42472090 case presentation gastro
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World Citi Colleges
960 Aurora Blvd. Quezon City
Case Presentation
In
NCM 103
Gastric Outlet Obstruction (Status post-Jejunostomy)
Submitted by:
Boncato, Ronnie Jay
Fernando, Christian
Flaminiano, Chris
Flores, Eunice Faith
Reyes, Daniel Victor
Reyes, Ella Mae
Salazar, James
Sanosa, Jasmin
Saquitan, RJ
Saring, Marie
Sherman, Myrna
Solatre, Carlo
Tabieros, Kristine Joy
Taclas, Josid
Tobari, Dianne
Ungos, Abby
Submitted to:
Mr. Dominic Bautista
Ms. Myla Lim
Mr. Sherwin Villegas
Date of Submission:
September 2010
I. Introduction
Our group chose this case as interesting to us because it is a rare case that is usually underestimated as a cause of mortality and morbidity to patients. We would like to make an outlook of what this case is and gather information that can help us to expand our knowledge and learn how it occurs, manifest, develop and cause a disease.
Gastric outlet obstruction (GOO), also known as pyloric obstruction) is not a single entity; it is the clinical and pathophysiological consequence of any disease process that produces a mechanical impediment to gastric emptying.
The major benign causes of gastric outlet obstruction (GOO) are PUD, gastric polyps, ingestion of caustics, pyloric stenosis, congenital duodenal webs, gallstone obstruction (Bouveret syndrome), pancreatic pseudocysts, and bezoars.
PUD manifests in approximately 5% of all patients with GOO. Ulcers within the pyloric channel and first portion of the duodenum usually are responsible for outlet obstruction. Obstruction can occur in an acute setting secondary to acute inflammation and edema or, more commonly, in a chronic setting secondary to scarring and fibrosis. Helicobacter pylori has been implicated as a frequent associated finding in patients with GOO, but its exact incidence has not been defined precisely. The incidence of gastric outlet obstruction (GOO) has been reported to be less than 2- 4 % in patients with PUD, which is the leading benign cause of the problem. Five percent to 5% of ulcer-related complications result in an estimated 950 operations per year in the Philippines. The incidence of GOO in patients with peripancreatic malignancy, the most common malignant etiology, has been reported as 10-12%.
Nausea and vomiting are the cardinal symptoms of gastric outlet obstruction. Vomiting usually is described as nonbilious, and it characteristically contains undigested food particles. In the early stages of obstruction, vomiting may be intermittent and usually occurs within 1 hour of a meal. Patients with gastric outlet obstruction resulting from a duodenal ulcer or incomplete obstruction typically present with symptoms of gastric retention, including bloating or epigastric fullness, indigestion, anorexia, nausea, vomiting, epigastric pain, and weight loss. They are frequently malnourished and dehydrated and have a metabolic insufficiency. Weight loss is frequent when the condition approaches chronicity and is most significant in patients with malignant disease.
II. Objectives
After successful accomplishment of this case presentation, the students will be able to:
General: • To make the students of third year BSN capable of understanding the case about Gastric Outlet
Obstruction (GOO).
Specific: • Select the appropriate nursing theory and apply its principles in rendering nursing care to a
patient who is currently suffering Gastric Outlet Obstruction (GOO).• Understand the Anatomy and Physiology of both the Digestive system that are directly affected
in Gastric Outlet Obstruction (GOO) and relate the concepts to the actual situation of the patient.
• Explain in detail the Pathophysiology of Gastric Outlet Obstruction (GOO) and relate it with the patient’s case.
• Establish the nursing priorities and nursing management applicable to patients with Gastric Outlet Obstruction (GOO) and incorporate these in the formulation of an essential nursing care plan.
• Differentiate the different pharmacologic actions of the drugs involved in the treatment of Gastric Outlet Obstruction (GOO).
• Formulate relevant health teachings for a patient with Gastric Outlet Obstruction (GOO).
III. Theoretical Framework
FAYE ABDELLAH- 21 Nursing Problems
Abdellah's Typology of 21 Nursing Problems are as follows:
1. To promote good hygiene and physical comfort.
2. To promote optimal activity, exercise, rest, and sleep.
3. To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection.
4. To maintain good body mechanics and prevent and correct deformities
5. To facilitate the maintenance of a supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition of all body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic responses of the body to disease conditions
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory function
12. To identify and accept positive and negative expressions, feelings, and reactions
13. To identify and accept the interrelatedness of emotions and organic illness
14. To facilitate the maintenance of effective verbal and nonverbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs
19. To accept the optimum possible goals in light of physical and emotional limitations
20. To use community resources as an aid in resolving problems arising from illness
21. To understand the role of social problems as influencing factors in the cause of illness
IV. Nursing Assessment
A. Personal Data
Name: A. M.
Age: 62 years old
Birthday: November 11, 1947
Nationality: Filipino
Gender: Male
Civil Status: Married
Address: San Mateo, Rizal
Occupation: Driver
Adm. Date: August 9, 2010
Adm. Time: 5:30 pm
Chief complaint: Abdominal pain (6/10) and vomiting
Clinical Impression: Gastric outlet obstruction
B. History of Present illness:Few weeks prior to admission, the patient experienced general body weakness,
constipation, and abdominal bloatedness. Persistence of the signs and symptoms mentioned prompted the patient to consult medical help. Upon admission, patient’s vital signs were documented as follows: BP- 140/80 mm Hg, T- 36.0°C, RR-18bpm PR- 82bpm. The patient has symptoms of nausea, vomiting. He complains of abdominal pain. Patient had undergone jejunostomy insertion on August 16, 2010. Patient is a diagnosed case of seminoma S/P orchidectomy (R), Gastric Outlet Obstruction, S/P jejunostomy tube insertion.
C. Past Health history:The patient was diagnosed to have a Gouty Arthritis way back 1990. He also had a
Diabetes Mellitus for 6 years but has been controlled through medication and proper diet as well as exercise. Further, he also had a Pulmonary Tuberculosis last 2007 and was treated using short course therapy for 6 months.
