Case Study Intestinal Obstruction 5h74x

Our Lady of Fatima University College of Nursing Valenzuela Campus

Intestinal Obstruction Partial Probably sec to Colonic Malignancy In Partial Fulfillment of requirements of NCM 107B RLE leading to the degree of Science in Nursing

A Case Study Presented to: Ms. Vanessa O. Umali, R.N. MAN

Presented by: Maria Paula M. Bungay July 26, 2015 TABLE OF CONTENTS

I. Introduction II. Objectives III. Patient’s Profile IV. Anatomy and Physiology V. Pathophysiology VI. Laboratory Examination Results VII. Gordon’s Assessment VIII. Nursing Care Plans IX. Drug Study X. Health Teachings

I. Introduction

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In the present generation, we cannot deny the reality that different diseases sprout as life progresses. The world is in the generation where diseases are widespread and the medical fields are doing their further research in order to stop them. Being responsible for one’s health is very important for it builds the foundation of a healthy body. It is our choice to live a disease free body. It is always our choice of what food will you eat, how much sleep you need, etc. There are a lot of fashion trends in the world that will make each individual’s life a masterpiece, but the best fashion trend at present is a fit, healthy body. Intestinal obstruction is significant mechanical impairment or complete arrest of the age of contents through the intestine. Symptoms include cramping pain, vomiting, constipation, and lack of flatus. Diagnosis is clinical, confirmed by abdominal x-rays. Treatment is fluid resuscitation, nasogastric suction, and, in most cases of complete obstruction, surgery. According to Bordeianou and Yeh of Wolters Kluwers, Bowel obstruction occurs when the normal flow of intraluminal contents is interrupted. Obstruction can be functional (due to abnormal intestinal physiology) or due to a mechanical obstruction, which can be acute or chronic. Advanced small bowel obstruction leads to bowel dilation and retention of fluid within the lumen proximal to the obstruction, while distal to the obstruction, as luminal contents , the bowel decompresses. If bowel dilation is excessive, or strangulation occurs, perfusion to the intestine can be compromised leading to necrosis or perforation, complications, which increase the mortality, associated with small bowel obstruction. The most common causes of mechanical small bowel obstruction are postoperative adhesions and hernias. Other etiologies of small bowel obstruction include disease intrinsic to the wall of the small intestine (eg, tumors, stricture, intramural hematoma) and processes that cause intraluminal obstruction (eg, intussusception, gallstones, foreign bodies). Acute, mechanical small bowel obstruction is a common surgical emergency. It is estimated that over 300,000 laparotomies per year are performed in the United States for adhesion-related obstructions. Ischemia, which complicates 7 to 42 percent of bowel obstructions, significantly increases mortality associated with bowel obstruction. The small bowel is involved in about 80 percent of cases of mechanical intestinal obstruction. The incidence is similar for males and females. In one Polish study of adult

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patients, the average age of patients with acute obstruction was 64 years, women comprised 60 percent of the group, and the small bowel was affected in 76 percent. In addition, I have learned and gained new knowledge regarding on Intestinal obstruction. The in-depth understanding of the etiology, pathophysiology, clinical manifestations, diagnosis, treatment and prevention of this condition has yield and enhanced my acquired knowledge. As a student nurse, I also believed that actual interaction with the patient who has the condition being studied can make it easier to understand. Also, to be able to learn completely, one must be able to know how the concepts learned be applied into the actual clinical practice. The knowledge I acquired through this study will give me the opportunity to improve my capability to deliver efficient and appropriate interventions and information to a variety of population. The knowledge, skills and attitude that comprise an effective nurse will be of high regard to promote a reduction in the morbidity and mortality rate. (http://www.uptodate.com/).

II. Objectives Nurse-Centered

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After the completion of this case study, the nurse will be able to: 1.

Understand the current statistics and latest trend regarding Intestinal Obstruction partial probably sec to Colonic Malignancy.

2.

Describe factually, the personal and pertinent family history of the patient and relate it to the present condition.

3.

Perform comprehensive physical assessment.

4.

Trace the book-based and client-centered pathophysiology of Intestinal Obstruction partial probably sec to Colonic Malignancy.

5.

Determine the predisposing and precipitating factors and the signs and symptoms and relate to the disease process.

6.

Enumerate and describe the diagnostic and laboratory procedures as well as the nursing responsibilities in relation to the disease condition

7.

Enumerate the different treatment modalities and their indication specifically for the patient’s condition.

8.

Identify the pharmacologic treatment provided to the patient, relate the actions of each drug with the disease process and evaluate the patient’s response to the medications given.

9.

Identify nursing diagnoses, formulate short-term goals, carry out appropriate interventions and evaluate the plan.

10. Appraise the effectiveness of medical and surgical nursing management in treating the patient. 11. List the preventive measure for the occurrence of Intestinal Obstruction partial probably sec to Colonic Malignancy for the benefit of the general public. Patient –Centered After the completion of this case study, the patient will be able to: 1. Report understanding of the disease process. 2. Understand the indications of the different diagnostic procedures and medical management involved in her care. 3. Cooperate with the necessary medical and nursing interventions. 4. Adhere with the health teachings provided. 5. Understand the different ways of health promotion and prevention in relation to the disease condition.

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6. Demonstrate improved conditions as evidenced by absence of further complications. III. Patient’s Profile Name: Mr. Isaw Age: 62 years old Birthday: February 18, 1952 Nationality: Filipino Religion: Roman Catholic Civil Status: Married Date ission: July 2, 2015 Time of ission: 12:15 PM Chief Complaint's: Abdominal Pain Initial Diagnosis: Intestinal Obstruction Partial Probably sec to Colonic Malignancy Final Diagnosis: None

HISTORY OF PAST ILLNESS During the previous years, Mr. Isaw was diagnosed Hypertensive in 2014 and a history of vehicular accident 20 years ago, which affected his Left femur. He is a non-smoker and non-alcoholic. As for childhood illness, he had chicken pox and measles. He also experienced coughs and colds for common illness. To relieve symptoms, he would take different herbal plants or purchase over-the-counter drugs. For the herbal plants, he prepares decoction with one to two glasses of water for fifteen minutes or until one half of the liquid is left. Then, he will drink it. He also experienced fever once in a while in which he takes over-the-counter drugs. Mr. Isaw, has no family history of hypertension, Diabetes, Arthymias, Pulpomonary Tuberculosis, and Cancer. For food allergies, crab and shrimp are contraindicated but no allergies to drugs. HISTORY OF PRESENT ILLNESS Prior to ission, Mr. Isaw complained of sudden onset abdominal pain described as bloatedness more prominent in the epigastric and right periumbilical area. There was no

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associated nausea, vomiting, change in bowel habits, hematochezia, melena, jaundice and fever. Patient consulted at PGH, Abdominal X-ray revealed dilated small bowels. He was then referred to the institution for further management. PHYSICAL ASSESSMENT Physician’s Physical Assessment done by the Resident on Duty (July 2, 2015, lifted from the patient's chart) Height: 5’6 Weight: 81 kg Vital Signs as follows: T: 36.9 °C

PR: 116 bpm

RR: 18m

BP: 150/90 mmHg

SAO2: 97%

GENERAL SURVEY Mr. Isaw, Assessed/received patient lying on bed, awake, conscious, responsive, and coherent. With the following vital signs: Temperature: 36.7 °C Heart rate: 70 bpm Respiratory rate: 20 bpm Blood Pressure: 140/90 mmHg SAO2: 96% NUTRITIONAL STATUS Upon ission, Mr. Isaw was placed on NPO and IVF of D5LR 1 x Q8. CBC, BT, PTPTT, FBS, BUN, CREA, Na, K, Cl, 12-LECG, Chest X-ray PA, abdominal series, and Urinalysis were requested. NGT and Foley Catheter were inserted.

