FAR EASTERN UNIVERSITY

Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

A case of 59 y/o female with Partial GUT Obstruction Probably 2°

Post-Operative Adhesion

Submitted by:

Fatima B. Rodrigo

Group 3- BSN 311

Submitted to:

Dr. Marites J. Ramos, DNM, MAN, RN, RM

 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

Table of Contents

II. Demographic
III. Nursing Health History
A. History of present illness
B. Past health history
C. Family health history
III. Gordon's Health Assessment
A. Health Perception
B. Cognitive
C. Self-perception
D. Role-relationship
E. Sexuality
F. Coping-stress tolerance
G. Value - belief
H. Nutritional- metabolic
I. Elimination
J. Activity and Exercise
K. Sleep and Rest Pattern
IV. Physical Assessment
A. General Survey
B. Measurements
V. Laboratory/Diagnostic examinations
VI. Drug study
VII. FDAR
VIII. Evidence-Based Nursing
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

II. DEMOGRAPHIC DATA

Name Patient E.D.

Address: Cavite
Age: 59 y/o
Gender: F
Birth Date: February 26, 1963 Birth Place: N/A
Religion: Roman Catholic
Race/Ethnic Origin: Filipino
Occupation: Housewife
Educational Attainment: N/A
Marital Status: Married Name of Spouse: N/A
Number of Children: 2
Chief Complaints: Abdominal Pain
Date of Admission: October 31, 2022
Room & Bed Number: Surgery Ward 1, Room 203-C
Admitting/Final Diagnosis: Partial GUT Obstruction Probably 2° Post-Operative
Adhesion

III. NURSING HEALTH HISTORY

A. History of Present Illness of Patient E.D.

Patient E.D. is a 59-year-old female with a chief complaint of pain in her

abdominal area for two days. The patient stated that her whole abdomen is in
pain; the pain is still present even in the left side-lying or right side-lying position.
During her admission, the patient stated that the pain scale was intermittent at 5 to
10 out of 10. The attending physician prescribed cefoxitin, antibiotics of 1 gram
every 8 hours through intravenous administration. Omeprazole, an antiulcer was
also prescribed, 40 mg once a day to be administered through the intravenous
route. The doctor also order Paracetamol, an analgesic, 600 mg p.r.n. or as per
needed administering through the intravenous route, and levothyroxine; a thyroid
replacement due to her past surgery, 100 mg to be administered 30 minutes before
breakfast. The patient stated that the pain is reduced after administering the pain
reliever, but the pain will occur again, and she has to request another pain reliever.
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

A. Past Health History

Immunization
Patient E.D. has no recollection of her past immunization aside from
Covid-19 vaccines and booster shot which means Patient E.D. had her complete
dose; first and second dose of Sinovac-Coronavac Covid-19 vaccine and a booster
shot of Sinovac.

Past Illness

Patient E.D stated that her common past illness is flu, cough, and colds,
and to alleviate the symptoms, the patient drinks Over-The-Counter medicines
such as Biogesic, Bioflu, Neozep, Tuseran, and water therapy. The patient also
stated that she had a goiter and she is currently taking levothyroxine, her
maintenance medicine due to one of her past surgical procedures.

Past Hospitalizations

Patient E.D. stated that she was hospitalized before, and she had a history
of surgical procedures, two cesarean sections,s and total thyroidectomy for her
goiter. She was given.

History of Travel

Patient E.D. has no travel history inside or outside of the Philippines.

B. Family Health History

Patient E.D. has no allergies, and according to her, both paternal and
maternal sides have no health history of allergies, any cancer, heart failure and
disease, hypertension, and diabetes.
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

IV. GORDON’S HEALTH ASSESSMENT

A. Health Perception-Health Management Pattern

Patient E.D. is a non-smoker, and she does not drink alcoholic beverages. She is taking
vitamin C and her maintenance medication which is levothyroxine regularly. The client is also
taking her medications as prescribed by the doctor, and she follows the instruction of her doctor
to move around or walk beside her bed little by little. The patient also stated that if becomes ill
she would immediately take care of her health and take medication, and if a family member of
hers becomes sick, they will advise them to take medication immediately as long as an
over-the-counter medication can alleviate and treat the illness. The patient also added, if an
illness wasn’t treated using over-the-counter medications or if the symptoms are still present, she
will immediately go to the nearest hospital to have a check-up, the same goes with her family
members.

