Case presentation volvulus in geriatric patient

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Case presentation volvulus in geriatric patient

  1. 1. Misamis University Ozamiz City Graduate School CASE PRESENTATION:Intestinal Obstruction (Volvulus) In Geriatric Patient In partial fulfillment of the requirements in ADM 212 Submitted to: Prof. Maricar M. Mutia, RN, MN-MAN Faculty, Graduate School Submitted by: Reynel Dan L. Galicinao, RN Student, Master in Nursing Major in Nursing Educational Administration October 15, 2011
  2. 2. Case Presentation: Intestinal ObstructionOBJECTIVESGeneral 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.Specific Objectives: Within the case presentation session, the audience will be able to: 1. Describe intestinal obstruction 2. List the risk factors of intestinal obstruction 3. Trace the pathophysiology of intestinal obstruction 4. Determine the signs and symptoms associated with intestinal obstruction 5. Identify diagnostic and laboratory procedures for intestinal obstruction and their corresponding nursing responsibilities 6. Enumerate possible medical and surgical interventions for intestinal obstruction 7. List the medications to be given for intestinal obstruction 8. Identify possible nursing diagnoses for intestinal obstruction 9. Plan appropriate independent and interdependent nursing interventions for intestinal obstruction 10. Write a discharge plan for intestinal obstructionOVERVIEW OF INTESTINAL OBSTRUCTIONIntestinal obstruction is an interruption in the normal flow of intestinal contents along theintestinal tract. The block may occur in the small or large intestine, may be complete orincomplete, may be mechanical or paralytic, and may or may not compromise the vascularsupply. Obstruction most frequently occurs in the young and the old.Pathophysiology and EtiologyTypes and Causes 2|Page
  3. 3. Case Presentation: Intestinal Obstruction Three causes of intestinal obstruction. (A) Intussusception. Note 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). Note that 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. Mechanical obstruction—a physical block to passage of intestinal contents without disturbing blood supply of bowel. High small-bowel (jejunal) or low small-bowel (ileal) obstruction occurs four times more frequently than colonic obstruction. Causes include: o Extrinsic—adhesions from surgery, hernia, wound dehiscence, masses, volvulus (twisted loop of intestine). Up to 70% of small bowel obstructions are caused by adhesions. o Intrinsic—hematoma, tumor, intussusception (telescoping of intestinal wall into itself), stricture or stenosis, congenital (atresia, imperforate anus), trauma, inflammatory diseases (Crohns, diverticulitis, ulcerative colitis). o Intraluminal—foreign body, fecal or barium impaction, polyp, gallstones, meconium in infants. o In postoperative patients, approximately 90% of mechanical obstructions are due to adhesions. In nonsurgical patients, hernia (most often inguinal) is the most common cause of mechanical obstruction. Paralytic (adynamic, neurogenic) ileus o Peristalsis is ineffective (diminished motor activity perhaps because of toxic or traumatic disturbance of the autonomic nervous system). o There is no physical obstruction and no interrupted blood supply. o Disappears spontaneously after 2 to 3 days. o Causes include:  Spinal cord injuries; vertebral fractures.  Postoperatively after any abdominal surgery.  Peritonitis, pneumonia.  Wound dehiscence (breakdown).  