SKIN

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> Pallor noted. > Good skin turgor in both upper and lower extremities; the skin returns to its previous state immediately after being tented. > warm moist skin, no active dermatoses. HAIR > Hair is black and is evenly distributed. > Silky and smooth hair. > No areas of hair loss noted. > Thick hair strands. NAILS > Trimmed clean nails. > Concave shaped; with a nail plate angle of about 160 degrees. > Smooth in texture. > Intact epidermal lining around the nails. > Capillary Refill Test less than 3 seconds. SKULL AND FACE > Rounded (normocephalic and symmetrical with frontal, parietal and occipital prominences). > Head has no cervical lymphadenophaties > No nodules or masses upon palpation. EYES AND VISION

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> Eyebrows and eyelashes are evenly distributed. > Eyelids are intact > Pink palpebral conjuctiva > Sclera appears white. > Pale conjunctiva. > No discharges and discoloration noted. > Blink reflex intact. EARS AND HEARING > Ears are symmetrical in size and in line with the outer canthus of the eyes. > Color of ears is the same with the facial skin. > No discharges and foul odor noted upon inspection. > Pinna and ear canal are clean. > Auricles are firm and recoil to previous state when folded. > No nodules or masses noted upon palpation NOSE AND SINUSES > No nasal discharge > No tenderness masses and pain noted upon palpation OROPHARYNX (Mouth and Throat) > Dry and pale lips noted upon inspection > Tongue is able to move freely

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> Good oral hygiene. > Thyroid gland moves with deglutition NECK > Jugular vein is not visible > Muscles are equal in size with the head centered > Slow muscle movement > Lymph nodes are not palpable CARDIOVASCULAR AND PERIPHERAL SYSTEM > Skin color of palm of the hand and feet is pink. > Pink nail beds upon inspection. > Symmetric pulse volumes, full pulsations of peripheral pulses. > Heart rate is 70 beats per minute. > Blood Pressure is 140/90 mmHg > (Vital signs taken during the time of assessment July 2, 2015 at 0715H) RESPIRATORY SYSTEM > + DOB > Symmetric chest expansion > Skin and chest wall are intact and has uniform temperature > No tenderness and masses noted upon palpation > Regular breathing pattern

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> Presence wheezing and crackles sound upon auscultation > Full and symmetric chest wall expansion BREAST AND AXILLAE > Breasts are symmetrical in size; color is the same as with the abdomen. > Both nipples are symmetrical in size. > No discharges noted. > No tenderness, masses, and nodules noted upon palpation. ABDOMEN > Direct tenderness at epigastric area. > Abdominal skin is intact. > Distended abdomen noted. > Audible bowel sound upon auscultation. > Abdominal dullness upon percussion. MUSCULOSKELETAL > Posture is good, able to stand straight and can walk alone properly but slowly > Scar at left thigh and right medial leg and foot NEUROLOGIC >with a GCS of 15 > Patient has times of looking in the distance and is slow in response when a question asked.

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> Patient was able to answer well when asked of her complete name, birth date and age. URINARY SYSTEM > Patient has indwelling Foley Catheter REPRODUCTIVE SYSTEM > The patient refused to be assessed with her external reproductive organ but she verbalized that she has minimal vaginal bleeding and complain of pain when secretions are expelled. REVIEW OF SYSTEM Integumentary System The patient has no history of bruises in both upper and lower extremities. Head The patient had no history of any form of head injuries. Eyes Patient had no history of any eye problems. Ears and Hearing Patient had no history of smelly discharges on both ears, and no complaints of hearing impairment. Breast and Axillae The patient had no history of breast nodules, no enlargement, no tenderness, no pain and unusual discharges. Respiratory System

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The patient has no history of asthma or other respiratory problems. Cardiovascular System The patient has a history of hypertension. Genitourinary System The patient had no history of any genital problems. Usually urinates 5 times a day. Gastrointestinal System The patient had experienced abdominal pain. Musculoskeletal System Patient has no history of t pain. Neurologic System Patient had no history of any major mental problems.

Cranial Nerve Assessment:

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CRANIAL NERVE

ASSESSMENT TECHNIQUE

EXPECTED OUTCOME

ACTUAL FINDINGS

I: Olfactory Type: Sensory Function: Smell

Ask the client to identify a scented object that you are holding.

Client is able to identify different smell with each nostril separately and with eyes closed unless such condition like colds is present.

The client was able to identify the aromas of cologne and alcohol that she had smelled.

II: Optic Type: Sensory Function: Vision

Provide adequate lighting and ask client to read words on a newspaper held at a distance of 36 cm (14 inches) with each eye first then both eyes.

The client should be able to read with each eye and both eyes.

The client was able to read the words in the newspaper at 14 inches.

III: Oculomotor, IV: Trochlear & VI: Abducens Type: Motor Function: Upward and Downward movement of Pupils.

-Hold a penlight 1 ft. -Client’s eyes should in front of the client’s be able to follow the eyes. Ask the client to penlight as it moves. follow the movements of the penlight with the eyes only. Move the penlight upward, downward, sideward and diagonally. -Ask the client to look straight ahead then approach the pupil with a penlight and observe for pupil constriction.

-The client’s eyes will have a normal reaction for PERRLA.

-Both eyes of the client were able to follow the Penlight’s movements.

-The client had a normal reaction to PERRLA as Pupils are equally round, reactive to light and accommodation.

V: Trigeminal Type: Sensory Function: Sensation of cornea

While client looks upward, lightly touch the lateral sclera of eye to elicit blink reflex.

Client should have a positive corneal reflex.

The client was able to elicit corneal reflex.

VII: Facial Type: Motor Function: Facial movements

Ask client to: smile, frown and wrinkle forehead, show teeth, puff out cheeks,

Client should smile, frown and wrinkle forehead, show teeth, puff out cheeks,

The client was able to do the facial movements symmetrically.

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purse lips, raise eyebrows, close eyes tightly against resistance

purse lips, raise eyebrows, close eyes tightly against resistance. Movements are symmetrical.

VIII: Vestibulocochlear/ acoustics Type: Sensory Function: Hearing

Have the Client occlude one ear. Out of the client’s sight, place a tickling watch 2 cm. Ask what the client can hear and repeat with the other ear.

Client should be able to hear the ticking of the watch in both ears.

The client was able to hear the ticking of the watch in both ears.

IX. Glossopharyngeal & X: Vagus Type: Motor Function: Swallowing and Speaking

Ask the client to swallow and say its name.

The client should be able to swallow without difficulty and speak audibly.

The client was able to swallow without difficulty and speak audibly.

XI. Spinal Accessory Type: Motor Function: strength and resistance

-Ask client to shrug the shoulders against your hands.

-There is symmetric, strong contraction of the trapezious muscles.

The client was able to symmetrically contract the trapezious muscle.

-Ask client to turn the head against resistance, first to the right then to the left, to assess the sternocleidomastoid muscle.

-There is strong contraction of the sternocleidomastoid muscle on the side opposite to the turned face.

-The client was able to contract strenocleidomastoid muscleon the side opposite to the turned face.

Ask the client to protrude the tongue and move in different directions.

The client will be able to protrude her tongue and move in different directions.

The client was able to protrude his tongue and move it in different directions.

XII: Hypoglossal Type: Motor Function: Movement and strength of tongue

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IV. Anatomy and Physiology The digestive system, sometimes called the gastrointestinal tract, alimentary tract, or gut, consists of a long hollow tube which extends through the trunk of the body, and its accessory structures: the salivary glands, liver, gallbladder, and pancreas. The digestive tract is divided into two sections, the upper tract, consisting of the mouth, esophagus, and stomach, and the lower tract, consisting of the intestines. FIGURE 20-1 Anatomy of the digestive system with associated events.

