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A care for client with Malabsorption Syndrome In partial fulfillment of Related Learning Experience (R.L.E) Submitted By: Roderos, Mitch Angela BSN 4C GROUP II S.Y 2011-2012 Clinical Instructor Sir. Oliver Virata
INTRODUCTION The human gastrointestinal (GI) tract is the site of absorption of a wide variety ofingested nutrients,including vitamins, proteins, carbohydrates and fats.Much of this absorptionoccurs in the small intestine(SI), where the high surface area provided by thevillous andmicrovillous architecture optimizes uptake of dietary substances. The specialized SI mucosacontains numerous digestive enzymes on its surface,as well as an intricate network of lymphaticsand blood vessels providing access to the bloodstream. Adequate digestion and absorptiondepend on a multitude of factors, including mechanical mixing, enzyme production and activity,proper mucosal function, adequate blood supply, intestinal motility and even normal microbialecology. Accordingly, malfunctions in any of these components can lead to failure to absorbnutrients from the diet, often resulting in some combination of diarrhoea,steatorrhoea,malnutrition, weight loss and anaemia. The resultant symptoms are known as the malabsorptionsyndrome(s), which can be grouped bytheir aetiology into three broad categories.Thus,malabsorption may result from maldigestion, such as occurs in inadequate mixing (e.g.after gastrectomy) or in enzyme or bile salt deﬁciencies, from mucosal or mural problems, suchas various enteropathies or neuromuscular conditions, or from microbial causes,such as bacterialovergrowth and various infections ⁄infestations. The vast number of causes of intestinalmalabsorption precludes an exhaustive review. Therefore, we will attempt an overview of themost common and interesting aetiologies in the three categories, with a morecomplete discussionof a handful of entities in each,along with a review of current concepts. Special emphasis will beafforded to mucosal problems, as well as to several microbial conditions.
DEMOGRAPHIC DATA 1. Client’s name : Patient A.D 2. Gender: Male 3. Age, Birth date and Birth place: 21 years old, September 2,1990 at Zamboanga City 4. Marital Status: Single 5. Nationality: Filipino 6. Religion: Roman Catholic 7. Address: 15 Natividad St. Bangkal Quezon City 8. Educational Background: College Undergraduate 9. Occupation: Student 10. Usual Source of Medical Care:A. SOURCE AND RELIABLITY OF INFORMATION Patient’s Chart Patient’s fatherB. REASON FOR SEEKING CARE “Ang sakit sakit ng tsyan ko” As verbalized by the patientC. HISTORY OF PRESENT ILLNESS 2 years prior to admission (September 2009) – Patient had his appendectomy last 2009, abdominal surgery done the same year. A tumor was marked visible in the colon and likewise excised. 1 year and 8 months prior to admission (January 2009) – Patient was operated due to dehiscense of his intestines 10 weeks prior to admission – Patient complaints of abdominal pain, with presence of nausea and vomitting and associated with on and off fever.D. PAST MEDICAL HISTORY Pediatric/Childhood/ Adult Illness: Mumps (7 y/o); Chiken Pox (17 y/o) Injuries or accidents: The client recieved multiple injuries due to stampede (10 y/0) Serious/ Chronic Illnesses: The client has Hypertension X4, HBP of 200/100 UBP 150/80
Hospitalizations: The client’s father verbalized of frequent admission for the previous months and up to present. The client’s father was not able to recall the recent of his son’s admission Operations: The client undergone appendectomy last 2009 and was operated due to intestinal dehiscence after 4 months of previous surgery around January of 2009 Immunizations: The client verbalized of having complete immunization of DPT, OPV, BCG and Measles vaccine. Allergies: No known Allergies Medications prior to confinement: Last Examination Date: December 13, 2011E. FAMILY HISTORY Father Mother (+) HPN (+) HPN (+) DM (+) Asthma ( 25 y/o 21 y/o 18 y/o LEGEND Male Female Client
1.) Heredo-Family Illness: Maternal – Patient B’s mother is known to have High blood pressre and Asthma. Currently, his older sister next to him has asthma and so as his only daughter started when she was 2 years old. Father- Patient’t B’s father has no known family illness running in their blood. F. SOCIO-ECONOMIC The client consists of a nuclear family and lives together with his parents and three siblings. His father works as a sea man and presently at home due to expiration of contract, however, they are able to generate income from their previous savings and from managing a computer shop at Zamboanga, and the client’s father obtains an approximate per month, adequate enough for a living. The client’s eldest brother works in a call center which also helps in shouldering some of their expenses. The client states that he contributes for the family financial expenses.DEVELOPMENTAL HISTORY Erik Erickson Age Task Patient’s Description Psychosocial Theory IntimacyVs. 19 – 30 Young adults need to form The client is presently Isolation y/o intimate, loving relationships stopped from studying with other people. Success college and known to have leads to strong relationships, frequent admission at while failure results in hospitals. loneliness and isolation. The client is evidenced to have activity intolerance due to poor nutrition that he is not able to interact from other people and to perform activitiees of daily living by himself. The Client at risk for isolation from social peers that will affect his Pyschosocial development if the problem still persists.