GI tract surgery. Strangulation—obstruction compromises blood supply, leading to gangrene of the intestinal wall. Caused by prolonged mechanical obstruction.Altered Physiology Increased peristalsis, distention by fluid and gas, and increased bacterial growth proximal to obstruction. The intestine empties distally. Increased secretions into the intestine are associated with diminution in the bowels absorptive capacity. The accumulation of gases, secretions, and oral intake above the obstruction causes increasing intraluminal pressure. Venous pressure in the affected area increases, and circulatory stasis and edema result. Bowel necrosis may occur because of anoxia and compression of the terminal branches of the mesenteric artery. Bacteria and toxins pass across the intestinal membranes into the abdominal cavity, thereby leading to peritonitis. ―Closed-loop‖ obstruction is a condition in which the intestinal segment is occluded at both ends, preventing either the downward passage or the regurgitation of intestinal contents.Clinical ManifestationsFever, peritoneal irritation, increased WBC count, toxicity, and shock may develop with alltypes of intestinal obstruction. 3|Page
  4. 4. Case Presentation: Intestinal Obstruction Simple mechanical—high small-bowel: colic (cramps), mid- to upper abdomen, some distention, early bilious vomiting, increased bowel sounds (high-pitched tinkling heard at brief intervals), minimal diffuse tenderness. Simple mechanical—low small-bowel: significant colic (cramps), midabdominal, considerable distention, vomiting slight or absent, later feculent, increased bowel sounds and ―hush‖ sounds, minimal diffuse tenderness. Simple mechanical—colon: cramps (mid- to lower abdomen), later-appearing distention, then vomiting may develop (feculent), increase in bowel sounds, minimal diffuse tenderness. Partial chronic mechanical obstruction—may occur with granulomatous bowel in Crohns disease. Symptoms are cramping, abdominal pain, mild distention, and diarrhea. Strangulation symptoms are initially those of mechanical obstruction, but progress rapidly—pain is severe, continuous, and localized. There is moderate distention, persistent vomiting, usually decreased bowel sounds and marked localized tenderness. Stools or vomitus become bloody or contain occult blood.Complications Dehydration due to loss of water, sodium, and chloride Peritonitis Shock due to loss of electrolytes and dehydration Death due to shockNursing 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.GERONTOLOGIC ALERT 4|Page
  5. 5. Case Presentation: Intestinal ObstructionWatch for air-fluid lock syndrome in elderly patients, who typically remain in the recumbentposition for extended periods. Fluid collects in dependent bowel loops. Peristalsis is too weak to push fluid ―uphill.‖ 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.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 obstructionNursing 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.Maintaining 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.Maintaining 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.Maintaining Proper Lung Ventilation Keep the patient in Fowlers position to promote ventilation and relieve abdominal distention. Monitor ABG levels for oxygenation levels if ordered.Preventing 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: o Metabolic alkalosis (slow, shallow respirations; changes in sensorium; tetany). 5|Page
  6. 6. Case Presentation: Intestinal Obstruction o Metabolic acidosis (disorientation; deep, rapid breathing; weakness; and shortness of breath on exertion).Relieving Fears Recognize the patients concerns, and initiate measures to provide emotional support. Encourage presence of support person.NURSING HEALTH ASSESSMENTDemographic DataName: ―Mr. William Lippincott‖Address: Poblacion, Midsalip, Zamboanga del SurAge: 77 years oldSex: MaleStatus: WidowerReligion: Roman CatholicOccupation: BookkeeperHealth HistoryA. Chief Complaint/s: Abdominal painB. Impression/Admitting Diagnosis: Acute abdominal problem secondary to volvulus; gangrenous ileum 35 cm fromileocecal valve with ileoileal anastomoses.C. History of Present Illness: One month prior to admission, patient had complaints of epigastric pain, described ascrampy, graded at 8/10, intermittent, aggravated by eating solid foods, patient can onlytolerate to eat porridge with flaked fish sprinkled on it, alleviated by application of Efficascentoil to abdomen, and rest. Patient had a feeling of strong urge to fart or expel flatus but wasunable to do. 