Inside this tube, ingested food and fluid, along with secretions from various glands, are efficiently processed. First, they are broken down into their separate constituents; then the desired nutrients, water, and electrolytes are absorbed into the blood for use by the cells, and waste elements are eliminated from the body. Within this system, the liver can reassemble the

component nutrients into new materials as they are needed by the body. For example, the proteins in milk are digested by enzymes in the digestive tract, producing the component amino acids, which are then absorbed into the blood. The individual amino acids are used by the liver cells to produce new proteins, such as albumin or prothrombin, or they may circulate as they are in the amino acid pool in the blood to be taken up by individual cells as necessary. The peritoneal cavity refers to the potential space between the parietal and visceral peritoneum. A small amount of serous fluid is present in the cavity to facilitate the necessary movement of structures such as the stomach. Numerous lymphatic channels drain excessive fluid from the cavity. Because serous membranes are normally thin, somewhat permeable, and highly vascular, the peritoneal membranes are useful as an exchange site for blood during peritoneal dialysis in patients with kidney failure. However, such an extensive membrane may also facilitate the spread of infection or malignant tumor cells throughout the abdominal cavity or into the general circulation. The mesentery is a double layer of peritoneum that s the intestines and conveys blood vessels and nerves to supply the wall of the intestine. The mesentery attaches the jejunum and ileum to the posterior (dorsal) abdominal wall. This arrangement provides a balance between the need for of the intestines and the need for considerable flexibility to accommodate peristalsis and varying amounts of content. The greater omentum is a layer of fatty peritoneum that hangs from the stomach like an apron over the anterior surface of the transverse colon and the small intestine. The lesser omen-tum is part of the peritoneum that suspends the stomach and duodenum from the liver. When inflammation develops in the intestinal wall, the greater omentum, with its many lymph nodes, tends to adhere to the site, walling off the inflammation and temporarily localizing the source of the problem. Inflammation of the omentum and peritoneum may lead to scar tissue and the formation of adhesions between structures in the abdominal cavity, such as loops of intestine, restricting motility and perhaps leading to obstruction. Intestinal Obstruction Intestinal obstruction refers to a lack of movement of the intestinal contents through the intestine. Because of its smaller lumen, obstructions are more common and occur more rapidly in the small intestine, but they can occur in the large intestine as well. Depending on the cause and location, obstruction may manifest as an acute problem or a gradually developing situation. For example, twisting of the intestine could cause sudden total obstruction, whereas

a tumor leads to progressive obstruction. FIGURE 20-37 Colostomy. A, sigmoid colostomy-a surgically created opening into the colon through the abdominal wall. B, The stoma is the new opening on the abdomen. It is always red and moist, is not painful, but may bleed easily. C, A plastic pouch to collect stools is attached to the stoma. (Courtesy of Hollister Incorporated, Patient Education Series.)

Intestinal obstruction occurs in two forms. Mechanical obstructions are those resulting from tumor, adhesions, hernias, or other tangible obstructions. Functional, or adynamic, obstructions result from neurologic impairment, such as spinal cord injury or lack of propulsion in the intestine, and are often referred to as paralytic ileus. While the end result can be the same, these types manifest somewhat differently and require different treatment.

Colon The colon is the last part of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided (largely bacteria) fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a major role in absorption of foods and nutrients. However, the colon does absorb water, potassium and some fat soluble vitamins. In mammals, the colon consists of four sections: the ascending colon, the transverse colon, the descending colon, and the sigmoid colon (the proximal colon usually refers to the ascending colon and transverse colon). The colon, cecum, and rectum make up the large intestine. The location of the parts of the colon are either in the abdominal cavity or behind it

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the retroperitoneum. The colon in those areas is fixed in location. Arterial supply to the colon comes from branches of the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). Flow between these two systems communicates via a "marginal artery" that runs parallel to the colon for its entire length. Historically, it has been believed that the arc of Riolan, or the meandering mesenteric artery (of Moskowitz), is a variable vessel connecting the proximal SMA to the proximal IMA that can be extremely

important if either vessel is occluded. However, recent studies conducted with improved imaging technology have questioned the actual existence of this vessel, with some experts calling for the abolition of the from future medical literature. Venous drainage usually mirrors colonic arterial supply, with the inferior mesenteric vein draining into the splenic vein, and the superior mesenteric vein ing the splenic vein to form the hepatic portal vein that then enters the liver. Lymphatic drainage from the entire colon and proximal two-thirds of the rectum is to the paraaortic lymph nodes that then drain into the cisterna chyli. The lymph from the remaining rectum and anus can either follow the same route, or drain to the internal iliac and superficial inguinal nodes. The pectinate line only roughly marks this transition. Ascending colon The ascending colon, on the right side of the abdomen, is about 25 cm long in humans. It is the part of the colon from the cecum to the hepatic flexure (the turn of the colon by the liver). It is secondarily retroperitoneal in most humans. In ruminant grazing animals, the cecum empties into the spiral colon. Anteriorly it is related to the coils of small intestine, the right edge of the greater omentum, and the anterior abdominal wall. Posteriorly, it is related to the iliacus, the iliolumbar ligament, the quadratus lumborum, the transverse abdominis, the diaphragm at the tip of the last rib; the lateral cutaneous, ilioinguinal, and iliohypogastric nerves; the iliac branches of the iliolumbar vessels, the fourth lumbar artery, and the right kidney. The ascending colon is supplied by parasympathetic fibers of the vagus nerve (CN X). Arterial supply of the ascending colon comes from the ileocolic artery and right colic artery, both branches of the SMA. While the ileocolic artery is almost always present, the right colic may be absent in 5–15% of individuals. Transverse colon The transverse colon is the part of the colon from the hepatic flexure to the splenic flexure (the turn of the colon by the spleen). The transverse colon hangs off the stomach, attached to it by a wide band of tissue called the greater omentum. On the posterior side, the transverse colon is connected to the posterior abdominal wall by a mesentery known as the transverse mesocolon. The transverse colon is encased in peritoneum, and is therefore mobile (unlike the parts of the colon immediately before and after it). Cancers form more frequently further along the large intestine as the contents become more solid (water is removed) in order to form feces. The proximal two-thirds of the transverse colon is perfused by the middle colic artery, a branch of SMA, while the latter third is supplied by branches of the IMA. The "watershed" area

between these two blood supplies, which represents the embryologic division between the midgut and hindgut, is an area sensitive to ischemia. Descending colon The descending colon is the part of the colon from the splenic flexure to the beginning of the sigmoid colon. The function of the descending colon in the digestive system is to store food that will be emptied into the rectum. It is retroperitoneal in two-thirds of humans. In the other third, it has a (usually short) mesentery. The arterial supply comes via the left colic artery. Sigmoid colon The sigmoid colon is the part of the large intestine after the descending colon and before the rectum. The name sigmoid means S-shaped (see sigmoid). The walls of the sigmoid colon are muscular, and contract to increase the pressure inside the colon, causing the stool to move into the rectum. The sigmoid colon is supplied with blood from several branches (usually between 2 and 6) of the sigmoid arteries, a branch of the IMA. The IMA terminates as the superior rectal artery. Sigmoidoscopy is a common diagnostic technique used to examine the sigmoid colon. Redundant colon One variation on the normal anatomy of the colon occurs when extra loops form, resulting in a longer than normal organ. This condition, referred to as redundant colon, typically has no direct major health consequences, though rarely volvulus occurs resulting in obstruction and requiring immediate medical attention.[4] A significant indirect health consequence is that use of a standard adult colonoscope is difficult and in some cases impossible when a redundant colon is present, though specialized variants on the instrument (including the pediatric variant) are useful in overcoming this problem. Standing gradient osmosis Water absorption at the colon typically proceeds against a transmucosal osmotic pressure gradient. The standing gradient osmosis is a term used to describe the reabsorption of water against the osmotic gradient in the intestines. This hypertonic fluid creates an osmotic pressure that drives water into the lateral intercellular spaces by osmosis via tight junctions and adjacent cells, which then in turn moves across the basement membrane and into the capillaries. Functions of the Colon

