University of the EastRamon Magsaysay Memorial Medical Center

College of Nursing Aurora Blvd. Quezon City

CASE PRESENTATION:NON-SMALL CELL LUNG CARCINOMA STAGE IV WITH BRAIN METASTASIS

Submitted by:Fourth Year - Group H29

Magpali, IrisMancao, Grace

Mangulabnan, NicoleMarcelino, Charina

Melgar, MoniqueMenrige, RB

Mendoza, EricsonNavarro, Isaac

Nery, KerenNoveda, Sibyl

August 28, 2009

I. Client’s Profile

Name: F. M.Age: 52 yrs. oldSex: FemaleDate of Birth: July 19, 1957Place of Birth: IsabelaLanguage: Tagalog, IlocanoAddress: Sampaloc, ManilaReligion: Roman Catholic Educational Attainment: Elementary graduateOccupation: Tobacco farmerDate and Time Admitted: Aug. 17, 2009 9:28 p.m.Chief Complaint: DOB x 1 dayFinal Diagnosis: Non-small cell carcinoma Stage 4 with brain metastasisAttending Physician: Dr. Dela Rosa

II. Health History

a. Present Health History

3 months prior to admission, the patient experienced difficulty of breathing and pain at her right anterior and posterior mid-clavicular area. She stated that pain was continuous, “kumikirot” and can range from 6-10/10 on the pain scale. She would cry because of the pain, and needs to always have pillows on her back to decrease difficulty of breathing, which was chracterized as “parang may nakadagan”. She drank Mefenamic acid and tried to relax and breathe in deeply to relieve pain. She was rushed to the hospital in Isabela. She was diagnosed of pleural fluid effusion. Xray was done and it shows minimal and unrecalled fluid amount. She was prescribed with TB drugs: Rifampicin, Isoniazid and Ethambutol taken OD for 2 months. The patient can’t remember the dosages of the drug taken.

2 months prior to admission, the patient experienced seizure at around 11 am during her visit to her cousin at Tugegarao. The seizure was 5 minutes in duration. patient said that her seizure was characterized as “nakalabas ang dila ko, naglalaway , tumitirik and mata at tnangingisay ang katawan ko.” The patient thought it was due to her high BP so she was not brought to the hospital. They decided that they will seek consult tomorrow morning. Furthermore, the patient still experienced difficulty of breathing and pain on her back despite being compliant with the medications. On the next day, the patient went to the hospital in Tugegarao for a check-up. Xray and CT Scan were done and revealed abnormalities in her brain and fluid in the lungs with unrecalled amounts. Hence, the patient stopped taking the TB drugs after knowing that she didn't have any TB. She was advised to have her symptoms and her CT scan plates to be checked by her doctor in Isabela. After she was checked, she was referred to Jose Reyes Hospital in Quezon City.

1 month prior to admission, the patient went to Jose Reyes Hospital under referral of her doctor in Isabela. CT Scan with biopsy was done and revealed Non-small Cell Carcinoma Stage IV with brain metastasis. She sought a second opinion at UERM hospital and was advised to

treat her brain metastasis first with radiation therapy because according to the patient, the doctor said it could be fatal if she had another episode of seizure again.

3 weeks prior to admission, the patient was started on brain radiation therapy at Jose Reyes Hospital for 15 sessions. After her brain radiation therapy, she was then admitted to UERM Hospital at the Medicine Ward and started her first cycle of chemotherapy for one day (Paclitaxel Carboplatin). She was scheduled for a follow-up and a second cycle of chemotherapy 18 days after her first cycle. The next day after her chemotherapy, the patient experienced syncope and seizures (unrecalled duration). She was then rushed to the E.R. at UERM hospital. She was given Oxcarbazepine 300mg and was admitted to the Pay ward (3N2). After 24 hours, the patient was discharged because of improved condition.

4 days prior to admission, the patient experienced another seizure episode and was brought again to the E.R. She was given Oxcarbazepine 300mg again and was admitted to the Medicine Ward. She was observed and was discharged 3 days after because she regained her strength and her condition improved.

On the day of admission, the patient received a call from a doctor in UERM informing her that she should come earlier than her scheduled follow up day because it was a holiday on her scheduled follow-up. Xray and biopsy of the pleural fluid was done which revealed worsening of the pleural effusion. Hence, she was advised to be admitted and have a chest tube insertion.

b. Past Medical History

The patient had two surgeries before and was confined to a hospital. She had a cholelithotomy last 1997 and had a Caesarean birth last 1999. The patient is a known hypertensive but is controlled with Norvasc 5mg taken twice per day. The patient can’t recall if she was fully immunized when she was young. But she already had chicken pox, mumps and measles. She has no known allergies to food or any medications.

c. Social History

The patient used to work as a tobacco farmer in a plantation in Isabela for 15 years before she was diagnosed with cancer. according to patient, when the tobacco plants are already dry, she gathers them into bundles. during this time, the plants have a strong and heavy smell. Sometimes they burn the extra tobacco plants together with other wastes, which takes around thirty minutes. She doesn't wear a mask when working. The patient doesn’t drink any alcohol and doesn’t smoke. She used to drink 1 cup of coffee every morning but stopped when she was diagnosed with hypertension in 1997. She lives in a two-storey house in Isabela with her husband and two children. The house is made up of mixed materials: concrete and wood. She was used to doing the household chores then but now her son hired a house-help that cleans their house every morning. According to her, the environment there is safe and peaceful. There were no reported crimes in the recent years and there’s a barngay tanod that’s roaming and guarding their barangay. She also verbalized that she’s in a good relationship with their neighbors and she frequently attends programs and barangay meetings held in their town center. Her income nowadays comes from her husband’s and children’s jobs. The patient had no any recent travels, local or foreign, in the past 3 years.

d. Family History

e. Developmental History

According to Erik Erikson’s Theory, the patient, who is 52 years old, is currently in the stage of Middle Adulthood wherein the ego development outcome is Generativity vs. Stagnation. Here, the basic strengths are production and care. It is a stage where work is most crucial since this is where the patient tends to be occupied with creative and meaningful work and with issues surrounding family. This is where she can be “in charge”. It is an important task for the patient to be able to teach values to her family and work to establish a stable environment. Strength comes from the care she receives and production of something for the betterment of society.

