Republic of the Philippines

Cebu Normal University

College of Nursing
S.Y. 2016-2017

A CASE OF M.E.

Submitted by:
Alinsug, Dan Kyle
Bangquiao, Honey Sheen
Bano, Maureen Kate
Bargamento, Princess Aliza
Carilo, Fritz Gabriel
Compuesto, Kryztal Joyce
Handayan, Cheryl
Lasaca, Kristel Jane
Menor, Jessa Marie
Mula, Trystan Francis
Phua, Shawntel Tracy Hayes

Clinical Instructors:

Ma’am Ma. Mayla Imelda Lapa

Ma’am April Kyle Inabangan
Sir Francis Archangel Milloren

GROUP ONE BATCH 2018

NOVEMBER 2016
INTRODUCTION
Cervical cancer is the second leading cause of cancer cases and deaths among Filipino
women because of inadequate access to screening and treatment services. It occurs when
abnormal cells on the cervix grow out of control. Cervical cancer is caused by a virus called
Human Papilloma Virus (HPV). The virus spreads through sexual contact. Most women's bodies
are able to fight HPV infection. But sometimes, the virus leads to cancer due to other
environmental factors. Some factors that place any woman at high risk are if that woman
smokes, have had many children, used birth control pills for a long time, have HIV infection, or
multiple sex partners.

According to annual statistical report, as of 2015, the cervical cancer is deemed as the
second leading cancer cases and deaths among Filipino women. Despite the establishment of
Millennium development goals, which includes aiming to improve maternal health, there is still
considerably a high number of women experiencing gynecologic diseases. This can be
attributed to a lot of factors including lack of access to screening and treatment services,
awareness. Even attitude plays a role. Filipinos are stubborn: shrugging off subtle signs and
symptoms and refusing to go to the hospital until they experience severe signs and symptoms.

Cervical cancer is an abnormal and out of control growth of cells in the cervix. This is
cause by a virus called Human Papilloma Virus, which is transmitted through sexual contact.
Most women are actually able to fight HPV infection; but some factors caused by lifestyle of
environment aggravate the existing infection, which leads to cervical cancer. Some of these
factors are smoking, long-term use of pills, grandmultiparity, HIV infection and multiple sex
partners. Genetic predisposition has also shown to be a contributor but the recent cases
revealed that most of cervical cancer cases now are caused by lifestyle.

From the World Cancer Research Fund International, as of 2015, out of all the cancer
cases worldwide, 4% are diagnosed with cervical cancer, which is approximately 528,000
people. The American Cancer Society has released an estimated statistics for cervical cancer: 1)
about 12,990 new cases of invasive cervical cancer will be diagnosed. 2) About 4,120 women
will die from cervical cancer. According to the Philippine Council for Health Research and
Development, Approximately 12 Filipino women die of cervical cancer every day. It is the
second most common cancer among women in the Philippines. About 6,000 women are
diagnosed with the disease each year and about 4,349 die of the disease annually. The figures
are undeniably high taking into account that, “cervical cancer is preventable and curable in its
early stages.” (De los Reyes, 2008).

This case was chosen among others as a form of validation of the members’ acquired
knowledge after almost 3 years in nursing school. It also helped the group develop the
necessary knowledge, skills needed in caring for a cancer patient, which could be useful in
caring for other terminally ill patients in the future. Most importantly, it helped the members
envision themselves in the patient’s shoe, how it feels to be diagnosed with a disease with
extremely high morbidity. In short, studying this case helped the members empathize more
with the patient and inspired the members to give care with knowledge and sincere
compassion and truly live out the college’s vision and mission
HISTORY AND ASSESSMENT

General Assessment

A case of M.E , female , 51 years old , married ,housewife , Roman Catholic , from Dumanjug
,Cebu , was referred by Barili hospital ,admitted at November 11 2016 around 9:35pm by
ambulance at Vicente Sotto Medical center with a complaints of right lower quadrant
abdominal pain , (+) bloody vaginal discharges , clubbing of nails noted , good skin turgor,
generalized body weakness noted ,lethargic ,lying on bed most of the time , with FBC attached
to urine bag , with oxygen via facemask @ 8-10L/min , with ISA at right arm ,skin is warm to
touch ,anicteric sclera , pale palpebral , clear breath sounds, with palpable mass @ right lower
quadrant , at first day patient was able to respond to questions asked by the student nurse , on
the 4th day of assessment the patient was unable to respond to questions , irritable ,4 times
seizure attack, no urine output for 2 days , with receiving vital signs of T-37.5C ,PR-95bpm,RR-
28cpm ,BP-180/100mmHg, pain score of 4/10.