There are differences in the large intestine between different organisms, the large intestine is mainly responsible for storing waste, reclaiming water, maintaining the water balance, absorbing some vitamins, such as vitamin K, and providing a location for flora-aided fermentation.Vitamin K is essential as a coagulation factor. By the time the chyme has reached this tube, most nutrients and 90% of the water have been absorbed by the body. At this point some electrolytes like sodium, magnesium, and chloride are left as well as indigestible parts of ingested food (e.g., a large part of ingested amylose, protein which has been shielded from digestion heretofore, and dietary fiber, which is largely indigestible carbohydrate in either soluble or insoluble form). As the chyme moves through the large intestine, most of the remaining water is removed, while the chyme is mixed with mucus and bacteria (known as gut flora), and becomes feces. The ascending colon receives fecal material as a liquid. The muscles of the colon then move the watery waste material forward and slowly absorb all the excess water. The stools get to become semi solid as they move along into the descending colon. The bacteria break down some of the fiber for their own nourishment and create acetate, propionate, and butyrate as waste products, which in turn are used by the cell lining of the colon for nourishment. No protein is made available. In humans, perhaps 10% of the undigested carbohydrate thus becomes available; in other animals, including other apes and primates, who have proportionally larger colons, more is made available, thus permitting a higher portion of plant material in the diet. This is an example of a symbiotic relationship and provides about one hundred calories a day to the body. The large intestine produces no digestive enzymes -— chemical digestion is completed in the small intestine before the chyme reaches the large intestine. The pH in the colon varies between 5.5 and 7 (slightly acidic to neutral).

Colonic Carcinoma / Colon Carcinoma / Colon Cancer Definition: It is a disease in which malignant (cancer) cells form in the tissues of the colon. The colon is part of the body's digestive system. The digestive system removes and processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) from foods and helps waste material out of the body. The digestive system is made up of the esophagus, stomach, and the small and large intestines. The first 6 feet of the large intestine are called the large bowel or colon. The last 6 inches are the rectum and the anal canal. The anal canal ends at the anus (the opening of the large intestine to the outside of the body). Risk Factors: Age and health history can affect the risk of developing colon carcinoma . Risk factors include the following: 

Age 50 or older.



A family history of carcinoma of the colon or rectum.



A personal history of carcinoma of the colon, rectum, ovary, endometrium, or breast.



A history of polyps in the colon.

Signs and Symptoms: 

A change in bowel habits.



Blood (either bright red or very dark) in the stool.



Diarrhea, constipation, or feeling that the bowel does not empty completely.



Stools that is narrower than usual.



Frequent gas pains, bloating, fullness, or cramps.



Weight loss for no known reason.



Feeling very tired.



Vomiting. A specimen removed from a patient with colonic carcinoma

V. Pathophysiology Pathophysiology of Intestinal obstruction

Risk Factors for Intestinal obstruction  

Crohn’s disease – narrows intestinal ageways due to thickening Abdominal Cancer



2 types of obstructions

Mechanical: (+) Physical obstruction or increased pressure from walls creating a blockage

(+) Increased fluid and gas

Functional: Intestinal muscles cannot propel the contents along the bowel

Increased pressure on intestinal wall causes more fluid to enter intestine

(+) Severe vomiting & pain

(+) Dehydration & Electrolyte Imbalance

Decreased blood pressure &pressure on Continued hypovolemic shock intestinal wall causes edema, ischemia and decreased peristalsis

(+) Increased peristalsis attempts to force contents past obstruction

(+) Abdominal distention

Prolonged ischemia causes increased permeability and necrosis of wall. Intestinal bacteria & toxins leak into blood.

(+) mass in the small intestine

Pathophysiology of Colon Cancer

Predisposing factors:  (+) Age (56% >70yrs old)  Colorectal polyps  Family history  Previous colorectal cancer  Ulcerative colitis /colonic crohn’s disease

Diagnostic test:  Fecal occult blood test  SigmoIdoscopy  Digital Rectum Exam

Surgical Treatment:  Colonoscopy  Virtual Colonoscopy



Precipitating factors: Patient broke her right leg due to falling on the stairs Precipitating factors:  Diet – high fat/low fiber  Smoking  Alcohol drinking  (+)Lack of exercise

Etiology: Unknown

Abnormal proliferation of cells in the colon area

Signs and Symptoms:  Rectal bleeding  Bloody stools  (+) Abdominal pain  (+) Fatigue  Constipation  (+)Diarrhea

Arising from epithelial lining of the intestine

Benign polyps occur



(+) Nausea and Vomiting

Continuous plorifetation of cells in the polyps

Polypectomy Reduction likelihood of regrowth

Increase in size of the polyps

Exposure to carcinogens

Development of malignant tumor

Uncontrolled Increase in proliferation COLON CANCER size of cells in the tumor

Complications DEATH occur

Diagnostic test:  SigmoIdos copy

VI.

Laboratory Examination

Results Diagnostic/ Laboratory Procedures

Date ordered Date results in

1. Complete Blood Count

Indications or Purposes

Results

Normal Value (Units used in the hospital)

Analysis and Interpretation of results

Hgb: 153

N: 115-175 g/L

The hemoglobin level is normal. This indicates that RBC is capable of carrying O2 and CO2 throughout the body.

Hct: 0.44

N: 0.40-0.52

The result indicates there is normal concentration of RBC within the blood

CBC is a screening test, used to diagnose and manage numerous diseases. The results can reflect problems with fluid or loss of blood.

a. Hemoglobin

Date ordered/ Date of Results: July 2, 2015

b. Hematocrit

Date ordered/ Date of Results: July 2, 2015

Hemoglobin determines the RBC that carries oxygen and carbon dioxide throughout the body

Hematocrit determines the

concentration of RBC within the blood volume c. RBC Date ordered/ Date of Results: July 2, 2015

volume.

RBC: 4.93

N:4.5-6.2

The result is within normal range which indicates that the body's RBCs containing hemoglobin, carrying oxygen to the body's tissues are functioning normally.

WBC: 13.0

N: 5-10x 109/L

WBC is high which indicates that there is infection presented in the body.

An RBC count is a blood test that measures how many red blood cells (RBCs) you have. RBCs contain hemoglobin, which carries oxygen. How much oxygen your body tissues get depends on how many RBCs you have and how well they work.

d. WBC Date ordered/ Date of Results: July 2, 2015

White blood cells (WBCs), also called leukocytes, are an important part of the immune system. These cells help

fight infections by attacking bacteria, viruses, and germs that invade the body. White blood cells originate in the bone marrow, but circulate throughout the bloodstream.

DIFFERENTIAL COUNT

a. Segmenters Segmenters: 0.84 Date ordered/ Date of Results: July 2, 2015

A type of white blood cell that respond to bacterial infections. Where the blood count has high levels of segmenters, this indicates the presence of a bacterial infection. Where there is a low level of segmenters, the patient is likely to be suffering from a viral infection or

N: 0.55-0.65

The result is higher than the normal range. Which indicates presence of bacterial infection.

an autoimmune disease.

b.Lymphocytes

Lymphocytes: 0.27 Date ordered/ Date of Results: July 2, 2015

Lymphocytes are responsible for immune responses. There are two main types of lymphocytes: B cells and T cells. The B cells make antibodies that attack bacteria and toxins while the T cells attack body cells themselves when they have been taken over by viruses or have become cancerous. Lymphocytes secrete products (lymphokines) that modulate the functional activities of many other types of cells and are often present at sites of chronic inflammation.

