FOUNDATION UNIVERSITY COLLEGE OF NURSING Dumaguete City In Partial Fulfillment of the Requirement In Nursing Care Management (NCM) 16 CASE

PRESENTATION ON ACUTE ABDOMINAL PAIN 2 TO GENERALIZED PERITONITIS 2 TO RUPTURED CECAL MASS RELATED TO MALIGNANCY WITH LIVER METASTASIS

Submitted to: Ms. Deborah Ann Ouano, BSN- RN Submitted by: Sarahmae P. Tiongco, SN Jhyne Cristy M. Tubaing, SN Date of Submission: August 15, 2011

TABLE OF CONTENT
I. II. III. IV. V. VI. Foundation University Mission, Vision and Life Purpose --------------------------------------------------------------------Acknowledgement ----------------------------------------------------------------------------------------------------------------Consent letter---------------------------------------------------------------------------------------------------------------------Introduction -------------------------------------------------------------------------------------------------------------------------Central and specific objectives --------------------------------------------------------------------------------------------------k Scope of limitation------------------------------------------------------------------------------------------------------Demographic data ----------------------------------------------------------------------------------------------------------------k Biographic information k Chief complaint k History of present illness k Final diagnosis k General impression:60 min. head to toe appraisal Developmental Milestone---------------------------------------------------------------------------------------------------------Genogram--------------------------------------------------------------------------------------------------------------------------Nursing history -------------------------------------------------------------------------------------------------------------------k k k k k

VII. VIII. IX.

Chief complaints Admitting impression History of present illness Past health history Anatomy and physiology of system -------------------------------------------------------------------------------

X. XI. XII. XIII.

Physical Assessment Findings-------------------------------------------------------------------------------------------------Review of related literature-----------------------------------------------------------------------------------------------------Pathophysiology -----------------------------------------------------------------------------------------------------------------Medical interventions/management--------------------------------------------------------------------------------------------k

Treatment modalities

k k

Laboratory results---------------------------------------------------------------------------------------------------------Drug study-------------------------------------------------------------------------------------------------------------------

XIV. XVI.

Nursing management------------------------------------------------------------------------------------------------------------------Gordons Functional Health Pattern---------------------------------------------------------------------------------------------------

XV. Nursing theory applicable

XVII. Summary of nursing diagnosis-------------------------------------------------------------------------------------------------------XVIII. Nursing Care Plan----------------------------------------------------------------------------------------------------------------------XIX. XX. XXI. Annotated readings--------------------------------------------------------------------------------------------------------------------Conclusion-------------------------------------------------------------------------------------------------------------------------------Bibliography------------------------------------------------------------------------------------------------------------------------------

FOUNDATION UNIVERSITY COLLEGE OF NURSING Dumaguete City VISION, MISSION AND LIFE PURPOSE
VISION:

Foundation University envisions itself as a progressive university that cultivates effective learning, generates creative ideas, responds to social needs, and offers equal opportunity to all. MISSION: In its quest for excellence in mind, body, and characteristics, and to the pursuit of truth and freedom, Foundation University commits: k k k k to develop in students a sound character and broad culture to prepare individual for definite career to imbue citizens with the spirit of universal brotherhood to advocate truth promotes justice and advance knowledge

LIFE PURPOSE:

The life purpose of Foundation University is to educate and develop individuals to become productive, creative, useful, and responsible citizens of society

ACKNOWLEDGEMENT
As we are rotated at Negros Oriental Provincial Hospital Emergency Department and we are up to comply each and every requirements that is assigned to us, one of those is this case study to be presented in formal class discussion and we consider to be one of the most challenging part during this 4th year of being a nursing students. This case book will not be attained without the aid of some people who showed their helping hand behind the making process. Being student nurses is really not that easy lots of works to do and it is already in the trend of a nursing to undergo like what we are experiencing right now. Likewise its a vital role of a nursing student to undergo much of sleepless nights just to spend time for paper works and lessons to study but we never give up from all those, because we knew at the end of all these sacrifices it will yield sweet fruits to be harvest in its season. And by that time we knew its not only us who will be happy but so with those people who did lots of sacrifices just to send us to school, thanks to all of them who became our very own motivations that inspires and cheer us up every time we find ourselves down. With that good deeds of yours (our dear beloved parents who never let us down) the only thing we could give back in return for all the kindness you have show, is that we will continue to strive hard in our study no matter how much struggles and challenges might we encounter along our long road of travel as a student nurses to reach out our endeavors in life and that is to become a REGISTERED NURSES. To our CI Ms. Deborah Ann Ouano, BSN-RN thank you for all the considerations you have given to us while we are still on the process of making our case book. To the ER head Nurse Ms. Maribel S. Fabe, BSN-RN we would like to extend our heartfelt gratitude for allowing us to have our duty in Emergency Department NOPH. Above all we give thanks to our dear almighty Father who guided us in this journey.

July 22, 2011 Mr. Eva Agustin A. Dear Sir, We, fourth year B3 students, of Foundation University College of Nursing, (assigned in the Emergency Department for this rotation at Negros Oriental Provincial Hospital) had selected your case to be presented in a formal class discussion. We have chosen your case acute abdominal pain 2 to generalized peritonitis 2 to ruptured cecal mass related to malignancy with liver metastasis for we find it very interesting to deal with; here in our study we are to trace how cecal mass invaded the normal functioning of your body most particular with regard to your system gastrointestinal tract as the major system involved in your case. All we have to do is to find out what is this condition? Where did it started? And why did it occur? Most probably we would also find out when is the onset of the condition? By way of observing possible signs and symptoms which is actually manifested by you and base on our kin observation through our contact with you. We would like to ask permission from you, as we choose your case in our case study presentation. Thank you and God Bless, Respectfully yours, Tiongco, Sarahmae P. Tubaing, Jhyne Cristy M.

Approved by: Ms. Deborah Ann Ouano, BSN-RN (Clinical instructor, Emergency Department)

INTRODUCTION

The cecum marks the beginning of the large intestine and is basically a big pouch that receives waste material from the small intestine. The cecum is about six centimeters (cm) long and 7.5 cm wide. The ileum (of the small intestine) dumps waste material into the cecum and the cecum passes it on to the colon, specifically the ascending colon. It doesn't do so through a little tube; the cecum is continuous with the colon.

picture of the cecum and a little squiggly thing hanging from it, is what called the appendix. The cecum accepts and stores processed material from the small intestine and moves it towards the colon. As the processed food approaches the end of the small intestine, a valve separating the small and large intestines opens, the cecum expands and the material enters. At this stage, the mixture normally contains; undigested food (fibre), a little bit of water, some vitamins, some minerals or salts.

SPECIFIC OBJECTIVE; In the making of this study, the case researchers shall: k k k k k k k k k k k k k Obtain the permission we wish to have from our client as our case subject and so with the corresponding family members. Gather all important information from our clients chart Pay particular attention in reviewing clients prescribed medications by physician Conduct interview to our client and significant others for some information that contributes our clients case Thorough explanation of procedures to clients level of understanding regarding the nursing procedures to be undertaken Thorough physical assessment to our client (cephalo caudal assessment) Being kin observant of the subjective and objective cues that client manifest during the assessment procedure Priority identification of our clients problem Keeping our own record about gathered information Allocation of responsibilities between group members for the success of the study conduction Time management promotion Report as a group about the level of progress of the case study Evaluation of case study

Scope and limitations Like any other studies being presented, the accuracy and consistency of this study are limited. This study reveals some limitations like the following: k We had few hours to interact with our patient. k Limited time of interaction (8 hours a day). k The history of the patients admission was not fully stated. k The information were purely retrieved from the patient and the chart although there was the presence of her significant others yet they cannot give a definite or more reliable information to support the patients present condition. k The continuity of interaction also depends on the mood of the patient on that particular day. k Sufficient information found in the patients chart. k The information coming from patients chart was not fully comprehended because of the penmanship that wasnt clear. k Failed to have copy to every detailed written on patients chart.

DEMOGRAPHIC DATA
Date and time of Assessment: July 22, 2011 (7:30 pm) Name of patient: Patient SJ Age: 68 years old Sex: male Religion: Roman Catholic Birth date: May 5, 1943 Address: Bindoy, Negros Oriental Rm & Bed #: alley Attending Physician: Dr. Nerves Date and time of admission: July 22, 2011 (8:43 am)

Chief Complaints: pain @ epigastric area radiating to left iliac on week PTA. Inability to move bowel for 3 days. History of present illness: according to the patient the pain felt at abdominal area (right upper quadrant) started a year ago but the pain was still tolerable during that time, it was then that the pain grew worst, July 19, 2011 when he experienced an intense pain associated with episodes of vomiting noting clear watery content of the vomitus that alarmed him and SO so they then sought medical attention. Final Diagnosis: Acute abdominal pain 2 to generalized peritonitis 2 to ruptured cecal mass related to malignancy with liver metastasis

General impression: receive lying on bed awake, conscious and coherent with bottle #1 0. 9 % sodium chloride KVO with SD lactated ringers solution 40 gtts/min, immediate family on bedside.

Developmental Milestone
Late Adult: 55 or 65 to Death developmental task: Integrity vs. Despair Wisdom Erikson believed that much of life is preparing for the middle adulthood stage and the last stage involves much reflection. As older adults, some can look back with a feeling of integrity that is, contentment and fulfilment, having led a meaningful life and valuable contribution to society. Others may have a sense of despair during this stage, reflecting upon their experiences and failures. They may fear death as they struggle to find a purpose to their lives, wondering What was the point of life? Was it worth it?

Correlation to Patient: He said his contented of what he had achieved, he and his wife was able to send their children to school, he loves his wife and children that much, his very thankful to have them in his life, he never blame God for his illness instead his thankful that God allow him to leave that long in this earth, he just continue to pray that may God bless him and his family and that they may continue to leave in peace.

GENOGRAM
80+ y/o *hypertension 70y/o

75 y/o

73 y/o

71 y/o

65 y/o

62y/o Liver cirrhosis

60 y/o

58y/o

Mr. SJ 68 y/o

LEGEND:
PATIENT --MALE FEMALE DECEASED

NURSING HISTORY
Chief Complaints: pain @ epigastric area radiating to left iliac on week PTA. Inability to move bowel for 3 days. General Impression: receive lying on bed awake, conscious and coherent with bottle #1 0. 9 % sodium chloride KVO with SD lactated ringers solution 40 gtts/min, immediate family on bedside. History of present Illness: according to the patient the pain felt at abdominal area (right upper quadrant) started a year ago but the pain was still tolerable during that time, it was then that the pain grew worst, July 19, 2011 when he experienced an intense pain associated with episodes of vomiting noting clear watery content of the vomitus that alarmed him and SO so they then sought medical attention.
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Kind of operation: Exploratory Laparotomy right hemicolectomy double barrel ileu transverse colostomy application of external retention suture. Pre. Medication: hydrocortisone IVTT. Operation performed: Exploratory Laparotomy right hemicolectomy, double barrel ileu transverse colostomy, lavage: application of external retention suture.

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Admitting Vital signs: BP: 150/90 mmHg, T:37.4 C, PR:140 bpm, RR: 24 cpm . Past Health History: hospitalized for the third time (first due cough, second due to gastric ulcer third is his present condition), not sure if has complete immunization

Family health history: HFD- hypertension

Psychosocial history: describes his social relationship as good, he has no enemy, SO added that the patient is very approachable a good man and good friend to his friends. Environmental History: he is a non smoker, but drinks occasionally, he describe their environment as peaceful, their house is surrounded with trees, describes their atmospheric air as less polluted less vehicles are seen I their area, unlike citys atmospheric air. Spiritual History: roman catholic they usually go to church every Sunday to attend mass, SO describe patient as a prayerful man and a God fearing person.

ANATOMY AND PHYSIOLOGY OF SYSTEM

1. Gastrointestinal tract

Gastrointestinal tract: The tube that extends from the mouth to the anus in which the movement of muscles and release of hormones and enzymes digest food. The gastrointestinal tract starts with the mouth and proceeds to the esophagus, stomach, duodenum, small intestine, large intestine (colon), rectum and, finally, the anus. Also called the alimentary canal, digestive tract and, perhaps most often in conversation, the GI tract. The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls. The primary purpose of the gastrointestinal tract is to break down food into nutrients, which can be absorbed into the body to provide energy.

