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LYCEUM OF THE PHILIPPINES UNIVERSITY- BATANGAS

College of Nursing
Capitol Site, Batangas City
Presented By:
Karen Michelle B. Lecaroz
BSN 3-5

Presented To:
Annabelle Iturralde MD, RN
(clinical Instructor)

DEC 8-12 2008


JAN. 5-9 2009
BATANGAS REGIONAL HOSPITAL
INTRODUCTION
Hemoperitoneum is the presence of blood in the
peritoneal cavity. The blood accumulates in the space between
the inner lining of the abdominal wall and the internal abdominal
organs. Hemoperitoneum is generally classified as a surgical
emergency and in most cases, urgent laparotomy is needed to
identify and control the source of the bleeding. The abdominal
cavity is highly distensible and may easily hold greater than five
liters of blood, or more than the entire circulating blood volume
for an average-sized individual. Therefore, large-scale or rapid
blood loss into the abdomen will reliably induce hemorrhagic
shock and may, untreated, rapidly lead to death.
Data from the World Health Organization indicate that
falls from heights of less than 5 meters are the leading cause of
injury, and automobile crashes are the next most frequent
cause. These data reflect all injuries, not just blunt injuries to
the abdomen.
In this case study, I am eager enough to know and
understand better the disease. It has been chosen as my case
because this is the first time that I encounter this kind of
problem and it is better for me to be educated with its causative
factors as well as the prevention and management to decrease
the mortality and morbidity of the patient whenever
HEMOPERITONEUM occurs.
OBJECTIVES
General Objective:

This study aims to develop and enhance the cognitive,


affective and psychomotor facets of the student nurses to
enable them acquire the information that will harness their
full potentials in rendering quality and competent nursing
care to a patient experiencing HEMOPERITONEUM.
Specific Objective
At the end of the study, the student nurses will be able to:

1. Introduce and understand Hemoperitoneum; its description


and definition.

2. Unfold and analyze the patient’s profile, past medical history,


as well as the family history, personal history, social history,
psychological history and the patient’s history of present
illness for further understanding his condition.
3. Assess the patient using Inspection, Palpation,
Percussion and Auscultation method that may help in
determining the clinical manifestation presented by the
disease.

4. Identify, interpret and analyze the laboratory and


diagnostic examination and its significant findings to
justify the presence of the disease.
5. Identify and enumerate the anatomical part of the body that
is involved and affected by the disease and its respective
functions.

6. Explain and identify the causes and predisposing factors


that contribute to the development of the disease.

7. Formulate and apply Nursing Care Plan for better delivery


of care based on the client’s needs and concerns.
8. Determine the drugs that were administered to the patient
and analyze its relevance in the treatment of the disease.

9. Note changes in the condition of the patient and the degree


of development of his condition

10. Discuss with the patient the discharge planning.

11. Enumerate all the references used to make the case more
effectively and much clearer.
PATIENT’S PROFILE
NAME: Patient X
AGE: 13 years old
SEX: Female
DATE OF BIRTH: January 5, 1995
CIVIL STATUS: Child
ADDRESS: Balibago, Rosario, Batangas
NATIONALITY: Filipino
RELIGION: Roman Catholic
DATE OF ADMISSION: December 8, 2008
ATTENDING PHYSICIAN: Dr. Tenorio/ Lanting/ Ilagan
CHIEF COMPLAINT: high fever and abdominal pain
ADMITTING DIAGNOSIS: Blunt abdominal Injury secondary to
fall
FINAL DIAGNOSIS: Hemoperitoneum secondary to jejunel
perforation secondary to blunt
abdominal injury.
CLINICAL APPRAISAL
Past Health History
The patient’s immunization was completed during
childhood. She has no known allergies to any drugs and
foods. She was never been involved in any accident and
serious injuries. It is her 1st time to be admitted at Batangas
Provincial Hospital. She takes over the counter drugs for
simple illnesses that she usually acquires. Paracetamol for
fever and Neozep for colds.
Family History
She have 2 siblings ages 21 and 25 both working at the
mango farm near to their house. There is no known family
history of heart disease, cancer, diabetes, mental disorders,
PTB, HPN or any communicable disease.