Patient’s History

On June 26 2016, patient was admitted to St. Vincent Hospital with chief complaint of
abdominal pain on right upper and lower quadrants, with pain score of 10/10; patient stayed
there for 8 days diagnosed with gastritis and UTI. Further examination revealed 5 small
myomas. M.E. chose surgical method as treatment of choice: Total abdominal hysterectomy
salphingooophorectomy. Her doctor advised her to undergo chemotherapy, which she refused
due to financial constraints. On the first week of October, patient was rushed to Tabunok
Hospital with chief complaint of vomiting; she stayed there for 5 days with the diagnosis of
gastritis and UTI and pain score of 10/10. After discharge, the pt.’s vomiting reoccurred
accompanied with vaginal bleeding. She decided to seek health care at Barili Hospital and was
admitted for 7 days with the same diagnosis: UTI and gastritis. One day prior to admission, M.E.
went for scheduled follow up check-up with complaint of persistent pain, thus, referred to
Vicente Sotto Memorial Medical Center. She was admitted to VSMMC last November 11, 2016
@9:35 PM with admitting impression of 1) Cervical cancer stage 1B1 with tumor persistence 2)
Anemia secondary to malignancy.

M.E.’s menarche was when she was 14 years old. Her usual periods last for 3-4 days at
moderate amounts. The patient had 5 sexual partners: 3 boyfriends and 2 husbands. Her first
coitus happened way back when she was 24 years old. No contraceptive used. Positive for pap
smear test taken may 16, 2016. Patient is the 7th of 10 children. She has history of Hypertension
on the paternal side of her family. Her first marriage resulted to 1 child; she didn’t have any
child on her second marriage.
 The patient does not smoke, does not drink alcoholic beverages, does not illegal drugs,
is fully immunized and has maintenance drug for her hypertension.

Central Nervous System

Patient is lethargic and weak, very irritable, not oriented to place and time but oriented to
person, weak grasps on left and right hands, presence of pain on her Right lower quadrant,
restless.

Cardiovascular System

Pulse rate is irregular and strong , present S1 and S2 heart sounds , blood pressure taken while
lying (180/100mmHg),warm upper and lower extremities , clubbing of fingers noted ,negative
Homan’s sign.

Respiratory System

Patient has symmetrical chest , with irregular shallow respiration ,absent cough , normal breath
sounds , with O2 via facemask 8-10L/min

Gastrointestinal System

Patient prescribed diet is low salt , low fat , vomiting (4 times) with greenish-black color ,unable
to feed self due to weakness , (+) bruise lips , last stool output dated –Monday (nov.14 2016)
,hard ,brownish color, distended abdomen

Integumentary System

Pallor skin, warm temperature, intact skin integrity, good skin turgor, (-) edema, (+) bruises on
the lips

Urinary System

Patients last urine output dated November 14 2016(Monday) with yellow color and moderate
amount, on November 15 2016 FBC attached to urine bag: no urine output for 2 days.

Musculoskeletal System

Patient was very dependent, needs assistance in doing ADLs, (+) seizure attacks-4 times, normal
gait, no assistance devices, normal posture and no deformities

Reproductive System

Patient starts menarche at the age of 14 years old, with 3 days duration, coitarche -24 years
old, no contraceptives used, menopause at the age of 46 years old, no sexually transmitted
disease, with positive vaginal bleeding
ANATOMY AND PHYSIOLOGY

The female reproductive system is designed to carry out several functions.

 It produces the female egg cells necessary for reproduction, called the ova or oocytes.
The system is designed to transport the ova to the site of fertilization.
 Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian
tubes.
 The next step for the fertilized egg is to implant into the walls of the uterus, beginning
the initial stages of pregnancy. If fertilization and/or implantation does not take place,
the system is designed to
menstruate (the monthly shedding
of the uterine lining).

Parts

 External

-Labia minora & majora

-Bartholin’s glands

-Clitoris

 Internal

-Vagina

-Uterus (Cervix & Corpus)

-Fallopian tubes

Anatomy and Physiology of the Cervix

The cervix is the lower, narrow part of a women’s uterus, or womb. The cervix connects the
main body of the uterus to the vagina, or birth canal.