N: 0.25-0.35

Normal count of lymphocytes indicates that there is no presence of infection in the body

c. Eosinophils

N: 0.02-0.04 0.00 Date ordered/ Date of Results: July 2, 2015

Eosinophils are a specific type of white blood cell that protects your body against certain kinds of germs, mainly bacteria and parasites. They're also what causes you to have allergic reactions.

d. Monocytes Date ordered/ Date of Results: July 2, 2015

The result is below the normal range. Which indicates no significant.

0.06 Monocytes are a type of white blood cell that fights off bacteria, viruses and fungi. Monocytes are the biggest type of white blood cell in the immune system. Originally formed in the bone marrow, they are released into our blood and tissues. When certain germs enter the body, they quickly rush

N: 0.03-0.06

The result is normal. Which indicates that the body can fights off bacteria, virus and fungi,

to the attack.

site

for

e. Basophils Date ordered/ Date of Results: July 2, 2015

N: 0.00-0.01

Platelet Count: 311

Platelet Count: 150- 400 x 109/L

Basophils are granulocytic white blood cells that are active in the inflammatory response. They are mostly found in the skin and mucosa tissues, which are the tissues lining the openings into the body. They represent about 1% of all white blood cells in the body.

Platelet Count Date ordered/ Date of Results: July 2, 2015

0.00

A platelet count is a test to measure how many platelets you have in your blood. Platelets are parts of the blood that help the blood clot. They are smaller than red

The result is normal, which indicates that body is active for inflammatory response.

The result is within the normal range indicates that there is enough platelet produces for coagulation.

or white cells.

blood

Nursing Responsibilities: BEFORE 1. Explain to the patient the procedure and its purposes. 2. If the patient has eaten a meal with high sodium content in the past 24 hours, this should be noted. 3. Be sure not to draw blood, which has infused IVF. 4. Note if patient’s on a diet that restricts sodium and other nutrients. 5. Note other conditions such as diabetes. 6. Carefully watch for signs of electrolyte imbalance. 7. Perform a complete cephalocaudal assessment especially cardiac assessment and vital signs. 8. Make sure to have the right patient, specimen and method. DURING 1. Clean injection site with alcohol. 2. Lower the patient’s arm to dilate the veins. 3. Apply tourniquet and ask the patient to open and close fist. 4. Remove the tourniquet when drawing the final tube of blood. AFTER 1. Note for any signs of discomfort or bruising at the puncture site. 2. Provide pressure at the puncture site to stop bleeding and reduce bruising. 3. Apply warm compress to puncture site to relieve discomfort. 4. Send the specimen at the laboratory.

B. Blood Chemistry Diagnostic/ Laboratory Procedures

Date ordered Date results in

Indications or Purposes

Date ordered:

A serum creatinine test — which measures the level of creatinine in your blood — can indicate whether your kidneys are working properly.

70.10 umol/L

It regulates body water along with potassium. It is responsible for nerve conduction and contraction of muscle.

Na: 141

Results

Normal Value (Units used in the hospital)

Analysis and Interpretation of results

2. CLINICAL CHEMISTRY TEST

Creatinine

July 2, 2015 Date of Results: July 2, 2015

Sodium

Date ordered: July 2, 2015 Date of Results: July 2, 2015

N: 71-115 umol/L

The result is lower than the normal range which indicate that the kidney has a slightlyl glomerular filtration and renal damage. Creatinine is more accurate for renal condition.

N: 135-148 mmol/L

The result is within normal range, it indicates no presence of hypernatremia or hyponatremia

Potassium

Date ordered: July 2, 2015 Date of Results: July 2, 2015

Chloride

Date ordered: July 2, 2015 Date of Results: July 2, 2015

It is a mineral, which with Sodium and Calcium maintains normal heart rhythm and regulates water balance. A chloride test measures the level of chloride in your blood or urine. Chloride is one of the most important electrolytes in the blood. It helps keep the amount of fluid inside and outside of your cells in balance. It also helps maintain proper blood volume, blood pressure, and pH of your body fluids. Tests for sodium, potassium, and bicarbonate are usually done at the same time as a blood test for chloride.

K: 4.10

104.4

N: 3.5-5.3 mmol/L

N: 98-107 mmol/L

The result is within normal range, which indicates no presence of hyperkalemia or hypokalemia

The result is within normal range, which indicates there is normal functioning of the muscles, heart, and nerves. Which is also essential for normal fluid absorption and excretion.

Alanine Aminotrans liquid

Date ordered: July 2, 2015 Date of Results: July 2, 2015

Aspartate Aminotrans liquid

Date ordered: July 2, 2015 Date of Results: July 2, 2015

The blood test for aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are usually used to detect liver damage. It is often ordered to screen for and/or help diagnose liver disorders. In the patient’s case, liver function is monitored due to metastasis of his cancer to his liver. The blood test for aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are usually used to detect liver damage. It is often ordered to screen for and/or help diagnose liver disorders. In the patient’s case, liver function is monitored due to metastasis of his cancer to his liver.

19.0 U/L

18.6 U/L

N:10.0-44.0

N: 10.0-34.0

The result is within the normal range. Which indicates that liver is functioning normally.

The result is within the normal range. Which indicates that liver is functioning normally.

Calcium Gen 2

Date ordered: July 2, 2015 Date of Results: July 2, 2015

The Calcium Gen.2 assay is an in vitro diagnostics reagent system intended for the quantitative determination of calcium in human serum, plasma, and urine on Roche/Hitachi cobas c systems. Calcium measurements are used in the diagnosis and treatment of parathyroid disease, a variety of bone diseases, chronic renal disease, and tetany.

2.18 mmol/L

N: 2.20-2.75

The result is within the normal range.

NURSING RESPONSIBILITIES BEFORE 1. Confirm the patient’s identity using two patient identifiers according to facility policy. 2. Explain the procedure and the indication. 3. Inform the patient that the test requires blood sample, and explain that he may experience slight discomfort from the tourniquet and the needle puncture. 4. Instruct the patient that he doesn’t need to restrict food and fluids. For triglycerides she should not eat 12 hours before procedure. 5. Notify the laboratory and practitioner about any medications the patient is taking that may affect test results; they may need to be restricted. DURING 1. Perform venipuncture and collect the sample in a 3- or 4-mL clot activator tube. 2. Handle sample gently to prevent hemolysis. AFTER 1. A report of the results will be sent to the requesting Health Care Provider, who will discuss the results with the patient. 2. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. 3. Evaluate test results in relation to the patient's symptoms and other tests performed.

Diagnostic/ Laboratory Procedures

Date ordered Date results in

2. Urinalysis

Date ordered: July 2, 2015 Date of Results: July 2, 2015

Indications or Purposes

Urinalysis yields a large amount of information about possible disorders of the kidney and lower urinary tract, and systemic disorders that alter urine composition

Results

Color:

Normal Value (Units used in the hospital)

Analysis Interpretation

Yellow

The result has color

Amber

The result is

Yellow

Transparenc y: Slightly turbid

clear 4.8-7.8

SP Gravity:

1.015-1.025

1.020

Sugar:

Negative

There is no pr suga

Negative

There is no pr protei

negative

Protein: +2 RBC: 2.5

Pus cells: 13 Epithelial

0.1/HPF

Indicates no pr infectio 0.2/HPG

Few

cells: few Mucus threads: few

Indicate p Infectio

Few

The kidney is in function.

Nursing Responsibilities for Urinalysis:

BEFORE 1. Check the doctor’s order. 2. Check the right client. 3.

Encourage the SO to increase the fluid intake of the patient.

