CASE STUDY PRESENTATION

I-INTRODUCTION
A. Description of the Disease

INTRODUCTION
B. Recent Trends and Innovations

INTRODUCTION
C. Local And International Statistics Worldwide USA Philippines

INTRODUCTION
D. Nurse centered Objectives:
At the end of the study, the student nurses will be able to:

Cognitive Psychomotor Affective

NURSING ASSESSMENT
A. Personal Data
a. Demographic Data
Mr. XY is a 66 year old male He is married He was born in Candaba, Pampanga on November 07, 1946. Works as a COMELEC officer in San Fernando, Pampanga. Now a retired government employee.

NURSING ASSESSMENT
b. Socio Economic and Cultural Factors
Mr. XY had an income of less than P18,000/month Usual diet is high in fat, total calories and processed foods. Four of the members of the family are in abroad. Prioritization of health is important. Believed that taking herbal medicines could be of help to promote health.

NURSING ASSESSMENT
c. Environmental Factors
House is privately owned. There are many trees in their farm such as ponkan tree, mango tree, longgan tree, and etc. A health center is accessible to their place and accessible by jeepney or tricycle.

NURSING ASSESSMENT
d. Family Health- Illness History

NURSING ASSESSMENT
D. History of Past Illness
Complete childhood immunizations Year 1944-Car Accident Year 2011-Coronary Artery Disease and experienced Mild
Stroke.

June 17, 2013 (Tuesday)-Underwent an operation.

Alcoholic drinker who consumes 6 bottles of beer a day.

NURSING ASSESSMENT
E. History of Present Illness
Few months to admission, Mr XY has been through check-ups and diagnostic exams in a hospital in San Fernando, Pampanga. He was admitted June 16, 2013 and have an initial diagnosis of Left Sided Colonic Adenocarcinoma Stage II-A, T3NoMo. June 17, 2013, he underwent Left Hemicolectomy.

NURSING ASSESSMENT
F. Physical Examination (IPPA, Cephalocaudal Approach) INITIAL ASSESSMENT Sunday, June 16, 2013 (lifted from the chart admission) Vital Signs: Temperature: 36.4 C Pulse Rate: 87 bpm Respiratory Rate: 21 bpm Blood Pressure: 120/70 mmHg (+) Fecal material with blood

NURSING ASSESSMENT
INITIAL NURSE-PATIENT INTERACTION(Tuesday, June 18, 2013)
General Appearance: Oriented to time. The patient was conscious and coherent; with an ongoing IVF of D5LRS IL x 40-41 gtts/min @ 950cc level, infusing well on the right hand; with Indwelling Foley Catheter connected to urine bag, draining dark yellow urine output @1L as of 8:30am and 500ml as of 10:40am; Patient is irritable because of the foley catheter inserted to his genital; with difficulty of moving because of his suture; with painscale of 10/10 ; with facial grimaces and guarded behavior.

NURSING ASSESSMENT
SKIN: light brown in color, no bruises or rashes, normal skin turgor NAILS: normal capillary refill, pink nail beds, with trimmed fingers and toe nails HEAD: round, symmetrical facial movements HAIR: short white/black hair, no presence of nits or lesions EYES: brown iris without cataract on both eyes EARS: symmetrical auricles, not tender, able to hear, normal voice tone audible NOSE: symmetrical, No discharge or flaring, no tenderness, no lesions, no nasopharyngeal congestion MOUTH: dryness and cracks on lips noted, no halitosis and ulceration in tongue, with yellow stained in his teeth, no dentures BODY: symmetrical, having a medium built in proportion to his age ABDOMEN: Skin is uniform in color; abdomen is soft with intact wound dressing, and no presence of blood in the surgical incision on its middle lower part of the abdomen. CHEST AND LUNGS: symmetrical chest expansion, spine is vertically aligned; skin is intact, with normal breaths sound in both lung fields. MUSCULOSKELETAL SYSTEM: Bones have no deformities, no tenderness or swelling. And joints have no tenderness or swelling.

