A CASE STUDY FOR HEPATIC ABSCESS

A Case Study Presented to the Faculty Of the College of Nursing Capitol University, CDOC

In Partial Fulfillment of the Subject: RLE 7

By: Abada, Joana Marie Z. Sogoc, Windel A. Soon, Richelle Anne B. Sosmeña, Vannessa M. Sugarol, Kristine Mae U. Sunico, Kennelyn A. Sumile, April Rose G. Supangan, Dan A. Supnet, Eden Rhea J. Tabasan, Robert Y. Tadlas, Bonimar R. Taganas, Ronna Marie R.

Submitted to: Rick Wilson Bunao, RN Clinical Instructor

January 2010

In d c n tro u tio
The liver is subject to a variety of disorders and diseases. One is Abscesses which is caused by acute appendicitis; those occurring in the bile ducts may result from gallstones or may follow surgery. The parasite that causes amebic dysentery in the tropics can produce liver abscesses as well. Various other parasites prevalent in different parts of the world also infect the liver. Certain drugs may also damage the liver, producing jaundice. A common sign of impaired liver function is jaundice, a yellowness of the eyes and skin arising from excessive bilirubin in the blood. Jaundice can result from an abnormally high level of red blood cell destruction (hemolytic jaundice), defective uptake or transport of bilirubin by the hepatic cells (hepatocellular jaundice), or a blockage in the bile duct system (obstructive jaundice). Failure of hepatic cells to function can result from hepatitis, cirrhosis, tumors, vascular obstruction, or poisoning. Symptoms may include weakness, low blood pressure, easy bruising and bleeding, tremor, and accumulation of fluid in the abdomen. Blood tests can reveal abnormal levels of bilirubin, cholesterol, serum proteins, urea, ammonia, and various enzymes. A specific diagnosis of a liver problem can be established by performing a needle biopsy. Bacterial abscess of the liver is relatively rare. It has been described since the time of Hippocrates (400 BC), with the first published review by Bright appearing in 1936. In 1938, Ochsner's classic review heralded surgical drainage as the definitive therapy; however, despite the more aggressive approach to treatment, the mortality rate remained at 60-80%. The development of new radiologic techniques, the improvement in microbiologic identification, and the advancement of drainage techniques, as well as improved supportive care, have decreased mortality rates to 5-30%; yet, the prevalence of liver abscess has remained relatively unchanged. Untreated, this infection remains uniformly fatal.

Prior to the antibiotic era, liver abscess was most common in the fourth and fifth decades of life, primarily due to complications of appendicitis. With the development of better diagnostic techniques, early antibiotic administration, and the improved survival of the general population, the demographic has shifted toward the sixth and seventh decades of life. Frequency curves display a small peak in the neonatal period followed by a gradual rise beginning at the sixth decade of life. Cases of liver abscesses in infants have been associated with umbilical vein catheterization and sepsis. When abscesses are seen in children and adolescents, underlying immune deficiency, severe malnutrition, or trauma frequently exists.

G oals and O bjectives of the study

1. To have an in-depth understanding of the Hepatic abscess disease. 2. Give appropriate application of physical assessment to detect actual and potential health problems which are to be given priority 3. Promote health education in relation to the health condition of the patient. 4. To determine the proper intervention regarding the health care management on the presenting disease and its associated complication.

He takes coffee occasionally for at least one glass per day. the patient would still have recurrence of fever episodes and increasing abdominal pain. Misamis Oriental Sex: Male Age: 29 years old Height: 5 feet and 5 inches / 168cm Weight: 149 pounds/ 68 kilograms Occupation: Farmer Civil Status: Married Nationality: Filipino Religion: Roman Catholic Date of Admission: January 10. Eventually referred at Northern Mindanao Medical Center. A in 2000. P stated that he has been a tobacco user for eleven years and smokes half to 1 pack per day. hence admitted. He was married to Mrs. Thus finally consulted at Balingasag Medical hospital and was admitted as a case of urinary tract infection. He also added that he has been drinking alcoholic beverages mostly five bottles thrice a week. A Address: Balingasag. He doesn’t exercise but plays basketball leisurely. Misamis Oriental. He has no known allergies. Two days prior to admission. patient A noted onset of moderate grade fever associated with chills and epigastric pain. A’s educational attainment was limited up to Grade 5 thus prompted him to work as a farmer in Balingasag. Environmental and Psychosocial History: Mr. Patient a tolerated his condition and no consult done. During the assessment.C IE T P O IL L N ’S R F E Name: Mr. Personal. Mr. The couple have two daughters and all of them are still dependent on the family. A manages a small convenient store near their house. History of Present Illness: One week before admission. 2010 Admitting Diagnosis: Hepatic Abscess Chief Complaint: Intermittent epigastric pain. Mrs. .

