ILIGAN MEDICAL CENTER COLLEGECollege of Nursing, Midwifery and Health AideSan Miguel Village Pala-o, Iligan City

Submitted to:

Rogelio Franco, RN

Submitted by:

Abucay, Julius Cezar Mandalones, Ami Lou

Belarmino, Genevieve Mutia, Jocelle

Labayo, Aimee Liza Moscoso, Renante

Largo, Greeck John Nillama, Eleonor

Loking, Celesty Ivy Sabayle, Maila Angela

Macataman, Settie Naillah Unabia, Louella Jo

A CASE PRESENTATION

in

Constricting, Ulcerating Mass partially obstructing the Lumen @ 25-30 cm

from the anus.

IntroductionMany people believe that CONSTIPATION is the

inability to have a daily bowel movement. In fact, it’s not necessary to have a bowel movement everyday. For some, regularity means having a bowel movement three times a week. For others, it may be three times a day. Chronic constipation refers to bowel movements that occur infrequently-generally less than three times a week- and in which the stool is hard and difficult to pass.

Alterations in the speed at which waste passes through the colon or in the amount water removed from the waste can affect normal bowel function and cause chronic constipation. The condition can also occur from use of medications such as codeine-containing pain relievers, and Aluminum-containing antacids, including some drugs used to treat Parkinson’s disease, Depression, Hypertension and some heart disorder. In addition, constipation often becomes more common with age. It may also be because of obstruction to the passage of stool.

Diagnostic test may include:

Colonoscopy or sigmoidoscopy examination and a barium X-ray. Signs and symptoms may include: Occasionally, abdominal bloating and discomfort, An intense urge to have a bowel movement, An inability to have a bowel movement, Rectal pain and abdominal cramping, Nausea and vomiting

An intestinal obstruction is a partial or complete blockage in either the small intestine or colon. It prevents contents from completing their journey through the intestines.

If you have a blockage in your intestine, you may feel cramp-like pain in the middle of your abdomen and have bouts of vomiting. Failure to pass feces can occur no matter how high up the obstruction is located. If your intestine is totally blocked, you may not be able to pass gas. A partial intestinal obstruction may stimulate your intestine to contract and secretes more fluid that can be absorbed, which may result in diarrhoea.

A dramatic feature of abdominal obstruction is abdominal distension. The abdomen will protrude more and more as the condition worsens. The swelling is produced by intestinal gas and fluid trapped within the obstructed segment of the intestine.

Several things can cause an obstruction. The most common cause in the small intestine is scar tissue (adhesion) from a prior operation. Hernias and a knotted or twisted intestine (volvulus) are also common causes of small bowel obstruction. In the colon, a tumor may create a blockage. These are called mechanical obstruction because they physically block movement of contents through the bowel.

Sometimes, abdominal swelling (distention) and an inability to have a bowel movement result not from a physical blockage but from failure of the intestine to move waste along the digestive tract. This is called adynamic (paralytic) ileus and sometimes occurs after an abdominal injury or operation. Other causes include pancreatitis, peritonitis, injury to the abdominal blood supply and metabolic disturbances, such as low blood potassium levels. Narcotics such as morphine also may result in adynamic ileus.

If the obstruction blocks the blood supply to the intestine, the tissue may begin to die. This increases the possibility of gangrene or perforation of the intestine. Both are life threatening.

A doctor may begin treatment by placing a small tube through your nose and into your stomach or small intestine. Suction is applied to remove intestinal secretions and air through the tube (nasogastric suction). This often relieves distension of the abdomen. Lost fluids are replaced with intravenous feedings. Sometimes, the cause of an obstruction resolves spontaneously after the swelling has been relieved. If the obstruction doesn’t resolve, surgery may be necessary to correct the blockage, such as removal of scar tissue or untwisting the intestinal knot. An underlying cause may then be identified.

Patient’s ProfileMr. X, is a 79 years old male patient of Dr. Uy Hospital, born in June

28, 1930, residing at Ubaldo Laya, Iligan City. He was admitted last August 13, 2009 at 2:45 pm, under the service of Dr. Maramara. He was admitted due to the chief complaint of constipation.

Patient X usually went to sleep at 8-9pm and wakes up at 4:30am. He opens his sari-sari store early morning and went to the market to buy fish to grill, his favorite meal. He is very independent at his age, walks to the market without companion. He loves to move around the house without assistance, he even chops logs and sweeps the floor.

Just recently, patient began to lose his appetite and seldom eats his meal and started to lost weight. He complained of abdominal pain and swelling of the stomach.

A few days prior to his admission, patient was constipated for a week and was vomiting. He is positive of DM and is hypertensive. He was given Dulcolax and Castor Oil to relieve his constipation but to no avail prompted his family to bring him in for confinement.

Past Health Status General Health Patient is well-groomed with normal skin color, even complexioned, conscious, oriented to time

and place. Dress in appropriate for age, gender and weather. Patient has normal affect; facial features are symmetric with movement. He has hypertension and intestinal obstruction but able to ambulate with assistance.

