SCHISTOSOMIASIS

IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS
IN
MSN 304

INDIVIDUAL CASE PRESENTATION

Giovanni B. Juan, RN

3RD TRIMESTER SY 2010-2011

 TABLE OF CONTENTS

Content Page Number

Title Page 1

Table of Contents 2

Introduction 3

Theories 5

Patient’s Profile 7

Health History 8

Physical Assessment & Review of Systems 13

Anatomy and Physiology 21

Diagnostic Tests 32

Pathophysiology 38

Nursing Care Plan 42

Medical Management 54

Surgical Management 59

Prognosis and Complications 63

Discharge Plan 68
Reference 72
 INTRODUCTION

An alarming number of patients in various hospitals in Bukidnon

are diagnosed of having Schistosomiasis. In Philippines alone,
Schistosomiasis accounts for the high incidence of deaths. It is
considered as one of the most important tropical diseases and among
the leading causes of morbidity, it is outranked only by malaria and
tuberculosis.
In 1988 schistosomiasis is endemic in 167 municipalities of 24
provinces. Dr. Renato Cerdena reported that within the 24 provinces
where schistosomiasis occurs, there are 1,152 endemic villages. The
total exposed population, defined as the population of endemic
municipalities, is estimated at more than 7 million, or about 10 percent
of the Philippine population. Despite annual chemotherapy,
schistosomiasis persists in many areas
(http://l05.cgpublisher.com/proposals/1215/index_html).
Schistosomiasis (aka bilharzia or “snail fever”), is a chronic
parasitic illness that affects between 200 to 300 million people in at
least 74 countries across the world. Of these, approximately 120
million people have symptoms, and 20 million are severely ill. Disease
prevalence is heterogeneous in vulnerable locales and tends to be
worse in areas with poor sanitation, increased freshwater irrigation
usage, and heavy schistosomal infestation of human and/or snail
populations.
Schistosomal species vary with geographic region: S mansoni
and S haematobium infections predominate in sub-Saharan Africa. S
mansoni is endemic in parts of South America and the Caribbean while,
S japonicum is restricted to the Pacific region including China,
Indonesia and the Philippines. Aside from that, there are also different
hosts for every type of schistosoma. S. haematobium is mainly
transmitted by Bulinus snails, S. mansoni by Biomphalaria, and S.
japonicum by amphibious Oncomelania snails.

Schistosoma japonicum continues to pose a public health

problem in Asia, particularly in parts of China and the Philippines. In
our country, it is a major public health problem with an estimated
national prevalence of 3%, i.e., 200,000 infected individuals. Children
have the highest prevalence and intensity of infection, but the
consequences of chronic schistosomiasis, such as growth stunting,
anemia, hepatic fibrosis, and impaired cognitive development,
continue to have an effect
throughout adulthood
(http://jn.nutrition.org/cgi/content/full/136/1/183).

Infection (in humans) begins with cercariae penetration of the

skin or buccal mucosal from contaminated water source. Basically,
people are infected when they come in contact with water where
infected snails live. Once inside a human host, cercariae (larval forms
of the parasite) transform into schistosomula and are transported to
the portal circulation of the liver, where they mature and mate.
Subsequently, adult worms of S. japonicum migrate to the mesenteric
vessels while parasite eggs (released by female worms) deposit in
several tissues, primarily the liver, the bladder and the urinary tract
(http://www.who.int/tdr/diseases/schisto/diseaseinfo.htm).
Within days after becoming infected, person may develop a rash
or itchy skin. Fever, chills, cough, and muscle aches can begin within 1-
2 months of infection. However, most people have no symptoms at this
early phase of infection.
 THEORIES

1. Nightingale’s environmental theory

Florence Nightingale, often considered the first nurse theorist,
defined nursing more than 100 years ago as “the act of utilizing the
environment of the patient to assist him in his recovery”
(Nightingale,1860/1969). She linked health with five environmental
factors: (1) pure or fresh air, (2) pure water (3) efficient drainage (4)
cleanliness (5) light. Deficiencies in these five factors produced lack of
health or person will become ill.
The patient failed to maintain pure water, drainage and
sanitation. As verbalized by the patient he was infected with
Schistosoma japonicum right at his work place with contaminated
water. In considering the present environment of the patient who’s still
in the hospital, the cleanliness, good lighting, efficient drainage, pure
water and pure air are given highest importance in the institution. It is
important for the nurse to maintain a noise free environment, and
attending to the client’s diet in terms of assessing intake, timeliness of
the food and its effect on the person.

2. Orem’s Self care deficit theory

Dorothea Orem’s theory includes three related concepts: self
care, self care deficit and nursing systems. Orem’s self care deficit
theory explains not only when nursing is needed but also how people
can be assisted through five methods of helping: acting or doing for,
guiding, teaching, supporting, and providing an environment that
promotes an individual’s abilities to meet current demand. Nursing
care is necessary only if client is unstable to fulfill biological,
psychological, development or social needs. Nursing is needed when
the self care demands are greater than the self-care abilities.
 There are three types of nursing system as indicated by Orem’s
self care deficit theory: Wholly compensatory, partly compensatory
and supportive-educative systems. The patient belongs to partly
compensatory wherein it is designed for individual who are unable to
perform some but not all, self care activities. He can clean and dress
his colostomy, he can urinate on his own and perhaps change clothes
but he still needs assistance from others. Health teachings are
emphasized to guide and assist him to promote independence.

3. Watson’s Human Caring theory

Jean Watson (1979) believes the practice of caring is central to
nursing; it is the unifying focus for practice. Nursing is concerned with
promoting health, preventing illness, caring for the sick and restoring
health. Caring is defined as the nurturing way of responding to a
valued client towards whom the nurse feels a personal sense of
commitment and responsibility. Caring accept the person as what s/he
may become in a caring environment. Watson’s carative factors are
the following: forming a humanistic-altruistic system of values,
instilling faith and hope, cultivating sensitivity to one’s self and others,
developing a helping trust relationship, promoting and accepting the
expression of positive and negative feelings, and systematically using
the scientific problem solving methods for decision making.
Caring is the basic concept of nursing that primarily focused on
the needs of the patient. Patient in severe case of schistosomiasis
needs a focused caring not only from the nurse but also from the
concern family. A caring attitude is shown on being responsive to the
needs of the patient physically, emotionally and mentally and these
are greatly emphasized by the nurse. Despite of the length of
hospitalization and bills, his family continues to support him all
throughout his treatment since the patient truly needs help not only
from the health care provider but also from his immediate family.
 PATIENT’S PROFILE

Client’s Name: Boy Tigas (not real name)

Address (past and present): Esperanza, Agusan Del Sur; Davao
del Norte; Kalasangan, Surigao Del
Sur; Cotabato and Purok 9B,
Crystal, North Poblacion, Maramag,
Bukidnon
Age: 28 years old
Gender: Male
Marital Status: Married
Race: Filipino
Primary Language: Bisaya (Cebuano)
Date of Birth: December 24, 1983
Place of Birth: Esperanza, Agusan Del Sur
Significant Others (Wife): Candy (not real name)
Source of Information: Patient himself, wife, chart, nurses,
doctors
Occupation: Contractual Worker; Body Guard
Religion: Roman Catholic
Health Care Financing: PhilHealth
Height: 5’4”
Weight: 30 Kg
Date Admitted: February 24, 2011
Time Admitted: 4:40 AM
Chief Complaints: Severe pain at anal area; (+)
inability to defecate; verbalized
“Sakit ang gioperahan sa akong
tiyan ug ang akong lubot sakit kay
dili nako kalibang”
Attending Physician: Dr. Surge
Admitting Diagnosis: Rectal Fibrosis secondary to
Schistosomiasis
 HEALTH HISTORY

History of Present Illness

As verbalized by the patient (Boy Tigas), he was asymptomatic
until early 2008. The signs and symptoms of the Schistosomiasis
disease started its gradual onset later that year. The first sign occurred
when he suffered body malaise while at home. He was feeling well
before the onset. It occurred in almost a day for nearly seven months
which continued even when he slept. The sign affected his daily
activities at home and in work. He fell asleep while doing his job. The
heavy work in the shop had precipitated the long-period body malaise
which oftentimes aggravated by warm weather. He rested and slept
most of the times to relieve the sign. Once during the bout of body
malaise, he consulted one of the doctors in St. Joseph Southern
Bukidnon Hospital, Maramag, Bukidnon and was given tablet and liquid
forms of medications in which the patient cannot recall the name. The
medications then relieved the symptom of body malaise.
Sometime in February 2009, the patient had diarrhea when he
was at home. He felt abdominal pain before he suffered diarrhea. It
was intermittent that he almost spent his whole day at the comfort
room. The feces were loose and watery with black and thin particles
and red streaks of blood on it. He approximately defecated 10½
glasses (2,500 mL) the whole morning as related by the patient. It was
accompanied by intermittent abdominal and anal pain. The pain was
searing in both areas (“di na jud to makaya ma’am” as he verbalized)
which had a pain scale of 10/10. The pain worsens when he defecates
and gets better when it stops. He was later hospitalized that made his
loose bowel movement palliated.
Last January 2010, while at home recuperating, he defecated
pea-sized black feces with blood on it. He related during the interview
that it occurred almost 20 times a day even when he was sleeping. He
felt sharp pain (“grabe na jud to kasakit ma’am” as he verbalized) on
his abdomen and anal area with a pain scale of 9/10 as verbalized by
the patient. The loss of control to defecate resulted to pain at the anal
area which radiates towards the buttocks. Again they admitted him to
the hospital due to this reason.
On July 2010, Boy Tigas said that he experienced distention of
the abdomen at home. It lasted for a minute then returns to its normal
size. It occurred irregularly for approximately 3 times a month. The
distention was likened to that of a 3-month pregnant woman according
to Candy. It was painless and occurred abruptly without any known
precipitating factors. No interventions were made on this sign.
On the same month, he was admitted at St. Joseph Southern
Bukidnon Hospital because of inability to control defecation and blood
in the feces. He was then referred to Northern Mindanao Medical
Center, Cagayan De Oro City.
On August 2, 2010, anoscopy with biopsy was performed. The
specimen was then sent for examination at the Department of
Pathology and Clinical Laboratories, Northern Mindanao Medical
Center, Cagayan De Oro City. The examination showed the presence of
Schistosoma eggs on the colonic tissues.
On the same month, proctosigmoidoscopy with biopsy on the
sigmoid colon for suspicion of possible malignancy was performed. The
specimen was sent for examination at the Department of Pathology
and Clinical Laboratories, Northern Mindanao Medical Center, Cagayan
De Oro City for neoplastic analysis. Results were negative of malignant
cancerous growth.
After being discharged from NMMC, Cagayan de Oro City the
patient experienced vertigo and dizziness, while en route to their home
in Maramag, Bukidnon. He, then, experienced trembling for
approximately 10 minutes as verbalized by Candy. He was then re-
admitted at the St. Joseph Southern Bukidnon Hospital. He had
shortness of breath for almost 5 minutes and recovered after being
administered with oxygen as verbalized by Candy. In addition, he had
searing pain (“di jud ‘to makaya bah!” as he verbalized) on his
abdomen and anal area with pain scale of 10/10.
On December 29, 2010 the patient underwent exploratory
laparotomy and double barrel sigmoid colostomy. Dr. Surge examined
his abdomen and created two separate stomas on the abdominal wall
of the patient.
Last March 15, 2011, the patient underwent fistulectomy under
Dr. Surge because of the patient’s complaints of pain on his anal area.

