Case of Amoebiasis

#1357 G. Masangkay Corner Mayhaligue Streets, Sta.
Cruz, Manila
METROPOLITAN HOSPITAL COLLEGE OF NURSING
INTRODUCTION Amoebiasis is due to invasion of the intestinal wall by the protozo
an parasite Entemoeba histolytica. Amoebic colitis results from ulcerating mucos
al lesions caused by the release of parasite-derived hyaluronidases and protease
s. It refers to infection of man by Entamoeba hystolytica initially involving th
e colon but which may spread to other soft tissues organs by contiguity or by he
matogenous or lymphatic dissemination most commonly to the liver and lungs. It i
s a worldwide parasitic disease. It creates many medical and surgical problems.
About 15 to 20 per cent of Indians are affected by the parasite. It can be acute
and chronic and can have intestinal and extra-intestinal manifestations. The ca
usative organism is a protozoa which remains in the large intestine and can be t
ransmitted to other organs like liver, lungs, brain, spleen and skin etc. It is
transmitted through contaminated food, water and infected human feaces. Amoebias
is can occur at any age. There is no gender or racial difference in the occurren
ce of the disease. It is a household infection and the human being is responsibl
e for spreading the disease. Most of the infected people remain asymptomatic (wi
thout symptoms) and are called as healthy carriers. If one person in a family ge
ts infected with the parasite, other family members are at the great risk of inf
ection. The human carrier can discharge up to 1.5x107 cysts per day. Pathogenic
amoeba which produce condition of a great clinical variation: Acute Amoebic Dyse
ntery stools contain blood and mucus which may give rise to amoebic hepatitis or
liver abscess Chronic Amoebic Dysentery with recurrent attack of diarrhea or re
latively mild dysentery Amoebic Colitis characterized by periods of constipation
and diarrhea and episodes of abdominal discomfort frequently stimulating append
icitis History of Discovery Human infections of the parasite are not a recent ph
enomenon. The earliest record of symptoms of the disease—bloody, mucose diarrhea—was
from the Sankskrit document Brigusamhita, written at around 1000BC. Assyrian an
d Babylonian texts also have references to the diseases, with descriptions of bl
ood in the feces, thus suggesting that amoebiasis occurred in the Tigris-Euphrat
es basin before the sixth century BC. Later records were able to distinguish bac
terial infections with those of amoebic origin: epidemics of dysentery by itself
are more likely to result from bacterial infections, while dysentery that is as
sociated with disease of the liver is more likely to be caused by amoeba. Thus,
around the second century AD, there was clearer understanding of the association
between liver abscesses and amoebas. Around the 16th century, amoebiasis became
more widespread in the developed world, mostly due to the growth of European co
lonies and increased world trade. There had been many clear descriptions of the
hepatic and intestinal forms of amoebiasis, considered as the cause of a “bloody f
lux” spreading through Europe, Asia, Persia, and Greece. The first accurate descri
ption of both forms of the disease came from the book Researches into the Causes
, Nature and Treatment of the More Prevalent Diseases of India and of Warm Clima
tes Generally by James Annersley, written in
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#1357 G. Masangkay Corner Mayhaligue Streets, Sta. Cruz, Manila
the 19th century. Considering their small size, protozoans were difficult to ide
ntify before the invention of the microscope in the 17th century. The causal age
nt, Entamoeba histolytica, was discovered in Russia in 1873 by Friedrich Losch.
His early observations came from the case of a young farmer who had from been su
ffering chronic dysentery. In his diagnosis, Losch found large numbers of of amo
eba in his feces and associated the amoebas to be the cause of the dysentery. Ca
usative Agent Entamoeba histolytica Entamoeba histolytica is an anaerobic parasi
tic protozoan, part of the genus Entamoeba. It infects predominantly humans and
other primates. It is estimated that about 50 million people are infected with t
he parasite worldwide. The active (trophozoite) stage exists only in the host an
d in fresh loose feces; cysts survive outside the host in water, soils and on fo
ods, especially under moist conditions on the latter. The cysts are readily kill
ed by heat and by freezing temperatures, and survive for only a few months outsi
de of the host.[1] When cysts are swallowed they cause infections by excysting (
releasing the trophozoite stage) in the digestive tract. The trophozoite stage i
s readily killed in the environment and cannot survive passage through the acidi
c stomach to cause infection. E. histolytica, as its name suggests (histo–lytic =
tissue destroying), causes disease; infection can lead to amoebic dysentery or a
moebic liver abscess. Symptoms can include fulminating dysentery, diarrhea, weig
ht loss, fatigue, abdominal pain, and amebomas. The amoeba can actually 'bore' i
nto the intestinal wall, causing lesions and intestinal symptoms, and it may rea
ch the blood stream. From there, it can reach different vital organs of the huma
n body, usually the liver, but sometimes the lungs, brain, spleen, etc. A common
outcome of this invasion of tissues is a liver abscess, which can be fatal if u
ntreated. Ingested red blood cells are sometimes seen in the amoeba cell cytopla
sm. Trophozoites are amorphous and range from 20-40um in diameter, and contain o
ne nucleus. They use a well-defined pseudopodium for their rapid, gliding locomo
tion. This pseudopodium is often extended greatly, such that there is no conspic
uous differentiation between ecto- and endoplasm. It was originally thought to l
ack mitochondria, but recent evidence of nuclear-encoded mitochondrial genes and
a remnant organelle proves otherwise. The cyst, which is capable of surviving i
n harsh environments as well as in the human stomach and small intestine; thus i
t is the cyst form that transmits the disease The trophozoite, which is involved
in the actual infection of the host by invading the host epithelial cells Infec
tion begins through fecal-oral contamination. Initially, a person ingests fecall
ly contaminated food or water that contains the E. histolytica cysts. The cysts
then pass through the stomach and small intestine (if any trophozoites were inge
sted, they would die from the acidic gastric juices of the stomach) and travel t
o the bowel lumen, where they excyst (with the help of the enzyme trypsin). Thus
, the potentially invasive trophozoite form is released into a safer environment
in which they can exist and cause infection. A total of four trophozoites emerg
e from each cyst.
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Most asymptomatic colonization (90% of all infections) arise because the trophoz
ites end up aggregating in the intestinal mucin layer and form new cysts, thus l
eading to a self-limited and asymptomatic infection. But in some cases (which ac
counts for the 10% of those who are both infected and symptomatic), the trophozo
ites adhere to and lyse the colonic epithelium, mediated by the GalNAc lectin th
at initiates invasion of the colon. Further damage at the site of invasion is ca
used by the presence of neutrophils that comes in as a response to the invasion.
In the process of invasion in the large intestine, the trophozoites also intera
ct with enteric bacteria, adapt to the changing oxygen environment, and ingest e
rythrocytes. Once the trophozoites have invaded the intestinal epithelium, they
may pass through damaged blood vessels and travel extraintestinally to invade th
e peritoneum, liver, lung, brain, and other sites. Trophozoites are often carrie
d in feces along with mucous and red blood cells. But what continues the cycle o
f infection from human to human is that most of the trophozoites encyst (convert
into the cyst form) at the end of the large intestine and are passed through fe
ces and contaminate soil, grass, fruits and vegetables, dirty hands, water and f
ood. Since the cysts can survive the harsh environment outside, they go on to sp
read the infection. Through all these sources, the cyst can once again enter the
digestive tract and continue the infectious cycle. The amoeba goes through asex
ual reproduction by binary fission Mode of Transmission Fecal-Oral Route Amoebia
sis occurs when E. histolytica parasites are somehow ingested—either taken in by m
outh, eaten or swallowed something infected with the parasite, or through person
-to-person spread. Those infected (though not necessarily symptomatic), pass the
parasite through their stools, and their contaminated hands can spread the para
sites to surfaces and objects which will be touched by other people. In some sit
uations, the disease can also spread sexually by oral-anal contact. The most com
mon mode of transmission is through water contaminated by feces or from food ser
ved by contaminated hands. As well, vegetables that were grown in feces-contamin
ated soil may lead to transmission of the disease. As well, geophagy (“the practic
e of eating earthy substances such as clay, chalk, and laundry starch, often to
augment a mineral-deficient diet”) is a common route of transmission in some cultu
res . Since E. histolytica can exist in two forms, both forms are present in con
taminated food and drinks: • Trophozoites (free amoeba) • Infective cysts (which are
surrounded by a protected wall Ingesting the trophozoite form is not harmful—the
trophozoites usually die in the acidic stomach of a person. However, the cysts f
orm are quite resistant to various environmental conditions, and are thus able t
o survive in the acidic contents of the stomach and go on to cause infection. Wh
en the cysts reach the intestine, the trophozoite forms are released in this saf
er environment where it can invade the epithelial cells of the large intestine,
causing flask-shaped ulcers. Trophozoites can also penetrate the intestinal muco
us layer and lead to colitis. The intestinal mucous layer serves an important ro
le in providing a barrier to invasion by blocking amoebic adherence to the under
lying epithelium and also by slowing motility of trophozoites.
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Thus, the trophozoites gain a strong advantage for infection when it is able to
invade this layer. It does this by killing epithelial cells, neutrophils and lym
phocytes—thus limiting the immune system’s response. It can also invade the venous s
ystem of the intestine and spread to other organs, including the liver, lungs an
d brain. When it reaches end of the large intestine, most of the trophozoites ar
e converted back to its cyst form and released into the environment through pass
age of stool, and a new cycle of infection begins. It is important to note that
although amoebic dysentery may not demonstrate any symptoms for long periods of
time (months, even years), the infected individuals still excrete cysts and, in
thus, infect their surroundings and aid in the spread of the disease. The motile
trophozoile is not an infected form whereas non-motile cyst is the infected one
. The infection is transmitted by cyst through ingestion. People discharge cyst
in the stool. The cyst remains live outside the body for days to weeks. It will
die quickly if it is not kept cool and moist. So the infection is transmitted fr
om one person to another through contaminated water. Food handlers are also the
immediate source of infection, if they are the healthy carriers. While handling
the food, they transmit the cyst in the food. Incubation period After infection,
it may take from a few days up to two to four weeks before developing overt sym
ptoms. However, some people may carry the parasite for several months or even ye
ars before they become ill. Thus, due to the slight variations in incubation per
iod, tracing the cause of the illness requires that one knows what he/she ate an
d drank and the places traveled in the weeks/months before becoming ill. Amoebia
sis is caused by protozoa. Amoebiasis is commonly spread by water contaminated b
y faeces or from food served by contaminated hands. It can also spread to other
organs like the liver, and brain by invading the venous system of the intestines
. Asymptomatic carriers pass cysts in the faeces. Contaminated drinking water ca
n also spread infection. The disease may also spread y oral-anal contact. Risk f
actors • Eating contaminated food. • Anal or directly from person to person contact.
• Eating Non-veggie foods. • Unhygienic conditions and Poor sanitation areas. • Eatin
g vegetables and fruits which have been contaminated by the harmful bacteria. Th
e most common symptoms of amoebiasis are diarrhoea, stomach cramps and fever. Ra
rely, amoebiasis can cause an abscess in the liver. Entamoeba histolytica parasi
tes are only found in humans. After infection, it may take a few days, several m
onths or even years before you become ill but it is usually about two or four we
eks.
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Signs and symptoms • Abdominal cramps. • Nausea. • Painful passage of stools. • Loss of
Weight. • Severe stomach pain. • Loss of Appetite. • Profuse diarrhoea. Treatment and
Diagnostic Exams help Consultation of a physician gastroentrologist; stool speci
men - Three fresh stool specimens diagnosis of 90 per cent of patients; sigmoido
s copy:
Treatment for carriers: idoquinot 650 mg x eight times a day for 20 days; furami
de 500 mg x eight times a day for 10 days; and paromomycin 25-30 mg/kg/day in di
vided three doses for seven days. Mild to moderate: metronidezole 750 mg thrice
a day x 10 days. No medicine should be taken without the prescription of the phy
sician/gastroentrologist. Self-medication is harmful than cure. Prevention 1. Im
provement of sanitary conditions: The sanitary conditions should be improved. As
mentioned earlier, the cyst can survive days to weeks in cool and moist conditi
ons. Proper disposal of human excreta should be there. 2. Control of flies: Flie
s should be controlled at living places. The flies must be eradicated from the h
ouse as they are responsible to transmit the disease from one place to another.
Foods and eatables should be covered and properly cooked before eating. 3. Safe
drinking water: Drinking water should be boiled. If one can afford, water filter
should be used. 4. Hand washing: Hand washing practices are also very helpful t
o control the infection. Hands should be properly washed with soap and water aft
er defecation. Especially before eating and preparing the food, hands should be
washed properly. 5. Washing of vegetables: Ground grown vegetables like carrot,
turnip, radish, should be washed thoroughly by running water. During infection,
these vegetables should be avoided because these may be contaminated with human
feaces.
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ANATOMY AND PHYSIOLOGY AN OVERVIEW ON THE DIGESTIVE SYSTEM
Digestion is the breaking down of food in the body, into a form that can be abso
rbed. It is also the process by which the body breaks down food into smaller com
ponents that can be absorbed by the blood stream. In mammals, preparation for di
gestion begins with the cephalic phase in which saliva is produced in the mouth
and digestive enzymes are produced in the stomach. Mechanical and chemical diges
tion begin in the mouth where food is chewed, and mixed with saliva to break dow
n starches. The stomach continues to break food down mechanically and chemically
through the churning of the stomach and mixing with enzymes. Absorption occurs
in the stomach and gastrointestinal tract, and the process finishes with excreti
on. Digestion is usually divided into mechanical processing to reduce the size o
f food particles and chemical action to further reduce the size of particles and
prepare them for absorption. In most vertebrates, digestion is a multi-stage pr
ocess in the digestive system, following ingestion of the raw materials, most of
ten other organisms. The process of ingestion usually involves some type of mech
anical and chemical processing. Digestion is separated into four separate proces
ses:
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2.
3.
4.
5. 6.
1. Ingesti on: The first activity of the digestive system is to take in food thr
ough the mouth. This process has to take place before anything else can happen.
Mechanical Digestion: The large pieces of food that are ingested have to be brok
en into smaller particles that can be acted upon by various enzymes. This is mec
hanical digestion, which begins in the mouth with chewing or mastication and con
tinues with churning and mixing actions in the stomach. Chemical Digestion: The
complex molecules of carbohydrates, proteins, and fats are transformed by chemic
al digestion into smaller molecules that can be absorbed and utilized by the cel
ls. Chemical digestion, through a process called hydrolysis, uses water and dige
stive enzymes to break down the complex molecules. Digestive enzymes speed up th
e hydrolysis process, which is otherwise very slow. Movements: After ingestion a
nd mastication, the food particles move from the mouth into the pharynx, then in
to the esophagus. This movement is deglutition, or swallowing. Mixing movements
occur in the stomach as a result of smooth muscle contraction. These repetitive
contractions usually occur in small segments of the digestive tract and mix the
food particles with enzymes and other fluids. The movements that propel the food
particles through the digestive tract are called peristalsis. These are rhythmi
c waves of contractions that move the food particles through the various regions
in which mechanical and chemical digestion takes place. Absorption: movement of
nutrients from the digestive system to the circulatory and lymphatic capillarie
s through osmosis, active transport, and diffusion Elimination: The food molecul
es that cannot be digested or absorbed need to be eliminated from the body. The
removal of indigestible wastes through the anus, in the form of feces, is defeca
tion or elimination
Underlying the process is muscle movement throughout the system, swallowing and
peristalsis. Human digestion process Phases of Gastric Secretion
•
•
•
Cephalic phase - This phase occurs before food enters the stomach and involves p
reparation of the body for eating and digestion. Sight and thought stimulate the
cerebral cortex. Taste and smell stimulus is sent to the hypothalamus and medul
la oblongata. After this it is routed through the vagus nerve and release of ace
tylcholine. Gastric secretion at this phase rises to 40% of maximum rate. Acidit
y in the stomach is not buffered by food at this point and thus acts to inhibit
parietal (secretes acid) and G cell (secretes gastrin) activity via D cell secre
tion of somatostatin. Gastric phase - This phase takes 3 to 4 hours. It is stimu
lated by distention of the stomach, presence of food in stomach and increase in
pH. Distention activates long and myentric reflexes. This activates the release
of acetylcholine which stimulates the release of more gastric juices. As protein
enters the stomach, it binds to hydrogen ions, which raises the pH of the stoma
ch to around pH 6. Inhibition of gastrin and HCl secretion is lifted. This trigg
ers G cells to release gastrin, which in turn stimulates parietal cells to secre
te HCl. HCl release is also triggered by acetylcholine and histamine. Intestinal
phase - This phase has 2 parts, the excitatory and the inhibitory. Partiallydig
ested food fills the duodenum. This triggers intestinal gastrin to be released.
Enterogastric reflex inhibits vagal nuclei, activating sympathetic fibers causin
g the pyloric sphincter to tighten to prevent more food from entering, and inhib
its local reflexes.
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The digestive system includes the digestive tract and its accessory organs, whic
h process food into molecules that can be absorbed and utilized by the cells of
the body. Food is broken down, bit by bit, until the molecules are small enough
to be absorbed and the waste products are eliminated. The digestive tract, also
called the alimentary canal or gastrointestinal (GI) tract, consists of a long c
ontinuous tube that extends from the mouth to the anus. It includes the mouth, p
harynx, esophagus, stomach, small intestine, and large intestine. The tongue and
teeth are accessory structures located in the mouth. The salivary glands, liver
, gallbladder, and pancreas are major accessory organs that have a role in diges
tion. These organs secrete fluids into the digestive tract Digestion begins in t
he oral cavity where food is chewed. Saliva is secreted in large amounts (1-1.5
litre/day) by three pairs of exocrine salivary glands (parotid, submandibular, a
nd sublingual) in the oral cavity, and is mixed with the chewed food by the tong
ue. There are two types of saliva. One is a thin, watery secretion, and its purp
ose is to wet the food. The other is a thick, mucous secretion, and it acts as a
lubricant and causes food particles to stick together and form a bolus. The sal
iva serves to clean the oral cavity and moisten the food, and contains digestive
enzymes such as salivary amylase, which aids in the chemical breakdown of polys
accharides such as starch into disaccharides such as maltose. It also contains m
ucin, a glycoprotein which helps soften the food into a bolus. the tongue which
tastes and manipulates the food Swallowing transports the chewed food into the e
sophagus, passing through the oropharynx and hypopharynx. The mechanism for swal
lowing is coordinated by the swallowing center in the medulla oblongata and pons
. The reflex is initiated by touch receptors in the pharynx as the bolus of food
is pushed to the back of the mouth. Pharynx, leads to both the trachea and the
esophagus. The Esophagus, a narrow, muscular tube about 25 centimeters (11 inche
s) long, starts at the pharynx, passes through the larynx and diaphragm, and end
s at the cardiac orifice of the stomach. The wall of the Esophagus is made up of
two layers of smooth muscles, which form a continuous layer from the Esophagus
to the oten and contract slowly, over long periods of time. The inner layer of m
uscles is arranged circularly in a series of descending rings, while the outer l
ayer is arranged longitudinally. At the top of the Esophagus, is a flap of tissu
e called the epiglottis that closes during swallowing to prevent food from enter
ing the trachea (windpipe) while. The uvula blocks off the nose. The chewed food
is pushed down the Esophagus to the stomach through peristaltic contraction of
these muscles. It takes only seconds for food to pass through the Esophagus, and
little digestion actually takes place. The stomach is a pear shaped pouch and i
t is also described as a thick walled elastic bag. The food enters the stomach a
fter passing through the cardiac orifice. In the stomach, food is further broken
apart, and thoroughly mixed with gastric acid and digestive enzymes that break
down proteins. The acid itself does not break down food molecules; rather, the a
cid provides an optimum pH for the reaction of the enzyme pepsin. The parietal c
ells of the stomach also secrete a glycoprotein called intrinsic factor which en
ables the absorption of vitamin B-12. Other small molecules such as alcohol are
absorbed in the stomach as well by passing through the membrane of the stomach a
nd entering the circulatory system directly. The form of the food in the stomach
is in semi-liquid form. The transverse section of the alimentary canal reveals
four distinct and well developed layers called serosa, muscular coat, submucosa
and mucosa. Serosa: It is the outermost thin layer of
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single cells called mesothelial cells. Muscular coat: It is very well developed
for churning of food. It has outer longitudinal, middle smooth and inner oblique
muscles. Submucosa: It has connective tissue containing lymph vessels, blood ve
ssels and nerves. Mucosa: It contains large folds filled with connective tissue.
