OUR LADY OF FATIMA UNIVERSITYValenzuela Campus

CASE STUDYS/P Exlap Double Barrel Colostomy, Distal Transrectal Biopsy for Intestinal Obstruction

Armed Forces of the Philippines Medical Center

Submitted by: Carmela Marie J. Estanislao BSN 4Y1-3

Clinical InstructorI.INTRODUCTIONII.LEARNING OBJECTIVESUpon completion of our affiliation here at Armed Forces of the Philippines Medical Center I will be able: To gain newinformation about the patients disease and its etiology, pathophysiology, clinical manifestations as well as the standard medical andnursing management so that wemay applythis newly-acquired knowledge to our patient as well as similar situations in the futureIII.PATIENT PROFILEName: M.DAge: 13 y/oCivil Status: SingleAddress: Date Admitted: Time Admitted: Sex: MaleReligion: CatholicDiagnosis:

IV.PATIENT HISTORYHISTORY OF PRESENT ILLNESS

FAMILY HISTORY (-) Cancer (+))Hypertension (-) DM (-) AllergyV.ANATOMY AND PHYSIOLOGYColon and RectumThe large intestine is a hollow tube that makes up the last 6 feet of the digestive tract. It is often referred to as the large bowel or colon (which is technically just one part of the large intestine). The large intestine consists of the cecum (a pouch-like structure at beginning of the large intestine), colon, rectum and anus. The colon and rectum are next to other organs, including the spleen, liver, pancreas, and reproductive and urinary organs. Each of these organs can be affected if colorectal cancer spreads beyond the large intestine.

StructureThe colon begins at the cecum, where it joins the end of the small intestine (ileum). The colon changes to rectal tissue in its last 6 inches. Because there is not a clear border between the colon and rectum, colon and rectal cancers are grouped together as colorectal cancer.The colon is divided into 4 parts: Ascending colon begins at the cecum, where it joins the end of the small intestine, and travels upward along the right side of the body to the transverse colon Transverse colon connects the ascending colon to the descending colon and lies across the upper abdomen Descending colon connects the transverse colon and the sigmoid colon and lies along the left side of the body Sigmoid colon connects the descending colon and the rectum

The colon and rectum are made up of a number of different tissues organized into layers: mucosa inner lining (epithelium), lamina propria (connective tissue) and thin layer of muscle (muscularis mucosa) submucosa connective tissue, glands, blood vessels, lymphatic vessels and nerves muscularis propria (muscular layer) serosa (serous layer) outer lining of the colon but not the rectum

Mesentery is a fold of tissue that connects organs to the body wall. Part of the colon is connected to the abdominal wall by mesentery. The upper two-thirds of the rectum is also covered by mesentery called the mesorectum. The mesentery is made up of fatty connective tissue that contains the blood vessels, nerves, lymph nodes and lymphatic vessels that supply the colon. When surgeons remove part of the colon or rectum to treat cancer in these areas, they will remove the mesentery next to these organs as well. The lymph nodes within the removed mesentery will be examined to see if they contain cancer.FunctionThe main functions of the colon and rectum are to absorb water and nutrients from what we eat and to move food waste out of our body. The colon receives partially digested food, in a liquid form, from the small intestine. Bacteria (bowel flora) in the colon break down some materials into smaller parts. The epithelium absorbs water and nutrients. It forms the remaining waste into semi-solid material (feces or stool). The epithelium also produces mucus at the end of the digestive tract, which makes it easier for stool to pass through the colon and rectum. Sections of the colon tighten and relax (peristalsis) to move the stool to the rectum. The rectum is a holding area for the stool. When it is full, it signals the brain to move the bowels and push the stool from the body through the anus.

