1. CASE PRESENTATION:Intestinal Obstruction (Volvulus) inGeriatric PatientReynel Dan L. Galicinao, RNStudent, Master in NursingMajor in Nursing Educational Administration
2. ContentsObjectivesOverviewNursing Health AssessmentGordon’s AssessmentPhysical Examination and Review of SystemsPathophysiologyLaboratory and Diagnostic Tests
3. ContentsMedical ManagementSurgical ManagementSummary of MedicationsDrug StudyNursing Care PlanConcept MapDischarge Plan
5. General Objectives• Within the case presentation session, the audience will be able to discuss the etiology, pathophysiology, and medical, surgical, and nursing interventions of intestinal obstruction.
6. Specific ObjectivesWithin the case presentation session, the audience will beable to:1. Describe intestinal obstruction2. List the risk factors of intestinal obstruction3. Trace the pathophysiology of intestinal obstruction4. Determine the signs and symptoms associated with intestinal obstruction5. Identify diagnostic and laboratory procedures for intestinal obstruction and their corresponding nursing responsibilities6. Enumerate possible medical and surgical interventions for intestinal obstruction7. List the medications to be given for intestinal obstruction8. Identify possible nursing diagnoses for intestinal obstruction9. Plan appropriate independent and interdependent nursing interventions for intestinal obstruction10. Write a discharge plan for intestinal obstruction
8. Intestinal Obstruction• Interruption in the normal flow of intestinal contents along the intestinal tract• The block: – may occur in the small or large intestine – may be complete or incomplete – may be mechanical or paralytic – may or may not compromise the vascular supply• Obstruction most frequently occurs in the young and the old
9. Causes(A) Intussusception - shortening of the colon by the movement of one segment of bowel into another(B) Volvulus of the sigmoid colon - the twist is counter clockwise in most cases of sigmoid volvulus(C) Hernia (inguinal) - the sac of the hernia is a continuation of the peritoneum of the abdomen and that the hernial contents are intestine, omentum, or other abdominal contents that pass through the hernial opening into the hernial sac
10. TYPES OF INTESTINALOBSTRUCTION
11. Mechanical obstruction• A physical block to passage of intestinal contents without disturbing blood supply of bowel• Causes: – Extrinsic—adhesions from surgery, hernia, wound dehiscence, masses, volvulus – Intrinsic—hematoma, tumor, intussusception, stricture or stenosis, congenital, trauma, inflammatory diseases – Intraluminal—foreign body, fecal or barium impaction, polyp, gallstones, meconium in infants.
12. Paralytic (adynamic, neurogenic)ileus• Peristalsis is ineffective• There is no physical obstruction and no interrupted blood supply• Disappears spontaneously after 2 to 3 days• Causes: • Spinal cord injuries; vertebral fractures. • Postoperatively after any abdominal surgery. • Peritonitis, pneumonia. • Wound dehiscence (breakdown). • GI tract surgery.
13. Strangulation• Obstruction compromises blood supply, leading to gangrene of the intestinal wall• Caused by prolonged mechanical obstruction.
14. NURSING HEALTHASSESSMENT
15. Demographic Data• Name: “Mr. William Lippincott”• Address: Poblacion, Midsalip, Zamboanga del Sur• Age: 77 years old• Sex: Male• Status: Widower• Religion: Roman Catholic• Occupation: Bookkeeper
16. Health HistoryA. Chief Complaint/s:• Abdominal painB. Impression/Admitting Diagnosis:• Acute abdominal problem secondary to volvulus; gangrenous ileum 35 cm from ileocecal valve with ileoileal anastomoses.C. History of Present Illness:• One month prior to admission, patient had complaints of epigastric pain, described as crampy, graded at 8/10, intermittent, aggravated by eating solid foods, patient can only tolerate to eat porridge with flaked fish sprinkled on it, alleviated by application of Efficascent oil to abdomen, and rest. Patient had a feeling of strong urge to fart or expel flatus but was unable to do.
17. Health History (cont.)• Patient had loose bowel movement for 3 days prior to admission, intermittent, brown-colored, unformed stool.• Few hours prior to admission, pain became generalized and unrelieved with oral medications thus prompted admission; no fever, no vomiting, no tarry stool. Last bowel movement was the morning before admission (September 26, 2011) with mucoid stool. Patient is a bookkeeper and a regular member of parish church.D. History of Past Illness/es:• Patient was hospitalized for 1 week last July 2008 due to Pneumonia. Patient reported he had “complete immunization”. Patient takes Centrum 500 mg 1 tablet, once a day. Patient had blood transfusion (1989) but he could not recall the details. No known allergies. Born via NSVD.