Past Health History

Immunization
Patient could not give exact childhood immunizations.

Past Illnesses
The patient had a bout with Chickenpox during childhood. He had
minor illnesses such as fever, cough and colds but never undergone
surgery (minor/ major). He only had diarrhea as a serious or chronic
illness.
When he was 18 years old, he and a childhood friend fell into a
cliff while riding a motorcycle at Kalasangan, Surigao Del Sur. He had a
bruise at the side of the left eye.
He has no known allergies to certain drugs, animals, insects or
other allergogenic agents.

Genogram

Emelita± ^¤¢ Tiopelo ^¡ <

Legend:
±-Hypertension
°-Heart Failure Boy Tigas¡ Ö
^- Deceased
¤-Female
¡-Male
¢-Mother
<-Father
Ö-patient

Emelita, the mother of Boy Tigas, was hypertensive and died

because of heart failure. The father, Tiofelo had no known disease and
cause of death was not known.
Boy Tigas, the patient, has no known herido-familial disease.

Functional History
Physical
The health of the patient was generally good. He had not
experienced any difficulty in breathing.
His plane of nutrition was also good. He ate his regular meals, 3
times with snacks, 2 times daily. He did not take any vitamin
supplements. His weight was 58 kg. He was not picky on foods and ate
almost any kind of food. He had not been into a special diet or any
dietary restrictions. His usual eating time was 7am-11am-6pm daily
pattern. He drank 8-10 glasses of water a day. He didn’t have any food
allergies and never had assistance in eating. He had a poor oral
condition. He had cavities and although his teeth weren’t complete he
didn’t wear dentures.
He had no difficulty in voiding urine and hadn’t experienced
incontinence, had no sense of urgency, frequency, pain on urination,
foul-smelling urine, cloudy urine, burning on urination or bloody urine.
He didn’t need assistance in urination.
He had a regular bowel habit. He defecate everyday during
morning. If he had problems on defecation such as diarrhea, he took
over the counter medications. He experienced diarrhea and
constipation but not frequent. This only happened depending on the
kind and quantity of food intake. He can go to the bathroom alone.
He slept from 7pm to 4am and would feel rested after sleep. He
had no difficulty sleeping at night. He turned off light before sleeping.
He was physically comfortable because of his good physique. He
was big boned person. He had good personal hygiene/ grooming. His
vision was good. He wasn’t using eyeglasses or contact lenses. His
hearing was very good and no pain experienced on either ear. His
sexual functioning was active.

Psychosocial
The patient got married at age of 24 years. He has 2 children
(male-4yrs. old; female-3 yrs old).
His coping abilities were very good. When upset, he dealt with it
immediately and most of the time, it helped.
When crises arise, the patient together with family members
cooperate in solving the problem.
The most important persons in his life were his family. He had
lots of good friends but also some rivals at work as a body guard.

Environmental
The patient and his family lived in an elevated small house with a
3-step stairs. The floor was covered with lumber and had a corrugated
galvanized iron sheets as roof. They had 2 rooms. Their dining table
was near the bedroom. Their comfort room was located outside the
house; it had the water-sealed bowl. They sleep in one room.

Economic/Vocational
His previous jobs were mostly on contractual basis and lately as
a body bodyguard. He transferred from one place to another in search
of a job and depending on the location of his contract. He had been to
Kalasangan, Surigao Del Sur, Cotabato and finally settled in Purok 9B,
Crystal, North Poblacion Maramag, Bukidnon where his family is now
living.
His financial resources were very good. His annual income was
Php 72,000.00.
His highest educational attainment was 1st year high school.

Cultural/Spiritual History
The patient was born and practicing Roman Catholic. He had no
religious rituals that may affect the health of the patient. He consulted
physician if any deviations of health is noted. The patient believed that
the disease was not cause of any curse or bad luck but because of a
parasite was developing inside his body that created his chronic
condition.
 PHYSIOLOGIC ASSESSMENT/ REVIEW OF SYSTEMS

General Survey
The patient was an ectomorph; had a flat chest, and lightly
muscled body. He was 5’4” tall and weighed 30kg as reflected in the
chart. He was grossly emaciated. He had a tensed and bent posture.
He had a slouch standing, sitting, and walking stance. He has altered
physical mobility.
The patient’s overall hygiene and grooming was generally
unclean and unkempt. There was a foul body odor due to the present
fistulae and aggravated by unhealthy practices such as not cleaning
body parts everyday. He also had foul breath due to lack of oral
hygiene.
There were signs of distress such as hyperventilation during
bouts of pain and emitted sounds of pain such as “uuuhhhh”. He
winced, shouted, bent over and grasped on object tightly because of
pain. He skin was generally pallid in appearance.
The patient’s attitude was cooperative but withdrawn. His
affect/mood were appropriate reflective to his situation. The speech of
the patient was slow paced, gentle, understandable and exhibited
thought association.

Vital signs
Temperature Pulse Respiratory Blood Pressure
Day Time Pain scale
(ºC) (bpm) Rate (cpm) (mmHg)
10a
37.1 83 14 140/90 9/10
1 m
2pm 36.1 100 12 140/90 10/10
10a
36.9 94 16 140/90 9/10
2 m
2pm 37.1 100 19 150/90 10/10
10a
36.4 103 16 140/90 8/10
3 m
2pm 36.9 125 40 150/100 10/10
4 10a 36.4 104 21 150/100 10/10
 m
2pm 36.6 98 14 140/90 7/10
10a
36.1 102 14 130/90 10/10
5 m
2pm 36.2 92 14 120/80 10/10
10a
6 36.6 106 16 130/90 10/10
m

Height and Weight

The patient was 5’4” tall and weighed 30 kg.

The Integuments
Skin
The skin was pallid, but not cyanotic or jaundiced, not erythemic,
with no noticeable vitiligo; the skin tone was light brown and was not
generally uniform, there were areas of hyperpigmentation (of varying
size and shape with brown to light brown spots); there were fissure and
crusts noted at the corner of his lips, hands and feet. Muscle atrophy
was observed. There was wound on his left lower abdominal area of
the abdomen due to the colostomy operation and on his left buttocks
due to the fistulectomy operation; the fistulectomy wound was
approximately 2-inch depressed and has serosanguinal discharge. No
moisture in skin folds and axillae were noted due to the cooler
environment temperature; normal skin temperature in upper
extremities while cold sensation was palpated in the lower extremities
were noted; skin returned back slowly during checking of skin turgor in
the lower extremities while skin on the upper extremities sprung back
immediately to previous state.

Hair
Patient had no hair on axilla since birth; scalp hair growth was
not evenly distributed and there were small areas that had no hair; he
had a thin and brittle hair; there were no infections and infestations
noted.

Nail
The fingernail and toenail were smooth in texture, the fingernail
plate shape was convex curvature, the fingernail bed was light pink in
color and toenail bed was pallid, the tissues surrounding nails was
intact. When blanch test was performed, there was a 2-second return
of pink color in the fingernail bed and 5-second return in toenail.

The Head
Skull and Face
The skull was rounded (normocephalic and symmetrical, with
frontal, parietal, and occipital prominences) and had smooth skull
contour. It had a smooth, uniform consistent skull; with absence of
nodules noted. The facial feature was symmetric. There was no eye
edema but sunken eyes were observed. There were symmetrical facial
movements.

Eye Structures and Visual Acuity

The hairs in the eyebrows were evenly distributed and eye skin
was intact. Eyebrows were symmetrically aligned and had equal
movement; Eyelashes were evenly distributed and curled outwardly;
the skin in the eyelids were intact and had no discharges; lids closed
symmetrically; blinking reflex was present; sclera on both eyes
appeared white; the palpebral conjunctiva was shiny, smooth and
pallid; the corneal surfaces on both eyes were shiny; details of iris were
visible; pupils were black in color, equal in size, and round; both pupil
reacted to light; peripheral visual fields and ocular movement were
normal on both eyes.
 The Ears and Hearing
Auricles color were the same as facial skin, these were also
symmetrical and were aligned with the outer canthus of the eye; the
auricles were mobile, firm, and not tender; pinna recoiled after folded;
with dry cerumen noted. Normal voice tones were audible.

Nose and Sinuses

The external nose was symmetric and straight; there were
hyperpigmentation in some areas and had no discharge It had no
tenderness or lesions; the mucosa was pink and no lesions noticed.
The nasal septum was intact in the midline and the maxillary and
frontal sinuses were not tender.
Mouth and Oropharynx
The outer lips were pallid, had fissures, scales and crusts and
were able to be pursed; the inner lips are likewise pallid; the gums are
pallid and were dry. He had 6 yellowish and black teeth; patient had no
dentures. The tongue was in central position, had no nodes,
ulcerations, discolorations and areas of tenderness. There was mobility
of the uvula and tonsils appeared pallid.

Neck
Neck muscles were equal and were flexible; head movement
were coordinated; head hyperextended, head flexed, head laterally
flexed, head laterally rotated; muscle strengths were equal but
minimal in strength due to present condition; lymph nodes in the neck
weren’t palpable.

Thorax and Lungs

Posterior Thorax
 Spine was vertically aligned with left and right shoulders and
hips were at the same height. The skin and chest wall were intact and
there were no tenderness and masses noted.

Anterior Thorax
Tachypnea and hyperventilation (RR: 40cpm) were noted; the rib
cage was well-defined due to emaciation.

Breast and Axillae

Breast were even with chest wall; slightly unequal in size but
generally symmetric; the skin on the breasts had hyperpigmentation
(of varying size and shape of brown to light brown spots); areola
appeared round and bilaterally the same, dark brown in color and had
irregular placement of sebaceous glands on the surface; it had no
tenderness, masses, or nodule and no tenderness, masses, nodules, or
nipple discharge noted.

Abdomen
The skin abdomen was not uniform in color, there was
hyperpigmentation (of varying size and shape of brown to light brown
spots) present, was tensed and slightly glistened. Abdominal contour
was prominent. When patient took a deep breath, distention on the
lower area of left rib was palpable. There were distended veins and
depression in area over the right portion of the abdomen below the
right rib cage; tenderness was present on left and right lower area of
the rib; there was an audible bowel sounds of 11; rib cage was well-
formed due to gross emaciation; the lower 4th-9th regions (umbilical,
left lumbar, right lumbar, hypogastric, left iliac and right iliac regions)
of the abdomen were depressed.