The gastric glands have a packing of lamina propria. Gastric glands may be simp
le or branched tubular secreting mucus, hydrochloric acid, pepsinogen and renin.
The cardiac sphincter which closes off the top end of the stomach and the pylor
ic sphincter, which closes off the bottom. Small intestine which has a length of
about 6 m. The surface of the small intestine is wrinkled and convoluted to pro
duce a greater surface area for absorption. the sections of the small intestine
include the duodenum, jejunum, ileum. After being processed in the stomach, food
is passed to the small intestine via the Pyloric sphincter. The majority of dig
estion and absorption occurs here as chyme enters the duodenum. Here it is furth
er mixed with three different liquids: 1. bile, which emulsifies fats to allow a
bsorption, neutralizes the chyme, and is used to excrete waste products such as
bilin and bile acids (which has other uses as well). It is not an enzyme, howeve
r. The bile juice is stored in a small organ called the gall bladder. 2. pancrea
tic juice made by the pancreas. 3. intestinal enzymes of the alkaline mucosal me
mbranes. The enzymes include: maltase, lactase and sucrase, to process sugars; t
rypsin and chymotrypsin are also added in the small intestine. Most nutrient abs
orption takes place in the small intestine. As the acid level changes in the sma
ll intestines, more enzymes are activated to split apart the molecular structure
of the various nutrients so they may be absorbed into the circulatory or lympha
tic systems. Nutrients pass through the small intestine s wall, which contains s
mall, finger-like structures called villi, each of which is covered with even sm
aller hair-like structures called microvilli. The blood, which has absorbed nutr
ients, is carried away from the small intestine via the hepatic portal vein and
goes to the liver for filtering, removal of toxins, and nutrient processing. The
small intestine and remainder of the digestive tract undergoes peristalsis to t
ransport food from the stomach to the rectum and allow food to be mixed with the
digestive juices and absorbed. The circular muscles and longitudinal muscles ar
e antagonistic muscles, with one contracting as the other relaxes. When the circ
ular muscles contract, the lumen becomes narrower and longer and the food is squ
eezed and pushed forward. When the longitudinal muscles contract, the circular m
uscles relax and the gut dilates to become wider and shorter to allow food to en
ter. In the stomach there is another phase that is called Mucus which promotes e
asy movement of food by wetting the food. It also nullifies the effect of HCl on
the stomach by wetting the walls of the stomach as HCl has the capacity to dige
st the stomach. If the form of food in the stomach is semiliquid form, the form
of food in the small intestine is liquid form. It is in the small intestine wher
e the digestion of food is completed. After the food has been passed through the
small intestine, the food enters the large intestine. The large intestine is ro
ughly 1.5 meters long, with three parts: the cecum at the junction with the smal
l intestine, the colon, and the rectum. The colon itself has four parts: the asc
ending colon, the transverse colon, the descending colon, and the sigmoid colon.
The large intestine absorbs water
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from the bolus and stores feces until it can be egested. Food products that cann
ot go through the villi, such as cellulose (dietary fiber), are mixed with other
waste products from the body and become hard and concentrated feces. The feces
is stored in the rectum for a certain period and then the stored feces is egeste
d due to the contraction and relaxation through the anus. The exit of this waste
material is regulated by the anal sphincter. The large intestine functions to r
e-absorb (resorb) water and in the further absorption of nutrients. The bacteria
l flora of the large intestine includes such things as Escherichia coli, Acidoph
ilus spp., and other bacteria, as well as Candida yeast (a fungus). These bacter
ia produce methane (CH4), hydrogen sulfide (H2S), and other gases as they fermen
t their food. Occasionally, some of this gas is released as flatus. As these bac
teria digest/ferment left-over food, they secrete beneficial chemicals such as v
itamin K, biotin (a B vitamin), and some amino acids, and are our main source of
some of these nutrients. the rectum is the terminal portion of the large intest
ine and functions for storage of the feces, the wastes of the digestive tract, u
ntil these are eliminated. The external opening at the end of the rectum is call
ed the anus. The anus has two sphincters, one voluntary and one involuntary. The
pressure of the feces on the involuntary sphincter causes the urge to defecate
and the voluntary sphincter controls whether a person defecates or not. Carbohyd
rate digestion Carbohydrates are formed in growing plants and are found in grain
s, leafy vegetables, and other edible plant foods. The molecular structure of th
ese plants is complex, or a polysaccharide; poly is a prefix meaning many. Plant
s form carbohydrate chains during growth by trapping carbon from the atmosphere,
initially carbon dioxide (CO2). Carbon is stored within the plant along with wa
ter (H2O) to form a complex starch containing a combination of carbon-hydrogen-o
xygen in a fixed ratio of 1:2:1 respectively. Plants with a high sugar content a
nd table sugar represent a less complex structure and are called disaccharides,
or two sugar molecules bonded. Once digestion of either of these forms of carboh
ydrates are complete, the result is a single sugar structure, a monosaccharide.
These monosaccharides can be absorbed into the blood and used by individual cell
s to produce the energy compound adenosine triphosphate (ATP). The digestive sys
tem starts the process of breaking down polysaccharides in the mouth through the
introduction of amylase, a digestive enzyme in saliva. The high acid content of
the stomach inhibits the enzyme activity, so carbohydrate digestion is suspende
d in the stomach. Upon emptying into the small intestines, potential hydrogen (p
H) changes dramatically from a strong acid to an alkaline content. The pancreas
secretes bicarbonate to neutralize the acid from the stomach, and the mucus secr
eted in the tissue lining the intestines is alkaline which promotes digestive en
zyme activity. Amylase is secreted by the pancreas into the small intestines and
works with other enzymes to complete the breakdown of carbohydrate into a monos
accharide which is absorbed into the surrounding capillaries of the villi. Nutri
ents in the blood are transported to the liver via the hepatic portal circuit, o
r loop, where final carbohydrate digestion is accomplished in the liver. The liv
er accomplishes carbohydrate digestion in response to the hormones insulin and g
lucagon. As blood glucose levels increase following digestion of a meal, the pan
creas secretes insulin causing the liver to transform glucose to glycogen, which
is stored in the liver, adipose tissue, and in muscle cells, preventing
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hyperglycemia . A few hours following a meal, blood glucose will drop due to mus
cle activity, and the pancreas will now secrete glucagon which causes glycogen t
o be converted into glucose to prevent hypoglycemia. Note: In the discussion of
digestion of carbohydrates; nouns ending in the suffix -ose usually indicate a s
ugar, such as lactose. Nouns ending in the suffix -ase indicates the enzyme that
will break down the sugar, such as lactase. Enzymes usually begin with the subs
trate (substance) they are breaking down. For example: maltose, a disaccharide,
is broken down by the enzyme maltase (by the process of hydrolysis), resulting i
n a two glucose molecules, a monosaccharide. Fat digestion The presence of fat i
n the small intestine produces hormones which stimulate the release of lipase fr
om the pancreas and bile from the gallbladder. The lipase (activated by acid) br
eaks down the fat into monoglycerides and fatty acids. The bile emulsifies the f
atty acids so they may be easily absorbed. Short- and medium chain fatty acids a
re absorbed directly into the blood via intestine capillaries and travel through
the portal vein just as other absorbed nutrients do. However, long chain fatty
acids are too large to be directly released into the tiny intestinal capillaries
. Instead they are absorbed into the fatty walls of the intestine villi and reas
sembled again into triglycerides. The triglycerides are coated with cholesterol
and protein (protein coat) into a compound called a chylomicron. Within the vill
i, the chylomicron enters a lymphatic capillary called a lacteal, which merges i
nto larger lymphatic vessels. It is transported via the lymphatic system and the
thoracic duct up to a location near the heart (where the arteries and veins are
larger). The thoracic duct empties the chylomicrons into the bloodstream via th
e left subclavian vein. At this point the chylomicrons can transport the triglyc
erides to where they are needed. Digestive hormones There are at least four horm
ones that aid and regulate the digestive system:
•
•
•
•
Gastrin - is in the stomach and stimulates the gastric glands to secrete pepsino
gen(an inactive form of the enzyme pepsin) and hydrochloric acid. Secretion of g
astrin is stimulated by food arriving in stomach. The secretion is inhibited by
low pH . Secretin - is in the duodenum and signals the secretion of sodium bicar
bonate in the pancreas and it stimulates the bile secretion in the liver. This h
ormone responds to the acidity of the chyme. Cholecystokinin (CCK) - is in the d
uodenum and stimulates the release of digestive enzymes in the pancreas and stim
ulates the emptying of bile in the gall bladder. This hormone is secreted in res
ponse to fat in chyme. Gastric inhibitory peptide (GIP) - is in the duodenum and
decreases the stomach churning in turn slowing the emptying in the stomach. Ano
ther function is to induce insulin secretion.
11
Significance of pH in digestion Digestion is a complex process which is controll
ed by several factors. pH plays a crucial role in a normally functioning digesti
ve tract. In the mouth, pharynx, and esophagus, pH is typically about 6.8, very
weakly acidic. Saliva controls pH in this region of the digestive tract. Salivar
y amylase is contained in saliva and starts the breakdown of carbohydrates into
monosaccharides. Most digestive enzymes are sensitive to pH and will not functio
n in a low-pH environment like the stomach. Low pH (below 5) indicates a strong
acid, while a high pH (above 8) indicates a strong base; the concentration of th
e acid or base, however, does also play a role. pH in the stomach is very acidic
and inhibits the breakdown of carbohydrates while there. The strong acid conten
t of the stomach provides two benefits, both serving to denature proteins for fu
rther digestion in the small intestines, as well as providing non-specific immun
ity, retarding or eliminating various pathogens. In the small intestines, the du
odenum provides critical pH balancing to activate digestive enzymes. The liver s
ecretes bile into the duodenum to neutralise the acidic conditions from the stom
ach. Also the pancreatic duct empties into the duodenum, adding bicarbonate to n
eutralize the acidic chyme, thus creating a neutral environment. The mucosal tis
sue of the small intestines is alkaline, creating a pH of about 8.5, thus enabli
ng absorption in a mild alkaline in the environment. COLON (LARGE INTESTINE) The
colon is approximately 4.5 feet long, 2.5 inches wide, and is a muscular tube c
omposed of lymphatic tissue, blood vessels, connective tissue, and specialized m
uscles for carrying out the tasks of water absorption and waste removal. The tou
gh outer covering of the colon protects the inner layer of the colon with circul
ar muscles for propelling waste out of the body in an action called peristalsis.
Under the outer muscular layer is a sub-mucous coat containing the lymphatic ti
ssue, blood vessels, and connective tissue. The innermost lining is highly moist
and sensitive, and contains the villi- or tiny structures providing blood to th
e colon. The location of the parts of the colon is either in the abdominal cavit
y or behind it in the retroperitoneum. The colon in those areas is fixed in loca
tion. The colon is actually just another name for the large intestine. The short
er of the two intestinal groups, the large intestine, consists of parts with var
ious responsibilities. The names of these parts are: the transverse colon, ascen
ding colon, appendix, descending colon, sigmoid colon, and the rectum and anus.
12
PARTS OF THE COLON
Several parts make up the continuous tube of the colon. Each part contributes to
the movement of materials and the formation of stools. The parts include: Illeo
cecal Valve: The illeocecal valve is a fold of mucus membrane at the entry way t
o the colon. It is located where the small intestine meets the colon. Materials
from the small intestine pass into the colon through this valve. Vermiform Appen
dix: The appendix is attached to the bottom of the cecum. This is a twisted coil
ed tube that is about 3 inches long. The function of the appendix is not known.
Cecum: It is located below the illeocecal valve at the base of the colon. The up
per part of the cecum is open to the colon. The muscles of the cecum and the col
on advance feces upward out of the cecum. Ascending Colon: The ascending colon i
s located on the right side of the abdomen above the cecum. Here, most of the wa
ter is absorbed from the feces as it moves upward through the ascending colon. T
he ascending colon “ends” at the hepatic flexure where the colon bends to the left a
nd connects to the transverse colon. Transverse Colon:
13
The transverse colon runs laterally across the abdomen below the belly button. A
s feces move across the transverse colon, stools begin to take form. The transve
rse colon “ends” at the splenic flexure where the colon bends again and connects to
the descending colon which heads down the left side. Descending Colon: The desce
nding colon runs down the left side of the abdomen. Stools move down the descend
ing colon. Stools are now more solid in form. Here, stools may be stored for a t
ime. The descending colon “ends” where it continues into the sigmoid colon. Sigmoid
Colon: The sigmoid colon angles to the right, curving down and inward to about t
he midline, then it curves slightly upward where it connects to the top of rectu
m. Stools continue their descent as they move through sigmoid colon. Stools may
also be stored here for a time before they are moved into the rectum. Rectum and
Rectal Sac: The rectum is a passageway about 8 inches long that leads to the an
us. The rectum is usually empty until mass peristalsis drives the stools into th
e rectum. When stools fill the rectum, the elastic qualities of the walls permit
the rectum to expand, creating a sac to accommodate stools just prior to elimin
ation. Anal Canal and Anus: The last inch of the rectum is called the anal canal
. The mucus membrane of the canal has folds called anal columns that contain art
eries and veins. The opening of the anal canal to the exterior is called the anu
s. The anus is guarded by internal and external sphincters (muscles) that keep t
he anus closed except during elimination of a stool. The colon has no villi (mul
tiple, minute projections of the intestinal mucous layer which serve to absorb f
luids and nutrients) as compared to the small intestine and produces no digestiv
e enzymes. It is like a tube of circular muscle lined with a layer of moist muco
us cells that lubricate the contents. The smooth folds of the colon are speckled
with glands that resemble skin pores.
These glands extract the fluids and electrolytes from the passing food residue.
Between 1/3 -1 liter of water (which is recycled and eventually filtered and exc
reted by the kidneys as urine), electrolytes, and some vitamins, are absorbed da
ily through the colon. If colon bacteria are normal, vitamins B-1, B-2, B-12 and
K are produced by them, and all with the possible exception of B-12 are absorbe
d and used by the body traveling first to the liver via the portal circulation.
Absorption and storing fecal material are the colon s two main functions. The co
lon does secrete mucus to help the digested food along and hold the fecal materi
al together. It also plays a role in protecting the walls of the colon from bact
erial activity and neutralizes some of the fecal acids.
14
After processed matter from the small intestine enters the colon much absorption
occurs in the cecum and ascending colon. Mixing movements called haustrations o
ccur every few minutes and last about one minute apiece. They roll and mix the m
atter to expose most of it to the colon’s surface for absorption. Over 80% of the
material reaching the colon is reabsorbed. There are no peristaltic waves in the
colon but a few times daily (usually after meals) a segment of the colon usuall
y eight inches long will constrict (usually in the transverse or descending colo
n) to force the fecal material along. Our Feces are usually 75% water, 7-8% dead
bacteria, 2-7% fat, .510% protein, 5-10% roughage, byproducts, digestive juices
, etc. Once the stool moves out of the sigmoid colon into the rectum, a parasymp
athetic reflex is set up and the brain gets the signal that nature is calling, a
nd so we go. The external sphincter is under voluntary control and we can mental
ly overcome this reflex and prevent defecation if we desire to. Of all the vital
organs in the body, the one that suffers the most abuse from modern dietary hab
its is the colon. Large Intestine Microscopic Cross Section
Mucosal layer on the surface is made up simple columnar cells and a mucosal musc
ularis on the deep side . Submucosa contains fibrous connective tissue and blood
vessels. The muscularis externa is made up of a circular and a longitudinal mus
cle layer with a myenteric plexus
15
in between the layers. A very thin layer of Serosa is also present .
PROCESSING AND ACTIVITY OF THE COLON Aided by enzymes and muscular action, the m
outh, stomach and small intestine perform their individuated jobs of breaking do
wn and absorbing nutrients. The liquid that these organs generate is called chym
e. However, when it passes to the colon, the liquid that is leftover is mostly w
aste matter. This liquid waste matter is called feces. It is passed to the colon
for further processing and elimination. In the colon, instead of the enzymatic
action that occurs in other organs of the G.I. tract, further breakdown of fecal
matter and the production of substances occur by way of bacterial fermentation.
Cellular exchanges, bacteria, and muscular actions all play a part in processin
g the feces as it passes through the colon: Fluid Absorption: The colon lining c
ontains epithelial cells that absorb fluids and other substances such as vitamin
s and electrolytes. It is the absorption of fluids and bacterial processing that
transforms the soupy fecal matter into a stool. Secretion of Mucus: The colon l
ining contains epithelial cells that secrete mucus. This mucus moisturizes and l
ubricates the colon lining. This lining protects the colon wall and nerve tissue
s. Bacterial Growth: Bacteria live and grow along the colon lining. Using the fl
uids and foods you intake, bacteria actually manufacture the nutrients that sust
ain their environment and their food supply. Manufacture of Some Vitamins & Elec
trolytes: Bacteria change proteins into amino acids and break these amino acids
down further into indole and skatole (which gives stools their odor), hydrogen s
ulfide, and fatty acids. Bacterial action also synthesizes some vitamins (K and
some B), electrolytes, and breaks down bilirubin into a pigment that gives stool
s their brown color. Production of Lubrication: Bacteria ferment soluble fiber i
nto a lubricating gel that is incorporated into the stool mass as it is formed.
This gel helps to make stools soft and flexible. Some of this gel also coats the
exterior of the stools and is used by the colon to moisturize the colon lining.
This lubrication helps to ease stool passage through the colon. Defense against
Infection: Healthy intestinal bacteria help to groom the colon and keep it clea
n so that infections do not develop. They also help to fight the growth of infec
tious bacteria. Stool Formation: To form stools, muscles in the colon churn the
soupy liquid fecal matter as fluids are extracted until the particles have the c
onsistency to form a stool. 16
PATHOPHYSIOLOGY OF AMOEBIASIS
Predisposing Factors Developing countries Tropical and subtropical countries Urb
an areas
Precipitating Factors Unsanitary food handling Ingestion of contaminated food an
d drinks Poor environmental sanitation Socioeconomic status Crowded areas
Etiologic Agent Entamoeba histolytica
Mode of Transmission Fecal-Oral route
Ingestion of cyst of the infecting microorganism
Enters the stomach
17
Survives the acid environment of the stomach
Enters the small intestine
Excsytation occurs
Emergence of trophozoites
Trophozoites migrate in the large intestine
Trophozoites multiply by means of binary fission
Contact with the intestinal mucosa
Lytic digestion occurs
Invades the epithelium cells of the colon
18
Release of enterotoxins
Decrease integrity of thee intestinal wall
Increase secretion of water and electrolytes (Chloride and Bicarbonate)
Stimulation of the symphatetic/parasymphatetic responses
Decrease absorption
Inhibits sodium reabsorption Stimulation of the emetic center Large amount of CH
ON rich fluids Nausea/ Vomiting Diarrhea
Increase Gastrocolic reflex
Increase peristalsis
Abdominal pain Deficient fluid volume
Dehydration
19
Damage of intestinal tissues
Burrows deeper invading the sub mucosa
Increase vascular permeability
Chemotaxis occurs
Activation of prostaglandin
Formation of lesions
Swelling
Mobilization of leukocytes and macrophages
Stimulates the goblets cells in the colon
Flask shaped ulceration
Edema Migration of RBC and WBC Increase mucus production
Squeezed out / contraction
Compression of nerve endings
Abdominal pain
Blood and pus formation
Carried to lower portion of the colon
Progressive ulceration
Irritation of the intestine Hematochezia Ulcerative Colitis
Blood streaked feces
20
PATHOPHYSIOLOGY OF AMOEBEASIS Normally human intestinal flora protects the bowel
from colonization of pathogens; however, the intestinal flora can be disrupted
by harmful bacteria and viruses that cause tissue damage and inflammation or dep
ressed by antibiotic c therapy. Amoeba cause tissue damage and inflammation by r
eleasing toxins (enterotoxins) that stimulates the mucosal lining of the intesti
ne, resulting greater secretion of water and electrolytes into the intestinal lu
men. The active secretion of chloride and bicarbonate ions in the small bowel le
ads to inhibition of sodium reabsorption. To balance the excess sodium, large am
ounts of protein rich fluids are secreted in the bowel, leading to diarrhea The
metacystic trophozoites or their progenies reach the cecum and those that cone c
ontact with cecal mucosa penetrate or invade the epithelium by the lytic digesti
on if condition is favorable. The trophozoites burrow deeper with tendency to sp
read laterally by flask shape ulcers. There may several points of penetration. F
rom the primary site of invasion, secondary lesions may be produced at the lower
levels of the large intestines. Progenies of the initial colonies are squeezed
out of the neck of the ulcer and carried to the lower portion of the bowel, thus
have opportunity to invade and produce additional ulcers. Eventually the whole
colon may be involved. When the integrity of the GIT impaired its ability to car
ry out digestive and absorptive functions can be affected as well as the sympath
etic and parasympathetic afferent nerve will be stimulated thru the vagus, gloss
opharyngeal, vestibular and splanhnic nerves, which is located at the proximal d
uodenum, thus stimulates emetic center resulting to vomiting. As inflammation oc
curred, inflammatory response happened, chemical mediators are released in he in
jured tissue causing blood dilation of the blood vessels which is beneficial bec
ause it increases the speed with which blood cells and other important for r fig
hting infections and repairing the injury and brought to the injury site.It also
increase permeability of the blood vessels and fluid leaves the capillaries, pr
oducing swilling of the tissue. WBC and RBC leave the dilated and move to the si
te of infection, where they begin to phagocytize foreign microorganisms and othe
r debris.