VI. PATHOPHYSIOLOGY

VII.LABORATORYCHEMISTRY TEST

Interpretation: Blood Urea Nitrogen (BUN) - Urea, which is normally excreted by the kidney, is a by-product of protein metabolism.1. High levels of BUN may be the result of a high protein diet, dehydration, ulcers in the digestive tract, kidney disease, or blockage of the normal flow of urine (from a kidney or bladder stone, for example).2. Low BUN levels can result from a low protein diet or liver disease. Calcium- This mineral is normally found in the body, and is important for normal muscle and heart function.1. High calciumlevelsoccurin some types of cancer, bone disease, parathyroid problems, and kidney diseases. A variety of other conditions may also cause an elevated calcium level.2. Low calcium levels can occurin a lactating womenafter giving birth. Low calcium levels are also associated with dietary insufficiencies, parathyroid problems, and intestinal problems. Other causes also exist. Total Protein- Several protein types circulate in the bloodstream. These protein types can be measured all together or may be separated out and measured one at a time. On a routine blood chemistry profile, total protein is measured as the total of all proteins together. Albumin, the most abundant protein type, is usually measured separately.1. High protein levels may result from dehydration, inflammation, some cancers, and infections.2. Low protein levels can occur in situations of malnutrition, intestine absorption problems, blood loss, and kidney or liver disease. Cholesterol1. High cholesterol levels can be associated with high-fat diets,hypothyroidism ,diabetes mellitus,pancreatitis, Cushings disease, liver disease, and kidney problems.2. Low cholesterol levels may occur with low-fat diets, liver failure, digestive and absorption problems, pancreas disease, and with some types of seizure therapy. CreatinePhosphokinase(CPK) - This is an enzyme found in muscle cells.1. High CK levels can occur in situations where muscles of the body are damaged, diseased, or inflamed. This can even occur with heart muscle problems. AlkalinePhosphatase(ALP)- This is an enzyme found in liver and bone cells.1. High ALP levels may indicate a liver problem, some cancers, and increased bone growth or destruction. ALP levels can also be elevated in cases where steroids are administered or in Cushings disease where natural steroids are elevated. High levels of ALP are normal in growing children. AlanineAminotransferase(ALT) - This is another enzyme found in liver cells.1. High ALT levels occur when the liver is damaged. This damage can occur because of toxins, not enough oxygen, inflammation, metabolic disorders, and other diseases. AspartateAminotransferase(AST) - This is another enzyme produced by a variety of tissues. Concentrations tend to be highest in muscle and liver cells.1. High AST levels occur most often when the muscles and/or the liver are damaged. This damage can occur because of toxins, lack of oxygen, inflammation, metabolic disorders, and other diseases. Chloride- This is a negatively-charged electrolyte (dissolved salt).1. High levels of chloride can occur with dehydration, fluid therapy, and acidosis (where the pH of the body is abnormally low). Some drugs such asphenobarbitalcan also cause elevated chloride levels.2. Low levels may be the result of vomiting,especiallyright after eating; and treatment with certain drugs (diuretics such asfurosemide). Potassium- This is an electrolyte with a positive charge.1. High levels are associated with acidosis, Addisons disease, during certain phases of severe kidney disease, rupture of the urinary bladder,,and with some treatments and syndromes.2. Low levels are seen with chronic vomiting anddiarrhealiverdisease, Cushings disease, certain phases of kidney disease, and administration of some drugs. Sodium- This is also another electrolyte with a positive charge.1. High sodium levels may accompany dehydration, a high salt diet, Cushings disease, chronic kidney disease, and diabetesinsipidus.2. Low sodium occurs with vomiting, diarrhea, Addisons disease, fluid therapy, kidney problems, and hypothyroidism.