The patient was previously admitted on July, 2010 due to abdominal mass and pain on his testes that started last June, 2010. It is when the patient was diagnosed to have seminoma and had undergone orchidectomy. Since then, he had experienced different signs and symptoms that lead to his present admission at WCC.
D. Family history:Both his parents have a history of Diabetes Mellitus. His mother had a breast cancer that
contributed to her death.
E. Social History:He works as a government driver. He has three children; all of them are already
graduated from school. He was a hard drinker. Also a chain smoker, he can consume 6 packs a day but has stopped for one month before hospitalization.
F. Physical Assessment:
Day 1
HAIR
The patient is bald at the upper portion of the head. Has gray thin hair on the back and on his side of his head
SCALP
White, oily clean scalp
FACE
Symmetrical facial movement, he looks worried and sad
EYES
The outer cantus of the patient eyes were symmetrical to the pinna of his ears. The eyebrows were thin but evenly distributed and have short eyelashes. Patient’s was observed to have yellowish sclera, pale conjunctivas, and black equally rounded pupils. Constriction were observed when light stimulation done at varying distance.
NOSE
The patient has pointed nose, with dry mucus membranes. NGT tube is attached to the left nostril
EARS
Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed when exposed to pen light. He is able to hear from both ears because he was able to respond to the questions that was asked to him.
MOUTH
He is able to open and close with ease.
TEETH
He has two missing molar tooth on his upper and lower teeth. Yellowish in color.
TONGUE
The patient has moist with white patches over the tongue.
LIPS
Dry and pale in color.
NECK
The patient’s neck has dry skin complexion. Muscle tone was fairly good and able to move his head. No masses palpated along lymph nodes. There’s a presence of wrinkles. The carotid pulse is palpable.
CHEST
Chest is symmetrical during respiration, fair skin in color and smooth with respiratory rate of 18 bpm. Torso- ribs are visible and palpable
ABDOMEN
There is an incision at the right side of his abdomen, with no discharge. There is jejunostomy tube attach to the left lower quadrant of his abdomen, tender to touch.
UPPER EXTREMITIES
The patient’s left and right upper extremities were symmetrical to each other; has brown complexion but pale. Patient’s arms and palms were dry, warm to touch with dry and good skin turgor. Capillary refill was within 3 seconds.
LOWER EXTREMETIES
The patient’s right and left lower extremities has brown complexion and both were symmetrical compared to each other. Patient’s legs and feet were dry and warm to touch. Capillary refill was within 3 seconds and skin turgor was good.
Day 2
HAIR
The patient is bald at the upper portion of the head. Has gray thin hair on the back and on his side of his head
SCALP
White, oily clean scalp
FACE
Symmetrical facial movement, he looks worried and sad
EYES
The outer cantus of the patient eyes were symmetrical to the pinna of his ears. The eyebrows were thin but evenly distributed and have short eyelashes. Patient’s was observed to have yellowish sclera, pale conjunctivas, and black equally rounded pupils. Constriction were observed when light stimulation done at varying distance.
NOSE
The patient has pointed nose, with dry mucus membranes. NGT tube is attached to the left nostril
EARS
Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed when exposed to pen light. He is not able to hear from both ears because he was having a hard time to hear the questions that was asked to him.
MOUTH
He is able to open and close with ease.
TEETH
He has two missing molar tooth on his upper and lower teeth. Yellowish in color.
TONGUE
The patient has moist with white patches over the tongue.
LIPS
Dry and pale in color.
NECK
The patient’s neck has dry skin complexion. Muscle tone was fairly good and able to move his head. No masses palpated along lymph nodes. There’s a presence of wrinkles. The carotid pulse is palpable.
CHEST
Chest is symmetrical during respiration, fair skin in color and smooth with respiratory rate of 18 bpm. / Torso- ribs are visible and palpable
ABDOMEN
There is an incision at the right side of his abdomen, with no discharge. There is jejunostomy tube attach to the left lower quadrant of his abdomen, tender to touch.
UPPER EXTREMITIES
The patient’s left and right upper extremities were symmetrical to each other; has brown complexion but pale. Patient’s arms and palms are dry, warm to touch with dry and good skin turgor. Capillary refill was within 3 seconds.
LOWER EXTREMETIES
The patient’s right and left lower extremities has brown complexion and both were symmetrical compared to each other. Patient’s legs and feet are dry and warm to touch. Capillary refill was within 3 seconds and skin turgor was good.
V. Usual Patterns of Daily Living
AREA BEFORE HOSPITALIZATION
DURING HOSPITALIZATION (DAY1)
DURING HOSPITALIZATION (DAY2)
1. Social history He works as a government driver. He has three children; all of them are already graduated from school.
He is always on the bed sleeping and he has only one companion.
He is awake but stays on the bed. He had his two companions throughout the day.
2. Mental Conscious and aware of time, date and reality
The patient is conscious and ambulatory but limited ROM
The patient is conscious and ambulatory but limited ROM
3. Emotional The patient is reacts depending on the situation.
He is approachable He is irritated because of the room ambiance.
4. Sensory perception
His sensory were all working, able to perceive stimuli.
The patient is answering whenever asked by the interviewer.
He can’t hear the person he is talking to clearly.
5. Motor Able to move his body The patient is able to He is able to stand and
Capabilities stand and walk alone. walk alone.