Structure

 Ectocervix- part of the cervix that can be seen from inside the vagina during a
gynecologic examination.

 Endocervix- is a tunnel through the cervix, from the external os into the uterus.

 The endocervical canal is the passageway from the uterus to the vagina.

 The 2 main types of cells in the cervix are:

  Columnar cells line the endocervical canal. They are glandular cells that make mucus.
They are called columnar cells because they are tall and shaped like columns.

 Squamous cells line the ectocervix and vagina. They are flat and thin like the scales on a
fish.

Function

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.

Cervix Conditions

 Cervical cancer: Most cervical cancer is caused by infection by the human papillomavirus
(HPV). Regular Pap tests can prevent cervical cancer in most women.
 Cervical incompetence: Early opening, or dilation, of the cervix during pregnancy that can
lead to premature delivery. Previous procedures on the cervix are often responsible.
 Cervicitis: Inflammation of the cervix, usually caused by infection. Chlamydia, gonorrhea,
and herpes are some of the sexually transmitted infections that can cause cervicitis.
 Cervical dysplasia: Abnormal cells in the cervix that can become cervical cancer. Cervical
dysplasia is frequently discovered on Pap test.
 Cervical intraepithelial neoplasia (CIN): Another name for cervical dysplasia.
 Cervix polyps: Small growths on the part of the cervix where it connects to the vagina.
Polyps are painless and usually harmless, but they can cause vaginal bleeding.
 Pelvic inflammatory disease (PID): Infection of the cervix, known as cervicitis, may spread
into the uterus and fallopian tubes. Pelvic inflammatory disease can damage a woman's
reproductive organs and make it more difficult for her to become pregnant.
 Human papillomavirus (HPV) infection: Human papillomaviruses are a group of viruses,
including certain types that cause cervical cancer. Less dangerous types of the virus cause
genital and cervical warts.

ANATOMY AND PHYSIOLOGY OF THE KIDNEY

>The kidneys are part of the urinary system. There are 2 kidneys in the body, one on either side
of the spine under the lower ribs, deep inside the upper part of the abdomen.

>The kidneys are bean-shaped organs. They are about 12 cm (4–5 in) long, 6 cm (2–3 in) wide
and 3 cm (1–2 in) thick. A layer of fatty tissue holds the kidneys in place against the muscle at
the back of the abdomen.
FUNCTION

>The main function of the kidneys is to filter water, impurities and wastes from the blood.

>The kidneys also act as endocrine glands. They make these hormones:
 Erythropoietin stimulates the bone marrow to make RBCs.
 Calcitrol, a form of Vitamin D, helps the colon absorb calcium from the diet.
 Renin helps control blood sugar.

PARTS
Gerota’s fascia is a thin, fibrous tissue on the outside
of the kidney. Below Gerota’s fascia is a layer of fat.

The renal capsule is a layer of fibrous tissue that

surrounds the body of the kidney, inside the layer of
fat.

The cortex is the tissue just under the renal capsule.

The medulla is the inner part of the kidney.

The renal pelvis is a hollow area in the centre of each

kidney where urine collects.

The renal artery brings blood to the kidney.

The renal vein takes blood back to the body after it has
passed through the kidney.

The renal hilum is the area where the renal artery, renal vein and ureter enter the kidney.

The nephrons are the millions of small tubes inside each kidney. Each nephron has 2 parts.
Tubules are tiny tubes that collect the waste materials and chemicals from the blood moving
through the kidney. The corpuscles contain a clump of tiny blood vessels called glomeruli that
filter the blood as it moves through the kidney. The waste products are passed through the
tubules to the collecting ducts, which drain into the renal pelvis.

THE ANATOMY AND PHYSIOLOGY OF THE PERITONEAL CAVITY

The peritoneal cavity is a potential space between
the parietal and visceral peritoneum.
It contains only a thin film of peritoneal fluid, which consists
of water, electrolytes, leukocytes and antibodies.
The fluid serves two main functions:

 It acts as a lubricant, enabling free movement of the

abdominal viscera.

 The antibodies fight infection.