46 kilograms. tingling or (GCS) of 14 (spontaneous eye opening. patent and infusing well at the left metacarpal vein. with pulse pressure of 2 seconds. functions tingling sensation were reported. blood pressure of 120/90 mmHg taken with pulse pressure of 40. jugular vein was not visible. Mr. bed. 5. oxygen saturation per minute. with Glasgow Coma Scale functions intact. and generally appears dusky. A was accompanied by his wife. 2010 General Survey Initial Assessment Final Assessment Mr. functions and localizes painful stimuli. Pinkish nail bed. place and Fully surroundings. no heart murmurs heard. with a GCS of 15. fully fully conscious and aware voice. minute. communicates verbally person. height. oriented and converses clearly. balance and stance for more than 5 no seconds when asked to stand. motor functions . ambulatory. Wearing a 48 kilograms. considerable in size. Peripheral of 30.Physical Assessment: Initial Assessment: January 14. A was accompanied by his wife. Capillary refill on the right arm. with vein was not visible. auscultation. patent Normal Saline Solution (PNSS) at 600 and infusing well at the left metacarpal milliliters level. Cardiovascular System Initial Assessment Final Assessment Mr. sensory and actively. A was lying on his bed in a semi. Mr. running at 30 drops per vein. on pulses with regular rate and rhythm. ongoing with intravenous fluid of PNSS at 900 level ongoing intravenous fluid of Plain running at 30 drops per minute. hoarse conscious still and with aware of of surroundings.Mr. can motor maintain intact. 5). 2010 Final Assessment: January 16. A showed cardiac rate of 67 beats Cardiac rate of 65 bpm. A was sitting at the right side of his fowlers position. were intact. 5 feet and 5 inches in white t-shirt and generally appears clean. no numbness. oxygen saturation of 95%.Blood pressure of 120/80mmH. burning sensation reported. or sensory numbness. intact. Flat a precordial area. surroundings. Jugular no evidence of bleeding. of 95%. burning 4. Central Nervous System Initial Assessment Final Assessment conscious and aware of Alert and oriented to time.

abrasions or other lesions noted. Integumentary System Initial Assessment Final Assessment Uniform deep brown skin color except No pressure sores. Respiratory System Initial Assessment Final Assessment Head of the bed elevated to 35-45 Breathing pattern with respiratory of 24 degree angle. he hematuria distended. bladder not distended.capillary refill of 3 seconds. nasal flaring as noted. Lung expansion symmetrical as well tactile fremitus. noted. abdomen was Abdomen was uniform in color. and percussion of abdomen as ordered by the physician. with regular rate and rhythm of peripheral pulses. rounded. Still with no difficulty of breathing. wounds. no other lesions noted. Still no Upon uniform in color. ventilator and endotracheal tube in place. With a respiratory rate of 30 endotracheal and mechanical ventilator cycles per minute. use of accessory muscles were evident. with good elasticity. Spine was ventrically aligned. . symmetrical chest expansion. no mechanical attached. pressure sores. no barrel chest noted. no tenderness noted. pale nail beds. A reported was 100mL for the last two hours. no clubbing noted. Gastrointestinal System Initial Assessment Final Assessment inspection. with evidence of cpm. Mr. skin sprang back to previous state when pinched. chest wall intact. no palpation palpation and percussion allowed. wounds. no that he had no difficulty in urinating. Urinary System Initial Assessment Final Assessment No urinary catheter noted urine output No urinary catheter noted. bladder not added that he urinated thrice in the last two hours and failed to measure it. abrasions or in areas exposed to the sun.

full range of motion. recover soon since he misses the quiet However. recover very soon as he modifies and strengthens his lifestyle by complying with his medical regimen. midline. .gait is coordinated. His support system was not adequate tho. A expressed that it was hard for Patient has understood the nature of his him to be hospitalized and experienced illness but still eager to get well and to difficulties due to his disease. was able to turn from side to side. he was hopeful that he can environment at home. Full range of motion. no deformities. tremors was not evident. equally strong in no weakness or paralysis.Musculoskeletal System Initial Assessment Final Assessment Equal size on both sides of the body. no joint pain or stiffness. Psychosocial System Initial Assessment Final Assessment Mr. no muscle tone and strength. Spine is in contracture in muscles and tendon. no tenderness noted. muscles were firm at rest with equal strength on each body side.

ANATOMY AND PHYSIOLOGY LIVER .

The liver consists of two main lobes. and on top of the stomach. beneath the diaphragm. right kidney. including the following: • • oxygenated blood flows in from the hepatic artery nutrient-rich blood flows in from the hepatic portal vein The liver holds about one pint (13 percent) of the body's blood supply at any given moment. including fatty acids (used for energy) and cholesterol Metabolize and store carbohydrates. and K.The Liver: Anatomy and Functions Anatomy of the liver: The liver is considered the largest organ in the body and is located in the upper righthand portion of the abdominal cavity. Shaped like a cone. and intestines. both of which are made up of thousands of lobules. the liver is a dark reddishbrown organ that weighs about 3 pounds. The liver has a multitude of important and complex functions. • • • . These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. E. store. which are used as the source for the sugar (glucose) in blood that red blood cells and the brain use Form and secrete bile that contains bile acids to aid in the intestinal absorption (taking in) of fats and the fat-soluble vitamins A. including albumin (to help maintain the volume of blood) and blood clotting factors Synthesize. The hepatic duct transports the bile produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine). and process (metabolize) fats. Some of these functions are to: • Manufacture (synthesize) proteins. There are two distinct sources that supply blood to the liver. D.