Upon observation, patient’s view about her life now is leading more towards stagnation. Patient is depressed and verbalized feelings of helplessness about her health. She believes she

Legend:□ - MALE

○ - FEMALE

H– hypertensionAR- arthritisC- cancer? – unknown cause

H ?

HAR

H, CA

cannot be productive in her current situation. Fortunately, she has a husband and family who are willing to support her. She needs to find significant relationship among her workplace, community and family to help her lead a life that is geared towards generativity.

Diagnostic Tests

Chest X-ray (Aug. 17, 2009)

Impression: Slight decrease in the amount of right sided pleural effusion. Presently moderate to massive in amount. The visualized aerated lung fields are clear.True cardiac size not ascertain.Atherosclerotic aorta.No evident pneumothorax seen.Other chest structures not remarkable.

Ultrasound report (Aug. 18, 2009)

The sonogram of the right lower hemothorax shows accumulation of free fluid at the dependent portion of the thoracic cavity, with approximate volume of 697 ml. Skin marker was placed at the posterior right lower lateral hemithorax. Depth of needle from skin to pleura and skin to central portion of fluid collection is 2.5 cm and 5.0 cm, respectively.

Thoracentesis was performed under local anaesthesia. Approximately 700 ml of reddish fluid was aspirated. Post aspiration sonogram demonstrates approximately 100 ml retained fluid.

Microbiology (Aug. 25, 2009)

No organism seen on the pleural fluid.

Pleural fluid analysis (August 25, 2009)

Panels Result ReferenceColor Light red ClearTurbidity TurbidClot Positive NegativeSpecific gravity 1.345 7.37–7.43 (usually 7.40)Albumin 31.0 g/L 30.0 g/dLLDH 469 iu/L 71 – 207 IU/LGlucose 3.7 mmol/L Parallels serum levelsWBC 17,424,000/mm3 0–1000/mm3, consisting mainly of lymphocytesLymphocytes 59%Neutrophils 41%

RBC 62,208,000/mm3 0–1000/mm3

Pleural fluid analysis is indicated to the patient to differentiate pleural transudates from exudates. According to the table above, it is a pleural exudates as it is light red in color, positive to clot, decreased pH, increased albumin, increased lactic dehydrogenase, increased WBC, and increased RBC.

Complete blood count with other serum tests

Panels Reference ResultAugust 17, 2009Hemoglobin 120-140 g/L 118 g/LMCH 27.5 – 33.2 ug 27.3 ugHCT 37 % – 47 % 35 %MCV 80 – 94 fL 81 fLMCHC 32 – 37 % 33 %RBC 4.0 – 4.5 4.3 x 1012/LWBC 5 – 10 x 109/L 6.2 x 109/LNeutrophils 40 – 75 % 73 %August 18, 2009Prothrombin time 10 – 13 sec. 9.9 sec.Partial thromboplastin time 29 – 34 sec. 25.1 sec.August 25,2009Albumin mass 38 – 50 g/L 30 g/LLDH – L 109 – 193 iu/L 205 iu/LGlucose substance 3.8 – 5.8 mmol/L 5.8 mmol/L

Complete blood count is indicated to the patient to rule out suspected hematologic disorder, neoplasm, or immunologic abnormality and to monitor effects of physical or emotional stress.

Haemoglobin 118 g/L (120-140 g/L) is the main intracellular protein of the RBC. Its primary function is to transport oxygen to the cells and to remove carbon dioxide from them for excretion by the lungs. Decreased haemoglobin count indicates decreased oxygen transportation to cells and removal of cardon dioxide for excretion to the lungs.

The Hct or packed RBC volume measures the proportion of RBCs in a volume of whole blood. Normally, Hgb and Hct levels parallel each other and are commonly used together to express the degree of anemia. Decreased hematocrit count indicates decreased RBC volume in proportion to other cellular components of the blood.

Mean corpuscular haemoglobin reflects the weight of haemoglobin in each RBC. Decreased MCH count indicates disproportionate haemoglobin in each RBC.

Non modifiable Modifiable

Stress

Smoking/ 2nd handAge

Alcohol

Fight and flight responseAdrenaline Epinephrine and nor epinephrine

Alter immune system function

APG

hydroxyl radical from hydrocarbons, acetaldehyde,etc

DNA damage

Carcinogenic Agents

Carcinogenic agents Agents

Inhaled , enters, nose, mouth, pharynx, larynx, trachea, bronchus, lungs

Benzene, nitrosamines, vinyl nicotine, arsenic, and hydrocarbons, acetaldehyde

Acetaldehyde, carbon radicals

Ingested into mouth, pharynx esophagus, stomach, colon,

Stress

1st Environmental Insult

Immune response failure

Immune response failure

DNA repair

Failure of Dna repair

Alter immune system function

2nd Environmental insult DNA damage

Oxidative stress

Free radicals

Damage cells

Reactive oxygen

Lifestyle / food

Increased o2 metabolism

Initiation

Promotion/ antipromotion

Progression

Susceptible to bacterial and viral attacks

Genetic alteration

Failure of Dna repair

ProgressionMultiple cell division

Multiple cell division

Cancer

HeredityReduced tumor suppressor genes

Cellular transformation/ Derangement

Imbalance along the cell cycle

Cell mutation

Etiology

Cancer

Occult (hidden) stage

Cancer cells are found in sputum No tumor can be found in the lung

Stage 0

abnormal cells in the innermost lining of the lung.

Stage I

Stage IA Stage IB

The tumor is in the lung only and is 3 centimeters or smaller.