Prophylactic Medical/ Dental Care The patient visits his dentist twice a year. Childhood Illness Patient has experienced chicken pox, colds, cough, fever, during his childhood years. Immunizations Patient has No immunizations done since childbirth. Major Illness/ Hospitalizations None Current Medications Patient has No Prescribed and Pon-Prescribed medications. Allergies Patient has no known allergies. Habits Patient occasionally drinks alcohol and no caffeine, drugs or tobacco habits. II. NUTRITION – METABOLIC PATTERN Appetite The patient has good appetite and able to consumes 90 % of his meal. Usual Daily Menu Breakfast Rice, fish, coffee Dinner vegetable, rice, hot soup or tinola Lunch hot soup or tinola, vegetable, rice Snacks juice, bread

III. ELIMINATION PATTERN Bowel Patient has difficulty defecating PTA. Bladder Patient urinates 3-4 times a day before admission. He used to have a urinary catheter before the

operation was done. IV. ACTIVITY – EXERCISE PATTERN Self – Care Ability _____0_____ Feeding ______II____ Toileting _____II_____ Dressing ______II_____ Home Maintenance ______II____ Shopping _____II_____ Grooming _____II_____ Bathing ______II_____ Bed Mobility _____II_____ Cooking _____II_____ General Mobility Legend: Function Level’s Code O - Full Self Care I - Requires use equipment of device II - Requires assistance or supervision III - Requires assistance or supervision from another personal equipment device IV - Is dependent and does not participate Oxygenation/ Perfusion Cardiac Risk Factors ( If applicable ) Positive Negative Not Known 1. Sedimentary life style _______ ____√___ ________ 2. Hypertension ___√____ ________ ________ 3. Obesity _______ ____√___ ________ 4. Hyper-vigilant personality _______ ____√___ ________ 5. Hyper-lipidemia _______ ____√___ ________ 6. Family history of heart disease _______ ____√___ ________ 7. Diabetes _______ ____√___ ________ 8. Cigarette smoking _______ ____√___ ________

V. SLEEP & REST PATTERN The patient has decreased sleep and rest pattern. The patient is easily aroused with

increase environment stimulation and still adjusting to the new environment. VI. COGNITIVE – PERCEPTUAL PATTERN Hearing - Patient has decreased hearing ability. Words need to be expressed

clearly and slowly. Vision - Patient has decreased visual acuity and use eye glasses when reading. Sensory Perception - Patient able to identify hot from cold and able to report any

pain. Learning Style - Patient is oriented to date, time, and place. VII. SELF – PERCEPTION/ SELF-CONCEPT PATTERN Patient has positive outlook toward his illness. His thinking that he will recover easily

with the help of God. VIII. ROLE – RELATIONSHIP PATTERN The patient has a good relationship toward his wife and children. IX. SEXUALLY – REPRODUCTIVE PATTERN The patient is no longer sexually active since he acquire his diseases. X. COPING-STRESS TOLERANCE PATTERN He enjoyed the company of his wife and children. Whenever he encounters problem

he openly shares it to his family. Patients mood is good with normal affect. XI. VALUE – CENTER PATTERN The whole family visits the church every Sunday to ask for spiritual growth and

guidance.

PHYSICAL EXAMINATION I. GENERAL SURVEY VITAL SIGNS Temperature 36.3 °C Pulse Rate/ Cardiac Rate 73 bpm Respiratory rate 21 cpm Blood Pressure 160/90 II. INTEGUMENTARY Skin : Color brown complexion Abnormalities

none Mucous membrane: pale, dry mucous membrane Nails : short nails, less than 3 seconds capillary refill Hair

Distribution : equally distributed Appearance : black and some part of it are gray Hygiene :good hygiene

III. HEENT Head : Shape normocephalic Eyes : Color ( optic disk & conjunctive ) :pale conjunctiva Visual acuity : Decrease and uses eyeglasses when reading Pupil Response: Constricted with the use of penlight. Accomodation : PERRLA

Ears : Symmetry : symmetrical Discharge/ Growth : none Hearing Ability : Poor hearing ability. Words needs to be

expressed clearly and slowly. Nose : Mucosal condition intact

Discharge Growth : none Mouth/ Throat/ Pharynx/ Teeth: ( Color/ Lesions/ Smoothness/ Presence of

Cavity ) : Absence of lesions & Smooth Oral Cavity, Presence of some cavities on teeth.