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 oralmedications thus prompted admission; no fever, no vomiting, no tarry stool. Last bowelmovement 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 hospitalizedfor 1 week last July 2008 due to Pneumonia. Patient reported hehad ―complete immunization‖. Patient takes Centrum 500 mg 1 tablet, once a day. Patienthad blood transfusion (1989) but he could not recall the details. No known allergies. Born viaNSVD.E. Health Habits Frequency Amount PeriodTobacco None None NoneAlcohol None None NoneOTC drugs/non-prescription drugs Specify: Centrum OD 500 mg Tab 1 yearF. Family History with GenogramHistory of Heredo-familial diseases: Cancer X _____ DM / _____ Asthma X _____ Hypertension X _____ Cardiac Disease _____ X X 6|Page
  7. 7. Case Presentation: Intestinal Obstruction Mental Disorder _____ Others _____ XG. Patient’s Perception of Present Illness: Pt reported, ―Nawala naman ang sakit sa akong tiyan karon, bag-opaman gud ko gitagaan ug tambal para mawala ang sakit.‖ Hospital Environment: Pt reported, ―Ok raman ang kwarto dire aircon, komportablera man.‖H. Summary of Interaction Patient was sleeping upon nurse’s arrival. During physical assessment, patient wokeup and nurse continued assessment. Patient appears weak but still answered the nurse’sinterview questions and cooperated in the assessment.GORDON’S ASSESSMENT Normal Pattern Before Hospitalization Clinical Appraisal1. Activities – Rest Pt usually sleeps at 9pm, Pt has been lying on bed the a. Activities and then wakes up at 6am. whole day. Moves/ changes b. Sleeping pattern Pt takes a bath every day position with assistance. Pt c. Rest except for Tuesdays and was not able to sleep in the Fridays r/t his cultural belief. morning due to pain, but was Pt goes to work as a able to sleep for 2 hours in bookkeeper, and then goes the evening. Pt appeared to city hall, BIR, and then very weak and sleepy. church. Few weeks PTA, pt usually takes naps in the afternoon.2. 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 e. Medication/Supplement once a day. 1 tab every 4 hours, prn; food Telmisartan (Micardis) 40 mg tab OD every HS.3. Elimination Pt was able to urinate Pt was able urinate once on a. Urine (frequency, color, approximately 1-2 times per his diaper, with clear and transparency) day, with clear and yellow yellow urine, had changed b. Bowel (frequency, urine. Pt defecated > 3x for diaper once. Pt has not been color) LBM with color brown, able to defecate this day. unformed, intermittent LBM for 3 days.4. Ego Integrity Pt reported, ―ok Pt reported ―ok koron‖. Pt a. Perception of Self rabayaakongkinabuhi‖. Pt has 8 children, with his b. Coping Mechanism has 8 children, has been whole family visiting him 7|Page
  8. 8. Case Presentation: Intestinal Obstruction c. Support Mechanism living with his daughter. He regularly, with friends also d. Mood/Affect goes to work, and a part of visiting him regularly. He lay ministerof parish church, prays for his health he goes to church regularly. condition. Pt appears very Pt has normal affect weak but with normal affect congruent to behavior c calm congruent to behavior, with mood. calm mood.5. Neuro-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 senses with normal pace. Pt has within normal pace. Pt has (sight, hearing, smell, intact senses: Able to read intact senses as tested: Able taste, touch) with aid, hear, feel, touch to read with aid, hear, feel, and discriminate, smell and touch and discriminate, smell taste. and taste.6. Oxygenation and Vital VS not taken but has history RR: 22 cpm Signs 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 respiratory and was hospitalized for a problems week last July 2008.7. Pain – Comfort Epigastric pain, graded Pain – 0/10 upon a. Pain (location, onset, 8/10, for 2 weeks already, assessment since pt has just intensity, duration, with LBM for 3 days but been given an analgesic. associated intermittent with brown symptoms, unformed