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I.

PERSONAL DATA
Name: S. A. Address: Pasay City Age: 21 years old Sex: Male Birthdate: February 5,1989 Birth Place: Manila Civil Status: Married Citizenship: Filipino Religion: Roman Catholic Physician: Dr. Barcelon Admission: 11 01 10 Chief Complaint: Abdominal Pain Diagnosis: Complete Gut Obstruction Secondary to Postoperative Adhesion

Two days prior to admission had sudden onset of abdominal pain with vomiting and fever. No medicines taken until few hours with persistence and increasing severity prompted consult hence admission.

The patient had been hospitalized on 2002 and was diagnosed to have appendicitis. The patient also undergo appendectomy. He had no allergy to any food or drug. Immunization was not remembered.

MATERNAL SIDE (+) Hypertension (-) Diabetes Mellitus Deceased PATERNAL SIDE ( -) Hypertension (-) Diabetes Mellitus Deceased

V. PSYCHOSOCIAL DATA He is known as an occasional alcohol beverage drinker and a smoker and can consume 8 sticks per day

ACTIVITES

BEFORE HOSPITALIZATION Patient drinks 6-8 glasses of water a day and eats nutritious foods like vegetables.

AFTER HOSPITALIZATION Patient increases fluid intake 8-10 glasses of water a day and limits the intake of sweet foods.

ANALYSIS Patient increases fluid intake since the colostomy procedure decreases the reabsorption of fluid from the stool. The patient expel his stool effortless to the colostomy bag which is easier for the patient.

Fluids/ Nutrition

Bowel and The patient is usually Bladder constipated but Eliminatio urinates regularly. n Pattern

The patient could easily expel stool through colostomy bag and urinates regularly.

ACTIVITIES

BEFORE HOSPITALIZATION

AFTER HOSPITALIZATION

ANALYSIS

Sleep- Rest Pattern

During night, the patient was able to sleep and rest but sometimes abdominal pain occurs which makes him feel uncomfortable.

He feels uncomfortable and sometimes couldn t get enough sleep.

Because of his abdominal pain, the patient feels uncomfortable and sometimes is disturbed due to pain. He was not able to perform exercises and sometimes remained sedentary because of feeling uncomfortable.

Activities/ Lifestyle The patient walks to his office everyday and it serves as an exercise.

He was not able to perform exercises and other activities, though he is ambulatory.

ACTIVITIES

BEFORE HOSPITALIZATIO N Patient regularly takes a bath and very particular with his hygiene

DURING HOSPITALIZATIO N Patient takes half bath but still have oral care with the help of his relative.

ANALYSIS

Hygiene

The patient will not be able to perform oral and personal hygiene without the help of his wife, since he feels pain and uncomfortable.

BODY PART
SKIN

TECHNIQUE
Inspection

NORMAL FINDINGS
Uniform brownish color; no skin lesions should be present; warm surface temperature

ACTUAL FINDING
The patient have a tattoo and have an incision on his abdomen

ANALYSIS

HEAD AND FACE

Inspection/ Palpation

Normocephalic & symmetric, smooth skull contour

Rounded, smooth, uniform consistency; symmetrical facial movements. Hair is thin, scalp with flaking and scaling

Normal

BODY PART
EYES & VISION

TECHNIQUE
Inspection

NORMAL FINDINGS
Eyebrows equally distributed & symmetrical, no discharges

CTUAL FINDINGS
Eyebrows symmetrically distributed; eyelashes curled slightly outward; white sclera; symmetric eye movements with briskly reactive pupils; no discharge. Reddish conjunctiva; eyelids with flaking and scaling Normoset ears; pinna recoils easily after it is folded; dry cerumen; brownish in color; responds to perceived sound & verbal commands.

ANALYSIS
Normal

EARS & HEARING

Inspection

Ear should be proportionally set to the head; recoils easily when folded & perceives sound clearly & equally on both ears.

Skin has flaking and scaling..