Face : Symmetry symmetrical IV. Neck / Lymph Nodes Symmetry : symmetrical; Growth : none v. Pulmonary ( Breath & Sounds ) Normal : clear breath sounds; Abnormal (please specify) : none VI. Breast and Axillary areas : Symmetry symmetrical Growth none Discharge none VII. Cardiovascular Rhythm normal Rate 21 bpm

Rhythm normal Rate 21 bpm VIII. Peripheral / vascular Peripheral Pulse ( state if equal – bilaterally ) Legend : Peripheral Pulse Scales Grade ______4______Temporal equally bilateral Grade ______4______Carotid equally bilateral 0 – Absent Grade ______4______Bronchial equally bilateral 1 – markedly

diminished Grade ______4______Radial equally bilateral 2 – moderately

diminished Grade ______4______Femoral equally bilateral 3 – slightly

diminished Grade ______4______Popliteal equally bilateral 4 - normal Grade ______4______Posterior Tibialis equally bilateral Grade ______4______Dorsalis Pedis equally bilateral IX. Abdomen General contour : Semi-hard to touch Tenderness : Non-tender to touch Bowel Sounds : Bowel sounds are present @ 5-10 min/ min per

quadrant

The DIGESTIVE SYSTEM The human digestive system is a complex series of organs and

glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste.

Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals.

The Digestive Process:

The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules).

On the way to the stomach: the esophagus - After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down.

In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme.

In the small intestine - After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food.

In the large intestine - After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon.

The end of the process - Solid waste is then stored in the rectum until it is excreted via the anus.

The Cardiovascular System Your heart and circulatory system make up your cardiovascular

system. Your heart works as a pump that pushes blood to the organs, tissues, and cells of your body. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. Blood is carried from your heart to the rest of your body through a complex network of arteries, arterioles, and capillaries. Blood is returned to your heart through venules and veins. If all the vessels of this network in your body were laid end-to-end, they would extend for about 60,000 miles (more than 96,500 kilometers), which is far enough to circle the earth more than twice!

The one-way circulatory system carries blood to all parts of your body. This process of blood flow within your body is called circulation. Arteries carry oxygen-rich blood away from your heart, and veins carry oxygen-poor blood back to your heart.

In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygen-poor blood into your lungs and the pulmonary vein that brings oxygen-rich blood back to your heart.

The heart has four separate compartments or chambers. The upper chamber on each side of the heart, which is called an atrium, receives and collects the blood coming to the heart. The atrium then delivers blood to the powerful lower chamber, called a ventricle, which pumps blood away from the heart through powerful, rhythmic contractions.

The human heart is actually two pumps in one. The right side receives oxygen-poor blood from the various regions of the body and delivers it to the lungs. In the lungs, oxygen is absorbed in the blood. The left side of the heartreceives the oxygen-rich blood from the lungs and delivers it to the rest of the body.

Systole The contraction of the cardiac muscle tissue in

the ventricles is called systole. When the ventricles contract, they force the blood from their chambers into the arteries leaving the heart. The left ventricle empties into the aorta and the right ventricle into the pulmonary artery. The increased pressure due to the contraction of the ventricles is called systolic pressure.

Diastole The relaxation of the cardiac muscle tissue in

the ventricles is called diastole. When the ventricles relax, they make room to accept the blood from the atria. The decreased pressure due to the relaxation of the ventricles is called diastolic pressure.

Electrical Conduction SystemThe heart is composed primarily of muscle tissue. A network of nerve fibers coordinates the contraction and relaxation of the cardiac muscle tissue to obtain an efficient, wave-like pumping action of the heart.

1. Sinoatrial node (SA node)

2. Atrioventricular node (AV node)

3. Common AV Bundle

4. Right & Left Bundle Branches

The Sinoatrial Node (often called the SA node or sinus node) serves as the natural pacemaker for the heart. Nestled in the upper area of the right atrium, it sends the electrical impulse that triggers each heartbeat. The impulse spreads through the atria, prompting the cardiac muscle tissue to contract in a coordinated wave-like manner.

The impulse that originates from the sinoatrial node strikes the Atrioventricular node (or AV node) which is situated in the lower portion of the right atrium. The atrioventricular node in turn sends an impulse through the nerve network to the ventricles, initiating the same wave-like contraction of the ventricles.

The electrical network serving the ventricles leaves the atrioventricular node through the Right and Left Bundle Branches. These nerve fibers send impulses that cause the cardiac muscle tissue to contract.

RISK FACTORS: Age. Polyps of the colon, particularly adenomatous polyps Heredity Smoking. Diet. Studies show that a diet high in red meat and low in

fresh fruit, vegetables, poultry and fish increases the risk Physical inactivity. People who are physically active are

at lower risk of developing Virus. Exposure to some viruses (such as particular

strains of human papilloma virus) Inflammatory bowel disease.  

Ingested fluid and food, digestive secretions, and gas accumulate above the obstruction.

The proximal bowel distends, and the distal segment collapses.

Bowel wall becomes edematous and congested

Severe intestinal distention is self-perpetuating and progressive

Intensifying the peristaltic and secretory derangements

Increasing the risks of dehydration and progression to strangulating obstruction.