18. Health History (cont.)E. Health Habits Frequency Amount PeriodTobacco None None NoneAlcohol None None NoneOTC drugs/non-prescription drugs Specify: Centrum OD 500 mg Tab 1 year F. Family History with Genogram History of Heredo-familial diseases: Cancer X _____ DM / _____ Asthma X _____ Hypertension X _____ Cardiac Disease _____ X Mental Disorder _____ X Others _____ X
19. Health History (cont.)G. Patient’s Perception of• Present Illness: Pt reported, “Nawala naman ang sakit sa akong tiyan karon, bag-o paman gud ko gitagaan ug tambal para mawala ang sakit.”• Hospital Environment: Pt reported, “Ok raman ang kwarto dire aircon, komportable ra man.”H. Summary of Interaction• Patient was sleeping upon nurse’s arrival. During physical assessment, patient woke up and nurse continued assessment. Patient appears weak but still answered the nurse’s interview questions and cooperated in the assessment.
21. Normal Pattern Before Hospitalization Clinical AppraisalActivities – Rest Pt usually sleeps at 9 pm, and Pt has been lying on bed the a. Activities then wakes up at 6 am. Pt whole day. Moves/ changes b. Sleeping pattern takes a bath every day except position with assistance. Pt c. Rest for Tuesdays and Fridays r/t was not able to sleep in the his cultural belief. Pt goes to morning due to pain, but was work as a bookkeeper, and able to sleep for 2 hours in then goes to city hall, BIR, the evening. Pt appeared and then church. Few weeks very weak and sleepy. PTA, pt usually takes naps in the afternoon.Nutrition – Metabolic Few days PTA, pt only eats Pt is on NGT early this a. Typical intake (food or quaker oats, drinks water, morning, but was removed fluid) coffee, and flaked fish on later in the morning then diet b. Diet porridge. No diet restriction. changed to clear liquids c. Diet restriction Weight not taken, unknown. limited to 15 ml/ hr Pt is d. Weight Takes Centrum 500 mg tab taking Paracetamol 500 mg 1 e. Medication/Supplem once a day. tab every 4 hours, prn; ent food Telmisartan (Micardis) 40 mg tab OD every HS.
22. Normal Pattern Before Hospitalization Clinical AppraisalElimination Pt was able to urinate Pt was able urinate once on a. Urine (frequency, approximately 1-2 times per his diaper, with clear and color, transparency) day, with clear and yellow yellow urine, had changed b. Bowel (frequency, urine. Pt defecated > 3x for diaper once. Pt has not color) LBM with color brown, been able to defecate this unformed, intermittent LBM day. for 3 days.Ego Integrity Pt reported, “ok ra baya Pt reported “ok ko ron”. Pt a. Perception of Self akong kinabuhi”. Pt has 8 has 8 children, with his b. Coping Mechanism children, has been living whole family visiting him c. Support Mechanism with his daughter. He goes regularly, with friends also d. Mood/Affect to work, and a part of lay visiting him regularly. He minister of parish church, he prays for his health goes to church regularly. Pt condition. Pt appears very has normal affect congruent weak but with normal affect to behavior c calm mood. congruent to behavior, with calm mood.