Ordinarily, the peritoneal cavity is only of capillary thinness;

however, it is referred to as a potential space because excess
fluid can accumulate in the peritoneal cavity resulting in the
clinical condition of ascites.
LABORATORY STUDIES

Clinical Chemistry Report

November 11, 2016

Test Result Reference Interpretation

Uric Acid 16.8 mg/dL 3.0 – 8.0 mg/dL Increase cell death
due to cancer
SGPT 17 U/L 5.0 – 50 U/L Within normal limits
Magnesium 2.2 mg/dL 1.2 – 2.2 mg/dL Within normal limits

November 12, 2016 @ 4:11 AM

Test Result Reference Interpretation

Urea 130.92 mg/dL 7.00 – 18.68 mg/dL Indicates kidney
dysfunction
Creatinine 22.11 mg/dL 0.6 – 1.1 mg/dL Indicates kindey
dysfunction
SGOT 37.79 U/L 0.0 – 31.0

November 12, 2016 @ 2:48 PM

Test Result Reference Interpretation

Urea 131.68 mg/dL 7.00 – 18.68 mg/dL Indicate kidney
dysfunction
Creatinine 23.77 mg/dL 0.6 – 1.1 mg/dL Indicates kidney
dysfunction
SGOT 19.10 U/L 0.0 – 31.0 Within normal limits

Hematology

November 12, 2016

Complete Blood Result Reference Interpretation

Count
WBC Count 13.99 x 10^9/L 4.5 – 11.0 x 10^9/L This can result from
bacterial infection
and inflammation
Hemoglobin 93.0 g/L 120.0 – 150.0 g/L This can result from
blood loss; anemia
Hematocrit 0.28 L/L 0.37 – 0.47 L/L This can result from
anemia, bleeding,
 destruction RBC,
malnutrition, too little
iron, vitamin B12, and
vitamin B6 in diet,
and too much water
in the body
MCV 84.2 fL 81.0 – 99.0 fL Within normal limits
MCH 28.2 pg 27 – 31 pg Within normal limits
RBC Count 3.30 x 10^12/L 4.0 – 5.2 x 10^12/L This can result from
RBC destruction,
sudden bleeding,
kidney failure,
nutritional deficiency,
and chronic
inflammatory disease
such as cancer
MCHC 33.5 g/L 32 – 36 g/L Within normal limits
RDW 12.8 11.6 – 14.6 Within normal limits
MPV 9.2 fL 7.2 – 11 fL Within normal limits
Platelet Count 346 x 10^9/L 150 – 400 x 10^9/L Within normal limits

Differential Count Result Reference Interpretation

Neutrophils 87.6 % 40 – 74 % This can result from
acute infection and
acute stress
Lymphocytes 7.4 % 19 – 48 % Indicates low
infection resistance
and susceptible to
infections like tumors
and cancers, can also
lead to damage of
various body organs
Monocytes 3.6 % 3–9% Within normal limits
Eosinophils 1.0 % 0–7% Within normal limits
Basophils 0.4 % 0–2% Within normal limits

November 14, 2016 @ 8:14 PM

Electrolytes-Stat Test Result Reference Interpretation

Sodium 126.5 mmol/L 135-148 mmol/L Due to conditions
such as vomiting,
 excessive sweating,
and decreased
sodium intake
Potassium 5.28 mmol/L 3.50- 5.30 mmol/L Within normal limits
Chloride 97.9 mmol/L 98- 107 mmol/L Due to dehydration,
excessive sweating,
vomiting, respiratory
acidosis which
happens when your
lungs cant remove
enough carbon
dioxide out of your
body
Ionized Calcium 1.03 mmol/L 1.13- 1.32 mmol/L Indicates kidney
failure and
malnutrition

November 15, 2016

Arterial Blood Gas

Result Reference Interpretation

Temperature 36.7 ◦C Within normal limits
pH 7.391 7.35 – 7.45 Within normal limits
PCO2 21.3 mmHg 35 – 45 Indicates
hyperventilation,
hypoxia, and anxiety
P02 67 mmHg 80 – 105 Indicates decreased
oxygen levels in the
body,
hypoventilation,
anemia, heart
decompensation
BEef -12.21 mmol/L -3 - -2 mmol/L Indicates lactic
acidosis, ketoacidosis,
ingestion of acids, and
possibility of shock
HCO3 13.0 mmol/L 22 – 26 mmol/L Indicates metabolic
acidosis, respiratory
alkalosis, shock
SPO2 93.7 % 95 – 98 % Indicates hypoxemia
ULTRASOUND REPORT

