I. INTRODUCTION Our patient had many complications brought about by infections spreading due to pyelonephritis.

She also refused treatment and surgery needed for her condition. She also opted to choose HAMA, and not seek further treatment. Pyelonephritis is an infection of the renal parenchyma. Infection usually occurs in a retrograde ascending fashion from the bladder, but it may occur hematogenously. The ureteral orifice becomes edematous and loses its one-way valve function during infection. a.Current Trends (Pyelonephritis): Acute pyelonephritis can occur at any age. In neonates it is 1.5 times more common in boys and tends to be associated with abnormalities of the renal tract. Uncircumcised boys tend to have a higher incidence than circumcised boys. Beyond that age girls have a 10-fold higher incidence. In adult life it reflects the incidence of urinary tract infection (UTI) in that it is much more common in young women. Over 65 the incidence in men rises to match that of women. Glomerulonephritis (GN) comprises 25-30% of all cases of end-stage renal disease (ESRD). About one fourth of patients present with acute nephritis syndrome. Most cases that progress do so relatively quickly, and end-stage renal failure may occur within weeks or months of acute nephritic syndrome onset.Geographic and seasonal variations in the prevalence of poststreptococcal glomerulonephritis (PSGN) are more marked for pharyngeally associated GN than for cutaneously associated disease. PGN has no predilection for any racial or ethnic group. A higher incidence (related to poor hygiene) may be observed in some socioeconomic group. Acute GN predominantly affects males (2:1 male-to-female ratio). PGN can occur at any age. Acute glomerulonephritis refers to a specific set of renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium. Hippocrates originally described the manifestation of back pain and hematuria, which lead to oliguria or anuria. With the development of the microscope, Langhans was later able to describe these pathophysiologic glomerular changes.Most original research focuses on the poststreptococcal patient. Acute glomerulonephritis is defined as the sudden onset of hematuria, proteinuria, and red blood cell casts. This clinical picture is often accompanied by hypertension, edema, and impaired renal function. Acute glomerulonephritis can be due to a primary renal or systemic disease.Glomerulonephritis represents 10-15% of glomerular diseases. Variable incidence has been reported due in part to the subclinical nature of the disease in more than one half the affected population. Despite sporadic outbreaks, incidence of poststreptococcal glomerulonephritis has fallen over the last few decades. Factors responsible for this decline may include better health care delivery and improved socioeconomic conditions.

With some exceptions, a reduction in the incidence of poststreptococcal glomerulonephritis has occurred in most western countries. It remains much more common in regions such as Africa, the Caribbean, India, Pakistan, Malaysia, Papua New Guinea, and South America. Immunoglobulin A (IgA) nephropathy glomerulonephritis is the most common cause of glomerulonephritis worldwide. Most epidemic cases follow a course ending in complete patient recovery (as many as 100%). Sporadic cases of acute nephritis often progress to a chronic form. This progression occurs in as many as 30% of adult patients and 10% of pediatric patients. Glomerulonephritis is the most common cause of chronic renal failure (25%). The mortality rate of acute glomerulonephritis in the most commonly affected age group, pediatric patients, has been reported at 0-7% .A male-to-female ratio of 2:1 has been reported.Most cases occur in patients aged 5-15 years and only 10% occur in patients older than 40 years. Acute nephritis may occur at any age, including infancy. Gastritis is a condition in which the stomach liningknown as the mucosais inflamed. The stomach lining contains special cells that produce acid and enzymes, which help break down food for digestion, and mucus, which protects the stomach lining from acid. When the stomach lining is inflamed, it produces less acid, enzymes, and mucus. Gastritis, an inflammation or irritation of the lining of the stomach, is not a single disease. Rather, gastritis is a condition that has many causes. Current trends (Gastrititis): Age-related trends of gastritis and intestinal metaplasia (IM) were studied in 476 endoscopically examined and bioptically proved cases of gastric carcinoma (GC), 263 of which were of intestinal (IGC) and 213 of diffuse (DGC) types. Endoscopic biopsy specimens from the area around the tumour were available in all cases, and from the antrum and/or body distant from the tumour area in 238 cases. A representative sample of an endoscopically and bioptically examined Finnish population consisting of 431 subjects was used as control material. In patients with IGC the prevalence of atrophic gastritis in the gastric area affected by the tumour was higher and that of superficial gastritis lower than expected and the age-group scores of gastritis and IM were situated above the age-dependent line of gastritis scores of controls in all age groups studied. This was seen to indicate a more rapid progression of gastritis in IGC patients than in the population at large. In the opposite area of the stomach, i.e. in the tumour-free area, the progression of gastritis and IM was virtually similar to that in controls. No such differences were seen with regard to DGC. It is concluded that IGC is dynamically closely linked to gastritis and IM, while in DGC no such relationship is demonstrable.

b. Reasons of choosing such case for presentation The group chose this study out of curiosity as it was our first time to encounter such case and because of that, the group was interested in it. We were willing to undergo new experiences which would bring new learning for the group as most of us have not been exposed yet to the diseases that we encountered. Another reason was that it was one of the suggestions of our clinical instructor to be used in making case study.

c. Importance of the case study This case study will help the group in understanding the disease process of the patient. This would also help the group in identifying the primary needs of the patient with PN. By identifying such needs and health problems of the patient associated with the disease and understanding why such needs and health problems arise the group can now formulate an individualized care plan for the patient that would address these needs and problems effectively. Effective management of the problems identified will help the patient to recover faster and maintain a holistic sense of sense of wellness even while in the hospital. This case study would also equip the group with knowledge, skills and attitude on how to manage future patients with the same or similar disease. d. Objectives (Nurse Centered) - To gain new information about the patients disease and its etiology, pathophysiology, clinical manifestations as well as the standard medical and nursing management so that we may apply this newly-acquired knowledge to our patient as well as similar situations in the future. - To learn new clinical skills as well as sharpen our current clinical skills required in the management of the patient with Pyelonephritis, Gastritis, Intestinal destruction, and colonic tumor. - To develop our sense of unselfish love and empathy in rendering nursing care to our patient so that we may be able to serve future clients with a higher level of holistic understanding as well as individualized care. Objectives ( Client-centered) - To provide the client with sufficient health information to help her cope with her condition. - To make the client aware of the things she needs to modify in order to maintain a healthy body and lifestyle and to prevent further complications brought about by many diseases - To make the patient aware of the importance of sufficient fluid intake and following proper diet in order to be healthy.

II. Nursing Assessment a. Personal History i. Name Age Sex Cilvil status Religion Adress Date of birth Place of birth Nationality Chief Complaint Diagnosis Date of Admission Date of operation Demographic Data : : : : : : : : : : : : : Patient X 59 years old Female married BornAgain Santiago Gerona Tarlac August 7, 1952 Lienera Nueva Ecija Filipino Abdominal pain Possible gastritis and Pyelonephritis July 13,2011 (2:55pm) July 25, 20011 (10:20am) Dr. Rebeson Faustino Exploratory Laparotomy Left Hemicolectomy with end to end Anastomosis Dr. Rebeson Faustino Dr. John Arcinue Lateral Obstruction secondary to Colonic Tumor Splenic Flexure Anemia sesondary; status post blood transfusion

Admitting Physician : Operation Surgeon Perform Final Diagnosis : : : :

ii.