6. Respiratory With in the normal range (16-20bpm).
RR: 17 (4pm)
18 (8pm)
RR: 18 (4pm)
20 (8pm)
7. Circulatory Within normal range
(PR: 60-100 bpm; BP: 150/90 mmHg)
PR: 110bpm (4pm)
117 bpm (8pm)
BP:120/80 mmhg (4pm)
120/80 mmhg (8pm)
PR: 118bpm (4pm)
118 bpm (8pm)
BP:120/80 mmhg (4pm)
110/80 mmhg (8pm)
8. Body temperature
Within normal range
(Temp: 36.5-37.5'C)
Temp: 36.5'C (4pm)
36.5’C (8pm)
Temp: 36.5'C (4pm)
36.7’C (8pm)
9. Nutritional He eats well at least 3-4 times a day. He always eat with fish and vegetables
Jejunostomy tube feeding (1800kcal). He take liquid substances by mouth
Jejunostomy tube feeding (1800kcal). He take liquid substances by mouth
10. Elimination She urinates and defacates regularly.
Urine: 2
Stool: 2
Urine: 1
Stool: 1
11. State of physical rest & comfort
She was able to sleep 7-8 hours
He is always sleeping He is awake but stays on the bed for the whole day
12. State of skin and appendices
Good skin turgor, skin He has dry skin especially on the mouth
He still has dry skin especially on the mouth.
VI. Anatomy and Physiology
Small Intestine
If the small intestine were not looped back and forth upon itself, it could not fit into the abdominal space it occupies. It is held in place by tissues which are attached to the abdominal wall and measures eighteen to twenty-three feet in the average adult, which makes it about four times longer than the person is tall. It is a three-part tube of about one and one-half to two inches in diameter and is divided into three sections: (1) the duodenum, a receiving area for chemicals and partially digested food from the stomach; (2) the jejunum, where most of the nutrients are absorbed into the blood and (3) the ileum, where the remaining nutrients are absorbed before moving into the large intestine. The intestines process about 2.5 gallons of food, liquids and bodily waste every day. In order for enough nutrients to be absorbed into the body, it must come in contact with large numbers of intestinal cells which are folded like gathered skirts. Each of these cells contain thousands of tiny finger-like projections called "villi," and each villus contains microscopic "microvilli". In one square inch of small intestine, there are about 20,000 villi and ten billion microvilli. Each villus brings in fresh, oxygenated blood and sends out nutrient-enriched blood. The villi sway constantly to stir up liquefied food and
remove the nutrients which can be absorbed and then passed through the membranes of the villi into the blood and lymph vessels. The fatty nutrients go to the lymph vessels, and glucose and amino acids go to the blood and on to the liver. The muscles which encircle this tube constrict about seven to twelve times a minute to move the food back and forth, to churn it, knead it, and to mix it with gastric juices. The small intestine also makes waves which move the food forward, but these are usually weak and infrequent to allow the food to stay in one place until the nutrients can be absorbed. If a toxic substance enters the small intestine, these movements may be strong and rapid to expel the poisons quickly.
VII. Pathophysiology Risk factors:
Sedentary lifestyle, gender, obstruction of the pyloric channel or duodenum
BOOK Patient
Organ Affected:
Small Intestine
Disease Process:
Mechanical impediment to gastric emptying
Clinical Manifestations:
-Nausea and vomiting is the cardinal symptom.
-Tolerance to liquids than solid food.
-May develop significant weight loss due to poor caloric intake ( Malnutrition).
-In the acute or chronic phase of obstruction, continuous vomiting may lead to dehydration and electrolyte abnormalities.
Medical Management:
- Jejunostomy tube insertion
- Osteurized Feeding: Jejunostomy tube feeding 1800 kcal
Diagnostic Evaluation:
Hemoglucotest
Uric acid
Albumin test
Creatinine
Glycosylated Hemoglobin
Calcium Ionized
Sodium, Routine Urinalysis
Blood typing
Clinical Manifestations:
General Body Weakness
Constipation
Feeling of bloatness
Nausea
Medical Management:
- Sodium chloride IV fluid solution
- Jejonostomy tube insertion
- Place a NGT to decompress the stomach.
Diagnostic Evaluation:
-Obtain a CBC. Check the hemoglobin and hematocrit
-Upper endoscopy
-Sodium chloride load test
-Barium upper GI studies
-CT scans
VIII. Laboratory
Medical Management:
- Jejunostomy tube insertion
- Osteurized Feeding: Jejunostomy tube feeding 1800 kcal
Medical Management:
- Sodium chloride IV fluid solution
- Jejonostomy tube insertion
- Place a NGT to decompress the stomach.
Date ordered Laboratory exams Results Normal values significant
August 11, 2010 Glycosylated Hemoglobin 8.8 4.50-6.30% Increase- found in people with persistent elevated blood sugar.
August 11, 2010 Calcium Ionized 1.21 1.00-1.20 mmol/L
August 12, 2010 Phosphorus 1.00 0.80-1.50 mmol/L Increase- kidney failure, hypo para- thyroidism, iabetic keto acidosis.
Decrease- Hyper calcemia, malnutrition, alcoholism, osteomalasia.
August 11, 2010 LDH 368 144.00-225.00 U/L Increase- CVA, hemolytic anemias, kidney, liver disease, pancreatitis, lymphoma.
Date ordered Laboratory exams results Normal values Significant
August 19, 2010 Uric Acid 236 208.30-428.40 umol/L Increased- gout, cardiovascular disease.
Decrease- multiple sclerosis
August 21, 2010 Chloride 88.60 98.00-107.00 mmol/L Decreased- metabolic alkalosis, respiratory acidosis, prolonged vomiting.
August 11, 2010 Albumin 25.64 35.00-52.00 G/L Decreased- liver disease, shock, malnutrition,
August 23, 2010 Creatinine 102.9 72.00-127.00 umol/L Increase- mascular dystrophy, fever, carcinoma of liver
Decrease- decreased muscle mass
August 23, 2010 Potassium 4.96 3.50-5.50 mmol/L Increased- hemolysis, chronic renal failure, acidosis, cushing’s diease, corpus luteum cysts.
Decrease – diarrhea, adrenocortical insuffiency.
August 23, 2010 Sodium 135.7 135.00-148.00 mmol/L Increased- useful in detecting gross changes in water and salt balanced
Decrease- Diarrhea, excessive sweating, kidney disease,
Date ordered Laboratory exams results Normal values Significant
August 11, 2010 Uric Acid 581 208.30-428.40 umol/L The results shows that the uric acid is above normal which can cause gout, cardiovascular disease.