G. REVIEW OF SYSTEMS 1. Regional Examinations (December 1, 2011 9:30 am) Vital Signs: Temp : 37.1°c RR: 18 cpm PR: 105 cpm BP: 100/80mmHg General Assessment: Patient is seen conscious and coherent; garbed clothing appropriate for weather and occasion.sitting on wheel chair with facial grimace, the client cannot fully perform activities and requires assistance. Skin is clean and smooth with normal skin turgor. Nails are long but not dirty and with normal capillary refill. Patient is with ongoing IVF of D5 NSS 1 L X 8 hr Infusing well at his left matacarpal vein.Date of Assessment System Normal Findings Actual FindingsDecember 14 ,2011 Integumentary Smooth and good I: skin turgor, no lesions or any Brown color, no lesion, no swelling discoloration, no and edema. clubbing, no breaks Weak Looking &abnormal Visible veins on both arms curvature. Has a temperature of 37.1°c. With visible longitudinal scar below the umbillicu In nails: Long and clean nails and round nails. Pale Nail beds P: Cold,dry scaly skin,normal capillary refill. Good skin turgorDecember 14 ,2011 Hair and Head No lesion, no I: tenderness, no pain on palpation, no -His hair color is black, hair is evenly masses, no lumps, distributed,
no nodules or -Has thick hair. depression, symmetrical -No presence of parasite and dandruff. -In scalp: Symmetrical and round and no lesion. P: -Hair texture is smooth and soft. -In head the texture is smooth and firm.December 14,2011 Eyes Eyelid intact, no I: redness, swelling, discharge or lesions. -Lid margins moist and light pink, Eyeballs are moist & lashes short, evenly spaced and curled glossy, conjunctiva outward. numerous small -Bulbar conjunctiva is clear with tiny blood vessels. Sclera vessels visible, palpebral conjunctiva white. Good eye is pale with no discharge, white sclera. contact. - In PERRLA: *Cornea is transparent and the shape of the iris and pupil is round and equal. *The left and right eye has a good reaction to light (constrict and dilate) -In extra ocular movements: *Both eyes coordinated well in all directions.December 14,2011 Ears Ears are symmetrical I: with 10 degrees angle. Color is same -Equal size and similar appearance. in facial with no -No lesions, brown in color same with
tenderness or any his complexion. nodule and without any presence of P: discharge. -Warm, smooth, no nodules and no tenderness in auricle and tragus.December 14,2011 Mouth and 32 adult teeth are I & P: Throat present with moist and pink mucous -Lips and surrounding tissue relatively membrane without symmetrical.No lesions, swelling and any lesions or drooping. swelling. -Lip is pale pink; moist, smooth and with no lesions. -Buccal mucosa is light pink, moist and without lesions.-Gums are light pink, and moist. -In tongue: *Moist, some papillae present, symmetrical appearance, midline fissures present and the color is pink and color white at the center and no lesions as well as the sides of the tongue. *Hard palate: slightly pink. *Soft palate: pink, -Has 32 teeth and stained with a hint of yellow color.December 14,2011 Neck No tenderness on I: -Neck is symmetric with head palpation, no pain, centered and without bulging masses. symmetrically align, no enlarged lymph P:-Smooth skin, firm, and none tender nodes, no tracheal and none enlarged nodules. lateral deviation.December 14,2011 Breast and No palpable nodules I: Axillae and lesions. Breast is -Nipples have no discharges and not firm and round. cracked.