Socio- Economic and Cultural Factors Patient X was the youngest dauther in their family. She was married to Mr. Y and have three daughters and a son. They believe in quack doctors, if they got sick they will go to the quack doctors immediately and when the illness got worst they rush to nearest clinic or hospital to consult a physician. Patient X and her husband are hardworking vegetable vendor in the market, they go the market around 12 midnight to 3 in the afternoon. Their income ranging from 3000 to 4000 a month and just enough to support their basic needs. Due to the nature of her work as a vendor, her eating habits are altered and not followed on time. Patient X always eat instant meals like coffe and cup noodles, because she have no time to cook and sometimes she skip her meal because of her work. She doesnt smoke nor drink alcoholic beverages. Her sleeping pattern always interrupt due to her work because she always woke-up early, after her work she goes to their house immediately to take a siesta.

b. History of Past Illness

During her childhood, she suffered from illness such as fever, cough and cold,chicken pox, measles and mumps. She has no allergies when it comes to food or medications. The client also verbalized that she is not use to taking vitamin supplements. According to Patient X she never been hospitalized before.

c. History of present illness

Admitted at Tarlac Provincial Hospital on Febuary and march 2011 due to peptic ulcer disease. Three days pain prior to admission, Patient X had abdominal pain in epigastric region, parang sinusuntok as verbalized by the client. Abdominal distension and deceased appetite, with associated vomitting its characteristic was watery with rice like substance,sticky and foul odor, with loose stool three times per day and no fever. .

Schematic Diagram

65 y/o

60 y/o

59 y/o

62 y/o

44 y/o

42 y/o

40 y/o

39 y/o

Male Female Died Hypertension Kidney stone

colors: Violet Parents orange - Siblings Green - Patient Blue - husband Gray son and dauther

INTERPRETATION There are no hereditary disease that the client could acquire from her parents and grandparents. The client could have acquired her disease within their community especially on her work at the market being a vegetable vendor and because of when shes not eating on time and when she skip her meals. In the father side of the client, he has history of having kidney stone. One of her brother has experiencing hypertension.

d. Physical Examination (per Visit) First Visit July 23, 2011 (pre-operation) Vital Sings: Tempirature: 100/70 mmHg Respiratory rate: 28 CPR Pulse rate: 74 BPM Blood pressure: 36.6C Physical Assessment: Method of Assessment  Inspection  Inspection  Inspection

Body Parts Skin

Actual Findings  The skin is yellowish in color, warm to touch, The skin turgor is poor. No leision.  -round nail with 160degrees nail base  The clients skull is appropriate to her body size; the contour is round andsymmetrical. There are no masses. Face is symmetrical and does easy movements.  Yellowish discoloration of sclera  Auricle has same color with the skin, has symmetrical shape and located a little bit higher than the eye., with no lesions. She has wet cerumen on both ears when pulled down and back for better visualization. She is able to hear on both ears.  Nose has uniform color and symmetrical in shape air moves freely as client breathes through the nares. Nasal mucosa is pinkish in color, has no discharges and no lesions. No tenderness of sinuses.  Dry mucous membrane  Trachea is in midline. No tenderness of thyroid. No enlargement of the neck. She is able to flex and extend neck and move it laterally

Interpretation  Abnormal  Normal  Normal

Nails Head & Face

Eyes Ears

 Inspection  Inspection

 Abnormal  Normal

Nose

 Inspection

 Normal

Mouth Neck

 Inspection  Inspection

 Abnormal  Normal

Abdomen

 Inspection and palpation  Inspection  Inspection  Inspection and palpation

Musculoskeletal Genitourinary

Extremities

 Abdominal bloating with tenderness when palpated. And estemated length of 20cm; Liver and bladder are not palpable  No evidence of swelling or deformity.  With indweling foley catheter; redish orange in color of urine with 300ml output.  With grade + edema in the lower extremities

 Abnormal

 Nornal  Abnormal  Abnormal

Second Visit july 30, 2011 (5th post-operation) Vital Sings: Tempirature: Respiratory rate: Pulse rate: Blood pressure: Body Parts Skin Method of Assessment  Inspection and Palpation  Inspection  Inspection

36.8C 35cpm 109bpm 100/80mmHg Findings  Afebrile  Generalized jaundice  -round nail with  160 degrees nail base  The clients skull is appropriate to her body size; the contour is round andsymmetrical. There are no masses. Face is symmetrical and does easy movements.  Yellowish discoloration of sclera  Auricle has same color with the skin, has symmetrical shape and located a little bit higher than the eye., with no lesions. She has wet cerumen on both ears when pulled down and back for better visualization. She is able to hear on both ears. interpretation  Normal  Abnormal  Normal  Normal

Nails Head & Face

Eyes Ears

 Inspection  Inspection

 Abnormal  Normal

Nose Mouth Neck

 Inspection  Inspection  Inspection

Chest Abdomen

Musculoskeletal Genitourinary

 Inspection  Inspection and Palpation  Inspetion  Inspetion  Inspection and Palpation

 With nasal cannula at 2-3 LPM ;Redness, irritarion  Dry mucous membrane  Trachea is in midline. No tenderness of thyroid. No enlargement of the neck. She is able to flex and extend neck and move it laterally  (+) Difficulty of Breathing  Abdominal abset; there is a pain and tenderness in the insition site  No evedence of swelling or deformity.  With indweling foley catheter; redish orange in color of urine with 225ml output.  With grade ++ edema in the lower extremities

 Abnormal  Abnormal  Normal

 Abnormal  Abnormal  Nornal  Abnormal`  Abnormal

Extemities

3rd Visit August 03 , 2011 Vital Sings: Tempirature: Respiratory rate: Pulse rate: Blood pressure: Body Parts Skin Method of Assessment  Inspection and Palpation  Inspection  Inspection

36.4C 32cpm 105bpm 70/50mmHg Findings  Afebrile interpretation  Normal

Nails Head & Face

Eyes

 Inspection

 -round nail with 160 degrees nail base  The clients skull is appropriate to her body size; the contour is round andsymmetrical. There are no masses. Face is symmetrical and does easy movements.  No discoloration of sclera

 Normal  Normal

 Normal

Ears

 Inspection

Nose Mouth Neck

 Inspection  Inspection  Inspection

Chest Abdomen

 Inspection  Inspection and Palpation

Musculoskeletal Genitourinary

 Inspetion  Inspetion  Inspection and Palpation

Extemities

 Auricle has same color with the skin, has symmetrical shape and located a little bit higher than the eye., with no lesions. She has wet cerumen on both ears when pulled down and back for better visualization. She is able to hear on both ears.  With nasal cannula at 3-4 LPM ;Redness, irritarion  Dry mucous membrane  Trachea is in midline. No tenderness of thyroid. No enlargement of the neck. She is able to flex and extend neck and move it laterally  (+) Difficulty of Breathing  Abdominal abset; there is a pain and tenderness in the insition site  With tube drained in the epigastric region of the abdomen; redish orange in colorand sticky discharge in amount of 200ml.  No evedence of swelling or deformity.  With indweling foley catheter; redish orange in color of urine with 400ml output.  With grade ++ edema in the lower extremities

 Normal

 Abnormal  Abnormal  Normal

 Abnormal  Abnormal

 Nornal  Abnormal`  Abnormal

4th Visit August 04 , 2011 Vital Sings: Tempirature: Respiratory rate: Pulse rate: Blood pressure:

36.6C 31cpm 103bpm 80/60mmHg

Body Parts Skin

Nails Head & Face

Method of Assessment  Inspection and Palpation  Inspection  Inspection

Findings  Afebrile

interpretation  Normal

Eyes Ears

 Inspection  Inspection

Nose Mouth Neck

 Inspection  Inspection  Inspection

Chest Abdomen

 Inspection  Inspection and Palpation

Musculoskeletal Genitourinary

 Inspetion  Inspetion  Inspection and Palpation

Extemities

 -round nail with 160 degrees nail base  The clients skull is appropriate to her body size; the contour is round andsymmetrical. There are no masses. Face is symmetrical and does easy movements.  No discoloration of sclera  Auricle has same color with the skin, has symmetrical shape and located a little bit higher than the eye., with no lesions. She has wet cerumen on both ears when pulled down and back for better visualization. She is able to hear on both ears.  With nasal cannula at 3-4 LPM ;Redness, irritarion  Dry mucous membrane  Trachea is in midline. No tenderness of thyroid. No enlargement of the neck. She is able to flex and extend neck and move it laterally  (+) Difficulty of Breathing  Abdominal abset; there is a pain and tenderness in the insition site  With tube drained in the epigastric region of the abdomen; redish orange in colorand sticky discharge in amount of 180ml.  No evedence of swelling or deformity.  With indweling foley catheter; redish orange in color of urine with 280ml output.  With grade +++ edema in the lower extremities