Interpretation: Normal

B. Cognitive-Perceptual Pattern

Patient E.D. has a clear vision and she is not wearing glasses during her stay in the
hospital. She has no history of hearing loss or using a hearing aid. She answers the question after
thinking for a minute, and she is also aware of her environment. The patient had trouble
remembering or recollecting small details from her activities during her childhood which is
normal because of her age, though aside from that, the patient still has good memory retention.

Interpretation: Normal

C. Self-perception- Self-Concept Pattern

Patient E.D. stated that in normal circumstances she feels good about her personality, and
she has no problem with her body image but during her stay in the hospital, she’s been feeling
down and agitated because of her health status. The recent changes in her health affect how she
projects herself, although the patient can stand and sit properly her movement is interrupted
because of the abdominal pain. The patient’s posture is not normal also, the back of the client
was slightly slumped.
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

Interpretation: Deviation from normal

D. Role-Relationship Pattern

Patient E.D. stated that she has a great relationship with her husband and her children.
According to her, if there is a conflict between her and her husband or between her and her
children, she will take action after she gets a hold of her emotions and talks it out properly. The
patient also stated that she has no problem with her in-laws, and she has a great relationship with
her siblings, she even indicated that her guardian during her stay in the hospital is her sister
because her children have to go to school and her husband is working.

Interpretation: Normal

E. Sexuality-Reproductive Pattern

According to Patient E.D., she is already menopause for nine years. She stated that she
was never hospitalized because of a genital problem. The patient did not provide any information
about her sexual activity with her husband aside from having no problem with it.

Interpretation: Normal

F. Coping-Stress Tolerance

According to Patient E.D., her coping mechanism for stress is being quiet for a while,
looking at her surroundings until she feels comfortable again, and then she will eventually talk to
her husband about it. The patient also stated that her stress tolerance is high and that she has long
patience.

Interpretation: Normal

G. Value - Belief

According to Patient E.D., she is a Roman Catholic, and she values her belief and
religion. She is a believer and she entrusts her life to God. She also added that she prays every
day and whenever she is facing a problem she always ask God to guide her and give her enough
strength and courage to get through any challenges that they will encounter.
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

Interpretation: Normal

H. Nutritional- Metabolic

According to Patient E.D., in normal circumstances, she usually prefers to cook healthy
foods for her and her family so vegetables are always part of their meal. They also eat regularly,
and their meals are occasionally accompanied by fruits. She also stated that she drinks more than
8 glasses of water every day, since the patient easily sweats. During her stay in the hospital, she
is currently on a soft diet from November 06, 2022, until November 08, 2022, and before that,
she was under NPO or non-per Orem. Soft diet, also known as bland diet refers to food that is
bland, soft in texture, low in fiber, easy to swallow that patients don’t need to chew, and easy to
digest. The patient stated that her usual food is tasty or bread, banana, or mashed potato.

Interpretation: Normal

I. Elimination

According to Patient E.D., she has no trouble urinating. Usually, the color of the urine is
light yellow to yellow with no unusual odor. The patient’s bowel movement is also regular and
no difficulty or discomfort while having a bowel movement. During her stay in the hospital, the
client is wearing a diaper for adults, she stated that on November 6 she did not have a bowel
movement, and she only urinate, which is normal because she was under NPO, the same thing
happened on November 7, and she is under soft diet during that day, November 8, she had a
bowel movement, and her stool is solid, and dark brown in color.

Interpretation: Normal

J. Activity and Exercise

Patient E.D. stated that her daily activity is doing household chores. She exercises but not
regularly in the morning by walking or riding a bike for 10 to 20 minutes. Although, she said that
her household chores every day keep her busy and physically active, such as cooking every
morning, lunch, and night, then cleaning the house and their surroundings. Patient E.D. also
stated that she takes a break after lunch.

Interpretation: Normal
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

K. Sleep and Rest Pattern

Patient E.D, stated that she usually sleeps at 10:00 PM and wake-up at 3:00 AM. Then
she will start now her daily routine. She also stated that she rest after lunch. While she is
admitted to the hospital, he indicated that her sleeping pattern is disrupted by her abdominal
pain, at some day she will sleep at 9:00 pm and will be awaken at 12 or 1:00 pm because she is
uncomfortable, and then she will then sleep at around 3 midnight.