Cancer has spread to the innermost layer of the membrane that covers the lungs. The tumor partly blocks the bronchus or bronchioles, compression of normal cells

Stage II

Stage IIA Stage IIB

Cancer has spread to nearby lymph nodes The tumor partly blocks the bronchus or bronchioles

Stage IIIA Stage IIIB

Stage III

Stage IV

Cancer has spread to the main bronchus of the lungs Spread to lymph nodes above the collar bone

Spread to the brain

require a blood supply and energy

Diversion of blood and nutrients

AngiogenesisPsychological emotions

Altered appetite and eating patterns

Radiation therapy Reduce fast dividing cells, including blood, hair etc

Reduce 02 perfusion

Weight loss

Destroy RBC

Fatigue

cancer cells block lymphatic ducts

Decreased lymphatic drainaige

Increase fluid in the peritoneal cavity

Pleural effusion

Coughing reflex Cough

Compression of nerves Back pain

Weight loss

Decreased HCT 35%

Low Hgb 118 g/L

Decreased CHON metabolism

Decreased albumin30g/l

Decreased rbc 4.3 x 1012/L

Decreased CHON, CHO, lipids etc

Sonogram

697 ml free fluid at dependent portion of the thoracic cavity

700ml fluid was aspirated

thoracentesis

Alcohol intake

Acetaldehyde

Inhibit protein export to the liver

Decreased CHON metabolism

Disrupted amino acid production

Decreased albumin30g/l

Pleural effusion

Compression of lungs

Dyspnea, shortness of breath

Difficulty of breathing

II. GORDON’S FUNCTIONAL HEALTH PATTERNS

A. Health Perception – Health Management’

Subjective:“Nasa hospital ako ngayon dahil may cancer ako at na sinabi na stage IV cancer. Pagkatapos ng

xray, nalaman na maraming tubig sa baga ko kaya kailangan daw tanggalin bago ako i-chemo ulit kasi di daw yun effective kung may tubig pa din ako sa baga. Hindi naman ako sakitin dati pero na-confine na ako noong 1997 kasi tinanggal yung bato ko sa apdo saka noong 1999 kasi nanganak ako ng CS sa bunso ko. Mahilig ako kumain ng prinitong pagkain tulad ng isda dati. Hindi ko hilig magpa-check-up pero kapag hindi ko na kaya, nagpapatingin ako. Kung hindi gumana yung gamot na nireseta ng doctor, bumibista din ako sa albularyo. Norvasc ang gamot ko para sa high blood, pinakamataas na BP na nakuha sa ‘kin 140/100 mmHg. Nasusunod ko naman yung schedule ng pag inom ng gamot ko. May malapit na hospital sa bahay namin kaya madali makakuha ng tulong kung sakali. Hindi ko maalala kung pina-bakuna ako noong bata. Wala naman akong allergies sa pagkain o gamot. Nagseself-medicate lang ako kapag may ubo or sipon, iinom ako ng Biogesic o vitamin C. Gumagamit din ako ng alternatibong paraan katulad ng pag-inom ng calamansi juice kapag may sipon o ubo ako. Sa ngayon, wala naman akong iniinom na gamot na hindi niriseta ng doctor kasi sumusunod ako kung ano lang pinapainom sa akin.”

Objective:She is dressed appropriately to the situation, with no foul body odor or bad breath. Her hair is

short (almost bald) and evenly distributed. Upon assessment, patient was oriented to time, place and person. Patient manifested willingness to participate during the interview and was able to maintain eye contact. Hair is color black. Good skin turgor and no edema. Capillary refill goes back 2 seconds after pinching. Nails were kept short and clean. Patient's hearing sensation was not impaired and was able to pass the whisper and tick test. She was able to determine and differentiate blunt, sharp, deep and light sensation. No numbness or tingling sensation was felt. Illuminated pupils were able to constrict. The pupils constricted from 5 mm to 3mm. He was able to differentiate sweet, sour and salty taste testers. No numbness or tingling sensation was felt. Cranial nerves III, IV and VI were intact upon assessment of eye movements. Other cranial nerves were intact upon assessment (smell and taste testing, corneal reflex, face, tongue movement, etc.) Has facial symmetry. Cervical lymph nodes are enlarged. Patient is able to walk with assistance but hesitates to do so because it might augment her pain. She showed facial grimaces when trying turn from side to side. The patient’s vital signs are as follows: BP=120/90 mmHg, PR=114, RR=22 Temp=36.8 C. (8:00 PM). Hemoglobin level: 118 g/L (Reference: 120-140 g/L), Hematocrit: 35% (Reference: 37-47%). Height = 5’4”, Weight = 127.8 lbs/58kg; BMI = 21.9. The patient’s current medications are the following: Oxcarbazepine (300 mg), Amlodipine (5mg OD), Dolcet (1 tablet, Q6), Celecoxib (200 mg, 1 cap, BID), Nalbuphine (PRN medication). Fiinal diagnosis: Non small cell lung cancer Stage IV with brain metastasis.

Analysis: Ineffective therapeutic regimen management related to lack of ability to make deliberate and

thoughtful judgements.

B. Nutritional – Metabolic Pattern

Subjective:“Karaniwan akong kumakain ng 3-5 beses sa isang araw, tapos may merienda rin. Madalas tubig

lang iniinom ako, hindi naman ako mahilig sa softdrinks. Nakaka-anim na baso ako na tubig sa isang araw.Mas gusto ko ang gulay at isda kaysa sa karne. Madalas ang kinakain ko sa umaga ay isa o dalawang pandesal tapos may palaman na itlog o cheese spread. Sa tanghalian, isang cup ng kanin at isang platito ng ulam ang dami Yung ulam ko nun kadalasan gulay o karne.. Sa gabi naman, isang cup din

ng kanin at pritong isda o gulay. Mahilig ako sa mga prinitong pagkain. Dati, yung merienda ko madalas prutas kasi maraming tanim dun sa probinsya namin sa Isabela ng mangga, guava o suha. Ngayon sa ospital, kinakain ko kung anong bigay sa akin na rasyon at pina-soft diet ako. Kaninang agahan, naka-dalawang tinapay ako. Kaninang tanghalian, sinigang na isda at kanin pero hindi ko naubos. Kagabi kumain ako ng isang mangkok ng sopas. Sa nakalipas na buwan, nangayayat ako pagkatapos nung radiation therapy, nung mga July 31 yun. Minsan nawawalan ako ng gana kumain kasi masakit ang ulo ko. Wala akong problema sa pag-nguya at paglunok. Hindi rin sumasakit yung lalamunan ko. Wala naman akong allergies sa pagkain at walang ipinagbabawal na pagkain ang aking relihiyon maliban na lang kung mahal na araw kasi bawala ang karne kapag ganun.”