Focus: liver, stomach and cecum

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Liver The liver, weighing roughly 1.2-1.6 kg, performs many of the functions necessary for staying healthy. It is located in the right side of the body under the lower ribs and is divided into four lobes of unequal size. Two large vessels carry blood to the liver. The hepatic artery comes from the heart and carries blood rich in oxygen. The portal vein brings the liver blood rich in nutrients absorbed from the small intestine. These vessels divide into smaller and smaller vessels, ending in capillaries. These capillaries end in the thousands of lobules of the liver. Each lobule is composed of hepatocytes, and as blood passes through, they are able to monitor, add, and remove substances from it. The blood then leaves the liver via the hepatic vein, returns to the heart, and is ready to be pumped to the rest of the body. Among the most important liver functions are: Removing and excreting body wastes and hormones as well as drugs and other foreign substances These substances have entered the blood supply either through production by metabolism within the body or from the outside in the form of drugs or other foreign compounds. Enzymes in the liver alter some toxins so they can be more easily excreted in urine. Synthesizing plasma proteins, including those necessary for blood clotting Most of the 12 clotting factors are plasma proteins produced by the liver. If the liver is damaged or diseased, it can take longer for the body to form clots. Other plasma proteins produced by the liver include albumin which binds many water-insoluble substances and contributes to osmotic pressure, fibrogen which is key to the clotting process, and certain globulins which transport substances such as cholesterol and iron. Producing immune factors and removing bacteria, helping the body fight infection The phagocytes in the liver produce acute-phase proteins in response to microbes. These proteins are associated with the inflammation process, tissue repair, and immune cell activities. Other important but less immediate functions include: Producing bile to aid in digestion Bile salts aid in fat digestion and absorption. Bile is continuously secreted by the liver and stored in the gallbladder until a meal, when bile enters the beginning of the small intestine. Bile production ranges from 250 mL to 1 L per day depending of amount of food eaten. Excretion of bilirubin Bilirubin is one of the few waste products excreted in bile. Macrophages in the liver remove worn out red blood cells from the blood. Bilirubin then results from the breakdown of the hemoglobin in the red blood cells and is excreted into bile by hepatocytes. Jaundice results when bilirubin cannot be removed from the blood quickly enough due to gallstones, liver disease, or the excessive breakdown of red blood cells. Storing certain vitamins, minerals, and sugars The liver stores enough glucose in the form of glycogen to provide about a day's worth of energy. The liver also stores fats, iron, copper, and many vitamins including vitamins A, D, K, and B12.

 Processing nutrients absorbed from digestive tract The liver converts glucose into glycogen, its storage form. This glycogen can then be transformed back into glucose if the body needs energy. The fatty acids produced by the digestion of lipids are used to synthesize cholesterol and other substances. The liver also has the ability to convert certain amino acids into others. Despite the wide variety of functions performed by the liver, there is very little specialization among hepatocytes (liver cells). Aside from the macrophages called Kupffer cells in the liver, hepatocytes all seem to be able to perform the same wide variety of tasks. One of the liver's most interesting abilities is self-repair and the regeneration of damaged tissues. In clearing the body of toxins, the liver is damaged by exposure to harmful substances, demonstrating why this capability is important. It also gives hope that if a failing liver can be supported for a certain period of time, it might regenerate and allow the patient to survive and regain a normal life. Hemostasis Glucose Proteins fat and cholesterol Hormones vitamins, in particular fat-soluble ones (A, D, E, K) proteins including the clotting factors (~50g/day) bile acids (important in fat digestion) heparin (anti-coagulant) somatomedins (homones that promote growth in bone, soft tissues) Estrogen Angiotensinogen Cholesterol acute phase proteins vitamins Glycogen Cholesterol iron, copper Fats cholesterol, bile acids, phospholipids Bilirubin Drugs poisons including heavy metals

Synthesis

Storage

Excretion

Filtering

Immune

Hormones Poisons nutrients including amino acids, sugars, and fats bilirubin, bile acids IgA Drugs dead or damaged cells in circulatory system excretes IgA into digestive tract Kupffer cells (macrophages) filter out antigens

Stomach
The stomach is a bean-shaped hollow muscular organ of the gastrointestinal tract involved in the second phase of digestion, following mastication. The word stomach is derived from the Latin stomachus, which derives from the Greek word stomachos. The words gastro- and gastric (meaning related to the stomach) are both derived from the Greek word gaster.

Functions The stomach is usually a highly acidic environment due to gastric acid production and secretion which produces a luminal pH range usually between 1 and 4 depending on the species, food intake, drug use, and other factors. Such an environment is able to break down large molecules (such as from food) to smaller ones so that they can eventually be absorbed from the small intestine. The stomach can produce and secrete about 2 to 3 liters of gastric acid per day.

Pepsinogen is secreted by chief cells and turns into pepsin under low pH conditions and is a necessity in protein digestion.Absorption of vitamin B12 from the small intestine is dependent on conjugation to a glycoprotein called intrinsic factor which is produced by parietal cells of the stomach. Other functions include absorbing water, some ions, and some lipid soluble compounds such as alcohol, aspirin, and caffeine. Anatomy of the human stomach The stomach lies between the esophagus and the duodenum (the first part of the small intestine). It is on the left side of the abdominal cavity. The top of the stomach lies against the diaphragm. Lying beneath the stomach is the pancreas, and the greater omentum which hangs from the greater curvature. Two smooth muscle valves, or sphincters, keep the contents of the stomach contained. They are the Cardiac or esophageal sphincter dividing the tract above, and the Pyloric sphincter dividing the stomach from the small intestine. The stomach is surrounded by parasympathetic (stimulant) and orthosympathetic (inhibitor) peluxes (anterior gastric, posterior, superior and inferior, celiac and myenteric), which regulate both the secretory activity and the motor activity of the muscles. In humans, the stomach has a volume of about 50 mL when empty. After a meal, it generally expands to hold about 1 litre of food, but it can actually expand to hold as much as 4 litres. When drinking milk it can expand to just under 6 pints, or 3.4 litres. The human stomach has more nerve endings than the human brain. Sections The stomach is divided into four sections, each of which has different cells and functions. The sections are:
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Cardia where the contents of the esophagus empty into the stomach. Fundus formed by the upper curvature of the organ Body or corpus the main, central region Pylorus or antrum the lower section of the organ that facilitates emptying the contents into the small intestine.

Histology of the human stomach Layers Like the other parts of the gastrointestinal tract, the stomach walls are made of the following layers, from inside to outside:
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mucosa The first main layer is the "mucosa". This consists of an epithelium, the lamina propria underneath, and a thin bit of smooth muscle called the muscularis mucosae. submucosa The "submucosa" lies under this and consists of fibrous connective tissue, separating the mucosa from the next layer The Meissner's plexus is in this muscularis externa The "muscularis externa" in the stomach differs from that of other GI organs in that it has three layers of smooth muscle instead of two.
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inner oblique layer: This layer is responsible for creating the motion that churns and physically breaks down the food. It is the only layer of the three which is not seen in other parts of the digestive system. The antrum has thicker skin cells in its walls and performs more forceful contractions than the fundus middle circular layer: At this layer, the pylorus is surrounded by a thick circular muscular wall which is normally tonically constricted forming a functional (if not anatomically discrete) pyloric sphincter, which controls the movement of chyme into the duodenum. This layer is concentric to the longitudinal axis of the stomach outer longituditinal layer: Auerbach's plexus is found between this layer and the middle circular layer

serosa Under these muscle layers is the "serosa", layers of connective tissue continuous with the omenta.

Cross section of stomach wall. Microscopic cross section of the pyloric part of the stomach wall.

Control of secretion and motility The movement and the flow of chemicals into the stomach are controlled by both the autonomic nervous system and by the various digestive system hormones:
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Gastrin The hormone gastrin causes an increase in the secretion of HCl, pepsinogen and intrinsic factor from parietal cells in the stomach. It also causes increased motility in the stomach. Gastrin is released by G-cells in the stomach to distenstion of the antrum, and digestive products. It is inhibited by a pH normally less than 4 (high acid), as well as the hormone somatostatin Cholecystokinin Cholecystokinin (CCK) has most effect on the gall bladder, but it also decreases gastric emptying Secretin In a different and rare manner, secretin, produced in the small intestine, has most effects on the pancreas, but will also diminish acid secretion in the stomach Gastric inhibitory peptide Gastric inhibitory peptide (GIP) decreases both gastric acid and motility Enteroglucagon enteroglucagon decreases both gastric acid and motility.

Other than gastrin, these hormones all act to turn off the stomach action. This is in response to food products in the liver and gall bladder, which have not yet been absorbed. The stomach needs only to push food into the small intestine when the intestine is not busy. While the intestine is full and still digesting food, the stomach acts as storage for food.

Cecum

The colon is about 5-6 feet long. Its primary purpose is to dehydrate and store the liquid stool that enters it. The colon begins in the right lower abdomen where the small intestine ends. This part of the colon is called the cecum. The ileocecal valve (ICV) at the end of the ileum regulates the flow from the small bowel into the colon. Image 1 shows the typical appearance of the ICV as seen from above. It usually has a puffy, orangish appearance and, at times, it is shaped like your lower lip. Image 2 looks directly at the slit opening of the valve. Image 3 is at the base of the cecum where the appendix is attached. Here you see the inside opening of the long finger-like appendix in the base of the cecum. Finally, Image 4 is a picture of the ileum or small bowel after the endoscope has passed through the ICV. You see that the lining here has a fine feathery appearance. The function of the ileum is different from the colon. In the small intestine nutrients are absorbed through tiny wavy fronds called villi, so you see a speckling of light being reflected back from these villi.

2. Circulatory system The circulatory system connects the capillary bed, which serves the exchange of substances, with the heart through the arteries and veins. The function of the arteries and veins is strictly to channel the blood, not to exchange substances. Arteries and veins may be distinguished by the fact that pressure in the arteries is high and that in the veins is low. The Structure of Arteries and Veins Arteries and veins resemble each other in that their walls contain three coats. However, the vessels adapt to their different circulatory tasks by differing in the structure of these coats. The inner coat (vascular endothelium, tunica intima) consists of a single layer of endothelial cells applied to a thin connective tissue layer, the basement membrane. The middle coat (tunica media) contains primarily smooth muscle and elastic tissue fibers. The outer coat (tunica adventitia, adventitious coat) embeds the vessel in its surroundings and consists mainly of connective tissue. In addition, the arteries have an elastic, fenestrated membrane (membrana elastica interna) between the inner and middle coat. Usually another, thinner elastic membrane (membrana elastica externa) lies between the middle and the outer coat. Arteries are distinguished by an especially well developed muscle coat, which contains a varying amount of elastic fiber according to its site (predominantly elastic and predominantly muscular arteries). This layer is the driving force of the blood vessels by dilating (vasodilatation) and constricting (vasoconstriction) the diameter of the blood vessels, it regulates blood flow and blood pressure. The arteries near the heart contain a high proportion of elastic fibers and this creates an elastic recoil. The blood ejected during systole is partly stored by expansion of the arterial wall, and is then moved forward during diastole by elastic recoil, thus achieving a continuous blood flow. Veins in general have wider lumina and thinner walls than arteries. The three coats are less well defined and the muscular coat is less well developed. Most veins, with the exception of those close to the heart, contain venous valves. These endothelial folds, projecting like pockets into the lumen of the vessel, act as one-way valves that guide the blood toward the heart and prevent backward flow.
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A liquid, blood, to transport o nutrients o wastes o oxygen and carbon dioxide o hormones Two pumps (in a single heart) o one to pump deoxygenated blood to the lungs; o the other to pump oxygenated blood to all the other organs and tissues of the body.

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A system of blood vessels to distribute blood throughout the body Specialized organs for exchange of materials between the blood and the external environment; for example o organs like the lungs and intestine that add materials to the blood and o organs like the lungs and kidneys that remove materials from the blood and deposit them back in the external environment.