stool, aggravated aggravation) with solid foods; alleviated b. Comfort with Efficascent oil and rest. measures/alleviation c. Medication/s8. Hygiene and activities of Pt takes a bath everyday Pt has not taken a bath since daily living upon waking up except for admission. Pt changes Tuesdays and Fridays. Pt position with assistance lies goes to work as bookkeeper, on bed the whole day. Sleep goes to City Hall, BIR, and is disturbed due to pain; was church. He sleeps at 9pm- only able to sleep for 2 hours 6pm this evening for this day.9. Sexuality Patient is a male, 77 years Patient is a male, 77 years a. Male (circumcision, civil old, widower, with 8 children, old, widower, with 8 children, status, number of circumcised at 6 years old. circumcised at 6 years old. children)PHYSICAL EXAMINATION AND REVIEW OF SYSTEMSGeneralPatient is male, 77 y/o, lying semi-fowler’s position in bed, sleeping, but later was awakened.Patient has mild body and breath odor. Patient is conscious, and oriented to person, andplace. Patient is calm and with normal affect congruent to behavior, speaks clearly, logically,and with normal pace. Patient appears very weak and sleepy. Patient has #17 D5 LR 1L with650 cc left, hooked at right arm, regulatedat 30 gtts/min, patent and infusing well.HEENTH-Patient has wavy, white-streaked hair, equally distributed, no infestations, facial featuresare symmetric, slightly oval in shape. Skin is wrinkled at the forehead and cheeks.E-Patient has moist, pink conjunctiva, anicteric sclera, able to read with aid, pupils are black,constricts 2mm when lighted, 4mm when not, PERRLA.E-Patient is able to hear adequately; ears have dry, brown cerumen, level with eyebrows 8|Page
  9. 9. Case Presentation: Intestinal ObstructionN- Patient is able to smell adequately, patent and equal nostrils, no nasal flaring, nasalseptum at midline, with dried up mucus.T- Patient’s 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, andgag reflex present.Integumentary SystemPatient’s skin is dry, warm, rough in some parts, and brownish in color. Skin in feet is dry,scaly, and pale. Patient has body hairs equally distributed on contralateral parts of the body.Patient has good skin turgor, with nonpitting edema on dorsal part of both feet, but with agrade 1+ pitting edema on the ankles. Patient has median incision on abdomen. Patient hasan open wound below the umbilicus, with length of 9cm and width of 6cm, yielding yellow-greenish drainage with foul odor. Patient’s nails are long, no clubbing, CRT 2-3 sec.Temperature is 37.8 ˚C. Patient’s nails are in normal angle and shape/ curvature, but withpale nail beds.Respiratory SystemPatient 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.Patient’s breath sounds on the upper lung fields are clear, but decreased breath sounds onthe lower fields. RR-22 cpm, and with effort. Patient uses abdominal accessory muscles andinternal intercostal muscles when breathing. Flaring nostrils noted. Pt breathes with openmouth. Pt’s respiration is rhythmic, with regular pattern and normal depth. No adventitiousbreath sounds. Pt has moderate ascites that pushes the diaphragm upwards, thus restrictinglung expansion, as reflected on UTZ, and physical assessment.Cardiovascular SystemPatient is pale, with pale extremities. Anterior chest has symmetrical features. Neck veins areflat on semi-fowler’s position. Skin is warm to touch. PMI is at fifth intercostal space, leftmidclavicular line. Pulse is graded 1+ on all extremities, equal bilaterally, weak, and threadyas 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.Digestive SystemAbdomen is flabby/globular, light brown, uniform all over. Umbilicus is at midline, with medianincision on abdomen. Landmarks are palpated in appropriate places, liver borders, xiphoidprocess, and bladder. No signs of enlargement. Chest rises on inspiration and deflates onexpiration. Hypoactive bowel sounds of 3/min. dull on liver, tympany on intestine, flat on ribsupon percussion. No pulsations or masses with thickness only on deep