21
BIOGRAPHICAL DATA Name Age Address Birthday Birthplace Gender Nationality Religi
on Marital Status Educational Attainment Occupation Informant Reliability HOSPIT
AL DATA Admission No. : Ward Room/Bed : Admitting Diagnosis : Chief Complaint :
Final Diagnosis : AMD : Date of Admission : Discharge Date : 78256 Station Annex
Room 105C Amoebiasis Loose bowel movement and abdominal pain Amoebiasis T/C Amo
ebic Colitis Dr. William Hoping Gan August 16, 2008 August 28, 2008 : : : : : :
: : : : : : : Ms. L.G. 33 years old Lim Compound, San Dionisio, Paranaque City J
anuary 21, 1975 Bohol Female Filipino Roman Catholic Single 2 yrs. Vocational Gr
aduate (Sewer) Businesswoman Patient and patient’s mother Total 95%
22
FAMILY BACKGROUND
Family Members Mr. R.G Mrs. D.G Ms. L.G (patient)
Position
Date of Birth 01/05/42 02/02/47 01/21/75
Age
Sex
Civil Status Married Married Single
Place of Residence Davao City
Educational Attainment High School Graduate High School Graduate 2-yr. Vocationa
l Course High School Graduate College Undergraduate
Occupation Unemployed
Salary N/A
Father Mother Eldest sibling
66 y/o 61 y/o 33 y/o
Male Female Female
Binondo, Sta. Cruz, Manila San Dionosio, Paranaque City Davao City Qatar
House helper Store vendor
3,500/ month 15,000/ month
Mrs. C.G Mr. J.G
Middle sibling Youngest sibling
09/04/78 07/24/81
30 y/o 27 y/o
Female Male
Married Single
Unemployed Factory Worker
N/A 20,000/ month
Currently, Ms. L.G is residing alone at San Dionisio, Paranaque City. She rents
a small house and has a sari-sari store as her means of income. Her father and m
iddle sibling lives together in Davao City together with their relatives. While
her mother is a stay in house helper at Binondo, Sta. Cruz, Manila. Ms. L.G’s youn
gest sibling works as a factory worker in Qatar. Ms. L.G finished a 2-year vocat
ional course in Bohol and had previously worked as a sewer and dressmaker at Afr
ica and Brunei for almost three years from 2003-2006. She went back here in the
Philippines last May 2006 since her contract to the agency she was employed alre
ady expired. She then decided not to return again abroad to work and started to
invest on a ‘sari-sari’ store which provided her with sufficient income. Her younges
t sibling is a college undergraduate and works as a factory worker in Qatar for
almost two years. SOCIO-ECONOMIC BACKGROUND Ms. L.G lives in a typical urban com
munity set-up situated at Lim Compound, San Dionisio, Paranaque City. The surrou
ndings in which her house is situated consists of compressed households and was
quite unsafe. Her mother verbalized, “ Medyo delikado nga dito sa lugar namin, Min
san may mga gulo at nag-aaway pero kahit papaano ligtas naman, may mga barangay
tanod naman dito.” While transportation, public and commercial establishments are
accessible within her house. She lives alone in a small bungalow type of househo
ld which she rents every month. But due to her recent health condition, her moth
er presently stays with her temporarily. The household comprises of a single bed
room, comfort room and a small space that serves as their living room and dining
area. The space of the household is approximately enough for two to three perso
ns only. In front of the house is a space provided for Ms. L.G’s small ‘sari-sari’ sto
re. The structure of the house is of mixed type built with wood and cement and t
wo medium size windows as a means of ventilation. The cleanliness of the house i
s maintained by the client herself. Ms. L.G’s water supply is from NAWASA. She pay
s for it monthly.
23
Ms. L.G. has her income through her small ‘sari-sari’ store. Her income every month
comprises of about 15,000 pesos. This income supports her alone with her basic n
eeds. However, part of it is given to her nephews and niece to support them with
their daily needs. The client verbalized, “ Sapat lang din para sa akin yung kini
kita ko sa tindahan pero sinusuportahan ko din yung mga pamangkin ko kasi wala n
aman trabaho yung pangalawa kong kapatid, kaya talagang nagigipit din ako.” On the
other hand, the youngest sibling of Ms. L.G. works abroad earning 20,000 pesos
a month which is given to support their family needs. While Ms. L.G’s mother earns
3,500 a month as a house helper which is also contributed to the family’s basic n
eeds. LIFESTYLE The client’s usual daily activity is more on housekeeping and watc
hing her ‘sari-sari’ store. She is not smoking and drinks alcohol occasionally. The
patient used to consider cleaning the house as a form of exercise and spends 7-8
hours of sleep per day. She seldom watches TV programs and prefers to read maga
zines and newspaper as well as listening to OPM music. She seldom goes to malls
and public places except when she needs to buy groceries for her ‘sari-sari’ store.
Ms. L.G. goes to church regularly every Sunday morning. She is not involved to a
ny organizations or social institutions and spends a lot of her time at home. FA
MILY HEALTH HISTORY The only recognized familial disease is hypertension, all ot
her hereditary diseases (e.g. diabetes mellitus, lung diseases, cancer etc.) was
not traced back to the client’s family generation. With her father side, both gra
ndparents are still alive with no alteration in their health condition. While he
r father is of good health status except that he smoked for almost 40 years from
now and denies any health problems. Hypertension is identified to the maternal
side. As evident, the client’s grandmother and mother were hypertensive and mainta
in a regular dose of antihypertensive drugs. However, the client herself is not
hypertensive in spite of having a family history of hypertension. The family see
ks medical consultation whenever they need to, but as for common health problems
such as flu, cough, fever and colds that are manageable, they practice self-med
ication. PAST MEDICAL HISTORY Medical History The patient had no previous medica
l records that are significant to her health condition prior to her recently dia
gnosed disease. The patient was never been admitted to a hospital and consider h
erself healthy prior to her sickness. She only consults medical advice for purpo
ses of going abroad as a requirement since the client previously worked outside
the country. The client verbalized, “Hindi pa naman ako na-ospital dati, ngayon la
ng talaga nung nagkasakit ako. Nung umpisa pa nga, ayoko din talaga magpa confin
e, kaso hindi ko na din talaga kaya. Nagpupunta lang ako sa ospital kapag magpap
a- medical kasi kailangan kapag mag-aabroad ako.” The patient had no surgical proc
edures done from the past. The client seldom take a dose of multivitamins and as
corbic acid. Uses Paracetamol (Biogesic) for fever, analgesic (Alaxan) for muscl
e or body pain, Diphenhydramine HCL (Neozep) for common colds and to relieve sym
ptoms of flu, and Guaifenessin (Robitussin) for coughs and colds. The patient ac
quired chicken pox and measles during her childhood years. No other communicable
disease noted from the past. The patient also have no allergic reactions to any
24
chemicals, foods or medications. The patient had an injury during an earthquake
attack on 1991 when she accidentally fell off the ground due to the intensity of
the earthquake and obtained a fracture in the wrist. Medical consultation was s
ought after the incident and was treated appropriately through anti inflammatory
medications and X-ray imaging. No complications was noted and complete bone hea
ling was achieved. The patient had an Oral Polio vaccination during her childhoo
d. Other immunizations were not remembered by the client. HISTORY OF PRESENT ILL
NESS Patient was in usual state of good health until April 2008 prior to confine
ment at the Metropolitan Medical Center. Four months prior to confinement, the p
atient had experienced mild abdominal pain and loose bowel movement. She had 3-6
times of bowel movement per day characterized with mucoid consistency, brownish
yellow in color and about 1 to ½ cup per bout. The onset of these symptoms begun
after the client ate from a usual ‘carinderia’ near her place. The client verbalized
, “ Pagkatapos ko kumain ng kaldereta dun sa karinderya malapit sa amin, sumama na
yung timpla ng tiyan ko. Tapos nagsimula na akong magtae, maaaring sa tubig din
na ininum ko dun sa karinderya kaya sumama yung timpla ng tiyan ko.” After which,
the client experienced persistent loose bowel movement and a gradual increase i
n the abdominal pain for consecutive days. Due to above symptoms, the client too
k an over the counter medication. She took ‘Imodium’ 1 tablet which offers a quite r
elief to her loose bowel movement. Eventually, 1 month after the onset of the sy
mptoms, the client continuously experienced loose bowel movement for 3-4 times p
er day with absence of the abdominal pain. She continues to take ‘Imodium’ as needed
and still offers relief to her condition. In this time, the consistency of her
feces is still of mucoid, foul odor, brownish yellow with blood streaked. This p
rompted the client to seek for medical consultation. Since the client is alone w
hile experiencing the above signs and symptoms, she contacts her mother to accom
pany her to the hospital for consultation. By late of May 2008, the client went
to San Juan de Dios Medical Center as an out patient. She was attended by Dr. Ma
riano and was prescribed for a fecalysis immediately during the time they consul
ted. Based on the result of the fecalysis, the attending medical doctor diagnose
d that the client has an Amoebiasis. She was then prescribed to take a daily dos
e of Flagyl for 7 days 750mg as a treatment regimen. After the consultation, the
treatment that was given to the client offered a great relief as compared to he
r recent condition prior to medical consult. She had a frequency of 23 bowel mov
ements per day but with same characteristics except with the presence of blood s
treak and amounts for about ½- 1 cup per bout. Still symptoms persist but with dec
rease in severity. However, by early June 2008, the client experienced severe ab
dominal cramping and aggravated loose bowel movements with a frequency of 3-5 ti
mes per day still with mucoid consistency, foul odor, brownish yellow with blood
streak, 1 ½ -2 cups per bout. This onset of aggravated symptoms was attributed wh
en the client had stopped taking her medication after experiencing a relief from
her previous conditions. Due to persistent above signs and symptoms, the client
once again consulted for a medical advice and was rushed to the emergency room
of Makati Medical Center. Upon the client’s confinement on the ER, she was again p
rescribed to have fecalysis as well as CBC and urine analysis. She was also give
n another set of antibiotics and advised to resume taking Flagyl for 7 days 750m
g. Once result of fecalysis was done, the client
25
was still diagnosed with Amoebiasis and was advised to continue medications. The
client was not admitted to the hospital since they preferred to went home and j
ust take the prescribed medications. From July 2008, the client’s condition stabil
ized and symptoms were alleviated. There was a gradual improvement on client’s bow
el movement. Normal bowel movement decreases from 1-2 times per day, semi formed
, brownish in color and 1 cup per bout. The abdominal pain was also relief. No f
ollow up consultation took place after symptoms was alleviated. By early August
2008, the client felt a sudden body weakness and loss of appetite with decrease
energy levels. This was accompanied again with loose bowel movements of at least
2-3 times per day, mucoid consistency, brownish yellow, foul odor and amounting
to 1 to 1 ½ cup per bout. These symptoms persist for almost a five days before th
e client started to consult for the third time. By August 13, 2008, the client c
onsulted for medical advice at Metropolitan Medical Center under the service of
Mr. William Hoping Gan, a specialist on internal medicine. The physician was ref
erred to client’s mother by her superior on the house she works. Another set of la
boratory test was prescribed to the client including fecalysis with culture and
sensitivity. They were advised to continue taking the medications previously pre
scribed and was advised to go back at his clinic after 3 days and reports if sym
ptoms still persist. By August 16, 2008, two hours prior to client’s admission, th
ey went back to Dr. Gan’s clinic for follow up consultation. The result of the fol
lowing test including fecalysis with culture and sensitivity revealed that the c
lient still suffered from a chronic Amoebiasis and considering the client of hav
ing a complication of amoebic colitis. This prompted the physician to advise the
client to be confined at the hospital institution for further medical managemen
t and treatment modalities. She was admitted at Metropolitan Medical Center at s
tation Annex room 105A.
26
DEVELOPMENTAL DATA Psychosocial Development Theory by Erik Erickson Stage 7: Mid
dle Adult (late 20’s to 50’s years) Psychosocial Crisis: Generativity vs. Stagnation
Psychosocial Virtue: Care Maladaption and Malignancies: Overextension, Rejectiv
ity Erik Erickson adapts and expands Freud’s theory of development to include the
entire life span, believing that people continue to develop throughout life. He
believed in the massive influence of culture on behavior and placed more emphasi
s on the external world such as depression and was according to his theory, each
stage signals a task that must be achieved. The resolution of task can be compl
ete, partial and successful. He believes that the greater the task achievements
the healthier the personality of the person. Failure to achieve a task influence
s the person’s ability to achieve the next tasks. Erickson emphasizes that people
must change and adapt their behavior to maintain control over their lives. The s
eventh stage is that of middle adulthood. It is hard to pin a time to it, but it
would include the period during which we are actively involved in raising child
ren. For most people in our society, this would put it somewhere between the mid
dle twenties and the late fifties. The task here is to cultivate the proper bala
nce of generativity and stagnation. Generativity is an extension of love into th
e future. It is a concern for the next generation and all future generations. As
such, it is considerably less "selfish" than the intimacy of the previous stage
. Generativity on Erikson considers teaching, writing, invention, the arts and s
ciences, social activism, and generally contributing to the welfare of future ge
nerations to be generativity as well -- anything, in fact, that satisfies that o
ld "need to be needed." Stagnation, on the other hand, is self-absorption, carin
g for no-one. The stagnant person ceases to be a productive member of society. I
t is perhaps hard to imagine that we should have any "stagnation" in our lives,
but the maladaptive tendency Erikson calls overextension illustrates the problem
: Some people try to be so generative that they no longer allow time for themsel
ves, for rest and relaxation. The person who is overextended no longer contribut
es well. I m sure we all know someone who belongs to so many clubs, or is devote
d to so many causes, or tries to take so many classes or hold so many jobs that
they no longer have time for any of them More obvious, of course, is the maligna
nt tendency of rejectivity. Too little generativity and too much stagnation and
you are no longer participating in or contributing to society. And much of what
we call "the meaning of life" is a matter of how we participate and what we cont
ribute. This is the stage of the "midlife crisis." Sometimes men and women take
a look at their lives and ask that big, bad question "what am I doing all this f
or?" Notice the question carefully: Because their focus is on themselves, they a
sk what, rather than whom, they are doing it for. In their panic at getting olde
r and not having experienced or accomplished what they imagined they would when
they were younger, they try to recapture their youth. Men are often the most fla
mbouyant examples: They leave their long-suffering wives, quit their humdrum job
s, buy some "hip" new clothes, and start hanging around singles bars. Of course,
they seldom find what they are looking for, because they are looking for the wr
ong thing. 27
But if you are successful at this stage, you will have a capacity for caring tha
t will serve you through the rest of your life. Ms. L.G, a 33 year old single wo
man lives most of her life alone and is independent as with regards to making de
cision. She finished a two-year vocational course and became a sewer in South Af
rica from 2004-2006 but had resigned last mid 2006 and went home. Now she owned
a sari-sari store from which she managed alone. The income she gets from her sar
i-sari store provides her needs and allows her to somehow support her nephew and
niece with their basic needs as well. Her usual activities are primarily focuse
d on household chores, watching her store and house keeping. She likes sewing mo
st especially when she had nothing so important to do. Ms. L.G. is not affiliate
d or involved to any organizations or institutions within their community or the
society as a whole. However, she is able to interact with her neighbors and min
gled with them during free her free time.
Physical Development Mrs. L.G.weighs 42.7 kg or 94 lbs and stands 5 foot or 1.52
4m and is conscious but appears irritable and less pleasant. She appears younger
than her chronological age. She has no deformities noted. According to her moth
er,“Hindi siya malakas kumain pero hindi naman siya mapili sa pagkain”. Neuromuscula
r skills are refined and eye-hand coordination is facilitated. Mrs. L.G can dres
s herself, is able to wash her own face and hands, brush teeth and attend to her
own toilet needs. She is able to write and read. In essence, she is able to do
the usual activities of daily living with no limitations. Her menstruation perio
d start at age 13 and she is regular since then. Psychosocial Development For ma
ny women in midlife, sexuality has achieved a degree of stability. A sense of fe
mininity and comfortable patterns of behavior has been established. This increas
ed security in identity can promote greater intimacy in sexual and social relati
onships. This may also be the time when adults allow themselves more freedom in
exploring and satisfying sexual needs. Menopause alters reproductive functioning
; it does not physically inhibit sexual functioning. Generally, a woman with a s
trong self- image, positive sexual and social relationship and knowledge regardi
ng her body and menopause is more likely to progress thru this natural biologica
l stage without problems and remain sexually active and satisfied. Midlife is of
ten a time. When women reexamine life goals, careers, accomplishments, values sy
stems and familial and social relationships, as a result some people adapt, wher
eas, other experience stress or a crisis. This reexamination can positively or n
egatively affect individual gender identity and sexuality. As with regards to Ms
. L.G’s developmental assessment, she remains single up to her present age and doe
s not have any affair with anyone. In this stage, it can be considered that thro
ugh this time where she is at her midlife, Ms. L.G. had already achieved a sense
of stability as with regards to her sexuality. However, exploring and satisfyin
g sexual needs might be a problem to Ms. L.G. This is of the reason that she was
not able to experience intimate relationship from her past as with regards to t
he opposite sex as to build her own family. Another reason is that she had lived
most of her life alone and independent that such support system coming from fri
ends, family and other significant others is less achieved.
28
Ms. L.G. is also experiencing current issues and problems that involve her famil
y and immediate relatives. These issues involve supporting her relatives, financ
ial constraints and conflicts that arises among family members. This had become
her stressor through this stage of her development which has greater impact to t
he way she thinks and make decisions. Such stressors and crisis might affect the
way Ms. L.G. reexamines her goal and value system as part of her task on her ag
e now. She is also at risk of failing her developmental task for the reason that
generating goals and values that focus on unselfish desires are hindered result
ing to stagnation and becoming self absorbed. This is evident to Ms. L.G. since
she happened to live alone and independent, limited support system and social fu
nctioning is quite unmet and might result to rejectivity. Robert Havighurts Deve
lopmental Task The idea of "developmental task" is generally credited to the wor
k of Robert Havighurst who indicates that the concept was developed through the
work in the 1930s and 40s of Frank, Zachary, Prescott, and Tyron. Others elabora
ted and were influenced by the work of Erik Erikson in the theory of psychosocia
l development. Havighurst states:. The Developmental Task Concept From examining
the changes in your own life span you can see that critical tasks arise at cert
ain times in our lives. Mastery of these tasks is satisfying and encourages us t
o go on to new challenges. Difficulty with them slows progress toward future acc
omplishments and goals. As a mechanism for understanding the changes that occur
during the life span. Robert Havighurst(1952, 1972, 1982) has identified critica
l developmental tasks that occur throughout the life span. Although our interpre
tations of these tasks naturally change over the years and with new research fin
dings. Havighurst s developmental tasks offer lasting testimony to the belief th
at we continue to develop throughout our lives. Middle Age (Ages 30-60) Achievin
g adult social and civic responsibility. * Reaching and maintaining satisfactory
performance in one’s occupational career. * Developing adult leisure time activit
ies. * Relating oneself to one’s spouse as a person. * To accept and adjust to the
physiological changes of middle age. * Adjusting to aging parents. Ms. L.G. is
able to achieve this stage of her life as evidence by the following aspects. Fir
st Ms. L.G. has finished a 2 year vocational course and is currently owning a sm
all sari-sari store that she is currently managing, also the client is able to h
ave her time for relaxation and she has a good relationship with her parents. Th
e client has not complained any emotional aspects regarding the state of her par
ents but there is no sign on her that she is not coping with the physiological c
hanges of her life.
