Mr.

Z is a 51-year-old man who has an existing condition of Type 2

Diabetes and was diagnosed with Ulcerative Colitis (UC) 5 months ago.
Within those months, he has been experiencing loose stools with blood.
More so, his weight drastically dropped from 74kgs to 63kgs. After
experiencing severe abdominal pain and cramping his family rushed him
to CLMMRH emergency room around 9:32am last December 1, 2020.
Upon assessment, he verbalizes that he is
scared and anxious because it is his first time
having the surgery. His initial weight is 63kgs
and height of 5 feet and 11 inches. Vital signs
are: BP: 110/80, PR: 80bpm, RR: 16, Temp:
36.8. Diagnostic and laboratory procedures
were done after assessment.
Mr. Z is currently admitted in the surgical ward, bed 2 station 5. His laboratory and
diagnostic results were cleared and he is ready for surgery. Consent form was given to
the folks and preoperative medications were administered. On the day of the surgery,
his vital signs showed a BP of 120/70, PR: 90bpm, RR: 16bpm, O2 SAT: 96%, and
Temperature of 36.8. On the other hand, he lost 10 pounds of weight from the initial
assessment of 63kgs. His folk also stated that he doesn’t have the will to eat any food
and finished only ¼ of the plate. Mr. Z is worrying about his weight loss and what he
would look like after.
More so, he is already experiencing severe pain on the
abdominal area with a pain scale of 9 out of 10 and has
been asking the nurse 3 times already on what to do
with it. He stated that he hasn’t been moving well
because of the pain. He also verbalizes that he is
scared and anxious for the surgery but can’t handle the
pain and is already uncomfortable.
Date Identified: December 1, 2020 at 9:35
am
Patient’s History  The patient has an existing condition of Type 2 Diabetes
and was diagnosed with Ulcerative Colitis (UC) 5
months ago.

 Within those months, he has been experiencing loose

stools with blood.

 Patient’s weight drastically dropped from 74kgs to

63kgs.

 After experiencing severe abdominal pain and cramping

his family rushed him to CLMMRH emergency room
around 9:32am last December 1, 2020

 His folk also stated that he doesn’t have the will to eat
 “Grabe gd ka sakit sang tiyan ko nurse”  “Wala ko gana mag kaon”
   
 “Mga 9 out of 10 guro ang ka sakit”  “Daw grabe gid pag niwang ko”
   
 “Na hadlok ko sa surgery nurse ah”  “Daw ka budlay gd mag giho sa sakit”
   
 “Ma okay lang man ko na diba?”  “Daw hindi gid ko comfortable sa amo ni”

PQRST Pain Assessment:

o P: Started in bowel movements and now every time I
am moving”
o Q: Crampy
o R: Abdomen and Rectum
o S: 9/10
o T: it started from mild pain and gradually worsened
 Abdominal guarding behavior
 Facial grimace noted
 Pain scale of 9/10
 Wong Baker FACES Rating Scale of 8
 Easy fatigability observed
 Weak in appearance
 Pale conjunctiva noted
 Pale mucous membranes noted
 Dry lips noted
Vital Signs:
 Temp: 36.8
 RR: 16 cpm
 PR: 80 bpm
 BP: 110/80 mmHg
 Pale lips observed
 Weight loss of 11kgs noted
 Lethargic in appearance noted
 Poor muscle tone was observed
 Worried face was observed
 Squinting of eyes when moving was observed
 Capillary refill of 2
 Afebrile
 Anicteric
 Height: 1.803m
 Weight: 63 kg
 BMI: 19.37 (Normal)
  Hair
 hair is black with gray streaks  Nose
HEAD    symmetrical, no nasal discharge
 no redness and inflammation
 Face
 with wrinkles, symmetrical  
 pallor noted  Mouth
 dry lips observed
 Eyes  pale lips was observed
 symmetrical, brown in color  slight yellowish teeth observed
 Redness in conjunctiva noted  Pale mucous membranes noted
 
 
 Neck
 Ears  no swelling and no venous
 symmetrical, no presence of distention
discharge or redness
 Normal voice tones are audible to
patient
SKIN dry skin noted
 pallor noted
 has no edema or abrasions
 when pinched, the skin immediately
springs back to the previous state
N AIL S convex curved shape noted
 pink nail beds noted
 when blanched test was
performed, color of the nail of the
client returns into pink in less than
2 seconds