 Normal  Normal

 Normal  Normal

 Abnormal  Abnormal  Normal

 Abnormal  Abnormal

 Nornal  Abnormal`  Abnormal

f. Diagnostic and Laboratory Procedures Hematology Results

Admission date (7/13/11) Tests WBC Normal 4.1-10.9 g/L Result 11.5 g/L Analysis and Interpretation The clients WBC is above normal which may indicate an infection, inflammation or allergy. The clients HGB is below the normal level which may indicate bleeding and distractions of RBCs. The clients HCT is below the normal level which may indicate anemia and bone marrow problems. The clients platelet count is above normal level which may indicate severe inflammation.

HGB

120-180 g/L

119

HCT

0.370-0.510 L/L

0.355 L/L

Platelet

140-440 g/L

472 g/L

Pre-operative (July 24,2011) Tests HGB Normal 120-180 g/L Result 104 g/L Analysis and Interpretation The clients HGB is below the normal level which may indicate bleeding and distractions of RBCs. The clients MCH is below the normal level which may indicate anemia.

MCH

26.0-32.0 pg

21.1 pg

Post operative (7/24/11)

Tests HGB

Normal 120-180 g/L

Result 104 g/L

Analysis and Interpretation The clients HGB is below the normal level which may indicate bleeding and distractions of RBCs. The clients MCH is below the normal level which may indicate anemia.

MCH

26.0-32.0 pg

21.1 pg

Electrolyte Results

Admission date (7/13/11)

Tests Sodium

Normal 136 142 mmol/L

Result 132.5

Analysis and Interpretation The clients Sodium is below the normal range and may resuly from excess water or fluid in the body and in chronic conditions it can be a result of kidney failure. The clients Chloride is above the normal level and may indicate kidney diseases.

Chloride

95 103 meq/L

104.9

Pre Operative (7/25/11)

Tests Sodium

Normal 136 142 mmol/L

Result 131.5

Analysis and Interpretation The clients Sodium is below the normal range and may resuly from excess water or fluid in the body and in chronic conditions it can be a result of kidney failure. The clients Chloride is above the normal level and may indicate kidney diseases.

Chloride

95 103 meq/L

105.9

Post Operative (7/26/11)

Tests Sodium

Normal 136 142 mmol/L

Result 143.1

Analysis and Interpretation The clients Sodium is below the normal range and may resuly from excess water or fluid in the body and in chronic conditions it can be a result of kidney failure. The clients Potassium is below the normal level and may indicate gastrointestinal tract destruction and kidney destruction. The clients Chloride is above the normal level and may indicate kidney diseases.

Potassium

3.85 5.0 mmol/L

2.69

Chloride

95 103 meq/L

112.4

Urinalysis Admission Date (7/13/11)

Tests Chemical Leukocytes

Normal

Result

Analysis and Interpretation

None

Trace

The clients urine has a presence of leukocytes and may indicate infection The clients urine has a presence of nitrite and may indicate infection. The clients urine has a presence of urobilonegen and may indicate liver damage. The clients urine has a presence of protein and may indicate glomeruli dysfunction.

Nitrite

Negative

Positive

Urobilonegen

Negative

Positive

Protein

Negative

Positive

pH

5.0 8.0

6.0

The clients urine is acidic and may indicate that theres UTI , E.Coli and renal disorders. The client urine is turbid and may indicate that theres a presence of bacteria or other suspended particles.

Transparency

Clear to slightly hazy

turbid

Microscopic Pus Cells None TNTC Pus cells in urine indicate that theres a problem in the kidney, such as kidney infection or the presence of kidney stones.

Red Cells

0-2

Blood in the urine can indicate that theres an infection, inflammation, or injury to the urinary system. Epithelial cells in the urine may indicate that theres a damage to various part of urinary tract. Urates in the urine may indicate that theres kidney stones. Phospahtes in the urine may indicate problem in the kidney. Bacteria in the urine is an indicator that theres an infection.

Epithelial Cells

None

Few

Urates

None

Moderate

Phosphates

None

Moderate

Bacteria

None

Plenty

Surgical Management

Exploratory Lapatotomy A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside of the abdominal cavity.Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure may be recommended for a patient who has abdominal pain of unknown origin or who has sustained an injury to the abdomen. Injuries may occur as a result of blunt trauma (e.g., road traffic accident) or penetrating trauma (e.g., stab or gunshot wound). Because of the nature of the abdominal organs, there is a high risk of infection if organs rupture or are perforated. In addition, bleeding into the abdominal cavity is considered a medical emergency. Exploratory laparotomy is used to determine the source of pain or the extent of injury and perform repairs if needed. Laparotomy may be performed to determine the cause of a patient's symptoms or to establish the extent of a disease. For example, endometriosis is a disorder in which cells from the inner lining of the uterus grow elsewhere in the body, most commonly on the pelvic and abdominal organs. Endometrial growths, however, are difficult to visualize using standard imaging techniques such as x ray, ultrasound technology, or computed tomography (CT) scanning. Exploratory laparotomy may be used to examine the abdominal and pelvic organs (such as the ovaries, fallopian tubes, bladder, and rectum) for evidence of endometriosis. Any growths found may then be removed.Exploratory laparotomy plays an important role in the

staging of certain cancers. Cancer staging is used to describe how far a cancer has spread. A laparotomy enables a surgeon to directly examine the abdominal organs for evidence of cancer and remove samples of tissue for further examination. When laparotomy is used for this use, it is called staging laparotomy or pathological staging.

Hemicolectomy Hemicolectomy (also referred to as right or left hemicolectomy) is a partial colon-removal procedure in which surgeons excise the right (ascending) part of the colon or the left (descending) side of the colon. The procedure is relatively common for treating diverticulitis, inflammatory bowel disease, benign or malignant polyps of the colon, and colon cancer. The hemicolectomy procedure traditionally begins with an incision in the abdomen, opening the area for access to the colon. Thereafter, the surgeon cuts away the infected or injured portions of the colon and reattaches the remaining tissue. Open surgery has long been the preferred method for hemicolectomy, but innovations in the field have allowed for less invasive colon resection treatments. By making smaller incisions and using a lighted scope (laparoscope) within the abdomen walls, surgeons can access the diseased portion without causing too much damage. Laparoscopic technology helps reduce many of the inherent risks of more open surgery. After hemicolectomy procedures, the surgeon either reconnects the bowel with stitches or creates an opening in the abdominal wall, called a colostomy, to allow the bowels to remove excrement. Surgeons dont make this decision lightly, because if the colonic sections pull free of the stitches, excrement can contaminate the body leading to disease and possibly death. Although colostomy is the safer choice, it carries several lifelong burdens (mental, physical, and emotional) on the patient.