4. Apply warm on hypogastric region. DURING 1. Provide privacy. 2. Decrease discomfort, and anxiety, allows adequate time. 3. Tell the patient to assume a normal voiding position. 4. Introduce stimuli for voiding. 5. Pour warm water over the perineum. 6. Collect a clean catch urine sample during midstream urination. AFTER 1. Ensure that the specimen label and laboratory requisition form are filled out correctly. 2. Securely attach the label to the container. 3. Send the specimen to the laboratory at once. 4. Document what you have done.

VII. Gordon’s Assessment A.

B.

C.

D.

Health Perception and Management o

Patient can recall being completely immunized

o

Visits a doctor for consultation

o

Takes OTC drugs and herbal medications

Nutrition/Metabolism o

Eats more of fruits and vegetables

o

Eats dried /preserved fish

o

Eats his meals three times a day

o

Allergic to sea foods

Elimination o

Voids usually five times a day

o

Urine color is yellow

o

Defecates usually once a day during morning

Activity/Exercise o

Patient does household chores

o

Able to bathe himself

o

He does simple exercises such as arm exercises by means of shaking and stretching

E.

F.

G.

Sexuality/Reproductive o

Married

o

A father of 3 children

o

No history of STDs

Cognitive/Perceptual o

Oriented to people, time and place

o

Responds to stimuli verbally and physically

o

Able to read and write

o

College graduate

o

In normal thought process

Roles/Relationship o

Married

o

With 3 children

H.

I.

J.

o

Well-ed by the family

o

Loves his family so much

Self –Perception/Self-Concept o

Hopeful to be relieve and treated

o

Manages to practice healthy lifestyle

Value/Belief o

A Roman Catholic

o

Has a strong faith in God

o

Attends Sunday mass

Coping/Stress o

Experienced MVC IN 1995

o

Copes up with problems by talking about it with the family and finds ways to resolve it together

K.

L.

Sleep/Rest o

No difficulties in sleeping

o

Have enough rest intervals

Medication History o

Over the counter medication (buscopan) before issio

VIII. Nursing Care Plans PROBLEM # 1: Decrease cardiac output related to altered heart rate/rhythm ASSESSMENT

S: ø

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

Decrease cardiac output

Occlusion in the artery 

O : The patient

related to altered

Decreased blood

manifested the

heart rate/rhythm

supply

following: Afebrile Conscious and coherent Pale palpebral

 Decreased venous return  Decreased

conjunctiva

amount of blood

With capillary refill

expelled by ventricles

time of 3 seconds



manifest: Decreased skin turgor Sunken eyeballs Sudden weight loss

Short term:

NURSING INTERVENTIONS 1.

Establish

RATIONALE

1.

EXPECTED OUTCOME

To gain

Short term:

After 1-2 hours of

therapeutic

trust of the

The patient

nursing

relationship

patient

shall have

interventions, the

To note any

participated in

patient will

patient’s

abnormaliti

activities that

participate in

general

es

reduce the

activities that reduce

condition

To have

workload of the

Take and

baseline

heart.

record the

data

the workload of the

2.

3.

heart.

Assess

patient’s vital . 4.

Decreasedcardiac output

The patient may

OBJECTIVES

5.

2.

3.

4.

For comfort

signs

and

Provide

hygiene to

morning care

the patient

Evaluate

5.

To assess

client reports

for signs of

and evidence

poor

of extreme

ventricular

fatigue,

function

intolerance of

and/or

activity and

impending

progressive

cardiac

shortness of

failure

Decreased urine output

breath 6.

Monitor

6.

To note

cardiac

effectivene

Vital signs

rhythm

ss of

taken:

continuously

medication

Decrease

s

T:36.9

7.

RR: 21

stimuli;

HR: 116

provide quiet

7.

adequate

environment

BP: 150/170 8.

9.

Schedule

To promote rest

8.

To

activities and

maximize

assessments

rest periods

Instruct client

9.

Which can

to avoid/limit

cause

activities

changes in

10. ncourage relaxation techniques 11. Provide for

cardiac pressures 10. To reduce anxiety and

diet

conserve

restrictions

energy

12. Encourage

11. To maintain

changing

adequate

positions

nutrition

slowly,

12. To reduce

dangling legs

risk for

before

orthostatic

standing

hypotensio

13. Give information

n 13. To provide

about

encourage

positive signs

ment

of improvement

PROBLEM # 2: Ineffective Peripheral Tissue Perfusion related to decreased cardiac output ASSESSMENT

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOME

S: ø

Ineffective

Ineffective tissue

Short term:

1.

Establish

1.

To build a

Short term:

Peripheral Tissue perfusion is the decrease

After 1-2 hours

therapeutic

good and

O : The patient

Perfusion related

in oxygen resulting in

of nursing

relationship

trusting

shall have

manifested the

to decreased

failure to nourish tissues

interventions,

Assess patient’s

relationship

verbalized

following:

cardiac output

at the capillary level. An

the patient will

general condition

with the

understanding

abrupt increase in

verbalize

Take and record the

patient

of condition,

pressure brings about a

understanding

patient’s vital signs

To assess for

therapy

Vital signs

rapid and reversible

of condition,

that contributes to

complications

regimen, side

taken:

vasoconstriction of small

therapy

the patient’s

To note and

effects of

T:36.9

resistance vessels due to

regimen, side

complaint.

assess for

medications,

RR: 21

their inherent myogenic

effects of

Note current

complicatons

and when to

HR: 116

tone. Prolonged

medications,

situation or

Affecting



BP: 150/170

elevations of pressure

and when to

presence of

systemic

healthcare

can cause a range of



conditions that can

circulation or

provider.

The patient may

more lasting changes in

healthcare

affect perfusion to

perfussion

manifest:

the microcirculation, 2 of

provider.

Hypertension

2.

3.

all body systems

3.

4.

Client at

olyguria

which, remodeling of

capillary refill

small arteries and

conditions

venous

arterioles and rarefaction

associated with

stasis, vessel

of arterioles and

thrombus or emboli

wall injury

Note location of

and

restrictive clothing,

hypercoagula

pressure dressings,

bility

time more than 3 seconds warm extremities

capillaries, will be

4.

2.

5.

considered briefly below.

cyanosis and

edema

higher risk for

circular wraps, cast,

pallor on extremities

Determine history of

6.

5.

That may

or traction device

restrict

Compare skin

circulation to

temperature and

limb. Helps

The patient

paresthesia

7.

color with other limb

differentiate

when assessing

type of

extremity circulation

problems

Assess presence,

6.

location, and degree

identifying or

of swelling or

quantifying

edema formation.

edema in

Measure capillary

involved

time 8.

9. 10. 11. 12.

13. 14.

Useful in

Note client’s

extremity 7.

To determine

nutritional and fluid

adequacy of

status

systemic

Inspect lower extremities for skin texture Palpate arterial pulses Determine pulse equality, as well as intensity Determine time that symptoms are worse, precipitating, or aggravating events Assess motor and sensory function ister medications such as antiplatelet agents, thrombolytics, antibiotics.

circulation 8.

Protein energy malnutrition and weight loss make ischemic tissues more prone to breakdown

9.

That often accompany diminished peripheral perfusion

10. To determine

level of circulatory blockage 11. To evaluate distribution and quality of blood flow, and success or failure of therapy 12. To help isolate and differentiate problems 13. Problems with ambulation; hypersensitivi ty or loss of sensation and numbness and tingling are changes that can indicate neurovascula r dysfunction

14. To improve tissue perfusion or organ function

PROBLEM # 3: Acute Pain as evidence by abdominal pain in the epigastric area secondary to intestinal obstruction

NURSING

SCIENTIFIC

S>O

DIAGNOSIS Acute Pain as

EXPLANATION Intestinal obstruction

O>patient

evidence

refers to a lack of

After 1-2 hours

condition.

manifested:

abdominal

movement

of

of

Monitor

>pain scale of

pain

intestinal

contents

7/10

epigastric area

through the intestine.

patientt will be

>bloatedness

secondary

Because

able to report

> + epigastric

intestinal

smaller

pain

obstruction

obstructions

ASSESSMENT

after

in

by the to

the

of

its

lumen, are

OBJECTIVES Short term:

interventions,

pain

in

epigastric

Vital signs

occur more rapidly in

area.

taken:

the small intestine,

T:36.9

but they can occur in

RR: 21

the large intestine as

BP: 150/170

the

cause

location,

Assess

2.

the

3.

