdominal skin is intact. Distended abdomen noted. Presence of striae gravidarum noted. Audible bowel sound upon auscultation. Abdominal dullness upon percussion. Presence of solid rounded mass noted upon palpation (left inguinal region). Abdominal pain (pain scale of 8/10) complained. Presence of scar at the right hypogastrium.

Musculoskeletal Skeletal Posture is good, able to stand straight and can walk alone properly but slowly. Movement of muscles has coordination. Muscles in the upper extremities are firm.

Neurologic Patient is oriented to time, person and place. She was able to state where she lives. Patient was able to answer well when asked of her complete name, birth date and age. Good patellar reflex noted, normal extension of the leg was obtained as the patellar tendon directly hit by percussion hammer. Levels Of Consciousness: Glasgow Coma Scale LOC Measured I. Eye Opening Response Spontaneous To verbal command To pain No response To verbal command To localized pain Flexes and withdraws Flexes abnormally Extends abnormally No response Oriented, converses Disoriented, converses Uses inappropriate words Makes incomprehensible sounds No response Score 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1 Results 4

II.

Motor Response

III.

Verbal Response

Total: 14/15 Interpretation: Conscious Normal Urinary System Patient usually urinates 6 times a day.

Reproductive System The patient refused to be assessed with her external reproductive organ but she verbalized that even without the bleeding she has discharges which appear white and watery and has foul odor.

12 CRANIAL NERVES ASSESSMENT CRANIAL NERVE I Olfactory II Optic TYPE Sensory Sensory FUNCTION Smell Vision and Visual Fields RESULTS Client was able to smell familiar odors of orange fruit and apple Client was able to read words in a distance of 18-20 inches.

III Oculomotor

Motor

IV Trochlear

Motor

V Trigeminal

Motor and Sensory

VI Abducens

Motor

VII Facial

Motor and Sensory

VIII Auditory IX Glossopharangeal X Vagus

Sensory Motor and Sensory Motor and Sensory

XI Accessory

Motor

XII Hypoglossal

Motor

Extraocular Eye Movement (EOM); Direct light reflex observed as movement of sphincter of evidenced by constriction of pupil; movement of pupil using penlight. ciliary muscles of lens Clients both eyes are moved in EOM; especially moves coordination w/o tenderness felt eyeball downward and when moved laterally up and laterally down. Client lids close symmetrically. Client reported feeling light Sensation of the cornea, touch and sharp stimuli in the skin of face, nasal forehead, cheek, and jaw on mucosa, anterior oral both sides of the face and able cavity; and mastication to clench his jaw. EOM; moves eyeball Client able to move her eyeball laterally as where the direction of gaze Client was able to smile, wrinkle her forehead, raise and Facial expression; taste lower her eyebrows, smile to (anterior 2/3 of tongue) show his teeth. The facial movement is symmetrical. Client was able to hear Equilibrium, and Hearing whispered voice, clapping of hands and ticking of watch. Swallowing ability, Client able to move her tongue tongue movement, taste to side up and down and able (posterior tongue) swallow foods. Sensation of pharynx and larynx; swallowing; Client can speak words clearly. vocal cord movement Client able to shrug her Head movement; shoulders and move head shrugging of shoulders against the resistance with the hands. Patient was able to protrude Protrusion of tongue; tongue and move her tongue moves tongue up and rapidly from side to side with down and side to side open mouth

REVIEW OF SYSTEM

Integumentary System The patient had history of bruises either on upper extremities or lower extremities especially during her menstrual period.

Head The patient had no history of any form of head injuries but sometimes experiences headache.

Eyes Patient had no history of any eye problems.

Ears and Hearing Patient had no history of smelly discharges on both ears, and no complaints of hearing impairment.

Nose and Sinuses The patient had history of common colds and nasal stuffiness.

Mouth and Oropharynx The patient had history of bleeding gums and mouth ulcers/mouth sores.

Neck The patient had history of neck problems such as stiffness.

Breast and Axillae The patient had no history of breast nodules, no enlargement, no tenderness, no pain and unusual discharges.

Respiratory System The patient experienced common colds and sometimes suffers from productive with yellowish characteristics sputum.

Cardiovascular System The patient had no history of any cardiovascular problems.

Genitourinary System The patient had no history of any genital problems. Usually urinates 6 times a day.

Gastrointestinal System The patient had history of difficulty in defecation; episodes of constipation.

Musculoskeletal System Patient had history of joint sprain.

Neurologic System Patient had no history of any major mental problems but had episodes of forgetfulness.

Reproductive System Patient had no history of dysmenorrheal problem; she had history of ectopic pregnancy (undergone surgery year 1991); had history of bleeding with pain (Sept. 11, 2011); had history of preterm delivery (8 months).

HEMATOLOGY

Date Requested: January 17, 2012

TEST NAME WBC (White Blood Cells)

RESULTS

NORMAL VALUES

SIGNIFICANCE This can result from bacterial

11.2

4.0-10.0

infections, inflammation, and leukemia.

HGB (Hemoglobin)

2.7810^12/L

3.9-5.6^12/L

Decreased in all anemias and after hemorrhage. Decreased in all various anemia

MCV (Mean Cell Volume) PLT (Platelet) MPV (Mean Platelet Volume) PDW (Platelet Distribution Width)

8.2g/dl

11.5-15.5g/dl

and

severe

or

prolong

hemorrhage. 87.7fL 315 82.0-92.0fL 150-450 Within the Normal Range. Within the Normal Range.

11.6fL 7.5fL

7.4-10.4fL 10.O-14.0fL

Indicates presence of bleeding. Indicates presence of bleeding.

PCT (Platelet Cell Total) 0.36% 0.10-0.28% Indicates more bacteria.

Blood Type: A

Ponciano S. Polangco, MD, FPSP Pathologist

Dates Requested: January 20 and 21, 2012; respectively.

TEST NAME WBC (White Blood Cells) LYM (Lymphocytes) MID (Monocytes) GRAN (Granulocytes) LYM # (Lymphocytes Total) MID # (Monocytes Total) GRAN # (Granulocytes Total)

RESULTS 7.0 34.1% 9.1% 56.8% 2.4 0.6 4.0

NORMAL VALUES 4.0-10.0 20.0-40.0% 1.0-15.0% 40.0-60% 0.6-4.1 10^9/L 0.1-1.8 10^9/L 2.0-7.8 10^9/L

SIGNIFICANCE This can result from bacterial infections, inflammation, and leukemia. Within the Normal Range. Within the Normal Range. Within the Normal Range. Within the Normal Range. Within the Normal Range. Within the Normal Range.

Ponciano S. Polangco, MD, FPSP Pathologist

TEST NAME RBC (Red Blood Cells) HGB (Hemoglobin) HCT (Hematocrit) MCV (Mean Cell Volume) MCH (Mean Cell Hemoglobin) MCHC (Mean Cell Hemoglobin Concentration) RDW CV (Red Cell Distribution Width Coefficient Variation) RDW SD (Red Cell Distribution Width Standard Deviation) PLT (Platelet)

RESULTS 2.43 10^12/L 6.6 g/dL 18.3 % 85.4/L 27.7 Pg 36.0 g/dL

NORMAL VALUES 3.5 - 5.5 10^/L 11.0-15.0/L 36.0-48.0/L 80.0-99.0/L 26.0-32.0 Pg 32.0-36.0 g/dL

SIGNIFICANCE Low RBC indicates anemia. Indicates anemia. Indicates Hemorrhage. Within the Normal Range. Within the Normal Range. Within the Normal Range.