29
LEVEL
OF
COMPETENCIES PHYSICAL COMPETENCY BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET
OF SIGNS AND SYMPTOMS DURING HOSPITALIZATION PRIOR DISCHARGE DATE DISCHARGE: AU
GUST 28, 2008 After hospitalization, the client regained some energy and was abl
e to tolerate activities such as walking, preparing her meals, managed her ‘sari-‘sa
ri’ store. However, there are still limitations on her activities such as those th
at are strenuous in nature (e.g. lifting, pushing etc.) The client verbalized, “Ma
s ok na ako ngayon. Mas nagagawa ko yung mga Gawain sa bahay at nakakapagbantay
uli ako ngb tindahan. Pero medyo nanghihina pa din ako lalo na kapag nagbubuhat.”
ANALYSIS
DURING HOSPITALIZATION ( APRIL 2008AUGUST 2008) DATE OF CONFINEMENT: AUGUST 16-2
8, 2008 The client is of During the onset of healthy condition. signs and sympto
ms She was able to and the time he was perform activities diagnosed of having a
of daily living disease and confined in with no limitation the hospital, the cli
ent and with no experience body alterations on weakness and decrease energy leve
ls. She energy levels. There was able to was a gradual decrease managed her on a
ctivities that were ‘sari-sario’ store. previously performed The client by the clien
t. The client verbalized, “ verbalized, “ Sobra Masigla at yung panghihina na malaka
s ako bago naramdaman ko noong ako magkasakit. nagkasakit ako, Wala akong nanghi
hina at wala nararamdaman na talaga akong ganang kakaiba sa magkikilos, kahit ng
a katawan ko.” maglakad, hirap ako.”
Client’s physical competency was altered during her illness state; there was a gra
dual decrease on her physical competency that includes activity intolerance in s
ome degree and decrease energy levels. Previous activities that were done prior
illness were not tolerated by the client. However, after illness state, the clie
nt was able to regain energy levels and tolerate activities previously performed
but still with little limitations on task that induce force or stress to client’s
physical attributes.
30
MENTAL COMPETENCY BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND S
YMPTOMS DURING HOSPITALIZATION PRIOR DISCHARGE DATE OF DISCHARGE: AUGUST 28, 200
8 After hospitalization, the client presently lives with her mother, she was abl
e to make decisions again on her own but her mother’s opinion is of great influenc
e in making decisions. The client verbalized, “ Sa ngayon, sinasanguni ko na din k
ay mama yung mga desisyon ko, pinaguusapan na namin.” Decisions of the client wher
e first informed ANALYSIS
8, 2008 Client finished a During her two year confinement, the vocational primar
y decision maker graduate. She is as with regards to capable of client’s condition
was making her own her mother, the client decisions and was irritable, loses he
r expressing her focus and decrease own opinions. attention span during She is q
uite her confinement. She independent with allows her mother to her decision tak
e decisions for the makings since she plan of care lives alone. There appropriat
e to her were no condition. The client significant others verbalized, “ Nung na th
at influences ospital ako, si nanay her decisions. The talaga ang client verbali
zed, nagdedesisyon para sa “ Wala naman akin. Syempre, hindi akong problema talaga
maganda yung pagdating sa pakiramdam ko.” pagdedesisyun, madalas ako talaga ang n
agdedesisyun kasi hindi ko din kasam ang pamilya ko simula ng nagtrabaho ako han
ggang sa pagbalik ko.”
As regards to client’s mental competency, the client is independent with regards t
o decision making prior to illness state. This is primarily affected since clien
t lives alone for almost a long time making responsible with all her decisions m
ade. But through the course of her illness up to her discharge, the mother of th
e client plays a significant role on the client’s decisions which heightens during
her hospitalization. to her mother and together they make a decision.
31
EMOTIONAL COMPETENCY BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AN
D SYMPTOMS DURING ILLNESS PRIOR DISCHARGE DATE OF DISCHARGE: AUGUST 28, 2008 Aft
er hospitalization, the client was still quite emotionally distressed but is rel
ief from being discharge to the hospital. The client verbalized, “ Syempre masaya
ako na nakalabas na ako sa ospital at wala na ako nararamdaman na masama sa kata
wan ko.” ANALYSIS
8, 2008 The client is quite The client was unhappy and is emotionally distress b
urden on how to during her support his family hospitalization; this and signific
ant was manifested by the relative. Since client by becoming their clan has irri
table, frowns all the problems with time and refrain from their finances, this t
alking to others. The serves as major patient verbalized, “ problem to the Sobrang
nahirapan din client which talaga ako nung naaffects her ospital ako. Ang dame
emotionally. The kong iniisip lalo na client verbalized, yung gastos tapos “ Mahir
ap talaga sabayan pa ng ang buhay masamang ngayon. Hindi din pakiramdam.” naman ka
mi mayaman, maraming panahon na medyo nagigipit talagga kami. Tapos ako din kasi
yung tunutulong sa mga kamag-anak ko.”
Due financial problems within the client’s family, the client was unhappy and feel
s burden on how she could manage to support the basic needs of her family and si
gnificant relatives. She is emotionally affected with this situation and was agg
ravated when she was confined to the hospital. Her peak of emotional disturbance
s reaches it’s height when she had a disease. But felt relief when she was healed
and discharged from the hospital. Still, existing problems within the client’s fam
ily affects the client emotionally.
32
SOCIAL COMPETENCY BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND S
YMPTOMS The client is of good interpersonal relationship with her friends and ne
ighbors. This is evident with client having conversation with neighbors during m
id-afternoon in front of her ‘sarisari’ store. She had good relationships with her p
revious coworkers at Africa and Brunei. The client verbalized, “ Wala naman akong
problema sa mga kaibigan ko at sa mga katrabaho ko dati, marunong naman kasi ako
makisama.” DURING ILLNESS DURING HOSPITALIZATION ( APRIL 2008AUGUST 2008) DATE OF
CONFINEMENT: AUGUST 16-28, 2008 During her confinement, the client interpersona
l relationship was interrupted. This is manifested during nurse-patient interact
ion. The client was irritable and refrains from speaking to others. The client v
erbalized, “ Ayoko talaga makipagusap sa kahit kanino nung nasa ospital ako. Hindi
kasi talaga maganda yung pakiramdam ko at irritable pa talaga ako.” PRIOR DISCHAR
GE DATE OF DISCHARGE: AUGUST 28, 2008 The client was able to return her good int
erpersonal relationship with others immediately after her discharge to the hospi
tal. She was visited by her neighbors and friends after hospitalization. The cli
ent verbalized, “Naging ok naman na yung pakikitungo ko sa mga kaibigan at kapit b
ahay ko simula nung na-discharge ako, wala naman nagbago.” ANALYSIS
The patient experienced an interrupted interpersonal relationship during her ill
ness state; this is possibly related with client experiencing an alteration in c
omfort that results to client’s becoming irritable and refrain interacting with ot
hers.
SEXUAL COMPETENCY
33
BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND SYMPTOMS The client’s
civil status is single and has no recent sexual affairs. The patient verbalized
, “ Wala akong asawa, medyo pihikan ako sa lalake eh. Pero dati may mga nanliligaw
sa akin.”
DURING ILLNESS DURING PRIOR HOSPITALIZATION DISCHARGE ( APRIL 2008DATE OF AUGUST
2008) DISCHARGE: DATE OF AUGUST 28, 2008 CONFINEMENT: AUGUST 16-28, 2008 There
was no There was still no significant change on significant changes to the clien
t’s sexual client’s sexual competency during her competency as illness state since t
he compared before her client is single and illness state. does not have any aff
airs to anyone.
ANALYSIS
The client has no significant changes with regards to her sexual competency. The
client was single and no recent sexual affairs.
SPIRITUAL COMPETENCY
34
DURING ILLNESS DURING PRIOR HOSPITALIZATION DISCHARGE ( APRIL 2008DATE OF AUGUST
2008) DISCHARGE: DATE OF AUGUST 28, 2008 CONFINEMENT: AUGUST 16-28, 2008 The cl
ient is a During her After hospitalization, Roman Catholic confinement, the clie
nt the client resumed her and attends was unable to attend regular attendance Su
nday mass on a Sunday mass but was during Sunday mass regular basis and able to
pray anytime and prays regularly practices religious she wants. The client anyti
me she wants. The beliefs. The client verbalized, “ Syempre client verbalized, “ ver
balized, “ nung nasa hospital ako, Nung makalabas na Palage ako hindi ako ako ng o
spital at nagsisimba nakakapagsimba. Pero medyo ok na yung tuwing lingo. kahit p
apaano pakiramdam ko, Pinapraktis nagdadasal ap din ako nagsisimba na uli ako.” na
ming yung mga lalo pa at may sakit prusisyon, ako.” penitensya kapag mahal na araw
.’
BEFORE ILLNESS ( BEFORE APRIL 2008) PRIOR ONSET OF SIGNS AND SYMPTOMS
ANALYSIS
The client was unable to attend with her religious activity such as attending ch
urch mass every Sunday when she was hospitalized. However, was able to resume ag
ain after hospitalization. The clients have an aptitude on attending regular chu
rch mass and have faith and believe to the Lord Almighty. She presented personal
, health and family problems to God through prayers and religious activities.
PATTERNS OF FUNCTIONING EATING PATTERN (Consists only of samples of what the pat
ient usually consumes.) 35
DURING ILLNESS Prior to Hospitalization During Hospitalization Before Illness (E
arly April 2008-Early (August 16 2008-August 28, (Daily Basis) August 2008 ) 200
8) Onset of recurrent signs and symptoms BREAKFAST (7 am- BREAKFAST (7 am-varies
) DIET UPON ADMISSION: varies) Usually consumes 1-2 pcs. Of Low fat diet Usually
consume 3-4 medium size pandesal, at least pcs. of medium size 2 thin slices of
dairy cream, ½ pandesal, 3-4 thin cup coffee with creamer Succeeding Diet: slices
of dairy cream BRAT diet and Bland Diet and 1 cup of coffee LUNCH without dairy
products with creamer (12:00 NN – time varies ) • Usual meal of the Usually consume
s a cup of client during LUNCH rice, approximately ¼ portion hospitalization varie
s (12:00 NN – time of meat or fish, and 1-2 to the hospital food varies ) glasses
of water being given. This Usually consumes a includes 1 cup of 1- 1 1/2 cup of
rice, SNACK rice, a portion of fish a portion of meat or (4:00 pm) or meat witho
ut fish,1 cup of soup Usually 3-4 pcs. Of crackers spices, side and 2 glasses of
or biscuits and a glass of vegetables, banana water or sometimes water. and app
le. However 12oz. of soft drinks. the client only DINNER consumes 3-6 tbsp. of S
NACK (8:00 – 8:30 pm) rice, ¼ portion of the (4:00 pm) Usually consumes a ¾ to 1 viand
, 2 tbsp. of the Usually just a glass cup of rice, a portion of meat side vegeta
bles, ¼ to of water or juice and or fish, and a glass of water. half servings of e
ither bread or banana cue. banana or apple, 1-2 glasses of water per DINNER meal
(7:30 – 8:00 pm) Usually consumes a Patient verbalized, “Wala cup of rice, a portio
n akong ganang kumain nung of meat or fish, and a nasa ospital ako. Sobrang glas
s of water. nanghihina din talaga ako.”
Analysis
There is a decreased in food intake of the patient prior to hospitalization. Dur
ing the onset of signs and symptoms, the client has a gradual decrease on servin
gs of her previous meals eaten. This could be related to client’s altered comfort
primarily by her recurrent loose bowel movements and abdominal pain. Once the cl
ient was hospitalized, there is a sudden change on client’s food preferences as or
dered by her physician. Previously eaten food such as dairy products, coffee and
soft drinks are prohibited for her. There is a remarkable loss of appetite by t
he client during hospitalization that leads her to some degree of weakness and d
ecrease energy levels.
DRINKING PATTERN DURING ILLNESS Prior to Hospitalization During Hospitalization
36
Before Illness (Daily Basis)
Analysis (Early April 2008-Early (August 16 2008-August 28, August 2008 ) 2008)
Onset of recurrent signs and symptoms Consumes 4 glasses of Consumes 3-4 glasses
of water per day water per day (approximately 840 ml (approximately 630- 840 pe
r day) ml per day). ½ cup of coffee ( 50-60 ml of per day)
Consumes 4-5 glasses of water per day (approximately 840-1050 ml per day). 1 cup
of coffee ( approximately 110 ml per day) 12 oz. soft drinks ( 360 ml.) but is
seldom
The client drinks insufficient amount of oral fluids required per day even befor
e illness state. Prior to hospitalization, a gradual decrease on fluid intake wa
s noted. This decrease on the client’s fluid intake persisted until the time she w
as hospitalized. There was a decrease of approximately 210 ml or 1 glass of wate
r from the client’s fluid intake during hospitalization as compared before her ill
ness state.
ELIMINATION PATTERN URINATION DURING ILLNESS 37
Urinary frequency – 3x/day – 4x/day Color – amber yellow Amount- moderate Odor – aromati
c APPROXIMATE TOTAL = 850- 900 ml/ day
Prior to Hospitalization (Early April 2008-Early August 2008 ) Onset of recurren
t signs and symptoms Urinary frequency 3x/day – 4x/day Color – amber yellow Amount – s
canty to moderate Odor – aromatic APPROXIMATE TOTAL = 650- 700 ml/day
During Hospitalization (August 16 2008-August 28, 2008) Urinary frequency – 2x/day
– 3x/day Color – amber yellow Amount- moderate Odor – aromatic APPROXIMATE TOTAL = 70
0-750 ml/day
Analysis
The patient’s urine output before illness state is within the normal range. Howeve
r, during the onset of signs and symptoms, the client had a decrease in urine ou
tput approximately 100200 ml. This significant drop on the client’s urine outputs
make her at risk to have a deficient fluid volume since during this time, the cl
ient had episodes of loose bowel movements. The decrease in urine output was gra
dually corrected during hospitalization where the client is within the minimum n
ormal urine output but is still insufficient since client still had episodes of
loose bowel movements.
BOWEL MOVEMENT DURING ILLNESS Prior to Hospitalization During Hospitalization 38
Analysis (Early April 2008-Early August 2008 ) Onset of recurrent signs and symp
toms Bowel Frequency – 3-6x/day recurrent in nature Color – brownish yellow with blo
od streak Consistency - loose and mucoid Amount- 1- 1 ½ cup per bout (August 16 20
08-August 28, 2008) Bowel Frequency2-3x/ day Color- brownish yellow with blood s
treak Consistency – loose and mucoid Amount- 1 cup per bout Before illness, client
had a usual bowel movement with normal characteristic and amount of feces. As s
oon as signs and symptoms occur prior to her hospitalization, the client had a f
requency of 3-6 times of loose bowel movement that occur recurrently. The feces
is brownish yellow in color, loose and mucoid in consistency and at least 1- 1 ½ c
up per bout. This episodes of loose bowel movement happened for almost 3-4 month
s even the client is under medications. However, during client’s hospitalization,
a decrease of 1-2x per day was observed but still with same characteristics of f
eces.
Bowel Frequency – once a day early in the morning Color – yellowish to light brown C
onsistency – semi-formed; soft bowel Amount- 1- 1 ½ cup per bout
BATHING PATTERN DURING ILLNESS Prior to Hospitalization During Hospitalization 3
9
Analysis (Early April 2008-Early (August 16 2008-August 28, August 2008 ) 2008)
Onset of recurrent signs and symptoms Complete bath once a day in Sponge or bed
bath once a The patient’s the morning day in the morning c/o bathing pattern has r
elative or student nurse. not changed except that the patient was not able to ba
the by herself during hospitalization. This can be related to client’s feeling of
weakness, decrease energy levels and unable to tolerate some activities.
Complete bath twice a day in the morning and afternoon.
SLEEPING PATTERN DURING ILLNESS Prior to Hospitalization During Hospitalization
(Early April 2008-Early (August 16 2008-August 28, August 2008 ) 2008) Onset of
recurrent signs and symptoms Duration : 5-6 hrs/day Duration : Irregular = Time
of sleep is usually but reaches 5-6 hours a day. 11:00 in the evening and awaken
s by 7:00 in the morning. Interruption of sleep is experienced whenever the clie
nt experienced defecating due to episodes loose bowel movement. = Does not take
naps during mid-afternoon since the client watches her ‘sari-sari’ store.
Before Illness (Daily Basis) Duration : 7-8 hrs/day = Time of sleep is usually 1
1:00 in the evening and awakens by 7:00 in the morning. = Does not take naps dur
ing midafternoon since the client watches her ‘sari-sari’ store.
Analysis
The client has enough sleeping hours before her illness. But prior to her hospit
alization, she experienced a decrease on the duration of her sleep and was inter
rupted whenever she felt the urge to defecate due to her loose bowel movement. O
nce the client was hospitalized, she had still insufficient time of sleep. This
interruption on client’s sleeping pattern is related to alteration in comfort due
to illness state.
40
DAY TO DAY APPRAISAL DATE/ TIME 08/17/08 0700H-1500H • • • • • • • • • • • 1500H-2300H The
scheduled for colonoscopy and proctosigmoidoscopy c/o gastro point of view by 08
/19/08 early in the morning With orders to give lemonada purgante 720 ml on 08/1
8/08 to start at 7pm to 10pm To give dulcolax 2 tabs at 6pm on 08/18/08 Client w
as instructed to have clear liquid diet on 08/18/08 after dinner until 5am of 08
/19/08 the nothing per orem prior the procedure With an on going IVF of D5LR 1L
+ 20meqs KCl as follow up to above consumed IVF. Flagyl discontinued- Dr. Gan aw
are Metronidazole 750mg/ tab every 8 hours if not ok. To start Diloxamide Furoar
te 500mg/tab 1 tab OD Requested for Acid Ether concentration technique of the st
ool with modified Kinyoun Acid fast stain- laboratory personnel aware For biopsy
noted plan for proctosigmoidoscopy- Dr. Acuesta aware (+) blood streaked stool-
Dr. Escalona aware NURSE’S OBSERVATION
• • • • •
For stool culture and sensitivity with specimen bottle For acid either concentra
tion tech. of the stool with SB. Client defered modified Kinyoun acid fast stain
of the stool with blue form and med. abstract with chart (+) blood streaked sto
ol, water with some particles, moderate in amount, mucoid in consistency, 1x Cli
ent has 3 episodes of vomiting of previously ingested food.
41
DATE/TIME 08/17/08 2300H- 0700H • • • • • • • • 08/19/08 0700H-1500H • • • • • •
NURSES OBSERVATION Client was awake in supine position with on going IVF of D5LR
1l + 20meqs KCl at 31gtts/min Client was instructed to have nothing per orem te
mporarily Scheduled for upper abdominal ultrasound on 08/19/08 early in the morn
ing- not requested For proctosimoidoscopy with biopsy scheduled on 8/19/08 early
in the morning on call-no consent, endoscopy request not yet sent Dulcolax 2tab
. @ 6pm tom. 8/18 night May have clear liquid post dinner 8/18 up to 5am (tues.)