23. Normal Pattern Before Hospitalization Clinical AppraisalNeuro-Sensory Pt is in well mental being. Pt Pt is in well mental being, a. Mental State speaks clearly and logically speaks clearly and logically b. Condition of 5 with normal pace. Pt has within normal pace. Pt has senses (sight, intact senses: Able to read intact senses as tested: Able hearing, smell, with aid, hear, feel, touch to read with aid, hear, feel, taste, touch) and discriminate, smell and touch and discriminate, taste. smell and taste.Oxygenation and Vital VS not taken but has history RR: 22 cpmSigns of Pneumonia and was PR: 86 bpm a. Respiratory rate hospitalized for a week last HR: 86 bpm b. Pulse rate 2007. BP: 130/80 mmHg c. Heart Rate Pt has decreased breath d. Blood pressure sounds on lower lobes. e. Lung sounds Pt has history of pneumonia f. History of and was hospitalized for a respiratory week last July 2008. problems
24. Normal Pattern Before Hospitalization Clinical AppraisalPain – Comfort Epigastric pain, graded Pain – 0/10 upon a. Pain (location, 8/10, for 2 weeks already, assessment since pt has onset, intensity, with LBM for 3 days but just been given an duration, associated intermittent with brown analgesic. symptoms, unformed stool, aggravated aggravation) with solid foods; alleviated b. Comfort with Efficascent oil and rest. measures/alleviatio n c. Medication/sHygiene and activities of Pt takes a bath everyday Pt has not taken a bathdaily living upon waking up except for since admission. Pt changes Tuesdays and Fridays. Pt position with assistance lies goes to work as on bed the whole day. Sleep bookkeeper, goes to City is disturbed due to pain; was Hall, BIR, and church. He only able to sleep for 2 sleeps at 9 pm-6 pm hours this evening for this day.
25. Normal Pattern Before Hospitalization Clinical AppraisalSexuality Patient is a male, 77 Patient is a male, 77 a. Male years old, widower, with years old, widower, with (circumcision, 8 children, circumcised 8 children, circumcised civil status, at 6 years old. at 6 years old. number of children)
26. PHYSICALEXAMINATION ANDRREVIEW OF SYSTEMS
27. General• Patient is male, 77 y/o, lying semi-fowler’s position in bed, sleeping, but later was awakened.• Has mild body and breath odor.• Conscious, and oriented to person, and place.• Calm and with normal affect congruent to behavior, speaks clearly, logically, and with normal pace.• Appears very weak and sleepy• Has #17 D5 LR 1 L with 650 cc left, hooked at right arm, regulated at 30 gtts/min, patent and infusing well.
28. HEENT• H- Patient has wavy, white-streaked hair, equally distributed, no infestations, facial features are symmetric, slightly oval in shape. Skin is wrinkled at the forehead and cheeks.• E- has moist, pink conjunctiva, anicteric sclera, able to read with aid, pupils are black, constricts 2 mm when lighted, 4 mm when not, PERRLA.• E- able to hear adequately; ears have dry, brown cerumen, level with eyebrows• N- able to smell adequately, patent and equal nostrils, no nasal flaring, nasal septum at midline, with dried up mucus.• T- oral mucosa is pale and dry, lips are parched. Tongue is pink, dry, and parched. With dental carries, tonsils are not enlarged/flat. Has slight breath odor, able to swallow, and gag reflex present.
29. Integumentary System• Patient’s skin is dry, warm, rough in some parts, and brownish in color; Temperature is 37.8 ˚C.• Skin in feet is dry, scaly, and pale• has body hairs equally distributed on contralateral parts of the body• Has good skin turgor, with nonpitting edema on dorsal part of both feet, but with a grade 1+ pitting edema on the ankles• Has median incision on abdomen; open wound below the umbilicus, with length of 9 cm and width of 6 cm, yielding yellow-greenish drainage with foul odor.• Nails are long, no clubbing, CRT 2-3 sec; nails are in normal angle and shape/ curvature, but with pale nail beds
30. Respiratory System• Patient has chest shape 1:2 anteroposterior to transverse.• Chest movement is symmetric, diaphragmatic exursion is equal and symmetric, but restricted. Spine is vertically aligned. Chest expansion is slightly restricted.• Tactile fremitus is palpated, symmetrical bilaterally.• Breath sounds on the upper lung fields are clear, but decreased breath sounds on the lower fields. RR-22 cpm, and with effort• Uses abdominal accessory muscles and internal intercostal muscles when breathing. Flaring nostrils noted. Pt breathes with open mouth.• Respiration is rhythmic, with regular pattern and normal depth. No adventitious breath sounds• Has moderate ascites that pushes the diaphragm upwards, thus restricting lung expansion, as reflected on UTZ, and physical assessment.
31. Cardiovascular System• Patient is pale, with pale extremities• Anterior chest has symmetrical features• Neck veins are flat on semi-fowler’s position.• Skin is warm to touch. PMI is at fifth intercostal space, left midclavicular line• Pulse is graded 1+ on all extremities, equal bilaterally, weak, and thready as palpated• Nonpitting edema on both feet. CRT is 2-3 sec. HR-86 bpm, PR-86 bpm, resonant to dull at midclavicular line• S1 is heard best on apex, S2 at base. No murmurs. Heart sounds have irregular pattern, with S4.