Objective:Weight loss of 7kg (July 31, 2009) from 65 kg to 58 kg (current weight). Height = 5’4”, Weight =

127.8 lbs/58kg; BMI = 21.9 kg/m2. Patient is dark skinned, uniform in color, smooth and no rashes were seen. Patient’s hair is thin and black (almost bald). There are no deviations in the shape and symmetry of the head. The scalp is clean, has no bruises. Patient’s nails are pinkish, convex in shape, smooth, not brittle and has good capillary refill (less than 2 seconds). Her nails are well trimmed and do not show signs of clubbing. Her tongue is light pink, rough in texture, freely movable, and has no lesions. The patient has dentures (upper and lower). Has no signs of tartar and gums are pink and moist. The uvula is in the midline. The patient has a flat abdomen. Bowel sounds on left upper and lower quadrant is 3/min; hypoactive. Right upper and lower quadrant: 1/min. Skin shows no lesions, rashes, has good skin turgor. Has a scar below the umbilicus, midline, 5 inches and a scar on the right upper quadrant of the abdomen measuring 4 inches. Patient has decreased appetite. There are no signs of lesions on the mouth. No edema seen on extremities and other parts of body. Gag reflex is present. Patient is on soft diet. She is hooked to PNSS 1L x 8hrs, regulated at 31 drops/min, infusing well.

Analysis: Risk for Imbalanced Nutrition: Less than body requirements related to increased metabolic

demand.

C. Elimination Pattern

Subjective:“3 hanggang 7 beses akong dumudumi dati sa loob ng isang lingo. Naka-diaper ako ngayon,

nagpapalit ako dalawa o tatlong beses sa isang araw. Hindi pa ako nadudumi magmula nung lagyan ako ng tubo sa may kanang baga. Bale dalawang araw na ngayon na di ako nakakadumi pagkatapos ng CTT. Ayoko din masyadong uminom ng tubig kasi baka makaapekto naman yun sa tubig sa baga.Yung dumi ko dati madalas brown, parang oblong na maliit at hindi matigas. Dati mga lima hangang siyam na beses ako umiihi sa isang araw, mga isang baso kada-ihi at kulay dilaw. Ngayon ganun din naman pero di ko matantsa kung gano kadami kasi naka-diaper ako. Pag-nagpapalit ako ng diaper, puno naman palagi ng ihi.1-3 beses ako nagpapalit ng diaper sa isang araw. Wala naman masakit kapag umiihi ako o dumudumi at hindi ko pa naman nae-experience na may dugo na sa ihi or dumi ko."

Objective:Upon conducting the abdominal assessment, abdominal contour is flat, uniform in color, has a

scar below the umbilicus, midline, 5 inches and a scar on the right upper quadrant of the abdomen measuring 4 inches. Upon palpation, suprapubic area was not distended. Patient's intake for the shift was 650cc from oral intake and output 0f 630cc (urine). Patient’s bowel sounds are audible. Bowel sounds on left upper and lower quadrant is 3/min. Right upper and lower quadrant: 1/min. Upon percussion, tympany was heard over stomach; dullness over liver and spleen. No tenderness or unusual mass felt upon palpation. Patient is wearing diaper.

Analysis:Alteration in bowel elimination: Constipation related to insufficient fluid intake.

D. Activity-Exercise Pattern

Subjective:The patient verbalized, “’Yung mga gawain sa bukid pati mga gawaing bahay ang exercise ko.

Gumigising ako ng 5 ng umaga para mag almusal kasama ng asawa ko.Tapos pupunta na siya sa bukid. Ako naman maiiwan kasi gagawa ako sa bahay saka aasikasuhin yung bunso ko kasi pumapasok yun sa eskwelahan eh. Pagkatapos nun, nagpupunta na ko sa bukid at doon na inaabot ng hapon. Magmula nung nagkasakit ako, sa bahay na lang ako. Gumagawa pa rin ako ng gawaing bahay pero di na kagaya ng dati na naglalaba at pati ibang mabibigat na gawaing bahay. Ngayon dito sa ospital, natatakot akong tumagilid kasi baka matanggal yung tubo ko sa may kanang baga ko. Sinubukan kong umupo, pero masakit pa din. 8/10 yung sakit. Dito lang banda (CTT insertion site), parang kumikirot yung pakiramdam. Sumasakit lang naman kapag gumagalaw ako eh, yung tipong uupo o tatagilid. Nawawala lang kapag di na ko gumalaw saka pinainom ako ng gamut.

Objective:Patient can perform full range PROM and almost all AROM exercises. Patient is ambulatory with

a muscle strength on RUE=4/5; LUE=4/5; RLE=4/5; and LLE=4/5. Patient is weak and has fatigue. Patient has normal capillary refill (less than 2 seconds). The pulses have a clear quality. There are no murmurs heard. During inspiration, the lungs expand, costal angle increases, diaphragm descends. Vibrations are symmetric and most intense in the thoracic area and least at the base. Use of accessory muscles during inspiration The patient is not cyanotic. The patient’s muscles are of equal size on both sides of the body. Pulses are readily palpable. Normo-active reflexes on the triceps, biceps and patellar. The patient’s vital signs are as follows: BP=120/90 mmHg, PR=114, RR=22 Temp=36.8 C. (8:00 PM). Hemoglobin level: 118 g/L (Reference: 120-140 g/L), Hematocrit: 35% (Reference: 37-47%). Height = 5’4”, Weight = 127.8 lbs/58kg; BMI = 21.9. (+)cough (+) crackles (+)dyspnea

Analysis:Activity intolerance related to decreased oxygen supply secondary to non small cell lung

carcinoma.

E. Sleep-Rest PatternSubjective:

“Dati mga 10:00pm na ko matulog pagkatapos ng “Tayong Dalawa” at 5:00 am ako nagigising. Maaga kasi dapat nasa bukid na ako, dun yun sa Isabela. Nakataas ang ulo ko kapag natutulog at gumagamit ako ng 2-3 na unan. Nakatagilid lang ako karaniwan pag-natulog. Ako sa kanan ng kama tapos and asawa ko sa kaliwa. Naka-electric fan lang kami pag natutulog. Wala naman akong ibang ritwal bago ako matulog, basta makaligo at mag-toothbrush lang. Sa ngayon, parehas lang din yung pattern ng pag-tulog ko. Buti nalang ngayon may gamot na ko para sa sakit kaya mas mahimbing ako nakakatulog at hindi ko masyado nararamdaman yung sakit.”

Objective:There is no presence of darkening around the periorbital area. The client appears to be well rested

from sleep the night before. Client responds immediately when asked. Px was oriented with time, place and person. the client was able to discuss logical sequence of ideas during the interview. Patient is observed to be alert and able to concentrate and maintain eye contact during interview and assessment.