May 26,2016

IMPRESSION:

 Cervical mass consistent with malignancy

 Thin endometrium
 Multiple small myoma uteri, intramural
 Left adnexal mass consider a hydro salpinx
 Atrophic left ovary

November 16, 2016

ULTRASOUND WHOLE ABDOMEN

CONCLUSION:

 Ascites
 Upper limits of normal size kidneys associated with bilateral mild hydronephrosis and
proximal hydroureters
 Normal sonographic evaluation of the liver (14.2 cm), gallbladder (7.3 x 3.0 cm; wall
thickness 0.1 cm), pancreas (7.3 x 2.8 cm) and spleen
 Unfilled urinary bladder with Foley catheter balloon
 Incidental note of pleural effusion, right lung
June 2, 2016

IMPRESSION:

 Lobulated heterogeneously enhancing cervical mass, as described.

 Myoma uteri
 Bilateral enlarged iliac lymph nodes likely metastatic
 Atherosclerotic vessel disease
Surgical Pathology Report

Breast Ultrasound

June 1, 2016

IMPRESSION:

 BI- RADS CATEGORY 1- NEGATIVE

 No mammographic evidence of malignancy
 Recommend 1 year follow-up
SURGICAL MANAGEMENT

IDEAL and ACTUAL:

Total Abdominal Hysterectomy and Bilateral Salpingo-Oopherectomy is the removal of

the uterus including the cervix as well as the tubes and ovaries using an incision in the
abdomen. A hysterectomy is the surgical removal of the uterus .It may be a total removal, as
removing the body and cervix of the uterus or partial, also called supra-cervical. Salphingo refers
specifically to the fallopian tubes, which connect the ovaries to the uterus. Oophorectomy is the
surgical removal of an ovary or ovaries.

Hysterectomy is often performed on cancer patients or to relieve severe pelvic pain

from endometriosis or adenomyosis. It is also used as a last resort for postpartum obstetrical
hemorrhage uterine fibroids that cause heavy or unusual bleeding.

The main goal of TAHBSO is to remove benign diseases, to decrease risk of development
of ovarian pathology, and decreases the need for future procedures.

ADVANTAGES AND DISADVANTAGES:

 Hysterectomy has been found to be associated with increased bladder

function problems, such as incontinence.

 When the ovaries are also removed, estrogen levels will fall. This removes the protective
effects of estrogen on the cardiovascular and skeletal system.

 A menopausal woman has a three times greater risk of developing

cardiovascular disease such as atherosclerosis, peripheral artery disease or of having a
heart attack when compared to premenopausal women

TECHNIQUE:

1. A lower midline incision is made vertically (up and down) in the skin with a No. 10 scalpel.

2. Dissection is done through the subcutaneous tissue with Bovie cautery.

3. The midline between the rectus muscles is appreciated and the fascia is incised.

4. Some clinicians performing a total abdominal hysterectomy may elect to use a transverse
skin incision called a Pfannenstiel incision placed just above the symphysis pubis (pubic bone).

Pfannensteil incision in suprapubic area

5. In the transverse incision approach in total abdominal hysterectomy the subcutaneous tissue
is dissected with Bovie cautery

6. Skin flaps are raised superiorly toward the skin to allow exposure of the midline of the rectus
muscles.

7. Occasionally in large patients receiving total abdominal hysterectomy, Â the rectus muscles
are cut to afford better exposure

8. After the midline fascia is dissected or the rectus muscles are cut, the peritoneum is
appreciated and grasped with forceps on either side of the midline (never with hemostats to
avoid trapping bowel inadvertently).

9. If possible, the uterus is grasped and pulled out of the incision and superiorly toward the
umbilicus (belly button) to expose the anterior uterine surface.

10. The peritoneum at the cervicovesical fold is incised transversely (side-to-side) close to
where it attaches to the uterus.

11. Blunt finger dissection is used in total abdominal hysterectomy to appreciate the avascular
(without blood vessels) plane in the posterior leaf of the broad ligament.

12. This is performed until the round ligament and fallopian tubes are appreciated.

13. The round ligament on each side is then controlled by placing an Ochsner clamp on it and
dividing it after a mattress 0 absorbable suture has been placed on the right and left round
ligaments to ligate the ovarian vessels.