HEMATOLOGY

COMPONENTS: RESULT NORMAL VALUES WBC COUNT 11.10 ADULT:5-10 NB:9-10 X10^9/LHEMOGLOBIN 91.0 M:140-170 F:120-140 NB:187-201 gm/LHEMATOCRIT 0.27 M: 0.40-0.50 F:0.38-0.48 NB:0.49-0.55RBC COUNT 3.05 4.5-5.9DIFFERENTIAL COUNT:NEUTROPHIL 0.27 ADULT: 0.45-0.65 NB:0.40-0.50%LYMPHOCYTES 0.10 ADULT: 0.25-0.50 NB:0.31-0.60%MONOCYTES 0.02 0.02-0.06%EOSINOPHILS 0.1 0.02-0.04% BASOPHILS 0.00-0.01% BANDS 0.02-0.04%PLATELET COUNT 585 150-450 X10^9/LMCV 86.9 80-100 flMCH 29.8 27-31 pgMCHC 34 320-360 g/LRDW 15.5 11.6-14.6 %Interpretation :High valuesRed blood cell (RBC) Conditions that cause high RBC values includesmoking, exposure tocarbon monoxide, long-termlung disease,kidneydisease, some cancers, certain forms ofheart disease,alcoholism,liverdisease, a rare disorder of the bone marrow (polycythemia vera), or a rare disorder of hemoglobin that binds oxygen tightly. Conditions that affect the body's water content can also cause high RBC values. These conditions includedehydration,diarrheaorvomiting, excessive sweating, severe burns, and the use ofdiuretics. The lack of fluid in the body makes the RBC volume look high; this is sometimes called spurious polycythemia.White blood cell (WBC, leukocyte) Conditions that cause high WBC values include infection, inflammation, damage to body tissues (such as aheart attack), severe physical or emotional stress (such as a fever, injury, or surgery), burns,kidney failure,lupus,tuberculosis (TB),rheumatoid arthritis, malnutrition,leukemia, and diseases such as cancer. The use ofcorticosteroids, underactiveadrenal glands,thyroid glandproblems, certain medicines, or removal of thespleencan also cause high WBC values.Platelets High platelet values may be seen with bleeding, iron deficiency, some diseases like cancer, or problems with the bone marrow.Low valuesRed blood cell (RBC) Anemia lowers RBC values. Anemia can be caused by heavy menstrual bleeding,stomach ulcers,colon cancer,inflammatory bowel disease, some tumors,Addison's disease,thalassemia,lead poisoning,sickle cell disease, or reactions to some chemicals and medicines. A low RBC value may also be seen if thespleenhas been taken out. A lack offolic acidorvitamin B12can also cause anemia, such aspernicious anemia, which is a problem with absorbing vitamin B12. The RBC indices value and a blood smear may help find the cause of anemia.White blood cell (WBC, leukocyte) A large spleen can lower the WBC count. Conditions that can lower WBC values includechemotherapyand reactions to other medicines,aplastic anemia, viral infections,malaria, alcoholism,AIDS,lupus, orCushing's syndrome.Platelets Low platelet values can occur in pregnancy oridiopathic thrombocytopenic purpura (ITP)and other conditions that affect how platelets are made or that destroy platelets. A large spleen can lower the platelet count.