Analysis:

Readiness for enhanced sleeping pattern

F. COGNITIVE-PERCEPTUAL PATTERN

Subjective: “Ako ay 52 years old na at nakatira ako sa Isabela. Hapon na ngayon at nandito ako sa ospital sa

Medicine Ward. Si Macapagal ang presidente ngayon.Wala naman nag-iba sakin pagdating sa pang-amoy, pang- lasa, pagdinig. Malabo ang aking paningin kaya minsan nahihirapan makita yung mga nakasulat sa mga magazines kaya nagsasalamin ako. Ngayon ang nararamdaman ko ay sakit sa may pinagpasukan ng tubo ko. Minsan umaabot siya ng 9/10 kapag gumagalaw. Parang pinipiga ‘yung paligid nung nilagyan ng tubo. Hindi naman kumakalat ‘yung sakit nasa kanang bahagi lang siya ng tagiliran ko”. Patient was asked questions about her current location, time and weather. “Ako ay nasa UERM hospital, 8:30 na ng umaga, medyo maaraw sa labas.”

Objective: The patient was oriented to person, time and place. She was able to answer the questions given to

her. Her thought is coherent. The sclera of the eye is white. The pupils are round, clear, equal and react to light and accommodation. The patient has reading glasses. The pinna is perpendicular to the eye. The external canal is pink in color. The nose is symmetric and straight. There’s no presence of discharge and the patient was able to distinguish 2 out of the 2 smell testers. Patient was able to distinguish sharp from blunt objects and heat from cold sensation.No numbness or tingling sensation notedThe cranial nerves are intactPatient shows a guarded behavior on the right side of the chest, and irritability when discussing about pain in abdomen. Manifested facial grimace and self focusing.Cranial nerves:I. The patient was able to smell stimulants.II. 20/100III, IV, VI. There’s parallel cardinal gaze.V. Tongue movement is normal and there’s positive sensation in the face and scalp.VII. Taste senses are normal.VIII. Patient was able to maintain her balance and is able to hear in both ears.IX. Gag reflex are active. X. Swallowing reflex is present.XI. Sternomastoids and trapezii are strong. Analysis:

Acute pain related to irritation of nerve endings secondary to CTT insertion.

G. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

Subjective: The patient verbalized, “Ako yung tipo ng tao na hindi nahihiya sabihin yung opinion ko.

Strength ko yung madali ako makihalubilo sa mga tao. Madali at magaan ako kasama. And weakness ko ay minsan may nakakabangga ako kapag sinasabi ko opinion ko. At kapag may gusto ako usually gagawin ko ang lahat para makuha yun. itong sakit ko lang sa ngayon ang iniisip ko. Sana nga lang gumaling ako para marami na ako magawa. Kasama ko naman dito asawa ko e. Nagdadasal na lang ako lalo na kapag may nararamdaman akong sakit. Medyo naiilang lang ako sa itsura ko kasi wala na akong buhok. Sabi ng doktor noon magpaiksi na ako ng buhok kasi pwede daw malagas ang buhok ko dahil sa

radiation. Pero nagulat ako, talagang makakalbo pala ako. Pero wala naman problema ‘yun handa naman ako kasi kasama ito para gumaling ako. Sa ngayon, pakiramdam ko mamamatay na ako. Sobrang lala na ng sakit ko. Bakit pa sa lahat ng tao ako pa ang dinapuan ng ganitong sakit. Gusto ko pa makasama ng matagal ang pamilya ko.”

Objective: The patient manifested teary eyes, facial tension and quivering of voice upon description of

health status. Speech pattern is normal and thoughts are organized. She answered all the questions correctly and attentively depending on the situation. She is calm and maintains good eye contact. She is cooperative.

Analysis: Anxiety r/t threat in health status (terminal illness)

H. ROLE-RELATIONSHIP PATTERN

Subjective:The patient verbalized, “Apat kaming tao na nakatira sa bahay. Maganda ang pakikisama ko sa

asawa ko. Sinosuportahan talaga naming ang isa’t-isa. Tignan mo siya ang nagaalaga sakin dito sa ospital. Minsan nag-aaway kami pero hindi naman ‘yung sobrang away, natural lang naman kasi sa mag-asawa ang ganoon. Ok rin naman din ang pakikitungo ko sa mga anak ko pero may mga times talaga na nagkakainisan kami, lalo na kung sinusuway nila ako. Dati sa bahay ako yung taga-bili ng pagkain sa palengke, tumutulong ako sa pagbayad ng gastusin, nangangaral sa mga anak ko at gumagawa ng gawaing bahay . Nung nagkasakit ako, di ko n lahat ito nagagampanan.”

Objective: The client has clear speech pattern and well-organized thoughts. She was able to relate one story

or event to the other without difficulty recalling information. Px uses Tagalog and Ilocano language in communicating. No speech problems were noted upon assessment. She has an open communication with her family especially with her husband. She manifests satisfaction with her husband and brother accompanying her. Inadequate opportunities to perform role enactment. Presence of anxiety.

Analysis:Ineffective role performance r/t present health status

J. SEXUALITY-REPRODUCTIVE PATTERN

Subjective: The patient verbalized, “Bilang isang babae, sa tingin ko nagampanan ko naman ang tungkulin

ko bilang asawa at ina.Hindi ako marunong ng breast exam. Una akong nagkaroon noong 14 pa ako. Regular naman yung mens ko noon, nakaka 4 na napkin ako sa isang araw.. Nagmenopause ako 2 years ago. Tanggap ko na naman na hindi na kami nagtatalik ng asawa ko kasi matanda na kami. Mas problema ko ang sakit ko ngayon.”

Objective:The client’s breasts are bilaterally symmetrical, has no presence of lesions, lacerations. No

palpated mass on both breasts. Refused to assess genital area.

Analysis:

Readiness for enhanced sexuality-reproductive pattern

K. COPING-STRESS TOLERANCE PATTERN

Subjective:The patient verbalized, “Itong sakit ko ang pinakaproblema ko ngayon. Minsan kapag may

pagtatalo sa aming mag-asawa, naayos din naming ito kaagad kasi nag-uusap naman kami. Nagdadasal din ako at pinapasa Diyos ko na lang ang sakit ko. Tapos ‘yung bunso nakakatanggal ng init ng ulo pati mga apo ko kasi malalambing sila. Sabik na nga ako makita sila ulit eh. Suportado naman ako ng pamilya ko kaya yun ang isa sa nagpapalakas ng loob ko. Minsan sobrang nalulungkot ako at naiiyak na lang ko ngayon kasi pakiramdam ko mamatay na ako. Hindi ko na alam gagawin ko, hindi ko na alam ang dapat kong maramdaman dahil sa saki kong ito.”