32. Digestive System• Abdomen is flabby/globular, light brown, uniform all over. Umbilicus is at midline, with median incision on abdomen. Landmarks are palpated in appropriate places, liver borders, xiphoid process, and bladder. No signs of enlargement• Chest rises on inspiration and deflates on expiration. Hypoactive bowel sounds of 3/min. dull on liver, tympany on intestine, flat on ribs upon percussion• No pulsations or masses with thickness only on deep palpation. Abdominal girth is 107 cm• Oral mucosa is pale and dry; tongue is pink, dry, and parched. With dental carries, has slight breath odor, able to swallow, and gag reflex present• On clear liquid diet. Pt has moderate ascites.
33. Excretory System• Patient has urinated on diaper, which was changed once for the whole day, with clear, yellow urine• No burning sensation upon urination• Bladder is slightly palpable• Unable to defecate for 2 days already.
34. Musculoskeletal System• Patient’s muscles on upper extremities are equal in size bilaterally, measures 24.5 cm thigh 23.5 cm on right and 27.5 cm on left, calf is 35 cm on right and 31.5 cm on left.• Has firm tone, smooth and coordinated in movement graded 4+ on extremities• PROM and AROM performed• Patient is able to change position with assistance• Patient is able to move toes• Pt has nonpitting edema on both feet, pitting on the ankles grading 1++. Pt has moderate ascites.
35. Nervous System• Patient is conscious, and oriented to person, place, but confusion noted at times• Calm and with normal affect congruent to behavior, speaks clearly, logically, and with normal pace• Cranial nerves tested and found functioning• Reflexes are 2+ bilaterally, superficial reflexes present• Able to contrast pain, temperature appropriately and able to differentiate temperatures• Able to move but slowly and with assistance. GCS=14, muscle strength 4+ on all extremities.
36. Endocrine System• Patient has no history of hormonal/endocrine problems, thyroid is not enlarged, skin is dry and warm to touch. Patient has no known allergies.Reproductive System• Patient is a widower, with eight children, was circumcised at age 6 y/o. no pain upon urination, no abnormal masses on his reproductive organ reported by patient.
37. LABORATORY ANDDIAGNOSTIC TESTS
38. Hematology NORMAL Sep 26 Sep 27 Sep 28 Sep 29 Sep 30 Oct 1 IMPLICATIONS VALUE 135-160 Anemia, decreased 2° to Hgb 133 136 105 103 116 110 g/L blood loss 3° surgery Decreased, anemia 2° Hct 0.40-0.48 0.4 0.4 0.31 0.21 0.34 0.32 blood loss 3° surgery Increased, indicates infection 2° current WBC 5-10 x10/L 11.3 12.8 13.1 12.8 abdominal problem and surgical procedures Increased, indicatesNeutrophil 0.55-.65 0.79 0.84 0.88 0.8 bacterial infection Decreased, indicates bacterial infection,Lymphocyte 0.25-0.4 0.21 0.14 0.1 0.2 decreased because outnumbered by neutrophilsMonocyte 0.02-0.06 0.01 Indicates infectionEosinophil 0.01-0.05 0.01 0.02 Normal
39. Urinalysis (10/2/2011) NORMAL VALUE RESULT IMPLICATIONS Color yellow/amber dark yellow normal pH 4.5-8.0 6 normal Sp. Gravity 1.005-1.030 1.015 normal Sugar negative ++ normal Protein negative 8-10/hpf Indicates proteinuria Pus negative 8-10/hpf Indicates bacteriuria RBC negative 2.4/hpf Indicates hematuria Epithelial cells rare few normal Indicates dehydration, or Crystals negative moderate improper hydration Bacteria negative moderate indicates bacteriuria, UTI Granular cast (coarse) 2-4/hpf 8-10/hpf indicates ineffective GRF
40. Blood Chemistry NORMAL Sep 28 Oct 2 Oct 3 IMPLICATIO VALUE NSSODIUM 135-148 143.4 Normal mmol/L mmol/LPOTASSIU 3.5-5.3 4.88 5.19 4.83 Normal M mmol/L mmol/L mmol/L mmol/L
41. Chest X-ray AP view (9/30/2011) INDICATION NORMAL VALUE RESULT IMPLICATIONSUsed to Normally appearing Hazy densities at the right - cardiomegalydiagnose and positioned paracardiac aorta and left - calcified aortapulmonary chest, bony thorax lung base suggestive of - pneumonitisdiseases and (all bones present, PNEUMONITIS. There is - pneumo-disorder of aligned, suspicious free-peritoneal peritoneummediastinum, symmetrical, and air below the hemi-and bony normally shaped), diaphragm suggestive of:thorax, to soft tissues, pneumo-peritoneumevaluate heart mediastinum, lungs, cardiomegaly AP viewcondition. pleura, heart, and Calcified aorta aortic arch.