bilirubin. The liver plays an important role in metabolizing nutrients such as carbohydrates. cholesterol. The liver synthesizes about 50 grams of protein each day. This "free bilirubin" is a lipid soluble form that must be made water-soluble to be excreted. The liver also contains small amounts of Vitamin C. Bilirubin production and excretion follow a specific pathway. proteins. Liver cells protect the body from toxic injury by detoxifying potentially harmful substances. Prothrombin and fibrinogen. The liver also produces the anticoagulant heparin and releases vasopressor substances after hemorrhage. phospholipids. the potentially harmful biochemical products produced by the body. Primary bile acids are produced from cholesterol. bilirubin is one of the waste products. Liver cells also chemically convert amino acids to produce ketoacids and ammonia. High concentrations of riboflavin or Vitamin B1 are found in the liver. The liver helps metabolize carbohydrates in three ways: • • • Through the process of glycogenesis. By making toxic substances more water soluble. and environmental toxins • The liver synthesizes and transports bile pigments and bile salts that are needed for fat digestion. Bilirubin is the main bile pigment that is formed from the breakdown of heme in red blood cells. Digested fat is converted in the intestine to triglycerides. phospholipids. where is it secreted into the bile by the liver. bile acids. primarily in the form of albumin. potassium. sodium. 95% of the body's vitamin A stores are concentrated in the liver. hormones. and Vitamins E and K. are both produced by the liver. bile pigments. through a process known as ketogenesis. by metabolizing and/or secreting. and galactose are converted to glycogen and stored in the liver. The broken-down heme travels to the liver. and chloride. When the reticuloendothelial system breaks down old red blood cells. Through the process of glycogenolysis. they can be excreted from the body in the urine. and lipoproteins. the liver breaks down stored glycogen to maintain blood glucose levels when there is a decrease in carbohydrate intake. . When bile acids are converted or "conjugated" in the liver. and drugs from the body. The liver also has an important role in vitamin storage. most of the body's Vitamin D stores. they become bile salts. from which urea is formed and excreted in the urine.• Eliminate. alcohol. Bile is a combination of water. Through the process of gluconeogenesis. the liver synthesizes glucose from proteins or fats to maintain blood glucose levels. and fats. fructose. The liver also plays a major role in excreting cholesterol. by metabolizing and/or secreting. These substances are converted in the liver into glycerol and fatty acids. cholesterol. such as bilirubin from the breakdown of old red blood cells and ammonia from the breakdown of proteins Detoxify. glucose. substances needed to help blood coagulate. The conjugation process in the liver converts the bilirubin from a fat-soluble to a water-soluble form. drugs.

monocytes and other WBCs enter the area Increased blood flow into the area Decreased albumin . histamine. and other chemicals (chemical “alarms”) Blood vessels dilate Capillaries become “leaky” Neutrophils.o.Predisposing Factor: Age: 29 y. Gender: Male Chronic alcohol drinker (for almost 11 years) Occupation: Farmer Poor hygiene P th p y io g a o h s lo y Precipitating Factor: Unsanitary food handing Infection of liver Activation of inflammatory response Release of kinins.

IVTT • ciprofloxacin 500mg 1 tab. IVTT Medical Management: • metronidazole q8h. 2010) • WBC-20. PO Increased metabolic rate of tissue cells Pain Malaise Swelling Abdominal pain (RUQ) Tramadol 50 mg. 10.Decreased oncotic pressure.9 x 10^3/uL . Increased hydrostatic pressure Redness • Heat Fever Fluids and proteins leave the blood vessel going to interstitial spaces of tissue Edema Paracetamol 500mg. PO Failure of inflammatory mechanism Severe infection Hematology Report: (Jan. q8h. bid.

Uncleared area of debris Sac of pus (mixture of dead neutrophils. broken-down tissue cells. dead pathogens) Pus are walled off the liver HEPATIC ABSCESS Blockage of bile duct Prevents bile from entering small intestine Bile accumulates and backs-up into the liver Pressure on liver cells Hepatomegaly .

Proteins enter bloodstream Bile salts and bile pigments enter bloodstream Circulation of bile pigments Jaundice Lab Result: Protein (+2) Circulation of proteins Enters kidney circulation Icteric sclera Protein in urine (Proteinuria) .

LABORATORY RESULTS Blood Chemistry Dr. Hyponatremia.3)mmol/L Sodium = 134.22 REFERENCE (4. result to experience nausea. The right hepatic lobe is uremarkable. MEDIAL ASPECT OF THE LEFT HEPATIC LOBE. Pancreas is unremarkable. % (3.2 (135 – 148)mmol/L ULTRASOUND REPORT January 13.) NON – REMARKABLR ULTRASOUND FINDINGS IN THE GALLBLADDER AND PANCREAS . and muscle cramps. Sarmiento 01-13-10 RESULTS Blood urea nitrogen = 15. % INTERPRETATI ON Normal Normal Low potassium resulting to have muscle weakness.6 – 1.4) mgs. headache and malaise. Creatinine Potassium = 0.5 – 5. Gallbladder is normal in size.73 = 3.) COMPLEX. muscle aches. DIAGNOSIS: 1.6 – 23.6 cm x 8. No intraluminal mass or lithiasis seen. Its wall is not thickened. vomiting.3 cm seen in its medial aspect. HYPOECHOIC MASS.27 (0. A complex hypoechoic mass measuring 9. POSSIBLY AN ABCESS 2.2) mgs. 2010 Tentative Diagnosis: FINDINGS: The left lobe is enlarged.8 cm x 7.

within the range from 1. globulins. and Bence-Jones protein at low concentrations Alkaline.INTERPRETATION: Hypoechoic on ultrasound means dark. also a sign that patient is not been drinking enough liquids Detected albumin.003 – 1.015 Excess sweating. a risk for infection Normal. 2010 INTERPRETATION PHYSICAL PROPERTIES: Color yellow Clarity Hazy pH Specific gravity 7. in liver at times there is inhomogenous fat deposition which appear which appears bright and areas of sparing appear dark or hypoechoic and can times mimic mass on ultasound URINALYSIS REPORT January 14.5 1.030 CHEMICAL PROPERTIES: proteins Glucose trace Normal negative Normal SEDIMENT/MICROSCOPIC EXAMINATION Moderate 2-3 4-6 Few Epithelial cells Puss cells (WBC) Red blood cells Bacteria Normal Kidney or bladder injury or UTI UTI .

infection in either the upper or lowe urinary tract Kidney or bladder injury or UTI high salt concentration Mucus threads are usually present in small numbers. normal normal May have kidney damage. Increased numbers are indicative of chronic inflammation of the urethra and bladder. an infection.030 CHEMICAL PROPERTIES: +2 Liver problems or jaundice Excessive cellular material or protein in the urine Acidic.0 1. alteration of liver function Normal Pyuria.URINALYSIS REPORT January 10. proteins Glucose negative SEDIMENT/MICROSCOPIC EXAMINATION 4-6 Puss cells (WBC) Red blood cells Coarsely granular Mucus threads 2-3 0-2 few . 2010 INTERPRETATION PHYSICAL PROPERTIES: Color Clarity Dark yellow Cloudy pH Specific gravity 5.