8/19 then NPO thereafter Advised client’s relative to inquire at DOH if Diloxamid
e Furgante is not commercially available in the pharmacy- Dr. escalona aware Afe
brile
Client was on pulse oximeter Dormicum 2.5mg given as stat dose given prior proce
dure Demerol 12.5 mg given prior procedure Proctosigmoidoscopy done Biopsy taken
from sigmoid colon to rectum and was sent to the laboratory With results of his
topathology and biopsy report to be follow up
DATE/TIME
NURSES OBSERVATION
42
08/19/08 1500H-2300H • • • • • 2300H-0700H • • •
• Seen patient by Dr. Cuaresma with suggestion- Dr. P. Te aware Vomited once; prev
iously ingested food Dr. P. Te with orders to give: Metronidazole tab shifted to
500mg IVT q8 Metronidazole 1g/supp. OD/rectum Imodium 2mg/tab given now then q4
PRN for loose stool BM-1x mucoid, brown in color, with blood streaked moderate
in amount. Dr. P. Te ordered same IVF as follow up to above consumed IVF Afebril
e
ASSESSMENT FINDINGS GENERAL SURVEY
43
The patient was conscious and coherent. However, she appears to be irritable and
uncomfortable and avoids conversing to others. She also appears to be ill with
thin and frail body. Her stated chronological appearance is not proportion with
her present appearance. The client appears to be younger than her age. PHYSICAL
ASSESSMENT Body Part Skin a. Color Technique Inspection Normal Findings Whitish
pink or brown in color; dark skin tone depending on patients race; no evidence o
f discoloration Assessment Findings Pale and dull skin; no evidence of discolora
tion Analysis Abnormal Pale and dull skin can be related to a decrease in fluid
volume in the body and decrease levels of oxygen carrying capacity of the blood
Normal
b. Bleeding, Ecchymosis and Vascularity c. Lesions
Inspection
Inspection & Palpation
d. Moisture
Palpation
e. Tenderness f. Texture
Palpation Palpation
No areas of increased vascularity, ecchymosis and bleeding No skin lesions prese
nt except freckles, birthmarks or nevi which may be flat or raised Dry with mini
mum perspiration. Moisture varies with changes in environment, stress, activity
and body temperature Skin surface should be nontender Feel smooth, even and firm
with rough
No bleeding, ecchymosis and increased vascularity was noted No evident skin lesi
ons noted
Normal
Skin feels dry; with minimal perspiration
Normal
Non tender with no evident inflammation Smooth and firm, minimal roughness on
Normal Normal
44
g.Turgor/Edema Palpation
Hair
Nails
surfaces Skin should return to it’s original contour rapidly when released; no ede
ma present Color varies from dark black to pale blonde; evenly distributed; pale
white to light brown scalp with no lesions; thin, straight, coarse, thick or cu
rly; shiny and resilient Pink to brown cast; 2-3 seconds capillary refill; smoot
h, flat and slightly rounded; 160 angle Normocephalic and symmetrical; smooth, no
ntender without masses and depression Facial features should be symmetrical; sha
pe can be oval, round or slightly square; no involuntary movements; no edema and
disproportion No discomfort with movement; no clicking or crepitus heard
elbows and knees No edema present; with fair skin turgor
Normal
Thin, dry, straight dark black; evenly distributed with moderate hair fall noted
, pale white scalp with no lesions noted
Pale nail beds; with normal capillary refill; smooth, flat and round; 160 angle
Head
Normocephalic and symmetrical; nontender; no masses and depression noted Symmetr
ical facial features; oval in shape; no involuntary movements, edema and disprop
ortion noted No pain or discomfort experienced upon movement of the
Abnormal Dryness and hair fall can be acquired both genetic and nutritional imba
lances due to lack of collagen, a protein than nourishes the hair for growth Abn
ormal This is due to decrease oxygen supply in the body. An early sign of oxygen
desaturation Normal
Face
Normal
Mandible
Palpation
Normal
45
tempomandibular joint; articulates smoothly Neck/Thyroid gland/ Lymph Nodes Insp
ection & Palpation Symmetrical neck muscles; able to move head in full ROM witho
ut discomfort; no palpable masses or enlargement of thyroid glands and lymph nod
es Symmetrical neck muscles with head in a central position; able to move head i
n full ROM without discomfort; no thyroid gland enlargement noted; with palpable
anterior cervical lymph nodes Unable to read within a distance of 14 inches; Ab
normal Palpable lymph nodes are attributed to infectious process in which the ly
mph drains and filters such foreign bodies and accumulates on the lymph nodes Ab
normal Decrease visual acuity is related to degenerative or hereditary factors w
ith some risk factors on nutritional intake Normal Normal
Eyes a. Visual Acuity
Inspection
20/20 vision; able to read within a near distance of 14 inches
b. Eye Alignment c. Eye Movement
Cover/Uncover Test Inspection
Eyelids
Inspection
Eyes are aligned if no movements of either eyes Both eyes move smoothly and symm
etrically in each of the six field of gaze Symmetrical; no drooping(ptosis), inf
ections or tumors
No movements noted; eyes are aligned Able to move both eyes in six field of gaze
smoothly and symmetrical Asymmetrical; right eyelid with mild ptosis noted
Lacrimal Apparatus
No enlargement, swelling,
No enlargement or swelling
Abnormal Ptosis is related to cranial nerve damages that affects the neuromuscul
ar attributes of the eye. Normal
46
Conjunctiva
Inspection
redness, exudates; no excessive tearing or discharge from the punctum Pink and m
oist; no swelling, lesions or foreign bodies
noted; with minimal discharges
Pale palpebral conjunctiva noted
Pupil
Inspection
Deep black, round, equal in diameter ( 26mm), constrict briskly to direct light
The patient should be able to repeat words whispered from a distance of 2 feet M
atch the flesh color of the entire skin; proportional; no pain or tenderness dur
ing palpation No redness, swelling, lesions, drainage, foreign bodies or scaly s
urface No evidence of swelling around nose and eyes; no discomfort during palpat
ion Symmetrically in the midline of the face; no
Deep black; equal in diameter; equally reactive to direct light; 2-3mm; brisk in
reaction Able to repeat words whispered from a distance of 2 feet Flesh in colo
r; proportional to head; non tender auricles; no pain experienced upon palpation
No redness, swelling, lesions and drainage noted; with minimal non-dry cerumen
noted No swelling and discomfort upon palpation noted
Abnormal Pale palpebral conjunctiva is a sign of decrease fluid volume and oxyge
n in the blood Normal
Ears a. Hearing Acuity
Voice-Whisper Test
Normal
b. External Ear
Normal
c. Ear Canal
Inspection
Normal
Sinuses
Normal
Nose a. External
Inspection
Located midline to the face; no lesion, swelling,
Normal
47
b. Internal
Inspection
lesion, swelling, bleeding and masses; no occlusion to air passage Nasal mucosa
should be pink or dull red without swelling or polyps; no deviation in septum; w
ith small amount of clear watery discharge Pink and moist with no evidence of le
sion or inflammation Midline in the mouth; pink, moist and rough ( from taste bu
ds), no lesions and swelling; moves freely Pinkish in color; moist, smooth and a
bsence of inflammation and lesions Pale-red stippled surface; well defined gum m
argins; no swelling or bleeding 32 set of teeth, white with smooth edges, proper
ly aligned and without caries
masses or bleeding noted; patent nostril Pale nasal mucosa without swelling or p
olyps; septum is at midline; with minimal thick, whitish discharge noted Abnorma
l Pale nasal mucosa is related to decrease oxygen supply in the blood
Mouth a. Lips
Inspection
Pale and dry lips; no swelling and inflammation noted Midline in the mouth; pink
, moist and rough; can move freely and stick out tongue Mildly pale; smooth and
moist; no lesions or inflammation noted Pale-red stippled surface; well defined
gum margins; mildly retracted from the teeth Incomplete set of teeth with areas
of tooth extraction; improperly aligned; with black patches
b. Tongue
Inspection
Abnormal Pale and dry lips is related to fluid volume deficit or dehydration Nor
mal
c. Buccal Mucosa
Inspection
d. Gums
Inspection
e. Teeth
Inspection
Abnormal Related to fluid volume deficit or decrease oxygen in the blood Abnorma
l Related to fluid volume deficit or decrease oxygen in the blood Abnormal Denta
l carries can be acquired if oral hygiene is inadequate and with decrease in
48
and erosion on the surface of certain teeth f. Palate Inspection Hard and soft p
alate are concave and pink; hard palate with many ridges; soft palate is smooth;
no lesion and malformations Pink, vascular and without swelling, exudates or le
sions; Uvula is midline; tonsillar size is 1+ to 2+; (+) gag reflex Flesh colore
d; areolar area and nipples with darker pigmentation; No thickening or edema; sy
mmetrical; convex; no lesions or masses Concave and pinkish; hard palate with ri
dges and soft palate is smooth. No lesion or malformations noted Pink, vascular
with no swelling or exudates noted; Uvula is at midline: Tonsillar size is 2+ wi
th (+) gag reflex Flesh in color; darker pigmentation on areolar areas and nippl
es; convex and symmetrical with breast on the side of the dominant arm being lar
ger ( right side); no thickening, lesions or dimpling noted. Thorax is elliptica
l in shape; left shoulder is lower in height compared to right shoulder; right s
capula higher in height bilaterally Eupnea; no
calcium and fluoride intake that makes teeth strong and free from carries Normal
Throat
Inspection
Normal
Breast
Inspection
Normal
Thorax and Lungs a. Shape and Symmetry
Inspection
Elliptical in shape; shoulders should be at the same height; scapula should be t
he same height bilaterally with no masses No accessory 49
Abnormal Related to misalignment of the spinal cord.
b. Muscles of
Inspection
Normal
Respiration muscles are used accessory in normal muscles being breathing used; n
o exaggerated respiratory effort upon breathing noted Normal Fremitus Buzzing is
felt is felt as buzzing on the ulnar on the ulnar aspect of the aspect of the h
and upon hand palpation; no increase or decrease Fremitus was observed Blowing o
r Fine crackles hollow sound, (rales) heard high in pitch upon ( Bronchial); aus
cultation gentle rustling or breezy, low in pitch ( Vesicular); no adventitious
breath sounds should be heard Symmetrical; no vibrations, thrills and expansions
noted Rhythm is regular; distinguishable S1 and S2; no murmurs heard No pallor,
cyanosis or ulceration noted; no complaints of pain or discomfort Flat or round
ed; Adynamic precordium; PMI at 5th Intercostal space, left midclavicular line R
egular heart sounds; S1 and S2 are distinguishable upon auscultation No discolor
ation and complains of pain or discomfort noted
c. Tactile Fremitus
Palpation
Normal
c. Breath Sounds
Auscultation
Abnormal Heard when there is fluid accumulation on the alveoli of the lungs
Heart a. Precordium
Normal
b. Heart Sounds
Auscultation
Normal
Peripheral Vasculature
Inspection
Normal
Abdomen a. Contour,
Inspection
Flat abdomen;
Normal
50
Symmetry and Pigmentation
symmetrical bilaterally; no discoloration
b. Umbilicus
Inspection
Should be depressed and beneath abdominal surface Intermittent gurgling sounds t
hroughout abdominal quadrants; high pitched and occurs 5 to 30 times per minute
Muscle shape may be accentuated in certain body areas but should be symmetrical;
no involuntary movement Complete voluntary range of joint motion against gravit
y and moderate to full resistance; strength is equally bilateral; no involuntary
muscle movements Able to perform full ROM; no 51
c. Bowel Sounds
Auscultation
non tender; symmetrical; uniform in color and pigmentation; no scars, striae or
lesions noted Umbilicus at lower midline of the abdomen; depressed and beneath a
bdominal surface Normoactive to hyperactive bowel sounds prominent at right lowe
r quadrant
Normal
Abnormal
Musculoskeletal System a. Muscle size and shape
Inspection
Reduced muscle size; thin and flabby muscles; contour is less distinct; no invol
untary movement noted
b. Muscle Strength
Inspection
Decrease muscle strength was observed on upper extremities; complete range of jo
int motion against both gravity and moderate manual resistance; good muscle stre
ngth Can perform full range of motion
Abnormal Decrease in muscle size and shape is due to nutritional imbalances and
lack of movements leading to atrophy Normal
c. Upper Extremities
swelling or inflammation noted; symmetrical; with five fingers on each hand; ali
gned; no numbness or paralysis noted d. Lower Extremities Inspection & Palpation
Able to perform full range of motion; no swelling or inflammation noted; symmet
rical; with five toes on each foot; aligned; no numbness or paralysis noted
e. Spinal cord
Inspection
Cervical concavity; thoracic convexity; lumbar concavity; with full ROM
but with slowed movements; no Normal digital clubbing observed; with five finger
s on each hand; symmetrical; equally aligned; no inflammation and swelling noted
Can perform full Abnormal range of motion; Slowed body with slowed gait movemen
ts observed; no may be swelling or attributed to inflammation pain or noted; alt
eration in symmetrical; discomfort. with five toes on Numbness is each foot; no
due to slowed complains of calf or blockage of pain and nerve impulse intermitte
nt from the axon claudication; to another with numbness neuron through on toes b
oth right the pre synaptic and left foot to post synaptic noted Cervical is Abno
rmal concave; thoracic Related to has increased curvature of the convexity ( sli
ght spinal cord such hump); lumbar is as scoliosis, concave; with lordosis etc.
full ROM
REVIEW OF SYSTEM The review of system is the client’s subjective response to a ser
ies of body system related questions. It follows a head-to-toe approach and incl
udes the signs and symptoms related to disease. Mentioned among are the positive
findings assessed from the client. Body Parts/System Positive Findings
52
General Subjective: “Hindi maganda ang pakiramdam ko, medyo sumasakit ang tiyan ko
at hindi at mapalagay. Nararamdaman ko din na nanghihina ako at para bang palag
e akong walang lakas.” Integumentary Subjective: “Wala naman ako mga peklat o sugat.
Medyo ‘dry’ nga lang ang balat ko, di kasi akon nakakapag lotion madalas” Subjective:
“ Medyo inuubo ako ngayon pero hindi naman ako nahihirapan huminga.” Subjective: “ Yu
ng nanay ko pati lola ko sa mother side, parehas silang high blood, pero ako nam
an sa awa ng Diyos, hindi naman.” Subjective: “Madalas ako nadudume na may kasamang
dugo at medyo basa. Nakaramdam din ako ng pagsusuka. Pabalik balik ang pananakit
ng tiyan, humihilab at para bang umiikot yung sikmura ko,” Subjective: “ Wla naman
akong problem sa pag-ihi o sakit na nararamdaman. Dalawa hanggang tatlong beses
ako umiihi. Medyo mahina din kasi ako uminom ng tubig eh.” Subjective: ” Nahihirapan
ako maglakad at magkikilos ngayon, nanghihna kasi ako at madaling mahapo.’ Subjec
tive: “Medyo nahihirapan ako magsalita ngayon, nauutal ako. Masakit din ang tiyan
ko. “Nagmamanhid nga din yung mga daliri ko sa paa, para bang hindi ako nakakaramd
am.” ( no positive findings)
Respiratory
Cardiovascular and Peripheral Vasculature
Gastrointestinal
Urinary
Musculoskeletal
Neurological
Female Reproductive
53
Nutrition Subjective: “Wala talaga akong ganang kumain. Mga 3-4 na subo lang ayoko
na agad. Sumasakit kasi ang tiyan ko at masama talaga ang pakiramdam ko” ( no pos
itive findings) Subjective “ Masakit yung leeg ko, para bang may bukol. Masakit ka
pag hinahawakan.” Subjective: “ Medyo nanghihina ako at walang gana. Madali ako mapa
god at mahapo.’
Endocrine Lymph Nodes
Hematological
DIAGNOSTIC PROCEDURES LABORATORY EXAMINATION COMPLETE BLOOD COUNT (CBC). Done to
assess if the patient has increase or decrease WBC due to detect infection. Req
uested By: Date received: Dr. William Hoping Gan 08/16/08 10; 09 AM 54
Date released: Hemoglobin Hct RBC WBC Platelet
08/16/08 Result 100 0.31 3.72 6.2 Adequate
10:54 AM Normal Values 112-157 g/L 0.34-0.3510^12/L 3.93-5.22 x 10 ^ 12/L 4.7810
^9/L 150-400 Normal Values 0.55- 0.70 0.25- 0.40 0.02- 0.08 0.01- 0.06 0.00- 0.0
5
Differential Count Results Segmenters 0.58 Lymphocytes 0.29 Monocytes 0.08 Eosin
ophils 0.04 Basophils 0.01
ANALYSIS: The result of e exam of hemoglobin 100 g/L show a decrease in number o
f circulating hemoglobin iron-protein compound in red blood cells which transpor
t oxygen for to the body tissue thus implicate a poor tissue perfusion. This als
o show a decrease number of RBC TO 3.72.Thus decreasing the percentage of a bloo
d sample that consists of red blood cells, measured after the blood has been cen
trifuged and the cells compacted called Hematocrit to 0.31. Differential counts
are within normal values. Hematology It is a series of screening test, which con
sists of hemoglobin and hematocrit measurement for the detection of certain dise
ases. It provides complete evaluation of all the formed elements of the blood. I
t can supply a great deal of information to diagnose hematopoietic system and he
lps to evaluate these stages and prognosis of certain diseases. Differential Cou
nt The differential count measures the percentage of each type of leukocytes. An
increased of percentage of one type of leukocyte, maybe a decreased in percenta
ge of the other type. The leukocyte type can be identified easily by their morph
ology in venous blood smear. Red Blood Cells The red blood cells are the cells t
hat carry oxygen to all parts of the body through the hemoglobin. White Blood Ce
lls It refers to the blood cells that do not contain hemoglobin. White blood cel
ls are made by bone marrow and help body fight infections and other diseases as
part of immune system. The white blood cell count also used to suggest the prese
nce of infections, allergy, and leukemia. It is also used to monitor the body s
response to various types of treatments and to monitor bone marrow function. Pla
telet Platelets are part of cytoplasm that are involved in the coagulation proce
ss. Platelet attach or 55
adhere to the walls of injures blood vessels, where they clump together or aggre
gate to form platelet plugs necessary for coagulation. It is produced by bone ma
rrow and processed and removed by the spleen when they are damaged or old. Lymph
ocytes Is a class of leukocytes produced in a variety of lymphoid organs through
out the body and is responsible for cellular and normal immune responses. Leukoc
ytes are often seen in sites of chronic inflammation. They produce many secretor
y products that modulate the functional of a wide variety of cell types. Eosinop
hils It is a variety of white blood cells distinguished by the presence of cytop
lasm. It is capable of ingesting foreign particles. Monocytes It is the largest
cell of a normal blood that transforms into macrophages and become responsible f
or phagocytosis of unwanted particular matter. Hematocrit and Hemoglobin Levels
Requested by: Dr. William Hoping gan Date Received: 08/17/08 05:00 AM Date Relea
sed: 08/17/08 5:39 AM Exam Hemoglobin Hematocrit Results 105 0.32 Normal Values
120-160 g/L 0.37-0.47
Analysis: The result of the exam for hemoglobin 105 g/L shows decrease in number
of circulating hemoglobin contained entirely in the red blood cells, amounting
to perhaps 35 percent of their weight. To combine properly with oxygen, red bloo
d cells must contain adequate hemoglobin. Hemoglobin, in turn, is dependent on i
ron for its formation. A deficiency of hemoglobin caused by a lack of iron in th
e body leads to anemia. Thus decreasing red blood cells in a blood sample in ord
er to determine the percentage of the blood that consists of cells Decrease in h
emoglobin, Hematocrit, and RBC shows the relation to amoebiasis in a way that tr
ophozoites a parasite that invade tissue found in liquid colonic contents burrow
deeper with tendency to spread laterally by continous lysis of cell until they
reach the muscalaris mucosae frequently erode the lymphatic or walls of the mese
nteric venules in the floor of ulcers, which may enter , and in carried into int
raheptic portal veins. If thrombi occur in small branches of the portal vein, th
e trohozoites held in the thrombi cause lytic necrosis of the wall of vessel and
digest s pathway into the lobules Date received: 08/22/08 02:25 PM Date release
d: 08/22/08 03:55PM Requested by: William Hoping Gan, MD Exam Hemoglobin Hematoc
rit Results 114 0.35 56 Normal Values 120-160 g/L 0.37-0.47
Analysis: The result of e exam of hemoglobin 114 g/L show a slightly decrease in
number of circulating hemoglobin. In addition alterations in the structure of h
emoglobin can lead to lifethreatening illnesses. The most important of these con
ditions is sickle-cell anemia, which involves a hereditary change in one of the
amino acids that make up hemoglobin. The thalassemias are a group of hereditary
diseases of similar origin. A decrease in the fraction of blood occupied by eryt
hrocyte or hematocrit.
Hemoglobin Hemoglobin is the main components of red blood cells. The main functi
on is to carry oxygen from the lungs to the tissue and transport carbon dioxide,
the product of metabolism, back to the lungs. It is often ordered as part of co
mplete blood count. Red blood cells are complete with hemoglobin. Hematocrit The
hematocrit is the percent of whole blood that is comprised of red blood cells.