December 14,2011 Respiratory Intercostals spaces I: are even and relaxed; chest -The color of his chest is similar to his symmetry is equal, complexion. no pain or -Visible Rib Cage tenderness, and no abnormal breath -Chest symmetry is equal sound. -Respiratory rate of 18. P: No pain or tenderness. A: Lung is clear to auscultation on inspiration and expiration.December 14,2011 Cardiovascular No fatigue on simple PR : 105 activities, no arrhythmias and BP: 100/80 mmHg heart murmurs. I:-Neck veins are not distended. PR=60-100bpm. P:-No vibrations or palpitation in aortic, pulmonic, or tricuspid area. A:-No murmur sound heard.December 14,2011 Abdominal No pain, No I: palpable masses and tenderness, Flat and -With round. P: -(+) Tenderness, with inflammation on intestines as observed in Lab ResultDecember 14,2011 Musculoskeletal Have good range of -Requires assistance to stand and toes motion and no point straight ahead. limitation of movements. With marked activity intolerance -With marked muscle waistingDecember 14,2011 Neurologic Have no tremors -No presence of tremors, oriented, no paralysis. Oriented, history of seizures,without mental no history of dysfunction or hallucinations. seizures, mental -Slow and low soft voice
dysfunction or -Weak looking hallucinations. Lethargic, slow response December 14,2011 Lympathic Has no bleeding No swollen lymph nodes. tendencies, normal lymph nodes.2. Laboratory Studies/Diagnostics 12/15/11 Clinical Chemistry Section Test Name Range Unit Result Interpretation Albumin 3.92 – g/dL 2.05 Below Normal 4.94 Indicates poor nutritional state, poor protein intake, Renal/Kidney DysfunctionH. FUNCTIONAL ASSESSMENT HEALTH PERCEPTION-HEALTH MANAGEMENT Prior to admission, patient’s father sasys the his son sees health being able to do everyday things well according to the manner he wants it. The client stated he doesn’t easilly get sick and when he does, he just let it subside not until if his condition worsens, that’s the time when he would visit the hospital. The client does not use any vitamins and medications. Client has not experienced colds in the past month. SELF-ESTEEM, SELF CONCEPT/SELF PERCEPTION PATTERN Prior to confinement, the client’s father states that his son has a good concept at himself and describes himself like any typical normal college boy. He says that his child perceives good self-concept as evidenced by being active in the activities held in his institution. Presently, the client stopped schooling due to persistent abdominal pain. The client permanently resides in Zamboanga and went to Cavite from a relative’s house to sought for treatment. ACTIVITY/EXERCISE PATTERN
Prior to confinement, the patient father remarks that his son used to have an activelifestyle, the client is once a varsity player in Basketball. The patient engages in sports such asBasket Ball, Volley Ball and Badminton. The patient studied college last semester but nowstopped due to present situation.Presently, the patient is admitted in ward 3A, under bed rest. The client assistance from anotherperson or device in terms of the following indicated below: Feeding III Grooming III Bathing III Gen. Mobility III Toiling III House III maintenance Bed mobility III Dressing IIILegends:Level 0 – Self CareLevel I – Use of equipmentsLevel II– Assistance from another personLevel III –Requires assistance from another person or deviceLevel IV – Dependent and does not participateSLEEP/REST PATTERNBefore the client was admitted, the client’s father stated that his son usually sleeps around 10:00pm and wakes up around 6:00 am with an average sleep of 8 hours without any use of sleepintaidsPresently, the client’s father describes that his son is experiencing difficulty in sleeping due topersistence of pain that he experiencing because of that the client frequently naps in the morningand still feels tiped upon waking upNUTRITIONAL-METABOLIC PATTERN The client presently eats in small frequent feeding at an average of 5 times a day. theclient has poor appetite and usually eats in soft-non-seasoned food or broths. The client cannottolerate to eat regular meals as observed from vomiting. The client’s father frequently observeshis child to vomit usually after eating. There is an observed muscle wasting as evidenced from aweight loss of 48 kg to 32 kg. The client has no dental problems and without foul odors.