Normal

BODY PART

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

NOSE & SINUSES

Inspection

Moist, pink to dull red mucosa; patent w/o lesions & discharge

Symmetric; nontender sinuses; Their s NGT attach to his nose. Symmetrical movement of lips and tongue; intact hard and soft palate; Lips have cracks and fissures; slightly dark in color (dark brown);

Normal

MOUTH & OROPHARYNX

Inspection

Lips should be symmetric, pink, moist; symmetrical movement of lips & tongue; no lesion & inflammation

Normal

BODY PART

TECHNIQUE

NORMAL FINDINGS Muscles are symmetrical; lymph nodes not palpable; able to move head in a full range motion w/o discomfort

ACTUAL FINDINGS Neck muscles are equal in size; coordinated and smooth movements without discomfort; No palpable lymph nodes

ANALYSIS

NECK

Inspection/ Palpation

Normal

BODY PART

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS

THORAX & LUNGS

Inspection/ Palpation/ Auscultation

Full & symmetric chest expansion; normal in shape; bilateral symmetry of vocal fremitus; superficial veins are not visible; no masses & tenderness; no adventitious breath sound should be auscultated.

Full & symmetric chest expansion; no adventitious breath sounds are auscultated; no visible superficial veins; no masses or tenderness. Skin is not uniform in color; Skin has scales, flaking and crusting. The patient received O2 via nasal cannula

Normal

When the patient experiencing difficulty in breathing.

ABDOMEN

Inspection/ Palpation/ Auscultation

Flat & slightly rounded abdominal contour; bilaterally symmetrical; uniform in color & pigmentation; no bruits or friction rub auscultated

There is an incision on his abdomen

The incision is caused by his surgery.

BODY PART
MUSCULO-SKELETAL SYSTEM

TECHNIQUE
Inspection

NORMAL FINDINGS
Muscles on both sides of the body are symmetrical; extremities proportional to body size & shape; walks smoothly; muscle strength allows for complete, voluntary joint ROM against gravity & moderate resistance Nail surface is smooth and flat; curved; No brittle edges;

ACTUAL FINDINGS
The patient experiencing muscle weakness. The extremities is proportional to body size

ANALYSIS
The patient experiencing muscle weakness due to his condition.

NAILS

Inspection

Capillary refill less than 3 seconds; no presence of finger clubbing;

Normal

TEST

HEMATOLOGY: DATE PERFORMED: NOV 8 2010 DATE PERFORMED: NOV 8 2010


RESULT

UNIT

REFERENCE RANGE

ANALYSIS

LEUKOCYTES

19.80

10^9/L

5.0-10.0

High level due to a high risk of infection. NORMAL Red blood cell production increases to compensate for low blood oxygen levels due to poor heart or lung function

ERYTHROCYTES HEMOGLOBIN

6.03 17.8

10^12/L g/dl

M: 4.6-6.2 F: 4.2-5.4 M: 12.0-17.0 F: 11.0-15.0

HEMATOCRIT THROMBOCYTES LYMPHOCYTES

53.50 246 4.900

% 10^9/L %

M:40.0-54.0 F:37.0-47.0 150-450 20.0-40.0

NORMAL NORMAL Increased when smaller numbers used, as with bleeding; it fights tumors and viruses NORMAL Elevated due to bone marrow over production of RBC

MONOCYTE GRANULOCYTE

3.200 91.900

% %

0.0-7.0 50.0-70.0

TEST
LEUKOCYTES ERYTHROCYTES

RESULT
5.30 4.37

UNIT
10^9/L 10^12/L

REFERNCE RANGE
5.0-10.0 M: 4.6-6.2 F: 4.2-5.4 M: 12.0-17.0 F: 11.0-15.0 M:40.0-54.0 F:37.0-47.0 150-450 20.0-40.0

ANALYSIS
NORMAL NORMAL

HEMOGLOBIN

13.2

g/dl

NORMAL

HEMATOCRIT

38.70

Low level due to a blood loss NORMAL Decrease production of RBC in the bone marrow NORMAL Elevated due to bone marrow over production of RBC