NURSING ASSESSMENT
SECOND NURSE-PATIENT INTERACTION(Monday, June 24, 2013)
General Appearance: The patient was conscious and coherent; with an ongoing IVF of D5LRS IL x 40-41 gtts/min @ 800cc level, infusing well on the right hand; with Indwelling Foley Catheter connected to urine bag, draining light yellow urine output @500ml as of 8:30am; Patient is irritable because of the foley catheter inserted to his genital; with difficulty of moving because of his suture.

NURSING ASSESSMENT
SKIN: light brown in color, no bruises or rashes, normal skin turgor NAILS: normal capillary refill, pink nail beds, with trimmed fingers and toe nails HEAD: round, symmetrical facial movements HAIR: short white/black hair, no presence of nits or lesions EYES: brown iris without cataract on both eyes EARS: symmetrical auricles, not tender, able to hear, normal voice tone audible NOSE: symmetrical, No discharge or flaring, no tenderness, no lesions, no nasopharyngeal congestion MOUTH: (-) dryness and cracks on lips noted, no halitosis and ulceration in tongue, without stained in his teeth, no dentures BODY: symmetrical, having a medium built ABDOMEN: Skin is uniform in color; abdomen is soft with dry and intact wound dressing, and no presence of blood in the surgical incision on its middle lower part of the abdomen. CHEST AND LUNGS: symmetrical chest expansion, spine is vertically aligned; skin is intact, with normal breaths sound in both lung fields. MUSCULOSKELETAL SYSTEM: Bones have no deformities, no tenderness or swelling. And joints have no tenderness or swelling.

NURSING ASSESSMENT
THIRD NURSE-PATIENT INTERACTION(Tuesday, June 25, 2013)
General Appearance: The patient was conscious and coherent; with an ongoing IVF of D5LRS IL x 40-41 gtts/min @ 550cc level, infusing well on the right hand.

NURSING ASSESSMENT
SKIN: light brown in color, no bruises or rashes, normal skin turgor NAILS: normal capillary refill, pink nail beds, with trimmed fingers and toe nails HEAD: round, symmetrical facial movements HAIR: short white/black hair, no presence of nits or lesions EYES: brown iris without cataract on both eyes EARS: symmetrical auricles, not tender, able to hear, normal voice tone audible NOSE: symmetrical, No discharge or flaring, no tenderness, no lesions, no nasopharyngeal congestion MOUTH:(-) dryness and cracks on lips noted, no halitosis and ulceration in tongue, without stained in his teeth, no dentures BODY: symmetrical, medium built ABDOMEN: Skin is uniform in color; abdomen is soft with intact wound dressing, and no presence of blood in the surgical incision on its middle lower part of the abdomen. CHEST AND LUNGS: symmetrical chest expansion, spine is vertically aligned; skin is intact, with normal breaths sound in both lung fields. MUSCULOSKELETAL SYSTEM: Bones have no deformities, no tenderness or swelling. And joints have no tenderness or swelling.

II-NURSING ASSESSMENT
G. DIAGNOSTIC and LABORATORY PROCEDURES

CBC (Complete Blood Count Test)

1.CBC (Complete Blood Count Test) Diagnostic/ Laboratory Procedures Date Ordered Date Results Indication (s)/ Purpose Result Normal Values Used in the Hospital Analysis and Interpretation Of Results

WBC

D.O: 06/16/13 D.R: 06/16/13

It is a blood test to measure the number of white blood cells and presence of infection

6.36/L

5-10 x 10 9/L

The result is normal which do not indicate risk for developing anemia,

infectious disease,
leukemia or tissue damage.

CBC (Complete Blood Count Test)

150-400 x10 9/L

Platelet

D.O: 06/16/13 D.R: 06/16/13

It is a blood test to monitor risk for hemorrhage.

261

Results show that Platelet is in the normal range this means that there are less chances of developing hemorrhage

Hgb

D.O: 06/16/13 D.R: 06/16/13

It measures the ability of the red blood cells to carry

104g/L

125- 175g/L

The result is below normal which indicates that

oxygen and to
screen for anemia.

there is risk of
having anemia. Oxygen perfusion is not normal.