Genitourinary System
 Patient verbalized “dugay ko kaihi ma’am pero dili man pud siya
sakit”; he is not using any assistive devices; no abnormal discharges
noted. Urine color is light yellow with presence of cloudy precipitate.

Gastrointestinal System
The patient has an attached improvised colostomy bag on his left
lower quadrant. Feces are loose and watery with greenish and thin
particles and red streaks of blood on it.

Musculoskeletal (Muscles, Bones, Joint)

The muscles were atrophied; no contractures noted; tremors can
be seen when arms and legs were put forward; had 75% of normal
strength. There was no palpable deformities on the bone but had
tenderness on left buttock area. Sometimes, pain on left hip joint was
noted; there was a limited range of motion in all joints of the body.
Neurologic System
Speech: Slurred
Orientation: Mostly oriented to time, place, person and event
Attention span: Relatively good except during incidences of
pain;
Mental Status: Conscious, coherent and restless most of the
time
GCS: 15
Language Spoken: Bisaya (Cebuano)
Ability to Read: Yes
Ability to Speak English: No.
Table 1. Summarized Deviation from the Normal based on the Review
of
Systems presented above.

Assessment Deviation from Normal

 Pallid
 Skin tone is not generally uniform
 there were areas of
hyperpigmentation (of varying size
and shape with brown to light brown
spots)
 fissure and crusts noted at the
corner of his lips, hands and feet
 Muscle atrophy
 wound on his left lower abdominal
Skin area of the abdomen due to the
colostomy operation and on his left
buttocks due to the fistulectomy
operation
 fistulectomy wound was
approximately 2-inch depressed and
has serosanguinal discharge
 cold sensation was palpated in the
lower extremities
 skin returned back slowly during
checking of skin turgor in the lower
extremities
 Scalp hair growth was not evenly
Hair distributed and there were small
areas that had no hair
 Thin and brittle hair
Nail  Toenail bed was pallid
 5-second return in toenail
The Head  None
Skull and Face
Eye structures and
 Palpebral conjunctiva was pallid
Visual Acuity
The Ears and  No impairment
Hearing
Nose and Sinuses  Hyperpigmentation in some areas
Mouth and  Outer lips were pallid, had fissures,
Oropharynx scales and crusts
  The inner lips were pallid
 6 yellowish and black teeth
 Gums were pallid and were dry
 Muscle strengths were equal but
Neck minimal in strength due to present
condition
Posterior Thorax  No impairment
 Tachypnea and hyperventilation
noted
Anterior Thorax
 Ribs were well-defined due to gross
emaciation.
 Skin on the breasts had
hyperpigmentation (of varying size
Breast and Axillae
and shape of brown to light brown
spots)
 Wound on his left lower abdominal
area of the abdomen due to the
colostomy operation and on his left
buttocks region due to the
fistulectomy operation
 There was hyperpigmentaion
(varying size and shape of brown to
light brown spots) present
 Tensed and slightly glistening skin
 Noticeable contour on the lower
area of left rib was palpable
Abdomen
 Distended veins over the right
portion of the abdomen below the
rib cage
 Tenderness on both right and left
area of rib
 Rib cage is well-defined due to
emaciation
 the lower 4th-9th regions (umbilical,
left lumbar, right lumbar,
hypogastric, left iliac and right iliac
regions) of the abdomen were
depressed.
Musculoskeletal
Muscles  Muscles atrophied
 Observable tremors when arms and
legs were put forward
 75% of normal strength
Bones  Tenderness on left buttocks area
  Pain on left hip joint was noted
 Limited range of motion in all joints
Joint of the body
 Speech: Slurred
Neurologic System
 Ability to Speak English: No
 ANATOMY AND PHYSIOLOGY

1. Circulatory
System Systemic
Circulation
The systemic circulation includes the arteries and arterioles that
carry oxygenated blood from the left ventricle to systemic capillaries,
plus the veins and venules that return deoxygenated blood to the right
atrium. Blood leaving the aorta and flowing through the systemic
arteries is a bright red color. As blood flows through capillaries, it loses
some of its oxygen and picks up carbon dioxide, becoming a dark red
color. All systemic arteries branch from the aorta completing the
circuit, all veins of the systemic circulation drain into the superior vena
cava, inferior vena cava, or the coronary sinus, which turn in empty
into the right atrium. The bronchial arteries, which carry nutrients to
the lungs, also are part of the systemic circulation.

Figure 1. Describes the main arteries and veins of the systemic circulation. The blood
vessels are organized in the exhibits according to body regions.
Hepatic Portal Circulation
The hepatic portal circulation carries venous blood from the
gastrointestinal organs and spleen to the liver. A vein that carries
blood from the one capillary network to another is called a portal vein.
The hepatic portal vein (hepat- = liver) receives blood from the
capillaries of gastrointestinal organs and the spleen and delivers it to
the sinusoid of the liver. After a meal, hepatic portal blood is rich in
nutrients absorbed from the gastrointestinal tract. The liver stores
some of them and modifies others into the general circulation. For
example, the liver converts glucose into glycogen for storage, reducing
blood glucose level shortly after a meal. The liver also detoxifies
harmful substance, such as alcohols, that have been absorbed from
the gastrointestinal tract and destroys bacteria by phagocytosis.
 Figure 2. The hepatic portal system.

The superior mesenteric and splenic veins unite to form the

hepatic portal vein. The superior mesenteric vein drains blood from the
small intestine and portion of the large intestine, Stomach, and
pancreas through the jejuna, ileac, elohcecal, right colic, middle colic,
pancreaticodoudenal, and right gastrorpiploic veins. The splenic vein
drains blood & from the stomach, pancreas, and portions of the large
intestine through the short gastric, left gastroepiploic, pancreatic, and
inferior mesenteric veins. The inferior mesenteric vein, which passes
through the splenic vein, Drains portion of the large intestine through
the superior rectal, sigmoid`, and left colic veins. The right and left
gastric veins, 7hich open directly into the hepatic portal vein, drains
the gallbladder.
At the same time the liver is receiving nutrients but
deoxygenated blood via the hepatic portal vein, it also is receiving
oxygenated blood via the hepatic artery a branch of the celiac trunk.
The oxygenated blood mixes with the deoxygenated blood in sinusoids.
Eventually, blood leaves the sinusoid of the liver through the hepatic
veins, which drains into the inferior vena cava.

Pulmonary Circulation

The pulmonary circulation (pulMo- = lung) carries deoxygenated

blood from the right ventricle to the air sacs (alveoli) within the lungs
and returns oxygenated blood from the air sacs to the left atrium. The
pulmonary trunk emerges from the right ventricle and passes
superiorly, postdpiorl and to the left. It then divides into the two
branches: the right pulmonary artery to the right Lung and28the left
pulmona2x artery to the left lung. After bi2th, the pulmonary arteries
are the only arteries that carry deoxygenated blood. On entering the
lung, the branches divide and subdivide until finally they form
capillaries around the air sacs (alveoli) within the lung. CO2 passes
from the blood into the air sacs and is exhaled. Inhaled O2 passes from
the air within the lungs into the blood. The pulmonary capillaries unite
to form venues and eventually pulmonary veins, which exit the lungs
and carry the oxygenated blood to the left atrium. Two left and two
right pulmonary veins enter the left atrium. After birth, the contraction
of the left ventricle then ejects the oxygenated blood into the systemic
circulation.
 Figure 3. The pulmonary circulation

2. Erythropoiesis

Erythropoiesis, the production of RBC’s starts in the red bone

marrow with a precursor cell called a proerythroblast. The
proerythroblast divides several times, producing cells that begin to
synthesize hemoglobin. Ultimately, a cell near the end of the
development sequence ejects its nucleus and becomes a reticulocyte.
Loss of the nucleus causes the center of the cell to shape. Reticulocyte
retains some mitochondria, ribosomes, and endoplasmic reticulum.
They pass from red bone marrow into the blood stream by squeezing
between the endothelial cells of blood capillaries. Reticulocytes
develop into mature red blood cells within 1 to 2 days after their
release from the red bone marrow.
 Normally, Erythropoiesis and red blood cell destruction proceed
at roughly the same pace. If the oxygen-carrying capacity of the blood
falls because erythropoeisis is not keeping up with the RBC
destruction, a negative feedback system steps up RBC production. The
controlled condition is the amount of oxygen delivered to the body
tissues. Cellular oxygen deficiency, called hypoxia, may occur if too
little oxygen enters the blood. For example, the lower oxygen content
of the air at high altitudes reduces the amount of oxygen in the blood.
Oxygen delivery may also fall due to anemia, which has many causes:
lack of iron, lack of certain amino acids, and lack of vitamin B12 are
but a few. Circulatory problems that reduce blood flow to tissue may
also reduce problems that reduce oxygen delivery. Whatever the
cause, hypoxia stimulates the kidneys to step up the release of
erythropoietin, which speeds the development of proerythroblast into
reticulocytes in the red bone marrow. As the number of circulating
RBCs increase, more oxygen can be delivered to body tissues.
Premature newborns often exhibit anemia, due in part to
inadequate production of erythropoietin. During the first weeks after
birth, the liver, not the kidneys, produce most EPO. Because the liver is
less sensitive than the kidneys
to hypoxia, newborns have a
Figure 4. The life cycle of a red blood cell.
smaa) lleKridneyEsPOresponrdestopa
onlosweer thaton
ane nomrmiaa.l oxygen concentration in
the blood by releasing the hormone
erythropoietin.
b) Erythropoietin travels to the red
bone marrow and stimulates an
increase in the production of red
blood cells (RBCs).
c) The red bone marrow
manufactures RBCs from stem cells
that live inside the marrow.
d) RBCs squeeze through blood
vessel membranes to enter the
circulation.
e) The heart and lungs work to
supply continuous movement and
oxygenation of RBCs.
f) Damaged or old RBCs are
destroyed primarily by the spleen.
3. Digestive System
Absorption
Absorption is the movement of molecules across the
gastrointestinal (GI) tract into the circulatory system. Most of the
end-products of digestion, along with vitamins, minerals, and water,
are absorbed in the small intestinal lumen by four mechanisms for
absorption: (1) active transport, (2) passive diffusion, (3) endocytosis,
and (4) facilitative diffusion. Active transport requires energy.
Nutrient absorption is efficient because the GI tract is folded with
several surfaces for absorption and these surfaces are lined with villi
(hairlike projections) and microvilli cells.

Protein, carbohydrate, lipid, and most vitamin absorption occur

in the small intestine. Once proteins are broken down by proteases
they are absorbed as dipeptides, tripeptides, and individual amino
acids. Carbohydrates, including both sugar and starch molecules, are
broken down by enzymes in the intestine to disaccharides called
sucrose, lactose, and maltose, and then finally into the end-products
known as glucose, fructose, and galactose, which are absorbed mostly
by active transport. Lipase, an enzyme in the pancreas and the small
intestine, and bile from the liver, break down lipids into fatty acids
and monglycerides; these end-products then are absorbed through villi
cells as triglycerides.