16.6 %

11.5-14.5%

Indicates Hemorrhage.

50.9 fL 156 10^9/L

39.0-46.0 fL 150-450^9/L

Indicates Hemorrhage. Within the Normal Range.

MPV (Mean Platelet Volume) PDW (Platelet Distribution Width) PCT (Platelet Cell Total)

7.9 fL 7.5 fL 0.11 %

7.4- 10.4 fL 10.0-14.0 fL 0.10-0.28%

Within the Normal Range. Indicates presence of bleeding. Indicates presence of bleeding and more bacteria. Ponciano S. Polangco, MD, FPSP Pathologist

URINALYSIS

Date Requested: January 17, 2012

RESULTS Color Reaction Sugar RBC (Red Blood Cells) E. Cell Yellow 6.0 Negative >5.0 hpf

NORMAL VALUES Yellow-amber 5.0-6.0 Negative Female: 0.0-5.0 hpf

SIGNIFICANCE Indicates dehydration. Within the Normal Range. Normal. Indicates presence of blood/bleeding. Indicates material. Cloudy urine indicates presence of excessive cellular material. Within the Normal Range. Indicates anemia. Indicates some infections. bleeding and cellular

Moderate

Negative

Transparency Specific Gravity Protein Pus cells

Cloudy 1.015 Few 8-10/ hpf

Clear 1.010-1.030 Negative 3-6/ hpf

CERVICAL BIOPSY

HUMAN ANATOMY AND PHYSIOLOGY (FEMALE REPRODUCTIVE SYSTEM) The reproductive role of a female is much more complex than that of the male. Not only must she produce the female gametes (ova), but her body must also nurture and protect a developing fetus during nine months of pregnancy. Functions are: Produces eggs (ova). Secretes sex hormones. Receives the male spermatazoa during sexual intercourse. Protects and nourishes the fertilized egg until it is fully developed. Delivers fetus through birth canal. Provides nourishment to the baby through milk secreted by mammary glands in the breast.

Anatomy (External Female Organ)

Physiology (External Female Organ) Mons Pubis a.k.a. Mons Veneris that protects the pubic bone and vulva from the impact of sexual intercourse. After puberty, it is covered by pubic hair (responsible for not easily harboring the microorganisms in the vagina. Prepuce of Clitoris protective cover of glans of clitoris. Glans of Clitoris a short erectile organ above the vagina that is responsible for sexual excitation or pleasure. Vestibule the gland at the point where vagina and vulva join that secretes lubricating substance. It consists of 3 parts: o Urethral Opening a.k.a. Meatus that drains urine from the bladder. o Clitoris functions sexual pleasures. o Vestibule of Vagina a.k.a. Vaginal Introitus that is for the vaginal entrance. Openings of Paraurethral connected to the urethra and lubrication. Labium a fleshy and liplike structure folds that protect the openings from bacterial invasion. It has: o Labia Majora elongated hair covered skin folds that are responsible for lubrication. o Labia Minora smaller folds enclosed by the labia majora and their function is to protect the vagina and urethra openings. And they also produce lubricant. Vagina receives penis and semen during mating, and passageway of childbirth and menstrual flow. Hymenal Caruncle a.k.a. Hymen, a membrane which partially covers the vaginal passage. Opening of Greater Vestibular Gland a.k.a. Bartholins Glands, the two glands at the side of the vagina and between the vulva that secretes a lubricating substance. Vestibular Fossa a.k.a. Navicular Fossa, a small cavity of between the vaginal orifice and fourchette. Frenulum of Labium the fold connecting the two labia minora posteriorly. Posterior Labia Commissure rear joining of the labia majora above the perineum. Perineal Raphe ridge along the median line that runs forward from the anus. Anus a.k.a. Anal Orifice, in which feces passes through.

Anatomy (Internal Female Organ)

Physiology (Internal Female Organ) Ovaries paired shape of almonds. It produces ova (singular, ovum), or eggs. The two ovaries present in each female are held in place by the following ligaments: o Broad Ligament is a section of the peritoneum that drapes over the ovaries, uterus, ovarian ligament, and suspensory ligament. It includes both the mesovarium and mesometrium. The mesovarium is a fold of peritoneum that holds the ovary in place. o Suspensory Ligament anchors the upper region of the ovary to the pelvic wall. Attached to this ligament are blood vessels and nerves, which enter the ovary at the hilus. o Ovarian Ligament anchors the lower end of the ovary to the uterus. The following two tissues that cover the outside of the ovary: o Germinal Epithelium is an outer layer of simple epithelium. o Tunica Albuginea is a fibrous layer inside the germinal epithelium. The inside of the ovary, or stroma, is divided into two indistinct regions: o Outer Cortex and the Inner Medulla embedded in the cortex are saclike bodies called ovarian follicles. Each ovarian follicle consists of an immature oocyte (egg) surrounded by one or more layers of cells that nourish the oocyte as it matures. o Follicular Cells the surrounding cells if they make up a single layer, or granulosa cells, if more than one layer is present. Uterine tubes (oviducts) transport the secondary oocytes away from the ovary and toward the uterus (the ovaries consist of primary oocytes, which develop into secondary oocytes). The following regions characterize each of the two uterine tubes (one for each ovary): o Infundibulum is a funnel-shaped region of the uterine tube that bears fingerlike projections called fimbriae. Pulsating cilia on the fimbriae draw the secondary oocyte into the uterine tube. o Ampulla is the widest and longest region of the uterine tube. Fertilization of the oocyte by a sperm usually occurs here. o Isthmus is a narrow region of the uterine tube whose terminus enters the uterus. Wall of the Uterine Tube consists of the following three layers: o Serosa a serous membrane, lines the outside of the uterine tube. o Middle Muscularis consists of two layers of smooth muscle that generate peristaltic contractions that help propel the oocyte forward. o Inner Mucosa consists of ciliated columnar epithelial cells that help propel the oocyte forward, and secretory cells that lubricate the tube and nourish the oocyte.

Uterus a hollow and pear-shaped organ that is to house, nourish and expel the fetus during delivery; and for menstrual flow. It composes 3: o Body or Corpus the main body part of the uterus. o Fundus superior rounded region above the entrance of the uterine tubes. o Isthmus slightly constricted portion that joins the corpus to the cervix. Uterus is held in place by the following ligaments: o Broad ligaments - fold of peritoneum supporting the uterus, extending from the uterus to the wall of the pelvis on either side. o Utero-sacral ligaments - a part of the thickening of the visceral pelvic fascia beside the cervix and vagina; called also Petit's Ligament. o Round ligaments - a fibromuscular band attached to the uterus near the uterine tube, passing through the inguinal ring to the labium majus. o Cardinal (lateral cervical) ligaments - part of a thickening of the visceral pelvic fascia beside the cervix and vagina, passing laterally to merge with the upper fascia of the pelvic diaphragm. Wall of the Uterus consists of the following three layers: o Perimetrium is a serous membrane that lines the outside of the uterus. o Myometrium consists of several layers of smooth muscle and imparts the bulk of the uterine wall. Contractions of these muscles during childbirth help force the fetus out of the uterus. o Endometrium is the highly vascularized mucosa that lines the inside of the uterus. If an oocyte has been fertilized by a sperm, the zygote (the fertilized egg) implants on this tissue. Endometrium itself consists of two layers: Stratum Functionalis (functional layer) is the innermost layer (facing the uterine lumen) and is shed during menstruation. Stratum Basalis (basal layer) is permanent and generates each new stratum functionalis. Vagina (birth canal) serves both as the passageway for a newborn infant and as a depository for semen during sexual intercourse. It consists of the following layers: o Outer Adventitia holds the vagina in position. o Middle Muscularis consists of two layers of smooth muscle that permit expansion of the vagina during childbirth and when the penis is inserted. o Inner Mucosa has no glands. But bacterial action on glycogen stored in these cells produces an acid solution that lubricates the vagina and protects it against microbial infection. The acidic environment is also inhospitable to sperm. The mucosa bears transverse ridges called rugae.