CBC (Complete Blood Count Test)

D.O: 06/16/13 Hct D.R: 06/16/13 To aid diagnosis of polycythemia, anemia, or abnormal states of hydration 0.30 0.40- 0.52g/L
Below normal Hct it suggests anemia or hemodilution

Neutrophils

D.O: 06/16/13 D.R: 06/16/13

- To identify if there is an infection

0.60

0.45- 0.65

The result is normal that indicates, there is no infection.

CBC (Complete Blood Count Test)

Lymphocytes D.O: 06/16/13 D.R: 06/16/13 - To identify if there is a viral infection or immunologic reaction 0.30 0.20-0.35 The result is normal that indicates, there is no infection.

Monocytes

D.O: 06/16/13 D.R: 06/16/13

To identify the presence of bacterial infection

0.05

0.02-0.06

Result is normal that indicates, there is no presence of bacterial infection

CBC (Complete Blood Count Test)

BUN
D.0: 06/16/13 D.R: 06/16/13

- To evaluate kidney function and to monitor patients with acute or chronic

6.3

1.7-8.3

The result is normal. It indicates normal blood flow to the kidneys.

kidney
dysfunction or failure.

Creatinine

D.0: 06/16/13 D.R: 06/16/13

- A test of renal function reflecting the balance between the production and

1.24

0.40- 1.40mg/dl

The result is normal which indicates that there is no impairment in clearance of creatinine in the kidneys.

filtration of renal
glomerulus.

Sodium

D.O: 06/16/13 D.R: 06/16/13

-To detect hyponatremia or hypernatremia associated with dehydration, edema, and a variety of diseases

144

135-145

- Result is in normal range that indicates less chances to develop hypertension, and hyper/hyponatrem ia.

Potassium

D.O: 06/16/13 D.R: 06/16/13

- To detect concentrations that is too high or too low (hyper/hypokalemia)

3.92

3.50- 5.50

- it is normal and there is no kidney disease, hyper/ hypokalemia

Chloride

D.O: 06/16/13 D.R: 06/16/13

- To monitor persons put on a low-salt diet and to help diagnose the cause of S&Sx such as prolonged vomiting, diarrhea, weakness, and respiratory distress.

104.7

98- 108

The result is normal that indicates of not having hyperchloremia.

NURSING RESPONSIBILITIES
Before: 1.Verify doctors order. 2.Verify the patient. 3.Instruct the patient about the schedule of the test. 4.Define and explain the test 5.State the purpose of the test. 6. Verify the patient. 7.Inform the patient that he need not restrict fluids but should not eat an excessive amount of meal before the test. During: 1.Assisting to adhere to standard precautions. 2.Provide emotional support during blood extraction. After: 1. Apply pressure or a pressure dressing to prevent bleeding. 2. Monitor for signs and symptoms of infection. 3. Provide health teachings. 4.Record all procedures done.

X-ray
Diagnostic/ Laboratory Procedures Date Ordered Date Results Indication (s)/ Purpose Result Normal Values Used in the Hospital Analysis and Interpretation Of Results

X-ray

D.O: 06/16/13 D.R: 06/16/13

- To detect fractures, dislocation, compressions, -

Both lungs are cleared. Cardiomegal y, Left

Structures are dense, and will appear white. Structures

There are some abnormalities seen on the test, this indicate that

curvature, and
degenerative processes either spinal, chest and the lungs. -

Ventricular
prominence. Atherosclero tic aorta

containing air will

be black and muscle, fat, liquid; will appear as shades of gray.

patient may have

a history of coronary artery diseases and sedentary

lifestyle.

NURSING RESPONSIBILITIES
Before:
1. 2. Explain the procedure and purpose of x ray. There is no advance preparation necessary for chest x rays. Once the patient arrives in the exam area, a hospital gown will replace all clothing on the upper body and all jewelry must be removed. Assisting to adhere to standard precautions. Interpret results Monitor patient appropriately. No aftercare is required by patients who have chest x rays.

3.

During:

After:
1. 2. 3.

1.