Signs and symptoms:

Abdominal pain, abdominal distension, Vomiting, Constipation, Unproductive faeces, Bowel Obstruction

 

Laboratory Studies Serology: Date: 8/20/2009 Physician: Dr. Marcella Crossmatching Blood Type “A” Positive Blood Bag Number: 09-148 DUH BB Extraction Date 8/12/09 Expiry Date 9/12/09 Component: Fresh Whole Blood Remarks: Compatible with pts. Blood Group Special Chemistry: CEA (Carcinoembryonic Antigen)

24.6

Normal Value: < 5 mg/ml.

Ultrasound 8/18/09

Exam: Chest PA

Finding:Streaky densities seen at the Right Lung Base. Minimal pleural thickening seen on the Left Lower Lung. No Significant interval change when compared with the previous study done last June 2009.The trachea is at the midline, the heart is Normal in size and orientation. The thoracic Aorta. The Diaphragm is intact. The Castophrenic Sulci are sharp and distinct. Impression: Minimal residual densities. Right lower lung and pleural thickening on the Left base. No significant interval change when compared with the previous study. Radiographically stable. However, clinical correlation suggested.

Atherosclerotic Aorta

Laboratory Examinations

Results Normal Values Significance

8/19/09 FBS

108.5

40-150 mg/dl 150-200 mg/dl 200-500 mg/dl >500 mg/dl

Normal

Sodium 141.1 135-145 mmol/liter

Normal

Potassium 3.00 3.4-5.0 mmol/liter

Decreased

Bleeding Time 3 3-10 minutes Normal Clotting time 4’30” 4-7 minutes Normal Platelet Count 198 130 – 400 x 10

3µ Normal

8/18/2009 Clinical Diagnosis:

1. Essential Hypertension 2. Constipation d/t Constricting and Ulcerating mass 25-30 cm. from the

anus. Reason for Study: To evaluate the cardiac valves and chambers: Dimension DT Normal Function PT Normal Lv (ed) 4.3 4.5-5.0 LVEDV 84 LV(es) 2.5 LVESV 24 RV(ed) 3.5 2.2-4.0 Stroke vol 60 LA(es) 3.3 3.0-3.5 CO 3.9 RA(ed) 3.2 3.5-4.0 EF% 72 55-77 Aorta 3.0 3.5-4.0 FS% 41 28-42 PA 2.3 3.0-4.0 VCF (clr/sec) 1.3 0.8-1.5 IVS(ed) 1.9 0.8-1.1 EPSS 0.8 <=1.0 IVS(es) 2.5 Wall stress <195 LVPW (ed) 1.9 0.8-1.1 <600 LVPW(es) 2.0 LVET 0.32 HR 65

SPECTRAL and COLON FLOW DOPPLER

MAX Velocity STENOSIS REGURGITATION VALVE SYSTOLE DIASTOLE Mean

Gradient

Orifice Area cm2

% RF

O Mild/ Moderate/

Severe Aortic 0.8/ 1.31 2.64/ 6.89 Mitral 0.68/0.86 1.86/ 1.93 14% Tricuspid 0.52/0.58 1.07/ 1.33 Pulmonic 0.81 2.60 PA Pressure

AT: 112

QP:QS DESD AORTA

VSD Doppler:

1. Reverse E/A Ration of the mitral and tricuspid valves indicative of diminished C and R Ventricular compliance respectively.

2. Mosaic color display across the mitral valve into the L Atrium during systole indicative of mitral regurgitation.

3. Red color display across the pulmonic valce into the R ventricular outflow during diastole indicative of pulmonic regurgitation.

4. Normal pulmonary artery pressure.

Conclusion:

1. The left ventriles is concentrically hypertrophied with normal wall motion and contractility.

a. Base – LV – 49 EF – 65% b. Mid – LV – 4.3 EF – 72% c. Apex – LV – 4.3 EF – 66%

2. Reverses E/A ratio of the mitral and tricuspid valves and indicative of diminished left & right ventricular of dimished left and right ventricular compliance respectively.

3. Mitral regurgitation, mild (14%) 4. Pulmonic Regurgitation

Normal Pulmonary Artery Pressure

8/18/09 PT

15.2

11-13 sec.

Increased. Vit. K deficiency, Biliary obstruction, Liver dses,

poor fat absorption. % activity 87 50% INR 1.14 Control Valve 13.3 FBC 150.7 Creatinine 1.08 M:0.9-1.3

mg/dL W:0.6-1.1 mg/dL

Normal

Protein total 61.4 Albumin 24.9 31 - 43

g/ liter Decreased. True decrease in the physiologically active ionized form of Ca++ occurs in many situations, including hypoparathyroidism, vitamin D deficiency, chronic renal failure, magnesium deficiency, prolonged anticonvulsant therapy, acute pancreatitis, massive transfusion, alcoholism, etc.

Globulin 36.5 Globulin is increased disproportionately to albumin (decreasing the albumin/globulin ratio) in states characterized by chronic inflammation and in B-lymphocyte neoplasms, like myeloma and Waldenström's macroglobulinemia. More relevant information concerning increased globulin may be obtained by serum protein electrophoresis.