Anatomy (Female Internal Cervix)

Physiology (Female Internal Cervix) Cervix is the 3rd lower portion of the uterus, neck like part (uteri cervix), narrowed where it joins of the top end of the vagina. Cylindrical in shape and protrudes through the upper anterior vaginal wall. It has cervical mucus that is made of 90% of water, depending on the water content which varies during the menstrual cycle that functions as barrier. It usually contains electrolytes, mainly Calcium, Sodium, and Potassium, organic components such as amino acids and soluble proteins. It is also composed of zinc, copper, iron, manganese, and selenium elements. After menstrual period, the external os is blocked by mucus that is thick and acidic and it undergoes a series of changes in position and texture of cervix uteri and wall.

Hormonal Regulation of Oogenesis and Menstrual Cycle

Three estrogens circulate in the bloodstream: (1) estradiol, (2) estrone, and (3) estriol. All have similar effects on their target tissues. Estradiol is the most abundant estrogen, and its effects on target tissues are most pronounced. It is the dominant hormone prior to ovulation. In estradiol synthesis, androstenedione is first converted to testosterone, which the enzyme aromatase converts to estradiol. The synthesis of both estrone and estriol proceeds directly from androstenedione. Estrogens have multiple functions that affect the activities of many tissues and organs throughout the body. Among the important general functions of estrogens are (1) stimulating bone and muscle growth, (2) maintaining female secondary sex characteristics, such as body hair distribution and the location of adipose tissue deposits, (3) affecting central nervous system (CNS) activity (especially in the hypothalamus, where estrogens increase the sexual drive), (4) maintaining functional accessory reproductive glands and organs, and (5) initiating the repair and growth of the endometrium.

Ovarian Cycle

Events

Uterine Cycle

Events

Follicular phase FSH secretion begins. Days 1-13 Follicle occurs.

Menstruation - Days Endometrium breaks down. 2-5

maturation Proliferative phase Endometrium rebuilds. Days 6-13

Estrogen secretion is prominent. Ovulation - Day LH spike occurs. 14* Luteal phase Days 15-28 LH secretion continues. Corpus luteum forms. Progesterone secretion is prominent. The purpose of these cycles is to produce an egg and to prepare the uterus for the implantation of the egg, should it become fertilized. The ovarian cycle consists of three phases: 1. Follicular Phase describes the development of the follicle, the meiotic stages of division leading to the formation of the secondary oocytes, and the secretion of estrogen from the follicle. 2. Ovulation, Occurring at midcycle is the ejection of the egg from the ovary. 3. Luteal Phase describes the secretion of estrogen and progesterone from the corps luteum (previously the follicle) after ovulation. The menstrual (uterine) cycle consists of three phases: 1. Proliferative phase describes the thickening of the endometrium of the uterus, replacing tissues that were lost during the previous menstrual cycle. 2. Secretory phase - follows ovulation and describes further thickening and vascularization of the endometrium in preparation for the implantation of a fertilized egg. 3. Menstrual phase (menstruation, menses) describes the shedding of the endometrium when implantation does not occur. The activities of the ovary and the uterus are coordinated by negative- and positive-feedback responses involving gonadotropin releasing hormone (GnRH) from the hypothalamus, follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary, and the hormones estrogen and progesterone from the follicle and corpus luteum. A description of the events follows): Secretory phase Days 15-28 - Endometrial thickens, glands are secretory. and

1. Hypothalamus and anterior pituitary initiate the reproductive cycle: The hypothalamus monitors the levels of estrogen and progesterone in the blood. In a negative-feedback fashion, low levels of these hormones stimulate the hypothalamus to secrete GnRH, which in turn stimulates the anterior pituitary to secrete FSH and LH. 2. Follicle develops: FSH stimulates the development of the follicle from primary through mature stages. 3. Follicle secretes estrogen: LH stimulates the cells of the theca interna and the granulosa cells of the follicle to secrete estrogen. Inhibin is also secreted by the granulosa cells. 4. Ovulation occurs: Positive feedback from rising levels of estrogen stimulate the anterior pituitary (through GnRH from the hypothalamus) to produce a sudden midcycle surge of LH. This high level of LH stimulates meiosis in the primary oocyte to progress toward prophase II and triggers ovulation. 5. Corpus luteum secretes estrogen and progesterone: After ovulation, the follicle, now transformed into the corpus luteum, continues to develop under the influence of LH and secretes both estrogen and progesterone. 6. Endometrium thickens: Estrogen and progesterone stimulate the development of the endometrium, the inside lining of the uterus. It thickens with nutrient-rich tissue and blood vessels in preparation for the implantation of a fertilized egg. 7. Hypothalamus and anterior pituitary terminate the reproductive cycle: Negative feedback from the high levels of estrogen and progesterone cause the anterior pituitary (through the hypothalamus) to abate the production of FSH and LH. Inhibin also suppresses production of FSH and LH. 8. Endometrium either disintegrates or is maintained, depending on whether implantation of the fertilized egg occurs, as follows: o Implantation does not occur: In the absence of FSH and LH, the corpus luteum deteriorates. As a result, estrogen and progesterone production stops. Without estrogen and progesterone, growth of the endometrium is no longer supported, and it disintegrates, sloughing off during menstruation. o Implantation occurs: The implanted embryo secretes human chorionic gonadotropin (hCG) to sustain the corpus luteum. The corpus luteum continues to produce estrogen and progesterone, maintaining the endometrium. (Pregnancy tests check for the presence of hCG in the urine). Menopause is the cessation of menstruation. This usually occurs in women between the ages of 45 and 50. Some women may reach menopause before the age of 45 and some after the age of 50. In common use, menopause generally means cessation of regular menstruation. Ovulation may occur sporadically or may cease abruptly. Periods may end suddenly, may become scanty or irregular, or may be intermittently heavy before ceasing altogether. Markedly diminished ovarian activity, that is, significantly decreased estrogen production and cessation of ovulation, causes menopause.