Interpretation: Deviation from normal.

IV. PHYSICAL ASSESSMENT

A. GENERAL SURVEY

GENERAL SURVEY AND MENTAL STATUS

BODY PART/AREA NORMAL ACTUAL INTERPRETATION

TO BE ASSESSED FINDINGS FINDINGS

Signs of distress in No distress noted in The posture of the Deviation from normal
posture and facial posture and facial patient is slumped,
expression expression. and there is distress
noted in her facial
expression

Body build, height, Proportionate and The patient’s body Normal

and weight in varies with lifestyle build, height, and
relation to the weight in relation to
client’s age, lifestyle, the client’s age,
and health lifestyle, and health
is proportionate.

Client’s posture and Relaxed, erect The patient is not Deviation from normal
gait, standing, posture, and relaxed, and she has
sitting, and walking coordinated coordinated
movement movement but she
moves slightly slow
because of her
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

abdominal pain

Client’s overall Clean and neat The patient is clean Normal

hygiene and and neat
grooming

Body and breathe No body/breath odor The patient has no Normal

odor in relation to or minor body odor body and breathe
activity level relative to work or odor.
exercise.

Obvious signs of Healthy Appearance The patient has signs Deviation from normal
health or illness of illness.

Client’s attitude Cooperative The patient is Normal

cooperative.

Client’s Appropriate to The patient’s mood is Normal

affect/mood; assess situation appropriate to the
the appropriateness situation
of the client’s
responses

Client’s quantity, Understandable, The patient exhibit Normal

quality, and moderate pace, thught association,
organization of exhibit thought and her speech is
speech association. understandable.

Relevance and Logical sequence, The patient is aware Normal

organization of makes sense, has of her surroundings,
thoughts sense of reality her thought have
logical sequence and
she has a sense of
reality.

SKIN

Skin color Varies from light to The skin color of the Normal
deep brown, from patient is white but
ruddy pink to light not pale
pink

Uniformity of skin Generally uniform There is a general Normal

 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila
Institute of Health Sciences and Nursing
First Semester, A.Y. 2022 - 2023
color except in areas
exposed to sun; areas
of lighter
pigmentation in dark
skinned
Describe skin lesions Freckles, some birth
marks, flat mark and
raised nevi, no
abrasion or other
lesion.
Skin moisture Moisture in skinfolds
and the axillae,
affected by different
factors.
Skin temperature Uniform; within
normal range.
Presence of edema No edema
Skin turgor When pinched, skin
springs back to
previous state
HAIR
Evenness of growth Evenly distributed
over the scalp hair
Hair thickness or Thick hair
thinness
Hair texture and Silky, resilient hair
oiliness
uniformity of the skin
The patient has Deviation from normal
freckles on the skin,
and bruise.
The skin of the Normal
patient is not dry.
The skin temperature Normal
of the patient is
uniform with normal
body temperature
There is no edema Normal
noted.
The patient’s skin Deviation from normal
took more than 5
seconds before it
springs back to
previous state
The hair is evenly Normal
distributed
The hair of the Deviation from normal
patient is thin
The hair of the Deviation from norma
patient is silky but
not resilient enough.
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

Presence of No infection or There is no infection Normal

infections or infestation and infestation in the
infestations hair of the patient

Amount of body Variable There is enough Normal

hair amunt of body hair

NAIL

Fingernail plate Convex curvature, The patient’s nail is Normal

shape angle between nail convex curvature
and nail is usually
160 degree

Fingernail and Highly vascular and The patient’s Normal

toenail bed color pink in light skinned: fingernail is pink and
dark skinned maybe highly vascular
black or brown

Tissues surrounding Intact epidermis The epidermis Normal

nails surrounding the
fingernail is intact

Fingernail and Smooth texture The fingernail has Normal

toenail texture smooth texture

Blanch test of Prompt return or pink The capillary refill of Normal

capillary refill or usual color on less the client
than two seconds. immediately return
pink color
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

B. MEASUREMENTS

Patient E.D. weight is 53 kilograms, and her height is 157 cm, after computing her body
mass index, the result is 21.5 which is normal and appropriate for her age and her lifestyle.