Decreased globulin may be seen in congenital or acquired hypogammaglobulinemic states. Serum and urine protein electrophoresis may help to better define the clinical problem.

RH Positive

Colonoscopy Date: 8/17/2009 Name: Asparin, Demetrio Dr. Age: 79 yrs old. Address: Iligan City Nationality: Filipino Medications: Fentanyl + Propofol Endoscopy: Dr. J. Kamlian Assist: E. Miquiabas Instrument: GF- EL Indication/ History: Chronic Constipation with Abdominal Pain and Bloatedness

Pre_endoscopic Diagnosis: Colonic Lesion Post- Endoscopic Diagnosis: Constricting, Ulcerating Mass Partially obstructing the lumen at 25-30 cm from the anus.

Hematology 8/13/09 WBC

6.0

4.5-11.0x103/mm3

Normal

RBC 5.1 W 3.9 – 5.2 x 1012/L M 4.4 – 5.8 x 10 12/L

Normal

Hemoglobin 15.3 W 12.0-16.0 g/dl M 13.0-18.0 g/dl

Normal

Hematocrit 0.46 W 36.0% - 46.0% of red blood cells M 37.0% - 49.0% of red blood cells

Normal

Differential Count: Neutrophil

0.82

45%-75% of white blood cells

Increased

Lymphocytes 0.16 16%-46% of white blood cells

Normal

Monocytes 0.02 4-11% of white blood cells

Decreased. Monocytosis is seen in the recovery phase of many acute infections. It is also seen in diseases characterized by chronic granulomatous inflammation (TB, syphilis, brucellosis, Crohn's disease, and sarcoidosis), ulcerative colitis

Ultrasound 8/13/09 Radiological Findings: Moderate mottled/ formed fecal materials colonic segment. No signs of intestinal obstruction nor peritonitis. Minimal hypertrophic degenerative spurs of the lumbar spines. Clinic/ laboratory correlation suggestion.

Urinalysis 8/13/09 Color

Yellow

Yellow

Normal

Reaction 6 Specific Gravity 1.024 5.0-9.0

1.001-1.035 Normal

Albumin trace Sugar Negative Negative Normal Microscopic: Pus cells

0-1 /HPF

RBC 4-6 /HPF M:4.2-5.4 W:3.6-5.0

Normal

Epithelial cells Few Amorphous substances Few

ECG Findings: 8/13/09 Rhythm

Sinus

Rate atria 60 Ventricular 60 PR 0.20 0.12 - 0.20

sec Normal

QRS 0.08 0.06 - 0.10 sec

Normal

QT 0.40 QTc < 0.40 sec

Normal

ECG Diagnosis Sinus Rhythm non-specific STT changes

Sinus tachycardia means normal rhythm at rate above 100. Nervousness accounts for the fast rate. PR interval is the time between contraction of the upper chambers of the heart and contraction of the lower chambers. Short PR is o.k. ST-T is the time between contraction and relaxation of the lower chambers of the heart.

Brand Name/ Generic Name

Date/ Dosage/ Frequency

Indications Action/ Mechanism of Action

Side Effects Nursing Precautions

Nexium

Adult Treatment of erosive reflux esophagitis 40 mg once daily for 4-8 wk. Long-term management of patients w/ healed esophagitis to prevent relapse 20 mg once daily.

Treatment of GERD as an alternative to oral therapy in patients when oral therapy is not appropriate. Short - term maintenace of hemostasis & prevention of rebleeding in patients following therapeutic endoscopy for acute bleeding of gastric or duodenal ulcers.

Esomeprazole is the S-isomer of omeprazole and reduces gastric acid secretion through a specific targeted mechanism of action. It is a specific inhibitor of the acid pump in the parietal cell. Both the R- and S-isomer of omeprazole have similar pharmacodynamic activity.

Headache, abdominal pain, constipation, diarrhea, flatulence, nausea, vomiting. Inj site reaction

Exclude gastric malignancy, severe renal or hepatic impairment. Pregnancy, lactation.

Morphine Sulfate

PO Pain 5-20 mg 4 hrly. Intractable cough associated w/ lung cancer As oral soln: Initial: 5 mg 4 hrly. IV Pain associated w/ MI 10 mg, then a further dose of 5-10 mg if needed.

Pain, intractable cough w/ lung cancer, acute pulmonary edema, unstable angina, chronic pain

Morphine is a phenanthrene derivative which acts mainly on the CNS and smooth muscles. It binds to opiate receptors in the CNS altering pain perception and response.

Convulsions; nausea, vomiting, dry mouth, constipation; urinary retention; headache, vertigo; palpitations; hypothermia; pruritus, urticaria; tachycardia, bradycardia; blurred vision; miosis; dependency; drowsiness; lightheadedness; dizziness; sweating; dysphoria; euphoria.

All patients who have been given morphine must be carefully observed for evidence of respiratory depression. This can be detected as a slow respiratory rate and a very sleepy patient with pin point pupils. Oxygen should be given by face mask, and positive pressure ventilation of the lungs started if necessary. Naloxone, 100-400 micrograms may be given intravenously if available.