VIII GORDONS FUNCTIONAL HEALTH PATTERN*HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERNBefore hospitalizationThe patient views health as an important matter. During HospitalizationThe patient and her SOs acquired help from the hospital when she experience pain on her abdomen. She was admitted because they believed that her condition is a serious matter.*NUTRITIONAL METABOLIC PATTERNBefore hospitalizationThe patient has no allergy on food. He usually eats 3x a day but sometimes losses his appetite. His usual meals is composed of milk, rice, while his lunch and dinner composed of rice, vegetables , fish. She drink 5-6 glasses a day.During HospitalizationThe patient was on general liquid diet, she consumed of share with fair appetite.*ELIMINATION PATTERNBefore HospitalizationThe patient has irregular bowel function. She sometimes defecate once or twice a week. During Hospitalization The patient had a dark yellow orange urine. She did not yet defecate.*SLEEP REST PATTERNBefore HospitalizationAccording to the patient, she hastrouble in sleeping. Then if she feels sleepy in the morning even if she was doing her household chores she goes to bed andsleeps. She doesnt take naps in the afternoon. She only sits and stay sat home and sometimes she watch TV. During Hospitalization According to her, she cannot sleep well due to the pain she feels. She usually get her sleep at 9 in the evening but wakes at 11 then she gets her sleep at 1 and wakes up at 5 am.*ACTIVITY EXERCISE PATTERNBefore HospitalizationThe patient considers he dailyhousehold chores to bea formof her exercisers. She cleans the house, washedthe clothes, andwashed thedishes.During HospitalizationThe patient almost stays on her bed lying flat. According to her she cannot do bathing alone. She needs assistance of her daughter in going to the C.R.*COGNITIVE PERCEPTUAL PATTERNBefore HospitalizationThe client is in good mental status. She knows a well in reading and writing .She can understand tagalog, ilokano. She knows how to compute.During hospitalizationThe client has a good communication skills. She answers my question immediately and comprehensively. But she is not aware of her disease she only that she has a serious disease and needs a prompt treatment.*ROLE-RELATIONSHIP PATTERNBefore hospitalizationAccording to the patient, she lives with her husband and stays their daughter at Quezon City. They have a good relationship with each other.During hospitalization Her daughter are there to care for her. She is vdry supportive and they provide all her needs in her hospitalization*SELF PERCEPTION-SELF CONCEPT PATTERNBefore HospitalizationThe patient said the she is always tired. She feelsthe she is weak and is not happy in her condition for she cannot do the usual things she used to do before.During HospitalizationShe considers herself as a burden to her family due to her condition. But she still believes that she can still help her family by helping herself to recover from her illness.*COPING-STRESS TOLERANCE PATTERNBefore HospitalizationAccording to the patient, dirty house, quarrels and noisy environment predispose her mostly to stress. When she encounters problems she solve it herself. As much as possible, she doesnt want to tell it to her family. But if he can no longer bear it, she tells it to her children.During HospitalizationShe feels stress all the time because of her condition. But she was able to manage it by talking to her daughter and her nurse.*VALUES- BELIEF PATTERNBefore HospitalizationShe was a roman catholic, sheattends mass every sunday. She hasa strong faithin God and she considers as a powerful instrument on her daily life.During HospitalizationThe clients faith was still very strong even if she has illness. She hopes that through the help ofGod, she will get soon. She always pray and trust God that He will be there for her. She entrusted her life to God.*SEXUALITY-REPRODUCTIVE PATTERNBefore HospitalizationAccording to the patient, she had her menarche when she was 13 years old and menopause at the age of 40. During hospitalizationAccording to the patient, she can no longer engage in sexual activity because she are too weak to do it.IX. MEDICAL RELATED TREATMENT

X.DRUG STUDYDRUG NAMEINDICATIONACTIONADVERSE EFFECTCONTRAIN-DICATIONNURSING CONSIDERATION

Generic Name: amlodipine besylate Brand Name:Norvasc:

Alone or withother agentsin themanagementofhypertension,anginapectoris andvasospasticanginaThese medications block the transport of calcium into the smooth muscle cells lining the arteries of the heart (coronary arteries) and other arteries of the body feeling like you might pass out; swelling in your hands, ankles, or feet; pounding heartbeats or fluttering in your chest; or chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling.Less serious amlodipine side effects may include: headache; dizziness, drowsiness; tired feeling; stomach pain; or flushing (warmth, redness, or tingly feeling).

Hypersensitivity.Blood pressure lessthan 90 mmHg.Use cautiously in:sever hepaticimpairment, historyof CHF, aorticStenosis* Monitor blood pressure and pulse before therapy, during dose titration, and periodically during therapy.MonitorECG during prolonged therapy.*Monitor intake and output ratios and daily weight.Assessfor signs of CHF (peripheral edema, rales/crackles,dyspnea, weight gain and jugular venous distention*Lab test considerations: Totalserum calcium are not affected by calcium channel blockers

Generic Name:Potassium Chloride

Brand Name:Apo-K , K-10,Kalium Durules,Kaochlor,Kaochlor-20 Concentrate, Kaon-Cl, Kato, Kay Ciel, KCl 5% and 20%, K-Long , Klor, Klor-10%, Klor-Con, Kloride, Klorvess, Klotrix, K-Dur, K-Lyte/Cl, K-tab, Micro-K Extentabs, Novolente K , Roychlor 10% and 20% , Rum-K, SK-PotassiumChloride, Slo-Pot , Slow-K

To prevent and treat potassium deficit secondary todiureticor corticosteroid therapy. Also indicated when potassium is depleted by severe vomiting, diarrhea; intestinal drainage, fistulas, or malabsorption; prolonged diuresis, diabeticacidosis. Effective in the treatment of hypokalemic alkalosis (chloride, not the gluconate).