III-ANATOMY and PHYSIOLOGY

Digestive System Lips and Cheeks Palate Tongue Teeth Pharynx Esophagus Stomach Small Intestine Large Intestine Rectum and Anus

 Structure

The colon is divided into 4 parts: Ascending Colon Transverse Colon Descending Colon Sigmoid Colon

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

 Function
To absorb water and nutrients from what we eat and to move food waste out of our body. Receives partially digested food, in a liquid form, from the small intestine. Bacteria (bowel flora) in the colon break down some materials into smaller parts. The epithelium absorbs water and nutrients. Produces mucus at the end of the digestive tract.

Tighten and relax (peristalsis) to move the stool to the rectum. The rectum is a holding area for the stool.
When it is full, it signals the brain to move the bowels and push the stool from the body through the anus.

IV-PATHOPHYSIOLOGY Bookbased
Schematic Diagram

Synthesis of the Condition

DEFINITION OF THE DISEASE
Our bodies are made up of billions of cells that grow, divide, and then die in a predictable manner. Cancer of the colon is the disease characterized by the development of malignant cells in the lining or epithelium of the first and longest portion of the large intestine. Most colon cancers are adenocarcinomas (cancers that begin in cells that make and release mucus and other fluids).

 Stages of Cancer
Stage 0 Stage 1 Colon Cancer Stage 2 Colon Cancer Stage 3 Colon Cancer Stage 4 Colon Cancer

IV.

PATHOPHYSIOLOGY Client Centered

 PRECIPITATING & PREDISPOSING FACTORS

-There are many precipitating factors that place an extra burden on a Colon cancer. Precipitating and Predisposing factors may include:

A personal history of colorectal cancer or polyps. Inflammatory intestinal conditions. Inherited syndromes that increase colon cancer risk. Family history of colon cancer and colon polyps. Low-fiber, high-fat diet. A sedentary lifestyle. Alcoholic drinker

 PATHOLOGIC CHANGES

Presence of polyps Abnormal cell proliferation Presence of malignant tumor

 SIGNS & SYMPTOMS WITH RATIONALE

Bloody stool Abdominal pain Fatigue Constipation Diarrhea Nausea and Vomiting

Synthesis of the Condition

DEFINITION OF THE DISEASE
Cancer developed from his kind of diet, lifesyle and alcoholic drinking. Family history and his age predisposes

PRECIPITATING & PREDISPOSING FACTORS Precipitating factors; Alcoholic drinker Diet Lifestyle Predisposing factors; Age Family History

 PATHOLOGIC CHANGES Abnormal cell proliferation Presence of polyps Presence of malignant tumor SIGNS & SYMPTOMS The sign and symptom that the client manifested is hematochezia.

V. THE PATIENT AND HIS CARE

Medical Management

i.IVF

Treatment

Date Ordered, Date performed, Date changed

General description

Indication / Purpose

Patients Reaction

Nursing Responsibility

D5LRS

June 16 to June 25 2013

Lactated Ringer's and 5% Dextrose Injection, USP is a

Treatment for persons

The client didnt experience

Prior:

sterile, nonpyrogenic solution for fluid

needing extra calories who

any adverse effect towards

-Confirm doctors order of

fluid prescribed. -Gather and prepare all

and electrolyte replenishment and caloric supply in a single cannot tolerate fluid overload treatment. dose container for intravenous administration. Each 100 mL contains 5 g Dextrose Hydrous, USP*; 600 mg Sodium Chloride, USP (NaCl); 310 mg Sodium Lactate (C3H5Na03); 30 mg of Potassium Chloride, USP (KCl); and 20 mg Calcium Chloride, USP (CaCl22H20). It contains no antimicrobial agents. The client tolerated the infusion.

materials needed. -Ensure correct Identification of patient. -Perform hand washing. During :

-Choose site for vein puncture.

-Use aseptic technique during IV cannula insertion. -Check patients condition

during infusion for the signs of reaction anaphylaxis. After: -IVF should be closely

monitored for cloudiness or

presence of particles; any of this the infusion should be stopped immediately. -Check IV site for patency extravasations and infiltration.