The heart and pulmonary system The heart is located roughly in the center of the chest cavity. It is covered by a protective membrane, the pericardium.
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Deoxygenated blood from the body enters the right atrium. It flows through the tricuspid valve into the right ventricle. The term tricuspid refers to the three flaps of tissue that make up the valve. Contraction of the ventricle then closes the tricuspid valve and forces open the pulmonary valve. Blood flows into the pulmonary artery. This branches immediately, carrying blood to the right and left lungs. Here the blood gives up carbon dioxide and takes on a fresh supply of oxygen. The capillary beds of the lungs are drained by venules that are the tributaries of the pulmonary veins. Four pulmonary veins, two draining each lung, carry oxygenated blood to the left atrium of the heart

The coronary system From the left atrium,

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Blood flows through the mitral valve (also known as the bicuspid valve) into the left ventricle. Contraction of the ventricle closes the mitral valve and opens the aortic valve at the entrance to the aorta. The first branches from the aorta occur just beyond the aortic valve still within the heart. Two openings lead to the right and left coronary arteries, which supply blood to the heart itself. Although the coronary arteries arise within the heart, they pass directly out to the surface of the heart and extend down across it. They supply blood to the network of capillaries that penetrate every portion of the heart.

The capillaries drain into two coronary veins that empty into the right atrium.

The Systemic Circulation The remainder of the system is known as the systemic circulation. The graphic shows the major arteries (in bright red) and veins (dark red) of the system. Blood from the aorta passes into a branching system of arteries that lead to all parts of the body. It then flows into a system of capillaries where its exchange functions take place. Blood from the capillaries flows into venules which are drained by veins.
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Veins draining the upper portion of the body lead to the superior vena cava. Veins draining the lower part of the body lead to the inferior vena cava. Both empty into the right atrium.

3. INTEGUMENTARY SYSTEM

The skin or cutis covers the entire outer surface of the body. Structurally, the skin consists of two layers which differ in function, histological appearance and their embryological origin. The outer layer or epidermis is formed by an epithelium and is of ectodermal origin. The underlying thicker layer, the dermis, consists of connective tissue and develops from the mesoderm. Beneath the two layers we find a subcutaneous layer of loose connective tissue, the hypodermis or subcutis, which binds the skin to underlying structures. Hair, nails and sweat and sebaceous glands are of epithelial origin and collectively called the appendages of the skin. The skin and its appendages together are called the integumentary system. Functions The integumentary system has multiple roles in homeostasis. All body systems work in an interconnected manner to maintain the internal conditions essential to the function of the body. The skin has an important job of protecting the body and acts as the bodys first line of defense against infection, temperature change, and other challenges to homeostasis. Functions include:

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Protect the bodys internal living tissues and organs Protect against invasion by infectious organisms Protect the body from dehydration Protect the body against abrupt changes in temperature

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Help excrete waste materials through perspiration Act as a receptor for touch, pressure, pain, heat, and cold Protect the body against sunburns Generate vitamin D through exposure to ultraviolet light Store water, fat, glucose, and vitamin D Participate in temperature regulation

Skin, thick - H&E, trichrome. A good starting point is to identify the main layers (epidermis, dermis and hypodermis) of the skin at low magnification. The three layers forming the skin can be identified in all skin sections. The epithelium forming the surface layer, the epidermis, is usually the darkest layer visible. Sublayers are visible in the epidermis. Their staining varies - not just between stains but also between different H&E stained preparations (possibly depending on tissue preservation and how fresh the staining solutions were). At the transition from the epidermis to the dermis, staining will become lighter. The lighter stained layer, the dermis, consists of dense irregular connective tissue. The dermis is much thicker than the epidermis. In thick skin, dermal papillae create a very irregular border between epidermis and dermis. The hypodermis is the lightest layer visible and consists mainly of adipose tissue. Dense connective tissue strands may extend from the dermis deep into the hypodermis and anchor the skin to underlying structures.

PHYSICAL ASSESSMENT FINDINGS

THREE SYSTEMS PRIORITY GIT, CIRCULATORY SYSTEM and INTEGUMENTARY HEALTH HISTORY 1. GASTROINTESTINAL TRACT Brown in color Slightly distended No prominent vein No rash no lesions Umbilicus sunken, centrally located Flat abdomen
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NORMAL FINDINGS

PHYSICAL SSESSMENT FINDINGS

Did not perform percussion and palpation because patient claims for pain rating pain as 8 (10 as highest and 1 as lowest). 1. CIRCULATORY SYSTEM No distention Color is the same with abdominal skin color (jaundice)

Normally paler, wth white striae Fine veins observable No rash or lesions Umbilicus sunken, centrally located Flat or rounded abdomen Bowel sound: hgh pitch, irregular 5-35 times/min. present equally in all four quadrants.

Slightly distended abdomen With prominent veian seen No rash or lesion Umbilicus sunken, centrally located Rounded abdomen No bowel sounds heard

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The same color with abdominal skin No vibrations no pulsation are palpated in Pulse: 60 -100 bpm Bp: 120/80 mmHg

Pulse 140 bpm rapid Irregular Bp- 150/90mmhg hypertensive

1. INTEGUMENTARY SYSTEM - jaundice - a scar was found at his right paraital lobe due vihecular accident. -has good skin turgo

Skin pigmentation ranges in tone from ivory or light pink to ruddy pink in light sined client and from light to deep brown or olive in dark-skinned people. Moisture: dry with minimal perspiration and oilness. Texture: smooth, soft, even and flexible in children and adults. Turgor: skin lifts easily and snaps back immediatly to its resting position. Vascularity: appearance of superficial blood vessels. Nails: nail bed is pink with transluscent white tips. With good capilliary refill test at least 5 seconds to return in normal color. Hair: equal distribution pattern for terminal hair (long, coarse, thick, easily, visible on the scalp, axilla, pubic areas, beard in men) And Vellus hair (small, soft, tiny hairs covering the wole body except the palms and soles, the dorsum of the distal fingers, the umbilicus, the glands penis and inside the labia.

Jaundice Skin is warm to touch With good skin turgor Hives present at his both legs skin Diaphoresis due to environmental factor Capilliary refill or blanch test more than 5 seconds (delayed) Pallor most visible in lips Equal hair distribution both terminal and vellus hair.

REVIEW OF RELATED LITERATURE

Research title: Cecal rupture in foals 7 cases (19962006) by: Juan J. Tabar and Antonio M. Cruz Abstract The objective of this study was to identify risk factors and describe clinical signs in 7 foals with cecal rupture; none of the foals survived. Six foals had undergone general anesthesia; 5 for orthopedic procedures. Six of the foals were receiving nonsteriod anti-inflammatory drugs. Most foals started showing colic signs on day 2 after surgery, preceded in 3 cases by dullness. Cecal rupture occurred between 4 hours and 2 days after the first signs of colic were noticed. Intestinal motility was decreased or absent in all foals for which it was recorded. Foals undergoing general anesthesia should be closely monitored for any sign of dullness, prolonged recumbency, reduced fecal output, and signs of abdominal discomfort for 3 days postoperatively, especially in cases following orthopedic surgery. If any of the above occurs, cecal impaction should be considered as a differential diagnosis. A prompt exploratory laparotomy may be a reasonable diagnostic option before the cecum ruptures with fatal consequences. Materials and methods Records of foals under 6 months of age that were admitted to the Large Animal Veterinary Teaching Hospital, Ontario Veterinary College (OVC) from 1996 to 2006 were examined. Foals under 6 mo of age that died or were euthanized due to cecal rupture were included. Postmortem examination confirmed the cause of death and determined whether cecal impaction was present. Information extracted for these foals included signalment, presenting complaint, previous medical history, concurrent treatments with NSAIDs or other drugs at the time of admission, physical examination, and blood gas analysis, packed cell volume, total plasma protein and electrolytes prior to the cecal rupture, administration of -2 sedatives during the week prior to the cecal rupture, previous general anesthesia and the anesthetic protocol used, duration of the anesthesia and the surgical procedure performed, presence of diarrhea during hospitalization, signs of colic and the intensity and frequency of pain, possible abnormal signs (dullness, depression, fever, or any other abnormality) before the signs of colic started, time between surgery and first signs of colic, duration of the signs before cecal rupture occurred, localization of the tear, and the nature of the cecal content.

Results Of the 1931 foals under 6 months of age that were hospitalized at the OVC from 1996 to 2006 for different reasons, 7 (0.36%) foals died due to cecal rupture and were included in this study, 6 of these were from the 735 that had undergone surgery and general anesthesia. Of these 6, 1 had had an exploratory laparotomy for small intestine volvulus and 5 were from the total of 452 that had undergone orthopedic surgery. Of the 7 foals included in the study, 5 were fillies and 2 were colts. The breed and age of the foals are shown in Table 1. The duration of anesthesia and the nature of the surgeries performed in the rest of the cases are shown in Table 2. The duration of anesthesia and other data for Foal 1 are unknown, because the surgery was performed at another facility. Table 1 Data collected from medical records of the 7 foals that suffered cecal rupture

Table 2 Data recorded from anesthesia

Hyperthermia (mean temperature = 39.57C; min-max = 39 to 40C) was recorded in 6 cases, but not recorded in 1. Every foal had tachycardia, [mean heart rate = 97 beats/min (bpm); range: 60 bpm to 120 bpm] and tachypnea (mean respiratory rate = 60 breaths/min; range: 44 to 80 breaths/min). The appearance of the mucous membranes was recorded as toxic (3 cases), purple (1 case), mildly injected (1 case), and normal (1 case). In 1 case, the appearance of the mucous membranes was not recorded. The capillary refill time was estimated at 3 s in 3 cases, >4 s in 1 case, and normal (<2 s) in 1 case; it was not recorded in 2 foals. There was no abdominal distension in 4 cases, mild distension in 2 cases, and

moderate distension in 1 case. Upon auscultation of the abdomen, the motility was noticed to be decreased in 2 cases, absent in 1 case, and decreased in the ventral quadrants and absent in the dorsal quadrants in 1 case. In 3 cases, the intestinal motility was not recorded. Most of the foals had hemoconcentration [mean packed cell volume (PCV) = 0.46 L/L; range: 0.33 to 0.61 L/L], and the total protein (TP) remained within reference values (mean TP = 53.57 g/L; range: 47 to 62 g/L). Blood gas analysis from venous samples indicated acidosis (mean pH of 7.22; range: 7.06 to 7.34) of metabolic origin (mean HCO3 = 17.04; range: 12.1 to 26 mmHg): [mean of adjusted base excess (ABEe) = 8.84 mmol/L; range: 17 to 0.7 mmol/L] without ventilatory compromise (mean pCO2 =45.67 mmHg; range: 30.3 to 56 mmHg); (mean pO2 = 46.98 mmHg; range: 94.9 to 33.2 mmHg). Electrolyte measurements were within normal limits as per reference values. Each of the 6 foals that underwent surgery had been treated with antibiotics and NSAIDs (type and dosages shown in Table 3) for a variable duration of time prior to the cecal rupture. All the foals that underwent surgery and anesthesia showed mild signs of colic starting on the 2nd day after surgery. The mean time between 1st signs of colic and rupture of the cecum was 21.33 h, ranging from 4 to 48 h, and the signs worsened immediately prior to the diagnosis of cecal rupture. They were classified as severe and continuous in 4 cases, as severe and intermittent in 1 case, and moderate and continuous in 2 cases. In 3 cases, the foals were noticed to be depressed 46 h before starting to show signs of colic Table 3 Drugs administered during the time preceding cecal ruptures

Abdominocentesis was performed in every foal, leading to a definitive diagnosis of intestinal rupture in 4 cases, where intestinal contents were found in the peritoneal fluid. In the other cases, the abdominal fluid demonstrated nonspecific inflammatory modifications. Abdominal ultrasonography was performed in 6 cases (Foal 4 collapsed and died suddenly when the abdominal ultrasonography was about to be performed) and showed a large amount of free fluid in the peritoneal cavity in all them and the presence of hyperechogenic floating structures in 3 cases. Cecal rupture was diagnosed in 3 cases by exploratory laparotomy and confirmed on postmortem examination in all cases. Cecal ruptures were located in different places along the cecal wall (Table 1) The content of the cecum was reported on postmortem examination as being impacted in 2 cases and as dry or firm but not impacted in 4 cases