Objective: The client was able to discuss logical sequence of ideas during the interview. She is alert and

immediately respond to the questions asked. The patient communicates calmly. Maintains good eye contact. Presence of anxiety. Quivering of voice, teary eyes and facial tension. Inability to meet role expectation.

Analysis:Ineffective coping r/t situational crisis

K. VALUE-BELIEF PATTERN

Subjective: “Katoliko ako. Lumaki ako at nasanay na nagsisimba tuwing lingo at nagdadasal lalo na kapag

mahal na araw. Pinalaki ako g magulang ko na may takot sa Diyos at may respeto sa ibang tao lalo na sa nakatatanda. Sa ngayon, dasal talaga ang isa sa mga nagpapalakas ng loob ko.”

Objective:the client was able to discuss logical sequence of ideas during the interview. She is alert and

immediately responds to the questions asked. The patient has religious articles and materials found on her bed. She answered all the questions consciously and coherently.

Analysis:Readiness for spiritual well being

Name of Drug; Class;

Dosage, Frequency and Route

Indication Action Contra-indication and Precaution

Laboratory Effects

Adverse Reaction

Interactions Nursing Responsibilities

Celecoxib

Pharmacologic Class: cyclooxygenase-2 (COX-2) inhibitor

Therapeutic Class: NSAID

Brand Name: Celebrex

200mg; BID; P.O.

Acute pain Thought to inhibit prostaglandin synthesis, impeding cyclooxygenase-2 (COX-2), to produce anti-inflammatory, analgesic, and antipyretic effects.

It is not contraindicated to the client.

Use cautiously in elderly patient.

May increase ALT, AST, BUN, and chloride levels. May decrease phosphate level.

CNS: Headache, dizziness

CV:Hypertension

Respiratory: upper respiratory tract infection.

Drug-Lifestyle: Long-term alcohol use, smoking: May cause GI irritation or bleeding. Check for signs and symptoms of bleeding.

Assess patient for CV risk factors before therapy.

Drug can cause fluid retention; monitor patient with hypertension, edema, or heart failure.

Drug may be hepatotoxic; watch for signs and symptoms of liver toxicity.

Drug can be given without regard to meals, but food may decrease GI upset.

NSAIDs may increase the risk of serious thrombotic events, MI, or stroke. The risk may be greater with longer use or in patients with CV disease or risk factors for CV disease.

Instruct patient to promptly report signs of GI bleeding such as blood in vomit, urine, or stool; or black, tarry stools.

Advise patient to

immediately report rash, unexplained weight gain, or swelling.

Instruct patient to take drug with food if stomach upset occurs.

Inform patient that it may take several days before he feels consistent pain relief.

Name of Drug; Class;

Dosage, Frequency and Route

Indication Action Contra-indication and Precaution

Laboratory Effects

Adverse Reaction

Interactions Nursing Responsibilities

Amlodopine besylate

Pharmacologic Class: calcium channel blocker Therapeutic Class: antianginal, antihypertensive

Brand Name: Norvasc

3mg/tab; O.D; P.O.

Hypertension

Inhibits calcium ion influx across cardiac and smooth-muscle cells, dilates coronary arteries and arterioles, and decreases blood pressure and myocardial oxygen demand.

It is not contraindicated to the client.

There were no reported effects on laboratory values

CNS: Headache, fatigue, dizziness

CV:Hypertension

Respiratory: dyspnea.

There were no reported drug-drug, drug-herb; drug-food; drug-lifestyle; interactions..

Monitor blood pressure frequently during initiation of therapy. Because drug-induced vasodilation has a gradual onset, acute hypotension is rare.

Assess patient for CV system before therapy.

Notify prescriber if signs of heart failure occur, such as swelling of hands and feet or shortness of breath.

Caution patient to continue taking drug, even when feeling better.

Name of Drug; Class;

Dosage, Frequency and Route

Indication Action Contra-indication and Precaution

Laboratory Effects

Adverse Reaction

Interactions Nursing Responsibilities

Oxcarbazepine

Pharmacologic Class: carboxamide derivative Therapeutic Class: anticonvulsant

Brand Name: Trileptal

300mg; BID; P.O.

Episodes of seizure activity

Thought to prevent seizure spread in the brain by blocking voltage-sensitive sodium channels, and to produce anticonvulsant effects by increasing potassium conduction and modulating high-voltage activated calcium channels.

It is not contraindicated to the client.

Use cautiously in elderly patient.

May decrease sodium and thyroxine levels.

CNS: Headache, fatigue, fever, dizziness, abnormal gait, anxiety, impaired concentration

CV: chest pain

GI: dry mouth, thirst

Respiratory: upper respiratory tract infection, coughing,

There were no reported any drug-drug; drug-lifestyle; drug-herb; drug-food interaction

Watch for signs and symptoms of hyponatremia, including nausea, malaise, headache, lethargy, confusion, and decreased sensation.

Monitor sodium level in patients receiving oxcarbazepine for maintenance treatment, especially patients receiving other therapies that may decrease sodium levels.

Oxcarbazepine use has been linked to several nervous system-related adverse reactions, including psychomotor slowing, difficulty with concentration, speech or language problems, somnolence, fatigue, and coordination abnormalities, such as ataxia and gait disturbances.

Drug may be taken with or without food.

Advise patient to report signs and symptoms of low sodium in the blood, such as nausea, malaise, headache, lethargy, and confusion.

Tell patient to report fever and swollen lymph nodes to his prescriber.

Monitor vital signs before giving medication

Name of Drug; Class

Dosage, Frequency and Route

Indication Action Contra-indication and Precaution

Laboratory Effects

Adverse Reaction

Interactions Nursing Responsibility

Tramadol hydrocchloride;

Pharmacologic class Narcotic and opioid analgesic

Brand Name Dolcet

1 tab; Q6 Moderate to moderately severe pain

Thought to bind to opiod receptors and inhibit reuptake of norepinephrine aand serotonin

It is not contraindicated to the patient.