THROMBOCYTES LYMPHOCYTES

200 19.400

10^9/L %

MONOCYTE GRANULOCYTE

3.200 77.400

% %

0.0-7.0 50.0-70.0

TEST NAME

CONVENTIONAL

REFERENCE RANGE

SI RESULT

REFERENCE RANGE

ANALYSIS

SODIUM POTASSIUM

139mmmol/L 3.8mmol

137-145 3.5-5.1

139mmol/L 3.8mmol/L

137-145 3.5-5.1

NORMAL NORMAL

Test Name

Com. Result
14 1.0 7.8 4.0 3.8 1.1

Unit

Range

SI Result

Unit

Range

Blood Urea Nitrogen Creatinine Total Protein Albumin Globulin (HIGH) A/G Ratio

mg/dl Mg/dl g/dl g/dl g/dl ___

7.00-18.00 0.60-1.30 6.4-8.2 3.4-5.0 3-3.2 1.1-1.6

5.00 88.40 78.00 40.00 38 1.10

mmol/L umol/L g/L g/L g/L ___

2.50-6.4 53.00-115.00 64-82 34-50 30-32 1.1-1.6

PHYSICAL: Color: DARK YELLOW Reaction: 5.5 Transparency: slightly turbid Quantity: 30ml Specific gravity: 1.030 CHEMICAL: ALBUMIN: trace SUGAR: negative ANALYSIS: traces of albumin in the urine may indicate infection.

DATE PERFORMED: NOV 8 2010 FINDINGS: gas dilatation of the small bowel loops noted some air in the colon. Soft tissue densities are remarkable. No abnormal calcification seen. COMMENT: Consider partial small bowel obstruction

FINDINGS: subtle upper and lingular reticular lesions noted. PTB vs. Pneumonia Heart, diaphragms, costophrenic sulci and bony cage are unremarkable. Ngt is in place.

Complete Gut Obstruction Intestinal obstruction is a partial

or complete blockage of the bowel that results in the failure of the intestinal contents to pass through.

Causes - Ileus, a condition in which the bowel doesn't work correctly but there is no structural problem Hernias Impacted feces (stool Foreign bodies (ingested materials that obstruct the intestines) Abnormal tissue growth Symptoms Abdominal distention Abdominal fullness, gas Abdominal pain and cramping Breath odor Constipation Vomiting

Internal hernia

Impairment of the passage of material through the bowel

Cessation of passage of flatus and feces

Distension of the proximal intestine with solids, fluid and gas

Pain, an increase in abdominal girth, and increased tension in the intestinal wall

Necrosis and perforation of the bowel

1. Activation of local and systemic inflammatory responses 2. Translocation of bacteria through the wall of the intestine.

1. Physical exam Your doctor will ask about your medical history and your symptoms. He or she will also do a physical exam to assess your situation. The doctor may suspect intestinal obstruction if your abdomen is swollen or tender or if there's a lump in your abdomen. 2. Imaging tests To confirm a diagnosis of intestinal obstruction, your doctor may recommend abdominal X-ray or computerized tomography (CT) scans. These tests also help your doctor determine if the obstruction is paralytic ileus or if it's a mechanical obstruction, and if it's a partial or a complete obstruction.

1. Hospitalization to stabilize your condition - Placing an intravenous (IV) line into a vein in your arm so that fluids can be given - Putting a nasogastric (NG) tube through your nose and into your stomach to suck air and fluid out to relieve abdominal swelling - Placing a thin, flexible tube (catheter) into your bladder to drain urine and collect it for testing 2. Treatment for a complete mechanical obstruction Complete obstruction, in which nothing can pass through your intestine, usually requires surgery to relieve the blockage. The procedure you undergo will depend on what's causing the obstruction and which part of your intestine is affected. Surgery typically involves removing the obstruction, as well as any section of your intestine that has died. Complete obstruction of the small bowel is preferentially treated with early laparotomy