August 17, 2010 Chloride 91.4 98.00-107.00 mmol/L Decreased- metabolic alkalosis, respiratory acidosis, prolonged vomiting.
August 9, 2010 Albumin 30.82 35.00-52.00 G/L Increased-dehydration
Decreased- liver disease, shock, malnutrition,
August 17, 2010 Creatinine 121.3 72.00-127.00 umol/L Increase- mascular dystrophy, fever, carcinoma of liver
Decrease- decreased muscle mass
August 21, 2010 Potassium 4.74 3.50-5.50 mmol/L Increased- hemolysis, chronic renal failure, acidosis, cushing’s diease, corpus luteum cysts.
Decrease – diarrhea, adrenocortical insuffiency.
August 22, 2010 Sodium 129.2 135.00-148.00 mmol/L Increased- useful in detecting gross changes in water and salt balanced
Decrease- Diarrhea, excessive sweating, kidney disease,
Date ordered Laboratory exams results Normal values Significant
August 14, 2010 Chloride 84.80 98.00-107.00 mmol/L Decreased- metabolic alkalosis, respiratory acidosis, prolonged vomiting.
August 15, 2010 Creatinine 93.6 72.00-127.00 umol/L Increase- mascular dystrophy, fever, carcinoma of liver
Decrease- decreased muscle mass
August 17, 2010 Potassium 4.76 3.50-5.50 mmol/L Increased- hemolysis, chronic renal failure, acidosis, cushing’s diease, corpus luteum cysts.
Decrease – diarrhea, adrenocortical insuffiency.
August 21, 2010 Sodium 125.60 135.00-148.00 mmol/L Increased- useful in detecting gross changes in water and salt balanced
Decrease- Diarrhea, excessive sweating, kidney disease,
Date ordered Laboratory exams results Normal values Significant
August 14, 2010 Creatinine 94,3 72.00-127.00 umol/L Increase- mascular dystrophy, fever, carcinoma of liver
Decrease- decreased muscle mass
August 15, 2010 Potassium 3.91 3.50-5.50 mmol/L Increased- hemolysis, chronic renal failure, acidosis, cushing’s diease, corpus luteum cysts.
Decrease – diarrhea, adrenocortical insuffiency.
August 17, 2010 Sodium 130.4 135.00-148.00 mmol/L Increased- useful in detecting gross changes in water and salt balanced
Decrease- Diarrhea, excessive sweating, kidney disease,
Date ordered Laboratory exams results Normal values Significant
August 11, 2010 Creatinine 125.5 72.00-127.00 umol/L Increase- mascular dystrophy, fever, carcinoma of liver
Decrease- decreased muscle mass
August 14, 2010 Potassium 3.72 3.50-5.50 mmol/L Increased- hemolysis, chronic renal failure, acidosis, cushing’s diease, corpus
luteum cysts.
Decrease – diarrhea, adrenocortical insuffiency.
August 15, 2010 Sodium 130.1 135.00-148.00 mmol/L Increased- useful in detecting gross changes in water and salt balanced
Decrease- Diarrhea, excessive sweating, kidney disease,
Date ordered Laboratory exams results Normal values Significant
August 9, 2010 Creatinine 163.4 72.00-127.00 umol/L Increase- mascular dystrophy, fever, carcinoma of liver
Decrease- decreased muscle mass
August 14, 2010 Potassium 3.72 3.50-5.50 mmol/L Increased- hemolysis, chronic renal failure, acidosis, cushing’s diease, corpus luteum cysts.
Decrease – diarrhea, adrenocortical insuffiency.
August 13, 2010 Sodium 125.20 135.00-148.00 mmol/L Increased- useful in detecting gross changes in water and salt balanced
Decrease- Diarrhea, excessive sweating, kidney
disease,
Date ordered Laboratory exams results Normal values Significant
August 9, 2010 Potassium 4.98 3.50-5.50 mmol/L Increased- hemolysis, chronic renal failure, acidosis, cushing’s diease, corpus luteum cysts.
Decrease – diarrhea, adrenocortical insuffiency.
August 9, 2010 Sodium 136.1 135.00-148.00 mmol/L Increased- useful in detecting gross changes in water and salt balanced
Decrease- Diarrhea, excessive sweating, kidney disease,
Date ordered Laboratory exams results Normal values Significant
August 23, 2010 Total Bilirubin 65.28 5.00-21 umol/L Increase- hemolytic, sickle cell or pernicious anemia.
August 23, 2010 Direct Bilirubin 25.42 0.00-3.40 umol/L
August 23, 2010 Indirect Bilirubin 39.86 5.00-17.60 umol/L
Date ordered Laboratory exams results Normal values Significant
August 14, 2010 Total Bilirubin 10.42 3.42-17.10 mmol/L Increase- hemolytic, sickle cell or pernicious anemia.
August 14, 2010 Direct Bilirubin 3.88 0.00-8.55 mmol/L
August 14, 2010 Indirect Bilirubin 6.54 2.60-12.00 mmol/L
Date ordered Laboratory exams results Normal values Significant
August 24, 2010
Hemoglucotest
140
70.00-140.00mgs/dl
Increase- found in people with persistent elevated blood sugar
Decrease- sickle cell disease, Vit-B12 or folate deficiency.
August 23, 2010 154
August 23, 2010 107
August 22, 2010 153
August 21, 2010 163
August 18, 2010 146
August 15, 2010 144
August 9, 2010 143
Routine Urinalyis
Macroscopic Results:
Date Ordered Result InterpretationAugust 10, 2010 Color Light Yellow Healthy and normal urineAugust 10, 2010 Character Slightly Turbid May be caused by normal or abnormal
processes. Normal= precipitation crystals or mucus.Abnormal= presence of blood cells, yeast or bacteria.