0 – 12.1 29.0 % % % % 17.0 37.9 33.0 27.0 18.0 15.0 – 2.0 8. 4.8 0.0 1.0 264 % % 10^3/uL 0.0 – 17.400 Normal Normal Infection infection or an inflammatory process in the body Normal --Normal .0 32.0 – 16.8 10.4 – 76.0 8. 2010 INTERPRETATION PHYSICAL CHARACTERISTIC Color and character yellow consistency watery PARASITIC ORGANISM Negative for any amoeba and other intestinal parasitic ova Normal Diarrhea Normal January 13.68 11.0 – 47.0 Basophils (%) Bands/scabs (%) PLATELET REMARKS 0.0 – 10.0 9. 2010 HEMATOLOGY REPORT TEST WHITE BLOOD CELS RED BLOOD CELLS HEMOGLOBIN HEMATOCRIT RESULT 14.0 – 10.2 43.6 fL Pg g/dL % fl fL 82.5 15.8 UNIT 10^3/uL 10^6/uL g/dL % REFERENCE 5.0 – 31.0 INTERPRETAION Infection Anemic Normal signal conditions such as anemia.0 12.0 31.4 – 48.0 – 98.FECALYSIS January 10.1 3.2 – 5.2 66.5 1.5 – 10.0 150 . bone marrow problems.5 – 35. dehydration Normal Normal Normal Normal Normal Normal MCV MCH MCHC RDW-CV PDW MPV DIFFERENTIAL COUNT Lymphocyte (%) Neutrophil (%) Monocyte (%) Eusinophils (%) 89.4 12.0 – 3.0 – 2.2 4.

0 27.4 – 48.0 7.7 221 % % % % 10^3/uL 4.0 – 31.0 31.0 – 98.0 INTERPRETATION Infection Normal poor diet/nutrition or malabsorption Normal Normal Normal Normal ------Risk for infrction Elevated levels of neutrophils may occur when the body is fighting a flu or other infection infection ------Normal HEMATOCRIT MCV MCH MCHC RDW-CV PDW MPV DIFFERENTIAL COUNT Lymphocyte (%) Neutrophil (%) 40. 4.0 – 2. 2010 .4 89.2 – 5.3 82.0 – 10.0 – 47.4 % fL Pg g/dL % fl fL 37.0 – 2.5 – 35.0 150 .0 UNIT 10^3/uL 10^6/uL g/dL REFERENCE 5.8 30.TEST WHITE BLOOD CELS RED BLOOD CELLS HEMOGLOBIN RESULT 20.400 HEMATOLOGY REPORT January 10.0 12.0 % % 17.5 1.0 9.0 – 17.0 – 16.0 – 3.0 8.50 13.4 14.2 Monocyte (%) Eusinophils (%) Basophils (%) Bands/scabs (%) PLATELET 10.4 – 76.0 0.9 4.2 43.0 33.0 – 12.0 1.0 – 16.5 – 10.0 82.

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Rationale: To increase gravitational blood flow Encourage use of relaxation techniques Rationale: To decrease tension level • Dependent: • Emphasize importance of avoiding use of aspirin. (This promotes optimal ventilation and perfusion) Teach patient breathing relaxation technique (to improve oxygen demand of patient) Elevate head of bed. as evidenced by: • 24 cpm • Capillary refill 2 sec • Demonstrate proper breathing relaxation technique . Respiration within normal range b. vitamins containing potassium.” as verbalized by the patient Objective: • Capillary refill of about 3 seconds assessed • Pallor • Muscle wasting Goals and Objectives: Long term goal:  After 2 days of nursing care. Balanced intake and output Nursing Interventions: Independent: • • • • Assist patient in ROM exercises (exercises prevent venous stasis) Proper positioning of patient. mineral oil or alcohol when taking anticoagulants. change every 2 hrs. Short term goal:  After 4 hours of nursing care. Rationale: Evaluation: Goals partially met. the patient will be able to demonstrate increased perfusion as appropriate. the patient will be able to demonstrate lifestyle changes to improve circulation. some OTC drugs.NURSING CARE PLAN Nursing Diagnosis Ineffective Tissue Perfusion related to interruption of venous flow Assessment Data Subjective: “Maglisod ko ug ginhawa bisan maghigda. as evidenced by: a.

absence of nasal flaring c.NURSING DIAGNOSIS Ineffective breathing pattern related to pain ASSESSMENT DATA (SUBJECTIVE AND OBJECTIVE CUES Subjective: “Usahay galisod ko og ginhawa maam” as verbalized Objective: .do not use of accessory muscle Long term goal: At the end of 1 day of nursing intervention the patient will: .Tachypnea RR = 30 .The patient’s respiration is 24 cpm .Nasal Flaring .Pallor .Use of accessory muscle .Have adequate ventilation as evidenced by: a.demonstrate appropriate coping behavior NURSING INTERVENTION • Independent • Elevate head of bed or position patient in a semi fowler’s position (to promote physiological/psychological ease of maximal inspiration) • Encourage deep breathing exercise by using purse-lip technique (to take control of the situation) • Assist client in the use of relaxation technique like breathing exercise (to promote rest) • • • Provide comfort position to patient (to prevent uneasiness ) Ambulate patient and assist in exercise as tolerated (maximize patient’s level of functioning) Encourage adequate rest period between exercise (to prevent fatigue)  Dependent • Administer analgesic.respiration within normal range from 30 cpm to 20 cpm b. if recommended by the physician (promotes respiration) EVALUATION Goals partially met .absence of nasal flaring and use muscle accessory .pain scale 10/10 GOALS AND OBJECTIVE Short term Goal: At the end of 30 minutes of nursing intervention the patient will: .