Anastomosis

An anastomosis is a surgical connection between two structures. It usually means a connection that is created between tubular structures, such as blood vessels or loops of intestine. For example, when part of an intestine is surgically removed, the two remaining ends are sewn or stapled together (anastomosed), and the procedure is referred to as an intestinal anastomosis.
y y

Between two loops of intestine (enteroenteric fistula) Between intestine and skin (enterocutaneous fistula)

III. ANATOMY AND PHYSIOLOGY ANATOMY OF THE STOMACH The stomach is an expanded section of the digestive tube between the esophagus and small intestine. Its characteristic shape is shown, along with terms used to describe the major regions of the stomach. The right side of the stomach is called the greater curvature and the left the lesser curvature. The most distal and narrow section of the stomach is termed the pylorus - as food is liquefied in the stomach it passes through the pyloric canal into the small intestine. The wall of the stomach is structurally similar to other parts of the digestive tube, with the exception that the stomach has an extra oblique layer of smooth muscle inside the circular layer, which aids in performance of complex grinding motions. In the empty state, the stomach is contracted and its mucosa and submucosa are thrown up into distinct folds called rugae; when distended with food, the rugae are "ironed out" and flat. The image below shows rugae on the surface of a stomach.

ANATOMY OF THE INTESTINE The large intestine is a hollow muscular tube about five feet in length. (See the graphic below) It is divided into the cecum,colon, and rectum. The cecum comprises the first two or three inches of the large intestine. The colon is subdivided into the ascending, transverse, descending, and sigmoid colon. The sigmoid colon bends toward the left as it joins the rectum which allows gravity to aid the flow of water from the rectum into the sigmoid colon. (This is the rationale for lying on the left side when receiving an enema.)

The last portion of the large intestine is the rectum which extends from the sigmoid colon to the anus (about six inches.) The last inch of the rectum is called the anal canal. It contains the internal and external regulating sphincters which play an important role in regulating defecation. Muscle contractions in the colon push the stool toward the anus. By the time it reaches the rectum, it is solid because most of the water has been absorbed. The nerve supply to the large intestine contains both parasympathetic and sympathetic nerves. In general, stimulation of the sympathetic fibers inhibits activity in the gastrointestinal (GI) tract. It also excites the ileocecal sphincter and the internal anal sphincter. Thus, stimulation of the sympathetic fibers can totally block movement of food through the GI tract both by inhibition of the wall and closure of two major sphincters. Stimulation of the parasympathetic fibers causes an increase in bowel activity and in the defecation reflexes The movement of the intestinal contents in the large intestine is slow. Mass peristalsis, which is a contraction involving a large segment of the colon, moves the fecal mass into the sigmoid colonwhere it is stored. It occurs two to three times per day, especially after breakfast. Defecation is a reflex involving the muscles of the anal canal and terminal bowel. Entry of the fecal mass into the rectum distends the rectal walls and stimulates mass peristaltic movements of the bowel which moves the feces toward the anus. As the fecal mass nears the anus, the internal anal sphincter is inhibited and if the external anal sphincter is relaxed (under voluntary control), defecation will occur. Defecation is also facilitated by an increase in intraabdominal pressure brought about by contraction of the chest muscles and simultaneous contraction of the abdominal muscles (Valsalva's maneuver or straining.)

ANATOMY OF THE SMALL INTESTINE The small intestine is a part of the digestive system. The digestive system consists of the stomach, small intestine and large intestine. The small intestine is the part that connects the stomach and the large intestine. This is the main region where maximum amount of absorption of food takes place. The small intestine is so named not because it is small, it measures on an average five meters (sixteen feet), when uncoiled. This part of the gastrointestinal tract is called the small intestine because it is only 2.5 - 3 cm in diameter. The small intestine is divided into three parts - the duodenum, jejunum and ileum. Given below are details regarding the small intestine anatomy. Small Intestine Anatomy and Physiology Duodenum The duodenum is the first section of the region of the small intestine that precedes the jejunum and the ileum. This is the shortest part of the intestine where most of the initial biochemical reactions take place. The duodenum is around 25 - 30 cm in length and it connects the stomach to the jejunum. It begins with a structure called the duodenal bulb and ends at the ligament of Treitz. The duodenum has the primary function of aiding in breakdown of food in the small intestine with the help of enzymes. Brunner's glands, which are a part of the glandular epithelium, are present in the duodenum and are responsible for secreting mucus. The duodenum also has the function of regulating the rate of emptying the stomach with the help of hormones, thus, preventing the occurrence of dumping syndrome. The duodenum is also responsible for secreting hormones like secretin and cholcystekinin. The duodenal lining consists of a very thin layer of cells which form the muscularis mucosae. Jejenum The jejunum is the middle section of the small intestine that is present between the duodenum and the ileum. The transition from the duodenum and the jejunum is called the ligament of Treitz. The jejunum is around 2.5m in length. The jejunum has a pH of around 7 to 8, that is, it is either neutral or slightly alkaline in nature. This kind of pH is brought about with the help of the bile, which is carried by the bile duct coming from the gallbladder. The pH in this region is maintained at 7 to 8 because, 7 to 8 is the optimum pH for the functioning of the enzymes in this region. The jejunum and the ileum are suspended in the abdomen by the mesentery, which gives them space for bowel movement. It is wrapped by smooth muscle that helps to move food forward, which is known as peristalsis. The microscopic structure of the jejunum consists of mucous membrane, which contains projections known as villi, which are a characteristic feature of small intestine anatomy. These villi are folded and convoluted, which eventually increase their surface area many fold, thus, increasing the amount of surface area available for absorption. The transport of nutrients across

these villi is in the form of both active ans passive transport. The villi in the jejunum are longer than the villi in the ileum. Ileum The ileum is the last part of the small intestine, which follows the jejunum. It eventually gives rise to the cecum, from which it is separated by the ileocecal valve. The ileum is the longest part of the small intestine, measuring around 2 - 4m. It is also responsible for performing most of the small intestine function. This region has a pH that is neutral to alkaline. The main function of the ileum is to absorb vitamin B12 and bile salts, along with whatever is not absorbed by the jejunum. The wall of the ileum is also made up of many villi, which as in the jejunum, increase the surface area for absorption of digested food and adsorption of enzymes. Thus, this was all about the small intestine anatomy. The small intestine anatomy is quite different from the large intestine anatomy, as their functions are different. However, the intestine is the main part that is responsible for absorption of digested food. If there is any kind of deviation from this anatomy and functioning of the small intestine, it could lead to various small intestine problems, which could be difficult to deal with.

ANATOMY OF THE SPLEEN The spleen, in healthy adult humans, is approximately 11 centimetres (4.3 in) in length. It usually weighs between 150 grams (5.3 oz) and 200 grams (7.1 oz) and lies beneath the 9th to the 12th thoracic ribs. Like the thymus, the spleen possesses only efferent lymphatic vessels. The spleen is part of the lymphatic system. Both the short gastric arteries and the splenic artery supply it with blood.

The germinal centers are supplied by arterioles called penicilliary radicles. The spleen is unique in respect to its development within the gut. While most of the gut viscera are endodermally derived (with the exception of the neural-crest derived suprarenal gland), the spleen is derived from mesenchymal tissue. Specifically, the spleen forms within, and from, the dorsal mesentery. However, it still shares the same blood supply the celiac trunk as the foregut organs. Function

Micrograph of splenic tissue showing the red pulp (red), white pulp (blue) and athickened inflamed capusule (mostly pink - top of image). H&E stain. Area Function Composition


"sinuses" (or "sinusoids"), which are filled with blood "splenic cords" of reticular fibers "marginal zone" bordering on white pulp

red pulp

Mechanical filtration of red blood cells. In mice: Reserve ofmonocytes[5]

 

Composed of nodules, called Malpighian corpuscles. These are composed of: white pulp Active immune response through humoral and cell-mediated pathways.