ELIMINATION PATTERN The client states that he defecates every other day usually in the morning in scanty softbrown stool. The client’s father believe that his son’s bowel pattern due to his poor fluid andfood intake. The client urinates 2X a day or varies in his fluid intake without no difficultySEXUALITY/REPRODUCTIVEThe patient is not sexually active and was circumcised at the age of 12.INTERPERSONALRELATIONSHIPS/RESOURCES The client is the second son among his 3 siblings. The client previously attended college butpresently stops due to persistence of abdominal pain affecting his studies. The patient’s fathersays that his son attends to school trying to tolerate his abdominal pain The client’s fatherverbalized that their family has an open and harmonious relationship. The client’s father statesthat he would allow his son to decide by himself to promote independence but would be there toguide and support him. In terms of major decisions affecting the client’s health, the father statesthe he will use his authority as a father to intervene.COPING & STRESS MANAGEMENT/ TOLERANCE PATTERN The client states the he feels discomfort from his abdominal pain. The client’s fatherverbalized that travelling far from home, unable to do his daily activities and being isolated andstopped from school has been the client’s stress factors. However, the client’s father remarkedthat his son has high tolerance from the pain, they would use ointment to help the client relievefrom painVALUES/ BELIEFS The Client is a Roman Catholic. The client stated that he barely attends the churchbecause of his studies and presently because of his abdominal pain.PERSONAL/SOCIAL HISTORY
Habits: The client is known an athletic student. The client prefers to do anything just to keephim from being bored. Despite of eating, the client ignores to rest but goes straight from doingsuch activities, that may be the reason why the client acquired appendicitis dated on year 2009Vices: The client stated does not consume alcoholic beverages and does not smoke.Lifestyle: The client was known to live in an active lifestyle.Client’s usual daily life: The client’s typical day is studying in school at the morning, andwould plau basketball for his varsity in the afternoons. The patient’s states that his son prefers tobeat home watching television or taking siesta during his free time.Rank/Order in the family: the Client is ranked as the second son from his 3 siblings.Travel: The client previous travel was from Zamboanga to Cavite I. ENVIRONMENTAL HISTORY The client lives together with his family composed of 5 house hold members. A bungalow type of house with 209 square meters is owned by the patient residing near the highway. The client narrated that it is a cemented house with 2 bedrooms and 1 bath room. The house is fully ventilated and well lit of 12 windows. Their doors for about the size of 180X1 meter. The client stated that their surroundings are well-sanitized. Their electricity supply comes from Meralco and their water supply are from Deep well. They order Mineral water for drinking. The client’s residence is advantageous, since it is near the public market, transportation, at school and Hospital.J. PEDIATRIC HISTORY K. MATERNAL AND BIRTH HISTORY Birth date: September 2, 1990 Hospital: Not assessed Birth weight: Unrecalled Type of delivery: Normal Spontaneous Delivery
Condition after birth: In fine stable conditionMother:Complications of delivery: NoneAnesthesia drug guring labor: UnrecalledExposure to Teratogenic Agents during Pregnancy: None
PATHOPHYSIOLOGY MALABSORPTION (Book Based) PREDISPOSING PRECIPITATING FACTORS FACTORS Age Family history of Intestinal Excessive Alcohol Use of Mineral Malabsorption Surgery Intake Oil or laxatives MaldigestionInadequate mixing Insufficient digestive Mucosal Problems Bacterial Infections mediators Of gastric juices MALABSORPTION SYNDROME
CONCEPT MAPPING 1. Acute Pain related to gastrointestinal inflammation as evidenced by pain scale of 7/10 Malabsorption Syndrome 2. Imbalanced Nutrition3. Activity Intolerance related Patient A.D 21 y.o/ Male related to impaired absorptionto failure to nourish muscleadequately as evidenced by Temp : 37.1°c RR: 18 cpm PR: 105 cpm BP: 100/80mmHg Wt: 32 kg of nutrients from the GI tractgeneralized weakness as evidenced by weight loss of Facial Grimace Painscale of 7/10 48 kg to 32 kg Guarding behavior Abdominal distention Weight loss from 48 kg to 32 kg Hypoalbuminemia (2.95 n=3.92-4.94 g/dl) Muscle waisting Generalized body weakness Slow movement Slow response Inaility to perfrom activities by himself Verbal reports of wearines