Personal history
She is a 2nd year High school student and fond of
playing with her cousins during weekends. According to her,
she usually eats egg, fish and vegetables and rarely eats pork
and beef. She sleeps for 8 hours a day.
Social History
They lived in a community in which, according to her, can
be considered safe. Their house is made up of cement but
mostly wood and it is located near the mango farm her family is
working. According to her father, their income is just enough to
meet their daily needs.

Psychological History
The major stressor they experience is financial problem,
because their family job is seasonal and sometimes they didn’t
know where to get money to buy food.
History of Present Illness

She was admitted in Batangas Regional Hospital last


December 8, 2008 at exactly 7:50 am with the complaint of
high fever, and abdominal pain. The pain she experience
started prior to admission when she and her cousin where
playing “luksong baka” and accidentally she slipped at her
cousins back and fell on the ground. She vomitted after the
incident.
GENERAL SURVEY
The general appearance of the patient is that she has
good body coordination. Foul mouth odor was noted
because of the poor hygiene of the patient. She is able to
speak and think normally within her age.

As the vital signs were assessed, her blood pressure


is 130/100 mm Hg. Her pulse rate is 88, respiratory rate of 30
and body temperature of 39 °C which indicates high fever.
PHYSICAL
ASSESSMENT
BODY METHOD FINDINGS ANALYSIS
PART
Skin >Inspection >Hot to touch >Abnormal. Hot
skin indicates
fever.

>Evenly colored skin >Normal.


tone.

>Palpation >No pitting edema. >Normal.

>With good skin turgor; >Normal.


pinches easily and
immediately returns to
its original position.
BODY PART METHOD FINDINGS ANALYSIS

Hair >Inspection >Black hair with >Normal.


normal
distribution.

Scalp >Inspection >Absence of >Normal


seborrhea.

>No abrasion. >Normal.


BODY METHOD FINDINGS ANALYSIS
PART
Nails >Inspection >Dirty finger nails seen. >Abnormal. Dirty
fingernails are seen with
poor hygiene.

>With 160o angle between the nail >Normal.


base and the skin.

>Palpation >Hard and immobile. >Normal.

>Smooth and firm. >Normal.

>Nail plate is attached to the nail >Normal.


bed.

>Capillary refill every 2 seconds; >Normal. (Normal=2 – 3


pink tone returns immediately to seconds)
blenched nail beds when pressure
is released.
BODY PART METHOD FINDINGS ANALYSIS
Head >Inspection >Head still and >Normal.
upright.

>Without lesions. >Normal.

>Palpation >Hard and smooth. >Normal.

>Absence of >Normal.
masses or
nodules.

>Head >Normal.
circumference of
52 cm.
Face >Inspection >Facial features >Normal.
and facials
movements are
symmetrical.
BODY PART METHOD FINDINGS ANALYSIS
Eyes
>Eyebrow >Inspection >symmetrically aligned. >Normal.

>equal movements. >Normal.

>Hair evenly distributed. >Normal.

>Eyelashes >Normal distribution. >Normal.

>Conjuctiva >Lower and upper palpebral >Normal


conjunctivas are clear and free of
swelling.

>Palpebral conjunctiva is free of >Normal.


swelling, foreign bodies and trauma.

>Pupils constrict when looking at >Normal.


>Pupillary near object; pupils dilate when
Reaction looking at far object.
BODY METHOD FINDINGS ANALYSIS
PART
Ear >Inspection >Symmetrically aligned. >Normal.

>Smooth with no lesion. >Normal.

>Color of the auricle is >Normal.


same as the face.

>No abnormal discharges. >Normal.

>Palpation >Auricles are mobile, firm >Normal.


and not tender.

>Pinna recoils after being >Normal.


folded.
BODY METHOD FINDINGS ANALYSIS
PART
Nose >Inspection >No abnormal >Normal.
discharges.

>Color is the same as >Normal.


the rest of the face.

>Symmetrically aligned. >Normal.