Principal intracellular cation; essential for maintenance of intracellular isotonicity, transmission of nerve impulses, contraction of cardiac,skeletal, and smooth muscles, maintenance of normal kidney function, and for enzyme activity. Plays a prominent role in both formation and correction of imbalances in acidbase metabolismGI:Nausea, vomiting, diarrhea, abdominal distension.BodyWhole:Pain, mental confusion, irritability, listlessness, paresthesias of extremities, muscle weakness and heaviness of limbs, difficulty in swallowing, flaccid paralysis.Urogenital:Oliguria, anuria.Hematologic:Hyperkalemia.Respiratory:Respiratory distress.CV:Hypotension, bradycardia; cardiac depression, arrhythmias, or arrest; altered sensitivity to digitalis glycosides. ECG changes in hyperkalemia: Tenting (peaking) of T wave (especially in right precordial leads), lowering of R with deepening of S waves and depression of RST; prolonged P-R interval, widened QRS complex, decreased amplitude and disappearance of P waves, prolonged Q-T interval, signs of right and left bundle block, deterioration of QRS contour and finally ventricular fibrillation and death

Severe renal impairment; severe hemolytic reactions; untreated Addisons disease; crush syndrome; early postoperative oliguria (except during GI drainage); adynamic ileus; acute dehydration; heat cramps, hyperkalemia, patients receiving potassium-sparingdiuretics, digitalis intoxication with AV conduction disturbance

Monitor I&O ratio and pattern in patients receiving the parenteral drug. If oliguria occurs, stop infusion promptly and notify physician. Lab test: Frequent serum electrolytes arewarranted. Monitor for and report signs of GI ulceration (esophageal or epigastricpainor hematemesis)Monitor patients receiving parenteral potassium closely with cardiac monitor. Irregularheartbeatis usually the earliest clinical indication of hyperkalemiaBe alert for potassium intoxication (hyperkalemia, see S&S, Appendix F); may result from any therapeutic dosage, and the patient may be asymptomatic.

GenericName:Amoxicillin

Brand Name:Amoxil, Polymox

ClassificationNon-narcotic analgesic,Antipyretic,Antibiotic

Infections due to susceptiblestrains; helicobacter pylori infections in combinationwith other agents; post-exposure prophylaxis againstbacillus anthracis;Chlamydia trachomatis in pregnancy

Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death.CNS:lethargy, hallucinations, seizuresGI : glossitis, stomatitis, gastritis, sore mouth, furry tongue (black hairy), nausea,vomiting, diarrhea (bloody), enterocolitis,pseudomembranous colitis, nonspecifichepatitis GU : nephritis Hematologic : anemia, thrombocytopenia, leucopenia, neutropenia, prolonged bleedingtime Hypersensitivity : rash, fever, wheezing, anaphylaxis Others : superinfections: oral and rectal moniliasis, vaginitisContraindicated with allergy to cephalosporins or penicillins, or other allergens.Use cautiously with renal disorders and lactationGive in oral preparations only; amoxicillin is not affected by foodContinue therapy for at least 2 days after signs of infection have disappeared;continuation for 10 full days is recommendedUse corticosteroids or antihistamines for skinTake this drug around-the-clock Take the full course of therapy; do not stop because you feel better

