Professional Documents
Culture Documents
PERSONAL DATA
Name: S. A. Address: Pasay City Age: 21 years old Sex: Male Birthdate: February 5,1989 Birth Place: Manila Civil Status: Married Citizenship: Filipino Religion: Roman Catholic Physician: Dr. Barcelon Admission: 11 01 10 Chief Complaint: Abdominal Pain Diagnosis: Complete Gut Obstruction Secondary to Postoperative Adhesion
Two days prior to admission had sudden onset of abdominal pain with vomiting and fever. No medicines taken until few hours with persistence and increasing severity prompted consult hence admission.
The patient had been hospitalized on 2002 and was diagnosed to have appendicitis. The patient also undergo appendectomy. He had no allergy to any food or drug. Immunization was not remembered.
MATERNAL SIDE (+) Hypertension (-) Diabetes Mellitus Deceased PATERNAL SIDE ( -) Hypertension (-) Diabetes Mellitus Deceased
V. PSYCHOSOCIAL DATA He is known as an occasional alcohol beverage drinker and a smoker and can consume 8 sticks per day
ACTIVITES
BEFORE HOSPITALIZATION Patient drinks 6-8 glasses of water a day and eats nutritious foods like vegetables.
AFTER HOSPITALIZATION Patient increases fluid intake 8-10 glasses of water a day and limits the intake of sweet foods.
ANALYSIS Patient increases fluid intake since the colostomy procedure decreases the reabsorption of fluid from the stool. The patient expel his stool effortless to the colostomy bag which is easier for the patient.
Fluids/ Nutrition
Bowel and The patient is usually Bladder constipated but Eliminatio urinates regularly. n Pattern
The patient could easily expel stool through colostomy bag and urinates regularly.
ACTIVITIES
BEFORE HOSPITALIZATION
AFTER HOSPITALIZATION
ANALYSIS
During night, the patient was able to sleep and rest but sometimes abdominal pain occurs which makes him feel uncomfortable.
Because of his abdominal pain, the patient feels uncomfortable and sometimes is disturbed due to pain. He was not able to perform exercises and sometimes remained sedentary because of feeling uncomfortable.
Activities/ Lifestyle The patient walks to his office everyday and it serves as an exercise.
He was not able to perform exercises and other activities, though he is ambulatory.
ACTIVITIES
BEFORE HOSPITALIZATIO N Patient regularly takes a bath and very particular with his hygiene
DURING HOSPITALIZATIO N Patient takes half bath but still have oral care with the help of his relative.
ANALYSIS
Hygiene
The patient will not be able to perform oral and personal hygiene without the help of his wife, since he feels pain and uncomfortable.
BODY PART
SKIN
TECHNIQUE
Inspection
NORMAL FINDINGS
Uniform brownish color; no skin lesions should be present; warm surface temperature
ACTUAL FINDING
The patient have a tattoo and have an incision on his abdomen
ANALYSIS
Inspection/ Palpation
Rounded, smooth, uniform consistency; symmetrical facial movements. Hair is thin, scalp with flaking and scaling
Normal
BODY PART
EYES & VISION
TECHNIQUE
Inspection
NORMAL FINDINGS
Eyebrows equally distributed & symmetrical, no discharges
CTUAL FINDINGS
Eyebrows symmetrically distributed; eyelashes curled slightly outward; white sclera; symmetric eye movements with briskly reactive pupils; no discharge. Reddish conjunctiva; eyelids with flaking and scaling Normoset ears; pinna recoils easily after it is folded; dry cerumen; brownish in color; responds to perceived sound & verbal commands.
ANALYSIS
Normal
Inspection
Ear should be proportionally set to the head; recoils easily when folded & perceives sound clearly & equally on both ears.
Normal
BODY PART
TECHNIQUE
NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS
Inspection
Moist, pink to dull red mucosa; patent w/o lesions & discharge
Symmetric; nontender sinuses; Their s NGT attach to his nose. Symmetrical movement of lips and tongue; intact hard and soft palate; Lips have cracks and fissures; slightly dark in color (dark brown);
Normal
Inspection
Lips should be symmetric, pink, moist; symmetrical movement of lips & tongue; no lesion & inflammation
Normal
BODY PART
TECHNIQUE
NORMAL FINDINGS Muscles are symmetrical; lymph nodes not palpable; able to move head in a full range motion w/o discomfort
ACTUAL FINDINGS Neck muscles are equal in size; coordinated and smooth movements without discomfort; No palpable lymph nodes
ANALYSIS
NECK
Inspection/ Palpation
Normal
BODY PART
TECHNIQUE
NORMAL FINDINGS
ACTUAL FINDINGS
ANALYSIS
Full & symmetric chest expansion; normal in shape; bilateral symmetry of vocal fremitus; superficial veins are not visible; no masses & tenderness; no adventitious breath sound should be auscultated.