Drug name

Date orde re d Date give n Date change d or discontinue d

Route , Dosage & fre que ncy

Ge ne ral action, classification, me chanism of action

Patie nts Re sponse

Nursing Re sponsibilitie s

Ge ne ric Name : Diclofe nac

June 18 to June 25

75mg IV q12

Analgesics Antiinfla mma tory Anti pyretic

The client didnt experience any Adverse Effect towards the

Take drug with food or meals if GI upset occurs. Do not cut, crush or chew delayed release or extendedrelease tablets.

Brand Name : Dife nax

NSAID

Inhibits prostagland in synthesis cause antipyretic antiinfla mma tory effects, the exact mechanism unknown. is and to

treatment.

Take only the prescribed dosage.

You may experience these side effects: dizziness or

drowsiness. Acute longterm treatment of mild to moderate pain. Advised pt to report sore throat, fever, rash, itching, weight gain,

Surgical Management
Brief Description & Visuals
Conventional surgery (open colectomy):

Surgical Management
Patients response to the operation -Mr. XY reported postoperative pain.
Nursing responsibilities > Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate > nurse should know that it may cause false positive results for urine test with sulfosalicylic acid > inform patient that it may cause drowsiness or dizziness > inform patient that increase fluid intake and fiber intake may minimize constipation > advised patient to report onset of black, tarry stools, fever, sore throat, diarrhea, dizziness, rash, confusion, or hallucinations to health car professional promptly > inform patient that medication may temporarily cause stool and tongue to appear gray black

Surgical Management
Pre-Operative care 1. Provide HIGH protein, HIGH calorie and LOW residue diet 2 .Provide information about post-op care and stoma care 3. Administer antibiotics 1 day prior 4. Enema or colonic irrigation the evening and the morning of surgery 5. NGT is inserted to prevent distention 6. Monitor UO, F and E, Abdomen PE

Surgical Management
Post-Operative care 1. Monitor for complications Leakage from the site, prolapse of stoma, skin irritation and pulmonary complication 2. Assess the abdomen for return of peristalsis 3. Assess wound dressing for bleeding 4. Assist patient in ambulation after 24H 5. Provide nutritional teachingLimit foods that cause gas-formation and or Cabbage, beans, eggs, fish, peanuts Low-fiber diet in the early stage of Recovery 6. Instruct to splint the incision and administer pain meds before exercise 7. The stoma is PINKISH to cherry red, slightly edematous with minimal pinkish drainage 8. Manage post-operative complication

Surgical Management

VI. NURSING CARE PLANS

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING

NURSING INTERVENTION

RATIONALE

EVALUATION

S:First time ko ksi ma Anxiety r/t pain for Vague operahan masyadong verbalized kaya wala alam

uneasy

feeling GOAL: After2hours of nursing

Provide information situation of

accurate To know his own GOAL: about client the perception about the and upcoming surgery It can point to the After2 hours of nursing intervention,

ako surgery as manifested of discomfort or dread as by :First time ko ksi accompanied ma operahan kaya autonomic by an

response(the intervention, wala ako masyadong source often non-specific or alam as verbalized unknown individual);a to the the client will feeling be able to

reasons for surgery

Identify clients perception clients level of anxiet the client will about the upcoming surgery Helps client to be able to Observe clients behavior Review coping skills the identify what is appear relax reality-based client used in past

of apprehension caused by anticipation of danger. It is appear relax an altering signal that warns of impending danger and enables the individual to take measures to deal with threat reduced to a Manageable level OBJECTIVES: The client will be able to: the clients condition will be ease and report anxiety is

To determine those and report that might be helpful in circumstances current reduced to a manageable level anxiety is

Scientific Assessment S= O= the patient manifest: > Increased perception of pain. Nursing Diagnosis Explanation Risk for infection r/t inadequate primary The skin is one of the bodys Short Term: first lines of defense. Any After 2 hours of nursing Planning

Nursing Rationale Interventions - Establish rapport -To develop patients trust -To asses patient and serve

defenses:Broken skin/injured break or disruption to this tissue as a result from an incision made in the abdomen protective covering may signal danger; in most cases infection. When there is a break in any layer of our skin, opportunistic pathogen could enter our sterile bodies would could multiply and cause

intervention, the patient

would be able to identify interventions to prevent infection from occurring. Long Term: After 6 hours of nursing -Asses and document skin condition around the suture site

as a basis for comparison if

indeed patient is developing infection -Serve as baseline data -Monitor Vital Signs -To assess acquired immuno-Monitor S/Sx of infection: observe appearance, competence

infection. In addition, with the intervention, the patient will presence of a wood, if not properly kept or maintained bacteria could grow thus resulting to infection. remain free of infection AEB normal v/s and absence of purulent secretions at the suture site. The patient will remain free from infection up until the abdominal incision is healed

character, & odor of the

suture site. -Provide regular cleansing and change of the dressing of the suture site. -Advise patient to keep the suture site dry.