"lymphoid follicles" (or "follicles"), rich in B-lymphocytes "periarteriolar lymphoid sheaths" (PALS), rich in T-lymphocytes

Other functions of the spleen are less prominent, especially in the healthy adult: Production of opsonins, properdin, and tuftsin. Creation of red blood cells. While the bone marrow is the primary site of hematopoiesis in the adult, the spleen has important hematopoietic functions up until the fifth month of gestation. After birth, erythropoietic functions cease, except in some hematologic disorders. As a major lymphoid organ and a central player in the reticuloendothelial system, the spleen retains the ability to produce lymphocytes and, as such, remains an hematopoietic organ. Storage of red blood cells and other formed elements. In horses roughly 30% of the red blood cells are stored there. The red blood cells can be released when needed. In humans, up to a cup (236.5ml) of red blood cells can be held in the spleen and released in cases of hypovolemia. It can also store platelets in case of an emergency. In mice, the spleen stores half the body's monocytes so that upon injury they can migrate to the injured tissue and transform into dendritic cells and macrophages and so assist wound healing.

ANATOMY OF THE KIDNEY The Human Renal System The human renal system is made up of two kidneys, two ureters, the urinary bladder, and the urethra. In addition to the production of urine the renal system has many other functions.

One quarter to one fifth of cardiac output passes through the kidneys at all times. This means that the kidneys filter approximately 1.2 liters of blood every minute. It is therefore not surprising that even slight abnormalities of renal function quickly lead to electrolyte disturbances. If untreated death will occur.

The Kidneys The kidneys are two bean shaped organs of the renal system located on the posterior wall of the abdomen one on each side of the vertebral column at the level of the twelfth rib. The left kidney is slightly higher than the right. Why do you think that the right kidney is lower than the left? (Q1). Human kidneys are richly supplied with blood vessels which give them their reddish brown color. The kidneys measure about 10cm in length and, 5cm in breadth and about 2.5 cm in thickness. The kidneys are protected by three highly specialized layers of protective tissues. The outer layer consists mainly of connective tissue which protects the kidneys from trauma and infection. This layer is often called the renal fascia or fibrous membrane. The technical name for this layer is the renal capsule. The next layer (second layer from the exterior) is called the fascia and it makes a fibrous capsule around the kidneys. This layer connects the kidneys to the abdominal wall. The inner most layer is made up of adipose tissue and is essentially a layer of fatty tissue which forms a protective cushions the kidney; and the renal capsule (fibrous sac) surrounds the kidney and protects it from trauma and infection. Blood and Nerve Supply: The kidneys receive their oxygenated blood supply from the renal arteries which come off the abdominal portion of the aorta. Venous blood from the kidneys drains into the renal veins to join the abdominal portion of the inferior vena cava. The hilum of the kidneys is located toward the smaller curvature. The opening in the hilum allows for the entry and exit of blood vessels and nerves. The funnel shaped extension of the kidneys is called the renal pelvis and it connects the kidneys to the two ureters. This structure facilitates the collection of the urine from the kidneys and drainage to the urinary bladder.

IV. THE PATIENT AND HER ILLNESS a. Schematic Diagram of Pathophysiology

COLORECTAL CANCER Causes:

Lifestyle Stress Benign Tumor Cell Hyperplasia Decreased organ efficiency (Colorectal cancer) Descending colon Peristaltic movement

Decreased Constipation Weight gain Dull sound on percussion Third spacin ascites abdominal distention abdominal pain

diverticulitis (E.Coli)

transverse infection to the kidneys (Pyelonephritis) (acute) Immune system recognizes the infection (leukocytosis)

Swelling of the renal parenchyma Hyperthermia

Decreased renal function Dec GFR Inc water and sodium reabsorption Inc RBC death Dec elimination of bilirubin jaundice erythrocytopenia dec elim. Of urobilinogen dec erythropoeisis third spacing

b. Synthesis of the Disease i. Definition of the disease Colorectal Cancer Colorectal cancer, less formally known as bowel cancer, is a cancer characterized by neoplasia in the colon, rectum, or vermiform appendix. Colorectal cancer is clinically distinct from anal cancer, which affects the anus. Colorectal cancers start in the lining of the bowel. If left untreated, it can grow into the muscle layers underneath, and then through the bowel wall, most begin as a small growth on the bowel wall: a colorectal polyp or adenoma. These mushroom-shaped growths are usually benign, but some develop into cancer over time. Localized bowel cancer is usually diagnosed through colonoscopy. Acute Gastritis Gastritis is a condition in which the stomach liningknown as the mucosais inflamed. The stomach lining contains special cells that produce acid and enzymes, which help break down food for digestion, and mucus, which protects the stomach lining from acid. When the stomach lining is inflamed, it produces less acid, enzymes, and mucus. Gastritis, an inflammation or irritation of the lining of the stomach, is not a single disease. Rather, gastritis is a condition that has many causes. Common to all people with gastritis is pain or discomfort in the upper part of the belly (abdomen), sometimes called dyspepsia. Gastritis can be a brief and sudden illness (acute gastritis), a longer-lasting condition (chronic gastritis), or a special condition, perhaps as part of another medical illness. Gastritis is associated with various medications, medical and surgical conditions, physical stresses, social habits, chemicals, and infections. Acute Pyelonephritis Kidney infection (pyelonephritis) is a specific type of urinary tract infection (UTI) that generally begins in the urethra or bladder and travels up into the kidneys. The most common causative organisms are bowel flora, typically gram-negative rods. Escherichia coli is the most commonly isolated organism from patients with UTIs. However, any organism that gains access to the urinary tract system may cause infection, including fungi (Candida species) and viruses. In some instances, UTI results in recognition of an important underlying structural or neurogenic abnormality of the urinary tract.

V. THE PATIENT AND HER CARE A. Medical Management i. IVF

DATE

IV FLUID

DROPS

NURSING RESPONSIBILITY

July 13, 2011

PLRS

20gtts/min

This medication is an intravenous (IV) solution used to supply water and electrolytes (e.g., calcium, potassium, sodium, chloride), either with or without calories (dextrose), to the body. It is also used as a mixing solution (diluents) for other IV medications.
9% Sodium Chloride (sodium chloride (sodium chloride injection) Injection, USP is also indicated for use as a priming solution in hemodialysis procedures. These intravenous solutions are indicated for use in adults and pediatric patients as sources of electrolytes and water for hydration.

July 26, 2011

PLRS PLRS D5LR

30gtts/min 30gtts/min 30gtts/min

July 28, 2011

D5LRS

D5LRS

30gtts/min 30gtts/min

Lactated Ringer's and 5% Dextrose Injection, USP is indicated as a source of water, electrolytes and calories or as an alkalinizing agent.

July 29, 2011 July 30, 2011

D5LRS D5LRS

30gtts/min 30gtts/min

ii.

Drugs ACTION May inhibit prostaglandin syntesis, to produce anti inflammatory, Analgesic, and anti pyretic effects INDICATION >short term management of pain >occular itching cause by seasonal allergic rhinitis >post operative inflammation following cataract surgery >pain and burning or stinging following corneal retractile surgery CONTRAINDICATION >important hyper sensitive to the drug or any of its component; in those history of nasal polyps angioedema, broncho spastic reactivity, or allergic reaction to aspirinor other NSAIDs >also contra indicated in patient with the high risk of bleeding and in those with suspected or confirmed cerebro-vascular bleeding. SIDE EFFECT >may decrease haemoglobin level and hematocrit >may increase eosinophil count and liver function test values. NURSING RESPONSIBILITY >carefully observe patient with coagulopathes and those taking coagulant >dont give drug epidurally or intrathecally because of alcohol content >NSAIDs may mask sign and symptoms of injection because of their anti pyretic and anti inflammatory action.