>Presence of >Abnormal. It is necessary because


Nasogastric tube. it removes stomach contents,
thereby decreasing volume and
pressure of gastric contents and the
chance of aspiration.

>Palpation >Able to sniff through >Normal.


each nostril while other
is occluded.

>No tenderness. >Normal.


BODY PART METHOD FINDINGS ANALYSIS
Sinuses >Palpation >Frontal and >Normal.
maxillary sinuses
and not tender.
Mouth >Inspection >Foul mouth odor >Abnormal. Foul odor of
noted. the mouth can result
from poor oral hygiene
practice.
>Lips
>Crack lips noted. >Abnormal. Because
the patient is in NPO.
>tongue
>Moves freely >Normal.

>At midline >Normal.


>uvula
>Hangs freely >Normal.

>At midline >Normal.


BODY PART METHOD FINDINGS ANALYSIS
Neck >Inspection >Symmetrically aligned >Normal.
with head centered

>Thyroid cartilage, cricoid >Normal.


cartilage and thyroid
gland move upward
symmetrically as the
client swallows.

>Palpation >No enlargement of >Normal.


lymph nodes

>Not tender >Normal.

Thyroid Gland >Inspection >No enlargement of the >Normal.


thyroid gland.

>Palpation >Not tender >Normal.


Trachea >Palpation >At middle of the neck >Normal.
BODY PART METHOD FINDINGS ANALYSIS

Chest and >Inspection >Sternum is positioned at >Normal.


Lungs midline.

>Not using of the accessory >Normal.


muscle when breathing.

>Respirations are relaxed, >Normal.


effortless and quiet.

>Palpation >No tenderness is palpated >Normal.


over the lung area with
respirations.

>No unusual surface >Normal.


masses or lesions are
palpated.

>Auscultation >No adventitious sounds >Normal.


are auscultated.
BODY PART METHOD FINDINGS ANALYSIS
Heart >Inspection >No lift or heave >Normal.

>Auscultation >No murmurs >Normal.


Abdomen >Inspection >Uniform in color >Normal.

>Flat, rounded >Normal.

>Symmetric >Normal.
movements caused by
respiration

>Auscultation >Hypoctive bowel >Abnormal. Hypoactive


sounds. sounds indicate
decreased motility and
peritoneal inflammation.

>Palpation >No tenderness was >Abnormal. Due to


noted at LLQ and peritoneal inflammation
Hypogastric region and and abdominal injury.
sometimes relocating.
BODY PART METHOD FINDINGS ANALYSIS
Upper Extremities
-Arms >Inspection >Arms are bilaterally >Normal.
symmetric
-Hands
>No edema >Normal.

>Presence of IV >Abnormal. Fluids are


- D5LR regulated regulated to replace losses.
at 30 gtts/minute
Lower Extremities
-Legs >Inspection >Legs are free of >Normal.
lesions.

>No edema >Normal.

>Toes, feet and legs >Normal.


are equally warm.

>No vein distention. >Normal.


BODY PART METHOD FINDINGS ANALYSIS

Genitals Inspection >Presence of >Abnormal. It is


Foley Catheter. necessary and
decompresses
bladder prior to
diagnostic
peritoneal lavage
and allow for
urinary output
monitoring as an
index of peripheral
perfusion.
SUMMARY OF PHYSICAL ASSESSMENT

Patient X, the subject of the study is diagnosed with


Hemoperitoneum. Physical Appearance of the patient was
assessed through inspection, palpation, percussion and
auscultation. This will serve as a baseline guide to recognize
the signs and symptoms of the disease.

As I assessed the patient for General Survey I noted


foul odor of the mouth results from poor oral hygiene practice.
Hot skin when touched was noted that indicates fever.
Upon inspecting the nails of the patient, dirty long nails were
seen and these findings are result from poor hygiene
practices.

Nasogastric Tube was seen at bedside and it is


necessary and is used to removes stomach contents, thereby
decreasing volume and pressure of gastric contents and the
chance of aspiration.