Coordination and Transport of Nutrients into the Blood or to

the Heart
 Hormones and the nervous system coordinate digestion and
absorption. The presence of food, or the thought or smell of food, can
cause a positive response from these systems. Factors that can inhibit
digestion include stress, cold foods, and bacteria.

After foods are digested and nutrients are absorbed, they are
transported to specific places throughout the body. Water-soluble
nutrients leave the GI tract in the blood and travel via the portal vein,
first to the liver and then to the heart. Unlike the vascular system for
water-soluble nutrients, the lymphatic system has no pump for fat-
soluble nutrients; instead, these nutrients eventually enter the
vascular system, though they bypass the activity of the liver at first.
 Figure 5. Pathway of digestion.

4. The Lymphatic System

The lymphatic system functions 1) to absorb excess fluid, thus
preventing tissues from swelling; 2) to defend the body against
microorganisms and harmful foreign particles; and 3) to facilitate the
absorption of fat (in the villi of the small intestine).
Capillaries release excess water and plasma into intracellular
spaces, where they mix with lymph, or interstitial fluid. "Lymph" is a
milky body fluid that also contains proteins, fats, and a type of white
blood cells, called "lymphocytes," which are the body's first-line
defense in the immune system.
Lymph flows from small lymph capillaries into lymph vessels that
are similar to veins in having valves that prevent backflow. Contraction
of skeletal muscle causes movement of the lymph fluid through valves.
Lymph vessels connect to lymph nodes, lymph organs (bone marrow,
liver, spleen, thymus), or to the cardiovascular system.
 Lymph nodes are small irregularly shaped masses through which
lymph vessels flow. Clusters of nodes occur in the armpits, groin,
and neck. All lymph nodes have the primary function (along with
bone marrow) of producing lymphocytes.
 The spleen filters, or purifies, the blood and lymph flowing
through it.
 The thymus secretes a hormone, thymosin that produces T-cells,
a form of lymphocyte.
 Figure 6. Lymphatic system

5. Histology and Blood Supply of the Liver

The lobes of the liver are made up of many functional units

called lobules. A lobule is typically a six-sided structure (hexagon) that
consists of specialized epithelial cells, called hepatocytes, arranged in
irregular, branching, interconnected plates around a central vein. In
addition, the liver lobule contains highly-permeable capillaries called
sinusoids, through which blood passes. Also, present in the sinusoids
are fixed phagocytes called stellate reticuloendothelial (Kupffer) cells,
which destroy worn-out white blood cells and red blood cells, bacteria,
and other foreign matter in the venous blood draining from the
gastrointestinal tract.
The liver receives blood from two sources. From the hepatic
artery it obtains oxygenated blood, and from the hepatic portal vein it
receives deoxygenated blood containing newly absorbed nutrients,
drugs, and possibly microbes and toxins from the gastrointestinal tract.
Branches of both the hepatic artery and the hepatic portal vein carry
blood into liver sinusoids, where oxygen, most of the nutrients, and
certain toxic substances are taken up by the hepatocytes. Products
manufactured by the hepatocytes and nutrients needed by other cells
are secreted back into the blood, which drains into the central vein and
eventually passes into a hepatic vein. Because blood from the
gasatrointestinal tract passes through the liver as part of the hepatic
portal circulation, the liver is often a site for metastasis of cancer that
originates in the GI tract. Branches of the hepatic portal vein, hepatic
artery, and bile duct typically accompany each other in their
distribution through the liver. Collectively, these three structures are
called a portal triad. Portal triads are located at the corners of the liver
lobules.
Figure 7. Anatomy of the liver lobule
 DIAGNOSTIC TEST

1. Pathologic Test: ANOSCOPY WITH BIOPSY

Definition: An anoscopy is an examination of the rectum in which a
small tube (anoscope) is inserted into the anus to screen,
diagnose, and evaluate problems of the anus and anal
canal. A biopsy is the removal of a sample of tissue from
the body for examination. The tissue will be examined
under a microscope to assist in diagnosis.
Date performed: August 2, 2010
Name & Address of the Laboratory: Department of Pathology and
Clinical Laboratories, Northern Mindanao Medical Center,
Cagayan De Oro City
Clinical Impression: Rectal new growth
Specimen Used: Rectal mass

Interpretation and Histopathologic Diagnosis:

 Colonic tissue with chronic inflammation and presence of
Schistosoma eggs.
 Gross Description: The specimen consist of several red brown
soft tissues altogether measuring 0.5 x 0.5 cm.
 Microscopic description: Micro sections of rectal mass disclose
colonic tissues showing several calcified Schistosoma eggs from
the mucosa to the muscular layer. Mild to moderate chronic
inflammation, cells are seen in the edematous and congested
stroma.

2. Pathologic Test: PROCTOSIGMOIDOSCOPY WITH BIOPSY

Definition: A visual examination of the rectum and sigmoid colon
using a sigmoidoscope. A biopsy is the removal of a sample
 of tissue from the body for examination. The tissue will be
examined under a microscope to assist in diagnosis.
Date performed: August 16, 2010
Name & Address of the Laboratory: Department of Pathology and
Clinical Laboratories, Northern Mindanao Medical Center,
Cagayan De Oro City
Specimen Used: Rectal mass

Interpretation and Histopathologic Diagnosis:

 Chronic inflammation: No evidence of malignant neoplastic
growth.
 Gross description: The specimen consists of tan-white firm tissue
fragments measuring 0.4cm.
 Microscopic description: Micro sections disclose a rectal tissue
with presence of abundant lymphoplasmacytic cells in the
lamina propria. No evidence of malignancy nor nuclear atypia
seen.

3. ULTRASOUND IMAGING
Definition: The use of sound waves at the very high frequency to
image internal structure by the differing reflection signals
produce when a beam of sound waves is projected into the
body and bounces back at interfaces between those
structures.
Date performed: February 25, 2011
Name & Address of the Laboratory: Radiology Department, St.
Joseph Southern Bukidnon Hospital – Maramag, Maramag,
Bukidnon

Ultrasound Report:
  Whole abdomen
Moderate free intraperitoneal fluid collection in the hepatorenal
and splenorenal spaces.
The liver is normal in the size with coarsened and lacelike
parenchymal echotexture. No focal mass lesions demonstrated. The
intrahepatic ducts are not dilated. The gallbladder is well distended
with no intraluminal echoes. The pancreas is obscured by overlying
bowel gas. The spleen is markedly enlarged measuring 11.9 x 11.9cm.
Both kidneys are normal in size hyperechoic parenchymal echo
pattern. The right kidney measures 9.0cm x 5.1cm x 4.1cm (LWT) with
cortical thickness of 1.0cm. The left kidney measures 9.7cm x 4.9cm x
5.0cm (LWT) with cortical thickness 1.2cm. No masses demonstrated.
Both pelvocalyceal system and ureters are not dilated. No definite
calculi seen.
No abdominal lymphadenopathy.
The visualized intestinal segments are fecal filled.
The urinary bladder is underfilled.
The prostate gland is normal in size with homogeneous
Parenchymal echotexture.
There is an irregular heterogeneous focus seen in the rectal area
measuring 6.6cm x 6.1cm (LW).

IMPRESSION:
 Moderate ascites
 Liver parenchymal disease
 Bilateral renal parenchymal disease
 Splenomegaly
 Fecal filled intestinal segments
 Heterogenous focus in the rectal area
 Sonographically normal gallbladder, biliary ducts and prostate
gland

4. COMPLETE BLOOD COUNT

Definition: A determination of the number of red and white blood
cells per cubicmillimeter of blood. A CBC is one of the most
routinely performed tests in a clinical laboratory and one of
the most valuable screening and diagnostic test.
 DATE COMPONENT RESULTS NORMAL SIGNIFICANCE
PERFORMED VALUES
Date: Hematocrit 31.7% 42-51% Decreased:
February 24, Hemodilution,
2011 Anemia
Hemoglobi 10.3 g/dL 13-18 g/dL Decreased:
n Insufficient carrier
of
oxygen,hemodiluti
on,
Anemia
WBC 5,700/ 5,000- Normal
mm3 10,000/mm
3

Neutrophils 75% 55-65% Increased: There is

bacterial infection
Lymphocyt 20% 25-35% Decreased: There
es is a viral invasion

Monocytes 5% 2-4% Increased: There is

a viral infection
Platelets 343,200 150,000- Normal
450,000/m
m3

DATE COMPONENT RESULTS NORMAL SIGNIFICANCE

PERFORMED VALUES
Date: Hematocrit 18.6 % 42-51% Decreased:
March 10, anemia,hemodiluti
2011 on
Hemoglobi 5.6 g/dl 13-18 g/dL Decreased:
n anemia,hemodiluti
on kidney disease
WBC 5,900/ 5,000- Normal
mm3 10,000/mm
3

Neutrophils 68% 55-65% Increased: There is

bacterial infection
Lymphocyt 26% 25-35% Normal
es
Monocytes 6% 2-4% Increased: There is
viral infection
 Platelets 308,000/ 150,000- Normal
mm3 450,000/m
m3

5. URINALYSIS

Definition: Ionizing a physical microscopic, or a chemical

examination of urine.
DATE CHARACTERISTICS RESULTS NORMAL SIGNIFICANCE
PERFORMED VALUES
Date: Color Straw Yellow Normal
February 25, ,
2011 straw,
amber
Transparency Clear Clear Normal

Specific gravity 1.010 1.010- Normal

1.025
Albumin Negativ Negative Normal
e
RBC 0-3/hpf 0-2/hpf Renal
parenchymal
alteration
Pus cells 1-3/hpf 0-1/hpf Inflammation in
the Urinary
tract

Epithelial cells Few Normally in Normal

small
amount

6. FECALYSIS/STOOL EXAMINATION

Definition: Stool examination is a procedure where fecal matter

is collected for analysis to diagnose the presence or
absence of a medical condition.
DATE CHARACTERISTICS RESULTS NORMAL SIGNIFICANCE
PERFORMED VALUES
Date: Color Reddish Brown Bleeding from
February 25, GI tract;
2011 melena
 Consistency Watery formed, Increased
soft,semiso intestinal
lid,moist motility due to
irratation of the
colon by
bacteria(diarrhe
a)
RBC Plenty Absent GI bleeding;
hematochezia
Pus cells Plenty Absent Bacterial
infection
Bacteria Moderat Few Bacterial
e
infection

DATE CHARACTERISTICS RESULTS NORMAL SIGNIFICANCE

PERFORMED VALUES
Date: Color Brown Brown Normal
March 8,
2011
Consistency Soft Formed, Normal
soft,semis
olid,moist
RBC Plenty Absent GI bleeding;
hematochezi
a
Pus cells 2-6/hpf Absent Bacterial
infection
Bacteria Plenty Few Bacterial
Infection
Parasites No Absent Normal
intestinal
parasites
and ova
seen
 PATHOPHYSIOLOGY
Modifiable factors: Non-Modifiable factors:
Occupation (Efren and his father) -Gender: Male (affects more men than women)
Exposure to contaminated bodies of water -Geographical location (endemic