palpation. Abdominalgirth is 107cm. Oral mucosa is pale and dry; tongue is pink, dry, and parched. With dentalcarries, has slight breath odor, able to swallow, and gag reflex present. On clear liquid diet.Pt has moderate ascites.Excretory SystemPatient has urinated on diaper, which was changed once for the whole day, with clear, yellowurine. No burning sensation upon urination. Bladder is slightly palpable. Patient has not beenable to defecate for 2 days already.Musculoskeletal SystemPatient’s muscles on upper extremities are equal in size bilaterally, measures 24.5cm thigh23.5cm on right and 27.5cm on left, calf is 35cm on right and 31.5cm on left. Has firm tone,smooth and coordinated in movement graded 4+on extremities. PROM and AROMperformed. Patient is able to change position with assistance. Patient is able to move toes. Pthas nonpitting edema on both feet, pitting on the ankles grading 1++. Pt has moderateascites.Nervous SystemPatient is conscious, and oriented to person, place, but confusion noted at times. Patient iscalm and with normal affect congruent to behavior, speaks clearly, logically, and with normalpace. Cranial nerves tested and found functioning. Patient’s reflexes are 2+ bilaterally, 9|Page
  10. 10. Case Presentation: Intestinal Obstructionsuperficial reflexes present. Patient is able to contrast pain, temperature appropriately andable to differentiate temperatures. Patient is able to move but slowly and with assistance.GCS=14, muscle strength 4+ on all extremities.Endocrine SystemPatient has no history of hormonal/endocrine problems, thyroid is not enlarged, skin is dryand warm to touch. Patient has no known allergies.Reproductive SystemPatient is a widower, with eight children, was circumcised at age 6 y/o. no pain uponurination, no abnormal masses on his reproductive organ reported by patient.PATHOPHYSIOLOGY 10 | P a g e
  11. 11. Case Presentation: Intestinal Obstruction 11 | P a g e
  12. 12. Case Presentation: Intestinal ObstructionLABORATORY AND DIAGNOSTIC TESTSHEMATOLOGY NORMAL Sep Sep Sep Sep Sep Oct 1 IMPLICATIONS VALUE 26 27 28 29 30 135- Anemia, decreased 2° Hgb 133 136 105 103 116 110 160g/L to 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 5- infection 2° current WBC 11.3 12.8 13.1 12.8 10x10/L abdominal problem and surgical procedures Increased, indicates Neutrophil 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 neutrophils Monocyte 0.02-0.06 0.01 Indicates infection Eosinophil 0.01-0.05 0.01 0.02 NormalIndication Basic screening test determines altered hematologic functioning.Nursing ResponsibilitiesPRE-TEST 1. Explain test purpose and procedure. 2. Ensure consent is secured. 3. Assess patient for bleeding disorder. 4. Instruct patient that slight discomfort maybe felt when skin is punctured. 5. Instruct pt to avoid stress and dehydration.POST-TEST 1. Apply manual pressure on punctured site. 2. Monitor vital signs. 3. Monitor puncture site for bruising, bleeding.URINALYSIS (Oct 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 GRFIndication Determines altered urine properties.Nursing ResponsibilitiesPRE-TEST 12 | P a g e
  13. 13. Case Presentation: Intestinal Obstruction 1. Explain test procedure and purpose. 2. Avoid excessive water and sodium intake. 3. Eliminate caffeine and alcohol in the diet.POST-TEST 1. Patient can resume normal fluid and dietary intake and medications.BLOOD CHEMISTRY NORMAL VALUE Sep 28 Oct 2 Oct 3 IMPLICATIONS SODIUM 135-148 mmol/L 143.4 mmol/L NormalPOTASSIUM 3.5-5.3 mmol/L 4.88 mmol/L 5.19 mmol/L 4.83 mmol/L NormalIndication Identify chemical blood constituents, to establish a pattern of abnormalities/ balance.Nursing ResponsibilitiesPRETEST 1. Explain test purpose and procedure. 2. Ensure legal consent is secured 3. Assess Patient for bleeding disorder 4. Instruct pt that slight discomfort maybe felt when skin is punctured 5. Instruct pt to avoid stress, DHNPOSTTEST 1. Apply manual pressure. 