Caution pt when rising and walking.

Use cautiously in pt at risk for seizures, in increase intracranial pressure.

May decrease hemoglobin

CNS: Dizziness, Headache,

EENT: visual disturbances

There were no reported drug-drug; drug-lifestyle; drug-food; drug-herb interaction.

Reassess level of pain at least 30 minutes after administration

Monitor CV and respiratory status

Monitor bowel and bladder function

For better effect, give it before onset of pain

Monitor for any

adverse reactions

Monitor for drug dependence and withdrawal syndrome if stopped.

Instruct patient to be careful when rising or moving.

Instruct patient not to stop drug abruptly

Tell pt to take drug as prescribed and not to increase dose or dosage interval unless ordered by the prescriber

Name of Drug; Class

Dosage, Frequency and Route

Indication Action Contra-indication and Precaution

Laboratory Effects

Adverse Reaction

Nursing Responsibility

paclitaxelPharmacologic class : miscellaneous antineoplastics

Brand name

135 mg/m2 through IV over 24 hours

Initial treatment of advanced non-small cell lung cancer

Prevents depoly-merization of cellular microtubules, thus inhibiting normal

Drug not contra-indicated to patient.

-May increase alkaline phosphatase, AST, and triglyceride levels

GI: nausea, vomitingMusculo-skeletal: myalgiaSkin: alopecia

Monitor blood counts often during therapy. Bone marrow toxicity is most common and dose-limiting toxicity. Packed RBC or platelet transfusions may be needed in severe cases. Institute bleeding precautions as

Taxol reorganiza-tion of microtubule network needed for mitosis and other vital cellular functions.

-May decrease hemoglobin and neutrophil, WBC and platelet counts.

appropriate.

Don't confuse paclitaxel with paroxetine.

Advise patient to report any pain or burning at site of injection during or after administration.

Tell patient to watch for symptoms of infection (sore throat, fever, fatigue) and bleeding (easy bruising, nosebleeds, bleeding gums, tarry stool).

Teach patient symptoms of peripheral neuropathy, such as tingling r burning sensation or numbness in limbs, and advise to report symptoms immediately.

Warn patient that reversible hair loss is common (up to 82% of patients)

Nursing Care PlansI. Ineffective airway clearance related to increased bronchial secretions and presence of tumor on the lungs secondary to non-small cell lung carcinomaAssesment Diagnosis Rationale Planning Implementation Rationale Evaluation

S> The patient verbalized, “inuubo parin ako hanggang ngayon simula pa nung bago ako maospital…kulay puti yung plema ko…sumasakit din yung dibdib ko kapag umuubo ako pero ngayon halos wala na...”

O> Received pt. conscious, coherent, afebrile, and lying on bed at semi-fowler position with attached O2 via nasal cannula at 2LPM administering well and with CTT insertion on right 6th

ICS anterior axillary line. Patient has slow capillary refill, (-) for clubbing, (-) cyanosis, (+) wheezes and (+) crackles on both upper and lower lobe of lungs, (+) Dyspnea, (+) productive cough

Ineffective airway clearance related to increased bronchial secretions and presence of tumor on the lungs secondary to non-small cell lung carcinoma

Tumor of the epithelial covering of lung airways grows invasively through surrounding tissue. Local invasion is likely to obstruct airways causing loss of ventilation, decrease in air volume, and subsequent infection behind the obstruction. Lung cancers of all various cell types have been observed similarly.

Source: human physiology by Bernardo Alberto houssay

;

Goal : After 5days of nursing intervention, the patient will have a patent airway as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions

Objective:After 8 hours of nursing intervention, the patient will be able to

a. Expectorate secretions more readily.

Independent

Assess status of respiratory system

Demonstrated and practiced deep breathing and coughing exercises.

Provided chest physiotherapy.

Teach patient about environmental factors that can precipitate respiratory problems.

Tachypnea, shallow respirations, and asymmetric chest movement are present because of discomfort of moving chest wall and/or fluid in lung.

Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways

To prevent stasis and loosen secretions.

Crackles are heard on expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction.

After 5days of nursing intervention, the patient had a patent airway as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions

After 8 hours of nursing intervention, the patient had:

a. Expectorated secretions more readily.

with whitish sputum. Vital signs: BP= 120/90; RR= 22; PR= 114;T=36.8; I= 650cc/ 8hrs; O= 630cc/ 8hrs.

Monitored CTT and regulated O2 administration via nasal cannula.

Watched out for significant bleeding greater than 100 ml per hour.

Dependent

For hourly chest draining of 100 cc than clamp

Collaborative

Refer to pulmonary clinical nurse specialist, home health nurse, or respiratory therapist as indicated

To facilitate drainage of excess pleural fluid and to supply oxygen demands.

To prevent excessive fluid loss.

To obtain pleural fluid to diagnostic tests

For co-management.

II. Alteration in Comfort: Acute Pain r/t irritation of nerve endings on the right 6th ICS anterior axillary line secondary to CTT insertion.Assessment Diagnosis Rationale Goal/ objectives Intervention Rationale EvaluationSubjective: The patient verbalized “Ngayon ang nararamdaman ko ay sakit sa may pinagpasukan ng tubo ko. Minsan umaabot siya ng 9/10 kapag

Alteration in Comfort: Acute Pain r/t irritation of nerve endings on the right 6th ICS anterior axillary line secondary to CTT insertion.

Neuropathic pain is non-nociceptive pain and may arise from disturbances or function or pathological change in peripheral and/ or central nervous system Neuropathic

Goal: After 8 hourss of nursing intervention, the pt will be able to report a decreased in pain scale from 9/10 to 2/10

Objectives:

Independent:Assessed pt’s general status.

Maintained pt. on semi-fowler position

Provided periods of

To serve as a baseline data

To prevent pt. from any complication of the vertebral disk.

To reduce any

Goal: After 2 days of nursing intervention, the pt will be able to report a decreased in pain scale from 9/10 to 2/10

Objectives:

gumagalaw. Parang pinipiga ‘yung paligid nung nilagyan ng tubo. Hindi naman kumakalat ‘yung sakit nasa kanang bahagi lang siya ng tagiliran ko”.