Tramal Single dose for adult & adolescent > 14 yr. Tramal cap 50-100 mg. Trmala inj 1. Tramal 100amp or 1-2 Tramal 50amp IM, slow IV, SC, or IV infusion. Tramal Retard 100-200 mg.

Moderate to severe acute or chronic pain & in painful diagnostic or therapeutic measures.

The mode of action of tramadol has yet to be fully understood, but it is believed to work through modulation of the noradrenergic and serotonergic systems in addition to its mild agonism of the μ-opioid receptor. The contribution of non-opioid activity is demonstrated by the fact that the analgesic effect of tramadol is not fully antagonised by the μ-opioid receptor antagonist naloxone.

Sweating, dizziness, muzziness, vomiting, dry mouth. In rare cases, influence on CVS regulation esp after IV administration, headache, retching, vomiting, constipation, GI irritation, skin reactions

Opioid dependence, reduced level of consciousness of unclear origin, resp disorders, increased intracranial pressure. Patients known to suffer from convulsions. Pregnancy & lactation. On long-term use, possibility of tolerance, psychic & physical dependence. May impair ability to drive or operate machinery, esp if taken w/ alcohol

Avodart ADULT:Take one 0.5-milligram capsule once a day. The capsule should be swallowed whole.

Avodart has not been evaluated for use in children under 18.

Treatment of moderate to severe symptoms of benign prostatic hyperplasia (BPH).

Reduction in the risk of acute urinary retention (AUR) and surgery in patients with moderate to severe symptoms ofBPH.

Breast tenderness, decreased sex drive, ejaculation problems, enlarged breasts in males, hives, impotence, itchy spots, rash.

Combination therapy should be prescribed after careful benefit risk assessment due to the potential increased risk of adverse events and after consideration of alternative treatment options including monotherapies.

Betaloc Adults: 50-450 mg/d as a single doe or 2 divided doses. Geriatic: 25-300 mg/d as a single dose or 2 divided doses. IV: Adults: 5 mg q 2min for 3 doses

Oral metoprolol is used in the treatment of high blood pressure, angina pectoris,myocardial infarction and as prophylaxis for migraines. Intravenous therapy: Metoprolol can be given intravenously to treat abnormal heart rhythms.

Metoprolol acts on beta-adrenoreceptors present in the heart slowing the heart rate and decreasing the amount of work the heart has to do. It reduces blood pressure, reduces the frequency of angina attacks and has also been shown to reduce mortality in patients who have had a myocardial infarction by mechanisms that are not completely understood. In patients with abnormal heart rhythms, metoprolol has a regulating effect on the heart rate. Metoprolol has been shown to exert a prophylactic effect in both classical and common migraine.

Gastrointestinal upsets Sleep disturbances Bradycardia Postural disorders Raynaud's phenomenon Palpitations Fatigue Dizziness headache Nausea Diarrhoea Constipation Abdominal pain Dyspnoea on exertion

Extended-release tablets should be swallowed whole; do not crush, break or chew. Additive brachycardia with digoxin. Additive hypotension with other antihypertensives. Altered effectiveness of insulins or oral hypoglycemic agents. Notify health care professional if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, fever, rash , Sore throat, unusual bleeding or bruising occur. Change positions slowly to minimize orthostatic hypotension.

Dynastat The recommended dose is 40 mg administered intravenously (IV) or intramuscularly (IM), followed every 6 to 12 hours by 20 mg or 40 mg as required, not to exceed 80 mg/day. The IV bolus injection may be given rapidly and directly into a vein or into an existing IV line. The IM injection should be given slowly and deeply into the muscle (see section 6.6 for instructions for reconstitution).

For the short-term treatment of postoperative pain. The decision to prescribe a selective COX-2 inhibitor should be based on an assessment of the individual patient's overall risks.

Powder and solvent for solution for injection White to off-white powder Solvent: clear and colourless solution

Aute renal failure, renal failure, myocardial infarction, congestive heart failure, abdominal pain, nausea, vomiting, dyspnoea and tachycardia and Stevens-Johnson syndrome.

Patients with significant risk factors for cardiovascular events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking) should only be treated with parecoxib sodium after careful consideration. Dynastat has been studied in dental, orthopaedic, gynaecologic (principally hysterectomy) and coronary artery bypass graft surgery. There is little experience in

Flagyl Adults: 400 mg 8 hourly during 24 hours immediately preceding operation followed by postoperative intravenous or rectal administration until the patient is able to take tablets.

The treatment of septicaemia, bacteraemia, peritonitis, brain abscess, necrotising pneumonia, osteomyelitis, puerperal sepsis, pelvic abscess, pelvic cellulitis, and post-operative wound infections from which pathogenic anaerobes have been isolated.

Prophylaxis and treatment of infections in which anaerobic bacteria have been identified or are suspected to be the cause.