DRUG NAME CLASSIFICATION Brand name: Analgesic, anti KETOROLAC inflammatory drugs Tromethamine Generic name: Acular, Toradol

Dosage: 30 mg IVP q 6 hours X 4 doses

DRUG CLASSIFICATI NAME ON Brand name: Anti ulcer drugs OMEPRAZO LE

ACTION Inhibits activity of acid pump and binds to hydrogenpotassium adenosine triphosphatase at secretory surface of gastric parietal cells to block formation of gastric acid.

INDICATION >erosive esophavitis; symptomatic poorly responsive gastroesophageal reflux disease.

CONTRAINDICATION >contra indicated in patients with hypersentive to the drug or any of its components.

Generic name: Losec, Prelosic, Zegerid

NURSING RESPONSIBILITY >CNS: >Gastrin level Headache, dizziness. risesin most >GI: patients during the Diarrhea, abdominal first 2 weeks of pain, nausea, vomiting, therapy. constipation, flatulence. >Dont confuse >MUSCULOSKELET Prilosec with AL Prozac, Prilocaine, Back pain. or Prinivil. >RESPIRATORY: Cough.

SIDE EFFECT

Dosage: 40 mg IVP q 12 hours X 2 doses

DRUG NAME Brand name: METRONIDA ZOLE Generic name: FLAGYL, NOVONIDAZOLE Dosage: 500mg IVP every 8 hrs.

CLASSIFICAT ION Amebicides and Antiprotozoal

ACTION Direct acting trichomonacide and amebicide that work inside and outside the intestine. Its thought to enter the cells of microorganism that contain nitroreductase, forming unstable compounds that binds to DNA and inhibits syntesis, causing cell death.

CONTRAINDICATION >amebic liver Contra indicated abscess in patients >intestinal hypersen-sitive to amebiasis drug or other >bacterial nitroimidazole infection cause by derivatives and in anaerobic patients in first microorganism trimester of >to prevent pregnancy postoperative infection in contaminated or potentially contaminated colorectal surgery.

INDICATION

ADVERSE EFFECT >CNS; fever, haedache, dizziness, weakness, seizure. >GI; abdominal cramping or pain, nausea, vomiting, diarhea, constipation, dry mouth

NURSING RESPONSIBILITY >monitor liver function test result carefully in elderly patient >give oral form with meals >observe patient wiyh edema, especialy if his receiving corticosteriod. Flagyl IV RTU may ccause sodium retension

DRUG NAME Brand name: CEFUROXI ME SODIUM

CLASSIFICAT ION Cephalosporins

ACTION

INDICATION

CONTRAINDICATION Contra indicated in patients hypersensitive to drug or other cephalosporins.

ADVERSE EFFECT CV: phebitis, thombophebitis

Generic name: CEFTIN

Second-generation cephalosporine that inhibit cell-wall synthesis, promoting osmotic instability; usualy bacterecsdal

Dosage: 1.5g IVP now then 750mg IVP every 8 hrs

>peoperative prevention >secondary bacterial infection of acute bronchitis >serious lower respirarory tract infection, UTIs, skin and skin-structure infection, bone and joint infections, septicemia, meningitis, and gonorrhea

NURSING RESPONSIBILIT Y >before administration, ask a pateint if she is allergic to cephalosporine >obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin while awaiting result >cefuroxime axetil film-coated tablet and oral suspention arent bioequivalent. Dont substitute on mg/mg basis

DRUG NAME

CLASSIFICATION

ACTION Relaxes bronchial, uterine, and vascular smoth muscle by stimulating beta2 receptors

INDICATION >to prevent or treat bronchospasm with reversible obstractive airway disease >to prevent exercise-induce bronchospasm

Brand name: Bronchodilator ALBUTEROL SULFATE (SALBUTAMOL SULFATE) Generic name: PROVENTIL, VENTOLIN

CONTRAINDICATION Contraindicated in patient hypersensitve to drug or ingredients.

ADVERS EFFECT CNS: tremor, nervousness, dizziness, insomia, headache, hyperactive, weakness >CV: tachycardia, palpitation, hypertention >GI: hearth burn, nausea, vomiting, anorexia, alterd taste, increased oppetite

Dosage: Nebule every 8 hrs

NURSING RESPONSIBILITY Patient may use tablets and aerosol together: monitor these patients closely for signs and symtoms of toxicity >drug may decrease sensitivity of spirometry used for for diagnosis of asthma >dont confuse albuterol with atenolol or albutein, or Flomax with Volmax

DRUG NAME

CLASSIFICATION

ACTION Unknown. A centrally acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptor and inhibit reuptake of norpinephrine

INDICATION Moderate to moderate severe pain

Brand name: Opioid analgesics TRAMADOL HYDROCLORIDE Generic name: ULTRAM

Dosage: 1 amp-IVP now

CONTRAINDICATION Contraindicated in patient hypersensitive to drug or other opioids, in breastfeeding women, and in those with acute intoxication from alcohol, hypotonics, centrally acting analgesics, opioids, or psychotropic drugs. Serious hypersensitivity reaction can occur, usually after the first dose

ADVERS EFFECT CNS: dizziness, vertigo, haedache, somnolence GI: nausea, vomiting, constipation, dyspepsia, dry mouth, diarrhea, abdominal pain, anorexia, flatulence GU: urine retention, urinary frequency, menopausal symtoms, proteinuria.

NURSING RESPONSIBILITY >Monitor CV and respiratory status. Withhold dose and notify prescriber if repiration decreaseor rate is below 12 breaths per minute. >monitor patients at risk for seizures. Drug may reduce seizure threshold. >monitor bowel and bladder function. Anticipate need for laxative.

DRUG NAME Brand name: FUROSEMI DE

CLASSIFICA TION Diuretic

ACTION A potent loop diuretic that inhibit sodium and chloride reabsorption at the proximal and distal tubules and assending loop of Henle

INDICATION >acute polmunary edema >edema >hypertention

CONTRAINDICATION Contraindicated in patient hypersensitive to drug and in those with anuria

ADVERS EFFECT >CNS: vertigo, headache, dizziness, paresthesia, fever >CV: orthostatic hypothention, thrombo-phlebitis with I.V administration >GI: abdominal discomfort and pain, diarrhea, anorexia, nausea, vomiting, constipation, pacreatitis >GU: nocturia, polyuria, frequent urination, oliguria

Generic name: NAVOSEMI DE

Dosage: 20mg IVP now

NURSING RESPONSIBILITY >monitor fluid intake and output electrolyte, BUN, and carbon dioxidelevel frequently >monitor glucose level in diabetic patients > monitor uric acid level, especialy in patients with history of gout >dont confuse furosemide with torsemide or Lasix with Lonox.

DRUG NAME Brand name: CIPROFLOX ACIN

CLASSIFICATI ON Fluoroquinolones

ACTION Inhibit bacterial DNA syntesis, mainly by blocking DNA gyrase; bactericidal

INDICATION >complicated intra-abdominal infection cause by E. coli or P. mirabilis. >acute uncomplicated cystitis >empirical therapy in febrile nuetropenic patient >inhalation antrax

CONTRAINDICATION Contraindicated in patient sensitive to fluoroquinolones

ADVERS EFFECT CNS: headache, tremor, dizziness, insomia, depression, confuse CV: edema, chest pain, thromboplebitis GI: nausea, vomiting, diarrhea, abdominal pain or discomfort, oral cardidiasis GU: crystalluria, intestinal nephritis

Generic name: CIPROXIN

Dosage: 200/100 2bots IV every 12 hrs

NURSING RESPONSIBILITY >monitor patients intake and output and observe patient for signs of crystalluria >long-term therapy may result in ove growth of organism resistant to ciprofloxacin >beware of drug interaraction. Some require waiting up to 6 hrs after ciprofloxacin administration before giving another drug to avoid decreasing drug effect.