-Cleansing the suture site

decreases the possibility of contaminating the wound with microorganism. -For faster healing and prevent the growth of microorganism. -Rubbing could further injure

-Discourage rubbing or scratching the healing wound.

the skin and could delay its healing. -This maintains optimum

-Encourage large intake of protein and carbohydrate rich foods. -Provide proper hygiene.

nutritional status. -Good hygiene keeps the

body clean and prevents the

microorganisms from invading the persons body.

Scientific Assessment S= Nursing Diagnosis Objectives

Nursing Rationale Evaluation Short term:

Explanation
Risk for Impaired Skin Integrity r/t left middle Skin is an organ of the integumentary system made up of multiple layers After 2 to 4 hours of Nursing Intervention, the of epithelial tissues that guard underlying muscles patient will identify individual risk factors. and organs. As the interface with the -pain scale of 10/10. surroundings, it plays the most important role in protecting against Long term: After 2 days of Nursing Interventions, the patient Short term:

Interventions
-establish rapport -to gain patients trust for effective nurse-patient interaction. -monitor and record vital signs -to prevent -provide adequate clothing/covers -observe for reddened vasoconstriction Long term: patient shall be able to -for baseline data

O= Patient manifested:
-disruption of skin surface -destruction of layers

abdominal incision.

Patient shall be able to

identified individual risk factors.

pathogens. Its other main

functions are insulation and temperature regulation, sensation and vitamin D and B synthesis. Skin is considered one of the most important parts of the body. It must be regularly cleaned. Unless enough care is taken it will become cracked or inflamed. Unclean skin favors the development of pathogenic organisms. The constantly peeling off dead cells of the epidermis mix with the secretions of

will demonstrate
behaviors, techniques to prevent skin breakdown.

areas and institute

treatment immediately. -emphasize importance of adequate nutritional, fluid intake.

-reduces likelihood of
progression to skin breakdown.

demonstrated behaviors,
techniques to prevent skin breakdown.

-to maintain general good health and skin turgor.

the sweat and sebaceous

glands and the dust found on the skin to form a filthy layer on its surface. Functions of the skin are disturbed when it is dirty and it becomes more easily damaged.

VII. PATIENT DAILY PROGRESS

VIII. DISCHARGE PLANNING

The student nurses were not able to handle the patient during his the date of discharge.

IX. CONCLUSION and RECOMMENDATION

X. BIBLIOGRAPHY and REFERENCES

Black & Hawks. Medical and surgical nursing. 6th Edition Doenges, Moorhouse, & Murr. Nurses pocket guide, 12th edition. Henry J. Kaiser Family Foundation. (2006, June 22). Medical News Today. Retrieved from http://www.medicalnewstoday.com/releases/154809.php http://emedicine.medscape.com/article/195652-overview http://nursingcrib.com/medical-laboratory-diagnostic-test/nursingconsiderations-for-abg / http://www.symptomsofappendicitis.org/Appendicitis-Statistics.html http://www.thefilipinodoctor.com/search-drugdetails.php?keyword=Bifix&id=20040416&secid=20030604&sec1id=2002 0006&sec2id=20020016&sec3id=&sec4id= http://www.mayoclinic .com/diseases/tof/risk-factors/ http://www.rightdiagnosis.com/p/tetralogy-of-fallot/stats-country.htm Lippincott Williams and Wilkins. Disease: a nursing process approach to excellent care. 4th Edition Pilliteri, Adele. (2010). Maternal and child health nursing: care of the childbearing and childrearing family.

END THANK YOU!