It is compound measures how much space in the blood is occupied by red blood cel
ls. It is useful when evaluating a person with anemia. ACTIVATED PARTIAL PROTRHO
MBIN TIME/ PROTHROMBIN TIME Requested by: William Hoping Gan, MD Date received:
08/16/08 07:25 PM Date released: 08/16/08 08:09PM Exam APTT Control Results 39.0
27.4 Normal Values 25-27 seconds 27-35 seconds
PROTHROMBIN PT Protime 14.6 % activity 84.4 INR 1.15 ISI 1.21 Control 13.0
sec % sec
Analysis An increase in APTT indicates a decrease clotting time which initiates
bleeding tendency and a blood-clotting factor in blood platelets that converts p
rothrombin to thrombin to promote scar formation and wound healing. Normal prohr
ombin activity in the blood depends on adequate absorption of Vitamin K from the
GI tract and adequate liver function. Therefore deficiency may arise from facto
r that affects vitamin K absorption such as diarrhea. Increase in APTT is relate
d in a amoebiasis in a way that it may affect the liver decreasing production of
several clotting factors may be due to deficient vitamin K from the gastrointes
tinal tract. This probably is caused by the 57
inability of liver cells to use vitamin K to make prothrombin. Absorption of the
other fat-soluble vitamin (vitamin A, D, and E) as well the dietary fats may al
so be impaired because of the decreased secretion of bile salt in the intestine.
The production of blood clotting factor of the liver is also reduced, leading i
n an increased incidence of bruising, nosebleed, bleeding from wounds and gastro
intestinal bleeding. BLOOD CHEMISTRY Requested by: Dr William Hoping Gan Date Re
ceived: 08/16/08 Date Released: 08/16/08 Conventional Unit TEST BUN L Creatinine
SGPT (ALT) Sodium Potassium L Analysis A decrease in BUN indicates a decrease i
n index of renal excretory capacity. Serum urea nitrogen is dependent on the bod
y’s urea production and on urine flow. Urea’s are nitrogenous end product of protein
metabolism and are also affected by protein intake. A decrease in potassium whi
ch can cause such problems as thirst, fatigue, low blood pressure, muscle cramps
, nausea, and irregular heartbeat. Some diuretics (medications that increase uri
nation) and heart drugs, as well as certain diseases, can cause potassium defici
ency. SGPT, Creatinine, Sodium are at normal range. Decrease in BUN and potassiu
m due to slight attack of diarrhea eructations after eating and slight nausea pa
rtly because potassium is actually lost when gastric fluid is lost; but more so
because potassium is lost through the kidneys in association with metabolic alka
losis. Relatively large amounts of potassium are contained in intestinal fluid f
or example diarrheal fluid may contain as much as 30 mEq.L. Therefore potassium
deficit occurs frequently with diarrhea that may cause cardiac dysrythmias as a
complication. A decrease in BUN indicates a low index in renal excretory capacit
y and is associated in low protein intake therefore decrease protein metabolism
causing by product urea to decrease. Date received: 08/22/08 02:25 PM Date relea
sed: 08/22/08 04:12PM Requested by: William Hoping Gan, MD Results 5.25 mg/dL 0.
61 mg/dL 8 u/L 139 meq/L 3.4 meq/L Reference 7.79- 21.40 0.50- 1.20 0-41 135- 14
5.0 3.80- 5.50 Results 1.97 mmol/.L 55.02 umol/L 8 u/L 139 mmol.L 3.4 mmol/L
SI Unit Reference 2.78- 7.64 44.0- 106.0 0- 41 135.0- 145.0 3.80- 5.50
58
TEST Potassium L
Conventional Unit Results Reference 3.6 meq/L 3.80- 5.50
SI Unit Results 3.6 mmol/L Reference 3.80- 5.50
Analysis The test show a slightly decrease in potassium which plays an important
role in normal muscle activity symptoms of deficiency include muscle weakness.
Potassium chloride works by controlling the body’s water balance and regulating su
ch processes as nerve transmission, muscle contraction, and normal heart rhythm.
Laboratory chemistry branch of science dealing with the structure, composition,
properties, and reactive characteristics of substances, especially at the atomi
c and molecular levels. BLOOD EXTRACTION Nursing responsibilities: Before: 1. Gr
eet client by name and validate client’s identification. Check full name and ID ba
nd – for verification purposes. 1. Explain the procedure and its importance. 2. Te
ll the patient that no special diet or fasting is required. 3. Give details abou
t the collection of the blood sample which is brief but if causes some discomfor
t. 4. Notify the patient that pressure will be applied to the puncture site for
few minutes. 5. Hand washing – to prevent contamination of microorganisms. During:
1. Inform the patient to avoid closing and opening the hand after the tournique
t is applied. 2. Position client’s arm to form a straight line from the shoulder t
o wrist. Place pillow under upper arm to enhance extension. Client should be in
supine or semi-fowler’s position – to facilitate easy blood drawing. 3. Indicate on
the laboratory slip any drugs that can affect the result. After: 1. Apply pressu
re or a pressure dressing area to the venipuncture site. 2. Assess the venipunct
ure site for bleeding. 3. Dispose the needles, syringe and soiled equipments to
proper container – to prevent contamination. 4. Hand washing – to prevent contaminat
ion. 5. Validate client’s reaction – to assess feelings and reactions of patient aft
er the procedure. 6. Send specimen into the laboratory with the client’s complete
identification – inaccurate identification on the specimen container can lead to e
rrors of diagnosis or therapy. 7. Follow up the result and report to AMD. COMPLE
TE URINALYSIS Requested by: Dr. William Hoping Gan Date released: 08/16/2008 01:
35 PM Date received: 08/16/2008 02:56 Pm
59
MACROSCOPIC Physical/Macroscopic Color Transparency Specific Gravity Ph Protein
Glucose Result Amber Slightly hazy 1.010 7.5 Negative Negative Alkaline
MICROSCOPIC RBC WBC Epithelial cells Bacteria Mucous Threads Amorphous Urates 0-
1/ HPF 1-2/ HPF Occasional Many Moderate Moderate
Analysis Urinalysis shown normal urine color amber and slightly hazy a decrease
urine specific gravity it is less precise than urine osmolality and reflects bot
h the quantity and the nature of particles. Therefore, protein, Glucose, and int
ravenous contrast agent specific gravity than osmolality. Urine is a good medium
for growth of bacteria that’s why urine ideally performed on fresh specimen prefe
rably the first voiding. If left standing at room temperature urine become alkal
ine because of contamination of urea-splitting bacteria. Mucous thread moderates
in amount, Bacteria many in amount A. Phosphate moderate epithelial cell occasi
onal. The normal urinary tract is sterile above the urethra bacteria may be due
to incomplete emptying of the bladder and urinary stasis. Decreased natural host
defense and instrumentation of the urinary tract including catheterization and
cystoscopic procedure MACROSCOPIC Physical/Macroscopic Color Transparency Specif
ic Gravity Reaction Protein Glucose Result Yellow Slightly hazy 1.030 6.0 Negati
ve Negative
60
MACROSCOPIC
RBC WBC Epithelial cells Bacteria Mucous Threads Renal Cells
0-1/ HPF 1-2/ HPF Occasional Moderate Few None
Analysis Show normal urine color and transparency increase specific gravity indi
cate presence of substances found in urine. Negative for protenuria and glycosur
ia. In addition urinalysis may provide important clinical information. Although
urinalysis is usually performed routinely it evaluates urine color, clarity and
odor. Measurement urine acidity and specific gravity. Test for presence of prote
in, glucose and ketone, hematuria, cast (cylinduria), crystals (crystalluria), p
us (pyuria) and bacteria (bacteriuria). NOTE: Hematology-Specimen rechecked Resu
lts verified Chem: Specimen rechecked. Abnormal results verified. Clinical micro
scopy verified. Specimen rechecked. Results verified FECALYSIS Requested by: Wil
liam Hoping Gan Date received: 08/15/ 08 Date released: 08/16/08 4: 09 PM MACROS
COPIC Color Red Consistency WATERY/MUCOID Others SPECIAL TEST Occult blood: NOT
REQUESTED Entamoeba histolytica Cyst Trophozoite Parasites Ascariasis ova: NONE
SEEN 1-3L/LPF 1-2/LPF MICROSCOPIC RBC 70- 80/ HPF Pus cells 12-20/ HPF
61
Hookworm ova: Trichiuris ova: Analysis:
NONE SEEN NONE SEEN
Stool exam show a red in color which is an indicator of blood entering the lower
portion of the GI tract or passing rapidly through it. Carrots and beets may ca
use a red stool. A normal mucoid consistency no presence of ascariasis ova, hook
worm ova, trichiuris ova a parasite usually found in stool. Color red watery muc
oid in consistency in relation to amoebiasis that a watery mucoid stool are char
acteristics of small bowel disease whereas loose, semisolid stool are associated
more often in the disorder of the colon it denotes inflammatory enteritis or co
litis. Color red stool may indicate a blood entering the lower portion of the ga
strointestinal tract or passing rapidly through it will appear bright or dark re
d that is associate4d in amoebiasis an a way that there is ulceration in lymphat
ic vessel of the gastrointestinal tract. STOOL ACID- ETHER CONCENTRATION TECHNIQ
UE Requested by: Dr. William Hoping Gan Date received: 08/18/08 Date released: 0
8/18/08 04:05 PM RESULT: NONE FOUND FOR OVA, PARASITES & AMOEBA Analysis Stool a
cid indicates no found for ova, parasites and amoeba no changes noted. In additi
on there are factors that interfere with the sensitivity and specificity of the
test. Careful assessment of diet and mediation regimen is necessary to eliminate
the chance of false-positive results. BACTERIOLOGY STOOL CULTURE AND SENSITIVIT
Y Date received: 08/18/ 08 Date released: 08/21/0808 Requested by: William Hopin
g Gan Result: No enteric Pathogen Isolated Analysis Stool culture shown no prese
nce of enteric pathogen it include inspection of the specimen for its amount, co
nsistency, and color, and a screening test for occult blood. The test done to pa
tient is a special test which includes for pathogen and collected in a random ba
sis. In addition bacteriology is the scientific study of bacteria, especially in
relation to medicine Computed Tomography Scan Report Date: 08/23/2008
62
Clinical history: slurring speech Canial CT scan: with delayed conttrast Finding
s: Tiny parenchymal is note in the left pareital lobe The gray white matter inte
rface is well defined Te ventricles, sulci, and cisterns are normal No evidence
of hydrocephalus, acute parenchymal hemorrhage of midline shift Posterior fossa
structure are intact Visualized paranasal sinises petromastoid are clear No abno
rmal enhancementis seen contrast study Impression: Tiny parenchymal calcificatio
n with adjacent edema, left lateral lobe. This may relate to vascular abnormal,
previous injection or less likely peoplastic process Indication: The test is don
e to the patient to see if there is mass, cyst, inflammatory lesions, abscess of
the chest, abdomen, pelvis and extremities.
ULTRASOUND REPORT Date: 08/19/2008 Findings: The liver is normal in size and ech
o pattern There is no dilation of the intra-hepatic ducts No mass seen The gallb
ladder5 measuring 6.1 x 2.0cm with anaerobis lumen. The wall is not thickened Th
e pancreas is normal in size and echo pattern No mass seen in at or near the reg
ion of the pancreas The spleen is not enlarged. Negative for intrasplenic mass.
Indication: This test is done to see if there is any problem like mass or cyst r
egarding the liver, gallbladder pancreas and spleen. Impression: Essentially the
re is normal COLONOSCOPY Date: 09/19/08 Findings: Anus Rectum Seen / / Finding /
/ Biopsy / /
63
Sigmoid / Descending colon Sple flexure Trans colon Hop. Flexure Ascending colon
/ / / / /
Scope was inserted until terminal ileum. Normal terminal ileal mucosa. From leve
l 40cm, there are multiple white base mucosa erosion with erythematotous border
seen. Circumferential mucosa erosion with whitish mucous seen from level 35cmdow
n to the rectum. Multiple biopsies taken from erosion and normal mucosa to send
for hiatopath. The rest of the examination are unremarkable. Indication: This te
st is done to see if client is at high risk of having colon cancer. Patient with
a history of diarrhea and constipation, persistent rectal bleeding or lower abd
ominal pain. Impression: There is normal ileal mucosa There is multiple whtie ba
se matter erosion with erythematotous Pathology Report Referring physician; Dr.
Purwanta Specimen: Normal and abnormal mucosa, sigmoid down to rectum Diagnosis:
A. Fragments of unremarkable mucosa B. Consistent with chronic active colitis w
ith ulceration Description of notes: Received in two parts A. The specimen label
ed “ normal mucosa sigmoid down to rectum” consist of tan gray tissues with an aggre
gate diameter all of 0.3cm. block B. The specimen labeled “abnormal mucosa sigmoid
down to rectum” consist of tan gray tissues with an aggregate diameter all of 0.5
cm. blocd.
MEDICAL MANAGEMENT INTRAVENOUS THERAPY Initial Intravenous Fluid upon admission:
• D5LR 1 liter to run for 10 hours, 25 gtts/min, 100 cc/hr
64
Succeeding Intravenous Fluid: Date Ordered 8/19/08 8/20/08 8/20/08 8/22/08 8/23/
08 8/23/08 8/26/08 8/26/08 Time 2:20 pm 6 am 1:30 pm 7:30 am 7am 12 MN 6:35 am 7
:37 am Name of IVF D5NM 1L X 8 hours D5NM 1L + 20 meqs Kcl x 12 hours D5NM 1L X
12 hours D5 NSS 1L X 10 hours TF: D5LR 1L X 10 hours D5LR 1L X 10 hours D5NM 1L
X 14 hours D5NM 1L X 16 hours PLR X 14 hours
Intravenous therapy or IV therapy is the giving of liquid substances directly in
to a vein. It can be intermittent or continuous; continuous administration is ca
lled an intravenous drip. The word intravenous simply means “within a vein”, but is
most commonly used to refer IV therapy. Therapies administered intravenously are
often called specialty pharmaceuticals. Compared with other routes of administr
ation, the intravenous route is the fastest way to deliver fluids and medication
s throughout the body. Some medications, as well as blood transfusions and letha
l injections, can only be given intravenously. D5LR/ PLR Lactated Ringer s solut
ion is a solution that is isotonic with blood and intended for intravenous admin
istration. Veterinary administration may also be subcutaneous. Lactated Ringer s
solution is abbreviated as "LR" or "RL". It is also known as Ringer s lactate s
olution (although Ringer s solution technically refers only to the saline compon
ent, without lactate). It is very similar - though not identical to - Hartmann s
Solution, the ionic concentrations of which differ. Lactated Ringer Lactated Ri
nger s Solution is often used for fluid resuscitation after a blood loss due to
trauma, surgery, or a burn injury. Previously, it was used to induce urine outpu
t in patients with renal failure.Lactated Ringer s Solution is used because the
byproducts of lactate metabolism in the liver counteract acidosis, which is a ch
emical imbalance that occurs with acute fluid loss or renal failure. The intrave
nous dose of Lactated Ringer s Solution is usually calculated by estimated fluid
loss and presumed fluid deficit. For fluid resuscitation the usual rate of admi
nistration is 20 to 30 ml/kg body weight/hour. Lactated Ringer s Solution is not
suitable for maintenance therapy because the sodium content (130 mEq/L) is cons
idered too high, particularly for children, whereas the potassium content (4 mEq
/L) is too low, in view of electrolyte daily requirement.
65
Other commonly used intravenous solutions include normal saline and hespan (used
in hypovolemic shock). Lactated Ringer s is also used as a conduit for the deli
very of drugs. Lactated Ringer s is usually given intravenously, but if a suitab
le vein is not found, it can be taken orally (although it has an unpleasant tast
e). D5NS The amount of normal saline infused depends largely on the needs of the
patient (e.g. ongoing diarrhea or heart failure) but is typically between 1.5 a
nd 3 litres a day for an adult. Other concentrations of saline are frequently us
ed for other medical purposes, such as supplying extra water to a dehydrated pat
ient or supplying the daily water and salt needs ("maintenance" needs) of a pati
ent who is unable to take them by mouth. Because infusing a solution of low osmo
lality can cause problems, intravenous solutions with reduced saline concentrati
ons typically have dextrose (glucose) added to maintain a safe osmolality while
providing less sodium chloride. As the molecular weight (MW) of dextrose is grea
ter, this has the same osmolality as normal saline despite having less sodium. B
ecause the dextrose used in these preparations is dextrose monohydrate (a commer
cial form having MW 198 in contrast to MW 180 for glucose), 5% dextrose is equiv
alent to 4.5% glucose. NURSING RESPONSIBILITIES: • Regulate the flow rate accurate
ly. • Check IVF insertion site and take note for any possible infection if is stil
l inserted in vein. • Maintain patent tube and assess for formation of bubbles. • In
struct patient not to move the site vigorously. DIET • Initial diet upon admission
: low fat diet Succeeding diet: Date Ordered 8/16/08 8/16/08 8/17/08 8/17/08 8/1
8/08 8/19/08 8/28/08 Time 10:30 am 6:00 pm 9:25 am 11:35 am 5:45 am 6:00 am 1:15
am Diet BRAT diet ,no dairy products Banana per meal TID BRAT, free of dairy pr
oducts Clear liquids after dinner up to 5 am Tuesday then NPO thereafter. Bland
diet, no dairy products BRAT diet Light meal, then NPO 5 am.
66
In nutrition, the diet is the sum of food consumed by a person or other organism
Dietary habits are the habitual decisions an individual or culture makes when c
hoosing what foods to eat. Although humans are omnivores, each culture holds som
e food preferences and some food taboos. Individual dietary choices may be more
or less healthy. Proper nutrition requires the proper ingestion and equally impo
rtant, the absorption of vitamins, minerals, and fuel in the form of carbohydrat
es, proteins, and fats. Dietary habits and choices play a significant role in he
alth and mortality, and can also define cultures and play a role in religion. BR
AT DIET The BRAT diet is a historically prescribed treatment for patients with v
arious forms of gastrointestinal distress such as diarrhea, dyspepsia, and/or ga
stroenteritis. The BRAT diet consists of foods that are relatively bland, easy t
o digest, and low in fiber. Low-fiber foods are recommended because foods high i
n fiber may cause gas, possibly worsening the gastrointestinal upset. The foods
from the BRAT diet may be added, but should not replace normal, tolerated foods.
Sugary drinks and carbonated beverages should be avoided.A well-balanced diet i
s best even during diarrhea, but studies have found that incorporating foods fro
m the BRAT diet can reduce the severity of diarrhea (see Contrary medical advice
). Applesauce provides pectin, as does toast with grape jelly. The BRAT diet sho
uld include additional protein supplements such as tofu or protein pills. BLAND
DIET Purpose: The bland or soft diet is designed to decrease peristalsis and avo
id irritation of the gastrointestinal tract. Use: It is appropriate for people w
ith peptic ulcer disease, chronic gastritis, Reflux esophagitis or dyspepsia. It
may also be used in the treatment of hiatal hernia. Description: The soft/ blan
d diet consists of foods that are easily digestible, mildly seasoned and tender.
Fried foods, highly seasoned foods and most raw or gas-forming fruits and veget
ables are eliminated. Drinks containing Xanthine and alcohol should also be avoi
ded. DIAGNOSTIC PROCEDURES: COLONOSCOPY A colonoscopy is an internal examination
of the colon (large intestine), using an instrument called a colonoscope. Colon
oscopy is a procedure that enables an examiner (usually a gastroenterologist) to
evaluate the appearance of the inside of the colon (large bowel). This is accom
plished by inserting a flexible tube that is about the thickness of a finger int
o the anus, and then advancing it slowly, under visual control, into the rectum
and through the colon. It is performed with the visual control of either looking
through the instrument or with viewing a TV monitor.
67
Why is colonoscopy done? This test may be done for a variety of reasons. Most of
ten it is done to investigate the finding of blood in the stool, abdominal pain,
diarrhea, a change in the bowel habits, or an abnormality found on colon x- ray
or a CT scan. Certain individuals with previous history of polyps or colon canc
er and certain individuals with family history of particular malignancies or col
on problems may be advised to have periodic colonoscopies because they are at a
greater risk of polyps or colon cancer. NURSING RESPONSIBILITIES: Client prepara
tion 1. Ensure presence of a signed informed consent for the procedure. 2. A liq
uid diet may be prescribed for two days prior to the procedure and the client is
usually NPO for 8 hours, just before the procedure. 3. Administer or instruct t
he client in bowel preparation procedures such as taking citrate or magnesia or
polyethylene glycol the evening before. 4. Sedation is usually given during the
procedure. Client and Family teaching: Before procedure • • • Explain dietary restrict
ions and their purpose. The procedure takes 30 minutes to 1 hour. The scope is i
nserted through the anus and advanced to the cecum.