4.

made

of

about

3.

interventio n is more

as soon as it

likely to be

begins

successful

provide comfort

in alleviating

position

-flank pain

example, twisting of

-distraction/

the

guarding

cause sudden total

behaviors

obstruction, whereas

-increased

a

provide

such

pain

of

4.

non-

quiet,

relaxing

pharmacol

environment

ogical pain

6.

5.

encourage

which

-diaphoresis

and discomfort.

activities

-sleep disturbance

7.

to provide adequate

diversional

could lead to pain

to provide

mgmt.

progressive

-pallor

timely

pt to report pain

situation.

obstruction

the

pain. Instruct the

-weakness

elevated BP

be

choices

change

or

info

encourage

gradually developing

PR,RR,

exact

treatment

manifest:

to

shall reported

pain

measures

leads

data

in

acute problem or a

could

the

can

of

rest

like

socialization with

periods

others and slow,

and

rhythmic

prevent

breathing

fatigue

6.

ister analgesics ordered

as

OUTCOME Short term:

baseline

assessment

may

5.

gather

significant

may manifest as an

tumor

a

To

comprehensive

The patient

For

2.

perform

feelings

and

1.

and

verbalization

obstruction

intestine

pt’s

record pt’s VS

decreased

more common and

well. Depending on

1.

EXPECTED

RATIONALE

INTERVENTIONS

nursing

eating

HR: 116

NURSING

to

these could draw the

pt’s

attention away from the pain

patient

decreased flank pain

in

PROBLEM #4: Activity intolerance r/t pain ASSESSMENT s> Ø

NURSING DIAGNOSIS Activity intolerance r/t

o> the patient

EXPLANATION Pain is an unpleasant sensory and emotional

Short term: After 2 hours

NURSING INTERVENTIONS 1. Establish rapport 2. Monitor VS 3. Note patient’s response

of NI, the patient

primarily associated

will identify

with tissue damage or

negative factors

describe in such

affecting activity

as damage, or both

intolerance and

Vital signs taken:

that can be a stressor

eliminate or

and move about and

T:36.9

in performing activities

reduce their

degree of assistance

 Pain scale of 7/10  Complaints of pain

RR: 21

of daily living due to

HR: 116

the pain being

BP: 150/170

experienced with certain movements.

The patient may manifest: 

OBJECTIVES

experience which I

manifested:

pain

SCIENTIFIC

May acquire risks related with



immobility Further difficulty with



mobility May develop insomnia due to severe pain

effects when possible.

of weakness, fatigue, pain, difficulty accomplishing tasks and/or insomnia 4. Ascertain ability to stand

necessary/use of equipment 5. Provide comfort measures and provide for relief for pain 6. Encourage patient to maintain positive attitude. 7. Instruct patient/SO (s) in monitoring response to activity 8. Plan for progressive increase of activity level, as tolerated by the patient 9. Involve patient/SO (s) in planning of activities

RATIONALE 1. To gain patient and trust and cooperation 2. To obtain baseline data 3. Symptoms may be result of/or contribute to activity intolerance 4. To determine current status and needs associated with participation in needed/desired activities 5. Enhance ability to participate in activities 6. To enhance sense of well being 7. To indicate need to alter activity level 8. Both activity tolerance and health status may improve with progressive

EXPECTED OUTCOME Short term: The patient shall have identified negative factors affecting activity intolerance and eliminate or reduce their effects when possible

PROBLEM #5: Readiness for enhanced knowledge as evidence by expressing interest in learning about disease condition ASSESSMENT

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

OBJECTIVES

NURSING INTERVENTIONS 1.

S: ø

Establish

RATIONALE 1.

EXPECTED OUTCOME

To build a

Readiness for

The first requirement in

Short term:

therapeutic

good and

Short term:

enhanced

for wellness is a desire

After 1 hour of

relationship

trusting

The patient

O : The patient

knowledge as

to attain a higher level

nursing

Assess patient’s

relationship

shall have

manifested the

evidence by

of well being. The

interventions, the

general condition

with the

verbalized

following:

expressing

patient must express

patient will

patient

understanding

interest in

readiness to engage

verbalize

the patient’s vital

To assess

of information

to health

learning about

and learn interventions

understanding of

signs

for

gained.

teachings

disease

that will help him reach

information

client’s

complicatio

given

condition

that next level.

gained.

level of

ns

Listens intently

2. 3.

4.

Take and record 2.

Assessing a patient’s

knowledge about

knowledge

readiness to respond to

specific topic

assess for

of the topic

wellness diagnosis

Assist client to

complicatio

Explains

5.

involves patient

identify learning

The patient

interviews and

goals

may manifest:

interaction. And

Anxiety Restlessness Fear

To note and

ns 4.

Provides

Ascertain

opportunity

readiness for enhanced

preferred

to ensure

management describes

methods of

accuracy

a patient who is willing

learning

and

Assist client to

completene

in her own treatment by

identify ways to

ss of

following

integrate and use

knowledge

recommendations and

information in all

base for

helping set new goals

appropriate areas

future

and able to participate

6.

3.

7.

for herself.

learning 5.

Helps to frame or focus content to be learned

6.

Identifies best approach to facilitate learning

7.

Ability to apply or use information increases desire to learn and retain information

IX. Drug Study Medical Management IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, etc. a. IVF MEDICAL

DATE ORDERED,

MANAGEMENT/

DATE PERFORMED,

TREATMENT

DATE CHANGE

GENERAL

INDICATION OR

DESCRIPTION

PURPOSES 

D5LR 1L X 8 HRS

Date ordered: July 2, 2015

For daily maintenance of body fluids and nutrition, and for rehydration.

Treatment for persons needing extra calories who

Date of Results:

cannot tolerate

July 2, 2015

fluid overload. 

CLIENT’S RESPONSE TO TREATMENT The patient willingly accepted treatment and is kept hydrated as evidenced by continuous infusion,

Treatment of

improvement in his

shock.

condition and good skin turgor. There were no negative effects noted.

NURSING RESPONSIBILITIES: BEFORE THE PROCEDURE: 1. Assess vital signs for baseline data, skin turgor, bleeding tendencies, disease or 2. 3. 4. 5. 6. 7.

injury to extremities, status of veins to determine appropriate puncture site. Consider: How long the patient is likely to have IV What kinds of fluids will be infused What medications the patient will be receiving or is likely to receive Prepare equipment needed Perform hand hygiene

DURING THE PROCEDURE: 1. Prepare the client: Introduce self and client’s activity 2. Explain the procedure to the client (IV infusion can cause discomfort for a few seconds, but no discomfort while the solution is flowing) 3. Make sure that the client’s clothing or gown can be removed over IV apparatus, if necessary 4. Clean the skin site of entry 5. Assess IV site for any redness, swelling, tenderness, or drainage 6. Ensure appropriate IV flow AFTER THE PROCEDURE: 1. Label the IV with date and time of attachment 2. Document the time of the start of infusion, flow rate, amount and type of solution and client’s general response 3. Teach the client ways to maintain the infusion system 4. Instruct the client to inform any side effects 5. Monitor patient frequently for: 6. 7. 8. 9.