Encephalopathy (eg. confusion, fever, headache, hallucinations, paralysis, light sensitivity, disturbances in sight and movement, stiff neck) and subacute cerebellar syndrome (eg. ataxia, dysathria, gait impairment, nystagmus and tremor) which may resolve on discontinuation of the drug.

Regular clinical and laboratory monitoring are advised if administration of Flagyl for more than 10 days is considered to be necessary. There is a possibility that after Trichomonas vaginalis has been eliminated a gonococcal infection might persist.

Vitamin K

Vitamin K 10mg slow IV supplemented with fresh frozen plasma. Review INR in 12 hours and repeat vitamin K if necessary.

Management of coagulation disorders when caused by vitamin K deficiency, or interference with vitamin K activity

Hypersensitivity and anaphylactoid reactions including flushing and sweating may occur following rapid IV injection pain, swelling,tenderness at injection site

Nausea, vomiting, loss of appetite, diarrhea, and abdominal pain.

To minimize the possibility of severe reactions following IV administration always dilute the drug with at least 10 mL of diluent and administer as slowly as possible

Erythromycin

500 mg 1 cap tid

This medication is used to treat or prevent a wide variety of bacterial infections. Erythromycin is known as a macrolide antibiotic.

Prevents bacteria from producing proteins, which interferes with bacterial growth and multiplication, while not affecting human cells.

Diarrhea; loss of appetite; nausea; stomach pain; vomiting.

If Generic Erythromycin 500 mg is essential to your health, your doctor may advise you to discontinue breastfeeding until your treatment is finished

CUES NURSING

DIAGNOSIS

PLAN/OBJECTIVE INTERVENTIONS

RATIONALE EVALUATION

S> “ Sakit ako opera” as verbalized by the patient.

O> received patient lying on bed; awake; with ongoing #1 D5LR 1 Liter @ 30 gtts/ min hooked @ right arm infusing well

with nasogastric tube

with O2 inhalation @ 3LPM

with pulse oximeter at right middle finger

With LLQ surgical incision attached to Jackson Pratt draining well

Facial grimace noted when moving

Guarding behavior at the incision site observed

With pain scale of 7 and 10 is the highest

With vital signs of T- 37.5 C,P- 90 bpm, R- 25 cpm, BP- 120/80 mmHg

Acute pain related to surgical incision secondary to sigmoidectomy

After 3 days of thorough nursing care the patient will be able to report pain is tolerable

Assess patient’s sign and symptoms

Determine possible

cause of pain Note location of

surgical procedure Perform pain

assessment each time occurs

Assess for referred pain

Perform Comfort measures to promote relaxation

Plan activities with

patient to provide distraction

Provide patient information to help increase pain tolerance like reasons for pain and length of time it will last

Give pan medication as ordered

Assessment allows plan of care modification as needed

To assess contributing factor

This can influence the amount of postoperative pain experience

To evaluate clients response to pain

To help determine

possibility of underlying organ dysfunctioning requiring treatment

These measures reduce muscle tension or spasm redistribute pressure on body parts and helps pt. focus on non- related subject

To help pt. focus in non-related manner

This educates pt. &

encourages compliance in trying alternative pain relief

To lessen pain and can tolerate movement

CUES PATHOPHYSIOLOGY NURSING DIAGNOSIS

PLAN/OBJECTIVE` INTERVENTION RATIONALE EVALUATION

Subjective – No Subjective cues available Objective – Received pt lying on bed asleep with IVF #8 D5NM 1L @40gtts/min; infusing well. -with v/s T – 36.5 P – 70 R – 20 BP – 140/80

- ascites noted - pitting

bipedal edema noted

> Excess fluid volume related to excess fluid or sodium intake @ retention of fluid because of Heart Failure as evidenced by bipedal edema

>verbalized understanding of individual dietary/fluid restrictions

>Stress need for mobility at or frequent position charges >Evaluate edematous extremities, change position frequently >Provide oral care, chewing gum/hard candy, use of lip balm >Measure abdominal girth >Ascultate breath sounds >Provide quiet environment, limiting external stimuli >Discuss importance of fluid restrictions @ “hidden sources”.

>To prevent stasis at reduce risk of tissue injury. >To reduce to tissue pressure @ risk of skin breakdown >To reduce discomforts of fluid restrictions >To know changes that may indicate increasing fluid retention/edema. >To note presence of crackles/congestion >To promote risk @ prevent fatigue >To prevent increasing fluid retention

CUES NURSING DIAGNOSIS PLAN INTERVETIONS RATIONALE EVALUATION Subjective: “ wala man koy kaon2x, tubig ra ug sabaw” as verbalized by the patient. Objective:

Received lying on bed with #6 D5NM 1 liter at 40 gtts/min, hooked at the right arm.

Passed watery stools for 5 times.

Poor muscle tone noted.

Pale conjunctiva noted.

Decreased subcutaneous fat noted.