After procedure • You may have increased flatus as air is instilled into the bowel
during the procedure. • Report any abdominal pain, chills, fever, rectal bleeding
or mucopurulent discharge. • If polyps have been removed, avoid heavy lifting for
7 days and avoid high fiber food foe 1-2 days. UPPER ABDOMINAL ULTRASOUND Abdom
inal ultrasound (US) is an important diagnostic method for evaluation of many st
ructures in the abdomen, such as the liver, gallbladder, biliary tract, pancreas
and kidneys. Indications include abdominal, flank and/or back pain, palpable ab
normalities, abnormal laboratory values suggestive for abdominal pathology, foll
ow-up of known or suspected abnormalities and search for metastatic disease or o
ccult primary. Abdominal US are frequently performed in Western societies.
68
The frequency with which even relatively inexpensive and non-invasive diagnostic
tests are performed clearly places a burden on health care. Therefore it is imp
ortant that their influence on patient management is assessed. Unnecessary diagn
ostic investigations may lead to incidental findings, or to additional unnecessa
ry diagnostic procedures or even over treatment. NURSING RESPONSIBILITIES: Clien
t preparation 1. Ask patient to wear comfortable, loose-fitting clothing for ult
rasound exam. The patient will need to remove all clothing and jewelry in the ar
ea to be examined. You may be asked to wear a gown during the procedure. 2. Ask
patient to inform the doctor if he/she have had a barium enema or a series of up
per GI (gastrointestinal) tests within the past two days. Barium that remains in
the intestines can interfere with the ultrasound test. Other preparations depen
d on the type of ultrasound you are having. • For a study of the liver, gallbladde
r, spleen, and pancreas, you may be asked to eat a fatfree meal on the evening b
efore the test and then to avoid eating for eight to 12 hours before the test. • F
or ultrasound of the kidneys, you may be asked to drink four to six glasses of l
iquid about an hour before the test to fill your bladder. You may be asked to av
oid eating for eight to 12 hours before the test to avoid gas buildup in the int
estines. For ultrasound of the aorta, you may need to avoid eating for eight to
12 hours before the test.
•
DURING AND AFTER THE PROCEDURE Most ultrasound examinations are painless, fast a
nd easy. 1. Inform the patient that after he or she positioned on the examinatio
n table, the radiologist, or sonographer will spread some warm gel on his/her sk
in and then press the transducer firmly against the body, moving it back and for
th over the area of interest until the desired images are captured. There may be
varying degrees of discomfort from pressure as the transducer is pressed agains
t the area being examined. 2. If scanning is performed over an area of tendernes
s, the patient may feel pressure or minor pain from the procedure. 3. If a Doppl
er ultrasound study is performed, the patient may actually hear pulse-like sound
s that change in pitch as the blood flow is monitored and measured. • Once the ima
ging is complete, the gel will be wiped off on skin.
69
•
After an ultrasound exam, the patient should be able to resume your normal activ
ities.
PROCTOSIGMOIDOSCOPY/ SIGMOIDOSCOPY Sigmoidoscopy is the minimally invasive medic
al examination of the large intestine from the rectum through the last part of t
he colon. There are two types of sigmoidoscopy, flexible sigmoidoscopy, which us
es a flexible endoscope, and rigid sigmoidoscopy, which uses a rigid device. Fle
xible sigmoidoscopy is today generally the preferred procedure. Sigmoidoscopy is
a very effective screening tool. Sigmoidoscopy is similar but not the same as c
olonoscopy. Sigmoidoscopy only examines up to the sigmoid, the most distal part
of the colon, while colonoscopy examines the whole large bowel. Client Preparati
on: The colon and rectum must be completely empty for flexible sigmoidoscopy to
be thorough and safe, so the physician will probably tell the patient to drink o
nly clear liquids for 12 to 24 hours beforehand. A liquid diet means fat-free bo
uillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea,
or diet soft drinks. The night before or right before the procedure, the patient
receives a laxative and an enema, which is a liquid solution that washes out th
e intestines. No sedation is required during this procedure as long as the exami
nation does not exceed the level of the splenic flexure COMPUTED TOMOGRAPHY SCAN
CT imaging is particularly useful because it can show several types of tissue w
ith great clarity, including organs such as the liver, spleen, pancreas and kidn
eys. Using specialized equipment and expertise to create and interpret CT scans
of the lower gastrointestinal (GI) tract, the colon and rectum, an experienced r
adiologist can accurately diagnose many causes of abdominal pain, such as an abs
cess in the abdomen, inflamed colon or colon cancer, diverticulitis and appendic
itis. Often, no additional diagnostic work-up is necessary and treatment plannin
g can begin immediately. What are some common uses of the procedure? Because it
is a non-invasive procedure that provides detailed, cross-sectional views of all
types of tissue, CT is becoming the preferred method for diagnosing many diseas
es of the bowel and colon, including diverticulitis and appendicitis, and for vi
sualizing the liver, spleen, pancreas and kidneys. In cases of acute abdominal d
istress, CT can quickly identify the source of pain. Especially when pain is cau
sed by infection and inflammation, the speed, ease and accuracy of a CT examinat
ion can reduce the risk of serious complications caused by a burst appendix or r
uptured diverticulum and the subsequent spread of infection. CLIENT PREPARATION
1. The client should wear comfortable, loose-fitting clothing for the CT exam. 7
0
2. Metal objects can affect the image, so avoid clothing with zippers and snaps.
The client may be asked to remove hairpins, jewelry, eyeglasses, hearing aids a
nd any removable dental work that could obscure the images. 3. The client may al
so be asked to refrain from eating or drinking anything for an hour or longer be
fore the exam. 4. Women should always inform their doctor or x-ray technologist
if there is any possibility that they are pregnant. How is the procedure perform
ed? The technologist begins by positioning the patient on the CT table. The pati
ent s body may be supported by pillows to help hold it still and in the proper p
osition during the scan. As the study proceeds, the table will move slowly into
the CT scanner. Depending on the area of the body being examined, the increments
of movement may be so small that they are almost undetectable, or large enough
that the patient feels the sensation of motion. A CT examination of the gastroin
testinal tract requires the use of a contrast material to enhance the visibility
of certain tissues. The contrast material may be swallowed or administered by e
nema. Before administering the contrast material, the technologist will ask whet
her the patient has any allergies, especially to medications or iodine, and whet
her the patient has a history of diabetes, asthma, a heart condition, and kidney
problems. These conditions may indicate a higher risk of reaction to the contra
st material. A CT examination usually takes from five minutes to half an hour. N
URSING RESPONSIBILITIES: DURING THE CT SCAN 1. The client will lie on a table th
at will pass slowly through a large opening in the scanner as x-rays are taken.
2. The client will be asked to lie perfectly still throughout the procedure, so
that blurring does not occur. Even though the client will be alone in the room,
the client will be closely observed at all times. If contrast is used, it will b
e injected into the client’s arm through an IV line. 3. At the time of injection,
client may have a momentary feeling of warmth and flushing, a salty taste in the
mouth, and possibly some mild nausea. AFTER THE SCAN 1. After the scan, inform
the client that he/she should be able to resume his/her normal diet and activiti
es. 2. Encourage to drink at least 5 to 6 glasses of water a day for 2 days afte
r the scan. The water helps flush the contrast media from the system. If the cli
ent must limit fluid intake because of a heart problem or for any other reason,
he/she should inform doctor about how much water he/she can safely drink. 3. If
the client is diabetic who takes any medication that contains metformin, the cli
ent must have a blood test to check kidney function before he/she can start taki
ng metformin again.
71
Call thedoctor for the results of the blood test and for instructions about resu
ming metformin. This is to prevent kidney damage and a serious reaction called l
actic acidosis
PHARMACOLOGICAL INTERVENTIONS Date Ordered: August 17, 2008
72
Date Discontinued: August 21, 2008 Generic Name: Metronidazole Brand Name: Flagy
l Drug Classification: Amebicides and antiprotozoals Dosage: 750mg 1 tab per ore
m Frequency: every 8 hours Mechanism of Action: To exert bactericidal effects, m
etronidazole must first be taken up by cells and then converted into its active
form; only anaerobes can perform the conversion.the active form interacts with D
NA to cause strand breakage and loss of helical structures, effects that result
in inhibition of nucleic acid synthesis and,ultimately cell death. Indication: I
ntestinal amoebiasis Adverse Reaction: CNS: headache, seizures GI: nausea, GU: v
aginitis, Hematologic: transient leucopenia, neutropenia Respiratory: Upper resp
iratory tract infection Skin: rash Contraindications: Contraindicated in patient
s with: • hypersensitive to drug or other nitroimidazole derivatoives • first trimes
ter of pregnancy • history of blood dyscrasia • CNS disorder • Retinal or visual field
changes Drug Interactions: Cimetidine: May increase risk of metronidazole toxic
ity because of inhibited hepatic metabolism. Disulfiram: May cause psychosis and
confusion. Lithium: May increase lithium level, which may cause toxicity. Oral
anticoagulants: May increase anticoagulant effects. Phenobarnital, phenytoin: ma
y decrease metronidazole effectiveness; may reduce total phenytoin resistance Nu
rsing Considerations: • Monitor liver function test results carefully in elderly p
atients • Give oral forms with meals • Observe patient for edema, especially if taki
ng corticosteroids; Flagyl IV may cause sodium retention • Record number and chara
cter of stool. Patient Teaching: • Instruct patient to take extended-release table
ts from at least 1 hour before or 2 hours after meals but to take all other oral
forms with food to minimize GI upset.
73
• •
Tel l patient to avoid alcohol and alcohol containing drugs during and for atlea
st 3 days after treatment course. Tell patient he may experience a metallic tast
e and have dark or red-brown urine Tell patient to report to prescriber any neur
ologic symptoms.
•
Date ordered: August 19, 2008 Date Discontinued: August 21, 2008 Generic Name: H
yoscine Butylbromide Brand Name: Buscopan Drug Classification: Antispasmodic Dos
age: 10 ml 1 tab per orem Frequency: every 4 hours PRN Mechanism of Action: Inhi
bits muscarinic action of acetylcholineon autonomic effectors innervated by post
ganglionic cholinergic neurons. May affect neural pathways originating in the in
ner ear to inhibt nausea and vomiting. Indication: Spasmodic state Adverse React
ions: CNS: disorientation, restlessness, irritability GI: constipation, dry mout
h, nausea, vomiting, epigastric distress GU: urinary retention Respiratory: depr
essed respiration Skin: rash, dryness Contraindications: Contraindicated in pati
ents with: • Angleclosure glaucoma, obstructive uropathy, obstructive disease of t
he GI tract, asthma, Chronic pulmonary disease, myasthenia gravis, paralytic ile
us, intestinal atony, unstable CV status. Drug Interactions: Antacid: May decrea
se oral absorption of anticholinergics. Separate doses by 2 or 3 hours CNS Depre
ssants: May increase risk of CNS depression Digoxin: May increase digoxin level
Ketoconazole: May interfere with ketoconazole absorption Nursing Considerations:
• Raise side rails as a precaution because some patients become temporarily excit
ed or disoriented and some develop amnesia or become drowsy. Reorient patient as
needed. • Tolerance may develop when therapy is prolonged • Atropine-like toxicity
may cause dose-related adverse reactions • Overdose may cause curarelike effects,
such as respiratory paralysis. Patient Teaching:
74
• • to avoid activities that require alertness until CNS effects of drug are known.
Urge the patient to report urinary hesitancy or urine retention.
Warn patient
Date Ordered: August 17, 2008 Date Discontinued: August 21, 2008 Generic Name: L
operamide Brand Name: Imodium Drug Classification: Antidiarrheals Dosage: 2 mg I
tab Frequency: every 4 hours PRN Mechanism of Action: Inhibits peristaltic acti
vity prolonging transit of intestinal contents. Indication: Acute, non-specific
diarrhea Adverse Reactions: CNS: drowsiness, fatigue, dizziness GI: dry mouth, a
bdominal pain, distention, constipation, nausea Skin: rash Contraindications: Co
ntraindicated in patients with: • hypersensitive to drug • bloody diarrhea • diarrhea
with fever greater than 101F • breastfeeding women Drug Interactions: • Saquinavir:
May increase loperamide levels and decrease saquinavir levels.ildren younger tha
n 2 Nursing Considerations: • If clinical symptoms don’t improve within 48 hours, st
op therapy and consider other alternatives • Drug produces antidiarrheal action si
milar to that of diphenoxylate but without as many adverse CNS effects. Patient
Teaching: • Advise patient not to exceed recommended dosage • Tell patient with acut
e diarrhes to stop drug abd seek medical attention if no improvement occurs with
in 48 hours. • Advise patient with acute colitis to stop drug immediately and repo
rt abdominal distention. • Tell patient to report nausea, abdominal pain or abdomi
nal discomfort.
75
Date Ordered: Auguts 17, 208 Date Discontinued: August 23, 2008 Generic Name: Pr
ednisone Brand Name: Deltasone Drug Classification: Corticosteroids Dosage: 10 m
g 1 tab per orem Frequency: three times a day Mechanism of Action: Decreases inf
lammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immun
e response; stimulates bone marrow; and influences protein, fat and carbohydrate
metabolism. Indication: Sever inflammation, immunosuppression Adverse Reactions
: CNS: euphoria, insomnia, pseudotumor cerebri, headache, seizures CV: heart fai
lure, arrhythmias, thromboembolism GI: peptic ulceration, pancreatitis, nausea,
GU: menstrual irregularities, increased urine calcium level Skin: hirsutism, del
ayed wound healing Contraindications: Contraindicated in patients with: • hypersen
sitive to drug • systemic fungal infection • client receiving immunosuppressive dose
s with live virus vaccines Drug Interactions: Aspirin: May increase risk of GI d
istress and bleeding Barbiturates, rifampin, phenytoin: may decrease corticoster
oid effect Cyclosporine: May increase toxicity Oral anti coagulants: May alter d
osage requirements Skin-test antigens: may decrease response Nursing Considerati
ons: a.) Determine whether patient is sensitive to other corticosteroids b.) Dru
g may be used for alternate-day therapy c.) Always adjust to lowest effective do
se d.) For better results and less toxicity, give a once-daily dose in the morni
ng e.) Give oral dose with meal to reduce GI irritation f.) Monitor patient’s bloo
d pressure, sleep pattern and sodium level. g.) Report sudden weight gain h.) Mo
nitor patient for Cushingoid effects i.) Drug may mask or worsen infections. Inc
luding latent amoebiasis. Patient Teaching: • Tell patient not to stop drug abrupt
ly or without prescriber’s consent • Instruct patient to take the drug with food or
milk • Teach patient signs and symptoms of early adrenal insufficiency • Tell patien
t to report slow healing
76
Generic Name: hydrocortisone sodium succinate Brand Name: Solucortef Drug Classi
fication: Corticosteroid Dosage: 100ml IV Frequency: every 8 hours Mechanism of
Action: Decreases inflammation, mainly by stabilizing leukocyte lysosomal membra
nes; suppresses immune response; stimulates bone marrow; and influences protein,
fat and carbohydrate metabolism. Indication: ulcerative colitis Adverse Reactio
ns: CNS: euphoria, insomnia, pseudotumor cerebri, headache, seizures CV: heart f
ailure, arrhythmias, thromboembolism GI: peptic ulceration, pancreatitis, nausea
, Hematologic: easy bruising GU: menstrual irregularities, increased urine calci
um level Skin: hirsutism, delayed wound healing Contraindications: Contraindicat
ed in patients with: • hypersensitive to drug • systemic fungal infection • client rec
eiving immunosuppressive doses with live virus vaccines Drug Interactions: Aspir
in: May increase risk of GI distress and bleeding Barbiturates, rifampin, phenyt
oin: may decrease corticosteroid effect Cyclosporine: May increase toxicity Oral
anti coagulants: May alter dosage requirements Skin-test antigens: may decrease
response Nursing Considerations: j.) Determine whether patient is sensitive to
other corticosteroids k.) Drug may be used for alternate-day therapy l.) Always
adjust to lowest effective dose m.) For better results and less toxicity, give a
once-daily dose in the morning n.) Give oral dose with meal to reduce GI irrita
tion o.) Monitor patient’s blood pressure, sleep pattern and sodium level. p.) Rep
ort sudden weight gain q.) Monitor patient for Cushingoid effects r.) Drug may m
ask or worsen infections. Including latent amoebiasis. Patient Teaching: • Tell pa
tient not to stop drug abruptly or without prescriber’s consent • Instruct patient t
o take the drug with food or milk • Teach patient signs and symptoms of early adre
nal insufficiency • Tell patient to report slow healing
77
Date Ordered: August 17, 2008 Date Discontinued: August 23,2008 Generic Name: Ra
beprazole sodium Brand Name: Aciphex Drug Classification: Anti ulcerant ( Proton
pump inhibitor) Dosage: 20 mg 1 tab per orem Frequency: twice a day Action of t
he Drug: Blocks proton pump activity and gastric acid secretion by inhibiting ga
stric hydrogen-potassium adenosine triphosphate at secretory surface of gastric
parietal cells. Indication: healing of duodenal ulcers Adverse Reactions: CNS: h
eadache Contraindications: Contraindicated in patients with: • hypersensitive to d
rug or other benzimidazoles Drug Interactions: Clarithromycin: May increase rabe
prazole level Cyclosporine: May inhibit cyclosporine metabolism Digoxin, ketocon
azole, other pH-dendent drugs: May decrease or increase drug absorption at incre
ased pH values Warfarin: May inhibit warfarin matebolism Nursing Considerations:
• Consider additional courses of therapy if duodenal ulcer isn’t healed after first
course therapy • Amoxicillin may trigger anaphylaxis in patients with a history o
f penicillin hypersensitivity • Symptomatic response to therapy doesn’t preclude pre
sence of gastric malignancy Patient Teaching: Explain importance of taking drugs
exactly as prescribed Advice patient to swallow delayed release tablets whole a
nd to crush, shew or split it Inform patient that drug may be taken without rega
rd to meals
78
Generic Name: Ciprofloxacin Brand Name: Cipro Drug Classification: Fluoroquinolo
nes Dosage: 500mg 1 tab per orem Frequency: twice a day Action of the Drug: Inhi
bits bacterial DNA synthesis mainly by blocking DNA gyrase; bactericidal Indicat
ion: Complicated intra-abdominal infection Adverse Reactions: CNS: headache, sei
zures GI: nausea, diarrhea, pseudomembranous colitis Hematologic: leukopenia, ne
utropenia, thrombocytopenia Skin: rash Contraindications: Contraindicated in pat
ients with: • hypersensitive to fluoroquinolones • Drug Interactions: Aluminum hydro
xide, aluminum-magnesium hydroxide, calcium carbonate Magnesium hydroxide: may d
ecrease ciprofloxacin absorption and effects Cyclosporine: May increase risk for
cyclosporine toxicity Nursing Considerations: • Obtain specimen for culture and s
ensitivity before giving first dose. • Some drugs require waiting up to 6 hours af
ter giving this drug to avoid decreasing its effects • Monitor patient’s intake and
output and observe patient for sign and symptoms of crystalluria. Patient Teachi
ng: 5. Tell patient to take drug as prescribed, even after he feels better. 6. A
dvise patient to drink plenty of fluids to reduce risk of urine crystals 7. Advi
se patient not to chew, crush or split the extended-release tablets 8. Instruct
patient not to take caffeine while taking drug because of potential increase caf
feine effects 9. Breastfeeding should be stop while taking the drug
79
TEN IDENTIFIED PROBLEMS 1. 2. 3. 4. 5. Diarrhea Fluid Volume Deficit Acute Pain
Altered Sensory Perception Imbalance Nutrition less than Body Requirements
80
NURSING CARE PLAN CUES SUBJECTIVE: “Madalas ako nadudume na may kasamang dugo at m
edyo basa. Nakaramdam din ako ng pagsusuka kung minsan at pananakit ng tiyan” NURS
ING DIAGNOSIS Diarrhea related to invasion of the lining of the colon secondary
to infectious processes as manifested by: SCIENTIFIC OBJECTIVES NURSING RATIONAL
E RATIONALE INTERVENTION Release of enterotoxins SHORT INDEPENDENT: by invading
TERM GOAL microorganism - Observe and -To note for After 30-45 record amount, de
gree of fluid minutes of characteristics and losses Increase nursing frequency o
f bowel secretion of intervention the movement. water and client will be electro
lytes able to - Increase oral -To replace promptly fluid intake fluid losses rep
lace fluids due to frequent and vowel Inhibits the electrolyte movement sodium l
osses through - Monitor intake reabsorption hydration and and output - To assess
for electrolyte decrease in supplement as fluid volume evident by resulting to
Large amount increasing oral dehydration of CHON rich fluid intake and fluids el
ectrolyte - Assess for signs -To determine balances of dehydration client’s hydrat
ion Diarrhea LONG TERM status and GOAL determine dehydration After 3-4 hours Ref
erence: nursing DEPENDENT: EVALUATION SHORT TERM GOAL After implementation of ap
propriate nursing intervention, the client was able to promptly replaced fluids
and electrolyte losses through hydration and electrolyte supplement as evidenced
by increased in oral intake and maintained electrolyte balance - Goal fully met
ACF of stool • 2-3X/ day • brownish OBJECTIVE: yellow with ACF of stool blood streak
, • 2-3X/ day loose and • brownish mucoid yellow with • 1 cup per bout blood streak, • H
yperactive bowel loose and sounds mucoid • 1 cup per bout • Abdominal cramps Hyperac
tive bowel sounds With patient verbalization, “Madalas ako nadudume • Abdominal cram
ps na may kasamang dugo at medyo basa. Nakaramdam Inferences: din ako ng pagsusu
ka Fecalysis (08/16/08) kung minsan at pananakit Presence of Entamoeba ng tiyan” h
istolytica •
81
Result: Cyst = 1-3L/LPF Trophozoite= 1-2/LPF
Medical Surgical Nursing by Black and Hokanson Pg 1078-1079
intervention the client will be able to reestablish hydration status as to preve
nt dehydration through physical assessment and careful monitoring of intake and
output.
