case presentation- gastro

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,


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 9, 2010 Albumin 30.82 35.00-52.00 G/L Increased-dehydration

Decreased- liver disease, shock, malnutrition,







August 14, 2010 Creatinine 94,3 72.00-127.00 umol/L Increase- mascular dystrophy, fever, carcinoma of liver









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, excessive sweating, kidney

disease,







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


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


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




Decreased- leukemia, bone marrow failure, collagen vascular disease, liver and spleen disease, radiation therapy or exposure.


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)


Increased in polycythemia, chronic obstructive pulmonary disease, failure of oxygenation because of congestive heart failure, and normally in people living at high altitudes


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 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 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.





Decreased- leukemia, bone marrow failure, collagen vascular disease, liver and

spleen disease, radiation therapy or exposure.


iron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary anemia, free radical pathology, toxic metals, catabolic methabolism. Increased-



Increased in polycythemia, chronic obstructive pulmonary disease, failure of oxygenation because of congestive heart failure, and normally in people living at high altitudes


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 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 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.


iron deficiency, vit. B6, b12 or/ and folic acid deficiency, chronic disease, hereditary anemia, free radical pathology, toxic metals, catabolic methabolism. Increased-



Increased in polycythemia,

chronic obstructive pulmonary disease, failure of oxygenation because of congestive heart failure, and normally in people living at high altitudes


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 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 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

http://en.wikipedia.org/wiki/Gynecomastia

http://en.wikipedia.org/wiki/Galactorrhea

http://en.wikipedia.org/wiki/Headache

http://en.wikipedia.org/wiki/Constipation

http://en.wikipedia.org/wiki/Diarrhea

http://en.wikipedia.org/wiki/Rash

http://www.mahalo.com/peristalsis

http://www.mahalo.com/acetylcholinesterase

http://www.mahalo.com/acetylcholinesterase

http://www.mahalo.com/dopamine-receptor-d2

http://www.mahalo.com/dopamine-receptor-d2

http://www.mahalo.com/acetylcholine

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

case presentation- gastro

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