and calm activities. • Observe nonverbal cues/pain behaviors (e. OBJECTIVE CUES: . which can mean constricted blood vessels) and other objective cues. as noted. ASSESSMENT DATA: SUBJECTIVE CUE: “ Sakit akoang tiyan sa tuo dapit. Acknowledge the pain experience and convey acceptance of client’s response to pain. R: to distract attention and reduce tension.NURSING CARE PLAN NURSING DIAGNOSIS: Acute Pain related to presence of pus in the liver. nurse’s presence) quiet environment.g. the patient pain will decreased from 10/10 to 5/10.Observed evidence of pain Muscle guarding noted with pain scale of 10/10. R: observations may/may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize. use of heat/cold packs. Instruct patient to encourage use of relaxation techniques such as focused breathing. Facial Grimace noted. the patient’s pain will be relieved from 5/10 to 0.. sits. repositioning.g. Provide comfort measures (e.”as verbalized. Expressive behavior observed ( sighing ) Doctor ordered not to palpate patient abdomen GOALS AND OBJECTIVE: Short term goal: • After 30 minutes of nursing interventions. cool fingertips/toes. holds body.. how the patient walks. Encourage also diversional activities. • • • . R: pain is subjective experience and cannot be felt by others. imaging and listening to calming music. R: it may vary to individuals coping capabilities. Long term goal: • After 8 hours of nursing intervention. facial expression. Determine patient’s acceptable level of pain/pain control goals. touch. NURSING INTERVENTIONS: • Accept client’s description of pain. R: to promote nonpharmacological pain management.

Notify the physician if regimen is in adequate to meet pain control goal.• Administer analgesics. as needed. to maximum dosage.as evidenced by: Pain scale of 5/10. as indicated. EVALUATION: GOALS PARTIALLY MET . . R: to maintain acceptable level of pain.

Short term goal:  After 1 hour of nursing care. as evidenced by reduced body temperature from 37. The patient’s temp. including Escherichia coli Evaluation: GOALS MET.  Ciprofloxacin 500mg 1tab. q4hrs for T≥38.8°C) assessed Skin is warm and dry to touch noted Increased respiratory rate (RR= 30 cpm) assessed Firm skin turgor noted Goals and Objectives: Long term goal:  At the end of 30 minutes.5. Rationale: To prevent dehydration • Maintain bedrest. Objective: • • • • Increased body temperature (T= 37. . the patient will be able to display signs of wellness. is 37. as ordered. Rationale: To provide a baseline data Promote surface cooling by means of tepid sponge bath Rationale: To promote heat loss by means of evaporation • Discuss importance of adequate fluid intake. twice a day • Indication: For treatment of infections caused by susceptible gramnegative bacteria. Nursing Interventions: Independent: • Monitor vital signs.NURSING CARE PLAN Nursing Diagnosis . Rationale: To reduce metabolic demands and oxygen consumption • Dependent: • Administer antipyretics. as verbalized by the patient.0 • Administer medications as indicated to treat underlying cause.Hyperthermia related to increased metabolic rate Assessment Data Subjective: “Sugod pa ko gihilantan atong pag-admit nako”.8°C to 37.5C.  paracetamol 500mg 1 tab. the patient will be able to identify contributing factors and importance of treatment.

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lifestyle changes to regain and maintain appropriate weight. R: To improve metabolism.5. Rationale: To implement interdisciplinary team management. Collaborative: • Consult a dietitian/ nutritional team as indicated. • Increase fluid intake to 2-3 liters/ day. Rationale: To prevent nausea and vomiting.Imbalanced Nutrition: Less than body requirements related to increased metabolic demands. Dependent: • Use flavoring agents. Rationale: To prevent constipation. Short term goal:  At the end of 1 hours patient will be able to verbalized understanding of causative factors when known and necessary interventions. • Served high fiber diet. Weight of patient below normal range of body mass index 17. patient will be able to demonstrate behaviors. RBC 3. Assessment Data Subjective: " magsakit akong tiyan kung magkaon" as verbalized by the patient. Rationale: To enhance food satisfaction and stimulate appetite. Nursing Interventions: Independent: • Provide small frequent meals. . Objective: • Body mass index: 17. Evaluation: Goals not met. • Encouraged exercise as tolerated like passive ROM.5 • pale conjunctiva • Abnormal laboratory findings a.NURSING CARE PLAN Nursing Diagnosis . Rationale: To manage fluid imbalanced.68 Goals and Objectives: Long term goal:  At the end of 8 hours.