Research title: Peritonitis Introduction: Peritonitis is an inflammation of the peritoneum, the thin membrane that lines the abdominal wall and covers the organs within. The inflammation is caused by a bacterial or fungal infection of this membrane. There are two major types of peritonitis. Primary peritonitis is caused by the spread of an infection from the blood and lymph nodes to the peritoneum. This type of peritonitis is rare -- less than 1% of all cases of peritonitis are primary. The more common type of peritonitis, called secondary peritonitis, is caused when the infection comes into the peritoneum from the gastrointestinal or biliary tract. Both cases of peritonitis are very serious and can be life threatening if not treated quickly. Signs and Symptoms: The signs and symptoms of peritonitis include:
y y y y y y y

Swelling and tenderness in the abdomen with pain ranging from dull aches to severe, sharp pain Fever and chills Loss of appetite Thirst Nausea and vomiting Limited urine output Inability to pass gas or stool

Causes: Primary peritonitis is usually caused by liver disease. Fluid builds up in the abdomen, creating a prime environment for the growth of bacteria. Secondary peritonitis is caused by other conditions that allow bacteria, enzymes, or bile into the peritoneum from a hole or tear in the gastrointestinal or biliary tracts. Such tears can be caused by pancreatitis, a ruptured appendix, stomach ulcer, Crohn's disease, or diverticulitis. Peritoneal dialysis, which uses the blood vessels in the peritoneum to filter waste from your blood when your kidneys are not able to do so, also may cause peritonitis. Risk Factors: The following factors may increase the risk for primary peritonitis:

y y y y

Liver disease (cirrhosis) Fluid in the abdomen Weakened immune system Pelvic inflammatory disease

Risk factors for secondary peritonitis include:

y y y y y y y y

Appendicitis (inflammation of the appendix) Stomach ulcers Torn or twisted intestine Pancreatitis Inflammatory bowel disease, such as Crohn's disease or ulcerative colitis Injury caused by an operation Peritoneal dialysis Trauma

Diagnosis: Peritonitis can be life threatening, so the doctor will first conduct a physical examination to determine whether you need surgery to correct the underlying problem. The doctor will feel and press the abdomen to detect any swelling and tenderness as well as signs that fluid has collected in the area. The doctor may also listen to bowel sounds and check for difficulty breathing, low blood pressure, and signs of dehydration. The following procedures also may be performed:
y y y y

Blood tests -- to see if there is bacteria present in your blood Samples of fluid from the abdomen -- identify the bacteria causing the infection CT scan -- identifies fluid in the abdomen, or an infected organ X-rays -- detect air in the abdomen, which indicates that an organ may be torn or perforated

Preventive Care: The best way to prevent serious complications from peritonitis is to seek medical attention as soon as symptoms appear. If you are receiving peritoneal dialysis, you can help avoid peritonitis by cleaning the area around the catheter with antiseptic and washing your hands before touching the catheter.

Treatment: Peritonitis is a potentially life-threatening condition, and you should see immediate emergency medical attention when symptoms occur. You will likely need to be hospitalized for treatment. You may need surgery to remove the source of infection, such as an inflamed appendix, or to repair a tear in the walls of the gastrointestinal or biliary tract. Antibiotics are used to control infection. Integrative therapies may also be used for supportive care when recovering from peritonitis. Medications Your doctor will prescribe antibiotics to kill bacteria and prevent the infection from spreading. The antibiotics prescribed vary, depending on the type of peritonitis and the organism causing the condition. Surgery and Other Procedures People with peritonitis often need surgery to remove infected tissue and repair damaged organs. Nutrition and Dietary Supplements Peritonitis is a medical emergency and should be treated by a medical doctor. Do not try to treat peritonitis with herbs or supplements. However, a comprehensive treatment plan for recovering from peritonitis may include a range of complementary and alternative therapies. Ask your team of health care providers about the best ways to incorporate these therapies into your overall treatment plan. Always tell your health care provider about the herbs and supplements you are using or considering using. When recovering from any serious illness, it is important to follow good nutrition habits:
y y y y y y y

Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes) and vegetables (such as squash and bell peppers). Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables. Avoid refined foods, such as white breads, pastas, and especially sugar. Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein. Use healthy oils in foods, such as olive oil or vegetable oil. Avoid caffeine and other stimulants, alcohol, and tobacco. Drink 6 - 8 glasses of filtered water daily.

y y

Ask your doctor about taking a multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium. Probiotic supplement (containing Lactobacillus acidophilus among other species), 5 - 10 billion CFUs (colony forming units) a day, for gastrointestinal and immune health. Probiotics can be especially helpful when taking antibiotics, because probiotics can help restore the balance of "good" bacteria in the intestines.

Herbs Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted. Herbs can be used as a supportive therapy when you are recovering from peritonitis, but do not use herbs alone to treat peritonitis. Ask your doctor before taking any of the herbs listed below.
y y y y

Green tea (Camellia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant, anti-inflammatory, and heart health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb. Cat's claw (Uncaria tomentosa) standardized extract, 20 mg three times a day, to reduce inflammation. Cat's claw also has antibacterial and antifungal effects. Olive leaf (Olea europaea) standardized extract, 250 - 500 mg one to three times daily, for antibacterial and antifungal effects. You may also prepare teas from the leaf of this herb. Milk thistle (Silybum marianum) seed standardized extract, 80 - 160 mg two to three times daily, for liver health.

Homeopathy Few studies have examined the effectiveness of specific homeopathic remedies. A professional homeopath, however, may recommend one or more of the following treatments for peritonitis based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person' s constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.
y y

Belladonna -- for people who are hypersensitive to touch, have sudden attacks of pain that come and go, and have a high fever Arsenicum album -- for people with a swollen abdomen, unquenchable thirst, extreme chills, and symptoms that worsen at night

Other Considerations: Prognosis and Complications Complications from peritonitis can include:
y y y y

Sepsis -- an infection throughout the blood and body that can cause shock and multiple organ failure Abnormal clotting of the blood (generally due to significant spread of infection) Formation of fibrous tissue in the peritoneum Adult respiratory distress syndrome -- a severe infection of the lungs

The prognosis for peritonitis depends on the type of the condition. For example, the outlook for people with secondary peritonitis tends to be poor, especially among the elderly, people with compromised immune systems, and those who have had symptoms for longer than 48 hours before treatment. The long-term outlook for people with primary peritonitis due to liver disease also tends to be poor. However, the prognosis for primary peritonitis among children is generally very good after treatment with antibiotics.

Research title: Sorafenib-RT Treatment for Liver Metastasis (SLIM) Purpose Cancers that have spread to the liver from the primary cancer location (liver metastases) that cannot be removed surgically (unresectable) can be treated with chemotherapy and/or radiation therapy. Previous research has shown that tumours often have abnormal blood vessels that may reduce the effect of radiation therapy. New drugs, known as "anti-angiogenic" drugs have been shown in animal and human studies to damage or change tumour blood vessels in ways that may make tumors more sensitive to radiation treatment. 32- 44 Patients diagnosed with unresectable liver metastasis will be invited to take part in this study. The purpose of this study is to investigate the use of a new anti-angiogenic drug called Sorafenib, in combination radiation therapy and chemotherapy. The study will test how effective the new treatment is, the side effects associated with the new treatment, and to help establish safe dosages of the study medication. Intervention Details: Drug: Sorafenib Sorafenib doses will be 200mg twice daily orally for 28 days in level I, 400 mg in the morning and 200mg in the evening in level II, and 400mg twice daily orally for 28 days in level III . Radiotherapy will be started at day 8, patients will receive a total of 6 fractions over 2 weeks. Patients will be assessed weekly during treatment, 1 month post-tx, then at 3-month intervals for up to a year after tx, and then followed-up at 6-month intervals up to 3 years. Detailed Description: In this study, Stereotactic Body Radiation Therapy(SBRT) and Whole Liver Radiotherapy (WLRT) will be used concurrently with sorafenib at 3 different dosages to determine the tolerability and efficacy of this combined treatment. Sorafenib doses will be 200mg twice daily orally for 28 days in level I, 400 mg in the morning and 200mg in the evening in level II, and 400mg twice daily orally for 28 days in level III . Radiotherapy will be started at day 8, patients will receive a total of 6 fractions over 2 weeks. Patients will be assessed weekly during treatment, 1 month post-tx, then at 3-month intervals for up to a year after tx, and then followed-up at 6-month intervals up to 3 years. Once the Maximum Tolerated Dose (MTD) is established, an expanded cohort for each stratum will accrue such that a total of 10 patients per strata. This will allow us to gain further experience with this regimen and consolidate the safety and efficacy data. Quality of Life (QOL) assessment will be carried out at baseline and 1/3/6/9 mos post-tx. Patients will also be offered correlative studies looking at biomarkers through tissue, blood, and urine samples, and an imaging study looking at tissue perfusion.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY OF ACUTE ABDOMINAL PAIN 2 TO GENERALIZED PERITONITIS 2 TO

RUPTURED CECAL MASS RELATED TO MALIGNANCY WITH LIVER METASTASIS

MODIFIABLE FACTORS
y y y y y

NON-MODIFIABLE FACTORS
y y

Are older than 60 Eat a diet high in red or processed meats, high in fats Have cancer elsewhere in the body Have colorectal polyps Have inflammatory bowel disease (Crohn's disease or ulcerative colitis)

y y y

Familial adenomatous polyposis (FAP) Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome Are African American of eastern European descent Have a family history of colon cancer Have a personal history of breast cancer

Mechanical obstruction at the distal large bowel

Tumor

Distention of cecal wall

Separates of ,muscular layers

-----------------------------------------------------------------------------------------------------------------Mucosa protrudes Pneumoperitoneum(gastrointesti nal air pattern indicates distal obstruction of the large bowel and marked dilatation of the cecal protrusion ) Ruptures at the sole of protrusion

Cecum is dilated

Ruptured cecal tumor

-----------------------------------------------------------------------------------------------------------------------------Perforation of organs
metronidazole

infection

----------------------------------------------------------------------------------Allows the bacteria to enter the peritoneum cavity

ceftriaxone

Inflammation of other organs(pancreas)

Inflammation process (pelvic, inflammatory disease)

Fluid accumulation from liver disease

Complications of surgery

The permeability state of the intestinal walls & capillaries continue c & immune respond to the invading microorganisms

N/V
omeprazole

Irritation from contents leaking into abdominal cavity

Infection of the peritoneum N/V ground coffee vomit lymphocytes

Injury to vessel walls of peritoneum Capillary walls & intestinal walls become leaky melena Peritonitis Fluid leaks from the vascular space extra to the intestine
Ranitidine

Mechanical penetration of foreign objects

No bowel sound No peristalsis movement

wound

bleeding

Fluid shift out of vascular space

Abdomina l rigidity

Allows foreign material to enter the abdominal cavity

Inflammation of the lining of the peritoneal cavity

Tramadol

Generalized pain and positive rebound tenderness , BP 150/90mmHg

Captopril

ketorolac

Alteration in the absorption of nutrients & fluids from the intestine

Large amounts of undigested food particles moves through the gastrointestinal quickly

OSMOTIC DIARRHEA occurs due to mal-absorption of carbohydrates

Break of cancer cells from original (primary) tumor

Portal vein (which carries blood from the intestines to the liver) carries CA cells .

Carry through the bloodstream to the liver which filters the blood.

CA cells stick to the liver

y
chemotherapy and radiation can be combined to lessen the effects of the cancer on life expectancy. Abdominal pain or bloating that continues an extended time without any obvious cause ache on the right side below the rib cage occasional sharp pain in the right side Yellowing of the skin or eyes (jaundice) Abnormal liver function blood tests

y y y y

Form new tumors (metastasis)

Stage I. The tumor is small and formed in 1 part of the liver

Stage II. There are several small tumors or a single tumor that has spread to nearby blood vessels.

There are 1 or more tumors that might have spread to nearby parts of the body, such as the stomach, blood vessels or lymph nodes .