I. PROBLEM LIST Actual Problem Number Problem Remarks Acute Pain related to The client presently complaints of 1 gastrointestinal inflammation as prsistent abdominal pain due to the evidenced by pain scale of 7/10 inflammation from malabsoprtion. Pain is prioritized for it is the 5th vital sign, and knwn to be the chief complaint likewise. Imbalanced Nutrition related to The body is unable to absorb the 2 impaired absorption of nutrients nutrients well due to occurence of from the GI tract as evidenced an imflammed GI tract. Thus, the by weight loss of 48 kg to 32 kg client is unable to be provided of proper nutirion approrpiate for his development thus manifested by weigh loss Activity Intolerance related to Due to failure of the client to have 3 failure to nourish muscle adequate nutrition for the body to adequately as evidenced by recieve it’s energy that is generalized weakness manifested by generalized weakness.
II. NURSING CARE PLAN Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Acute pain By the end of Monitored Vital signs q 30 until the Baseline data is important to By the end“Masakit ang related to 8 hours of patient stable especially respiratory rate help Determine patient’s current of 8 hours oftsyan ako” as inflammation nursing and blood pressure health status and evaluate nursing intervention, efficacy of nursing interventions intervention,verbalized by the and swelling the rendered thepatient of the liver as Patient will Patient will evidenced by verbalize a Assess the patient’s pain by using the 10 The client’s report of pain is the verbalized aObjective: pain in right decrease in point pain rating scale q4 hrs or PRN single most reliable indicator of decrease in Pain Scale of upper pain scale during the 2-10pm shift. pain. pain scale 7/10 quadrant from 6/10 to from 76/10 Facial grimace 0/10 to 3/10 Gurading Performed comprehensive assessment to Pain is a subjective experience behavior pain include location , characteristic, and must be described by the “Mejo With abdominal onset, duration, frequency, client in order to plan effective natitiis ko na distention quality, intensity or severity treatment yung kirot” as verbalized by the patient Provided nonpharmacologic pain relief Relaxation techniques decrease methods, such as breathing exercises, oxygen consumption, respiratory music therapy, distraction and progressive rate, heart rate, and muscle relaxation before, after, and if possible tension, which interrupt the during painful activities. cycle of pain–anxiety–muscle tension. Kept side rails up and bed in low position. To reduce likelihood of falls and to promote a safe environment. Administered Pain medications as ordered To promote pharmacologic such as Tramadol measures in relieving pain
Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Imbalanced After 8 hours of Assessed the present weight of the Provides baselinedata about the After 8 hours“Ang lake na nga Nutrition Nursing client by the use of weighing scale client. of Nursingng pinangayat ng related to intervention, the intervention,anak ko” as impaired client will Determined the client’s attitude towards Psychological factors towards the client eating. eating may affect one person’sverbalized by the absorption of demonstrate Participated appetite and also to know thepatient’s father nutrients from behaviors to client’s eating habits. and the GI tract as regain and enumeratedObjective: evidenced by maintain proper To promote and sustain Ways to Weight loss weight loss of weight Encourged the client tomash the foods adequate nutrition needed by regain and from 48 kg to 48 kg to 32 kg mechanically and to eat in small the body and minimizing the maintain 32 kg frequent feeding occurance of malabsorption proper Hypoalbumine weight mia (2.95 Instructed the client to avoid To decrease the likelihood of n=3.92-4.94 caffeineated beverages like coffee, tea, GI upset g/dl) softdrinks, chocolates and foods rich in Muscle waisting fats To keep the client hydrated and Generalized to monitor the fluid intake of body weakness Monitored and regulated IV fluid patient To provide pharmacological Administered medications as ordered means of reducing occurance of abdominal pain thereby promoting the patient to eat. Cues/Needs Nursing Planning Implementation Rationale Evaluation