42. Ultrasound-Liver (10-5-2011)INDICATION NORMAL VALUE RESULT IMPLICATIONSValuable in The size and shape of Normal in size exhibiting Ultrasonicallydetecting a the abdominal homoenous parenchymal normal sizevariety of organs appear Echo pattern in relation to the liverpathologies, normal. The liver, system Moderateincluding spleen, and pancreas It has smooth outline ascitesfluid appear normal in size No definite focal nor diffuse Incidentalcollections, and texture. No mass lesions small pleuralmasses, abnormal growths No dilated intrahepatic vessels fluid, rightinfections are seen. No fluid is There is moderate amount ofand found in the free- intraperitoneal fluidobstruction. abdomen. collection
43. Fasting Blood Sugar (9/29/2011) INDICATION NORMAL VALUE RESULT IMPLICATIONSTo monitor the blood glucose level of a Increased, possible patient and is vital for DM 72-125 mg/dL 131 mg/dL component of And advanced liver diabetes disease management.
45. IDEAL ACTUALDiagnostic Evaluation Diagnostic Evaluation Fecal material aspiration from NG tube Hematology Abdominal and chest X-rays Chest X-ray -AP view o May show presence and location of small or large intestinal distention, gas or Blood Chemistry fluid Abdominal Ultrasound o “Bird beak” lesion in colonic volvulus Urinalysis o Foreign body visualization Abdominal X-ray flat plate and upright Contrast studies Treatment o Barium enema may diagnose colon obstruction or intussusception. With oxygen inhalation at 2-3L/min o Ileus may be identified by oral barium or Gastrografin. NGT removed Laboratory tests Drainage of transudate fluid with suction o May show decreased sodium, potassium, and chloride levels due to vomiting Fluid taken for cell block, cell count o Elevated WBC counts due to inflammation; marked increase with necrosis, Vital signs monitoring every hour strangulation, or peritonitis Intake and output monitoring every shift o Serum amylase may be elevated from irritation of the pancreas by the bowel Refer if urine output is less than 30mL/hr loop On general liquids diet Flexible sigmoidoscopy or colonoscopy may identify the source of the obstruction such Medication as tumor or stricture Tramadol 50mg IVTT q8h Ketorolac 30mg IVTT q6h RTCNonsurgical Management Cefuroxime 750mg IVTT q8h Correction of fluid and electrolyte imbalances with normal saline or Ringers solution Metronidazole 500mg IVTT q8h with potassium as required. Paracetamol 300mg IVTT for temp>38°C NG suction to decompress bowel. Azithromycin Treatment of shock and peritonitis. Telmisortan TPN may be necessary to correct protein deficiency from chronic obstruction, paralytic Simvastatin ileus, or infection. Furosemide 20mg IVTT now Analgesics and sedatives, avoiding opiates due to GI motility inhibition. IVF Antibiotics to prevent or treat infection. D5LR Ambulation for patients with paralytic ileus to encourage return of peristalsis. D5NM
47. IDEAL ACTUALSurgery ExploratoryConsists of relieving obstruction. Options include: Laparotomy Closed bowel procedures: lysis of adhesions, reduction of volvulus, intussusception, Ileal Resection or incarcerated hernia and Enterotomy for removal of foreign bodies or bezoars Anastomosis Resection of bowel for obstructing lesions, or strangulated bowel with end-to-end anastomosis  Surgical Intestinal bypass around obstruction preparation Temporary ostomy may be indicated done. Surgical preparation is often lengthy, taking as long as 6 to 8 hours.  Postoperative It includes correction of fluid and electrolyte imbalances; decompression of the care done. bowel to relieve vomiting and distention; treatment of shock and peritonitis; and administration of broad-spectrum antibiotics. Often, decompression is begun preoperatively with passage of a nasogastric (NG) tube attached to continuous suction. This tube relieves vomiting, reduces abdominal distention, and prevents aspiration. In strangulating obstruction, preoperative therapy also usually requires blood replacement and I.V. fluids. Postoperative care involves careful patient monitoring and interventions geared to the type of surgery. Total parenteral nutrition may be ordered if the patient has a protein deficit from chronic obstruction, postoperative or paralytic ileus, or infection.