Vital Signs

Date and Blood Heart Rate Respiration Body O2

Time Pressure Rate Temperature Saturation

November 111/71 74 bpm 19 cpm 36.7° C 94%-95%

07, 2022 mmHg

9:00 am

November 110/60 80 bpm 15 cpm 36.5° C 93%

07, 2022 mmHg

1:00 pm

November 100/70 71 bpm 20 cpm 36.4° C 97%

08, 2022 mmHg

12:00 am

November 110/66 79 bpm 20 cpm 36.7° C 93%

08, 2022 mmHg

9:00 am

November 110/60 87 bpm 20 cpm 37.1° C 93%

08, 2022 mmHg

1:00 pm
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

V. LABORATORY/DIAGNOSTIC EXAM

Patient E.D. had an Ultrasound on her reproductive organ on November 4, 2022. Patient
E.D. is G2P2 2002, which means gravida 2 and parity 2, the patient had two preganancies and
two deliveries that reach the age of gestation. According to the laboratory result of her
ultrasound, Patient E.D.’s uterus is 4.03 × 4.16 × 2.24 cm, and the uterus is Anteverted with a
volume of 19.708 cc. The endometrium is thin, 0.25 cm and hyperechogenic. The endometrial
midline is not defined with regular endometrial myometrial junction and no color on color flow
mapping (score of 1). The diagnosis are Patient E.D. has normal sized menopause anteverted
uterus, thin endometrium, there is an adnexal mass, right probably ovarian in orgin, malignant by
iota simple rules, the chance of benign tumor is 94.7, and the risk of malignancy is 5.3. There is a
gastrointestinal mass, and ascites. The physician who did an ultrasound suggested a correlation
with serum tumor markers for further risk stratification and a gyne-oncologist.
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

VIII. EVIDENCED-BASED NURSING

1. General Question: Can a non-pharmacological method or intervention become a

part of nursing intervention in managing or reducing pain from post-operative
patients aside from administering analgesia?

2. Reconstruction of General Question related to the client’s problem identified

in the RLE.
Which methods or interventions in managing pain among post-operative patients
are more effective: pain relievers or non-pharmaacological intervention?

Patient Focus Intervention Comparison Outcome

Population

This study focuses on Use of pain relievers Non-pharmacological It is shown that

people who prescribed by the intervention such as patients who did not
experience pain from doctor such as distraction or use
post-operative, hence analgesia in relaxation techniques. non-pharmacological
patient managing pain methods had little yet
reduction for significantly more
post-operative pain relief than
patients. patients who used
non-pharmacological
methods.

3. Critical Review with Summary of the Literature

Non-pharmacological methods or intervention is widely used in clinical settings

when it comes to pain reduction. Healthcare provider does not only rely on medications
and drugs in relieving the pain of the patients due to post-surgical. There are only a few
published studies about the use of non-pharmacologic methods in alleviating pain from
post-operation, and mostly non-pharmacologic methods (NPM) are used in chronic pain.
According to Komann, et. al, (2019), non-pharmacologic methods such as acupuncture
offer a small analgesic effect to the post-operative patient. Distraction, another NPM can
 FAR EASTERN UNIVERSITY
Nicanor Reyes Street, Sampaloc, Manila

Institute of Health Sciences and Nursing

First Semester, A.Y. 2022 - 2023

have an analgesic effect as well, it can be compared to having a placebo effect, and music
therapy help in reducing acute post-surgical pain by about 0.5 on a 0 to 10 scale. Some
promising NPM is transcutaneous electrical nerve stimulation (TENS) can help alleviate
pain by 2.5 out of 10, however, analgesia works better. Another NPM is meditation, but it
can only work in noxious situations and it can reduce pain by 40% after meditating for 4
days, the disadvantage of this method is it slow in reducing the pain, and if compared to
pharmacologic intervention, analgesia is still better (Komann, et al., 2019).

In conclusion, pain relievers such as analgesia are effective and work better than
the non-pharmacologic method in reducing the pain of post-operative patients. However,
the researcher suggested that pain relievers can be administered and some of the
mentioned non-pharmacologic methods can be used together with the pain reliever to
have a better outcome because there are NPMs that were proven to be helpful in reducing
pain from post-operative.

Reference:

Komann M, Weinmann C, Schwenkglenks M, Meissner W. Non-Pharmacological Methods and

Post-Operative Pain Relief: An Observational Study. Anesth Pain Med. 2019 Apr
20;9(2):e84674. doi: 10.5812/aapm.84674. PMID: 31341822; PMCID: PMC6612372