R> to make the patient prepare and know what to expect The med should be given in IVTT route according to the doctor R> Follow the doctor’s order as prescribed to the patient. ADVERSE EFFECTS OF THE DRUG Seizures have been reported in patients receiving tramadol within the recommended dosage range. Route: IVTT Frequency: q8h . opioids.Drug Study MECHANISM OF ACTION An analgesic that binds to mu-opioid receptors and inhibits reuptake of norepinephrine and serotonin reduces the intensity of pain stimuli reaching sensory nerve endings. Tramadol may not have prolonged duration of action and cumulative effect in patients with hepatic or renal impairment. or psychotropic drugs. before and after withdrawing the med R> so that the medicine is properly checked according to the doctor’s prescription. Overdose results in respiratory depression and seizures. hypnotics. DRUG ORDER Generic name: Tramadol hydrochloride Brand name: Ultram Classification: Analgesic Dosage: 50mg INDICATIONS Management of moderate to moderately severe pain. Therapeutic Effect: Alters the perception of and emotional response to pain. CONTRAINDICATIONS Acute alcohol intoxication. NURSING RESPONSIBILITIES/ PRECAUTIONS Check the prescribed medication for 3 time on the first encounter. Give first health teaching before giving the patient. hypersensitivity to opioids. concurrent use of centrally acting analgesics.

CONTRAINDICATIONS Hypersensitivity to other nitroimidazole derivatives. before and after withdrawing the med R> so that the medicine is properly checked according to the doctor’s prescription. ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS Check the prescribed medication for 3 time on the first encounter. is Cautions: blood usually reversible if dyscrasias.DRUG ORDER Generic name: Metronidazole Brand name: Metronidazole Benzoate Classification: Antibacterial. Produces antiinflammatory and immunosuppressive effects when applied topically. Treatment of trichomoniasis. antiprotozoal Dosage: 750mg Route: IVTT Frequency: q8h MECHANISM OF ACTION A nitroimidazole derivative that disrupts bacterial and protozoal DNA. antibioticassociated pseudomembranous colitis (AAPC). lower respiratory tract. Question for hypersensitivity on metronidazole R> to determine if the med is applicable to patient. INDICATIONS For treatment of anaerobic infection (skin and skin structures. bone and joints). amebiasis. amebicidal. Peripheral neuropathy. Seizures occur ocassionally. and trichomonacidal effects. . Give first health teaching before giving the patient. antiprotozoal. appear. inhibiting nucleic acid synthesis. CNS. immediately after CNS disease. R> to make the patient prepare and know what to expect The med should be given in IVTT route according to the doctor R> Follow the doctor’s order as prescribed to the patient. manifested as numbness and tingling in hands or feet. neurologic symptoms predisposition to edema. Therapeutic Effect: Produces bactericidal. severe treatment is stopped hepatic dysfunction.

H. skin and skinstructure. chest pain. typhoid fever febrile neutropenia. including photosensitivity (as evidenced by rash. CNS disorders. bone and joint. and cerebral thrombosis may occur. influenzae. pruritus. Therapeutic Effect: Bactericidal INDICATIONS For treatment of infections due to E. Shigella species. interfering with bacterial cell replication. NURSING RESPONSIBILITIES/ PRECAUTIONS Question for hypersensitivity for the medicine R> since it will harm the patient Monitor for any dizziness. blisters. coli. sinusitis. mirabilis. edema and burning skin) have occurred in patients receiving fluoronolones. infectious diarrhea. for ophthalmic administration: vaccinia. visual changes. cloacae. vulgaris. Do not take with antacids R> since it could reduce or destroy the drug’s effectiveness. headache. pneumoniae. typhi including intraabdominal. S. ADVERSE EFFECTS OF THE DRUG Superinfection. tremors. protastitis. E. those taking caffiene. Hypersensitivity reaction. P. K. Route: Oral Frequency: BID . lower respiratory tract. cardiopulmonary arrest. and urinary tract infections. varicella. Cautions: renal impairment. seizures. CONTRAINDICATIONS Hypersensitivity to ciprofloxacin or other quinolones. P. R> to determine client’s response to the med. pephropathy.DRUG ORDER Generic name: Ciprofloxacin hydrochloride Brand name: Ciloxan Classification: Anti-infective Dosage: 500mg 1 tab MECHANISM OF ACTION A fluoroquinolone that inhibits the enzyme DNA gyrase in susceptible bacteria.

CONTRAINDICATIONS History of acute porphyria. Cautions: renal or hepatic impairment. elderly. ADVERSE EFFECTS OF THE DRUG Reversible hepatitis and blood dyscrasias occur rarely. Reduces volume and hydrogen ion concentration of gastric juice. INDICATIONS For short term treatment of duodenal ulcer.DRUG ORDER Generic name: Ranitidine hydrochloride Brand name: Zantac Classification: Antiulcer Dosage: 150mg 1 tab Route: Oral Frequency: BID MECHANISM OF ACTION An antiulcer agent that inhibits histamine action 2 receptors of gastric parietal cells. R> to determine if the patient’s organ could metabolize the drug Assess mental status of the elderly R> to determine if the drug affects the mental state of the patient Inform or give health teachings to patient on what to expect after drug administration like headache R> so that the patient would be aware about the side effects that he would experience . NURSING RESPONSIBILITIES/ PRECAUTIONS Obtain baseline liver/renal function tests. caffeine. Prevention of duodenal ulcer recurrence. or when stimulated by food. Therapeutic Effect: Inhibits gastric acid secretion when fasting. at night. or insulin.

Therapeutic Effect: Essential for normal clotting of blood. rapid or weak pulse. NURSING RESPONSIBILITIES/ PRECAUTIONS Inform patient and SO that discomfort may occur with parenteral administration. II. dizziness. antihemorrhagic Dosage: 1 ampule Route: IVTT Frequency: q24h MECHANISM OF ACTION A fat-soluble vitamin that promotes hepatic formation of coagulation factors I. and X. CONTRAINDICATIONS Hypersensitivity.DRUG ORDER Generic name: Vitamin K Brand name: AquaMEPHYTON Classification: Nutritional supplement. dyspnea. facial flushing. cardiac arrest) occurs rarely just after IV administration. complaint of abdominal or back pain. rash diaphoresis. INDICATIONS Antidote for hemorrhage induced by oral coagulants. VII. hypotension progressing to shock. increase in PR. R> to be aware what will be the expexted affect after administration of med Do not use OTC medication without physician’s approval R> this may interfer with platelet aggregation Assess for decrease in BP. chest pain. antidote. severe headache R> this may be evidence of hemorrhage . IX. hypoprothrombinemic states due to vitamin K deficiency. ADVERSE EFFECTS OF THE DRUG A severe reaction (cramplike pain.