14. The clamps are then removed on either side of the fundus of the uterus.

15. The gynecologist palpates the cervix with two fingers to gain an appreciation of the position
of the bladder.

16. The bladder is then bluntly dissected off the uterus with a gauze-covered finger caudally
(towards the feet).

17. Care must be taken when doing a total abdominal hysterectomy to keep the blunt
dissection in the midline to avoid inadvertently tearing the vessels in the broad ligament.
18. The dissection is carried downward until the vaginal wall can be compressed between the
gynecologist’s fingers.

19. The uterus is the pulled forward and the posterior surface is visualized to insure that it is
not adherent to the rectum.

20. The uterus is grasped with a tenaculum and rotated slightly to one side to expose the
uterine vessels.

21. Two Ochsner clamps are then placed at 45 degrees to the uterus and slid down onto the
uterine vessels.

22. The uterine vessels are incised with a Metzenbaum scissors and the vascular pedicle doubly
ligated with silk suture.

23. The similar procedure to ligate the uterine vessels is performed on the opposite side.

24. Teale forceps are applied to the cervical tissue at the level of the vagina.

25. The posterior cervical peritoneum is incised and gently bluntly downward.

26. The incision is carried circumferentially around the cervix.

27. The uterus is held forward the posterior vaginal wall is incised using curved scissors.

28. The anterior and posterior walls of the cut vagina are grasped by Teale forceps.

29. The lateral edges of the cut vagina are sutured together with figure of eight absorbable zero
sutures.

30. The rest of the vaginal opening is then closed with additional figure of eight absorbable zero
sutures.

31. The reapproximated vagina is the released from the Teale forceps to visualize any bleeding
points.

32. The peritoneum is then closed with a running absorbable suture (general surgeons almost
never close the peritoneum after abdominal surgery)

33. Fascia is reapproximated using either a running or interrupted large suture.

34. Subcutaneous tissue may be closed using absorbable 2-0 or 3-0 suture.

35. The skin is closed using staples or sutures to complete the total abdominal hysterectomy.
COMPLICATIONS:

Early:

 Heavy blood loss requiring blood transfusion

 Bowel injury
 Bladder injury
 Blood clot in lung
 Anesthesia problems (such as breathing or heart problems)
 Need to change to abdominal incision during surgery
 Wound pulling open (dehiscence)
 Collection of blood (hematoma) at the surgery site needing surgical drainage

Late:

 Difficulty urinating. This is more common after removal of lymph nodes, ovaries, and
structures that support the uterus (radical hysterectomy).
 Weakness of the pelvic muscles and ligaments that support the vagina, bladder, and
rectum. Kegel exercises may help strengthen the pelvic muscles and ligaments. But
some women need other treatments, including additional surgery.
 Continued heavy bleeding. Some vaginal bleeding within 4 to 6 weeks following a
hysterectomy is expected. But call your doctor if bleeding continues to be heavy.
 Some women may experience early menopause.
 The formation of scar tissue (adhesions) in the pelvic area.
SURGICAL MANAGEMENT

INTRAJUGULAR CATHETER

IDEAL:

Central venous access allows the placement of various types of intravenous (IV) lines to
facilitate the infusion of fluids, blood products, and drugs and to obtain blood for laboratory
analysis. It is also an essential procedure in patients in whom placement of a line in a peripheral
vein is impossible. A central line may be the only means of venous access in such cases.

The jugular veins are reliable access sites for temporary and permanent venous
cannulation to support hemodynamic monitoring, fluid and medication administration, and
parenteral nutrition. Jugular venous access can also be used for the placement of inferior vena
cava filters and other venous devices.

Internal jugular venous access is commonly used in situations that require reliable tip
positioning for immediate use, such as drug administration or transvenous pacing. The jugular
veins are one of the most popular sites for central venous access due to accessibility and overall
low complication rates, and are the preferred site for temporary hemodialysis.