The lips of the patient was seen cracked due to


dehydration because the patient is in NPO.
A Hypoactive bowel sound was auscultated that indicates
decreased motility and peritoneal inflammation. Tenderness is
present while palpated due to peritoneal inflammation and
abdominal injury.

There is also a presence of D5LR regulated at 30


gtts/minute was also noted to replace losses.

Lastly, upon inspecting the genitals of the patient there is


a presence of Foley catheter that decompresses bladder prior
to diagnostic peritoneal lavage and allow for urinary output
monitoring as an index of peripheral perfusion.
DIAGNOSTIC
AND
LABORATORY RESULTS
URINALYSIS DATE TAKEN: December 8, 2008

TEST RESULT NORMAL VALUES ANALYSIS


EXAMINATION
Appearance Slightly Turbid Clear Abnormal. May
indicate Urinary
Tract Infection.

Color Yellow Straw, amber Normal.


transparent

pH 6.0 4.5 – 8.0 Normal.

Specific Gravity 1.030 1.005-1.035 Normal.


HEMATOLOGY DATE TAKEN: December 8, 2008

TEST RESULT NORMAL VALUES ANALYSIS


EXAMINATION

Erythrocyte 4.38 x 10 12/L 4.2-5.4 x 10 12/L >Normal.

Hemoglobin 129.7 g/L 120-140 g/L >Normal.

Thrombocyte 247 x 109/L 150-4009/L >Normal.


>MCH 29.62 pg 27-31 pg >Normal.
>MCV 91.27 fl 80-96 fl >Normal.
>MCHC 0.32 0.32-0.36 >Normal.
HEMATOLOGY DATE TAKEN: December 8, 2008

TEST RESULT NORMAL ANALYSIS


EXAMINATION VALUES

Leukocyte 22.52 x 10 9/L 4.5-11 x 10 9/L >Abnormal. Elevated


Leukocyte indicates acute
hemorrhage and infection.

>Neutrophil 0.896% 54-75% >Abnormal. Elevated


neutrophil indicates infection.

>Eosinophils 0.012 % 0.01-0.04% >Normal.


>Basophils 0.005% 0-0.01% >Normal.
>Lymphocytes 0.047% 0.25-0.4% >Normal.
>Monocytes 0.040% 0.02-0.08% >Normal.
December 9, 2008: 8pm
TEST RESULT NORMAL ANALYSIS
EXAMINATION VALUES
Leukocyte 15.77 x 10 9/L 4.5-11 x 10 9/L >Abnormal. Elevated
Leukocyte indicates
acute hemorrhage
and infection.

>Neutrophil 0.882% 54-75% >Abnormal. Elevated


neutrophil indicates
infection.

>Eosinophils 0.010 % 0.01-0.04% >Normal.


>Basophils 0.004% 0-0.01% >Normal.
>Lymphocytes 0.061% 0.25-0.4% >Normal.
>Monocytes 0.043% 0.02-0.08% >Normal.
DATE HEMOGLOBIN HEMATOCRIT ANALYSIS
RESULT RESULT
(120-140 G/L) (0.38-0.47%)

December 8, 128.3 g/L 0.397% > Normal.


2008 8:00 pm

December 9, 122.8 g/L 0.397% > Normal.


2008: 12:00 nn

December 10, 116.5 g/L 0.354% > Normal.


2008: 12 nn

December 10, 117.3 g/L 0.359% > Normal.


2008: 8pm
Date Hemoglobin Hematocrit Analysis
Result Result
(120-140 g/L) (0.38-0.47%)
Pre-operative 120.7g/L 0.371% > Normal.
evaluation
December 10, 2008:
12:15 pm
POST-OPERATIVE 117.6g/L 0.358%
December 11, > Normal.
2008; 12nn
December 11, 114.1 g/L 0.342% >Abnormal.
2008; 8 pm Decrease
hemoglobin level
indicates
dehydration and
hemorrhage.