Penetration of S. japonicum

Uses an enzyme to force its

S. japonicum cercariae loses its tail during penetration &

Locates a post-capillary venule

Along with blood, travels towards the heart,

Undergoes further developmental changes

Migrates to the liver

Juvenile S. japonicum worms develop an oral sucker

Begins to feed on Anemi

Nearly-matured S. japonicum
pair with each other; with

Pairs of S. japonicum relocate to the Poor peripheral

Parasites reach
Poor blood and oxygen
Skin pallor,
supply topoor
the
capillary refill,
Legend: SCHISTOSOMIA cold sensation on
lower extremities
- clinically manifested by patient during the course of his disease Eggs pass through the wall of blood and skin turgor
Produce & lay
Matured eggs crosses into the digestive tract through the release of

Other eggs become trapped within the mesenteric & rectal vein
Some will be excreted Eggsintrapped
Others will remain the in the mesenteri Eggs washes back into the liver through t

(will be continued on (w i l l be c o n tI n u e d o n p
 Some will be excreted in Others will remain in the intestinal

Irritates intestinal Immune response of

Increase gastric Cellular

Diarrhe Inflammatory response

Inflammati

Causes ulceration to the intestinal mucosa Anal

Melena & hematoche

As lesion progresses, it developed Pus in stool

Anemia
Narrowing of

Pea-sized
Obstructio

Formation of abnormal

Legend:

- clinically manifested by patient during the course of his disease

Multiple anal

48
Eggs trapped in the mesenteric &
Eggs washes back into the liver through the

Eggs matures
Eggs in the Eggs being dislodged in the

Secretes antigens that illicits a

Immune response of the body causes cellular
Occlusi

Cellular Causes lesions that leads to Blocks the blood flow through the liver sinusoids to the hepatic veins

Inflammati Liver parenchymal

Increased venous pressure in the

Reduces the liver’s ability to synthesize normal Decrease protein and carbohydra te
Pain
Increase amino acid -
Portal

Can cause Hypoalbumin

SOB, chest Congesti on of lymph Systemic hypertensi
pain, Increas e
Fatigue, body malaise, muscle atrophy, atonia, flaciddity,
tachypnea, Loss of oncotic
hyperventilat

Hyperpigmen Tachycardi
Blood volume
Leakage of plasma proteins into the

Increase secretion of Splenomeg

Shifting of fluid from intravascular to peritoneal

Stimulate the kidney to retain sodium
Liver is unable to inactivat e

As this progresses, it lead to Bilateral renal parenchymal Ascite

Legend:

- clinically manifested by patient during the course o

49
 NURSING CARE PLANS

Cues Nursing Diagnosis Objective Intervention Rationale Evaluation

Subjective: Altered Comfort:  Within 8 hours  Within 8
 “Sakit ang severe pain related nursing care,  Assessed pain  To rule out hours nursing
gioperahan sa to presence of patient will be including worsening of care, patient
akong tiyan ug stoma at the left able to reduce location, underlying was able to felt
ang akong lower quadrant and pain characteristic, condition of reduced pain
lubot sakit kay wound at the left duration and complication with
dili nako buttocks area quality  Pain is appropriate
kalibang,” as  Accepted subjective nursing
verbalized by clients experienced intervention
patient description of and can’t be and
 “Sakit pain felt by others pharmacologic
akong lubot,  It may not be management.
murag congruent with
makapatay,  Observed for verbal reports
pati akong nonverbal cues indicating need
bukog murag  At the end of 2 for further
gakutkuton,” as days nursing evaluation
verbalized by care, patient  To divert  At the end of
patient will be able to  Performed attention to 2 days nursing
 emitted demonstrate diversional pain care, patient
sounds of pain the use of activities such was able to use
such as relaxation as massage some of the
“uuuhhhh” as techniques in  Taught deep  To calm patient relaxation
noted minimizing breathing techniques
level of pain of exercises  Reduce level of introduce to
Objective: the patient  Provided quiet anxiety help minimize
 winces, environment by level of pain
shouts, bends limiting noise such as deep
over and grasps and visitors  To provide non breathing when
an object  Provided pharmacologica pain occurs
tightly as noted comfort l pain
measures by management
 facial
teaching deep
grimace noted

5
0
 intermittent breathing
searing pain on exercises
abdominal area
and scalding
pain on anal  To maintain
area with pain Dependent: acceptable
scale of 10/10  Administered level of pain
as noted nalbuphine HCl
5mg IVTT q6h
PRN for severe
pain as
ordered by AP
Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3 rd edition, 1994
 Cues Nursing Diagnosis Objective Intervention Rationale Evaluation
Subjective: Impaired gas  Within 8 hours  Monitored  Check for  Within 8
 “Galisod ko exchange related nursing care, and alterations hours nursing
ug ginhawa,” as to immobility patient will be recorded  To determine care, patient
verbalized by secondary to able to achieve vital signs degree of was able to
patient complications of adequate  Assessed movement achieve
schistosomiasis oxygenation energy level by  To maintain adequate
and reduce RR asking the pt airway oxygenation
to 15 cpm level of activity through
Objective:  Elevated head  Promote compliance of
 Shortness of of bed optimal chest therapeutic
breath noted  Taught expansion regimen and
 Hyperventil frequent reduce RR to 16
ation noted position cpm
 Increased changes, deep
respiratory rate breathing and
to 40 cpm coughing  Helps limit
exercise and oxygen
 Pallor skin
 At the end of 2 allowed pt to consumption
noted
days nursing perform  At the end of
 Nasal flaring
care, patient  Advised SO to 2 days nursing
noted
will be able to limit activities care, patient
demonstrate such as walking was not able to
interventions in and roaming meet the long
improving gas and limit term objective
exchange hospital noise  To reduce due to
by minimizing oxygen occurrence of
visitors around demands pain
to within pt’s
tolerance
 Recommended
energy
conservation
techniques
such as
 adequate bed
rest
Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3 rd edition, 1994
Cues Nursing Objective Intervention Rationale Evaluation
Diagnosis
Subjective: Ineffective  At the end of 3  At the end
 “Maglisod breathing hours nursing  Assessed for  To know of 3 hours
ko ug ginhawa pattern related care, the patient discomfort. any nursing care
sa kasakit sa to pain will be able to restriction in the patient
akong gibati,” demonstrate  Elevated Head of the was able to
as verbalized effective bed respiratory verbalize
by patient breathing pattern tract. understanding
with proper  To promote of awareness
nursing  Taught patient physiologic of factors
Objective: intervention and deep breathing ease of affecting
 Shortness of pharmacologic exercise maximal breathing
breath noted management  Positioned pt in inspiration. pattern and
 Increased and reduce RR to a comfortable  To help reduced RR to
respiratory rate 15 cpm position increase 17 cpm
to 40 cpm oxygen intake.
 Used of  Reposition
accessory  Maintained calm client
muscles: nasal environment frequently in a
flaring through limiting comfortable
 Decreased  At the end of 2 visitors of pt position
chest days nursing  Provided  To limit  At the end of
expansion care the patient adequate level of 2 days nursing
will be able to rest periods anxiety. care the
 Pallor skin
establish a  Limited walking patient felt
noted
normal or and moving decrease
effective around  To limit occurrence of
respiratory fatigue shortness of
pattern though breath.
following proper  Administered  To decrease
therapeutic nalbuphine HCl oxygen
regimen when 5mg IVTT q6h demands &
pain occurs PRN for severe conserve energy
 pain as ordered  To maintain
by AP acceptable
level of
pain
Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3 rd edition, 1994
Cues Nursing Diagnosis Objective Intervention Rationale Evaluation
Subjective: Decreased cardiac  Within 8 hours  At the end
 “Sakit kaau output related to nursing care,  Monitored  Provides of 8 hours
ako dughan dislodgement of patient will baseline vital opportunities to nursing care,
murag schistosoma eggs minimize signs/ track changes patient was
gakomoton” as in the portal fatigue hemodynamic not able to
verbalized by system parameters meet short
patient. including term objective
peripheral
 
Objective: At the end of 2 pulses and To limit fatigue
 Fatigue days nursing recorded

noted care, patient’s Promote
 atonia, cardiac output adequate rest  At the end
muscle atrophy will increase as by providing of 2 days

and flaccidity evidenced by quiet To prevent nursing care,
noted pt’s muscle environment bolus or patient
 cold, movement and and minimize  overdose participated in
the
clammy skin stable vital  visitors To reduce
signs Monitored rate anxiety interventions
 pallor noted
of IV drugs to increase
 hair loss
 closely  cardiac output
noted
Encouraged To maintain following
 capillary proper
relaxation adequate
refill time in relaxation
the lower
 techniques nutrition and
Provided diet fluid balance technique
extremities of 5
seconds high in
 Increased carbohydrates,
respiratory rate proteins and
to 40 cpm less fatty foods
 Increased
pulse rate to
125 bpm
 Elevated
Blood pressure
of
150/100mmHg
Reference:
th
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 edition, 2004
Gulanick, et.,al., Nursing Care Plans, 3 rd edition, 1994
 Cues Nursing Diagnosis Objective Intervention Rationale Evaluation
Subjective Altered tissue  Within 8 hours Independent:  Within 8
 “Sakit kaau perfusion: nursing care,  Monitored  Provides hours nursing
ako dughan cardiopulmunary patient will be baseline data comparison care, patient
murag related to relieved of (vital signs) with current felt reduced
gakomoton” as interruption of hyperventilatio and recorded findings hyperventilatio
verbalized by blood flow n n with proper
patient. secondary to  Provided quiet  To conserve nursing
complications of and peaceful energy and intervention
Objective schistosomiasis environment by lower oxygen and
 tachycardia limiting visitors demands pharmacologic
with pulse rate  Cautioned management.
of 125beats client to avoid  Lower oxygen
per minute activities that demands
 shortness of may increase
breath cardiac
 used workload like  At the end of
accessory  At the end of 2 unnecessary 2 days nursing
muscles; nasal days nursing movement  To decrease care, patient
flaring care, patient  Encouraged tension level was able to
 increased will be able to relaxation verbalized
BP to verbalize techniques like awareness of
150/100mmHg awareness of deep breathing factors
causative exercises  To increase contributing to
 capillary
factors and  Elevated head gravitational causes of
refill time in
initiate needed of bed at night blood flow interruption of
the lower
lifestyle blood flow
extremities is
changes
5 seconds

Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3 rd edition, 1994
 Cues Nursing Diagnosis Objective Intervention Rationale Evaluation
Subjective: Risk for Infection  Within 8 hours  Assessed  To assess  within 8
 “Sakit ang related to site for nursing care characteristics the patient‘s hours nursing
akong organism invasion the patient will of wound current care the
gioperahan secondary to be able to  Monitored status. patient was
Maam,” as colostomy and identify vital signs and  To monitor able to
verbalized by fistulectomy interventions recorded alterations verbalize
patient that will  Taught  To minimize learning
decrease or proper hand transmission of towards
lower the risk washing microorganism interventions
of infection and techniques to s to decrease
Objective: demonstrate pt and SO infection.
 Increased techniques and  Maintained  To minimize
segmenters to lifestyle sterile transmission
68-75% and changes to technique and to insure
monocytes to promote a safe during evasive sterility.
5-6% environment. procedures.
 Presence of  Dressing  Prevent
pain at double- done with contamination
barrel aseptic from fecal
colostomy at technique and discharges
Left Lower  At the end of 2 covered from
Quadrant with days nursing dressing with colostomy.  At the end of
watery and care the sterile gauze 2 days nursing
greenish fecal patient will be care the
discharges able to achieve  To prevent patient was
 Presence of timely wound  Administere d return of able to
wound soaked healing and be Cefuroxime infection. demonstrate
with serous free of purulent 750mg IVTT changes to
sanginous drainage or q8h as ordered promote a safe
discharge with erythma. by AP environment.
foul odor at the
buttocks area
Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3 rd edition, 1994
Cues Nursing Objective Intervention Rationale Evaluation
Diagnosis
Subjective Imbalanced  Within 8  within 8
 “Wala koy Nutrition less hours nursing  Assessed  This would hours nursing
gana sa than body care the weight, age, provide a care patient
pagkaon” as requirements patient will be activity and rest baseline data. was able to
verbalized by related to able to level. consume 3
patient. inability to consume food  Recorded  To reveal table spoons
 “Nangalagas absorb proper RDA total daily changes that per meal
ang iyang nutrients intake. should be
buhok last secondary to made in
week” as schistosomiasis client’s dietary  At the end of
verbalized by  At the end of intake. 2 days nursing
significant 2 days nursing  Encouraged care the
other care the intake of  To increase patient was
patient will be carbohydrates stores of not able to
able to (rice), proteins energy giving meet objective
Objective Demonstrate (meat) and fiber foods.
 Loss of progressive (vegetables)
weight from weight gain diet
58kg to 30kg toward the  Promoted  Increase
(48%) goal. adequate fluid fluid intake
 Weakness of intake of 8-10
muscles noted glasses per day.  Emphasis of
 Hair loss  Provided well balanced
noted information nutritional diet.
regarding
 Decrease
nutritional
subcutaneous
needs.
fats noted.
 Loss of
muscle
strength
 Body
malaise noted
 Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3rd edition, 1994
 Cues Nursing Diagnosis Objective Intervention Rationale Evaluation
No subjective cue. Fluid Volume  Within 8 hours Independent:  within 8
Deficit related to nursing care,  Monitored color  Check for hours nursing
chronic illness and patient will be and consistency presence of care, patient
malnutrition able to of fecal hematochezia was able to
Objective: consume fluid discharges consume 2
 Tachycardia as indicated hematochezia glasses of fluid
with pulse rate  Provided  To restore fluid per day
of 125bpm nutritious diet losses
 Dry mucous and give
membranes adequate fluid
with fissure in (8-10 glasses  To prevent
the lips as per day) injury from
noted  At the end of 2  Moistened lips dryness
 Sunken days nursing with cotton  Promote
eyeballs noted care, patient swabs comfort
 Weight loss will be able to  Changed  At the end
of 48% demonstrate position q2h  To promote of 2 days
behaviors to  Identified and awareness nursing care,
monitor and instructed patient was
correct deficit nutritional able to
as indicated needs demonstrate
when condition increased
is chronic such  restore awareness of
as recovery electrolyte ways to correct
from sunken  Administered losses and goes fluid volume
eyeballs D5NSS 1L @ directly into deficit
30gtts\min intravascular
fluid

Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3 rd edition, 1994
 Cues Nursing Diagnosis Objective Intervention Rationale Evaluation
Subjective Activity intolerance  Within 8  Noted presence of  To assess the  within 8
 “Luya kaayo related to general hours nursing factors patient’s hours nursing
ako pamati weakness. care the contributing to condition care the
karon,” as patient will be fatigue. patient was
verbalized by able have  Provided  To enhance able to identify
patient. adequate rest comfort ability to negative
and to measures like participate. factors that
increase deep breathing may affect
Objective energy exercises  To provide ability to
 Poor skin  Noted patient’s comparative perform ADL
turgor. reports of baseline.
 Generalized weakness and  At the end of
weakness  At the end fatigue.  To identify 2 days nursing
 Needs of 2 days  Monitored vital alterations. care the
assistance in nursing care signs and  To reduce patient will be
walking and the patient will recorded fatigue able to
standing as be able to  Planned care demonstrate
noted increase with rest factors to
 Tensed and activity periods  To enhance increase
bent posture tolerance between activity and to activity
noted activities. perform ADL. tolerance.
 Promoted  To enhance
 Fatigue
comfort sense of
noted
measures. wellbeing.
 Body
malaise
 Encouraged
patient to
maintain
positive
attitude.
Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3 rd edition, 1994
 Cues Nursing Diagnosis Objective Intervention Rationale Evaluation
Subjective: Self-care deficit:  Within 8 hours  Within 8
 “Dili ko hygiene and nursing care,  Assessed  Assessed lack hours nursing
ganahan maligo toileting related to patient will be barriers to of information care, patient
tungod sa presence of stoma able to take a participation in and was able to
akong and pouch bed bath regimen psychological take a bed bath
gabatiun,” as problems
verbalized by affecting

patient Established condition
   At the end of
At the end of contractual To promote
Objective: 2 days nursing partnership for trust and 2 days nursing
 Generally care, patient patients cooperation care, patient

unclean will increase Promoted was able to
 Unkempt willingness to participation in increase

appearance perform daily problem Enhances willingness to
noted self-care as identification commitment to perform daily
 Noted foul assisted by SO and decision plan, optimizing self-care as
odor due to  making outcome assisted by SO
presence of Planned time to 
colostomy listen to To discover
 Foul breath  patient barriers to
noted participation in
Encouraged  regimen
 Poor 
personal food and fluid To meet
hygiene as choices nutritional

noted  Provided needs
 Unchanged information on To minimize
clothing noted stoma cleaning risk for
Reviewed infection
safety
concerns
 To reduce risk
to injury
Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3 rd edition, 1994
 Cues Nursing Diagnosis Objective Intervention Rationale Evaluation
Subjective: Impaired physical  Within 8 hours  Within 8
 “Dili kayo mobility related to nursing care,  Assessed  To determine hours nursing
ko makalihok decreased muscle patient will be muscle degree of care, patient
ug tarong kay strength and able to strength immobility was able
endurance  participate in
luya akong participate in To increase
 performing
lawas,” as performing Performed muscle
verbalized by Passive- Passive- strength Passive-
patient Assistive ROM Assistive Rom  Assistive ROM
exercises exercises with To provide exercises
Objective:  pt comfortable
 Postural Changed  position
instability in position q2h Enhance self-

performing At the end of 2  concept and
ADLs days nursing Participated sense of
 Slowed care, patient in self-care  independence  At the end
movements will increase activities like To increase of 2 days
 Limited muscle  ADLs tolerance nursing care,
range of motion strength as  patient was not
Provided
 Generalized evidenced by To reduce able to meet
progressive
weakness 85% muscle 
fatigue objective
mobilizations
 Decrease strength Provided 
muscle adequate rest
strength periods by To avoid risk for
limiting visitors injury
 Placed pt in a
safe position
Reference:
Doenges, M., et.,al., Nurse’s Pocket Guide, 9 th edition, 2004
Gulanick, bet.,al., Nursing Care Plans, 3 rd edition, 1994
 MEDICAL MANAGEMENT

Date Doctor’s Order Rationale

February 24,  Admit  Due to the present
2011 complaints of the
patient, he needs an
 Consent intensive care.
 This requirement
protects clients from
form having any
medical procedure
they do not want or
do not understand. It
also protects the
hospital and the
health care provider
 TPR & BP q 4 hours from a claim by the
client or the family
that permission was
not granted.
 Vital signs reflect the
patient's condition--
and changes in the
 DAT; high fiber, low fat patient's condition or
in the patient’s body
function that
otherwise might not
be observed.
 High fiber- for healing;
 Start IVF of PLR 1 liter, low fat-to prevent
fast drip 200 cc, then cardiovascular
regulate @ 40 gtts/min; complications; 1 egg
TF: D5 NM 2 liters @ per day -egg contains
same rate albumin protein for
wound healing
 Plain Lactated
 Labs: CBC, Blood typing Ringer’s Solution- a
fluid and electrolyte
replenisher prescribed
for
 Meds: correction of
1. Nalbuphine 1 amp. IVTT extracellular volume
q 8 hours, then PRN and electrolyte
depletion
 Routine blood
examination is needed
to determine values
6
8
of

6
9
  Refer Anesthesiologist blood components.

February 25, 1. For moderate to severe

2011  IVFTF: D5 NM 1 liter pain since patient was
@30 gtts./min having a 10/10 pain scale

 For evaluation of pain

 D5NM- is a hypertonic
 solution that draws
Cefuroxime 750 mg. IV q
8 hours. fluid out of the
intracellular and
interstitial
February 26,  compartments into the
2011 IVTF: D5 NM 1 liter @ SR.
vascular
compartment,

expanding vascular
February 27, Cont. Meds.
 volume.
2011  Prophylaxis
 IVFTF with D5 NM 1 liter
@ 20 gtts/min
Diazepam 5 mg. 1 tab.
@ h.s PRN for pain.  Same as above


 Nalbuphine 5 mg. IVTT  To sustain patient’s

February 28, now medication
2011 Diazepam 5 mg. IVTT  Same as above
now

 For pain
March 1, 2011 
IVF @ D5 NM 2 liters @
SR
Revise Nalbuphine to  For mod. to severe
10 mg IV PRN for pain
 moderate to severe  For pain
 pain.
March 4, 2011

  Same as above
 Cont. All meds.  For moderate to
March 5, 2011 IVTF: D5 NM 2 liters @ severe pain
20 gtts/min

Cont. Meds
Ketorolac 30 mg. IV q 6
 hours RTC.  Same as above
 IVFTF: D5 NM 1 liter  Same as above
@ 20 gtts/min.
March 7, 2011
 Same as above
 Schedule for  For severe pain
Fistulectomy March 15,
2011 at 1 pm.  Same as above
 Secure consent, signed

 To remove anal fistula

 This requirement
protects clients from
form having any
medical procedure
they do not want or do
 Notify OR and not understand. It also
Anesthesiologist protects the hospital
March 8, and the health care
2011 provider from a claim
by the client or the
family that permission
 IVTF: D5 NM 2 liters was not granted.
@ SR  For them to be
 Metroclopromide 1 informed and be
March 9, 2011 amp. IVTT now q 8 prepared for the
hours, PRN for operation
vomiting