August 10, 2010 Reaction 5.0August 10, 2010 Specific Gravity 1.025 The specific gravity is in range of the normal of
1.020-1.030 g/ml, hence the urine’s concentration is normal
August 10, 2010 Protein Trace Protein is present in the urine that may indicate kidney damage/disease.
August 10, 2010 Sugar Negative Sugar is not present in the urine.Microscopic Results:
Date Ordered Result InterpretationAugust 10, 2010 Red Blood Cells 0-2/ HPF Normal presence of RBCs in the
urineAugust 10, 2010 Pus Cells 0-2/HPF Normal presence of Pus cells in the
urineAugust 10, 2010 Epithelial Cells FEW NormalAugust 10, 2010 Amorphus Urates FEWAugust 10, 2010 Amorphous Phosphates N/AAugust 10, 2010 Bacteria N/AAugust 10, 2010 Mucus Threads FEW Normal presence of mucus which
causes the slight turbidity of the client’s urine
August 10, 2010 Yeast Cells
Complete Blood Count ( August 21, 2010)
Date ordered Laboratory exams results Normal values significant
August 21, 2010 WBC 8.4 4.00-10.00 10^9/L Increased- neurosyphilis, anterior poliomyelitis, encephalitis lethargic.
August 21, 2010 RBC 3.92 4.50-6.50 10^12/L Decreased-
iron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary anemia, free radical pathology, toxic metals, catabolic methabolism.
August 21, 2010 HGB 116.00 130.00-170.00 g/L Decreased in various anemias, pregnancy, severe of prolonged hemorrhage, and with excessive fluid intake.
August 21, 2010 HCT 0.35 0.40-0.54 Decrease in severe anemias, anemia in pregnancy, acute massive blood loss.
August 21, 2010 MCV
August 21, 2010 MCH
August 21, 2010 MCHC
August 21, 2010 PLT Slight Increase 150.00-350.00 10^9/L Increased in malignancy, myeloproliferative disease, rheumatoid arthritis, and postoperativerly; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy;
August 21, 2010 Lymphocytes 0.19 0.25-0.50 Increase with infectious mononucleosis, viral and some bacterial infections, hepatitis; decreased with aplastic anemia, SLE, immunodeficiency including AIDS.
August 21, 2010 Monocytes 0.05 0.02-0.10 Increase with viral infections, parasitic disease, collagen and hemolytic disorder; decreased with use of corticosteroids, RA, HIV infection.
August 21, 2010 Neutrophils 0.75 0.50-0.80 Increase with acute infection, trauma or surgery, leukemia, malignant disease,
necrosis; decrease with viral infections, bone marrow suppression, primary bone marrow disease.
August 21, 2010 Eosinophils 0.01 0.00-0.05 Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(ACTH, epinephrine, thyroxin
Complete Blood Count ( August 17, 2010)
Date ordered Laboratory exams results Normal values significant
August 17, 2010 WBC 8.7 4.00-10.00 10^9/L Increased- neurosyphilis, anterior poliomyelitis, encephalitis lethargic.
Decreased- leukemia, bone marrow failure, collagen vascular disease, liver and spleen disease, radiation therapy or exposure.
August 17, 2010 RBC 3.25 4.50-6.50 10^12/L Decreased-
iron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary
anemia, free radical pathology, toxic metals, catabolic methabolism. Increased-
chronic respiratory insufficiency, emphysema, respiratory distress, living at a high altitudes, cystic fibrosis (non-respiratory)
August 17, 2010 HGB 93.00 130.00-170.00 g/L Decreased in various anemias, pregnancy, severe of prolonged hemorrhage, and with excessive fluid intake.
Increased in polycythemia, chronic obstructive pulmonary disease, failure of oxygenation because of congestive heart failure, and normally in people living at high altitudes
August 17, 2010 HCT 0.30 0.40-0.54 Decrease in severe anemias, anemia in pregnancy, acute massive blood loss.
Increased in erythrocytosis of any cause, and in
dehydration or hemoconcentration associated with shocks.
August 17, 2010 MCV
August 17, 2010 MCH
August 17, 2010 MCHC
August 17, 2010 PLT Increase 150.00-350.00 10^9/L Increased in malignancy, myeloproliferative disease, rheumatoid arthritis, and postoperativerly; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy; decreased in thrombocytopenic purpura, acute leukemia, aplastic anemia, and during cancer chemotherapy
August 17, 2010 Lymphocytes 0.18 0.25-0.50 Increase with infectious mononucleosis, viral and some bacterial infections, hepatitis; decreased with aplastic anemia, SLE, immunodeficiency including AIDS.
August 17, 2010 Monocytes 0.01 0.02-0.10 Increase with viral infections, parasitic
disease, collagen and hemolytic disorder; decreased with use of corticosteroids, RA, HIV infection.
August 17, 2010 Neutrophils 0.79 0.50-0.80 Increase with acute infection, trauma or surgery, leukemia, malignant disease, necrosis; decrease with viral infections, bone marrow suppression, primary bone marrow disease.
August 17, 2010 Eosinophils 0.02 0.00-0.05 Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(ACTH, epinephrine, thyroxin
Complete Blood Count ( August 14, 2010)
Date ordered Laboratory exams results Normal values significant
August 14, 2010 WBC 9.2 4.00-10.00 10^9/L Increased- neurosyphilis, anterior poliomyelitis, encephalitis lethargic.
Decreased- leukemia, bone marrow failure, collagen vascular disease, liver and
spleen disease, radiation therapy or exposure.
August 14, 2010 RBC 3.69 4.50-6.50 10^12/L Decreased-
iron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary anemia, free radical pathology, toxic metals, catabolic methabolism. Increased-
chronic respiratory insufficiency, emphysema, respiratory distress, living at a high altitudes, cystic fibrosis (non-respiratory)
August 14, 2010 HGB 110.00 130.00-170.00 g/L Decreased in various anemias, pregnancy, severe of prolonged hemorrhage, and with excessive fluid intake.