NURSING RESPONSIBILITIES/ PRECAUTIONS The medication should be given in orally R> this is according to the doctor’s order. . neutropenia.g. It produces antipyresis by inhibiting the hypothalamic heat – regulating center. thrombocytopenia. ADVERSE EFFECTS OF THE DRUG Nausea. allergic reaction. agranulocytosis). liver damage. R> to determine if the patient is allergic to drug Intruct the patient/ give first health teaching before giving the patient. skin rashes. acute renal tubular necrosis. blood dyscrasias (e.. Potentially Fatal: Very rare.380C MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS Hypersensitivity. R> to make the patient prepare and know what to expect Give only the med for presence of fever or pain R> overdose could lead to drug-resistance Paracetamol exhibits For treatment of mild to analgesic action by moderate pain and peripheral blockage of fever. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS. leukopenia.DRUG ORDER Generic name: Paracetamol Brand name: Boigesic Classification: Analgesics and Antipyretics Dosage: 500mg Route: Oral Frequency: PRN or q4h for temp. pain impulse generation. Assess patient for any drug allergy to the medicine.

fever.  Promoting proper skin and wound care.6 weeks). contributing factors.HEALTH TEACHINGS Treatment of hepatic abscess condition can be life-threatening in 10-30% of patients. as well as side effects to report to the physician or nurse. care and treatment. • Discuss the proper use medication. If not. Explain the purpose. chills. Such as chalk-colored stool. dark urine. by weighting the client daily and record the result if necessary. & unintentional weight loss. dosage. • Discuss and encourage proper techniques in preventing further infection and injury. . nausea. vomiting. Along with the procedures. In order for the patient to understand his condition and for him to be able to participate in improving it. schedule.  Maintaining good personal hygiene. life-threatening sepsis can develop. and pain in right abdomen (more common) or through out the abdomen.  Encouraging patient to increase fluid intake. loss of appetite. That’s why treatment usually consists of surgery or going through the skin with a needle or tube (percutaneous) to drain the abscess.  Weigh patient daily.  Assess presence and extent of edema. • Explain the importance of maintaining fluid and electrolytes balance. • Teach signs and symptoms that require immediate medical attention.  Monitoring for fluid and electrolytes balance  Assess intake and output. causes. Tell the client and family members to maintain the ideal body weight of the patient. because sometimes antibiotics alone can cure the infection. That’s why we stress the importance of the following: • Explain the disease process. the patient will also receive long-term antibiotic therapy (usually 4 . The risk is higher in people who have many abscesses. and route of administration of any prescribed drugs.

within his condition’s capacity. Remind also the family members to support the patient in his activity of daily living.Passes help the patient adjust to the home environment and to practiced self care activities at home and help the family adjust to living with patient and to any alterations in physical. Avoiding stress which can aggravate symptoms.  Protecting patient from exposure to infectious agents.  Maintaining good asepsis during treatments and procedures. cognitive.  Medicating patient as needed for pain. to perform many self-care activities as possible.  Providing comfort measures and relaxation techniques.  Encouraging proper diet. .  Therapeutic passes .  Providing calm. • Teach the family of how to promote comfort.  Promoting hope  Providing opportunity for patient to express feelings about self.  Protecting from injury when carrying out activities. supportive environment • Tell the family to assist with coping in life-style and self-concept. Tell also the family members to encourage the patient.  Encouraging activity within prescribed limits but avoid fatigue.  Encouraging rest for fatigue. and emotional functioning (after discharge).  Encouraging good oral hygiene. and let them explain to the patient how it benefits for him to be as independent as possible.

or any. Exercises Treatment: Very important treatment includes strict compliance to the prescribed medication most especially significance antibiotic of therapy and the nutritional supplements promoting healing of the damage liver cells and improves general nutritional status. This will help the patient for fast recovery and prevention to further complication. prescribed time and as on how many days will it be consumed. Health teaching: With emphasis on: >compliance to medication regimen > importance of proper diet.DISCHARGE PLAN Medications: Patient is advised to take all the medications prescribed by the physicians as to the prescribed dosage. >avoidance of alcoholic beverages > importance of immediate consultation whenever symptoms of complications or progression of disease occurs like. trouble breathing all of the sudden. >regular exercises like walking. vomiting and seizures. prescribed route. stretching and other form of activities that would help maintain joint mobility & enhance circulation >Avoiding strenuous activities. >importance of good hygiene >significance of adequate rest Out-Patient: Patient should return to the institution one or two-weeks after discharge for follow-up check-up on his physician for health assessment. painful abdomen. and faster recovery .