48. SUMMARY OFMEDICATIONS
49. DATE MEDICATION DOSAGE ROUTE FREQUENCY REMARKS09/27-10/2 Tramadol 100 mg IV PUSH q 8 hrs Ketorolac 30 mg IV PUSH q 6 hrs RTC09/27-10/4 Cefuroxime 750 mg IV PUSH q 8 hrs Metronidazole 500 mg IV PUSH q 8 hrs Paracetamol 500 mg tab PO q 4 hrs, PRN10/1-10/3 Azithromycin 50 mg tab PO OD Administere10/1-10/4 Telmisartan 40 mg tab PO OD d and Simvastatin 40 mg tab PO q HS tolerated10/5 Metronidazole 500 mg IV PUSH q 8 hrs well Cefuroxime 750 mg IV PUSH q 8 hrs Tramadol 50 mg IV PUSH q 8 hrs Ranitidine 50 mg IV PUSH q 8 hrs Ketorolac 30 mg IV PUSH q 6 hrs
50. NURSING CARE PLAN
51. Nursing Assessment Assess the nature and location of the patients pain, the presence or absence of distention, flatus, defecation, emesis, obstipation. Listen for high-pitched bowel sounds, peristaltic rushes, or absence of bowel sounds. Assess vital signs. Watch for air-fluid lock syndrome in elderly patients, who typically remain in the recumbent position for extended periods. o Fluid collects in dependent bowel loops. o Peristalsis is too weak to push fluid “uphill”.• o Obstruction primarily occurs in the large bowel. Conduct frequent checks of the patients level of responsiveness; decreasing responsiveness may offer a clue to an increasing electrolyte imbalance or impending shock.
52. Nursing Diagnoses• Acute Pain related to obstruction, distention, and strangulation• Risk for Deficient Fluid Volume related to impaired fluid intake, vomiting, and diarrhea from intestinal obstruction• Diarrhea related to obstruction• Ineffective Breathing Pattern related to abdominal distention, interfering with normal lung expansion• Risk for Injury related to complications and severity of illness• Fear related to life-threatening symptoms of intestinal obstruction
53. Nursing InterventionsAchieving Pain Relief• Administer prescribed analgesics.• Provide supportive care during NG intubation to assist with discomfort.• To relieve air-fluid lock syndrome, turn the patient from supine to prone position every 10 minutes until enough flatus is passed to decompress the abdomen. A rectal tube may be indicated.
54. Nursing InterventionsMaintaining Electrolyte and Fluid Balance• Measure and record all intake and output.• Administer I.V. fluids and parenteral nutrition as prescribed.• Monitor electrolytes, urinalysis, hemoglobin, and blood cell counts, and report any abnormalities.• Monitor urine output to assess renal function and to detect urine retention due to bladder compressions by the distended intestine.• Monitor vital signs; a drop in BP may indicate decreased circulatory volume due to blood loss from strangulated hernia.
55. Nursing InterventionsMaintaining Normal Bowel Elimination• Collect stool samples to test for occult blood if ordered.• Maintain adequate fluid balance.• Record amount and consistency of stools.• Maintain NG tube as prescribed to decompress bowel.
56. Nursing InterventionsMaintaining Proper Lung Ventilation• Keep the patient in Fowlers position to promote ventilation and relieve abdominal distention.• Monitor ABG levels for oxygenation levels if ordered.
57. Nursing InterventionsPreventing Injury Due to Complications• Prevent infarction by carefully assessing the patients status; pain that increases in intensity or becomes localized or continuous may herald strangulation.• Detect early signs of peritonitis, such as rigidity and tenderness, in an effort to minimize this complication.• Avoid enemas, which may distort an X-ray or make a partial obstruction worse.• Observe for signs of shock—pallor, tachycardia, hypotension.• Watch for signs of: – Metabolic alkalosis (slow, shallow respirations; changes in sensorium; tetany). – Metabolic acidosis (disorientation; deep, rapid breathing; weakness; and shortness of breath on exertion).