>Abnormal.
Decrease
Hematocrit level
indicates massive
blood loss.
December 9, 2008
ULTRASOUND

No demonstrable fluid collection is seen in the


hepatorenal and splenorenal angles. Fluid collection
amounting to more than 73.2 cc is noted in the pelvic region.
SUMMARY OF DIAGNOSTIC
AND LABORATORY RESULTS
As the laboratory exam for urinalysis has been released I found
out that the patient’s urine appearance is slightly turbid that may indicate
Urinary Tract infection.
Hematology was also released and I found out that the Leukocyte
and Neutrophil was elevated that indicates acute infection and acute blood
loss. After series of monitoring the hemoglobin and hematocrit level
preoperatively it is in normal range. Postoperatively, the client’s
hemoglobin and hematocrit decreased, that indicates blood loss during the
operation.
As the ultrasound had been released there is a fluid collection
amounting to more than 73.2 cc that is noted in the pelvic region.
Other findings were all normal.
ANATOMY
AND
PHYSIOLOGY
The SMALL INTESTINE, which is coiled in the center of the abdominal
cavity, is divided into three sections.

The upper portion includes the pylorus, the opening at the lower part of
the stomach, through which the contents of the stomach pass into the
duodenum.

The duodenum is a horseshoe-shaped section surrounding part of the


pancreas and the pancreatic duct, as well as ducts from the liver and gall
bladder that open into it.

The middle part of the small intestine, extending from the duodenum to
the ileum, is called the jejunum, and the terminal portion is the ileum, which
leads into the side of the first part of the large intestine, the cecum.
The lining membrane, or mucosa, of the small intestine is especially
suited for the purpose of digestion and absorption.

The mucosa is folded; the folds are covered with minute mucosal
projections called villi.

Each villus is a small tube of epithelium surrounding a small lymphatic


vessel, or lacteal, and many capillaries.

Tiny glandular pits, called the crypts of Lieberkühn, open at the bases
of the villi; these pits secrete the enzymes necessary for intestinal
digestion.
Digested carbohydrates and proteins pass into the capillaries of the villi
and then to the portal vein, which enters the liver; digested fats are
absorbed into the lacteals in the villi, and they are transported through the
lymphatic system into the general bloodstream.

The lining of the small intestine also secretes a hormone called


secretin, which stimulates the pancreas to produce digestive enzymes.
Small intestine
pathophysiology
MODIFIABLE FACTORS NON- MODIFIABLE FACTORS

FEMALE
EATING PATTERN

PLAYING PATTERN 13 YEARS OLD


SOCIO ECONOMIC STATUS
COMPRESSION/ CONCUSSION
ENVIRONMENT FORCES

DIRECT BLOWS OR EXTERNAL COMPRESSION


AGAINST FIXED OBJECT

DEFORM HOLLOW ORGANS AND TRANSIENT TEARS AND SUBCAPSULAR HEMATOMA TO THE
INCREASE INTRALUMINAL PRESSURE SOLID VISCERA

BLUNT TRAUMA TO THE SMALL


INTESTINE(PARTICULARLY TO THE
JEJUNUM)

ACUTE
JEJUNAL PERFORATION ABDOMINAL PAIN
HEMORRHAGE

HEMOPERITONEUM
SUMMARY OF PATHOPHYSIOLOGY
Eating and playing pattern as well as the environment and Socio-
economic status are under modifiable factor. Age, gender and
compression or concussion forces are factors that cannot be modify.
Compression or concussive forces may result from direct blows or
external compression against a fixed object. The force cause tears
and subcapsular hematomas to the solid viscera. These forces also
may deform hollow organs and transiently increase intraluminal
pressure, resulting in rupture. This transient pressure increase is a
common mechanism of blunt trauma to the small intestine. Acute
hemorrhage, jejunal perforation and abdominal pain was felt by my
patient having Hemoperitoneum.
NURSING CARE
PROCESS
ASSESSMENT NURSING SCIENTIFIC PLANNING
DIAGNOSIS EXPLANATION
S> “Ang init po Elevated body Is usually caused After 3 hours of
ng pakiramdam temperature by bacterial nursing
ko ngayon!” related infection invasion as a intervention the
secondary to result of patient will
O> 39°C intra abdominal contamination of maintained body
bleeding. the peritoneum temperature from
>Hot skin through the 39°C to 37°C.
vascular system.
>Irritable (Medical-Surgical
Nursing, Critical
Thinking for
>Poor skin turgor collaborative care,p.
1341)
>tachypneic– 30
breaths per
minute
INTERVENTION RATIONALE
>Determined >Identification and management of underlying cause
precipitating factors. are essential to recovery.(Nursing Care Plan 6th edition,
Gulanic/Myers)