Signs of infiltration/sluggish flow signs of phlebitis/infection well time of catheter and need to be replaced Condition of catheter dressing

10. Check the level of the IVF:    

Correct solution, medication, and volume. Check and regulate the drop rate. Change the IVF solution if needed. Do not connect flexible plastic.

b. Drugs

NAME OF

DATE

ROUTE OR

DRUGS,

ORDERED,

ISTRATION

GENERIC

DATE

DOSAGE AND

NAME, BRAND

TAKEN/GIVEN,

FREQUENCY OF

NAME

DATE CHANGED

ISTRATION

GENERAL

CLIENT’S

ACTION,

INDICATION OR

RESPONSE TO

MECHANISM OF

PURPOSES

THE

ACTION

MEDICATION

General action: Generic name:

Date ordered:

OMEPRAZOLE

July 2, 2015

Brand names: LOSEC

Date of Results: July 2, 2015

Antiulcer

It is use to

The patient did

decrease the

not experience

Mechanism of

amount of acid

any adverse

Action:

produced in the

effect.

40 mg TIV O.D.

Inhibits proton pump

PRILOSEC

activity by binding to hydrogenpotassium adenosine triphosphatase, located at secretory surface of gastric parietal cells, to suppress gastric acid secretion. Nursing Responsibilities BEFORE 1. Observe 10 R’s of istration of drugs 2. Check doctor’s order three times and the patient 3. Check the label of the drug, its name and its expiration date 4. Wash hands before handling the medication

stomach

5. Assess patient’s vital signs prior to istering the medication DURING 1. ister as indicated (right drug, right dosage, right frequency) 2. Clean the IV insertion for medication with a cotton ball with alcohol. 3. Gradually inject the drug into the port. Slow IV push to prevent infiltration and phlebitis. 4. ister cautiously and slowly with aseptic technique. AFTER 1. Observe for the sensitivity and side effects to the drug 2. Reassess patient’s level of pain at least 15 and 30 minutes after parenteral istration 3. Monitor circulatory and respiratory status and bladder and bowel function. 4. Caution ambulatory patient about getting out of bed or walking.

NAME OF

DATE ORDERED,

DRUGS,

DATE

GENERIC NAME,

TAKEN/GIVEN,

BRAND NAME

DATE CHANGED

ROUTE OR ISTRATION DOSAGE AND FREQUENCY OF ISTRATION

GENERAL ACTION, MECHANISM OF ACTION

INDICATION OR PURPOSES

Generic name:

Date ordered:

CEFUROXIME

July 2, 2015

Brand names:

Serious lower

Antibiotic

respiratory tract infection, UTI,

Mechanism of

skin or skin-

Action:

structure

CEFTIN,

Inhibits cell-wall

infections, bone

ZINACEF

synthesis,

of t

promoting osmotic

infection,

instability; usually

septicema,

bactericidal.

meningitis and

KEFUROX,

Date of Results:

750 g TIV Q8

General action:

July 2, 2015

gonorrhea - Pharyngitis and tonsillitis - Early lyme disease

Nursing Responsibilities BEFORE 6. Observe 10 R’s of istration of drugs 7. Check doctor’s order three times and the patient 8. Check the label of the drug, its name and its expiration date 9. Wash hands before handling the medication 10. Assess patient’s vital signs prior to istering the medication DURING 5. ister as indicated (right drug, right dosage, right frequency) 6. Clean the IV insertion for medication with a cotton ball with alcohol. 7. Gradually inject the drug into the port. Slow IV push to prevent infiltration and phlebitis. 8. ister cautiously and slowly with aseptic technique. AFTER 5. Observe for the sensitivity and side effects to the drug 6. Reassess patient’s level of pain at least 15 and 30 minutes after parenteral istration 7. Monitor circulatory and respiratory status and bladder and bowel function. 8. Caution ambulatory patient about getting out of bed or walking.

NAME OF DRUGS, GENERIC NAME, BRAND NAME

DATE ORDERED, DATE TAKEN/GIVEN, DATE CHANGED

ROUTE OR ISTRATION DOSAGE AND FREQUENCY OF ISTRATION

GENERAL ACTION, MECHANISM OF ACTION

INDICATION

OR PURPOSE

Generic name: METRONIDAZOLE

Date ordered: July 2, 2015

500 mg TIV Q8

General action:

- Amebic Liver

Antiprotozoal

abscess - Intestinal

Brand names: FLAGYL, FLAGYL

Date of Results: July 2, 2015

Mechanism of

amebiasis

action:

- Trichomonias

ER, FLORAZOLE

Direct acting

ER, NOVO-

trichomonicide and

NIDAZOLE,

amebicide that

FLAGYL IV RTU

works inside and outside the intestines. It's thought to enter the cells of microorganisms that contain nitroreductase. forming unstable compounds that binds to DNA and inhibit synthesis, causing cell death.

Nursing Responsibilities BEFORE 11. Observe 10 R’s of istration of drugs 12. Check doctor’s order three times and the patient 13. Check the label of the drug, its name and its expiration date 14. Wash hands before handling the medication 15. Assess patient’s vital signs prior to istering the medication DURING 9. ister as indicated (right drug, right dosage, right frequency) 10. Clean the IV insertion for medication with a cotton ball with alcohol. 11. Gradually inject the drug into the port. Slow IV push to prevent infiltration and phlebitis. 12. ister cautiously and slowly with aseptic technique. AFTER 9. Observe for the sensitivity and side effects to the drug 10. Reassess patient’s level of pain at least 15 and 30 minutes after parenteral istration 11. Monitor circulatory and respiratory status and bladder and bowel function. 12. Caution ambulatory patient about getting out of bed or walking.

c. Diet TYPE OF DIET

DATE ORDERED,

GENERAL

INDICATION

DATE

DESCRIPTION

SPECIFIC FOOD

CLIENT'S

TAKEN

RESPONSE AND

TAKEN/GIVEN,

REACTION TO

DATE CHANGED

THE DIET NPO

NPO (Nothing per

Date ordered:

Orem)

July 2, 2015

stands

for

Nothing Per Orem

take food or drink

which

through mouth.

means

nothing by mouth. Date of Results: July 2, 2015

Patient cannot

Doctors use this on

orders

when

they do not want the patient to take in any type of food or liquid by mouth. For instance, when a patient is getting ready

for

a

surgery, they are ordered for NPO.

None

Patient cannot eat by mouth thought he can still receive nutrients needed by his body via NGT

Nursing Responsibilities (NPO): Before:  Check for the doctor’s order for type of diet preferred.  Explain the importance and purpose of the prescribed diet.  Place an NPO sign on the bed.  Remove all foods at bedside and emphasize strict compliance on the diet regimen. During:  Monitor patient closely for compliance of the diet.  Reiterate diet frequently to the patient or SO.  Check bedside for presence of food, remove if necessary. After:  Assess patient’s condition.  Document

TYPE OF DIET

NGT

DATE ORDERED,

GENERAL

DATE

DESCRIPTION

INDICATION

SPECIFIC FOOD

CLIENT'S

TAKEN

RESPONSE AND

TAKEN/GIVEN,

REACTION TO

DATE CHANGED

THE DIET

Date ordered: July 2, 2015 Date of Results: July 2, 2015

These are special It It is indicated to preparations for patients who are prevent further unable to digest increase in the solid foods. patient’s blood pressure and to lower down cholesterol levels.

none only

As stated by the

medications

patient, there's a feeling of discomfort.

IX. Health Teachings METHOD M: instructed the patient to take the following Omeprazole Cefuroxime Metronidazole E: Instructed the client to have adequate bed rest T: Instructed the client on strict compliance to medication and therapy H: Instructed patient to always have adequate rest periods in a comfortable position  Instructed patient to avoid high fat and high sodium content food  Instructed patient to schedule regular follow-up check-up appointments with physician to monitor progress O: Instructed client to continue therapy D: Instructed client on low fat low salt diet