Stage IV. There are 1 or more tumors in the liver, and cancer cells have spread to other parts of the body.

MEDICAL INTERVENTION/MANAGEMENT TREATMENT MODALITIES

TREATMENT Secure consent to care Vital signs Q4h MIO every shift and record Urinalysis CBC Medications  Ranitidine 30 mg slow IVTT q6  Metronidazole 500 mg IV drip q6 RATIONALE An ethical principle that requires voluntary participation of the parents after informing them of possible risks and benefits. Serves as baseline data and to assess and notice any changes and stability of vital signs. Provides information about adequacy of fluid volume and replacement needs Used as a screening to help detect substances or cellular material in the urine associated with different metabolic and kidney disorders To determine body condition and evaluates the composition and concentration of the cellular components of the blood. Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion. Synthetic compound with direct trichomonacidal and amebicidal activity as well as antibacterial activity against anaerobic bacteria and some gram-negative bacteria. Centrally acting analgesic not chemically related to opioid receptors and inhibits reuptake of norepinephrine and serotonin.

 Tramadol 50 mg IVTT q6

 Ketorolac 30 mg slow IV q8

Analgesic, anti-inflammatory and antipyretic. Inhibits prostaglandin synthesis by inhibition of cyclo-oxygenase enzyme. It also inhibits leukotriene synthesis, help stabilize lysosomal membranes and exert anti-bradykinin activity. Bind to the bacterial cell wall membrane, causing cell death Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen. Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also increase plasma renin levels and reduce aldosterone levels. Net result is systemic vasodilation. Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.

 Ceftriaxone 1g IVTT q8 hrs.  Omeprazole 20 mg 1 tab. OD

 Captopril 25mg 1tab. Q6 hrs. SL PRN for BP > 160/100

 Furosemide 1 amp. IVTT CRP

LABORATORY RESULTS
Laboratory Exams Urinalysis Color Result Dark Yellow Normal Values Straw to dark yellow Correlation and Implication Within normal range.The color shows the degree of concentration. Normal urine ranges from pale, straw colordilute urine (more water intake) to amber (very concentrated). Urine is usually more concentrated during morning or with fluid volume deficits. Bleeding from the kidneys or ureters causes the urine to become dark red; bleeding from the bladder or urethra causes bright red urine. Indicates protein in the urine and a microbial growth infection. In acidic urine, cloudiness maybe caused by precipitation of urates, uric acid, and calcium oxalate. The most common substance that may cause cloudiness are WBC, RBC, bacteria, and epithelial cells. Normal. Patients kidneys are functioning well.

Transparency

Turbid

Clear-hazy

Specific gravity

1.032

1.002-1.035

pH

5.6

4.6-6.5

Patients urine is neither acidic nor basic which indicates that the patient eats proper diet. Normal. Presence may indicate a pathologic condition Normal. Presence may indicate a pathologic condition Abnormal. Denotes sloughing off of epithelial cells in the renal tubules. Abnormal. Indicates presence off infection in the genitourinary tract. Within normal range Indication of renal disease. Have traces of protein in her urine

Pus cells RBC Epithelial cells

2-3/hpf 1-2/hpf Abundant

0-5/hpf 0-2/hpf Small amounts

Bacteria

Moderate

None

Glucose Protein

Negative Positive

Negative Negative

Complete Blood Count Hemoglobin

12.8gm %

M: 13-16 g % F: 12-14 g %

Measures the oxygen carrying the blood, evaluates the total amount of erythrocytes in the blood by measuring her 100 ml of blood. In our case decrease hemoglobin level indicates hemodilation, (over load), anemia, recent hemorrhage. Hemoglobin is an ironcontaining red pigment which is responsible to transport oxygen from the lungs to the various tissues of the body and assist in the transport of carbon dioxide from tissues to the lungs.
Hematocrit measures the percentage of blood that is occupied by RBCs. A compound measure of red blood cell, number & size. In our case as the hemoglobin dereases hematocrit also decreased which are the components of RBCs. Also indicates possible anemia. Hematocrit is calculated as the percentage of RBCs in the total blood volume.

Hematocrit

36.0%

M: 42-50 g % F: 37-44 g %

Within acceptable range: no infection or autoimmune disease White Blood Cell 7,200/cumm 5-10 T/cumm The most numerous circulating WBC and they respond more

*Segmented Neutrophil

80%

55-70%

rapidly to the inflammatory and tissue injury sites than the other types of WBC. In our case, Increased neutrophil levels produced during acute bacterial infections and trauma. Primary function is phagocytosis. Decreased. Lymphocyte is any of the colorless weakly motile cells originating from skin cells and differentiating in lymphoid tissue that are the typical cellular elements of lymph include the cellular mononucleosis, chronic bacterial infections. Within normal range Within normal range

Lymphocytes

8%

20-35%

Monocyte Eosinophil Platelet

1% 0% 176 T/cumm

1-6% 0-4% 150-400 T/cumm

Increase in platelet count could lead to malignancies. In our case, the platelet count of our patient is within normal range.

Within normal range Within normal range

Blood Chemistry (July 22,011) Sodium Potassium Protein INR % activity BUN Creatnine Total protein Albumin Globulin 123.5mml/L 3.72mml/L 16.17 sec. 1.42 67.89% 46mg/dl 1.08mg/dl 6.0g/dl 0.8g/dl 5.2 g/dl 135-148mmol/ L 3.5-5.3mml/L 11-36 o.64-1 6.6- 8.3 3.5-4 3.1-4.3

Within normal range

High High Low Low High

DRUG STUDY
Tramadol 50mg IVTT q 6 hrs Brand names: Dolotral, Euromed Tramadol HCl, Gesidol, Milador Inj, Milador-Retard, Peptrad, Siverol, Tramal Action: Centrally acting analgesic not chemically related to opioid receptors and inhibits reuptake of norepinephrine and serotonin. Indication: Moderate to severe pain. Contraindication: Hypersensitivity. Acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids, or psychotrpic agents. Side effects: Vasodilation; dizziness/vertigo, headache, somnolence, stimulation, anxiety, confusion, coordination disturbances, euphoria, nervousness, sleep disorder, seizures. Pruritus, sweating, rash. Visual disturbances, dry mouth. Nausea, diarrhea, constipation, vomiting, dyspepsia, abdominal pain, anorexia, flatulence. Urinary retention/frequency, menopausalsymptoms, increased creatinine, proteinuria. Decreased hemoglobin, elavatedliver enzymes, asthenia, hypertonia. Nursing Responsibilities: (Assessment) y y y Assess patients pain (location, type, character) before therapy and regularly thereafter to monitor drug effectiveness (give before pain become extreme) Assess for hypersensitivity reactions: pruritus, rash and urticaria Monitor for possible drug induced adverse reactions : CNS: stimulation, dizziness, vertigo, headache, somnolence, anxiety, confusion, coordination disturbance, malaise, euphoria, nervousness, sleep disorder, seizures CV: vasodilation GI: nausea, vomiting, consipation, dyspepsia, diarrhea, abdominal pain, anorexia, flatulence, dry mouth GU: retention, frequency menopausal symptoms Musculoskeletal: hypertonia Respiratory: respiratory depression Skin: pruritus, sweating, rash Monitor for CNS changes: dizziness, drowsiness, hallucinations, euphoria, loss of consciousness and pupil reaction Monitor input-output ratio and check for decreasing output which may indicate retention. Assess changes in vowel pattern. Increase diet bulk and oral fluids and to prevent constipation.

y y y

Assess patients and familys knowledge on drug therapy.

(Implementation) Patient/Family Education y y y y y Instruct patient to take drug only as prescribed and not to increase dosage or interval without medical advice. Advice patient to avoid alcohol and OTC medication without medical advice. Warn ambulatory patients to be careful (call for assistance) when getting out of bed or walking or to refrain from performing activities that require alertness until CNS effects are known. Instruct patient to change positions slowly to prevent orthstatic hypotension. Instruct patient to monitor for and report ocurrence of drug induced adverse reactions.

Ketorolac 30mg slow IV q 8 hrs Brand names: Avular, Kortezor, Toradol, Remopain Action: Analgesic, anti-inflammatory and antipyretic. Inhibits prostaglandin synthesis by inhibition of cyclo-oxygenase enzyme. It alos inhibits leukotriene synthesis, help stabilize lysosomal membranes and exert anti-bradykinin activity. Indication: Short term management of moderate to severe acute post-operative pain. Contraindications: Active peptic ulcer disease, recent gastrointestinal (GI) bleeding or perforation, moderate to severe renal impairment, hypovolemia or dehydration, during labor or delivery, lactation, hypersensitivity to aspirin (ASA) or non-steroidal anti-inflammatory drugs (NSAIDs), history of asthma, prophylactic analgesic before major surgery or intra-op, operations woth high risk of bledding or incomplete hemostasis, suspected or confirmed cerebrovascular bleeding, anticoagulants including low-dose heparin, epidural or intrathecal administration, children under 16 years. Concurrently with other NSAIDs, pentoxifylline, probenecid, lithium salts. Lactation. Nasal polyps. Side effects: GI ulceration, bleeding and perforation, post-operative bldding, acute renal failure, anaphylactic and anaphylactoid reactions, liver failure. Hypertension, pruritus, rash, GI disturbances, nausea, dyspepsia, diarrhea, purpura, headache, drowsiness, dizziness, sweating, edema, injection site pain. Nursing Responsibilities: (Assessment) y y y Assess patients pain before and 1 hour after treatment: type, location, intensity and ROM. Assess for hypersensitivity reactions. Obtain history of aspirin sensitivity and asthma; these patients are more likely to develop hypersensitivity to NSAIDs. Monitor for possible adverse reactions: CNS: drowsiness, insomnia, syncope, dizziness, headache CV: edema, hypertension, palpitations EENT: transient stinging and burning, corneal edema, ocular irritation GI: nausea, dyspepsia, GI pain, diarrhea GU: hematuria, polyuria, renal failure Hematologic: purpura, eosinophilia, anemia. Assess for blood dyscrasias and signs of bleeding: bruising, fatigue or poor healing. Monitor CBC, Hgb, Hct and platelet count. Assess patients eyes for redness, swelling, tearing and itching. Assess for GI bleeding: blood in sputum, stools and emesis.

y y y

Assess patients and familys knowledge of drug therapy.

(Implementation) Patient/Family Education y y y y y y Teach patient not to crush, break or chew tablets and to take with a full glass of water to enhance absorption. Advice patient to report persistence or worsening of pain. Teach patient that drug is intended only for short term use but must be continued for prescribed time to be effective. Instruct patient to report bleeding, bruising, fatigue, malaise, and to avoid aspirin, alcoholic beverages, other NSAIDs, and acetaminophen. Instruct patient to use caution when driving because drowsiness and dizziness may occur. Caution patient that this drug may cause eye redness and burning if soft contact lenses are worn.

Ranitidine 30mg slow IVTT q 6 hrs Brand names: Ceranid, Cygran, Entac, Incid, Ranid, Raxide, Ulceral, Ulcin, Zantac Action: inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion. Indication: Used in the management of various GI disorders such as dyspepsia, GERD, peptic ulcer and Zollinger-Ellison syndrome. Prophylaxis of GI hemorrhage from stress ulceration and in patients at risk for developing acid aspiration during general anesthesia. Contraindication: Hypersensitivity. History of acute porphyria. Long-term therapy. Side effects: Cardiac arrhythmias, bradycardia. Headache, somnolence, fatigue, dizziness, hallucinations, depression, insomnia. Alopecia, rash, erythema multiforme. Nausea, vomiting, abdominal discomfort, diarrhea, constipation, pancreatitis.

Nursing Responsibilities: (Assessment) y y y y y Use caution in presence of renal or hepatic impairment. Assess potential for interactions with other pharmacological agents patient may be taking (e.g., increased/decreased levels or effects and toxicity). Monitor AST, ALT, serum creatinine; when used to prevent stress-related GI bleeding, measure the intragastric pH and try to maintain ph>4; signs and symptoms of peptic ulcer disease, occult blood with GI bleeding, monitor renal function to correct dose; monitor for side effects. Evaluate results of laboratory tests, therapeutic effectiveness, and adverse reactions. Assess knowledge/teach patient appropriate use, possible side effects/appropriate interventions, and adverse symptoms to report.