 TF: D5 NM 2 liters @ SR.  Same as above

 May use Diazepam 5 mg.  For vomiting
IVTT q 8 hours, PRN
March 10, for pain
2011  Morphine Sulfate 10 mg
controlled- release 1 tab
BID  Same as above
 For pain

March 14,  For severe and chronic

 IVTF: D5 Nm 2 liters
2011 pain
@ 15 gtts/min
 Diazepam 5 g. IVTT
now
  IVTF: D5 NM 1 liter @ SR  Same as above
 Cont. All meds
 Same as above
March 15,
2011
 Same as above
 Same as above
POST OP NOTES
 Soft diet

 Supine in bed x 6 hours

 O2 via nasal cannula at
2LPM
 V/s q 15 mins  Low residue and easily
 Regulate present IVF @ digested and well
March 16, 30 gtts tolerated
2011  IVTF: D5 NM 2 liters @  To prevent aspiration
SR  To relieve tachypnea
 Meds: Nalbuphine 2 tab  Same as above
 Same as above

 Nalbuphine 5 mg. IVTT  Same as above

now, q 8 hours  Same as above
 IVTF: D5 LR @ SR
 Cont. Meds.
March 18,  Hot sitz bath for 15 mins  Same as above
2011 QID
 Same as above
 Same as above
 to decrease pain and
prevent inflammation
March 21,  Morphine Sulfate 1 tab after fistulectomy.
2011 10 mg. TID
 IVF decreased @ 15 gtts/
min  Same as above

 Same as above
 Meds: PCM 600 mg. IV
March 22, now
2011  For fever- temperature of
 IVTF: D5 NSS 1 liter @ 38.1C
SR  D5NSS-It is an efficient
and effective method
of supplying fluids
 directly into the
 IVTF: D5 NSS 1 liter @ intravascular fluid
SR compartment and
replacing electrolyte
losses. D5NSS or 5%
dextrose in normal
March 23, saline is a hypertonic
2011 solution that draws
fluid out of the
intracellular and
interstitial
compartments into the
vascular
March 24, compartment,
2011 expanding vascular
 Nalbuphine 10 g. IVTT volume.
 IVTF: D5 NM 1 liter @ SR
 Refer to Anesthesiologist
for eveluation of pain.
 Same as above
 Same as above
March 25,  Discontinue Tramadol  For evaluation of pain
2011 IVTT
 May give Nalbuphine 5
mg. IVTT q 6 hours PRN
for severe pain  Patient was tolerant to
 IVF: D5 NM @ SR drug
 Same as above

March 26,  IVF: D5 NM 1 liter + 1

2011
mg Amino Acid @ 20  Same as above
gtts/ min

 Shift Cefuroxime IV to  Same as above, amino

500 mg BID PO acids are building
March 28,
blocks of proteins
2011
 For infections
 IVF: D5 NM 1 liter @ SR
 1 egg/day
 Tramadol 50 g 1 cap TID
 Same as above
 egg contains albumin
 Cont. Meds protein for wound
 IVTF: D5 NM 1 liter + 2 healing
amp. Morphine Sulfate @
 SR
 Refer to Anesthesiologist  Same as above
for pain management 
Same as above
 Provide medical abstract
c/o NOD  Same as above
 IVTF: D5NM 1 liter @ 20
gtts/ min  To collect data

 Same as above
 SURGICAL MANAGEMENT

Title of Operation Performed: Exploratory Laparotomy, Double

Bowel Sigmoid Colostomy
Date Performed: December 29, 2010
Surgeon: Dr. Surge

 Exploratory laparotomy. An abdominal exploration

(laparotomy) is done while patient is under general anesthesia,
which means patient is asleep and thus shall feel no pain during the
procedure. In this procedure, the surgeon makes a cut into the
abdomen and examines the abdominal organs. The size and
location of the surgical cut depends on the specific health issue.
 The surgery on “Boy Tigas” was primarily performed to
examine his abdominal organs and determine the location of
his bowel obstruction prior to colostomy
 Usually, patients can resume normal eating and drinking
about 2 - 3 days after the surgery.
 Complete recovery usually takes about 4 weeks

Colostomy is a surgical opening of the colon brought to the surface

of the abdomen. A colostomy is not a disease rather it is a change
in anatomy. This results in a change of normal body function to
allow elimination of bowel contents following disease or injury.
 Double-barrel colostomy was used in the operation of “Boy
Tigas”. This colostomy involves the creation of two separate
stomas on the abdominal wall. The proximal (nearest) stoma is
the functional end that is connected to the upper
gastrointestinal tract and will drain stool. The distal stoma,
connected to the rectum which is also called a mucous fistula,
drains small amounts of mucus material.
  This is most often a temporary colostomy performed to rest
an area of bowel, and to be later closed.

Aftercare of Colostomy
 Post-operative care for the patient with a new colostomy, as
with those who have had any major surgery, involves
monitoring of blood pressure, pulse, respirations, and
temperature. Breathing tends to be shallow because of the
effect of anesthesia, the patient's reluctance to breathe deeply
and the experience of pain caused by the abdominal incision.
 The operative site is observed for color and amount of wound
drainage. For the first 24-48 hours after surgery, the colostomy
will drain bloody mucus.
 Fluids and electrolytes are infused intravenously until the
patient's diet is can gradually be resumed, beginning with
liquids. Usually within 72 hours, passage of gas and stool
through the stoma begins. Initially the stool is liquid, gradually
thickening as the patient begins to take solid foods.

Title of Operation Performed: Fistulectomy

Date Performed: March 15, 2011
Surgeon: Dr. Surge

 Fistulectomy is the surgical excision of a fistula. Also called

syringectomy. In this surgery, the fistula tract is totally taken out.
The resultant wound is generally not closed and left open to heal of
its own. Thus, this leads to a large wound from the anal opening to
the buttock.
 “Boy Tigas” was diagnosed with mutiple in-ano fistula thus
fistulectomy was performed. A two-inch wound is located at his
 left buttock area as a result of the fistulectomy. Understandably
this leaves the patient with lot of pain.
 Complete fistulectomy creates larger wounds that take longer
to heal and offers no recurrence advantage over fistulotomy.
Title of Operation Performed: Anoscopy with biopsy
Date Performed: August 2, 2010
Surgeon: Dr. Gacus

 Anoscopy is a method to view the rectal area, including the

anus, anal canal, and lower rectum. A digital rectal exam is first
done to make sure there isn't anything blocking the rectal area.
After this is done, a lubricated instrument (anoscope) is placed a
few inches into the rectum. Patient will feel some pressure when
this is done.
 The anoscope has a light on the end, so the health care
provider can see the entire anal canal.
 A laxative, enema, or other preparation may be given prior to
the procedure so that patient can completely empty bowels.
 A specimen for biopsy can be taken if needed.

Title of Operation Performed: Proctosigmoidoscopy with biopsy

Date Performed: August 16, 2010
Surgeon: Dr. Llosa

 Sigmoidoscopy also called proctosigmoidoscopy or

proctoscopy, is the inspection of the rectum and lower colon using
a thin lighted tube called a sigmoidoscope. Samples of tissue or
cells may be collected for examination under a microscope.
 During the test, patient is positioned on his left side with
knees drawn up toward chest. A gastroenterologist or surgeon
will perform the test. First, the doctor does a digital rectal exam
by gently inserting a gloved and lubricated finger into the
rectum to check for blockage and to dilate (gently enlarge) the
anus.
  Next, the sigmoidoscope -- a hollow tube with a camera on
the end -- is inserted into the rectum. Air is introduced into the
colon to expand the area and help the doctor see better. The
air may cause the urge to have a bowel movement.
 The sigmoidoscope is advanced, usually as far up as the
sigmoid colon or descending colon. Then, as the scope is slowly
removed, the lining of the bowel is carefully examined. The
hollow channel in the center of the scope allows for the
passage of forceps for taking biopsies or for other instruments
for therapy.
 During a proctoscopy, a slightly longer instrument than the
anoscope is used to view the inside of the rectum. Patient
usually will have to undergo enemas or use laxatives to empty
the colon before the test is done.

 Biopsy or tissue sampling is the removal of a small piece of

tissue for laboratory examination.
 A needle (percutaneous) biopsy removes tissue using a
hollow tube called a syringe. A needle is passed thru the
syringe into the area of concern. The tissue is taken out using
this needle. Needle biopsies are often performed using x-rays
(usually CT scan), which guide the surgeon to the appropriate
area.

Rectal biopsy was performed to Boy Tigas. This is a procedure done

to remove a small piece of rectal (anal) tissue for examination. It is
usually part of anoscopy or sigmoidoscopy. A digital rectal exam is first
done to make sure there isn't anything blocking the rectal area. After
this is done, a lubricated instrument (anoscope, rectal speculum, or
proctoscope) is placed into the rectum.
 Rectal biopsy is useful in cases with light, chronic, or inactive
infections. It is also beneficial in assessing the response to
chemotherapy.
 Biopsy is helpful when stool sample findings are negative
infection.
 Obtain multiple biopsy samples and crush them between
slides (to increase egg-detecting sensitivity).
 PROGNOSIS & COMPLICATIONS

1. Schistosomiasis
 If treated early, prognosis is very good and complete recovery is
expected. The illness is treatable, but people can die from the
effects of untreated schistosomiasis. The severity of the disease
depends on the number of worms, or worm load, in addition to
how long the person has been infected. With treatment, the
number of worms can be substantially reduced, and the
secondary conditions can be treated. The goal of the World
Health Organization is to reduce the severity of the disease
rather than to completely stop transmission of the disease. There
is, however, little natural immunity to reinfection. Treated
individuals do not usually require retreatment for two to five
years in areas of low transmission. The World Health
Organization has made research to develop a vaccine against
the disease one of its priorities.

 Almost all patients improve with treatment.

 Most patients with early disease or without severe end-organ
complications recover completely.
 Surprisingly, patients with hepatic and urinary disease, even with
fibrosis, may improve significantly over months or years
following treatment.
 Resolution of pulmonary disease is less well documented.
o Patients with heavier worm burdens are less likely to
improve and are more likely to require re-treatment.
o Treatment is indicated for patients with end-stage
complications of portal hypertension and severe pulmonary
hypertension, but these patients are much less likely to
benefit.
  Co-infection (with malaria, HIV, or hepatitis) worsens the
prognosis.

2. Anal fistula, abscess, fissures and strictures

 In most cases, the prognosis is excellent. Almost all acute

fissures heal quickly with conservative treatment, and almost all
fistulas and chronic fissures can be corrected with surgery.
Appropriate treatment of anal strictures will allow stool to pass
easily and comfortably.