PATHOPHYSIOLOGY (NARRATIVE FORM)

Cancer of the cervix typically originates from a dysplastic or premalignant lesion previously present at the active squamous columnar junction. The transformation from mild dysplastic to invasive carcinoma generally occurs slowly within several years, although the rate of this process varies widely. Carcinoma in situ is particularly known to precede invasive cervical cancer in most cases. In different reported series of patients with untreated carcinoma in situ who were followed up for many years, invasive carcinoma developed in about 30% of patients at 10 years and in about 80% of patients at 30 years. However, the carcinoma-in-situ lesion may regress after the initial diagnosis; such an occurrence was reported in 17 (25%) of 67 patients who were followed up for at least 3 years. Progression to invasive carcinoma becomes established and is considered irreversible once the malignant process extends through the basement membrane and invasion of the cervical stroma occurs. Multiple local growth patterns of invasive cervical cancer have been described, with combination growth patterns being common. The patterns include the following: exophytic, nodular, infiltrative, and ulcerative. The exophytic variety is the most common growth pattern. It usually arises from the exocervix and is often polypoid or papillary in form. Exophytic cervical cancer may result in a large, friable, bulky mass that involves only the superficial aspect of the cervix and has the tendency for excessive bleeding. The nodular variety typically arises in the endocervix and grows through the cervical stroma into confluent, firm masses that cause the cervix and isthmus to expand. Large, nodulartype tumors that circumferentially involve the endocervical region and large, exophytic-type tumors that originate from the endocervix and extend into the endocervical canal result in what has been referred to as a barrel-shaped cervix. The infiltrative growth pattern leads to a stone-hard cervix that may be predicated to have minimal visible ulcerations or an exophytic mass. Infiltrative exocervical lesions tend to invade the vaginal fornices and the upper part of the vagina. On the other hand, infiltrative endocervical lesions tend to extend into the corpus and the lateral parametrium.

PATHOPHYSIOLOGY (SCHEMATIC DIAGRAM)

PREDISPOSING FACTORS Age (48 years old) Sex (exclusively for female) Heredity (history of cervical CA) PRECIPITATING FACTORS Sexual partner who had multiple sexual partner (HPV exposure) Low economic status Diet and lifestyle Multiple Pregnancies (7 and above delivered) Somatic Mutation in DNA or Gene Altered genetic structure and autoimmune response Activated oncogene or deactivate cell tumor suppressor gene

Malignant transformation of lymphoid stem cells Formation of clones or uncontrolled proliferation lymphocytes Cervix cells dysplasia after lymphoblastic cell event

Acquisition of invasive characteristics

Tumor cells engulf lymphocytes Altered production of normal cells

Through sexual intercourse: HPV penetrates squamous columnar epithelial cervix cells Virus transcripts stroma Activation of oncogenic cell growth factor Host cells put up tissue barrier Tumor cells attach in the cervix cells Treatment: ampicillin Spread and invades distant tissues (vagina)

Hematology Lab Result: Increased WBC 11.2

Hematology Lab Result: Decreased RBC 2.43 10^12/L

S/Sx: Infection Fatigue Pallor Increased RR: 25cpm

Autoimmune inhibition progression (malignant)

Asymptomatic tumor growth Cervical Cancer Stage III Affection of the surrounding tissues of the cervix along the vagina Diagnostic Test: Cervical Biopsy

Necrosis and infection of the tumor

Gain access to pelvic lymph nodes Fundus

Treatment: tranexamic acid

S/Sx: Vaginal Bleeding Dark and Foul Odor

Increased tumor growth Hypermetabolic activity

Irritation of nerve endings

S/Sx: Excruciating pain in back and legs

Hematology Lab Result: Decreased HGB 2.78 10^12/L

Weight loss: 45 40 kl. of the pt. weight.

Pressure on the surrounding tissue

Treatment: analgesic

PROGNOSIS

With Medical Management: Hysterectomy Chemotherapy Radiation Therapy

Without Medical Management: Tumor Metastsis may occur

Good Prognosis

Poor Prognosis

IVF Replacement Follow prescribed medication by the physician

Multi-organ failure or complication and Sepsis

Possible for recovery

Coma

35 40% Rate of Survival; about 5 yrs. in Cervical CA Stage III

Death

LEGENDS:

RISK FACTORS

PATHOLOGY

MANAGEMENT/DIAGNOSTIC TEST

MANIFESTATIONS

LABORATORY TEST/RESULT

DRUG STUDY # 1

Generic name: Tranexamic Acid Brand name: Hemostan Classification: Anti-fibrinolytic, antihemorrhagic Prescribed & Recommended Dosage, frequency, & Route of Administration: 500 mg slow IVTT q8 Mechanism of Action: A synthetic derivative of the amino acid lysine. It exerts its antifibrinolytic effect through the reversible blockade of lysine-binding sites on plasminogen molecules. Anti-fibrinolytic drug inhibits endometrial plasminogen activator and thus prevents fibrinolysis and the breakdown of blood clots. The plasminogen-plasmin enzyme system is known to cause coagulation defects through lytic activity on fibrinogen, fibrin and other clotting factors. By inhibiting the action of plasmin (finronolysin) the anti-fibrinolytic agents reduce excessive breakdown of fibrin and effect physiological hemostasis. Indication: It is used for the prompt and effective control of hemorrhage in various surgical and clinical areas: Treating heavy menstrual bleeding Hemorrhage Contraindications: Allergic reaction to the drug or hypersensitivity Presence of blood clots (e.g., in the leg, lung, eye, brain), have a history of blood clots, or are at risk for blood clots Adverse Reactions: Nausea and vomiting Anorexia Headache may appear Impaired renal insufficiency Nursing Implications: Unusual change in bleeding pattern should be immediately reported to the physician. For women who are taking Tranexamic acid to control heavy bleeding, the medication should only be taken during the menstrual period. The medication can be taken with or without meals. Swallow Tranexamic Acid whole with plenty of liquids. Do not break, crush, or chew before swallowing. If you miss a dose of Tranexamic Acid, take it when you remember, then take your next dose at least 6 hours later. Do not take 2 doses at once. Inform the client that he/she should inform the physician immediately if the following severe side effects occur.

DRUG STUDY # 2

Generic name: Ampicillin Brand name: Apo-Ampi Prescribed & Recommended Dosage, frequency, & Route of Administration: q6 ANST (-) (after negative skin testing) Mechanism of Action: Inhibit cell-wall synthesis during bacterial multiplication. Indication: GU infection or UTIs Contraindication: Contraindicated in patient hypersensitive to drug or other penicillin Use cautiously in patient with other drug allergies (especially to cephalosporin) because of possible cross-sensitivity, and in those with monocleosis because of high risk of maculopapular rash. Adverse Reactions: CNS: seizure, lethargy, hallucinations, anxiety, confusion, agitation, depression, dizziness, fatigue. CV: vein irritation, thrombophlebitis. GU: interstitial, nephristis, nephrophaty, vaginitis. Hematologic: leukopinia, thrombocytopenia, thrombocytopenic pupura, anemia, Mg IVTT

eosinophilia, haemolytic anemia, agranulocytosis. Skin: pain at injection site. Other: hypersensitive reaction, over growth of nonsusceptable organism.

Nursing Implications: Do not use this medication if you are allergic to ampicillin or to any other penicillin antibiotic. Inject this medication for the full prescribed length of time. Take vital signs.

DRUG STUDY # 3

Generic name: Multivitamin w/ iron Brand name: Fero-folic 500 Classification: Vitamins & Minerals Dosage: 1 tab OD Mechanism of Action: Enhance immune function to increase resistance and maintain optimum health. Indications: helps ensure optimum energy and increases body resistance against infections and stress conditions. Contraindications: Allergies to medicine, foods, or other substances. Side Effects: Rash, itching, tightness in the chest, and swelling in mouth and lips. Adverse Reactions: Severe allergy reactions and DOB Nursing Implications: Assess if the patient is taking any prescription or herbal preparation because it may interact with multivitamin Assess patient if he/she has allergy of food, or any substances. Educate the patient that multivitamin may counteract with other medicine intake. Instruct the patient to check with health care provider before they start, stop, or change the medicine. If stomach upset occurs, take with food to reduce stomach irritation. Inform the patient/SO not to take the medicine twice a day.