THORAX
 symmetrical anterior chest wall  Abdomen
 Mild tenderness was elicited in the
 Resonance in sound with clear
peri-umbilical region but no
breath sound
palpable abdominal mass,
hepatomegaly or splenomegaly.
 Abdominal pain noted
L IM BS R ECT UM
 Rectal examination was painful,
 Extremities
no palpable rectal mass. The
 Lesions on lower extremities noted rectum appeared to be narrowed
and the examination finger was
stained with frank blood.

GE NITA LIA MENTAL STATE

 no discharges or any bleeding  patient is awake, responsive but
anxious
COM PL ETE B L OOD UR INA LY SIS
COU N T4.45 trillion
 RBC:  Color: Dark
cells/L  WBC: 5,000 amber
 HGB: 14.3 cells/mcL  Clarity: Clear
grams/dL  Platelet:  pH: 4.5  Blood: Negative
 HCT: 47% 250,000/mcL
 Ketones: None  Leukocyte
 Nitrates: Negative Esterase:
Negative
E CG  Protein: Negative
 Bacteria: None
 RR Interval: 0.8 seconds X-RAY
(NORMAL) Yeast: None
 Both lungs are clear and
 P-Wave: 82 milliseconds
expanded with no infiltrates.
(NORMAL)
Heart size normal. (NORMAL)
 PR Interval: 125 milliseconds
Date Identified: December 1, 2020
• “Grabe gd ka sakit sang tiyan ko nurse”
Subjective Cues • “Mga 9 out of 10 guro ang ka sakit”
The following were verbalized • “Na hadlok ko sa surgery nurse ah”
by the patient: • “Ma okay lang man ko na diba?”
• PQRST Pain Assessment:
o P: Started in bowel movements and now every time I am
moving”
o Q: Crampy
o R: Abdomen and Rectum
o S: 9/10
o T: it started from mild pain and gradually worsened
•  “Wala ko gana mag kaon”
•  “Daw ka budlay gid mag giho sa sakit”
•  “Daw hindi gid ko comfortable sa amo ni” 
Objective Cues
• abdominal guarding behaviour
• Facial grimace noted
• irritable at times
• Pain scale of 9/10
• Wong Baker FACES Rating
Scale of 8
• easy fatigability
• ¼ plate of food finished
• Weight of 58 kgs
• BMI of 17.89
• Weak in appearance
• Pale conjunctiva noted
• Pale mucous membranes noted
• Dry lips noted
• Difficulty in changing position
• Limited movement
Focus Problem
Rank 1: PAIN PHYSIOLOGICAL BEHAVIORAL

• ACTUAL • ACTUAL
 Acute Pain related to  Death Anxiety related to
inflammation of the GI the discussion of the
tract epithelial lining possible complications
secondary to of the incoming surgery.
Ulcerative Colitis.
• POTENTIAL
• POTENTIAL  Risk for Hopelessness
 Risk for Ineffective related to death anxiety.
Breathing Pattern
related to Acute Pain.
Focus Problem
PHYSIOLOGICAL BEHAVIORAL
Rank 2:
NUTRITION • ACTUAL • ACTUAL
 Imbalanced nutrition:  Disturbed body image
less than the body related to excessive
requirements related to weight loss.
lack of appetite as
manifested by weight • POTENTIAL
loss.  Risk for Powerlessness
related to perceived
• POTENTIAL lack of control over the
 Risk for Activity situation.
Intolerance related to
generalized weakness.
Focus Problem
Rank 3: PHYSIOLOGICAL BEHAVIORAL
COMFORT • ACTUAL
• ACTUAL
 Alteration in comfort  Mild Anxiety related to
related to abdominal perceived threat to
pain as evidence by health.
facial grimace and
abdominal guarding. • POTENTIAL
 Risk for Ineffective
• POTENTIAL Coping related to
 Risk for sleep changes in health status.
deprivation related to
physical discomfort.
General Objective:
To recognize the physiologic responses of the body to disease conditions—
pathologic, physiologic, and compensatory.