3. Treatment for a partial mechanical obstruction If you have mechanical obstruction in which some food and fluid can still get through (partial obstruction), you may recover after you've been stabilized in the hospital. You may not require further treatment. Your doctor may also recommend a special low-fiber diet that is easier for your partially blocked intestine to process. If the obstruction does not clear on its own, you may need surgery to relieve the obstruction. 4. Treatment for paralytic ileus If your doctor determines that your signs and symptoms are caused by paralytic ileus, he or she may monitor your condition for a day or two in the hospital. Paralytic ileus is often a temporary condition that gets better on its own. If paralytic ileus doesn't improve within several days, your doctor may prescribe medication that causes muscle contractions, which can help move food and fluids through your intestines.

Name drug
Cefoxitin(Manowel) 1 gram/IV ANST IV q8 Anti infectives; Antibiotic; secondgeneration Cephalosporin

Mechanism of Action
Inhibits bacterial cell wall synthesis by binding to one or more of the penicillinbinding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.

Indication
Peri-operative prophylaxis.

Side Effects/ Contraindication


Nausea; vomiting; diarrhea; hypersensitivity reactions; nephrotoxicity; convulsions; CNS toxicity; hepatic dysfunction; hematologic disorders; thrombophlebitis. Contraindicated to hypersensitivity to cephalosporins.

Nursing Responsibilities
Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Report onset of loose stools or diarrhea. Monitor I&O rates and pattern Report any

Name drug

Mechanism of Action

Indication

Side Effects/ Contraindication

Nursing Responsibilities

Pantoprazole (Pantoloc) 40mg/IV OD Antacids, Antireflux Agents & Antiulcerants. Proton-pump Inhibitor

Inhibits the secretion of hydrochloric acid in the stomach by specific action on the proton pumps of the parietal cells.

Maintenance of healing of GERD associated with history of erosive esophagitis.

Headache, diarrhea. Edema, fever, onset of depression, blurred vision. Contraindicated to patients with known hypersensitivity to any of the constituents of Pantoloc or of the combination partners. Mild gastrointestinal complaints eg, nervous dyspepsia.

-Note indications for therapy, onset, characteristics of symptoms. -Record abdominal assessment, urea breath, or endoscopic findings if available.

Name drug

Mechanism of Action

Indication

Side Effects/ Contraindication Drowsiness, GI Bleeding, Exfoliative, Dermatitis, StevensJohnsons Syndrome, Toxic Epidermal Necrolysis, Anaphylaxis Concurrent use with aspirin may effectiveness, adverse GI effects with aspirin, potassium supplements, corticosteroids, or alcohol, chronic use with acetaminophen may risk of adverse renal reactions, bleeding risk with arnica, chacomile, clove.

Nursing Responsibilities

Ketorolac (Toradol) Nonsteroidal antiinflammatory agents, nonopiod analgesics Every 6 hours

Inhibits prostaglandin synthesis, producing peripherally mediated analgesia, Also has antipyretic and antiinflammatory properties. Antiinflammatory, Pain relief

Analgesia for moderate to severe acute pain. Alternative to Narcotic Analgesic.

(Pre-administration assessment) Patients who have asthma, aspirininduced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions.

Cues Subjective: --Objective: Post surgical incision Risk Factors: Environmental factor Decrease wound healing time Malnutrition (NANDA Edition11)

Nursing Diagnosis Risk for infection related to post surgical incision

Background Knowledge At increased risk for being invaded by pathogenic organisms

Goal After an 8 hours of nursing intervention the client should: Short Term identify the risk factors present in the clients condition client should partially understand the infection and its risk factors Long Term Effective prevention of infection Clients full understanding to the risk of infection

Intervention Assess the clients perception, level of understanding and needs

Rationale to identify and assess the different nursing intervention needed and to be done

Evaluation After the 8 hours of nursing intervention: goals met client have increased his level of understanding about the risks for infection

(NANDA Edition 11)

Obtain clients vital signs and pain scale

- to obtain a baseline data and assess the effectiveness of the nursing intervention - fever maybe secondary to infection