NURSING CARE PLAN # 1

ASSESSMENT Subjective Cue: Sakit ang akong pus-on, as verbalized by the patient. Pain scale 8/10. Objective Cues: Guarding/protecting the affected site Facial grimace noted Restlessness noted Diaphoretic noted V/S noted Temp.: 36.3 C; HR: 80 bpm; RR: 25 cpm; BP: 100/70 mmHg NURSING DIAGNOSIS: Chronic pain related to pressure in the left inguinal region secondary to cervical cancer PLANNING: Within 35 mins. of giving appropriate nursing interventions, patient will be able to verbalize reduction of pain from 8/10 to 0/10. INTERVENTIONS: Independent 1. Provided cutaneous stimulation; e.g., heat/cold, massage. 2. Provided non-pharmacologic comfort measures and diversional activities. 3. Evaluate pain relief/ control at regular intervals. Adjust medication regimen as necessary. 4. Assessed for referred pain as appropriate. 5. 6. 7.

Rationale May decrease inflammation, muscle spasms, reducing associated pain. Promotes relaxation and helps refocus attention. Goal is maximum pain control with minimum interference with ADLs.

1.

To help determine the possibility of underlying condition. Noted and investigated changes from previous To rule out worsening of underlying condition or reports. development of complications. Provided comfort measures and quiet To promote non-pharmacological pain environment. management. Instructed and encouraged used of relaxation To destruct attention and reduce tension. technique such as focus breathing. Dependent A wide range of analgesics and associated agents Administered analgesic as indicated by the may be employed around the clock to manage the physician. pain.

EVALUATION: After 35 mins. of giving appropriate nursing interventions, goal partially met. Patient verbalized reduction of pain from 8/10 to 5/10.

NURSING CARE PLAN # 2

ASSESSMENT Subjective Cue: Dili ok ang ako gibati karon, as verbalized by the patient. Objective Cues: Weakness noted Restlessness noted Capillary Refill Test: < 3 seconds V/S noted Temp.: 36.3 C; HR: 80 bpm; RR: 25 cpm; BP: 100/70 mmHg NURSING DIAGNOSIS: Ineffective tissue perfusion related to interruption of blood flow as manifested by left inguinal region chronic tenderness PLANNING: Within 3 days of giving appropriate nursing interventions, patient will be able to verbalize from being not feeling to good condition. INTERVENTIONS: Independent 1. Established rapport. 2. Monitored and recorded V/S. 3. 4. 5.

6. 7. 1.

Rationale To gain trust and cooperation. To establish baseline data. To determine fluid volume for oxygen Monitored and recorded intake and output. transportation and circulation. Advised the patient to have quiet Quiet environment conducive to rest alleviates atmosphere/environment. stress. Compared skin temperature and color with other limb when assessing extremity Helps differentiate type of underlying problem. circulation. Measured capillary refill test. To determine adequacy of systemic circulation. Loss of sensation, numbness or any changes that Assessed motor and sensory function. can indicate limb ischemia. Dependent Administered IVF (D5LR) as prescribed by Replacement of blood losses maintains circulating the physician. volume and tissue perfusion.

EVALUATION: After 3 days of giving appropriate nursing interventions, goal partially met. Patient verbalized that she is in a bit of good condition.

NURSING CARE PLAN # 3

ASSESSMENT Subjective Cue: Kaluja na jud sa ako lawas kay sige pa gihapon nagdugo, as verbalized by the patient. Objective Cues: Weight loss from 45 to 40 kl. Pallor noted Feeling of dizziness noted Irritability noted Dry skin mucus membrane noted Hematology: HGB (low) 2.78 10^12/L; HCT (low) 18.3%; RBC 2.43 10^12/L V/S noted Temp.: 36.3 C; HR: 80 bpm; RR: 25 cpm; BP: 100/70 mmHg NURSING DIAGNOSIS: Fluid volume deficient related to cervical bleeding PLANNING: Within 3 days of giving appropriate nursing interventions, patient will be able to maintain fluid volume at a functional level as evidenced by moist mucus membrane. INTERVENTIONS: Independent 1. Established rapport to the patient. 2. Assessed V/S. 3. 4. 5.

6. 1.

Rationale To gain trust and cooperation. To obtain baseline data. It flushes kidneys/bladder of bacteria and debris Encouraged fluid intake to 3000 ml a day, but may result in water intoxication/fluid overload unless contraindicated. if not monitored closely. Recommended restriction of caffeine. To reduce effects of dieresis. Evaluated CFAC (Color, Frequency, Amount, Usually indicates arterial bleeding that required and Consistency) of urine, e.g. bright red with aggressive therapy. red clots. Regulated IVF level (D5LR) accurately. Necessary for fluid volume replacement. Dependent Infused PRBC with IVF as ordered by the Useful in evaluating blood losses/ replacement physician. needs.

EVALUATION: After 3 days of giving appropriate nursing interventions, goal partially met. Patient was able to slightly maintained fluid volume balance.

NURSING CARE PLAN # 4

ASSESSMENT Subjective Cue: Murag naimpeksyon na ang ako gibati nga sakit, as verbalized by the patient. Objective Cues: Weakness noted Restlessness noted Pallor noted Hematology: HGB (low) 2.78 10^12/L; HCT (low) 18.3%; WBC (high) 11.2 V/S noted Temp.: 36.3 C; HR: 80 bpm; RR: 25 cpm; BP: 100/70 mmHg NURSING DIAGNOSIS: Actual infection related to cervical tissue destruction and immunosuppression secondary to Stage III Cervical CA PLANNING: Within 3 days of giving appropriate nursing interventions, patient will be able to verbalize the understanding of her factors to infection. INTERVENTIONS: Independent Established rapport. Monitored and recorded V/S. Instructed patient to have a proper perineal care. Instructed patient to have a daily mouth care. Maintained adequate hydration. Dependent Administered ampicillin (Apo-Ampi, IVTT Q6 ANST) as prescribed by the physician.

1. 2. 3. 4. 5. 1.

Rationale To gain trust and cooperation. To establish baseline data. To prevent spreading of infection. To prevent descending microbial invasion. To prevent bladder distention and urinary stasis. To prevent or lessen infection.

EVALUATION: After 3 days of giving appropriate nursing interventions, goal partially met. Patient verbalized that she is in a bit of good condition.