CONTRAINDICATION Brand name: Analgesic: Relaxant Relief of mild to Hypersensitive to PARACETAMOL and uricosurics moderate pain parirazine, alcohol, treatment of tablet sugar, fever saccharin Dosage: 1amp IVP every 4 hrs for Temp of 38oC

DRUG NAME

CLASSIFICATION

INDICATION

ADVERS EFFECT Stimulation, drowziness, nausea and vomiting, abdominal pain, hepatoxicity, hepatic seizure, renal failure, leukopenia, neutropenia, hemolytic anema, thrombocytopenia, pancytopenia, jaundice

NURSING RESPONSIBILITY >teach patient to avoid alcohol, recognice signs chronic over dose bleeding, for throat >to route: give food with milk to decrease gastric sign. Give 30 min before or 2 hrs after meal absorption may be slowed.

iii. Date ordered/ Date performed/ Date change July 13-28

Diet General description Indication or purpose Specific foods taken Nursing responsibilities

NPO

 Due to before and after operation make sure the stomach is clean to prevent infection in other parts of the body and blood stream.  To avoid aspiration

July 29,2011

Sips of water

to moisten mucus membrane

Due to before  Explain the and after importance of operation make the diet sure the stomach restriction to is clean to the procedure prevent to be infection in performed to other parts of gain the body and cooperation of blood stream. the patient To avoid  Coordinate aspiration. with significant others to hide or put away any food to prevent patient from being tempted to eat or drink  Instruct patient to use lip balm or wet cotton balls to moisten lips to prevent injury to the lips due to dehydration  water  Coordinate with significant others to hide or put away any food to prevent patient from being tempted to eat or drink

July 30,2011

Soft diet

To introduce >soup solid foods >water in a slow >bread manner to prevent ulcer formation

 Prevent aspiration by feeding the diet in small amount of food  Feed the client in semi or high fowler`s position

iv. Date ordered/ date performed/ date changed July 26,2011

Activities General description Indication or purpose Specific activity done Nursing responsibilities

Moderate high back

 To prevent pneumonia  To prevent ulceration

July 27,2011

May turn side to side

July 28,2011

May sit up on bed

 Deep breathing exercise  R.O.M activity such as abduction adduction of fingers or toes

 Raise side rails to prevent falls  Assess the ability of the patient to ambulate  Assist the patient in ambulation

July 2930,2011

Ambulatory

VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL a. Clints Daily progress Chart ADMISSION July 13, 2011  Afebrile  Body weakness  Good skin turgor  Facial grimace  Abdominal pain  Pain scale 7/10 Pre-OP July 24, 2011  Afebrile  Discomfort  Jaundice  Distended abdomen  Abdominal pain  Pain scale 7/10 Pre-OP July 25,2011  Afebrile  Discomfort  Jaundice  Distended abdomen  Abdominal pain  Pain scale 7/10 BP: 140/100 mmHg Temp.: 37.4 o C RR: 31 PR: 105  Repeat serum Electrolyte now Post-OP July 25, 2011  Afebrile  Tachypnea  Tachycardia  Body weakness  Immobile  Jaundice  Abdominal pain  Pain scale 8/10 BP: 140/90 mmHg Temp.: 37.2 o C RR: 31 PR: 112  For repeat CBC 4 o post BT  For repeat Serum Electrolyte

DAYS Nursing Problems

Vital Signs

Diagnostic and Laboratory Procedures

Medical Management

BP: 110/80 mmHg Temp.: 36 o C RR: 24 PR: 77  CBC endoscopy, U/A  RBS, Na, K, Cl  Serum Amylase  RL, ECG  CXR, PA  KUB Pelvic UTZ 

BP: 140/100 mmHg Temp.: 37 o C RR: 28 PR: 107  10:20 am = For Stat CBC  6:20 pm = For official reading of CXR Plate

 For NGT removal  Monitor V/S

 For emergency exploratory laparotomy  Insert NGT  Monitor I and O q2o  KCL incorporate: PNSS 1 L + 50 mEq KCL x 8o  + 1-2 units of blood for the procedure

 PNSS 1 Liter TRA 30-31 gtts/min, KVO rate BT in using as side drip  D5LRS 1 Liter TRA 30-31 gtts/min may fast drip if BP < 90/60 mmHg  IVF TF: D5LRS 1 Liter + Tramadol 1 amp TRA 30-31 gtts/min (3X)

IVF

 PLR 1 Liter + Lysmix amp #2 x 12o

 10:20 am = D5LRS 1 Liter x 8o  Iron +sucrose 1 amp incorporate TF

 6:20 pm = Stat KCL incorporate: PNSS 1 L + 50 mEq KCL x 8o

Drug/Medication

 Omeprazole 80 mg + D5W 80cc in Solu set to run for 10 hours  Omeprazole 40 mg IV now then 12o  Cifrofloxacin 200/100 2 Bottles IV q12 ANST (-)

 HNBB 1 amp IVP now  07-25-11 = + Tramadol 1 amp IVP now

 Omeprazole 80 mg + D5W 80cc in Solu set to run for 10 hours  Omeprazole 40 mg IV now then 12o  Cifrofloxacin 200 /100 2 Bottles IV q12 ANST (-)   Dulcolax 10 g/tab X 2 Tabs  Castoroil 30cc  Maintain NPO as ordered  Deep breathing exercises  Flat on bed  Turn side to side  Passive range of motion such as abduction and adduction

 Cefuroxime 1.5 g IVP now ANST (-), then 750 mg q 5o  Metronodazole 500mg IVP q 8 o  Ketorolac 300 mg IVP q 6 o X 4 doses  Omeprazole 4 mg IVP q 12 o X 2 doses

Diet

 NPO as ordered  Deep breathing exercises  Flat on bed  Turn side to side  Passive range of motion such as abduction and adduction

 Maintain NPO as ordered  Deep breathing exercises  Flat on bed  Turn side to side  Passive range of motion such as abduction and adduction

 NPO temporarily as ordered  Deep breathing exercises  Flat on bed  Turn side to side  Passive range of motion such as abduction and adduction

Activities

b. Nursing Management (actual SOAPIERs)

ASSESSMENT SUBJECTIVE: Masakit kapag umiihi ako, as verbalized by the patient. OBJECTIVE: Guarding/ distracting behaviors. Self focusing. V/S taken as follows: T: 37.6 P: 90 R: 19 BP: 140/100

DIAGNOSIS

SCIENTIFIC EXPLANATION Acute pain related to acute inflammation of renal tissues. Pyelonephritis is an inflammation of the kidney and upper urinary tract that usually results from noncontiguous bacterial infection of the bladder (cystitis). It presents with dysuria (painful voiding of urine), abdominal pain (radiating to the back on the affected side) and tenderness of the bladder area and the side of the involved kidney ("renal angle tenderness"). In many cases there are systemic symptoms in the form of fever, rigors (violent shivering while

PLANNING

IMPLEMENTATION INDEPENDENT Assess pain, noting location, characteristics, intensity (0-10 scale). Note urine flow and characteristics.

RATIONALE

EVALUATION

Acute pain related to acute inflammation of renal tissues.

After 1 hours of nursing interventions, the patient will verbalize relief or control of pain.

Helps evaluate degree of discomfort and may reveal developing complications. Decreased flow may reflect urinary retention with increased pressure in upper urinary tract.

After 1 hours of nursing interventions, the patient was able to verbalize relief or control of pain.

Encourage patient to verbalize concerns. Active listen these concerns and provide support by acceptance, remaining with patient and giving appropriate information. Provide comfort measure like back rub or deep

Reduction of anxiety or fear that can promote relaxation and comfort.

Reduces muscle tension, promotes

the temperature rises) and headache.

breathing exercises.

relaxation, and may enhance coping abilities. Reduces muscle or joint stiffness. Ambulation returns organs to normal position and promotes feeling of well being.