Increased in polycythemia, chronic obstructive pulmonary disease, failure of oxygenation because of congestive heart failure, and normally in people living at high altitudes
August 14, 2010 HCT 0.33 0.40-0.54 Decrease in severe anemias, anemia in pregnancy, acute massive blood loss.
Increased in erythrocytosis of any cause, and in dehydration or hemoconcentration associated with shocks.
August 14, 2010 MCV
August 14, 2010 MCH
August 14, 2010 MCHC
August 14, 2010 PLT Adequate 150.00-350.00 10^9/L Increased in malignancy, myeloproliferative disease, rheumatoid arthritis, and postoperativerly; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy; decreased in thrombocytopenic purpura, acute leukemia, aplastic anemia, and during cancer chemotherapy
August 14, 2010 Lymphocytes 0.17 0.25-0.50 Increase with infectious mononucleosis,
viral and some bacterial infections, hepatitis; decreased with aplastic anemia, SLE, immunodeficiency including AIDS.
August 14, 2010 Monocytes 0.04 0.02-0.10 Increase with viral infections, parasitic disease, collagen and hemolytic disorder; decreased with use of corticosteroids, RA, HIV infection.
August 14, 2010 Neutrophils 0.78 0.50-0.80 Increase with acute infection, trauma or surgery, leukemia, malignant disease, necrosis; decrease with viral infections, bone marrow suppression, primary bone marrow disease.
August 14, 2010 Eosinophils 0.01 0.00-0.05 Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(ACTH, epinephrine, thyroxin
Complete Blood Count ( August 9, 2010)
Date ordered Laboratory exams results Normal values significant
August 9, 2010 WBC 10.10 4.00-10.00 10^9/L Increased-
neurosyphilis, anterior poliomyelitis, encephalitis lethargic.
Decreased- leukemia, bone marrow failure, collagen vascular disease, liver and spleen disease, radiation therapy or exposure.
August 9, 2010 RBC 4.50 4.50-6.50 10^12/L Decreased-
iron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary anemia, free radical pathology, toxic metals, catabolic methabolism. Increased-
chronic respiratory insufficiency, emphysema, respiratory distress, living at a high altitudes, cystic fibrosis (non-respiratory)
August 9, 2010 HGB 129.00 130.00-170.00 g/L Decreased in various anemias, pregnancy, severe of prolonged hemorrhage, and with excessive fluid intake.
Increased in polycythemia,
chronic obstructive pulmonary disease, failure of oxygenation because of congestive heart failure, and normally in people living at high altitudes
August 9, 2010 HCT 0.42 0.40-0.54 Decrease in severe anemias, anemia in pregnancy, acute massive blood loss.
Increased in erythrocytosis of any cause, and in dehydration or hemoconcentration associated with shocks.
August 9, 2010 MCV 94.00 80.00-100.00 fl Increase in macrocytic anemias;
decrease in microcytic anemia
August 9, 2010 MCH 28.70 27.00-32.00 pg Increase in macrocytic anemias;
decrease in microcytic anemia
August 9, 2010 MCHC 305.00 320.00-360.00 g/L Decreased in severe hypocromic anemia.
Increased and decreased is same with MCV two
exceptions in spherocytosis, the MCHC is elevated but not in pernicious anemia
August 9, 2010 PLT Increase 150.00-350.00 10^9/L Increased in malignancy, myeloproliferative disease, rheumatoid arthritis, and postoperativerly; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy; decreased in thrombocytopenic purpura, acute leukemia, aplastic anemia, and during cancer chemotherapy
August 9, 2010 Lymphocytes 0.23 0.25-0.50 Increase with infectious mononucleosis, viral and some bacterial infections, hepatitis; decreased with aplastic anemia, SLE, immunodeficiency including AIDS.
August 9, 2010 Monocytes 0.02 0.02-0.10 Increase with viral infections, parasitic disease, collagen and hemolytic disorder; decreased with use of corticosteroids, RA,
HIV infection.
August 9, 2010 Neutrophils 0.75 0.50-0.80 Increase with acute infection, trauma or surgery, leukemia, malignant disease, necrosis; decrease with viral infections, bone marrow suppression, primary bone marrow disease.
August 9, 2010 Eosinophils 0.00 0.00-0.05 Increase in allergy, parasitic disease, collagen disease, subacute infections; decrease with stress, use of some medications(ACTH, epinephrine, thyroxin
August 18, 2010
BLOOD TYPING
Specimen: Blood
Result: “AB” Positive
August 15, 2010
ELECTROCARDIOGRAM
Interpretation: Non-specific ST-T wave changes
August 15, 2010
X-RAY
Interpretation:
-There is unchanged appearance of the fibrosis on the right upper lobe since 7/11/10.
-Suspicious thin walled lucency is seen in the left apex w/c may represent a bulla.
-Suggest apicolordotic view
-Heart is not Enlarged
-Diaphragm & costophrenic sulci are intact.
August 10, 2010
CT SCAN SECTION
Interpretation: CT KUB Stonogram
-Follow up to 07.12.10 shows increase in size of the previously noted
right supra renal mass now measuring 4x6 cm w/ previous
measurement of 3.2x4.7cm. There is likewise increase in size of the
previously noted mass
in the perivical & right psoas region now measuring
7x10 cm w/ previous measurement of 5.6x5 cm now showing signs
of central necrosis.
-Right perirenal fat stranding, pelvocalectasis & proximal ureterectasis
is also noted.
The inferior vena cava, right psoas & right ureter appear is
is to be encased by the mass. Subcentimeter mesenteric adenopathies
are likewise noted.
-The stomach is distended w. no intraluminal mass.
-The liver, gall bladder, pancreas. Left adrenal, left kidney & spleen
are unremarkable.
- Negative for pelvic mass nor adenopathies.
- No other finding of note.
IX. Drug Study
Date Ordered
MedicationGeneric Brand
Action Indication Nursing Considerations
08-09-10 Ketorolac tromethamineRemopain30 mgQ8°PRN
NSAID. Acts on cyclooxigenase route, inhibits prostaglandins synthesis
Short-term (≤ 5 days) management of moderate and severe acute pain that requires analgesia at the opioid level.