NURSING CARE PLAN # 5

ASSESSMENT Subjective Cue: Kausa ra ako makalibang sa usa ka semana kay dili man gud ko mag sigeg lihok diri sa hospital, as verbalized by the patient. Objective Cues: Distended abdomen noted Flatus Abdominal dullness upon percussion 6 bowel sounds per min. upon auscultation Limited physical activity noted NURSING DIAGNOSIS: Constipation related to insufficient physical activity PLANNING: Within 6 hrs. of giving appropriate nursing interventions, patient will be able to defecate. INTERVENTIONS: Independent Rationale 1. Established rapport to the patient. To gain trust and cooperation. 2. Assessed V/S. To obtain baseline data. 3. Noted energy and activity levels and exercise Sedentary lifestyle may affect elimination pattern. patterns. Individuals may fail to allow time for good bowel 4. Identified areas of stress. habits and/or suffer GI effects from stress. 5. Palpated abdomen. For presence of distention or masses. Provides a baseline comparison, and promotes 6. Noted CFAC recognition of changes. 7. Noted bowel sounds. For reflecting bowel activity. 8. Instructed and encouraged patient an To improve consistency of stool and facilitate appropriate balance diet (more on fiber and passage through colon. bulk). 9. Provided adequate fluid intake. To promote passage of soft stool. 10. Encouraged activity and exercise within limits To stimulate contraction of the intestines. of individual ability. EVALUATION: After 6 hrs. of giving appropriate nursing interventions, goal met. Patient was able to defecate.

NURSING CARE PLAN # 6

ASSESSMENT Subjective Cue: Usahay di ako katuyog tag tuyo ka adlaw, as verbalized by the patient. Objective Cues: Restlessness noted Presence of eye bags noted Lack of energy noted Frequent yawning noted NURSING DIAGNOSIS: Sleep pattern disturbance related to interruptions on V/S monitoring, and her condition PLANNING: Within 2 days of giving appropriate nursing interventions, patient will be able to report good sleep pattern in absence of disturbance. INTERVENTIONS: Independent 1. Established rapport to the patient. 2. Assessed V/S. 3. 4. 5. 6. 7.

Rationale To gain trust and cooperation. To obtain baseline data. Sleep problems can arise from internal and Identified presence of related sleep external factors, and may require assessment over disturbance factors. time to differentiate specific cause. Recommended restriction of caffeine. To prevent from being always awake. Assessed patients usual sleep pattern. To ascertain intensity and duration of problems. Individual may have faulty beliefs or attitudes Determined patients sleep expectations. about sleep or unrealistic expectations. Provided quiet environment. To enhance relaxation.

EVALUATION: After 2 days of giving appropriate nursing interventions, goal met. Patient was able to sleep within 4-5 hrs. in absence of disturbance.

NURSING CARE PLAN # 7

ASSESSMENT Subjective Cue: Dali ra ako kapuyon, as verbalized by the patient. Objective Cues: Weakness noted Discomfort noted Tiredness facial expression noted Hematology: HGB (low) 2.78 10^12/L V/S noted Temp.: 36.3 C; HR: 80 bpm; RR: 25 cpm; BP: 100/70 mmHg NURSING DIAGNOSIS: Activity intolerance related to body weakness PLANNING: Within 2 days of giving appropriate nursing interventions, patient will be able to report activity tolerance and will participate willingly in necessary or desired activities. INTERVENTIONS: Independent Established rapport to the patient. Assessed V/S. Provided health teaching to the patient regarding the organization and time management technique to prevent while on activity. Provided enough air from the electric fan or the window. Assisted patient with activity. Promoted comfort measures on the activity.

1. 2. 3.

Rationale To gain trust and cooperation. To obtain baseline data. To provide adequate knowledge on the patient. To enhance patients ability to participate in activity. To prevent over exertion. To protect patient from injury.

4. 5. 6.

EVALUATION: After 2 days of giving appropriate nursing interventions, goal met. Patient was able to report activity tolerance and was able to participate willingly in necessary or desired activities.

NURSING CARE PLAN # 8

ASSESSMENT Subjective Cue: Di ko kayo makalihok karon kay dali ra ako kapuyon bisag maglakaw ra ko, as verbalized by the patient. Objective Cues: Patient is always lying Easy fatigability noted With limited movement noted Weakness noted Hematology: HGB (low) 2.78 10^12/L V/S noted Temp.: 36.3 C; HR: 80 bpm; RR: 25 cpm; BP: 100/70 mmHg NURSING DIAGNOSIS: Fatigue related to decreased hemoglobin and diminished oxygencarrying capacity of the blood PLANNING: Within 2 days of giving appropriate nursing interventions, patient will be able to show signs of improved tolerance in doing physical activity without experiencing fatigue. INTERVENTIONS: Independent Rationale 1. Established rapport to the patient. To gain trust and cooperation. 2. Assessed V/S. To obtain baseline data. 3. Assessed patients ability to perform normal Influences choice of interventions or need task or activities. assistance. To enhance rest to lower bodies oxygen 4. Provided quiet and relaxed environment. requirements, and reduces strain on the heart and lungs. 5. Assisted patient to establish a balance between To reduce fatigue. activity and rest. 6. Assisted patient in self care needs and with To protect the patient from injury. ambulation as needed. EVALUATION: After 2 days of giving appropriate nursing interventions, goal met. Patient was able to show signs of improved tolerance in doing physical activity without experiencing fatigue.

NURSING CARE PLAN # 9

ASSESSMENT Subjective Cue: Di na ako makighilawas sa akong bana kay tungod sa akong sakit, as verbalized by the patient. Objective Cues: No objective cues applied here NURSING DIAGNOSIS: Ineffective sexuality pattern related to decreased libido and altered sexual function PLANNING: Within 1 hour of giving appropriate nursing interventions, patient will be able to verbalize knowledge and understand sexual limitations. INTERVENTIONS: Independent Established rapport to the patient. Provided ways to obtain privacy. Provided non-threatening atmosphere and encourage patient to ask questions about personal sexuality. Allowed patient to express feelings openly in non-judgmental atmosphere. Obtained sexual history.

1. 2. 3.

Rationale To gain trust and cooperation. This demonstrates respect to the patient. This encourages patient to ask specifically related to current issues. Enhances communication. To maximize communication. Helps patient to focus on specific issues, clarifies misconceptions, and build trust. Sexual concerns are often disguised as humor or other remarks. questions

4. 5.

6. Provided answers to specific questions. 7. Be alert on the comments of the patient.

EVALUATION: After 1 hour of giving appropriate nursing interventions, goal met. Patient was able to acknowledge and understand sexual limitations.

NURSING CARE PLAN # 10

ASSESSMENT Subjective Cue: Ngano ako paman ang nagkasakit ng ing ani?, as verbalized by the patient. Objective Cues: Always wandering on herself noted Asking several questions noted Feeling of crying noted Feeling of hopelessness noted Showing slight anger noted NURSING DIAGNOSIS: Anticipatory grieving related to loss of significant on processes of body (cervix area) PLANNING: Within 6 hrs. of giving appropriate nursing interventions, patient will be able to identify and express feelings freely and effectively. INTERVENTIONS: Independent 1. Established rapport to the patient. 2. 3. 4. 5. 6. 7. 8.

Rationale To gain trust and cooperation. Grief can provoke a wide range of intense and Determined circumstances of current situation. often conflicting feelings. Evaluated patients perception of anticipated To promote thorough communication. situation. Indicators of severity of feelings of a patient Identified problems with sexual, and desire. experienced. Provided open environment and trusting Promotes a free discussion of feelings and relationship. concerns. Be honest when answering questions, Enhances sense of trust and nursing-client providing information. relationship. Reviewed past life experiences and previous May be useful with current situation and problem loss, noting strengths and successes. solving existing needs. Expression of feelings can facilitate the grieving Given information that feelings are okay and process, but destructive behavior can be are to be expressed appropriately. damaging.

EVALUATION: After 6 hrs. of giving appropriate nursing interventions, goal met. Patient was able to identify and express feelings freely and effectively.