Subjective Cues • “Grabe gd ka sakit sang tiyan ko nurse”

The following were verbalized • “Na hadlok ko sa surgery nurse ah”
by the patient:
• “Mga 9 out of 10 guro ang ka sakit”
• “Ma okay lang man ko na diba?”
• PQRST Pain Assessment:
o P: Started in bowel movements and now every time I am
moving”
o Q: Crampy
o R: Abdomen and Rectum
o S: 9/10
o T: it started from mild pain and gradually worsened
•  “Wala ko gana mag kaon”
•  “Daw ka budlay gid mag giho sa sakit”
Objective Cues:
• abdominal guarding behaviour
• Facial grimace noted
• irritable at times
• Pain scale of 9/10
• • BMI of 17.89
Wong Baker FACES Rating Scale of 8
• easy fatigability • Weak in appearance
• ¼ plate of food finished • Pale conjunctiva noted
• Weight of 58 kgs • Pale mucous membranes noted
• Dry lips noted
• Difficulty in changing position
Nursing • Limited movement
Diagnosis
Acute Pain related to inflammation of the GI tract epithelial lining
secondary to Ulcerative Colitis.
 Inflammation
Inflammation Fluid leak out
Rationale
increases
of the GI tract permeability of the of capillaries
epithelial blood vessels into GI tract
supplying the GI
lining tract wall wall

Swelling Edema
Bowel narrows the
obstruction GI tract and
lumen swelling
The inflammation of the GI tract epithelial lining
starts at the rectum and moves up to the colon that
CRAMPY affects the mucosal and submucosal. Due to
inflammation there is an increase in permeability of
ABDOMI blood vessels wherein swelling begins and leads to
a bowel obstruction that causes the patient to have
NAL PAIN crampy abdominal pain.
Specific Objectives:
Within 8 hours of rendering care at CLMMRH Surgical Ward, the patient will be
alleviated from pain.

Intervention & Rationale

Independent
1. Perform a comprehensive assessment on the location, characteristic,
onset, duration, frequency, quality and severity of pain.
 Assessment is the first step in managing pain, and ensures that the
patient receives pain relief.

2. Determine patient’s perception of pain.

 Provide an opportunity to know how the patient view the pain and
what the pain means to the patient.
Intervention & Rationale
Independent
3. Observe for non-verbal indicators of pain, such as facial grimace, crying, guarding, or
moaning.
 Non-verbal indicators help in proper evaluation of pain.
4. Obtain patient’s vital signs.
 Vital signs are usually affected.