- Treatment should not exceed 5 days- Food decreases the absorption rate
08-12-10 TramadolTramal50 mgSTATPO
Analgesic. Binds to mu-opiod receptors and inhibits the reuptake of norepinephrine and serotonin
Relief of moderate to severe pain; Patient experienced surgery-related pain.
- Control environment (temperature, lighting) if sweating or CNS effects occur- Report severe nausea, dizziness, sever constipation
08-16-10 CefuroximeZinacef750 mgIVANST (-)
Antibiotic. 2nd generation cephalosporin. Inhibits synthesis of bacterial cell wall, causing cell death.
Perioperative prophylaxis. Surgery – Jejunostomy tube insertion on August 16
- Given 30-60 minutes prior to initial incision- May experience stomach upset or diarrhea
08-21-10 Metformin Antidiabetic. Exact Adjunct to diet to - Monitor for blood glucose
hydrochloride.Metformin500 mg½ tabBIDPO
mechanism not understood. Perhaps increases peripheral utilization of glucose, decreases hepatic glucose production, and alters intestinal absorption of glucose
lower blood glucose with type 2 DM. Patient has had DM for six years.
and ketones as prescribed- Report fever, sore throat, unusual bleeding or bruising, rash, dark urine, light-colored stools, hypo/hyperglycemia reactions
08-23-10 Conzace1 capODPO
Multivitamin.Vitamin supplement of vitamins A, C, E, and zinc.
Extra vitamins A, C, E, and zinc to fight infection and promote wound healing post-op.
- Assess for nutritional deficiencies
08-24-10 EtoricoxibArcoxia1 tabSTATPO
cyclooxygenase-2 (COX-2) specific inhibitors aka Coxibs. Reduces pain and inflammation by blocking COX-2.
Relief of acute pain. Treatment of acute gouty arthritis. Relieves pain and inflammation with less risk of stomach ulcers compared to NSAIDS.
- Swallow them with a glass of water. Do not cut the tablet in half- Take the same time daily- It does not matter if taken before or after food
Date Ordered
Medication Action Indication Nursing Consideration
8/09/10 Generic Name: omeprazoleBrand Name: Omepron40mg/IVSTAT
-Binds to an enzyme on gastric parietal cels in the presence of acidic gastric pH, preventing the final transport of hydrogen ions to the gastric lumen.- THERAPEUTIC EFFECT: anti ulcer agents.-PHARMACOLOGIC ACTION: proton-pump inhibitors
GERD/maintenance of healing in erosive esophagitis. Duodenal ulcers. Short-term treatment of active benign gastric ulcer. Reduction of risk of GI bleeding in critically ill patients
-Assess patient routinely for epigastric or abdominal pain and frank or occult blood, stool, emesis,
8/09/10 Generic Name: metoclopramideBrand Name:Plasil1ampq8 PRN
-Block dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of the upper GI tract and accelerates gastric emptying.
Treatment of postsurgical and diabetic gastric stasis. Facilitation of small bowel intubation in radiographic procedures. Management of
-Assess patient for N/V, abdominal distention, and bowel sounds before and after administration.
-THERAPEUTIC EFFECT: antiemetics
gastroesophageal reflux. Treatment and prevention of post operative N/V when nasogastric suctioning is undesirable.
8/09/10 Generic Name: bisacodylBrand Name: Dulcolax supp1suppSTAT
-Stimulates peristalsis. Alters fluid and electrolyte transport, producing fluid accumulation in the colon.-THERAPEUTIC EFFECT: Laxatives-PHARMACOLOGIC ACTION: stimulant laxatives
Treatment of constipation.
-Assess patient for abdominal distention, presence of bowel sounds, and usual pattern if bowel function.-Assess color, consistency, and amount of stool production.
8/11/10 Generic Name: allopurinolBrand Name:N/A1tab OD
-Inhibits the production of uric acid by inhibiting the action of xanthine oxidase.-THERAPEUTICE EFFECT: antigout agents-PHARMACOLOGIC ACTION: xanthine oxidase inhibitors.
Prevention of attack of gouty arthritis and nephropathy.
-Monitor I/O ratios. Decreased kidney function can cause drug accumulation and toxic effects.-Assess patient for rash and more severe hypersensitivity reaction. Discontinue allopurinol if rash occurs.
8/11/10 Generic Name: itoprideBrand Name: Ganaton Tab1tab TID
- Itopride increases acetylcholine concentrations by inhibiting dopamine D2 receptors and acetylcholinesterase. Higher acetylcholine increases GI peristalsis, increases the lower esophageal sphincter pressure, stimulates gastric motility, accelerates gastric emptying, and improves gastro-duodenal coordination.-THERAPEUTIC EFFECT: antiemetic
Itopride hydrochloride is used in the treatment of gastrointestinal symptoms of functional, nonulcer dyspepsia (chronic gastritis) i.e., sensation of bloating, early satiety, upper abdominal pain or discomfort, anorexia, heartburn, nausea and vomiting.
- Watch out for some common side-effects of itopride; rash, diarrhea, giddiness, exhaustion, back or chest pain, increased salivation, constipation, abdominal pain, headache, sleeping disorders, dizziness, galactorrhea, and gynecomastia.
8/11/10 Generic Name: tramadol + paracetamolBrand Name: Dolcet
Pharmacological:-Analgesic, Muscle Relaxants and Uricosurics MOA:-Centrally acting analgesic not chemically
Vasodilation; dizziness, vertigo, H.A, stimulation, anxiety confusion nervousness, sleep disorders, seizures, N&V, Diarrhea
-Assess pt’s pain (location, type and character) before therapy,and regularly thereafter to monitor drug effectiveness.-Assess for
related to mu-opioids receptors a inhibits reuptake of norepinephrine and serotonin.INDICATIONS:Moderate to Severe pain
hypersensitivity reactions: pruritus, rash, urticaria -Monitor for CNS changes: dizziness, drowsiness-Monitor I&O ratio and check for decreasing output w/c may indicate retention.