Full & symmetric chest expansion; no adventitious breath sounds are auscultated; no visible superficial veins; no masses or tenderness. Skin is not uniform in color; Skin has scales, flaking and crusting. The patient received O2 via nasal cannula
Normal
ABDOMEN
Flat & slightly rounded abdominal contour; bilaterally symmetrical; uniform in color & pigmentation; no bruits or friction rub auscultated
BODY PART
MUSCULO-SKELETAL SYSTEM
TECHNIQUE
Inspection
NORMAL FINDINGS
Muscles on both sides of the body are symmetrical; extremities proportional to body size & shape; walks smoothly; muscle strength allows for complete, voluntary joint ROM against gravity & moderate resistance Nail surface is smooth and flat; curved; No brittle edges;
ACTUAL FINDINGS
The patient experiencing muscle weakness. The extremities is proportional to body size
ANALYSIS
The patient experiencing muscle weakness due to his condition.
NAILS
Inspection
Normal
TEST
UNIT
REFERENCE RANGE
ANALYSIS
LEUKOCYTES
19.80
10^9/L
5.0-10.0
High level due to a high risk of infection. NORMAL Red blood cell production increases to compensate for low blood oxygen levels due to poor heart or lung function
ERYTHROCYTES HEMOGLOBIN
6.03 17.8
10^12/L g/dl
% 10^9/L %
NORMAL NORMAL Increased when smaller numbers used, as with bleeding; it fights tumors and viruses NORMAL Elevated due to bone marrow over production of RBC
MONOCYTE GRANULOCYTE
3.200 91.900
% %
0.0-7.0 50.0-70.0
TEST
LEUKOCYTES ERYTHROCYTES
RESULT
5.30 4.37
UNIT
10^9/L 10^12/L
REFERNCE RANGE
5.0-10.0 M: 4.6-6.2 F: 4.2-5.4 M: 12.0-17.0 F: 11.0-15.0 M:40.0-54.0 F:37.0-47.0 150-450 20.0-40.0
ANALYSIS
NORMAL NORMAL
HEMOGLOBIN
13.2
g/dl
NORMAL
HEMATOCRIT
38.70
Low level due to a blood loss NORMAL Decrease production of RBC in the bone marrow NORMAL Elevated due to bone marrow over production of RBC
THROMBOCYTES LYMPHOCYTES
200 19.400
10^9/L %
MONOCYTE GRANULOCYTE
3.200 77.400
% %
0.0-7.0 50.0-70.0
TEST NAME
CONVENTIONAL
REFERENCE RANGE
SI RESULT
REFERENCE RANGE
ANALYSIS
SODIUM POTASSIUM
139mmmol/L 3.8mmol
137-145 3.5-5.1
139mmol/L 3.8mmol/L
137-145 3.5-5.1
NORMAL NORMAL
Test Name
Com. Result
14 1.0 7.8 4.0 3.8 1.1
Unit
Range
SI Result
Unit
Range
Blood Urea Nitrogen Creatinine Total Protein Albumin Globulin (HIGH) A/G Ratio
PHYSICAL: Color: DARK YELLOW Reaction: 5.5 Transparency: slightly turbid Quantity: 30ml Specific gravity: 1.030 CHEMICAL: ALBUMIN: trace SUGAR: negative ANALYSIS: traces of albumin in the urine may indicate infection.
DATE PERFORMED: NOV 8 2010 FINDINGS: gas dilatation of the small bowel loops noted some air in the colon. Soft tissue densities are remarkable. No abnormal calcification seen. COMMENT: Consider partial small bowel obstruction
FINDINGS: subtle upper and lingular reticular lesions noted. PTB vs. Pneumonia Heart, diaphragms, costophrenic sulci and bony cage are unremarkable. Ngt is in place.
or complete blockage of the bowel that results in the failure of the intestinal contents to pass through.
Causes - Ileus, a condition in which the bowel doesn't work correctly but there is no structural problem Hernias Impacted feces (stool Foreign bodies (ingested materials that obstruct the intestines) Abnormal tissue growth Symptoms Abdominal distention Abdominal fullness, gas Abdominal pain and cramping Breath odor Constipation Vomiting
Internal hernia
Pain, an increase in abdominal girth, and increased tension in the intestinal wall
1. Activation of local and systemic inflammatory responses 2. Translocation of bacteria through the wall of the intestine.