(Implementation) Patient/Family Education

y y y y y y y

Do not take any new medication during therapy without consulting physician. Take exactly as directed; do not increase dose- may take several days before noticeable relief. Allow 1 hour between any other antacids (if approved by physician) and ranitidine. Avoid excessive alcohol. Follow diet as physician recommends. May cause drowsiness, dizziness, or fatigue (use caution when driving or engaging in tasks requiring alertness until response to drug is known). Consult physician if breast-feeding.

Metronidazole 500mg IV drip q6 hrs Brand name: Flagyl, Flagyl ER, Flagyl IV RTU, Flagyl 375, Metizol, Metric 21, Metro I.V., MetroGel, MetroGel Vaginal, MetroLotion, Noritate, Protostat Action: Synthetic compound with direct trichomonacidal and amebicidal activity as well as antibacterial activity against anaerobic bacteria and some gram-negative bacteria. Indication: Treatment of pseudomembranous colitis, Crohn's disease, H. pylori eradication. Contraindications: Blood dyscrasias; active CNS disease; first trimester of pregnancy (category B), lactation. Side effects: Body as a Whole: Hypersensitivity (rash, urticaria, pruritus, flushing), fever, fleeting joint pains, overgrowth of Candida. CNS: Vertigo, headache, ataxia, confusion, irritability, depression, restlessness, weakness, fatigue, drowsiness, insomnia, paresthesias, sensory neuropathy (rare). GI: Nausea, vomiting, anorexia, epigastric distress, abdominal cramps, diarrhea, constipation, dry mouth, metallic or bitter taste, proctitis. Urogenital: Polyuria, dysuria, pyuria, incontinence, cystitis, decreased libido, dyspareunia, dryness of vagina and vulva, sense of pelvic pressure. Special Senses: Nasal congestion. CV: ECG changes (flattening of T wave). Nursing responsibilities: Assessment & Drug Effects
y y y y y y

Discontinue therapy immediately if symptoms of CNS toxicity (see Appendix F) develop. Monitor especially for seizures and peripheral neuropathy (e.g., numbness and paresthesia of extremities). Lab tests: Obtain total and differential WBC counts before, during, and after therapy, especially if a second course is necessary. Monitor for S&S of sodium retention, especially in patients on corticosteroid therapy or with a history of CHF. Monitor patients on lithium for elevated lithium levels. Report appearance of candidiasis or its becoming more prominent with therapy to physician promptly. Repeat feces examinations, usually up to 3 mo, to ensure that amebae have been eliminated.

Patient & Family Education

y y y y y y y

Adhere closely to the established regimen without schedule interruption or changing the dose. Refrain from intercourse during therapy for trichomoniasis unless male partner wears a condom to prevent reinfection. Have sexual partners receive concurrent treatment. Asymptomatic trichomoniasis in the male is a frequent source of reinfection of the female. Do not drink alcohol during therapy; may induce a disulfiram-type reaction (see Appendix F). Avoid alcohol or alcohol-containing medications for at least 48 h after treatment is completed. Urine may appear dark or reddish brown (especially with higher than recommended doses). This appears to have no clinical significance. Report symptoms of candidal overgrowth: Furry tongue, color changes of tongue, glossitis, stomatitis; vaginitis, curd-like, milky vaginal discharge; proctitis. Treatment with a candidacidal agent may be indicated. Do not breast feed while taking this drug.

Captopril 25mg 1tab. Q6 hrs. SL PRN for BP > 160/100 Brand name: Capoten Action: Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also increase plasma renin levels and reduce aldosterone levels. Net result is systemic vasodilation Therapeutic Effects: Lowering of blood pressure in hypertensive patients Improved survival and reduced symptoms in patients with heart failure Improved survival and reduced development of overt heart failure after myocardial infarction Decreased progression of diabetic nephropathy with decreased need for transplantation or dialysis Indication: Alone or with other agents in the management of hypertension Management of heart failure Reduction of risk of death, heart failure-related hospitalizations, and development of overt heart failure following myocardial infarction Treatment of diabetic nephropathy in patients with Type 1 diabetes mellitus and retinopathy Contraindications: Contraindicated in: Hypersensitivity History of angioedema with previous use of ACE inhibitors Pregnancy and lactation Use Cautiously in: Renal impairment, hypovolemia, hyponatremia, elderly patients, concurrent diuretic therapy (dosage reduction may be necessary) Surgery/anesthesia (hypotension may be exaggerated) Black patients (monotherapy for hypertension less effective, may require additional therapy; higher risk of angioedema) Children (safety not established)

Exercise Extreme Caution in: Family history of angioedema Side effects: CNS: dizziness, fatigue, headache, insomnia, Resp: cough, CV: hypotension, chest pain, palpitations, tachycardia, GI: taste disturbances, abdominal pain, anorexia, constipation, diarrhea, nausea, vomiting, GU: proteinuria, renal failure, Derm: rashes, pruritis, F and E: hyperkalemia, Hemat: AGRANULOCYTOSIS, neutropenia, Misc: ANGIOEDEMA, fever, Nursing responsibilities: ASSESSMENT Hypertension: Monitor blood pressure and pulse frequently during initial dosage adjustment and periodically throughout therapy. Notify physician or other health care professional of significant changes Monitor frequency of prescription refills to determine compliance Assess patient for signs of angioedema (dyspnea, facial swelling) Heart Failure: Monitor weight and assess patient routinely for resolution of fluid overload (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention) Lab Test Considerations: Monitor BUN, creatinine, and electrolyte levels periodically. Serum potassium may be increased, and BUN and creatinine transiently increased while sodium levels may be decreased. If elevated BUN or serum creatinine concentrations occur, dosage reduction or withdrawal may be required May cause elevated AST, ALT, alkaline phosphatase, and serum bilirubin Assess urine protein prior to and periodically during therapy for up to 1 yr in patients with renal impairment or those receiving >150 mg/day of captopril. If excessive or increasing proteinuria occurs, re-evaluate ACE inhibitor therapy May cause positive antinuclear antibody (ANA) titer CBC with differential should be monitored prior to initiation of therapy, every 2 wk for the first 3 mo, and periodically thereafter for up to 1 yr in patients at risk for neutropenia(patients with renal impairment, or collagen-vascular disease) or at first sign of infection. Discontinue therapy if neutrophil count is <1000/mm3

May cause false-positive test results for urine acetone PATIENT/FAMILY TEACHING Instruct patient to take captopril exactly as directed at the same time each day, even if feeling well. Missed doses should be taken as soon as possible but not if almost time for next dose. Do not double doses. Warn patient not to discontinue ACE inhibitor therapy unless directed by health care professional Caution patient to avoid salt substitutes containing potassium or foods containing high levels of potassium or sodium unless directed by health care professional (see Appendix B ) Caution patient to change positions slowly to minimize hypotension, particularly after initial dose. Patients should also be advised that exercising in hot weather may increase hypotensive effects Advise patient to consult health care professional before taking any OTC medications, especially cold remedies May cause dizziness. Caution patient to avoid driving and other activities requiring alertness until response to medication is known Advise patient to inform health care professional of medication regimen prior to treatment or surgery Advise patient that medication may cause impairment of taste that generally resolves within 8-12 wk, even with continued therapy Instruct patient to notify health care professional if rash; mouth sores; sore throat; fever; swelling of hands or feet; irregular heart beat; chest pain; dry cough; hoarseness; swelling of face, eyes, lips, or tongue; difficulty swallowing or breathing occurs; or if taste impairment or skin rash persists. Persistent dry cough may occur and may not subside until medication is discontinued. Consult health care professional if cough becomes bothersome. Also notify health care professional if nausea, vomiting, or diarrhea occurs and continues Instruct patient to notify health care professional immediately if pregnancy is planned or suspected Emphasize the importance of follow-up examinations to monitor progress Hypertension: Encourage patient to comply with additional interventions for hypertension (weight reduction, low sodium diet, discontinuation of smoking, moderation of alcohol consumption, regular exercise, and stress management). Medication controls but does not cure hypertension Instruct patient and family on correct technique for monitoring blood pressure. Advise them to check blood pressure at least weekly and to report significant changes to health care professional

Furosemide 1 amp. IVTT CRP Brand names: Apo-Furosemide, Furoside, Lasix, Lasix Special, Myrosemide, Novosemide, Uritol Action: Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule Increases renal excretion of water, sodium, chloride, magnesium, hydrogen, and calcium May have renal and peripheral vasodilatory effects Effectiveness persists in impaired renal function Therapeutic Effects: Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions) Decreased blood pressure Indication: Edema due to: CHF Hepatic or renal disease Hypertension Unlabelled Uses: Hypercalcemia of malignancy Contraindications: Contraindicated in: Hypersensitivity Cross-sensitivity with thiazides and sulfonamides may occur Pre-existing electrolyte imbalance, hepatic coma, or anuria Some liquid products may contain alcohol, avoid in patients with alcohol intolerance Use Cautiously in: Severe liver disease (may precipitate hepatic coma; concurrent use with potassium-sparing diuretics may be necessary) Electrolyte depletion

 Geri: Geriatric patients may have increased risk of side effects, especially hypotension and electrolyte imbalance, at usual doses Pedi: Increased risk of renal calculi and patent ductus arteriosis in premature neonatesDiabetes mellitus Increasing azotemia Pregnancy and lactation Side effects: CNS: dizziness, encephalopathy, headache, insomnia, nervousness, EENT: hearing loss, tinnitus, CV: hypotension, GI: constipation, diarrhea, dry mouth, dyspepsia, nausea, vomiting, GU: excessive urination, Derm: photosensitivity, rashes, Endo: hyperglycemia, F and E: dehydration, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis, Hemat: blood dyscrasias, Metab: hyperglycemia, hyperuricemia, MS: arthralgia, muscle cramps, myalgia, Misc: increased BUN Nursing responsibilities: ASSESSMENT Assess fluid status during therapy. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify physician or other health care provider if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs Monitor blood pressure and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension Geri: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digitalis glycosides are at increased risk of digitalis toxicity because of the potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia

 Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose IV therapy. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs Assess for allergy to sulfonamides Lab Test Considerations: Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. May cause serum potassium, calcium, and magnesium concentrations. May also cause BUN, serum glucose, creatinine, and uric acid levels PATIENT/FAMILY TEACHING Instruct patient to take furosemide as directed. Take missed doses as soon as possible; do not double doses Caution patient to change positions slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension Instruct patient to consult health care professional regarding a diet high in potassium (see Appendix B ) Advise patient to consult health care professional before taking OTC medication or herbal products concurrently with this therapy Instruct patient to notify health care professional of medication regimen before treatment or surgery Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions Geri: Caution older patients or their caregivers about increased risk for falls. Suggest strategies for fall prevention Advise patient to contact health care professional immediately if muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs Advise patient taking furosemide tablets not to change brands when refilling prescription; bioavailability among brands is variable Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels Emphasize the importance of routine follow-up examinations Hypertension: Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Furosemide controls but does not cure hypertension Reinforce the need to continue additional therapies for hypertension (weight loss, exercise, restricted sodium intake, stress reduction, regular exercise, moderation of alcohol consumption, cessation of smoking)

Ceftriaxone 1g IVTT q8 hrs. Brand name: Rocephin Action: Bind to the bacterial cell wall membrane, causing cell death Therapeutic Effects: Bactericidal action against susceptible bacteria Spectrum: Similar to that of second-generation cephalosporins, but activity against staphylococci is less, whereas activity against gram-negative pathogens is greater, even for organisms resistant to first- and second-generation agents Notable is increased action against Enterobacter Haemophilus influenzae Escherichia coli Klebsiella pneumoniae Neisseria Proteus Providencia Serratia Moraxella catarrhalis Borrelia burgdorferi Some agents have enhanced activity against: Pseudomonas aeruginosa (ceftazidime, cefoperazone) All except ceftibuten, and cefpodoxime have some activity against anaerobes, including Bacteroides fragilis Indication: Treatment of: Skin and skin structure infections (not cefixime) Bone and joint infections (not cefixime) Urinary and gynecologic infections including gonorrhea (ceftriaxone) or respiratory tract infections