>Assessed Vital >Vital Signs provide more accurate indication of core


signs. temperature. (Nursing Care Plan 6th edition, Gulanic/Myers)

>Measured input and >Fluid resuscitation may be necessary to correct


output. dehydration.(Nursing Care Plan 6th edition, Gulanic/Myers)

>Removed excess >This decreases warmth and increases evaporative


clothing cooling. (Nursing Care Plan 6th edition, Gulanic/Myers)
and covers.

>Provided Tepid >May reduce fever. (Delmar’s Pediatric NCPs 3rd edition,
Luxner)
Sponge Bath.
INTERVENTION RATIONALE EVALUATION

>Maintained >Additional fluids helps prevent >The client’s


fluids: elevated temperature associated with body
-IVF D5LR dehydration. (Nursing Care Plan 6th edition, temperature
regulated at 30 Gulanic/Myers) maintains below
gtts per minute 39°C to 37°C.
as ordered by
the physician.

>Provided >Decreases fever by inhibiting effects


antipyeretic or heat regulating centers and by
medications as hypothalamic action leading to
ordered. sweating and vasodilation (MIMS 7th
edition,2006)
>Paracetamol
30 mg q4.
ASSESSMENT NURSING SCIENTIFIC PLANNING
DIAGNOSIS EXPLANATION
S>”Ang sakit po talaga Acute pain Pain can interfere After 2 hours of
ng tiyan ko!” related to with ventilatory efforts nursing
abdominal when the client has interventions the
O>Pain particularly at injury. an increased oxygen client will
LLQ and Hypogastric demand because of verbalized relief
region. the infectious of pain and may
>Pain while moving
process. (Medical- lessen the pain
>Pain scale of 8 out of 10
Surgical Nursing, Critical scale from 8 to
>referred pain- shoulder Thinking for collaborative
>Direct and rebound 5 out of 10
care,p. 1340)
tenderness.
>39°C
>tachypneic – 30 breaths
per minute.
>restless
>crying
>rubbing the area
>Holding father’s hand
INTERVENTION RATIONALE
>Assessed pain >Assessment of pain
characteristics. experience is the first step in
planning pain management
strategies. (Nursing Care Plan 6th
edition, Gulanic/Myers)

>Some people deny to


>Observed/ monitored sign experience of pain it is present.
(Nursing Care Plan 6th edition,
and symptoms associated with Gulanic/Myers)
pain such as BP, Heart rate,
temp, color and moisture of
skin, restless and ability to
focus.
INTERVENTION RATIONALE

>Assessed for probable cause >Different etiological factors


of pain. respond better to different
therapies. (Nursing Care Plan 6th edition,
Gulanic/Myers)

>Assessed the patient >Some patient may be content


expectations for pain relief. to have pain decreased. (Nursing
Care Plan 6th edition, Gulanic/Myers)

>Responded immediately to >In the midst of painful


complaint of pain. experiences, a patient’s
perception of time may become
distorted. (Nursing Care Plan 6th edition,
Gulanic/Myers)
INTERVENTION RATIONALE
>Provided rest periods to >The patient experiences of
facilitate comfort, sleep and pain may become
relaxation. exaggerated as the result of
fatigue. (Nursing Care Plan 6th
edition, Gulanic/Myers)

>Provided analgesics as >the Patient should receive a


ordered by the doctor. non opioid analgesic around-
>Ketorolac 15 mg q8 the-clock. (Nursing Care Plan 6th
edition, Gulanic/Myers)
EVALUATION
The client verbalized relief of pain and
may lessen the pain scale as evidence
by

>” Hindi na po masyado masakit ang tiyan


ko ngayon kumpara kanina”

>Pain scale of 5 out of 10.


ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC PLANNING
EXPLANATION
O>Foul mouth odor >Self care deficit A state in which the After 5 hours of
related to inability individual nursing
>Inability to go to to perform bathing, experiences an interventions the
CR.
dressing, grooming impaired ability to client will perform
>Pain at the and toileting perform or self-care activities
incision site secondary to complete bathing/ within the level of
postoperative pain. hygiene activities ability with
>Pain while moving for self related to assistance.
pain and discomfort
>Inability to change
postoperatively.
dress for 4 days
(Nursing
Fundamentals, Caring
>Post exploratory
and Clinical Decision
Laparotomy
Making, Rick Daniels,
page 890)
INTERVENTION RATIONALE
>Assessed ability to carry >The patient may only
out activities of daily living, require assistance with
such as dressing, grooming, some self-care measures.
bathing, toileting, (Nursing Care Plan 6th
transferring and ambulating edition, Gulanic/Myers)
on a regular basis.

>Assessed the specific > Different etiological factors


cause of each deficit may require more specific
interventions to enable self
care. (Nursing Care Plan 6th
edition, Gulanic/Myers)
INTERVENTION RATIONALE

>Assisted the patient in accepting >if disease, injury, or illness resulting


necessary amount of dependence. in self-care deficit is recent, the
patient may need to grieve before
accepting that dependence is
necessary. (Nursing Care Plan 6th
edition, Gulanic/Myers)

>Set short-range goals with the >Assisting the patient to set realistic
patient. goals will decrease frustration.
(Nursing Care Plan 6th edition,
Gulanic/Myers)
INTERVENTION RATIONALE
Dressing / grooming >Patients may take longer to
> Provided privacy during dress and may be fearful of
dressing. breaches in privacy.
(Nursing Care Plan 6th
edition, Gulanic/Myers)

Provided frequent >Assistance can reduce


encouragement and energy expenditure and
assistance with dressing as frustration. (Nursing Care
needed. Plan 6th edition,
Gulanic/Myers)
EVALUATION
>The client performs self-care
activities with assistance
within the level of activity.
DRUG STUDY
NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Generic Name: Anti-ulcer Drugs >Active duodenal >Headache
Ranitidine and gastric ulcer.
Hydrochloride >Competitively >Burning and
inhibits action of itching at injection
Brand Name: histamine on the H2 site
Apo-Ranitidine at receptor sites of
parietal cells,
Dose: decreasing gastric
30 mg acid secretion.

Route:
IV

Frequency:
Q8
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >Assess patient for >May increase
patients hypersensitive to abdominal pain. Note creatinine and ALT
drug and those with acute presence of blood in levels.
porphyria. emesis, stool or gastric
aspirate. >May cause false-
>Use cautiously in positive results in urine
patients with hepatic >Drug may be added to protein test using
dysfunction. Adjust total parenteral Multistix.
dosage in patients with solutions.
renal function.
NORMAL VALUES:
Creatinine=18-35
ALT=10-35 u/L
NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Generic Name: >Non-Steroidal >Short term >Headache
Ketorolac Anti-inflammatory management of
Tromethamine Drugs. moderately >Dizziness
severe, acute
Brand Name: >May inhibit pain for single >Drowsiness
Toradol prostaglandin dose treatment.
synthesis, to >Sedation
Dose: produce anti-
15mg inflammatory, >GI pain
analgesic and
Route: antipyeretic >Constipation
IV effects.
>Vomitting
Frequency:
Q8 >Pain at injection
site
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >Correct hypovolemia >May increase ALT and
patients hypersensitive before giving. AST levels.
to drug and in those
with active peptic >ALERT: the maximum >May increase bleeding
disease; recent GI combined duration of time.
bleeding or perforation, parenteral and oral
advance renal therapy for 5 days.
impairment,
cerebrovascular >When appropriate,
bleeding, hemorrhagic give by deep IM
diarthresis, or injection. Patient may NORMAL VALUES
incomplete hemostasis, feel pain at injection ALT= 10-35 unit
and in those at risk for site. Put pressure on Bleeding Time= 3-10
renal impairment from site for 15-30 seconds minutes
volume depletion or at after injection to
risk for bleeding. minimize local effects.
NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Generic Name: >Peri-operative >Fever
Cefotaxime Cephalosporins prevention in
Sodium contaminated >Headache
3rd generation surgery
Brand Name: cephalosporin that >Dizziness
Claforan inhibits cell wall
synthesis,
Dose: promoting osmotic
500 mg instability; usually
bactericidal.
Route:
IV
Frequency:
Q8
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >Before giving drugs, >May increase alkaline
patients hypersensitive ask the patient if he is phosphate, ALT, AST,
to drug or other allergic to penicillins or bilirubin, GGT and LDH
cephalosporin. cephalosporins. levels.