-Administer IV fluids as indicated with electrolyte supplements (KCl)
-To replenish and establish hydration and maintain electrolyte balance -Inhibits
nucleic acid of the bacteria there by eliminating spread of infection
LONG TERM GOAL After implementation of appropriate nursing intervention, the cli
ent was able partially reestablished hydration status as to prevent dehydration
through absence of signs of dehydration minimum intake and output - Goal is part
ially met
-Administer antiprotozoal medication (Flagyl)
CUES
NURSING
SCIENTIFIC
OBJECTIVES
NURSING
RATIONALE EVALUATION
82
SUBJECTIVE: “Nararamdaman ko din na nanghihina ako at para bang palage akong walan
g lakas.” OBJECTIVES: ACF of Bowel movement • Frequency2-3x/ day • Color- brownish yel
low with blood streak • Consistency – loose and mucoid • Amount- 1 cup per bout • • • • • •
se in urine output ( 700-750ml) Decrease oral fluid intake ( 630-840 ml) Fair sk
in turgor Pale nail beds Pale palpebral
DIAGNOSIS Fluid Volume Deficit related to active fluid volume loss ( diarrhea) s
econdary to infectious process as manifested by ACF of Bowel movement • Frequency2
-3x/ day • Colorbrownish yellow with blood streak • Consistency – loose and mucoid • Amo
unt- 1 cup per bout • • • • • • Decrease in urine output Decrease oral fluid intake Fair sk
n turgor Pale nail beds Pale palpebral conjunctiva Slightly pale
RATIONALE Infectious process Invades the lining of the intestines Stimulation of
the SNS/PNS and decrease water reabsorption Increase gastrocolic reflex Diarrhe
a results ( Active fluid volume loss) SHORT TERM GOAL After 1-2 hours of nursing
intervention, the client will maintain adequate fluid volume versus active flui
d volume loss through fluid hydration and monitoring of intake and output as evi
dence by moist mucous membranes, good skin turgor, and increase in oral fluid in
take from 840 ml to at least 1000ml and urine output of at least 850cc
INTERVENTION INDEPENDENT > Encourage client to increase oral fluid intake SHORT
TERM > To replenish GOAL patient with fluid volume After 1-2 hours losses of imp
lementing appropriate nursing intervention, the > To moisten client maintained t
he mucous adequate fluid membrane and volume versus prevent injury active fluid
from dryness volume loss as evidenced by an increase in oral > To check for flui
d intake from an increase or 840ml to at least decrease fluid 1000ml with losses
moistened mucous > To decrease membrane, good oxygen skin turgor and demand inc
rease urine thereby output of 800 cc resulting from weakness - Goal partially me
t > To assess for signs of LONG TERM
> Provide meticulous oral care (toothbrush and mouthwash)
> Check voiding and record amount
> Promote a quiet environment and bed rest
Fluid Volume Deficiency
> Regularly assess client for changes
83
• • •
conjunctiva Slightly pale nasal and buccal mucosa Dry and cracked lips Thready/w
eak pulse
nasal and buccal mucosa INFERENCES • Slight increase in urine specific gravity- 1.
030
INFERENCES • • • Slight increase in urine specific gravity- 1.030 Fecalysis (08/16/08)
Presence of Entamoeba histolytica
Reference: Medical Surgical Nursing by Black and Hokanson Pg. 1078-1079
LONG TERM GOAL After 4-6 hours of nursing intervention, the client will have an
increase in energy levels and prevent further complication as evident by client’s
verbalization of an increase in energy levels
in conditions (e.g. mental status, fatigability, restlessness etc.) > Strictly m
onitor I/O
dehydration and monitor progress of client.
GOAL
With client’s verbalization, “Nararamdaman ko din na nanghihina ako at para bang pal
age akong walang lakas.”
DEPENDENT > Administer IV fluids as indicated
> Monitor client’s urine specific gravity
After 4-6 hours of implementing appropriate nursing >To measures intervention, t
he if client had client reported a enough fluid slight increase in intake and en
ergy level and output absence of complications as verbalized by the client, “ > Fo
r Medyo ok na replacement of ang pakiramdam fluids and ko, hindi na ako electrol
ytes gaano nanghihina.” > To assess for hydration - Goal partially status of the m
et. client
CUES SUBJECTIVE:
NURSING DIAGNOSIS Acute pain related to inflammatory
SCIENTIFIC RATIONALE Damage to the intestinal
OBJECTIVES SHORT TERM GOAL
NURSING INTERVENTION INDEPENDENT: >Encourage adequate
RATIONALE
EVALUATION SHORT TERM GOAL
>To promote
84
“Pabalik balik yung response sakit ng tiyan ko. secondary to Humihilab at para com
pression of bang umiikot yung nerve endings sikmura ko” • Recurrent abdominal pain • P
ain scale of 7-8 out of 10 • Guarding behavior OBJECTIVES: during episodes of • Recu
rrent pain abdominal pain • Slight facial • Guarding grimace behavior during • Irritab
le and episodes of less pleasant pain • Narrowed focus ( less • Slight facial intere
sted grimace with conversing to others) • Normal to • Irritable and hyperactive less
pleasant bowel sounds • Narrowed focus ( less With verbalization interested of pa
tient, “Pabalik with balik yung sakit ng conversing to tiyan ko. Humihilab others)
at para bang umiikot
tissue Increase vascular permeability Vasodilation Swelling Edema Compression of
nerve endings Pain Perception Reference: Medical Surgical Nursing By: Brunner a
nd Suddarths Pg. 810-812
relaxation as to prevent fatigue After 15-30 rest periods minutes of After 15-30
implementing minutes of > To decrease appropriate nursing pain through nursing
intervention the >Provide comfort stimulation of intervention the patient will b
e measures (e.g. back release of patient was able report a rub, proper endorphin
s reported a decrease in pain positioning etc.) decrease in pain perception scal
e from 7-8 to through 6 out of 10 providing > To assist in methods to muscle and
Goal fully met alleviate pains generalized as evident by a > Encourage deep rel
axation LONG TERM decrease in pain breathing exercise GOAL scale from 7-8 >To le
ssen to at least 6 preoccupation After 1-2 hours of implementing > Provide diver
sional to pain and lessen it appropriate LONG TERM activities such as nursing GO
AL listening to music and >To reduce intervention the watching television stimul
ation patient After 1-2 hours that may demonstrated of nursing >Provide quiet an
d behavioral intervention the calm environment and trigger pain perception modif
ications patient will be cluster nursing care that has lessened able pain percep
tion demonstrate > To release through appropriate endorphins and relaxation skil
ls behavioral > Encourage right enhance well and other modifications to sided br
ain being comfort lessen pain stimulation such as
85
•
Normal to yung sikmura ko” hyperactive bowel sounds • Pain scale of 7-8 out of 10
perceived through relaxation skills and comfort measures as evident by decrease
irritability and preoccupation to pain
love, laughter and music Dependent: >Administer anti inflammatory drugs ( Predni
sone)
> To decrease inflammation that may cause pain
measures as evidenced by decrease irritability and decrease preoccupation to pai
n -Goal fully met
CUES SUBJECTIVE:
NURSING DIAGNOSIS Altered Sensory Perception; Tactile
SCIENTIFIC OBJECTIVES NURSING RATIONALE INTERVENTION Prolonged used SHORT TERM I
NDEPENDENT of GOAL
RATIONALE
EVALUATION SHORT TERM GOAL
86
“Nagmamanhid nga yung mga daliri ko sa paa, hindi ako nakakaramdam.” OBJECTIVES: • Pos
itive (+) numbness of toes both in right and left feet Change in usual response
to tactile stimuli Unable to feel touch or object applied to both toes
related to prolonged use of medication (Flagyl) secondary to chronic bacterial i
nfection of the colon as manifested by Positive (+) numbness of toes both in rig
ht and left feet • Change in usual response to tactile stimuli • Unable to feel touc
h or object applied to both toes With client’s verbalization, ““Nagmamanhid nga yung m
ga daliri ko sa paa, hindi ako nakakaramdam.” •
•
•
After 30-45 minutes of nursing Damage nerve intervention, the endings client wil
l be safe from any cause of dangers Altereation on that may the axonal precipita
te injury regions of the due to altered neurons tactile perception through Decre
ase measures that amplitude on will promote nerve safety to the conduction clien
t to as velocity evident by absence of Altered nerve injury or trauma transmissi
on to caused by periphery sensory deficit
Metronidazole
>Provide client with shoe wear or slippers when ambulating
>To prevent injury ( e.g. punctured wound) while ambulating > To prevent falls,
slipping or wound to get unnoticed > To protect from thermal/cold damage or burn
s
> Remove sharp or unnecessary objects ( needles, clutters etc.) within client’s ar
ea > Monitor use of heating pads as well as cold packs and temperature of water
use for sponge bath
After 30-45 minutes of implementing appropriate nursing care, the client had bee
n safe from any cause of dangers that may precipitate injury due to altered tact
ile perception as evidenced by absence of injury, trauma or hazards caused by se
nsory deficit. -Goal fully met
> Assist during ambulation
> To aid in maintaining balance and avoid unwanted injury > To allow easy access
to when client needs help and when emergency
LONG TERM GOAL After 1-2 days of implementing appropriate nursing care, the clie
nt had
Altered sensory perception ( Tactile) Reference:
LONG TERM GOAL After 1-2 days of >Place call bell nursing within client’s reach in
tervention, the client will
87
cases happen Neurologyindia recognize website alteration on tactile perception t
hrough health teaching and be able to compensate to it by providing measures or
ways of dealing with perceptual deficit as evident by client able to make indepe
ndent compensatory techniques that will aid in making necessary activities
>Provide diversional activities for the client (e.g. watching TV, listen to musi
c, read etc.)
> Provide tactile stimulation (cotton ball, pin, feather , pinching etc.)
recognized alteration in > To promote tactile perception stimulation of and lear
ned other sense independent unaffected and skills as a avoid client’s compensatory
preoccupation technique which to sensory aided her in deficit making necessary
activities. > It communicate -Goal fully met connection to other people and prov
ide stimulation to sense of touch > To presume path to be taken is free from har
m
> Instruct client to check her path during ambulation
> To assist client when ambulating if decrease tactile > Use assistive device de
ficit is severe as necessary (e.g. wheelchair, cane etc.) > To recognize
88
> Discuss with the client the cause of the alteration in tactile perception and
measures to deal with it
and understand the reason of sensory deficit and allow client to make appropriat
e ways to deal with it
> To promote stimulation of COLLABORATIVE tactile perception and regain it > Adv
ice client to undergo physical rehabilitation or therapy
CUES SUBJECTIVE: “Wala talaga akong
NURSING DIAGNOSIS Imbalance nutrition less than body
SCIENTIFIC RATIONALE Chronic damaged of intestinal tissue
OBJECTIVES SHORT TERM GOAL
NURSING INTERVENTION INDEPENDENT > Give a health
RATIONALE EVALUATION SHORT TERM GOAL After 45-60
>To determine
89
ganang kumain. Mga 3-4 na subo lang ayoko na agad. Sumasakit kasi ang tiyan ko a
t masama talaga ang pakiramdam ko” • Reports of abdominal pain
requirements related to loss of appetite due chronic illness state secondary to
abdominal pain as manifested by 94 lbs ( ABW) • Stands 5’0 feet • IBW vs. ABW 104lbs =
94 lbs • BMI = 18.6 ( Underweight) • Appears thin and frail • Decrease subcutaneou s
and muscle mass • Pale conjunctiva • Moderate hair loss was observed • Weak and decrea
se energy level •
Inflammatory response Compression of nerve endings Pain perception Narrowed focu
s Preoccupation to pain perceived Loss of appetite ( Anorexia)
OBJECTIVES: 94 lbs ( ABW) • Stands 5’0 feet • IBW vs. ABW 104lbs =94 lbs • BMI = 18.6 (
Underweight) • Appears thin and frail • Decrease subcutaneou s and muscle mass • Pale
conjunctiva • Moderate •
Imbalanced Nutrition less than body requirements
After 45-60 minutes of nursing intervention, the client will be able to understa
nd the need to eat a well balanced diet both in quality and quantity as to impro
ved nutritional status through health teaching and demonstration as evidence wit
h client’s desire to make appropriate diet modifications of improving general heal
th status LONG TERM GOAL
teaching on the importance of a balanced diet and adequate hydration that it hel
ps in building strong immune system. > Prepare food samples that are nutritious
and demonstrations of food preparations that is within client’s income >Assess cli
ent’s condition such as energy levels and feeling of body weakness
health knowledge of client that needs to be modified or to enhance regarding foo
d management.
>Encourage to eat a well balanced meal After 1-2 days and proper hydration of nu
rsing by citing some health intervention the benefits that could
minutes of implementing appropriate nursing intervention, the client understood
the need to eat a well balance diet both in quality >Stimulates and quantity by
the client’s means of health desire to teaching as initiate ways in evidenced by h
ow to achieve client’s desire to an optimum make health. appropriate diet modifica
tion with > To verbalization of, determine “ Gusto ko client’s talaga maging physiol
ogic masustansya ang response to kinakian ko para food intake as makaiwas sa wit
h regards to sakit. At least quality and ngayon alam ko quantity na ang mga dapa
t kong >Balanced diet piliing pagkain.” and adequate hydration are -Goal fully met
known to
90
•
hair loss was observed Weak and decrease energy level
With verbalization of the client, “Wala talaga akong ganang kumain. Mga 3-4 na sub
o lang ayoko na agad. Sumasakit kasi ang tiyan ko at masama talaga ang pakiramda
m ko”
Reference: Pathophysiology by Carol Mattson Porth
patient will be able to increase food intake both in quality and quantity approp
riate to her illness status through proper preparation of food to serve with cli
ent reports on an increase in energy levels and decrease body weakness
build strong line of defense. > Encourage bed rest during acute phase of illness
contribute to a good nutrition.
LONG TERM GOAL
>Provide foods that are high in calories, proteins and carbohydrates
> Provide the client with adequate time to eat and prepare food aesthetically
After 1-2 days of implementing > Decrease appropriate metabolic nursing needs ai
ds in intervention, the preventing client had a caloric gradual increase depleti
on and in food intake conserves both in quantity energy and quality appropriate
to >To provide her illness state client nutrients through proper that will boost
preparation of energy levels food to serve during illness with client state and
repair verbalized, bodily tissues “Medyo hindi na ako nanghihina at mas maganda a
ng pakiramdam ko ngayon kesa dati. Mas > To facilitate madame na din adequate fo
od ako nakakain intake and ngayon.” make food attractive -Goal fully met
91
> Prepare foods that are easy to chew and palatable
> To enhance mechanical digestion of food and promote client’s appetite
DEPENDENT >Administer vitamins and supplements as per doctors order
> To build strong immune system and body resistance to COLLABORATIVE diseases >
Refer to dietician > To for diet regimen determine appropriate dietary regimen
92
DISCHARGE PLANNING TAKE HOME MEDICATIONS • daily large baking soda enemas followed
with flax seed enemas • Psyllium husks - treatment of mild to moderate hyperchole
sterolemia. • Steroids for relief of inflammation • Drugs that suppress the immune s
ystem • Drugs that relieve diarrhea • Medication is necessary DIETARY MANAGEMENT • cle
ar liquids such as water, juice, tea • oral rehydrating or electrolyte solutions • D
rinking small amounts at frequent intervals is better accepted in cases of nause
a. • Avoid solids because they can cause cramps • Light soups, toast, rice and eggs
are good foods ACTIVITIES • bed rest upon arrival from the hospital • light exercise
every morning • eventually the patient can return to its normal activities of dai
ly living HYGENIC PRACTICES • wash hands with soap after going to the toilet and b
efore eating or preparing food • Avoiding sexual practices that may lead to fecal-
oral contact • Proper hand washing is necessary • Cut and keep your nails clean • Avoi
d sharing towels with infected persons • Avoid alcohol for preventing intestinal c
omplications • Take care of drinking water - either opt for mineral water or water
boiled for 20 minutes SPECIAL CARE • Never use any soap or chemical that are not
specifically stated by your doctor • Eating slippery elm will usually ease ulcer p
ain in less than twenty minutes with no negative side effects • Specifically no wa
ter containing chlorine • No milk or milk products should be taken as this could c
ause irritation SCHEDULE CLINIC • Continuous follow-up care - a schedule of follow
-up care • Return again after a month for follow up check- up
93
HOME PREVENTION • Avoidance of drinking unboiled or unbottled water in endemic are
as. • Uncooked food such as fruit and vegetables that may have been washed in loca
l water should also not be consumed. • Amoebic cysts are resistant to chlorine at
the levels used in water supplies, but disinfection with iodine may be effective
. • Wash hands with soap and warm water after going to the toilet and before eatin
g or preparing food. • Proper food storage and preventing its contamination with f
aeces, flies, and contaminated water • Avoiding sexual practices that may lead to
fecal-oral contact PUBLIC HEALTH PREVENTION
•
• • • •
• • • • •
One important public health strategy is to make sure to treat infected individua
ls who appear asymptomatic, since these people also pass cysts in their stool an
d thus contributed to spreading the disease. Good sanitation and water facilitie
s are also important in preventing the disease. Food handlers, child care worker
s, and health care workers with amoebiasis should not be allowed to work until t
heir symptoms are gone. If children have symptoms, they should not attend child
care centers or schools until their symptoms are gone. In general, people should
practice good hygiene, since the fecal matter from those infected could contami
nate food and water that is then transferred to others. This includes careful ha
nd washing with soap and hot running water for at least 10 seconds after going t
o the toilet, as well as practice frequent hand washing in general to eliminate
any parasite that one may have picked up throughout the day. Travelers should ta
ke precaution Clean bathrooms and toilets often. Boil water Avoid uncooked foods
Practice safe food storage and handling: thoroughly cook all raw foods, thoroug
hly wash raw vegetables and fruits, and reheat food until the internal temperatu
re of food reaches at least 167°F.
94
BIBLIOGRAPHIES Joyce M. Black, et al. Study Guide for Medical-Surgical Nursing -
- Clinical Management for Positive Outcomes. Saunders: 2004 Marilynn E. Doenges,
et al. Nursing Care Plans: Guidelines for Individualizing Client Care Across th
e Life Span. F. A. Davis Company: 2006 Marilynn E. Doenges, et al. Nurse s Pocke
t Guide: Diagnoses, Prioritized Interventions, and Rationales. F. A. Davis Compa
ny: 2006 Meg Gulanick, et al. Nursing Care Plans: Nursing Diagnosis and Interven
tion. Mosby: 2006 Sue Huether, et al. Study Guide and Workbook to Accompany Unde
rstanding Pathophysiology. Mosby: 2003 Suzanne C Smeltzer, et al. Brunner and Su
ddarth s Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins: 20
06
95

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