1. Physical exam Your doctor will ask about your medical history and your symptoms. He or she will also do a physical exam to assess your situation. The doctor may suspect intestinal obstruction if your abdomen is swollen or tender or if there's a lump in your abdomen. 2. Imaging tests To confirm a diagnosis of intestinal obstruction, your doctor may recommend abdominal X-ray or computerized tomography (CT) scans. These tests also help your doctor determine if the obstruction is paralytic ileus or if it's a mechanical obstruction, and if it's a partial or a complete obstruction.
1. Hospitalization to stabilize your condition - Placing an intravenous (IV) line into a vein in your arm so that fluids can be given - Putting a nasogastric (NG) tube through your nose and into your stomach to suck air and fluid out to relieve abdominal swelling - Placing a thin, flexible tube (catheter) into your bladder to drain urine and collect it for testing 2. Treatment for a complete mechanical obstruction Complete obstruction, in which nothing can pass through your intestine, usually requires surgery to relieve the blockage. The procedure you undergo will depend on what's causing the obstruction and which part of your intestine is affected. Surgery typically involves removing the obstruction, as well as any section of your intestine that has died. Complete obstruction of the small bowel is preferentially treated with early laparotomy
3. Treatment for a partial mechanical obstruction If you have mechanical obstruction in which some food and fluid can still get through (partial obstruction), you may recover after you've been stabilized in the hospital. You may not require further treatment. Your doctor may also recommend a special low-fiber diet that is easier for your partially blocked intestine to process. If the obstruction does not clear on its own, you may need surgery to relieve the obstruction. 4. Treatment for paralytic ileus If your doctor determines that your signs and symptoms are caused by paralytic ileus, he or she may monitor your condition for a day or two in the hospital. Paralytic ileus is often a temporary condition that gets better on its own. If paralytic ileus doesn't improve within several days, your doctor may prescribe medication that causes muscle contractions, which can help move food and fluids through your intestines.
Name drug
Cefoxitin(Manowel) 1 gram/IV ANST IV q8 Anti infectives; Antibiotic; secondgeneration Cephalosporin
Mechanism of Action
Inhibits bacterial cell wall synthesis by binding to one or more of the penicillinbinding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.
Indication
Peri-operative prophylaxis.
Nursing Responsibilities
Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Report onset of loose stools or diarrhea. Monitor I&O rates and pattern Report any
Name drug
Mechanism of Action
Indication
Nursing Responsibilities
Pantoprazole (Pantoloc) 40mg/IV OD Antacids, Antireflux Agents & Antiulcerants. Proton-pump Inhibitor
Inhibits the secretion of hydrochloric acid in the stomach by specific action on the proton pumps of the parietal cells.
Headache, diarrhea. Edema, fever, onset of depression, blurred vision. Contraindicated to patients with known hypersensitivity to any of the constituents of Pantoloc or of the combination partners. Mild gastrointestinal complaints eg, nervous dyspepsia.
-Note indications for therapy, onset, characteristics of symptoms. -Record abdominal assessment, urea breath, or endoscopic findings if available.
Name drug
Mechanism of Action
Indication
Side Effects/ Contraindication Drowsiness, GI Bleeding, Exfoliative, Dermatitis, StevensJohnsons Syndrome, Toxic Epidermal Necrolysis, Anaphylaxis Concurrent use with aspirin may effectiveness, adverse GI effects with aspirin, potassium supplements, corticosteroids, or alcohol, chronic use with acetaminophen may risk of adverse renal reactions, bleeding risk with arnica, chacomile, clove.
Nursing Responsibilities
Inhibits prostaglandin synthesis, producing peripherally mediated analgesia, Also has antipyretic and antiinflammatory properties. Antiinflammatory, Pain relief
(Pre-administration assessment) Patients who have asthma, aspirininduced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions.
Cues Subjective: --Objective: Post surgical incision Risk Factors: Environmental factor Decrease wound healing time Malnutrition (NANDA Edition11)
Goal After an 8 hours of nursing intervention the client should: Short Term identify the risk factors present in the clients condition client should partially understand the infection and its risk factors Long Term Effective prevention of infection Clients full understanding to the risk of infection
Rationale to identify and assess the different nursing intervention needed and to be done
Evaluation After the 8 hours of nursing intervention: goals met client have increased his level of understanding about the risks for infection
- to obtain a baseline data and assess the effectiveness of the nursing intervention - fever maybe secondary to infection