5. Encourage patient to use non-pharmacological pain relief methods such as

relaxation exercises or diversional activities.
 To distract attention and reduce tension.
6. Provide a quiet and therapeutic environment for the patient.
 To prevent additional stressors that can intensify patient’s perception and
tolerance of pain.
Intervention & Rationale
Independent
7. Note presence of anxiety or fear in relation to the preparation
of procedure.
 Concern about the unknown can heighten patient’s
perception of pain.
8. Encourage patient to assume position of comfort.
 To reduce abdominal tension and promotes sense of
control.
9. Provide comfort measures such as back rub and
repositioning.
 To promote relaxation.
Intervention & Rationale
Dependent
1. Provide optimal pain relief by administering prescribed pain
relief medication.
 Doctor’s prescription is important to ensure that the
patient’s pain is managed with drugs that is specified for
them along with the correct dosage.
2. Provide IV fluids as prescribed by the physician.
 To restore or maintain normal fluid volume and electrolyte
balance.
3. Obtaining of CP clearance 
 To ensure that the patient is cleared to undergo surgery
Intervention & Rationale
Collaborative
1. Collaborate with medical technologists to obtain blood 
 To obtain laboratory results that can ensure that the patient
is cleared to undergo surgery as well as have their blood
cross-matched for BT.
2. Refer patient to a physiotherapist 
To provide more specialized care for the patient after they
have undergone surgery.
3. Refer patient to a dietician
To provide a more specific care in terms of the patient’s
nutrition and diet.
Intervention & Rationale
Health Teaching Before
Surgery 1. Obtaining informed consent
 To protect the patient from unsanctioned surgery and indicates
that the client’s decision was made without force or pressure.
2. Explaining pain management
 Instruct patient to take medications as frequently as prescribed
during the initial postoperative period
For postoperative pain relief.
 Instruct patient to notify nurse when unbearable pain is felt.
To notify the physician of the patient’s current condition.
Intervention & Rationale
Health Teaching Before
Surgery
6. Attending to family’s needs.
 Reassure the family they should not judge the seriousness of an
operation by the length of time the patient is in the operating
room.
 Inform those waiting to see the patient after surgery that the
patient may have certain equipment or devices in place
 When the patient returns to the room, provide explanations
regarding the frequent postoperative observations.
 To reduce the anxiety and fear of the patient’s family or
guardian.
Evaluation
After 8 hours of rendering nursing care, patient’s pain is alleviated as
evidenced by:
 Verbalized level of pain as 7 out of 10.
 Less guarding behavior observed.
 Minimal facial grimace noted.
 Able to change position with assistance noted.
  Seldom irritability observed.
Generic Name: Classification:
cefuroxime Pharmacological Classification:
2g PO 6o minutes before surgery Second generation Cephalosporins
Brand Name: Therapeutic Classification:
Ceftin Anti-infectives
Mechanism of Action:
Second-generation cephalosporin that inhibits cell-
wall synthesis, promoting osmotic instability;
usually bactericidal.
Indication:
Is used for surgical prophylaxis, reducing or
eliminating infection.
Side/Adverse Effects:
• GI: Diarrhea, nausea, antibiotic- associated • Hema: Hemolytic anemia
colitis.
• MISC: Anaphylaxis
• Skin: Rash, pruritus, urticaria.
• Urogenital: Increased serum creatinine and
BUN, decreased creatinine clearance.
Nursing Considerations: Before
Administration
• Determine history of hypersensitivity reactions to cephalosporins,
penicillin, and history of allergies, particularly to drugs, before therapy is
initiated.
• Lab tests: Perform culture and sensitivity tests before initiation of
therapy and periodically during therapy if indicated. Therapy may be
instituted pending test results. Monitor periodically BUN and creatinine
Nursing Considerations: During
Administration
 Monitor for manifestations of hypersensitivity. Discontinue drug and report their appearance
promptly.
 Monitor I&O rates and pattern: Report any significant changes.
 Report onset of loose stools or diarrhea. Although pseudomembranous colitis rarely occurs, this
potentially life-threatening complication should be ruled out as the cause of diarrhea during and
after antibiotic therapy.

Nursing Considerations: After Administratio

 Instruct patient to take medication around the clock at evenly spaced times
and to finish the medication completely, even if feeling better.
 Advise patient to report signs of superinfection and allergy.
 Instruct patient to notify health professional if fever and diarrhea develop
Nursing Considerations: Patient & Family
Education
 Tell your doctor and pharmacist what prescription and nonprescription
medications, vitamins, nutritional supplements, and herbal products
you are taking or plan to take. Be sure to mention any of the
following: anticoagulants ('blood thinners') such as warfarin
(Coumadin, Jantoven), cimetidine, diuretics ('water pills'), famotidine
(Pepcid), nizatidine (Axid), omeprazole (Prilosec, in Zegerid),
pantoprazole(Protonix), probenecid (Probalan) and ranitidine
(Zantac). Your doctor may need to change the doses of your
medications or monitor you carefully for side effects.
 If you are taking antacids that contain magnesium or aluminum, take
them at least 1 hour before or 2 hours after cefuroxime.
Generic Name: Classification:
midazolam Pharmacological Classification:
5mg IM 1 hour before surgery Benzodiazepine
Therapeutic Classification:
Brand Name:
Produces anxiolytics, hypnotics, anticonvulsant,
Midazolex
muscle relaxant and amnestic effect.
Mechanism of Action:
Short-acting parenteral benzodiazepine. Intensifies
activity of gamma-aminobenzoic acid (GABA), a major
inhibitory neurotransmitter of the brain, by interfering
with its reuptake and promoting its accumulation at
neuronal synapses. This calms the patient, relaxes
skeletal muscles, and in high doses produces sleep.
Indication:
To relieve anxiety, muscle relaxant and amnesiac effect.
Side/Adverse Effects:
• CNS: Retrograde amnesia, headache, euphoria,• Special Senses: Blurred vision,
drowsiness, excessive sedation, confusion. diplopia, nystagmus, pinpoint
• CV: Hypotension. pupils.
• GI: Nausea, vomiting.
• Respiratory: Coughing, laryngospasm (rare),
respiratory arrest.
• Skin: Hives, swelling, burning, pain, induration at
injection site, tachypnea.
• Body as a Whole: Hiccups, chills, weakness.
Nursing Considerations: Before
Administration
 Obtain vital signs before administration.
 Assess level of consciousness.
 Inspect insertion site during administration.