Imbalanced nutrition: less than body

requirements related to insufficient intake of

nutrients secondary to dietary restrictions.

After 8 hours of Nursing care, the patient will

demonstrate progressive weight gain toward goal

as indicated.

1. determine ability to chew or swallow, presence of dentures.

2. discuss eating habits, including food preferences, and intolerance.

3. note total daily intake and output.

4. encourage client to choose foods that are appealing.

5. minimize unpleasant odors/sights.

6. provide oral care. 7. give ice chips as

indicated. 8. encourage

adequate fluid intake.

9. consult the dietitian as necessary.

1. these are factors that affect ingestion of food.

2. to appeal to client’s likes and dislikes.

3. this serves as baseline data.

4. stimulate the client’s appetite.

5. may have negative effect on appetite.

6. promote appetite. 7. to prevent drying

of the mouth and also aid in appetite.

8. to prevent dehydration.

9. to know appropriate diet.

On going resolution.

CUES PATHOPHYSIOLOGIC BASIS

NURSING DIAGNOSIS

PLAN/OBJECTIVE INTERVENTIONS RATIONALE EVALUATION

S- “Lisod kau ilihok-lihok, gumikan ani akong samad”, as verbalized by the patient. O-Received patient lying in bed, conscious & coherent with #7 D5NM 1 L @ 40 gtts/min. > pain and discomfort noted upon movement

Operation

(sigmoidectomy)

↓

Skin and tissue destruction and injury

↓

Excessive stimulation of nerve endings

↓

Pain/alteration in comfort

↓

Activity intolerance

Activity Intolerance r/t imbalance between oxygen supply and demand secondary to sigmoidectomy

After 12hours of effective nursing care patient must be able to participate in necessary/desired activities.

To ascertain patient’s ability to stand and move about and degree of assistance necessary. To increase activity levels gradually, but emphasize to client that the faster to ambulate, then the better for post-operation. To place client in a comfortable position and turn from side to side. To place the side rails up and other safe precautions. To teach client deep breathing exercises.

As part of assessment. Tissues heal faster when there is blood circulation and activity. To prevent skin ulcers and bedsores. To prevent injury especially since client is activity intolerant. To maximize oxygen supply.

CUES PATHOPHYSIOLOGIC BASIS

NURSING DIAGNOSIS

PLAN/OBJECTIVE INTERVENTIONS RATIONALE EVALUATION

S- “Lisod kau ilihok-lihok, gumikan ani akong samad”, as verbalized by the patient. O-Received patient lying in bed, conscious & coherent with #7 D5NM 1 L @ 40 gtts/min. > pain and discomfort noted upon movement

Operation

(sigmoidectomy)

↓

Skin and tissue destruction and injury

↓

Excessive stimulation of nerve endings

↓

Pain/alteration in comfort

↓

Activity intolerance

Activity Intolerance r/t imbalance between oxygen supply and demand secondary to sigmoidectomy

After 12hours of effective nursing care patient must be able to participate in necessary/desired activities.

To ascertain patient’s ability to stand and move about and degree of assistance necessary. To increase activity levels gradually, but emphasize to client that the faster to ambulate, then the better for post-operation. To place client in a comfortable position and turn from side to side. To place the side rails up and other safe precautions. To teach client deep breathing exercises.

As part of assessment. Tissues heal faster when there is blood circulation and activity. To prevent skin ulcers and bedsores. To prevent injury especially since client is activity intolerant. To maximize oxygen supply.

Health Teachings

•Teach your patient that frequent laxative use causes contraction of the bowels, as well as electrolyte imbalances, both of which predispose him to obstruction. •The improper use of bulk-forming laxatives increases constipation and blockage when inadequate fluid intake occurs. •Tell him to avoid laxatives and increase fluid intake to promote good bowel hygiene. •Stool softeners will help avoid the need to strain to pass stool, and regular exercise such as walking will strengthen abdominal walls and aid with the passing of stool. •Encourage him to consume a diet rich in fruits and vegetables, which will increase fiber intake with the added bonus of providing vitamins and minerals to accelerate tissue synthesis.•Explain to your patient the purpose of any tubes and clarify the sequence of procedures to alleviate his anxiety. •Advise the patient to engage in the level of activity that's appropriate for his condition. •Teach him how and when to take his prescribed medications. •Counsel the patient to drink plenty of fluids if not contraindicated and when applicable and to choose nutritious foods. •Teach him to recognize signs and symptoms of recurrent problems, such as infection, so he'll know when to seek help from his health care provider.

Prognosis

    Based on the patient condition, prognosis is partially good.

Patient was responsive to the treatment rendered. Patient was undergone to surgery for the best treatment for her and it’s a good sign.  And also Surgical treatment decreased the risk of future admissions for ASBO, but the risk of new surgically treated intestinal obstruction episode was the same regardless of the method of treatment. In addition to the pain related to hospital admissions for ASBO, these patients seem to be more prone to experiencing abdominal pain than the normal population, especially those having matted adhesions.