ADVANTAGES AND DISADVANTAGES:

Central venous catheterization via the internal jugular vein has a lower incidence of
pneumothorax compared to catheterization via the subclavian vein, and it can be easily
compressed after catheter removal or after unintentional arterial puncture. Ultrasound can be
a valuable adjunct for IJV cannulation, because the incidence of anatomical variants may be as
high as 8.5%. Subclavian vein catheterization is more comfortable for awake patients and less
prone to contamination from respiratory secretions, particularly in patients with
tracheotomies.
TECHNIQUE:

 Infiltrate local anesthetic all around the site, working down toward the vein.
 Flush each port of the central line with saline or heparin saline, and close off each line
except the distal (usually brown) line; the wire threads through this line.
 Attach a syringe to the large needle provided, and then proceed as follows:
– right femoral line: find the arterial pulse and enter the skin 1 cm medial to this, at a
45° angle to the vertical and heading parallel to the artery. Advance slowly, aspirating all
the time, until you enter the vein

– right jugular line: palpate the carotid artery with your left hand, covering the artery
with your fingers. Insert the needle 0.5–1 cm laterally to the artery, aiming at a 45°angle
to the vertical. When the needle is in the vein, ensure that you can reliably aspirate
blood. Remove the syringe, keeping the needle very still.

 Insert the central line over the wire. When the central line is 2 cm away from the skin,
slowly withdraw the wire back through the central line until the wire tip appears from
the line port. Hold the wire here while you insert the line. Leave a few centimeters of
the line outside the skin. Withdraw the wire and immediately clip off the remaining
port.
 Attach the line to the skin with sutures. Tie loosely so as not to pinch the skin; this
causes necrosis and detachment of the line. Clean the skin around the line once more,
dry, and cover with occlusive dressings.
 Ensure that you can aspirate blood from each lumen of the line, then flush each lumen
with saline or heparin saline.
 Order a chest x-ray to check for line position and pneumothorax if a jugular or
subclavian line has been inserted. Femoral lines do not require an x-ray.
COMPLICATIONS:

Early:

 Failure to place the catheter

 Arterial puncture
 Catheter malposition

Late:

 Pneumothorax
 Subcutaneous hematoma
 Hemothorax
 Asystolic cardiac arrest
DISCHARGE PLANNING

Client’s Initials: M.E.

Diagnosis: 1) Cervical cancer stage 3 with persistent tumor 2) Anemia secondary to malignancy
Destination: Dumanjug, Cebu
Transportation: ambulatory

Medications: Instruct patient to comply with the following take home medications:
Neobloc 100 mg 1 tab PO OD for
Multivitamins + Ferrous Sulfate 1 tab PO BID

Exercise:
>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

Treatment: Dialysis twice a week to cleanse the blood because the kidneys’ function is
severely impaired
Chemotherapy and radiation to kill cancer cells and stop it from metastasizing
from other parts of the body.
Encourage patient to take supplemental drinks, which are ideal for increasing
protein and carbohydrate without increasing volume of foods to eat
Emphasize importance of coming to scheduled follow up checkups

Health Education: To attain the best possible rehabilitation, the patient and significant others
must cooperate. Thus, it’s important to teach the following:
>Role of nutrition in the recovery process
>Types of food to eat, especially the ones that show promising results against cancer
cells based on researches
>Importance and types of exercise to maintain muscle strength and mass
>Patient is counseled regarding importance of eating meals on time and in a relaxed
setting.
>Instructed patient to avoid any strenuous or heavy activities.

Observable signs and symptoms: Instruct M.E. to look out for the following signs and
symptoms and immediately seek the help of a health care professional
>vaginal bleeding or discharges
>persistent abdominal pain
>vomiting (excluding side effect of chemotherapy)
>unable to void
>lethargy
 >seizures
>increased BP
>Dyspareunia

Dietary Prescription: Recommend the following nutrient-dense foods to maintain ideal body
weight:
>Foods that are high in carbohydrate (starchy fruits and vegetables), high in protein
(soya milk, egg white, etc.), rich in vitamins and minerals (green, leafy vegetables and fruits)
>Fruits and vegetables that are proven to fight cancer cells according to research such as
malunggay, guyabano, mangosteen, etc.

Spirituality: M.E. is Roman Catholic; advise pt. to join a healing mass if she can tolerate.
Encourage to express anger, grief, or thoughts about present condition to God as an emotional
outlet. Also encourage the S.O. to pray for the patient’s recovery and make an effort to spend
quality time with M.E. regularly
PROGNOSIS
The patient is already on cervical cancer, stage 3 and has started exhibiting signs of
metastasis. Proposed IJ catheter insertion for hemodialysis as palliative care was declined as
well as suggested chemotherapy due to financial problems. Her kidneys are severely impaired
and quick examination of the pt. will certainly not yield good results. Thus, the patient will
inevitably expire.