58. Nursing InterventionsRelieving Fears• Recognize the patients concerns, and initiate measures to provide emotional support.• Encourage presence of support person.
59. Patient Education andHealth Maintenance• Explain the rationale for NG suction, NPO status, and I.V. fluids initially. Advise the patient to progress diet slowly as tolerated once home.• Advise plenty of rest and slow progression of activity as directed by surgeon or other health care provider.• Teach wound care if indicated.• Encourage the patient to follow-up as directed and to call surgeon or health care provider if increasing abdominal pain, vomiting, or fever occur prior to follow-up.
60. Evaluation: ExpectedOutcomes• Maintains position of comfort, states pain decreased to 3 or 4 level on 0-to-10 scale• Urine output greater than 30 mL/hour; vital signs stable• Passed flatus and small, formed brown stool, negative occult blood• Respirations 24 breaths per minute and unlabored with head of bed elevated 45 degrees• Alert, lucid, vital signs stable, abdomen firm, not rigid• Appears relaxed and reports feeling better
61. CONCEPT MAP
62. 10 INEFFECTIVE AIRWAY RISK FOR INJURY r/t HYPERTHERMIA r/t Increased 9 CLEARANCE r/t Ineffective Generalized Weakness and Metabolic Demands 2° to1 Cough Reflex 2° Pain in Activity Intolerance Disease Process Incision Site and Generalized Weakness ACTIVITY INTOLERANCE r/t Generalized Weakness 2° to 8 INEFFECTIVE BREATHING Mr. William Lippincott Surgical Procedure2 PATTERN r/t Restricted Lung 77 years old, Male Expansion 2° to Moderate Abdominal Pain Ascites Acute Abdominal Problem 2° to Volvulus; Gangrenous Ileum RISK FOR SECONDARY 35 cm from Ileus Cecal Valve INFECTION r/t Traumatized DECREASED CARDIAC with Ileo-ileal Anastomoses Tissue 2° to Surgical 73 OUTPUT r/t Impaired Heart Procedure Contractility 2° to Cardiomegaly 5 FLUID VOLUME DEFICIT IMPAIRED SKIN INTEGRITY r/t ACUTE PAIN r/t Abdominal (Isotonic) r/t Active Fluid Loss Abdominal Incision 2° to 64 Incision 2° to Surgical 2° to Ascites Fluid and Fluid Surgical Procedure Procedure Drainage
64. • Date of Discharge: October 7, 2011 • Condition upon Discharge: Improved Review the proper use of prescribed medications, focusing on their correct administration, desired effects, and possible adverse reactions.Medication Instruct client not to abruptly stop the medication without any order from the physician. Discuss side effects of the drugs Allow physical exercises as tolerated. Ensure adequate physical activity.Exercise Encourage patient to have adequate rest periods to prevent fatigue.
65. Advice patient to progress diet slowly as tolerated once home. Encourage high-calorie, high vitamins foods. Teach patient about the food pyramid and recommended daily servings for age.Diet Advice patient and SO to have adequate intake of nutritious foods like vegetables, fruits and other foods rich in vitamins. Encourage patient to have adequate intake of fluids to help in elimination and prevent dehydration 2-3 L of fluids per day. Teach the patient about his disorder, focusing on his type of intestinal obstruction, its cause, and signs and symptoms.Health Teaching Listen to his questions and took time to answer them. Demonstrate techniques for coughing and deep breathing. Teach wound care. Encourage patient to follow-up as directed.Schedule for Next Instruct patient to call surgeon or health care provider ifVisit increasing abdominal pain, abdominal distention, nausea, vomiting, or fever occur prior to follow-up.
66. Encourage client to always pray and never give up hope in any cases or conditions they may pass through. Also encourage client to have faith and seek for strengthSpiritual in God Respect beliefs of clients but be ready to explain and correct misconceptions. Advise plenty of rest and slow progression of activity as directed by surgeon or other health care provider. Encourage a healthy lifestyle by eating a well-balancedLifestyle diet and maintaining proper body exercise. Encourage active lifestyle and participation in activities appropriate for age and socialization. Refer to the barangay health center/station for follow up check-up and evaluation.Referral Refer also to health center for minor problems. Refer to nearest hospital for any complications.