 Most anal abscesses heal after being drained by a doctor. Some

develop into anal fistulas. If a fistula does complicate the healing
of an abscess, a fistulotomy will totally eliminate both the fistula
and any remaining abscess in most patients.
 Approximately two thirds of patients with rectal abscesses
treated by incision and drainage or by spontaneous drainage will
develop a chronic anal fistula.
 The recurrence rate of anorectal fistulas after fistulotomy,
fistulectomy, or use of a Seton is about 1.5%.
 The overall incidence of major fecal incontinence after surgical
management of complex suprasphincteric fistulas is estimated at
approximately 7%.

3. Splenomegaly
 Past history in a group of 159 individuals with schistosomal
splenomegaly revealed hematemesis in 12.6 percent and
ascites, edema and/or jaundice in 1.9 percent. One hundred nine
patients were followed for an average of 3.6 years. During this
time liver failure was observed in eight and hematemesis in
eleven (five of these had experienced bleeding prior to the
beginning of the study). Liver failure was more often lethal than
 was gastrointestinal hemorrhage, death in the latter usually
occurring after a series of such events.
 Fifteen (9.4%) patients died during follow-up. Death occurred in
four shortly after a voluminous hematemesis; in five it was a
result of liver failure and in six it was the result of other diseases
or accidents.
 Since the complications of schistosomal splenomegaly are not as
frequent as they are in other diseases leading to portal
hypertension, we believe that the policy of prophylactic venous
shunts in individuals who have never experienced hematemesis
should be seriously questioned.

4. Portal Hypertension
 Mortality during acute variceal hemorrhage may exceed 50%.
Prognosis is predicted by the degree of hepatic reserve and the
degree of bleeding. For survivors, the bleeding risk within the
next 1 to 2 yr is 50 to 75%. Ongoing endoscopic or drug
therapy lowers the bleeding risk but decreases long-term
mortality only marginally.

5. Ascites
 The prognosis depends upon the condition that is causing the
ascites. Carcinomatous ascites has a very bad prognosis.
However, salt restriction and diuretics can control ascites caused
by liver disease in many cases.
 Therapy should also be directed towards the underlying disease
that produces the ascites. Cirrhosis should be treated by
abstinence from alcohol and appropriate diet. The new interferon
agents maybe helpful in treating chronic hepatitis.

6. Anemia
  Usually, the prognosis depends on the underlying cause of the
anemia. However, the severity of the anemia and the rapidity
with which it developed can play a significant role. Similarly, the
age of the patient and the existence of other comorbid
conditions influence outcome.
 The most serious complications of severe anemia arise from
tissue hypoxia. Shock, hypotension, or coronary and pulmonary
insufficiency can occur. This is more common in older individuals
with underlying pulmonary and cardiovascular disease.
 Hemolytic transfusion reactions and transmission of infectious
disease are risks of blood product transfusions. Patients with
autoimmune antibodies against RBCs are at greater risk of a
hemolytic transfusion reaction because of difficulty in cross-
matching the blood.
 Occasionally, the blood of patients with autoimmune hemolytic
anemia cannot be cross-matched in vitro. These patients require
in vivo cross-matching in which incompatible blood is transfused
slowly, and periodic determinations are made to ensure the
patient is not developing hemoglobinemia. This method should
only be used in patients with either significant hypoxia from the
anemia or evidence of coronary insufficiency.

7. Seizures
 About 30% of patients with severe seizures (starting in
early childhood), continue to have attacks and usually never
achieve a remission state. In the United States, the prevalence of
treatment-resistant seizures is about one to two per 1,000
persons. About 60–70% of persons achieve a five-year remission
within 10 years of initial diagnosis. Approximately half of these
patients become seizure-free. Usually the prognosis is better if
 seizures can be controlled by one medication, the frequency of
seizures decreases, and there is a normal EEG and neurological
examination prior to medication cessation.
 People affected by seizure have increased death rates
compared with the general population. Patients who have
seizures of unknown cause have an increased chance of dying
due to accidents (primarily drowning). Other causes of seizure-
associated death include abnormal heart rhythms, water in the
lungs, or heart attack.

8. Liver Parenchymal Disease

 Historically mortality has been unacceptably high, being in

excess of 80%. In recent years the advent of liver transplantation
and multidisciplinary intensive care support have improved
survival significantly. At present overall short term survival with
transplant is more than 65%.

9. Colostomy complications
 Death (necrosis) of stomal tissue. Caused by inadequate blood
supply, this complication is usually visible 12-24 hours after the
operation and may require additional surgery.
 Retraction (stoma is flush with the abdomen surface or has
moved below it). Caused by insufficient stomal length, this
complication may be managed by use of special pouching
supplies. Elective revision of the stoma is also an option.
 Prolapse (stoma increases length above the surface of the
abdomen). Most often results from an overly large opening in the
abdominal wall or inadequate fixation of the bowel to the
 abdominal wall. Surgical correction is required when blood
supply is compromised.
 Stenosis (narrowing at the opening of the stoma). Often
associated with infection around the stoma or scarring. Mild
stenosis can be removed under local anesthesia. Severe stenosis
may require surgery for reshaping the stoma.
 Parastomal hernia (bowel causing bulge in the abdominal wall
next to the stoma). Usually due to placement of the stoma where
the abdominal wall is weak or creation of an overly large opening
in the abdominal wall. The use of an ostomy support belt and
special pouching supplies may be adequate. If severe, the defect
in the abdominal wall should be repaired and the stoma moved
to another location.
 DISCHARGE PLAN

Medications Drug : Praziquantel

Dose and frequency: Three doses of 20 mg/kg as a 1-
day treatment with an interval between doses not
less than 4 hours or more than 6 hours
Indication: Schistosomal infections due to S. japonicum
Nursing Precaution:
 Swallow tablets unchewed with liquid during
meals. Keeping the tablets in the mouth may
cause gagging or vomiting; do not chew the
tablets as their bitter taste can cause retching
and vomiting.
 Use caution while driving or performing tasks
requiring alertness; may cause
dizziness/drowsiness.
 Schistosomal worms are usually dead 7 days
following treatment. However, re-infection of the
parasite is very possible, especially if the skin
has contact with contaminated bodies of water.

Drug: Ferrous sulfate

Dose and Frequency: 1 cap OD
Indication: Iron deficiency
Nursing Precaution:
 GI upset may be related to dose
 Between-meal doses are preferable. Drug can
be given with soft foods, although absorption may
be decreased.
 Monitor hemoglobin level, hematocrit and
reticulocyte count during therapy.
  Tell patients to take tablet with juice (preferably
orange juice) or water, but not with milk or
antacids.
 Instruct patient not to crush or chew extended
release form.
Exercise Deep breathing exercises to promote relaxation.
 Places hands palm down on the border of the rib cage
and inhale slowly and evenly through the nose until
the greatest chest expansion is achieved.
 Hold the breath for 2-3 seconds, exhale slowly through
the mouth with pursed lips and continuous exhalation
until maximum chest expansion is achieved.
ROM exercise
 Neck: flexion, extension, hyperextension, lateral
flexion, rotation.
 Elbow: flexion and extension, supination, pronation.
 Wrist: flexion, extension, hyperextension, radial
flexion, ulnar flexion
 Fingers: flexion, extension, hyperextension, abduction
adduction.
 Thumb: flexion, extension, abduction, adduction,
opposition.
Passive ROM exercise
 Hip: instruct significant other to move each leg
forward and up (flexion), move the leg back beside the
other (extension) and move the leg back behind the
body (hyperextension). Move each leg out to the side
(abduction) and move each leg back to the other leg
and beyond in front of it (adduction). Then move each
leg backward, up, to the side, and down in a circle.
Treatment  Educate patient and significant others how to clean
 the stoma and changing or emptying of the pouch to
prevent contamination of the fecal discharges of the
stoma to the wound.
 Teach patient and significant others to maintain
hygienic measures during cleaning of the stoma.
 Encourage patient to change position every 2 hours
(side lying position is advised)
 Position patient in a semi-fowlers position with pillows
to support the back, to maximize lung expansion.
 Caution patient to avoid anything that may increase
cardiac workload.
 Weigh patient weekly in a RHU.
 Discuss eating habits and food reference.
 Instruct to position patient in a side lying position to
avoid injury in the colostomy and wound.
Heath  Provide patient with information regarding proper
Teachings positioning and diversional activities.
 Provide patient with information regarding proper
hand washing and infection control.
 Instruct significant others to report any unusualities.
 Inform patient to avoid strenuous activities that will
cause abdominal muscle contraction.
 Maintain calm attitude to limit anxiety.
 Encourage patient to stay in a quiet and peaceful
environment to promote relaxation and rest,
 Stress proper hand washing techniques.
 Encourage patient to use diversional activities.
 Provide information on proper stoma cleaning.
 Teach patient and significant others proper wound
dressing techniques.
  Stress proper safety precaution.
Out-patient Appropriate consultations depend on the suspected
check-up complications but may include an infectious disease
physician, urologist, or gastroenterologist.

Diet  Low salt diet

 High Protein Diet
o From meat like chicken meat, beef meat,
red and white meat and from fish.
o To increase muscle tone and to help in the
tissue repair.
 High Carbohydrate Diet
o From rice, corn, bread, camote.
To help sustain patient’s needs for metabolic activities.
 Take Vitamin C
o Take at least 1-2 servings of vitamin c rich
fruits such as calamansi and lemon.
 Add 1 egg to every meal to increase protein and
albumin.
 REFERENCE

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 Web links
o http://en.wikipedia.org/wiki/Schistosomiasis
o http://www.answers.com/topic/schistosomiasis?cat=health
o http://www.merck.com/mmpe/sec14/ch183/ch183h.html
o http://www.emedicine.com/med/TOPIC2071.HTM
o http://content.nejm.org/cgi/content/full/346/16/1212
o http://www.fascrs.org/patients/conditions/anal_abscess_fist
ula/
o http://www.mayoclinic.org/anal-fistula/
o http://www.answers.com/topic/anal-fistula
o http://www.emedicine.com/med/topic2733.htm
o http://www.emedicinehealth.com/anal_abscess/page2_em.
htm
o http://www.gicare.com/pated/ecdgs38.htm
o http://en.wikipedia.org/wiki/Cellular_infiltration
o http://www.stanford.edu/group/parasites/ParaSites2008/Le
ah%20Machen_Kirsten%20Rogers/SCHISTOPROJECT.htm
o http://l05.cgpublisher.com/proposals/1215/index_html
o http://jn.nutrition.org/cgi/content/full/136/1/183
o http://www.who.int/tdr/diseases/schisto/diseaseinfo.htm
o http://www.nlm.nih.gov/medlineplus/ency/article/003890.ht
m
o http://www.webmd.com/digestive-
disorders/sigmoidoscopy-anoscopy-proctoscopy
o http://www.kidneyatlas.org/book3/adk3-02.QXD.pdf
o http://en.wikipedia.org/wiki/Image:Gray591.png
o http://health.allrefer.com/health/rbc-urine-results.html
o http://www.encyclopedia.com/doc/1G2-3405200122.html