DiagnosisSubjective: Activity After 8 hours Determine factors contributing to The client marks to have After 8 hours“Hinang hina ang Intolerance of nursing fatigue pulmonary congestion and under of nursingpakiramdam ko” as related to intervention, observation to have acute intervention,verbalized by the failure to the client will coronary syndrome the clientpatient nourish participate participated muscle willingly in Evaluate client’s percieved limitations To provide comparative baseline willingly in adequately as necessary and by asking past activities and present data and to provide information necessaryObjective: evidenced by desired activities about needed intervention and desired generalized activities. activities. Generalized body weakness Assess cardiopulmonary response to Manifestations results weakness physical activity, including vital signs intolerance of activity The client Slow movement verbalized of before, during and after activity Slow response incorporating Inaility to perfrom activities by Assist client wit activities when To protect the client from injury such himself walking to the wash room, getting up in exercises and Verbal reports of bed and lying back to bed exposure to wearines sunlight in Provide intervals of rest between To minimize occurrences of his daily activities fatigue living Encourage and acknowledge the difficulty of the situatio of the clientHelps to minimize frustration and rechannel energy Sunlight is rich in Vitamin D and Encouraged patient to expose himself in will help the client to increase sun light around 7-8 am vitality Assist and provide passive and active To maintain and enhance muscle ROM tone of client
MEDICAL-SURGICAL MANAGEMENT i. Pharmacotherapeutics DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING EFFECTS RESPONSIBILITIES Hydrocortisone Therapeutic: Management of Supress CNS: depression, _Assess patient for _Instruct patient on correct Antiasthmatics, adrenocortical inflammation euphoria,headache,increased swigns of adrenal technique of medication Brand Name: corticosteroids insufficiency; and the normal intracranial pressure insufficiency. administration. Cortef chronic use in immune (Children only),personality _Monitor intake and _Caution patient to avoid Dosage: Pharmacologic other situations is response. changes, pyschoses, output ratios and daily vaccinations without first 5 mg I.V q8 Corticosteriods limited because Replacement restlessness weights. Observe consulting health care (systemic) of theraphy in EENT: cataracts, increased patient for peripheral prifessionals. mineralocorticoid adrenal intraocular pressure. CV: edema, steady weight _Review side effects with activity. insufficiency. hypertension GI: Peptic gain, rales/crackles, or patient. Instruct patient to Ulcer, anorexia, nausea, dyspnea. inform health care vomitting. Derm: acne, _Children should professional promptly if decreased wound healing, have periodic severe abdominal pain or tarry ecchymoses, fragility, evaluation of growth. stools occur. Patient should hirsutism, petichiae Endo: _Assess involvrd also report unusual swelling, Adrenal suppresion, systems before and weight gain, and tiredness, hyperglycemia. Hemat: periodically during bone pain, bruising, none Thrombophlebitis, Metab: theraphy healing sores, visual Weight gain MS: Muscle disturbances, or behavior wasiting. Misc: Cushingoid changes. apperance
DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING EFFECTS RESPONSIBILITIEShyoscine butylbromide Therapeutic: Paroxysmal pain Acts by Agranulocytosis, _Patients who have Asthma, _Instruct patient to take Gastro/ in diseases of interfering with pancytopenia. aspirin-induced allergy, and medication exactly as Brand Name: Antispasmodics stomach & the transmission Bronchospasm, nasal polyps are at increased directed. Take missed dose Buscopan Pharmacologic: intestine. Spastic of nerve Constipation, dry risk for developing as soon as remembered ifDosage: Pyrroziline pain & functional impulses by mouth, trouble hypersensitivity reactions. not almost time for next 5 mg I.V q8 carboxylic acid disorders in acetylcholine in urinating, nausea, fast Assess for rhinitis, asthmas dose. Do not double dose biliary & urinary the heart rate and urticaria _Instruct Patient to notify tracts, female parasympathetic _Assess pain (note type, health genital organs nervous system location, and intensity) prior Health care professional if (specifically the to 1 -2 hr following allergic reactions occurred vomiting center). administration (rash, pruritus, laryngeal _Evaluate liver function edema, wheezing). tests, especially AST and _Ask for your doctors ALT, periodically in patients advice if you are receiving prolonged therapy. breastfeeding or likely to May cause inccreased levels breastfeed during the _May cause prolonged course of your medication bleeding time that may persist _Special care is for 24-48 hour following recommended during discontinuation of therapy pregnancy, particularly in _May cause increased BUN, the first three months. serum, creatinine or Ask for your doctors potassium concentrations advice if you are pregnant, or likely to become pregnant during your course of medication.
DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING EFFECTS RESPONSIBILITIES Prednisone Therapeutic: Paroxysmal pain in Acts by Agranulocytosis, _Patients who have _Instruct patient to take Gastro/ diseases of stomach interfering with pancytopenia. Asthma, aspirin-induced medication exactly asBrand Name: Antispasmodics & intestine. Spastic the transmission Bronchospasm, allergy, and nasal polyps are directed. Take missed dose as Buscopan Pharmacologic: pain & functional of nerve impulses Constipation, dry at increased risk for soon as remembered if not V q8 Pyrroziline disorders in biliary & by acetylcholine mouth, trouble developing hypersensitivity almost time for next dose. Do carboxylic acid urinary tracts, female in the urinating, nausea, reactions. Assess for not double dose genital organs parasympathetic fast heart rate rhinitis, asthmas and _Instruct Patient to notify nervous system urticaria health (specifically the _Assess pain (note type, Health care professional if vomiting center). location, and intensity) prior allergic reactions occurred to 1 -2 hr following (rash, pruritus, laryngeal administration edema, wheezing). _Evaluate liver function _Ask for your doctors tests, especially AST and advice if you are ALT, periodically in breastfeeding or likely to patients receiving prolonged breastfeed during the course therapy. May cause of your medication inccreased levels _Special care is _May cause prolonged recommended during bleeding time that may pregnancy, particularly in the persist for 24-48 hour first three months. following discontinuation of Ask for your doctors advice therapy if you are pregnant, or likely _May cause increased to become pregnant during BUN, serum, creatinine or your course of medication. potassium concentrations
DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING EFFECTS RESPONSIBILITIESPantoprazole Therapeutic: Paroxysmal pain in Acts by Agranulocytosis, _Patients who have _Instruct patient to take Gastro/ diseases of stomach interfering with pancytopenia. Asthma, aspirin-induced medication exactly asBrand Name: Antispasmodics & intestine. Spastic the transmission Bronchospasm, allergy, and nasal polyps directed. Take missed dose as Buscopan Pharmacologic: pain & functional of nerve impulses Constipation, dry are at increased risk for soon as remembered if not V q8 Pyrroziline disorders in biliary & by acetylcholine mouth, trouble developing hypersensitivity almost time for next dose. Do carboxylic acid urinary tracts, female in the urinating, nausea, reactions. Assess for not double dose genital organs parasympathetic fast heart rate rhinitis, asthmas and _Instruct Patient to notify nervous system urticaria health (specifically the _Assess pain (note type, Health care professional if vomiting center). location, and intensity) allergic reactions occurred prior to 1 -2 hr following (rash, pruritus, laryngeal administration edema, wheezing). _Evaluate liver function _Ask for your doctors advice tests, especially AST and if you are breastfeeding or ALT, periodically in likely to breastfeed during the patients receiving course of your medication prolonged therapy. May _Special care is cause inccreased levels recommended during _May cause prolonged pregnancy, particularly in the bleeding time that may first three months. persist for 24-48 hour Ask for your doctors advice if following discontinuation you are pregnant, or likely to of therapy become pregnant during your _May cause increased course of medication. BUN, serum, creatinine or potassium concentrations