Assist with range of motion exercises and encourage ambulation.

Investigate and report abdominal muscle rigidity, involuntary guarding and rebound tenderness. COLLABORATIVE: Administer medications as indicated e.g analgesics and antibiotics.

Requiring prompt medical intervention.

Relieves pain, enhances comfort and promotes rest.

ASSESSMENT

DIAGNOSIS

SCIENTIFIC EXPLANATION Limitation in independent, purposeful physical movement of the body or of one or more extremities.

PLANNING

INTERVENTION THERAPEUTIC: Assist patient correctly execute muscle exercises as able or when allowed out of bed; execute abdominaltightening exercises and knee bends; hop on foot; stand on toes. Assess skin on a regular basis, especially over bony prominences. Note affected side for color, edema, or other signs of compromised circulation. Softly massage any reddened areas and give aids such as sheepskin pads as indicated. Check skin integrity. Assess for signs of redness, tissue ischemia particularly over ears, shoulders,

RATIONALE

EVALUATION

Subjective: Nanghihina ako. Objective: >VS: BP 100/70 T 37.1 C PR 87 RR - 27 -Discomfort

Impaired Physical Mobility R/T Limitations imposed by condition as evidenced by pain and discomfort

After 2-3 hours of nursing interventions, the Patient will be free of complications of immobility, as manifested by intact skin and normal bowel pattern.

Adds to gaining enhanced sense of balance and strengthens compensatory body parts.

After 2-3 hours of nursing interventions, the Patient will shows signs of improvement and free of complications of mobility as manifested by intact skin and normal bowel pattern.

-Edematous tissue is prone to trauma and heals more gradually. Pressure points over bony prominences are most at risk for reduced perfusion. Circulatory stimulation and padding help avoid skin breakdown and ulcer progression.

elbows, sacrum, hips, heels, ankles, and toes. Clean, dry, and moisturize skin as necessary. Execute passive or active assistive ROM exercises to all extremities. Exercise enhances increased venous return, avoids stiffness, and sustains muscle strength and stamina. Keep limbs in functional alignment with one or more of the following: pillows, sandbags, wedges, or prefabricated splints. Maintain side rails up and bed in low position. This provides a safe environment. Turn and position every 2 hours or as -This maximizes circulation to all tissues and -Avoids contracture deformities, which can build up quickly and could hinder prosthesis usage.

-This avoids footdrop and/or too much plantar flexion or tightness. Maintain feet in dorsiflexed position.

indicated and perhaps more frequently if placed on affected side.

alleviates pressure. Lowers risk of tissue ischemia or injury. Affected side has poorer circulation and diminished sensation and is more inclined to skin breakdown. -Permits family or Significant Other to be active in patient care and facilitates more consistent therapy.

EDUCATIVE: Persuade family or significant other support and assistance with ROM exercises. Give emphasis to the significance of actions such as position change, ROM, coughing, and exercises. Persuade patient to help out with movement and exercises using unaffected extremity to support or move weaker side.

-May react as if affected side is no longer part of body and requires support and active training to reincorporate it as a part of own body.

ASSESSMENT SUBJECTIVE: Masakit ang tahi ko. OBJECTIVE: >VS: BP 140 / 90 T 36.2 C PR 31 RR 112 WBC 11.5 g/L (4.1 10.9 g/L)

DIAGNOSIS

SCIENTIFIC EXPLANATION At increased risk for being invaded by pathogenic organisms.

PLANNING

INTERVENTION THERAPEUTIC INTERVENTION: INDEPENDENT: Keep asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access treatment. COLLABORATIVE: Give antimicrobial/ antibiotic drugs as ordered..

RATIONALE

EVALUATION

Risk for infection R/T post surgical incision.

After 1-2 hours of nursing interventions, Patient will be free of infection, as manifested by normal vital signs and nonexistence of purulent drainage from wounds, incisions, and tubes.

Reduces chance for introduction of bacteria.

After 1-2 hours of nursing interventions, Patient was free of infection as manifested by normal vital signs and nonexistence of purulent drainage from wounds, incisions, and tubes.

Antimicrobial drugs comprise antibacterial, antifungal, antiparasitic, and antiviral agents. Every of these agents are either toxic to the pathogen or retard the pathogens growth Friction and running water efficiently take away microorganisms from hands. Washing between procedures decreases the risk

EDUCATIVE: Wash hands and educate other caregivers to wash hands prior to contact with patient and between measures with patient.

of transmitting pathogens from one area of the body to another. Utilization of disposable gloves does not lessen necessitate for hand washing. It also lowers risk of crosscontamination.

VII. Learning Derived This case study will help the group in understanding the disease process of the patient. This would also help the group in identifying the primary needs of the patient with. By identifying such needs and health problems of the patient associated with the disease and understanding why such needs and health problems arise the group can now formulate an individualized care plan for the patient that would address these needs and problems effectively. Effective management of the problems identified will help the patient to recover faster and maintain a holistic sense of sense of wellness even while in the hospital. This case study would also equip the group with knowledge, skills and attitude on how to manage future patients with the same or similar disease. We learned how to effectively connect diseases to each other in creating our pathophysiology for our patient.

VIII. Conclusions and Recommendation In this case, we learned on how to think critically and to create a care plan effectively for our patients. In this study, we experienced firsthand on how to handle a patient with multiple complications due to a current disease condition. We also learned that it should be vital to assess the condition of the patient in order to provide the best possible care to the patient. We recommend to the patient that she should adhere strictly and comply with the treatment procedures administered to cure her disease. We also would like to recommend health information and teachings in order to promote a healthy lifestyle and to avoid further disease and complications.

X. Bibliography Websites: http://emedicine.medscape.com/article/231574-overview#a0156

http://www.nejm.org/medical-research/uti-pyelonephritis http://digestive.niddk.nih.gov/ddiseases/pubs/gastritis/ http://www.emedicinehealth.com/gastritis/article_em.htm http://ukpmc.ac.uk/abstract/MED/6608953/reload=0;jsessionid=8EA091BE83A78F7FCA8F58DE621DE926 http://medical-dictionary.thefreedictionary.com/Intestinal+Obstructions http://www.nlm.nih.gov/medlineplus/ency/article/002231.htm http://www.medicinenet.com/colon_cancer/article.htm Books: Nursing 2006 Drug Handbook 26th edition, Lippincott Williams & Wilkins Medical-Surgical Nursing Clinical Management for positive outcomes, 6th edition, Joyce M. Black, Jane Hokanson Hawks, Annabelle M. Keene

THE UNITED METHODIST CHURCH

Ecumenical Christian College

Mangga II Brgy. Matatalaib Tarlac City, Tarlac College Department College of Nursing

In Partial Fulfillment of Requirements in NCM 103 (SURGERY WARD)

Submitted By: Group III Bautista, Rose Marie L. (HEALTH ASSESSMENT) Capinding, Hans Chester R. (CLIENTS DAILY CHART, CASE EDITOR) Cruz, Martin Kevin O. (NURSING CARE PLAN) David, Diana Rose D. (DIET, ACTIVITIES) Mejia, Joan I. (PHATOPHYSIOLOGY, ANATOMY AND PHYSIOLOGY) Paran, Patrick L. (INTRODUCTION, LEARNING DERIVED, CONCLUSION) Pineda, Pia Jane B. (HEALTH ASSESSMENT) Santos, Ditas J. (IV FLUID, MEDICATION) Vega, Vinda A. (PHATOPHYSIOLOGY, ANATOMY AND PHYSIOLOGY) Villa, Karla Monique B. (DIAGNOSTIC TEST) Submitted to: Mrs. Carmen D. Lising RN, MSN Clinical Instructor

A Case Study of

(Hemicolectomy)