Nursing Care Plans
Risk for impaired skin integrity
Assessment Planning Intervention Evaluation
Subjectivenone
ObjectiveThe patient manifested dry skin.
Diagnosis:Risk for impaired skin integrity r/t dry skin and behaviors that may lead to skin integrity impairment.
After 1-2 hours of nursing intervention the client and the relatives will be able to verbalize understanding of individual factors that may contribute to possibility of skin integrity impairment and takes steps to correct the situation.
Establish rapport
R: to gain client and relative’s trust.
Provide health teachings regarding the importance of maintaining an intact and moist skin.
R: To evaluate patient’s which may contribute to skin breakdown.
Teach the relative to givethe client a balance, andnutritious food especiallyfoods rich in Iron andvitamin C
R: To increase the relative’s knowledge thus prevention of skin breakdown is realized and taken into consideration by the relative.
After 1-2 hours of nursing intervention the client and the relatives shall have verbalized understanding of individual factors that contribute to possibility of skin integrity impairment and takes steps to correct the situation.
Subjective:
“Medyo nanghihina ako” as verbalized by the patient
After 3-4 hours of nursing intervention the family members
I: Record the patient’s weight regularly.
The patient’s family members or relatives are able to understand what
Objective:
Before hospitalization
Weight: 60kg
Height: 167.6
BMI: 20.8
During hospitalization
(OF: 1800kcal/day)
Weight: 50kg
Height: 167.6
BMI: <18.5 or 17.3
Nursing Diagnosis:
Imbalanced Nutrition:
Less than body requirement related to weight loss.
and other relatives will be able to recognize the foods or the type of diet that will regain the patient’s appetite and demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.
R: This ensures accurate record of weight changes.
I: conduct nutritional assessment.
R: It’s critical that the health care provider openly discuss and have an understanding on complex food and weight related to behaviors of the patient so that appropriate supports can be integrated into the treatment plan.
I: Asses cardiovascular metabolic, renal, gastric hematological and endocrine system.
R: This assessment provides data on the severity of malnutrition
would be the appropriate diet, behavior and lifestyle that could regain patient’s appetite.
Imbalanced Nutrition
Fluid volume deficit
Assessment Planning Intervention Evaluation
Subjective
“Nanunuyo ang labi ko , nararamdaman ko makapal ang labi ko at uhaw” as verbalized by the patient
Objective
Weakness
Dehydration
Decreased skin turgor
Decreased urine output
Weight loss
Diagnosis:
Fluid volume deficit related to dehydration
After 1-2 hours of nursing intervention the patient will demonstrate adequate fluid balance and will show moist mucus membrane.
Monitor and record vital sign
R: to obtain baseline data
Assess patient’s condition
R: to be aware of the patient’s condition and feeling
Monitor input and output balance
R: to ensure accurate fluid status
Maintain adequate hydration increase fluid intake.
R: to prevent dehydration and maintain hydration status
Provide oral care
R: to prevent from dryness
Restrict solid food intake as indicated
R: to allow for bowel rest and to reduce intestinal workload
Discuss individual risk factors or potential and specific interventions
After 1-2 hours of nursing intervention the patient shall have reported understanding of causative factors for fluid volume deficit
R: to prevent or limit occurrence of fluid deficit
RISK FOR INFECTION
Assessment Planning Intervention EvaluationSubjectivenone
Objective*T- 36.5*P- 110bpm*R- 18bpm*BP- 120/80 mmHg
*With NGT and Jejunostomy tube.
Diagnosis:Risk for infection related to post surgical incision.
After 2-3 hours of nursing intervention the patient and his relatives will have enough knowledge on how to prevent infection.
IndependentMonitor vital signs and records
R: To provide baseline data for comparison. Elevation in rates may signal infection
Assess insertion site for signs of infection
R: To check for skin integrity and identify need for further management
Provide regular wound
R: To promote comfort and hygiene. To prevent growth of microorganisms in dressings, tube
Change linens and pt’s robes
R: To promote comfort and hygiene. To prevent growth of microorganisms in linens and robes
Encourage patient to verbalize any untoward feelings esp. discomfort or pain on
After 2-3 hours of nursing intervention the patient and his relatives had enough knowledge on how to prevent infection.
operative/insertion site
R: To allow continuous monitoring and assessment of patient condition
DependentAdminister antibacterial antibiotics as ordered
R: Inhibits bacterial wall synthesis making the pathogen vulnerable to changing osmotic pressures thereby rendering microorganism weak until it dies.
X. Evaluation
Medication: Continue prescribed medications for PULMONARY TUBERCULOSOS, and be aware of their complications.
These include:
- Allopurinol 300mg/ tab 1 tab once a day- Conzace 1 cap once a day- Dolcet 1 tab every 8 hours- Etoricoxib (arcoxia)
Exercise: Avoid strenuous activities, such as heavy lifting and any other extreme sports or activities that may trigger an increase in heart rate. After recovery if the patient discharged the patient should start with short slow walks for about 10-15 minutes and with time gradually increase the duration and intensity of the walk. Patient should also be advised to “take it easy” to do activates that their body can handle.
Treatment: Educate the patient how to properly take the medications and explain the action of it and the considerations to be taken during medication intake.
Hygiene: Educate patient to practice proper hygiene to prevent any further complications and avoid any further infections.
Out Patient: Remind patient about upcoming check ups needed to increase the patients health. Also advice patient about any further appointments that need to be made. Educate the patient about physical limitations and the time needed to make a full recovery before resuming normal activates before hospitalization.
Diet: Avoid foods that will cause constipation and strain during bowel movements. Stick to a soft diet such as pureed diet to ease the digestion process to avoid any further complications with the patient’s condition.
Spiritualism – joining to some activities like bible studies and attending events to further develop the client’s condition after being discharged from the hospital.
Prognosis
The client’s prognosis is not good because it shows in his body that he looks weak and tired
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