Intra-abdominal infections (not cefixime) Septicemia Otitis media (cefdinir, cefixime) Cefotaxime, ceftazidime, ceftizoxime, ceftriaxone: Meningitis Ceftriaxone: Perioperative prophylaxis Cefepime: Empiric treatment of febrile neutropenic patients Ceftriaxone: Single-dose treatment of acute bacterial otitis media Cefotaxime, ceftriaxone: Lyme disease Cefdinir, cefditoren: Acute exacerbations of chronic bronchitis Contraindications: Contraindicated in: Hypersensitivity to cephalosporins Serious hypersensitivity to penicillins Hypersensitivity to L-arginine (Ceptaz formulation only) Carnitine deficiency or inborn errors of metabolism (cefditoren only) Use Cautiously in: Renal impairment (decreased dosing/increased dosing interval recommended for: Cefdinir if CCr <30 ml/min, cefepime if CCr <60 ml/min, cefotaxime if CCr <20 ml/min, cefpodoxime if CCr <30 ml/min, ceftazidime if CCr <50 ml/min, ceftibuten and cefditoren if CCr <50 ml/min, ceftizoxime if CCr <80 ml/min) Severe hepatic/biliary impairment (dosage reduction/increased dosing interval recommended for cefoperazone) Combined severe hepatic and renal impairment (dosage reduction/increased dosing interval recommended for cefoperazone and ceftriaxone) Diabetes (ceftibuten and cefdinir suspension contain sucrose) History of GI disease, especially colitis Geriatric patients (consider age-related decrease in body mass, renal/hepatic/cardiac function, concurrent medications and chronic disease states) Pregnancy and lactation (have been used safely) Side effects: CNS: SEIZURES (HIGH DOSES), GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, nausea, vomiting, cramps, janudice (ceftazidime), pseudolithiasis (ceftriaxone),

Derm: rashes, urticaria, Hemat: bleeding (increased with cefoperazone), blood dyscrasias, hemolytic anemia, Local: pain at IM site, phlebitis at IV site, Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS AND SERUM SICKNESS, superinfection, Nursing responsibilities: ASSESSMENT Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy Before initiating therapy, obtain a history to determine previous use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify the physician or other health care professional immediately if these symptoms occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction Lab Test Considerations: May cause positive results for Coombs' test in patients receiving high doses or in neonates whose mothers were given cephalosporins before delivery Monitor prothrombin time and assess patient for bleeding (guaiac stools; check for hematuria, bleeding gums, ecchymosis) daily in patients receiving cefoperazone or cefditoren, as this agent may cause hypoprothrombinemia May cause serum AST, ALT, alkaline phosphatase, bilirubin, LDH, BUN, and creatinine May rarely cause leukopenia, neutropenia, agranulocytosis, thrombocytopenia, eosinophilia, lymphocytosis, and thrombocytosis PATIENT/FAMILY TEACHING Instruct patient to take medication at evenly spaced times and to finish the medication completely, even if feeling better. Missed doses should be taken as soon as possible unless almost time for next dose; do not double doses. Advise patient that sharing of this medication may be dangerous Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy Caution patients that concurrent use of alcohol with cefoperazone may cause a disulfiram-like reaction (abdominal cramps, nausea, vomiting, headache, hypotension, palpitations, dyspnea, tachycardia, sweating, flushing). Alcohol and alcohol-containing medications should be avoided

during and for several days after therapy Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional

Omeprazole 20 mg 1 tab. OD Brand names: Losec, Prilosec, Prilosec OTC, Zegerid Action: Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen Therapeutic Effects: Diminished accumulation of acid in the gastric lumen with lessened gastroesophageal reflux Healing of duodenal ulcers Indication: GERD/maintenance of healing in erosive esophagitis Duodenal ulcers (with or without anti-infectives for Helicobacter pylori) Short term treatment of active benign gastric ulcer Pathologic hypersecretory conditions, including Zollinger-Ellison syndrome Reduction of risk of GI bleeding in critically ill patients OTC: Heartburn occurring >twice/wk Contraindications: Contraindicated in: Hypersensitivity Use Cautiously in: Liver disease (dosage reduction may be necessary) Pregnancy, lactation, or children <2 yr (safety not established)

Side effects: CNS: dizziness, drowsiness, fatigue, headache, weakness, CV: chest pain, GI: abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea, vomiting, Derm: itching, rash, Misc: allergic reactions, Nursing responsibilities: ASSESSMENT Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate Lab Test Considerations: Monitor CBC with differential periodically during therapy May cause AST, ALT, alkaline phosphatase, and bilirubin May cause serum gastrin concentrations to during first 1-2 wk of therapy. Levels return to normal after discontinuation of omeprazole Monitor INR and prothrombin time in patients taking warfarin PATIENT/FAMILY TEACHING Instruct patient to take medication as directed for the full course of therapy, even if feeling better. Take missed doses as soon as remembered but not if almost time for next dose. Do not double doses May cause occasional drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation Advise patient to report onset of black, tarry stools; diarrhea; abdominal pain; or persistent headache to health care professional promptly

NURSING THEORY APPLICABLE

MYRA LEVINES FOUR CONSIDERATION PRINCIPLES
The goal of Myra Levines conservation principles it to promote adaptation and maintain wholeness using the four conservation principles which are: y CONSERVATION OF ENERGY- this principle refers to balancing energy input and output to avoid excessive fatigue. CORELLATION: In our care we made sure that the patient gets enough rest to maintain her stamina, and gain energy to use for mobilization. Was put on NPO diet scheduled for an operation. y CONSERVATION OF STRUCTURAL INTEGRITY- this refers to maintaining or restoring the structure of body preventing physical breakdown and promoting early healing. CORELLATION: with our preoperative care, we had observed that he cannot ambulate on his own. y CONSERVATION OF PERSONAL INTEGRITY- recognizes and individual as one who strives for recognition, respect, self-awareness, selfhood and self determination. CORELLATION: The patient was able to do hygienic practices on his own prior to becoming very ill as claimed. With our contact with him we found out that he values respect and indeed he and his family treated us well. y CONSERVATION OF SOCIAL INTEGRITY- an individual is recognized as someone who resides with in a family, a community, a religious group, and ethnic group, a political system and a nation. CORELLATION: his social aspects are really achieved he said he has lots of friends, no enemy, he has good relationship with his siblings; he also claimed that going to church every Sundays is what he usually do. In political aspects she says even how unclean is our political life is, the decision do always lays on the person who vote whether a politician is righteous enough or not.

Gordons Functional Health Pattern

USUAL PATTERN ( July 22, 2011) I.HEALTH PERCEPTON MANGEMENT PATTERN y y y The patient has been hospitalized three times Has been suffering from pain way back in 2005 as claimed Experienced On and off upper quadrant pain radiating @ the back and lumbar area noted 1 month PTA. Quite not sure if he undergone any immunization No food or drug allergy. Has been undergone operation(ulcer operation as claimed) when he was still 14 years old INITIAL APPRAISAL (July 22, 2011) y y y ON-GOING APPRAISAL ()

y y y

Admitted last 07-22-2011 Admitting V/S: T-37.4C, PR- 90 bpm, On-going ex lap Right hemicolectomy, RR-24 cpm, BP- 140/90 double barrel ileu transverse colostomy, lavage : Medications: application of external retention suture @ -Metronidazole 500 mg/ IV drip q 6 hrs. OR -Ranitidine 50 mg / IVTT q 8 hrs. -Captopril 25mg 1tab. Q6 hrs. SL PRN for BP > 160/100 -Furosemide 1 amp. IVTT CRP -Tramadol 50mg IVTT q6 hrs. -Ketorolac 30 mg IVTT q8 hrs. -Ceftriaxone 1g IVTT q8 hrs. -Omeprazole 20 mg 1 tab. OD

LABORATORY RESULTS  CBC -hgb: 12.8 g/dl -hct: 36.0 L % - wbc count: 23.O H k/ul - platelet count - Neutrophil seg: 96 H% - Band: - Lymphocytes : 3L% - Monocytes: 1%

Eosinophils:0% Basophils: 0%

II.NUTRITIONAL METABOLIC MANAGEMENT PATTERN y y y y Appetite is good s claimed Usual food intake rice, vegetables, and dried fish. He loves to eat spicy and salty foods s claimed Not taking any supplemental vitamins y On-going ex lap Right Dried skin, dark brown skin is warm to hemicolectomy, double barrel ileu transverse touch, with some kind of age spots covering his both arms, posterior and colostomy, lavage : application of external anterior chest, both lower extremities skin, retention suture @ OR evidence of wrinkled face. three seconds capillary refill test, schamroths test 160 angle. Rounded abdomen, and distended. Auscultation of the abdominal region reveals normal bowel sound (BS) 25 BS/min. Palpation was not performed since he complained of abdominal pain .

y y

III. ELIMINATION PATTERN BLADDER BLADDER y Frequency: 4 times a day y color: dark yellow orange y Color: yellowish y voided 500 ml since catheter was inserted y No problem with urination no pain upon voiding y LABORATORY RESULTS y No assistive devices use, practiced  Urinalysis urinate all by himself and ambulates - Color: dark yellow himself in going to the comfort room. - Transparency: turbid - Specific gravity: 1.032 - Glucose: trace - Protein: positive - Ph:5.6  Microscopic examation: - Pus cells: 3-6/ hpf - RBC: 8-12/hpf - Epith. Cells: few - Bacteria: moderate On-going ex lap Right hemicolectomy, double barrel ileu transverse colostomy, lavage : application of external retention suture @ OR

BOWEL y Frequency: ones a day

BOWEL y Frequency: once(7pm) y Color: yellowish

y y y y SKIN y y

Color: yellow- brown Consistency: soft to formed No assistive device use Color: signs of aging is evident Warm to touch

Consistency: soft

SKIN y y y y y

color: signs of aging skin is evident diaphoresis presence of age spots warm to touch T-36.6C

IV. ACTIVITY EXERCISE PATTERN Doing his daily activities as a farmer

IV. ACTIVITY EXERCISE PATTERN Lying on the bed. .

IV. ACTIVITY EXERCISE PATTERN On-going ex lap Right hemicolectomy, double barrel ileu transverse colostomy, lavage : application of external retention suture @ OR

y .

V. SLEEP-REST PATTERN

y y y y

Usually sleep at 8 pm and wake 3 am Usual sleeps 6 - 7hours a day Seldom napping time is 1-2pm No difficulty in sleeping

On-going ex lap Right hemicolectomy, Claims that his hospital stay does affect double barrel ileu transverse colostomy, lavage : his sleeping pattern. application of external retention suture @ OR

VI.COGNITIVE PERCEPTUAL PATTERN y y y Not using eye glasses No hearing aids Elementary level y y y y y

Speaks slowly with a low pitch voice Papillary constriction equal Dark brown iris Evenly distributed eyebrows and eye lashes Tip of the ears a line with the outer cantus of the eye. Evidence of cerumen in both ear canals. Symmetrical nose, small.

On-going ex lap Right hemicolectomy, double barrel ileu transverse colostomy, lavage : application of external retention suture @ OR

VII. SELF- PERCEPTION SELF CONCEPT PATTERN y In his long stay in this world he claimed that a person who is abusive of his/her God given body will just experience the revenge of her/his on body in later age. y On-going ex lap Right hemicolectomy, With present heath condition he felt anxious and claimed that he made hinself double barrel ileu transverse colostomy, lavage : application of external retention suture @ ready for the incoming operation. OR

VIII. ROLE RELATIONSHIP PATTERN

On-going ex lap Right hemicolectomy, double barrel ileu transverse colostomy, lavage :

y y

Live with his wife and daughter Can understand vernacular language

He stay in the hospital with his wife.

application of external retention suture @ OR

CULTURAL y They do believe in quack doctors/ faith healers.

Even if they do believe in some superstitious beliefs they still priorities patronizing medical issues especially when talking about serious health problem

IX. SEXUALITY REPRODUCTIVE PATTERN y Claimed that they still perform sexual activities even in this age but there are already changes unlike when still young and vigorous. y

On-going ex lap Right hemicolectomy, Claimed that sexual activity is not anymore double barrel ileu transverse colostomy, lavage : an excitement because they are lod application of external retention suture @ OR already..