Generic Name:Paracetamol

Brand Name:Biogesic

Classification

Nonopioid Analgesics & Antipyretics

Mild pain or feverProduce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin inthe CNS or of other substances that sensitize pain receptors to stimulation. The drug mayrelieve fever through central action in the hypothalamic heat-regulating center.Hematologic: Hemolytic Anemia, Neutropenia, Leukopenia, PancytopeniaHepatic: JaundiceMetabolic: HypoglycemiaSkin: Rash, UrticariaContraindicated in patients hypersensitive to drug.Use cautiously in patients with long-term alcohol use because therapeutics dosescause hepatotoxicity in these patients.Use liquid form for children and patients who have difficulty in swallowing.In children, dont exceed five doses in 24 hours.Patient Teaching:Tell parents to consult prescriber before giving drug to children younger than age 2.Advise patient or parents that drug is only for short-term use; urge them to consult prescriber if giving to children for longer than 5 days or adults for longer than 10days.ALERT: Advise patient or caregiver that many OTC products contain acetaminophen,which should be counted when calculating total daily dose.Tell patient not to use for marked fever (temperature higher than 103.1F [39.5C]),fever persisting longer than 3 days, or recurrent fever unless directed by prescriber.

Generic Name:Prednisone

Brand Name:Deltasone, Orasone, Prednicen-M, Liquid Pred

ClassificationCorticosteroidHormones

Treatment of endocrine, rheumatic & hematologic disorders, allergic & edematous states, collagen, dermatologic & opth, resp & neoplastic diseases. Suppression of inflammatory disordersUsed to treat conditions such asarthritis, blood disorders, breathing problems, severeallergies, skin diseases,cancer, eye problems, and immune system disorders.Fluid, electrolyte, visual & psychic disturbances, Cushingoid state,hirsutism, growth retardation, skin atrophy, facial erythema, asepticosteonecrosis, amenorrhea

Gastric and duodenal ulcers, systemic fungal & certain viral infections,glaucoma, psychoses or severe psychoneuroses; live vaccines; hypersensitivityto glucocorticoids

*Take immediately after meals* Special Precautions to those who has Heart failure, recent MI or HTN, DM, epilepsy, glaucoma, hypothyroidism,hepatic failure, osteoporosis, peptic ulceration, psychoses or severeeffective disorders & renal impairment

XI.DISCHARGE PLANNINGMEDICATION: Instruct and explain to the patients mother that the medication is way important to continue depending on the duration that the doctor ordered for the total recovery of the patient.EXERCISE: Exercise may improve your energy levels and appetite.TREATMENT: Instruct to consult physicicna first if what activities must be avoided or put into limits. Encourage patient to compliance of medication regimen to promote optimal health. Eating plenty of fruits, vegetablesandwhole grainswhich contain fibre and antioxidants.

Limiting fatespecially saturated fat from animal sources such as red meat, milk, cheese and ice cream. Plant-based "vegetable oil" can also be high in saturated fat. Quitting smoking and alcohol intake. Stayingphysically activeand maintaining a healthy body weight.HEALTH TEACHING: Importance of personal hygiene to prevent infection. Intake of nutritious food like vegetables and fruits and intake of food that is rich in fiber such as green leafy vegetables and pineapple, also increased fluid intake to prevent further constipation. Strict compliance of medication regimen to promote wellness. Immediate report to the physician if unusualities occursDIET: Drink liquids as directed:Ask how much liquid to drink each day and which liquids are best for you. If you have nausea or diarrhea from cancer treatment, extra liquids may help decrease your risk of dehydration. Eat healthy foods:Healthy foods include fruits, vegetables, whole-grain breads, low-fat dairy products, beans, lean meats, and fish. This may help you feel better during treatment and decrease side effects. You may need to change what you eat during treatment. Do not eat foods or drink liquids that cause gas, such as cabbage, beans, onions, or soda. A nutritionist may help to plan the best meals and snacks for you.

SPIRITUALITY: For some seriously ill patients, spiritual well-being may affect how much anxiety they feel about death. For others, it may affect what they decide about end-of-life treatments. Some patients and their family caregivers may want doctors to talk about spiritual concerns, but may feel unsure about how to bring up the subject.