Diet: >Patient encouraged having adequate nutritional supplements. Eating healthy foods may help him have more energy and heal faster. lean meat and fish. beans. low-fat dairy products. >Encouraged to eat variety of healthy foods such as fruits. . whole-grain breads. Spiritual: Significant others were reminded to continue offer emotional support to patient and help to strengthen his spiritual faith so that patient will both have spiritual and emotional outlet to avoid depression. vegetables.

consequences that we have right now. It is where we put all of what we are in extreme preparation. You should not waste time doing senseless distractions.LEARNING EXPERIENCE As new day arises. we will realize that regardless of everything that is going on. Life is great and beautiful and we realize it when we are open to learning and never are afraid to take challenges and opportunities that come along the way. new trials are challenging us. We should start making a move. At a short period stay at (NMMC) Northern Mindanao Medical Center. it is a good feeling to know that you have controlled yourself and leading it to make a difference. If you want your life to have an impact. Whatever trials. difficulties. One of this if we call it a trial is the challenge of making a case study on trisomy 21 disorder. testing every learning and knowledge we obtain in the previous days. brave enough to win success. It is more than just a group. in the end. you have to focus on it. Make life with less regrets. do good. We never fail to be concerned towards each other. A few of us know the importance of living life positively. There are many choices that surround us but it specifies on two questions: To do good? Or do it badly. Medical ward. Yes. it serves as a reminder to trust in ourselves and our God. it leads us to many channels. DOCTOR’S ORDER . We learn together. This Duty reminded us that life is too short to keep on committing the same mistakes all over again. life may be short. That is the beauty in our group. Although change does not happen overnight. you are on your own. despite the harshness of reality. but we should use our freedom wisely. we are family. we have to put impact on every good thing that we do. whether many will hinder our path. We have to be careful of our actions each day for the days are sometimes evil. We make our life. handling cases and interactions are just a few that we have mastered. we have established a great bond among our group mates. we work together and care for each other. rather gain from your opportunities. After. reading. yet. Many may know if not all that this type of disorder is hard to accept in the parenting side. we are student nurses on action. we are always reminded not to be enticed with worldly matters. As our duty progresses. temptation. We should not give up. be wise and strengthen your faith.

Alk. D5NR !L @ 40gtts/min. then q 4 hrs for T≥38.  Avoid vasalva maneuver(straining.  Monitor VS q2 hr. Cipro 7 2. facilitate transport  Cont. 2.0 Tramadol 50mg IVTT q8 hrs. poin RUQ area Jan. . Celsius 6. SOB..-given 1st done  Watch out for severe abdominal pain.HOT tomorrow AM pls. K. • Jan. Phos. present medications  IVF TT: D5NR 1L @ 20gtts/min D5NR 1L @ 20gtts/min Refer accordingly  For utz of HBT today  for repeat Na. stool exam Urea. IVTT now then Q 24 hr. Ranitidine 100mg 1 tab. Creat.K. BUN. then 750 mg IVTT q 8 hrs.1 week undocumented on and off fever with chils and nausea (+) epigastric pain Refer accordingly • ↓fever episode •  Schedule for UTZ. K 1 am. Vita k 1 amp. or any unusualiies and refers to MROD  Refer accordingly  Continue present meds. SGOT CXR: PAT UTZ: HBT Therapeutic: Paracetamol 500mg 1 tab now. Paracetamol PRN if 38 deg.• Jan. Metronidazole 750 mg IVTT now. 10 2010 6pm BP 110/70 HR 80 RR 10 T 37  Start_____: PNSS 1L @ 60 gtts/min_ongoing  IVF TF: 1. Metronidazol 750 mg 3. seen in the ward  Continue present meds. BID 4. Tramadol 50mg IVTT q8 hr. BID Vit. 14 2010 9 am Pt. refer if with abdominal pain and severe hypotension  D5LR 1L @ 20 gtts/min x 2 cycles  Refer accordingly • Jan. 11. PNSS 1L @ 30 gtts/min. Diagnostic: CBC with pH U/A. 2010 4:30 pm BP. Na. 13. SGPT. 2010 11:30 pm BP:120/80 HR:76 RR:20 Dec. Ranitidine 150 mg 1 tab.100/60 HR 80 RR 20 Still with fver episodes (+) tenderness RUQ Jan.  IVF TF: PNSS 1L @ 30gtts/min. 12. BUN CBC with platelet  Repeat PTPA-Partial  Requests: 1. 2010 s. D5NR 1l @40 gtts/min. 5.

soft + tenderness  Non swollen abdomen as of examiner  Will do UTZ. Na . SGPT. Q4hr then q4hr. 15. SGOT. distress  + flat abdomen. facilitate aspiration of hepatic abscess as ordered by SROD  Pls. 16. murmur UT2 noted Jan.Check-epigastric pain and fever up to 40 hr UT2. ROPA.consider abcess(liver)     carrying heavy objects) and abdominal manipulation Monitor VSq 4hr. x 3 cycle .aspiration of Hepatic abscess “emergency”  Secure consent to procedures  To secure 3-way stop  To secure Epidoral needle for aspiration • Jan.  IVTT D5LR 1L @ 30gtts/min x 2 cycle  For referral to surgery  Refer accordingly  Pt seen and examined  HX & PE received  Lab and UTZ notedexamined and febrile noted in resp. & chart IVTT D5LR 1L @ 30gtts/min D5LR 1L @ 30gtts/min ↑ IVF to 40 gtts( present IVF) Refer accordingly • 10:20 pm Awake. inform SROD once 3-way stop cock in available  Give paracetamol nonce a day 1 tab. 2010 11:25 -afebrile -C/C -DAT 3pm  For referral to surgery for abdominal evaluation if possible transfer of service  Continue meds Refer accordingly •  Continue meds.. crea. 2010 7am ↓abdominal pain Awke febrile 9:30 am (-) adbdominal pain Afebrile For possible aspirationof hepatic abscess today  Pls. secure consult to procedure  Pls. PRN for nfever there after  For repeat CBCOH. afebrile DHS. Alk phosphate  Give tramadol Prn for pain  Continue meds: IVTT D5LR !L @ 30gtts/min. K.

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