X. COPING PATTERN

STRESS

TOLERANCE

Whenever he feels something wrong he would usually tell his wife and not to theyre children.

On-going ex lap Pampered by her husband, children and Right hemicolectomy, double barrel ileu siblings. transverse colostomy, lavage : application of external retention suture @ OR

XI. VALUE BELIEF PATTERN y Religion: Roman Catholic believed in God, as verbalized y On-going ex lap Right hemicolectomy, Claimed that going to church is their usual routine it may not be all of them but at double barrel ileu transverse colostomy, lavage : least 1 of the family member does attends application of external retention suture @ OR masses every Sunday.

SUMMARY OF NURSING DIAGNOSIS

Pain Related to Inflammatory process Secondary to ruptured cecal mass, liver metastasis and peritonitis. y Ineffective breathing pattern related to pain secondary to ruptured cecal mass y Deficient knowledge regarding disease condition, related to unfamiliar S/S of current medical condition.

NURSING CARE PLANS

CUES/ EVIDENCES NURSING DIAGNOSIS
Pain Related to Inflammatory process Secondary to ruptured cecal mass, liver metastasis and peritonitis.

OBJECTIVES
Within our care the patient will manifest decrease pain as evidenced by: a. Absence of facial grimacing b. Vital signs within normal limit  T:36.5 37.5 C  PR: 60-100 bpm  RR: 12-20 cpm  BP: 120/80 mmhg c. rated pain at least 5 in a scale (1-10) 1 as not painful and 10 very painful d. Demonstrate use of relaxation skill:  deep breathing  absence guarding behavior  skin warm to touch  pqrst

INTERVENTION
INDEPENDENT: Observe and document location of pain ( e.g., steady, intermittent). Promote bed rest, allowing client to assure positioning comfort. Encourage use of deep breathing exercise. v/s health teching minimized stimatio

RATIONALE
y Assists in differentiating cause of pain and provides information about disease profession resolution, development of complication, and effectiveness of interventions. Bed rest in low fowlers position reduces intra abdominal pressure; however, it will naturally assume least painful

EVALUATION
within our one day care the patient has partially met the objectives as evidence by: MET:  Able to perform the proper technique of deep breathing. UNMET:  (wheeled In to OR) Exploratory Laparotomy hemicolectomy double barrel ileu transverse colostomy application of right

Subjective: Sige gasakit ako tiyan.

Objectives: y Vital signs y Bp 150/90 y Respiratory rate: 24 cpm y PR: 140 bpm y Facial grimacing y Rated pain 7 (10 as highest 1 is the lowest)

y y y

Preop meds

y y

Guarding behavior

 characterized pain radiate where

position. Promote rest, redirects attention, may enhance coping.

external suture.

retention

y DEPENDENT: y Tramadol 50 mg IVTT every 6 hours.

Ketorolac 30 mg slow IV every 8 hours

A centrally acting analgesic, reduces pain felt by patient Analgesic, antiinflammatory and antipyretic.

CUES/ EVIDENCES
Subjective cue: usahay sakit ekalibang wla ko kabalo nganu as claimed.

NURSING/ DIAGNOSIS
Deficient knowledge regarding disease condition, related to unfamiliar S/S of current medical condition.

OBJECTIVES
Within our care the patient will manifest:

INTERVENTIONS

RATIONALE
y Information can decrease anxiety, thereby reducing sympathetic stimulation. Provides knowledge from which client can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing. Promotes flow of bile and general relaxation during initial digestive

EVALUATION
Within our nursing care the objectives has been partially met as evidence by: a. Verbalize understanding of disease process, potential complications. b. Verbalize understanding of therapeutic needs. c. Initiate necessary lifestyle changes and participate in treatment regimen.

Objectives cues: y y y y Vital signs Respiratory rate: 24 cpm PR: 140 bpm BP:150/90 mmhg facial grimacing frequently

INDEPENDENT: y Provide explanations of/ reasons for test Adequacy of procedures and knowledge. preparation needed. a. Verbalize y Review disease understandin process/ g of disease y Discuss process, hospitalization potential and prospective complication treatment as s. indicated. b. Verbalize y Encourage understandin questions, g of expressions of therapeutic concerns. needs. y Recommend c. Initiate resting in seminecessary fowlers position lifestyle after meals. changes and participate in treatment

asking y wala me kablo nganu maovnow pmai anhi

regimen. y DEPENDENT: y Tramadol 50 mg IVTT every 6 hours. y Ketorolac 30 mg slow IV every 8 hours y Ranitidine 30 mg slow IVTT q6 y Metronidazole 500 mg IV drip q6

process. A centrally acting analgesic, reduces pain felt by patient Analgesic, antiinflammatory and antipyretic. Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion. Synthetic compound with direct trichomonacidal and amebicidal activity as well as antibacterial activity against anaerobic bacteria and some gramnegative bacteria. Analgesic, antiinflammatory

y y Ketorolac 30 mg slow IV q8

Ceftriaxone 1g IVTT q8 hrs. Omeprazole 20 mg 1 tab. OD y

Captopril 25mg 1tab. Q6 hrs. SL PRN for BP > 160/100

Furosemide 1 amp. IVTT CRP

and antipyretic. Bind to the bacterial cell wall membrane, causing cell death. Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen. Angiotensinconverting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other

vasodilatory prostaglandins. ACE inhibitors also increase plasma renin levels and reduce aldosterone levels. Net result is systemic vasodilation. y Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.

Ineffective coping

CUES/ EVIDENCES
Subjective cue: usahay maglisod kog ginhawa tungog sa ka sakit

NURSING/ DIAGNOSIS
Ineffective breathing pattern related compression of the diaphragm 2 to

OBJECTIVES
Within our care the patient will manifest: effective breathing pattern. As evidenced by: a. Established effective breathing pattern b. Experience no signs of respiratory compromised/ complication. c. Activity tolerance d. No use of accessory muscles.

INTERVENTIONS
INDEPENDENT: y Observe respiratory rate/ depth.

RATIONALE

EVALUATION
Within our nursing care the objectives is partially met as evidence by: Activity tolerance No use of accessory muscles Breath sounds clear

Check everything Objectives cues: Vital signs: y y y y y RR=24cpm BP: 150/ 90 mmhg Diaphoresis Facial grimace Decreased physical performance noted y Guarded mobility Risk for Infection

Shallow breathing, splinting with respirations, holding breath may result in hypoventilati on Promote ventilation.

y y y

Assist the client to turn, cough and deep breath periodically

Health teaching on breathing

Facilitate ease when breathing

techniques.

and aid in pain discomfort.

ANNOTATED READINGS Mashe stool in colostomy

Liver Metastasis is cancer that has spread to the liver from somewhere else in the body. Alternative Names Metastases to the liver Causes, incidence, and risk factors Cancers that may spread to the liver include:
y y y y y y y

Breast cancer Colorectal cancer Esophageal cancer Lung cancer Melanoma Pancreatic cancer Stomach cancer

Cancer cells often have aggressive tendencies and will invade other areas of the body. They usually do this by floating in the bloodstream and then multiplying themselves in a new place.Where and how cancer cells spread varies. It depends both on blood flow and on the characteristics of the different cancer cells. For example, cancers of the GI tract often spread to the liver because their blood drains directly through the liver. Melanoma usually spreads through the body's blood vessels to the liver.The risk of cancer spreading to the liver depends on the site of the original cancer. The liver cancer may also be present when the original (primary) cancer is diagnosed, or it may occur months or years after the primary tumor is removed.

Symptoms (In some cases, there are no symptoms) ,Anorexia, Fevers , Jaundice , Nausea, Pain, usually in the upper right part of the abdomen, Sweats, Weight loss Tests that may be done to diagnose liver metastases include:
y y y y y

Bilirubin blood test CT scan or MRI Liver function tests PET scan Ultrasound of the liver

Treatment depends on:

y y y y

The primary cancer site How much of the cancer has spread to the liver (for example, only one tumor versus many tumors in the liver) Whether it has spread to other organs outside of the liver The patient's condition

When the cancer has spread to the liver and other organs, whole-body (systemic) chemotherapy is usually used. When the spread is limited to the liver, systemic chemotherapy may still be used. However, other treatment methods may be effective. When the tumor is only in a few areas of the liver, the cancer may be removed with surgery. The use of radiofrequency waves or injection of toxic substances may also be used to kill tumors. When larger areas of the liver are involved, treatment may involve chemotherapy directly into the liver, or a procedure to block blood flow to parts of the liver (embolization) to "starve" the tumor cells.

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CONCLUSION
The whole experience in the EMERGENCY DEPARTMENT allowed us to appreciate more on how it is being in the area. Indeed, we are like a soldier in a war always prepared for a battle because youll never know what the case is/ situation does the patient coming in. We are like a soldier because we will take the armor of knowledge, critical thinking, and to provide efficient emergency care to a client as quickly as possible.

The skills of performing physical assessment and getting patients history are vital in planning for the best nursing care. Your other supplementary subjects that you took when you are still studying would also back you up, as you unravel the demographic profile of the patient as you relate it with his condition.

A case study is the application of how much you learned about your patients disease condition.

During the making of our case study, patience, efforts, money and time were used and tested. Team effort, cooperation and lots of decisive minds are the key in making this paper. Even just for a short period of time, we are able to secure, complete and correct data regarding our clients condition, and we done this because we are determined to do so. We learned to prioritize our work and manage our time effectively.

And here we are today, sharing with you what we have gone through in taking care of our client and everything that we experienced in this paper. At this time, we learned not to let ourselves be undertaken by fears and doubts because if we do so, we could not make and do everything we have done. For us, it is one of the best signs of our progress and improvements as a student nurse.

The demographic profile introduces our patients personal information, the developmental task used that is appropriate for his age, system involved for his case , the nursing theory to related to the way he handles himself that lead to the development of his case, the nursing care plans that were especially made to somehow relieve the situation he had. The limitation of the study include the time when we started making the case book which is really near from the deadline, the money expenses, and the free time during week days. We recommend this study to improve in planning and giving for the patients wellness and make ways to avoid from coming back to the hospital for another treatment. We hope that this book will help the readers as well as the learners to understand more on the information about ex lap Right hemicolectomy, double barrel ileu transverse colostomy, lavage : application of external retention suture.

BIBLIOGRAPHY

Books:
Ahswill J.W & Droske, S.C (1997). Nursing Care of Children: Principles and Practice. U.S.A.,W.B. Saunders. Black, Joyce M. (2008).Medical and Surgical Nursing Management for Positive Outcomes. 8th ed. vol.2. Singapore: Elsevier Pte Ltd Doyle R.M & Turkington C.A. (2004). Nursing 2004 Drug Handbook.24th ed.U.S.A.,Springhouse Lipincott Williams & Wilkins Ignatavicius,D.D & Workman, M.L. (2006). Medical-Surgical Nursing: Critical Thinking for Collaborative Care. 5th ed. Elsevier Pte Ltd 3 Killiney Road, Saunders Elsevier Inc. McCance, K.L. & Huether,S.E. (1998).Pathophysiology: The Biophysical Basis for Disease in Children and Adults.St. Louise Missouri.Mosby Inc. Seeley, R.R, Stephens, T.D. & Tate, P. (1998). Anatomy and physiology. Boston, MA:WCB McGraw-Hill. Sparks,S.M. (2001). Nursing Diagnoses and Reference Manual: An indispensable guide to better patient care.5th ed.U.S.A.,Springhouse Spratto G.R. & Woods A.L. (2005). 2005 Edition: PDR Nurses Drug Handbook.Singapore.Thompson Learning Asia. Tomey,A.M. & Alligod, M.R. (2002).Nursing Theorists and their Work.5th ed.Singapore.Elsevier PTE Ltd. Tortora, G.J & Grabowski. (1996). Principles of anatomy and physiology. New York, NY:HarperCollins Weber, J. & Kelly Jane. (2007). Health Assessment in Nursing. 3rd ed. Lippincott Wiliams and Wilkin