NURSING CARE PLAN # 11

ASSESSMENT Subjective Cue: Basin mao na ni ang akong ikamatay na sakit, as verbalized by the patient. Objective Cues: Restlessness noted Pallor noted Worrying about the disease noted V/S noted Temp.: 36.3 C; HR: 80 bpm; RR: 25 cpm; BP: 100/70 mmHg NURSING DIAGNOSIS: Fear related to potential stressful situation of the condition PLANNING: Within 6 hrs. of giving appropriate nursing interventions, patient will be able to perceive available support system (family support) to assist in coping up from fear. INTERVENTIONS: Independent Established rapport to the patient. Assessed V/S. Presented information at patients level of understanding or acceptance. Conveyed acceptance of the patients perception of fear. Used calm and reassuring approach.

1. 2. 3. 4. 5.

Rationale To gain trust and cooperation. To obtain baseline data. To reduce patients doubt cooperation.

and

enhance

To encourage open communication. To promote smooth communication. To allow time for expression of feelings, provide emotional outlet, and promote feeling of acceptance.

6. Spent time with patient in each shift.

7. Oriented family to patients specific needs, allowing family members to participate in This helps them provide effective support. giving care. 8. Arranged for family member to stay with the To help patient cope up from fears. patient. 9. Used relaxation technique to reduce attention To relax patients mind from fear. of fear. EVALUATION: After 6 hrs. of giving appropriate nursing interventions, goal met. Patient was able to perceive available support system (family support) to cope up form fear.

NURSING CARE PLAN # 12

ASSESSMENT Subjective Cue: Wala ako kabalo kung ngano nakuha man nako ni nga sakit, as verbalized by the patient. Objective Cues: Frequent asking of questions NURSING DIAGNOSIS: Knowledge deficient related to perception limitation of the disease information PLANNING: Within 50 mins. of giving appropriate nursing interventions, patient will be able to demonstrate motivation to learn as measured by verbalization desired. INTERVENTIONS: Independent 1. Established rapport to the patient. 2.

3.

4.

5. 6.

Rationale To gain trust and cooperation. Learning best occurs when learners are motivated Assessed patients ability and readiness to and when instruction is tailored to the patients learn. cognitive ability. Providing interventions that incorporate personal Assessed personal context and meaning of perspectives and meaning of illness results in illness including perceived changes in improved symptoms management and patients lifestyle, and financial concerns. satisfaction. Provided information to support self-efficacy, self regulation and self-management by Educational programs based on empowerment focusing on problem solving and decision have demonstrated effectiveness. making. Tailored the delivery of instruction to the Patients with lower literacy benefit from wellpatients cognitive level. tailored materials. Serves as an assessment of the effectiveness of Evaluated learning outcomes using client care and allows opportunity for adjustments to the verbalization. plan of care.

EVALUATION: After 50 mins. of giving appropriate nursing interventions, goal met. Patient was able to express desire to learn and identified baseline knowledge.

NURSING CARE PLAN # 13

ASSESSMENT Subjective Cue: Tungod sa akong sakit, basin waya na mutagad sa ako maski usa, as verbalized by the patient. Objective Cues: Sadness face noted Sought to be alone noted Slightly poor eye contact noted NURSING DIAGNOSIS: Social Isolation related to fear of rejection of friends and other relatives PLANNING: Within 4 hrs. of giving appropriate nursing interventions, patient will be able to verbalize willingness to be involved with others. INTERVENTIONS: Independent 1. 2.

3.

4. 5.

6.

Rationale This may mean just sitting in silence for a while. Spent time with patient. Your presence may help improve patient's perception of self as a worthwhile person. Developed a therapeutic nursing-client Shows unconditional positive regard. Your relationship through frequent, brief contacts presence, acceptance, and conveyance of positive and an accepting attitude. regard enhance the client's feelings of self-worth. After patient felt comfortable in a one-to-one May need to attend with patient the first few times relationship, have a thorough support from to offer support. patients family. Verbally acknowledged patient's absence from Knowledge that patients absence was noticed any activity. may reinforce the client's feelings of self-worth. Taught assertiveness techniques. Interactions Knowledge of the use of assertive techniques with others may be discouraged by patient's could improve client's relationships with others. use of passive or aggressive behaviors. Provided direct feedback about patient's interactions with others. Do these in a nonHaving practiced these skills in role-play judgmental manner. Help patient learn how to facilitates their use in real situations. respond more appropriately in interactions with others.

EVALUATION: After 4 hrs. of giving appropriate nursing interventions, goal met. Patient was able to verbalize willingness to be involved with others.

NURSING CARE PLAN # 14

ASSESSMENT Subjective Cue: Maglisod ako pagdawat sa akong kaugalingon nga sakit, as verbalized by the patient. Objective Cues: Restlessness noted Irritability noted Inability to cope up problem noted NURSING DIAGNOSIS: Ineffective individual coping related to situational crisis as evidenced by inability to cope a valid consideration of the disease PLANNING: Within 4 hrs. of giving appropriate nursing interventions, patient will be able to verbalize awareness of coping abilities regarding on her own condition. INTERVENTIONS: Independent Established rapport. Assessed s/sx of ineffective individual coping. Determined of previous methods of dealing with life problems. Called patient by name. Ascertained how patient prefers to be addressed. Explained disease process, procedures, and events in a concise manner. Provided quiet environment. Given updated or additional information needed about events, cause, and potential course of illness as soon as possible.

1. 2. 3. 4. 5. 6. 7.

Rationale To gain trust and cooperation. Validates patients perceptions carefully. To identify successful techniques that can be used in current situation. Using patients name enhances sense of self and promotes individuality and self-esteem. May help patient to express emotions, grasp situation, and feel more in control. To provide relaxation. Knowledge helps reduce fear, allows patient to deal with reality.

EVALUATION: After 4 hrs. of giving appropriate nursing interventions, goal met. Patient was able to verbalize awareness of coping abilities regarding on her own condition.

DISCHARGE PLAN Upon discharge from Caraga Regional Hospital OB-Gyne Ward, the patient, as well as the SO will be given a home care instruction which contains the following:

MEDICATION Take home medicine Multivitamin with Iron 1 tab OD NSAID drug: Metoclopramide as needed (when in pain)

ENVIRONMENTAL CONCERNS Instructed patient to provide a peaceful relaxing, comfortable and well ventilated room. Instructed patient to provide a stress free environment. Instructed patient to follow the prescribed meal plan. Instructed to provide clean environment to prevent lodging of infectious microorganisms.

TREATMENTS Discussed on the importance of strict adherence to medication regimen to ensure complete healing. Instructed patient to understand and follow discharge instruction religiously and accurately. Instructed patient to follow proper instruction on medication prescribed by the physician.

HEALTH TEACHINGS Review information about medications to be taken at home, including name, dosage, frequency and possible side effects, discussed the importance of continuing to take. Patient is counseled regarding importance of eating meals on time and in a relaxed setting. Instructed patient to avoid any strenuous or heavy activities. Notify MD if s/sx noted (ex: fever, chills, redness around the incision, and any discharges).

OUT PATIENT (FOLLOW UP CHECK-UP) Patient is advised for follow up check-up to her physician one (1) week after discharge. Instructed patient to notify physician of there is any undesired feeling about the disease.

DIET Advised patient to avoid raw foods. Encouraged the patient to eat green leafy vegetables.