>Use cautiously in >Obtain specimen >May increase


patients hypersensitive culture and sensitivity eosinophil count. May
to penicillin because of test before giving. decrease granulocyte,
possibility of cross Therapy may begin neutrophil and platelet
sensitivity with other pending results. count.
beta- lactam antibiotics

NORMAL VALUES
ALT=10-35 unit
AST=15- 30 U/L
Prognosis
The prognosis is fair although the client’s pain
has subsided, there is still a risk for infection at the
incision site.

Because of the continuous care that is given to


the client, Patient X’s condition has improved.
DISCHARGE PLANNING

M Instructed the significant others to give home medications that the physician
will prescribe upon discharge.

E Encouraged the patient to ambulate for her fast recovery.


Emphasized client to have a clean and safe environment.

T Advised client and significant others to clean the incision site to prevent
further complications.

H Advised the client to provide good personal hygiene of the client.


O Encouraged the patient to have a follow-up check-up after one week.

D Advised relatives to have the client eat foods that are good for her health
and need for her body requirements.

S Advised the client and significant others to keep her faith in GOD and

never forget to ask guidance and support from our Lord.


ACKNOWLEDGEMENT
I am extending my deepest and heartfelt gratitude to those
who patiently helped me in fulfilling this task and to whom who I
owe this success of my endeavor.

First, to our Almighty God, for the knowledge and wisdom he


showered upon us; for His continuing guidance, for giving us
the strength to overcome our trials and for every little thing He’d
done for us.
To my family, for assisting me in my needs, financially and
emotionally; for being there whenever I need them, for staying
on our side through ups and downs and most of all for making
us responsible individuals.

To the patient, especially to her mother for allowing me to


make the study of her child’s illness. My Patient who is
suffering from deprivation of health and are ailing, they are the
reasons why this study was conducted, though no bad intents
of continued agony is felt.
To the different theorists and authors that influenced the large
arena of patient care, differentiating nursing among other
profession in dealing with its clientele. Their works served as
basis of this study.

To my clinical instructor, Dra. Anabelle Iturralde, for giving


necessary inputs towards providing descent and theory-based
care to the patients. Also, for the guidance during our duty in
Batangas Regional Hospital.

To my friends and to all the important persons in my life.


For suggestions they gave for the enrichment of this work.
THANK YOU VERY MUCH!!!
bibliography
Delmar’s Pediatric NCPs 3rd edition, Luxner
Essentials of Surgery: Scientific Principles and Practice. Hagerstown, MD:
Lippincott Williams & Wilkins. p. 209.
http://emedicine.medscape.com/article/821995-overview
en.wikipedia.org/wiki/Inferior_mesenteric_artery
www.wikipedia.org/wiki/ligament of Treitz
www.med.unc.edu/medicine/web/hemoperitoneum.pdf
MIMS 7th edition,2006
Nursing Care Plan 6th edition, Gulanic/Myers
www.med.unc.edu/medicine/web/hemoperitoneum.pdf
Brunner & Suddharth’s textbook of Medical-Surgical Nursing Eleventh Edition,
Smeltzer,et.al.p.2532
Medical-Surgical Nursing, Critical Thinking for collaborative care,p. 1341