DRUG NAME CLASSIFICATION INDICATION ACTION SIDE/ADVERSE NURSING PATIENT TEACHING EFFECTS RESPONSIBILITIES Tramadol Therapeutic: Paroxysmal pain in Acts by Agranulocytosis, _Patients who have _Instruct patient to take Gastro/ diseases of stomach interfering with pancytopenia. Asthma, aspirin-induced medication exactly asBrand Name: Antispasmodics & intestine. Spastic the transmission Bronchospasm, allergy, and nasal polyps directed. Take missed dose as Buscopan Pharmacologic: pain & functional of nerve impulses Constipation, dry are at increased risk for soon as remembered if not V q8 Pyrroziline disorders in biliary by acetylcholine mouth, trouble developing hypersensitivity almost time for next dose. Do carboxylic acid & urinary tracts, in the urinating, nausea, reactions. Assess for not double dose female genital parasympathetic fast heart rate rhinitis, asthmas and _Instruct Patient to notify organs nervous system urticaria health (specifically the _Assess pain (note type, Health care professional if vomiting center). location, and intensity) allergic reactions occurred prior to 1 -2 hr following (rash, pruritus, laryngeal administration edema, wheezing). _Evaluate liver function _Ask for your doctors advice tests, especially AST and if you are breastfeeding or ALT, periodically in likely to breastfeed during the patients receiving course of your medication prolonged therapy. May _Special care is cause inccreased levels recommended during _May cause prolonged pregnancy, particularly in the bleeding time that may first three months. persist for 24-48 hour Ask for your doctors advice if following discontinuation you are pregnant, or likely to of therapy become pregnant during your _May cause increased course of medication. BUN, serum, creatinine or potassium concentrations
DISCHARGE HEALTH TEACHING Content StrategyM-medication To adhere in prescribed Instruct patient to take the prescribed therepautic regimen for medications as ordered by the physician. health maintainance and Instruct patient to avoid taking OTC drugs resistance. unless given with medical advice Assist patient in performing passive ROME-exercise To promote a healthy exercises to maintain muscle tone and increase lifestyle, maximizing the blood circulation. level of health and increase Provide schedules of minimal activites tolerable the body’s immunity. by the patient to incease self-reliance.T-treatment Attending the follow up Educate client by adhering maintainance check up. theraphy. Teach patient of non-pharmacological treatment Health teaching about the for occurences of abdominal pain such as deepH-health disease, exercise and diet. breathing exercises, plinting with a pillow,teaching applying warm compress, and utilizing diversional activitities Encourage patient to expose self from the sun early morning for good source of Vitamin D Instruct that they need toO-OPD have a health check up. Emphasize the importance of adhering to medications and attending follow-up check up. Maintain and ensure Instruct patient to avoid consumption highlyD-diet adequate intake for seasoned foods, high in salt, fath, caffeneited noursihment, beverages, and chocolates Instructed patient to mash the foods well and eat in small frequent feeding to reduce likelihood of gastric upset Encourage patient to drink energy drink as adjuct supplement from client’s undernutritionS-signs and If any signs of symptoms are Advise patient to refer to health caresymptoms present go to the nearest professional for persistence of abdominal pain, hospital for check up. fever, vomitting, diarhea, and occurence of black stools.
III. ONGOING APPRAISAL Patient A.D a 21 year old male, has been admitted to St, Dminic Medical Center last December 14,2011 with a chief complaint of abdominal pain. Hence was admitted with initial diagnosis of to consider colon cancer and and hooked of D5 NSS 1 L X 8 hr. Vital signs shows Temp : 37.1°c RR: 18 cpm PR: 105 cpm BP: 100/80mmHg Wt: 32 kg Patient was orderd for Albumin Test and ordered medication of Hyrocortisone 100 mg TIV, Buscopan 1 amp TIV q* RTC, Prednisone 250 mg/ Tab BID PO, Pantoprazole 40 mg 1 tab OD PO and Tramadol 50 mg TIV q8. Preesently, a final diagnosis of Malabsorption Syndrome was confirmed and the client is still undergoing treatment, the client’s latest vital signs of Temp.: 37.5°c RR: 19cpm PR: 86 cpm BP: 100/70mmHg. And for endoscopy