Objective: Received patient conscious, coherent, afebrile, and lying on bed in semi-fowler’s position with attached O2 via nasal cannula at 2LPM administering well and with CTT insertion on right 6th ICS anterior axillary line. The pt. has (+) facial grimace, (+) guarding behavior on the affected side. The pt. has limited range of motion and difficulty of turning and changing position independently. Vital signs: BP= 120/90; RR= 22;PR= 114;T=36.8; I= 650cc/ 8hrs; O= 630cc/ 8hrs.

pain is therefore not a discrete entity. It may comprise peripheral nerve injury, central nervous injury and a mixed type. Major causes of neuropathic pain in patients with cancer are compression or infiltration of nerves by tumor. Cranial nerve involvement due to base of skull metastasis mainly from breast or lungs… Source: Cancer nursing: care in context by Jessica Corner, Christopher Bailey

After 8 hours of nursing intervention the patient will:

a. Verbalize feelings and concerns regarding pain.

b. Demonstrate use of relaxation techniques and diversional activities as indicated for individual situation.

bed rest

Demonstrated and practiced with patient deep breathing exercise

Instructed to perform guided imagery as pain occurs

Instructed to practice pain diversionary activities such as listening to music

Assisted on changing position

Encouraged verbalization of feelings

Provided morning care and changed in bed linens

Advised the relative to maintain the pt on complete bed rest

Provided safe environment by raising the side rails

occurrence of pain

Serve as a form of comfort measure

Divert the pain thoughts into a happy thought

To facilitate divertion of attention to other things instead of pain

To prevent any further injury

To determine the level of pain and any concern of the pt

To provide as one of means of comfort measures

To maximize the energy capacity and to prevent any further complication upon movement vigorously

To prevent any falls and injury to the patient

After 8 hours of nursing intervention the patient: a. Verbalized feelings and concerns regarding pain.

b. Demonstrated use of relaxation techniques and diversional activities as indicated for individual situation

Encouraged to increase fluid intake

Monitored vital signs

Monitored I and O

Dependent:

Administered pain medications

Dolcet Celecoxib

Collaborative:

Instructed relative to assist patient in doing ADLs.

To prevent dehydration

To provide baseline data

Serve as a baseline data

To reduce the level of pain

To reduce occurrence of pain due to movement.

III. Activity intolerance r/t to decreased oxygen supply secondary to non-small cell lung carcinoma.Assessment Diagnosis Rationale Goal/ objectives Intervention Rationale EvaluationSubjective: The patient verbalized “ nanghihina at nahihilo ako tuwing sinusubukan kong gumagalaw…”

Objective: Received pt. conscious, coherent, afebrile, and lying on bed at semi-fowler position with attached O2 via nasal cannula at 2LPM administering

Activity intolerance r/t to decreased oxygen supply secondary to non-small cell lung carcinoma.

Insufficient physio-logical or psycho-logical energy to en-dure or complete re-quired or desired daily activities

Most activity intol-erance is related to generalized weak-ness and debilitation secondary to acute or chronic illness and disease. This is especially apparent

Goal: After 2 days of nursing intervention, the pt will be able to demonstrate gradual increase in activity tolerance.

Objectives: After 8 hours of nursing intervention the patient will:

a. Identify factors affecting activity

Independent:

Determine patient's perception of causes of fatigue or activity intolerance

Assess patient's level of mobility

These may be temporary or permanent, physical or psychological. Assessment guides treatment.

This aids in defining what patient is capable of, which is necessary before setting realistic goals.

After 2 days of nursing intervention, the pt was able to demonstrate gradual increase in activity tolerance.

Objectives: After 8 hours of nursing intervention the patient had:

a. Identified factors affecting activity tolerance and

well and with CTT insertion on right 6th ICS anterior axillary line. The pt. has functional level of , with (+) facial grimace, (+) guarding behavior, with (+) wheezes and (+) crackles on both upper and lower lobe of lungs, (+) Dyspnea, and slow capillary refill. Muscle strength on upper and lower extremities is 5/5, has limited range of motion and difficulty of turning and changing position independently. Vital signs: BP= 120/90; RR= 22; PR= 114;T=36.8; I= 650cc/ 8hrs; O= 630cc/ 8hrs. Decreased hemoglobin= 118g/L

in elderly patients with a history of or-thopedic, cardiopul-monary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and func-tion, which can im-pair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourish-ment, side effects of medications (e.g., -blockers), or emo-tional states such as depression or lack of confidence to ex-ert one's self. Nurs-ing goals are to re-duce the effects of inactivity, promote optimal physical ac-tivity, and assist the patient to maintain a satisfactory life-style.

Source: Nursing Care Plans, Diagno-sis and Intervention by Gulanick, Myers,

tolerance and eliminate or reduce their effects when possible.

b. Use identified techniques to enhance activity tolerance such as use of assistive devices

c. Demonstrate a decrease in physiological signs of intolerance.

Assess nutritional status.

Assess potential for physical injury with activity.

Assess need for ambulation aids: bracing, cane, walker, equipment modification for activities of daily living (ADLs).

Monitor patient's sleep pattern and amount of sleep achieved over past few days.

Observe and document response to activity.

Assess emotional response to change in physical status.

Encourage adequate rest periods,

Adequate energy reserves are required for activity.

Injury may be related to falls or overexertion.

Some aids may require more energy expenditure for patients who have reduced upper arm strength (e.g., walking with crutches). Adequate assessment of energy requirements is indicated.

Difficulties sleeping need to be addressed before activity progression can be achieved.

Certain changes in vital signs may need to be reported.

Depression over inability to perform required activities can further aggravate the activity intolerance.

Rest between activities provides

eliminated or reduced their effects when possible.

b. Used identified techniques to enhance activity tolerance such as use of assistive devices

c. Demonstrated a decrease in physiological signs of intolerance.

Klopp, Galanes, Gradishar, Puzas

especially before meals, other ADLs, exercise sessions, and ambulation.

Dependent:

Administer oxygen @ 2 LPM via nasal cannula.

Collaborative:

Teach caregivers to recognize signs of physical overactivity.

Involve patient and caregivers in goal setting and care planning

Encouraged relative to assist patient in doing ADLs

time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of a rest period.

To supply oxygen demands.

This promotes awareness of when to reduce activity.

Setting small, attainable goals can increase self-confidence and self-esteem.To prevent overexertion in doing activities.