SPIRITUAL Patient must go to church and pray regularly together with her family. Never forget to thank god for all the blessings she and her family has been receiving. Patient must find time with his family members and friends and share the good news written in the bible. SO must pray for the health of the patient.

1. Benign not recurrent or progressive cancerous growth. 2. Biopsy a tissue sample removed from the body for microscopic examination, usually to establish a diagnosis. 3. Cancer malignant neoplasia marked by the uncontrolled growth of cells, often with invasion of healthy tissues locally or throughout the body. 4. Carcinoma cancers that arise from epithelial tissues. 5. Cervarix an HPV vaccination type, which only provides protection against cervical cancer. 6. Cervical Cancer is the term for malignant neoplasm arising from cells originating in the cervix uteri. 7. Colposcopy combines a bright light with a magnifying lens to make tissue easier to see at the cervix. 8. Dysplasia abnormal development of tissue. 9. Gardasil an HPV vaccination type, which provides against cervical cancer and genital warts. 10. Human Papillomavirus (HPV) Vaccination for the prevention of infection and related disease is being considered as an additional cervical cancer control strategy. 11. Malignant the cancerous growth that is worse. 12. Neoplasm a new and abnormal formation of tissue, as a tumor or growth. 13. Pap Smear is a simple test used to look at cervical cells. 14. Promiscuity having multiple sex partners or having a partner, who is promiscuous, increases the chances of developing cervical cancer.

DOCTOR(S) ORDER

Please conduct to CVR 01-16-12 7:10 pm Admit to Gyne TPR q 4 DAT CBC, BT, U/A Start IVF with D5LR 1L+Amino acid 2 amp to flow @ 20gtts Tranexamic acid 500mg 1L Amp IVTT q8 Multi vit. with Iron 1 cap BID Refer for profuse vaginal bleeding Refer to PIC

01-17-12 12:00nn CBC now Ampicilin 1g IVTT q6 hours (ANST) IVF to follow D5 LR 1L + amino acid 2amps @ 20 gtts Continue meds

01-18-12 12:15 pm Secure 1 unit of pack RBC (PRBC) of patient blood type order to transfusion of the cross matching and screening IVF for follow up D5LR 1L and 2 amp of amino acid @ 20 gtts/min Continue meds proper

01-19-12 12:00nn Volume of 1 unit of blood Repeat HCT 6 hours post blood transfusion Continue meds IVF follow up D5LR 1L + 2 cegalle of amino acids @ 20 gtts/min To continue Ampicillin 1 OD to cefalexine 500mg 1amp TID

01-20-12 12:50pm Repeat hematocrit now. BP 110/70 please refer result To consume Tranexamic acid 500mg 1amp IVTT Tranexamic acid 500mg /cap TID Combine after p.o meds IVF to follow with D5LR @ 20 gtts/min V/S every 6 hours

5:20pm Secure additional 2 units PRBC of patient blood type and transfusion after proper crossmatching and screening

INTRAVENOUS FLUID SHEET

Jan. 16, 2012 Jan. 17, 2012 Jan. 18, 2012 Jan. 19, 2012

1L D5LR 1L D5LR 1L D5LR 1L D5LR

20 gtts/min. 20 gtts/min. 20 gtts/min. 20 gtts/min.

7:40 PM 8:40 PM 9:40 PM 10:40 PM

FAMILY GENOGRAM PATERNAL SIDE MATERNAL SIDE

Grandfather (Patient forgot the cause of death)

Grandmother (Patient forgot the cause of death)

Grandfather (Patient forgot the cause of death)

Grandmother (Patient forgot the cause of death)

1 Sibling 79

st

2 Sibling 77

nd

Father, 69 Suicide Alcoholism

4 Sibling 75

th

5th Sibling 74

6th Sibling 71

Mother, 62 Aneurysm

1st Sibling 55

2nd Sibling 53

3rd Sibling 50

Patient 48

5th Sibling 45

6th Sibling 44

LEGENDS:
Male

Female

Male Deceased

Female Deceased

Patient

MORTALITY RATE OF CERVICAL CANCER IN SURIGAO CITY

Summary of Mortality Rate of Cervical CA in Surigao City (Year 2011-January 2012)

In Surigao City, (Brgy. Sitio, Brgy. Talisay, Brgy. Togbongon, Brgy. San Juan, Brgy. Canlanipa, Brgy. Ipil, Borromeo St., and Espina St.), 11 women died of Cervical Cancer as of year 2011 to January 2012.

2011 January March June August September October 3 patients 1 patient 2 patients 1 patient 2 patients 1 patient

2012 January 1 patient

Source: City Health Office (Surigao City)

BIBLIOGRAPHY/REFERENCES

A. Textbook References/Primary References: Assessment: Lippincott; 2007 Edition. Tabers Cyclopedic Medical Dictionary: 18th edition Fundamentals of Nursing: Kozier and Erb; 8th Edition. Medical-Surgical of Nursing: Bunner and Suddarth; 12th Edition. NANDA: Doenges, Moorhouse and Murr; 12th Edition. Nursing Care Plans: Doenges, Moorhouse and Murr; 8th Edition. Nursing Drug Guide: Lippincott; 2010 Edition. PDQ for RN:Mosby; 2nd Edition. PPD for Registered Nurses: Mosby; 2nd Edition. Principles of Internal Medicine: Harrison and Braunswald; 11th Edition. Public Health Nursing: Nurses Contributors; 2007 Edition.

B. Electronic Research/Secondary References: World Health Report 2004. Geneva, World Health Organization; 2004. Laudico AV, Esteban DB, Reyes L. Philippine cancer facts and estimates. Manila. Philippine Cancer Society; 1998. Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; & Mitchell, Richard N. (2007). Robbins Basic Pathology (8th Ed.) Ed.). Saunders Elsevier. pp. 718721. ISBN 978-1-4160-2973-1. Walboomers JM, Jacobs MV, Manos MM, et al (1999). "Human papillomavirus is a necessary cause of invasive cervical cancer worldwide". J. Pathol. 189 (1): 129. Doi: 10.1002/ (SICI) 1096-9896(199909)189:1<12: AID-

PATH431>3.0.CO; 2-F. PMID 10451482. "FDA Licenses New Vaccine for Prevention of Cervical Cancer". U.S. Food and Drug Administration.2006-06-08.

http://www.fda.gov/bbs/topics/NEWS/2006/NEW01385.html.Retrieved 2007-1202.

 "Prophylactic human papillomavirus vaccines". J. Clin. Invest. 116 (5): http://www.jci.org/articles/view/JCI28607. Retrieved 2007-12-01. National Cancer Institute".

http://www.cancer.gov/cancertopics/factsheet/risk/HPV-vaccine. Retrieved 200807-18. http://www.naturalnews.com/034841_Gardasil_HPV_vaccines_Canada.html#ixzz 1ogkts4pr http://www.naturalnews.com/034841_Gardasil_HPV_vaccines_Canada.html#ixzz 1ogk2QTFY Cervical Cancer Causes/Risk Factor | Medindia

http://www.medindia.net/patients/patientinfo/cervicalcancercauses.htm#ixzz1ofyRJO9z Cervical Cancer - Introduction, Etiology and Pathology, Symptoms, Signs, Diagnosis and treatment http://www.health.am/cr/cervical-

cancer/#ixzz1o6JXRLQz