Nursing Considerations: During & After

Administration
 Monitor blood pressure, pulse, respirations during IM administration
 Assess level of sedation during and for 2-6 hours following.
 The antidote for overdose is flumazenil.
 Monitor vital signs for entire recovery period.
 Be aware that overdose symptoms include somnolence, confusion,
sedation, diminished reflexes, coma, and untoward effects on vital signs.
Nursing Considerations: Patient & Family
Education
 Be prepared for amnesia to prevent an upsetting
postoperative period.
 Review written instructions to assure future
understanding and compliance. Patient teaching
during amnestic period may not be remembered.
Even if dose is small and depth of amnesia is
unclear, relearn information.
Generic Name: Classification:
propofol Pharmacological Classification:
Usual maintenance infusion:
Phenol derivative
3-6 mg/kg/hr IV infusion
Therapeutic Classification:
Brand Name:
Anesthetic
Diprivan
Mechanism of Action:
Propofol is a short-acting anesthetic given for
induction and maintenance of general anesthesia.
Indication:
• Induction and maintenance of general anesthesia
• Sedation
Side/Adverse Effects:
• CNS: Involuntary muscle movements, headache, fever
• GI: nausea and vomiting
• Potentially Fatal: Apnea, bradycardia, hypotension, convulsions;
anaphylaxis, respiratory depression

Nursing Considerations: Before

Administration
• Examining patients' histories for allergies or illnesses that
would affect anesthesia.
• Determining the amount and type of anesthesia needed for
the patient and the best way to administer it.
Nursing Considerations: During & After
Administration
 Patient must be Intubated and ventilated.
 Monitor: HR, ECG, Pulse Ox, BP3. Abrupt discontinuation of infusion may
result in rapid awakening with agitation, anxiety.
 Maintain strict aseptic technique because emulsion will support rapid growth
of microorganisms.
 If hypotension or bradycardia occurs, decrease or stop Diprivan
and monitor BP & HR, notify MD.
 Document neuro assessment on awakening (Ramsey Level of
Sedation Scale).
 Instruct to remain flat on bed.
 Instruct patient to notify nurse if flatulence and belching occurs.
Nursing Considerations: Patient & Family
Education  If you are permitted to leave hospital within hours of the surgery,
don’t try to drive home because your coordination may be
affected by the medication. Ask a relative or friend to pick you
up or take a taxi.
 Avoid taking herbal medicines in the days or weeks following
surgery. Ask your doctor for further information.
 It is important that you get enough rest and exercise. When you
feel tired, stop and rest awhile. Be sure to plan regular naps and
quiet activities.
 Advise the family to see the attending Physician for further
follow-up check-up.
 We were still able to work seamlessly despite it not being the
usual PBL task; on top of that, we were also able to improve in
producing our case scenario in details, to further aid our outputs.
 By having clear communication within the group, the task was
distributed accordingly and all of the members worked hard in
order to complete of their parts on time.
 We were able to procure a sound nursing care plan where even the
cues we dutifully noted and fabricated coordinate well with the
rest of the NCP components. The interventions we chose are
holistic as we carefully considered the different aspects of our
patient along with his condition.
 We were able to prioritize the problems accordingly through
critical thinking and holistic assessment.
 Through this week’s requirement, we were able to hone our
capabilities, review our lessons, and build more of our
teamwork and individual learning as well.
 We understand better the span of our responsibilities in the
area, to ourselves, and with our team.
 We were able to attain our objective of demonstrating a
problem-solving attitude .