2. Monitor V/S. 3. Monitor puncture site for bruising, bleedingCHEST X-RAY AP View (Sep 30, 2011) INDICATION NORMAL VALUE RESULT IMPLICATIONSUsed to diagnose Normally appearing Hazy densities at the right - cardiomegalypulmonary and positioned chest, paracardiac aorta and left - calcified aortadiseases and bony thorax (all lung base suggestive of - pneumonitisdisorder of bones present, PNEUMONITIS. There is - pneumo-mediastinum, aligned, symmetrical, suspicious free-peritoneal air peritoneumand bony thorax, and normally below the hemi- diaphragmto evaluate heart shaped), soft tissues, suggestive of:condition. mediastinum, lungs, pneumo-peritoneum pleura, heart, and cardiomegaly AP view aortic arch. Calcified aortaNursing ResponsibilitiesPRETEST 1. Explain test purpose and procedure. 2. Remove all jewelry and other ornamentation in the chest area before X-ray. 3. Remind pt should remain motionless and follow breathing instructions.POSTTEST 1. Provide and return pt to comfortable room environment and inform result later.ULTRASOUND- LIVER (Oct 5, 2011) INDICATION NORMAL VALUE RESULT IMPLICATIONSValuable in The size and shape of Normal in size exhibiting Ultrasonicallydetecting a the abdominal organs homoenous parenchymal normal sizevariety of appear normal. The Echo pattern in relation to the liverpathologies, liver, spleen, and system Moderateincluding pancreas appear It has smooth outline ascitesfluid normal in size and No definite focal nor diffuse mass Incidental smallcollections, texture. No abnormal lesions pleural fluid,masses, growths are seen. No No dilated intrahepatic vessels rightinfections fluid is found in the There is moderate amount ofand abdomen. free- intraperitoneal fluid 13 | P a g e
  14. 14. Case Presentation: Intestinal Obstructionobstruction. collectionNursing ResponsibilitiesPRETEST 1. Explain test purpose, benefits, and procedure. 2. Instruct patient to remain NPO for a minimum of 8 hours before the examination to improve anatomic visualization of all structures. 3. Assure the patient that there is no pain involved. However, the patient may feel uncomfortable lying quietly for a long period. 4. Explain that a liberal coating of coupling agent must be applied to the skin that there is no air between the skin and the transducer and to allow for easy movement of the transducer over the skin. 5. Explain that the patient will be instructed to control breathing patterns while the images are being made.POSTTEST 1. Normal diet and fluids are resumed. 2. Interpret test outcomes and counsel appropriately.FASTING BLOOD SUGAR (Sep 29, 2011) INDICATION NORMAL VALUE RESULT IMPLICATIONS To monitor the blood Increased, possible forglucose level of a patient DM 72-125 mg/dL 131 mg/dLand is vital component of And advanced liver diabetes management. diseasePRETEST 1. Explain test purpose and procedure. 2. Tell patient that the test requires at least one overnight fast; water is permitted. Instruct the patient to defer insulin or oral hypoglycemics until after blood is drawn, unless specifically instructed to do otherwise. 3. Note the last time the patient ate in the record and on the laboratory requisition.POSTTEST 1. Tell patient that he or she may eat and drink after blood is drawn. 2. Interpret test results and monitor appropriately for hyperglycemia and hypoglycemia. Counsel regarding necessary lifestyle changes 3. Give the patient the following checklist: a. Take special care of the feet b. Use a lubricant or unscented hand cream on dry, scaly skin. c. Look for calluses on your soles. Rub them gently with pumice stone. d. Make sure new shoes fit properly; wear freshly washed socks or stockings. e. Never go barefoot f. Avoid using hot water bottles, tubs of hot water, or heating pads on your feet. g. Trim your toe nails straight across 4. Persons with glucose levels >200mg/dl should be placed on a strict intake and output program.MEDICAL MANAGEMENT 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 Blood Chemistry of small or large intestinal Abdominal Ultrasound distention, gas or fluid Urinalysis o ―Bird beak‖ lesion in colonic Abdominal X-ray flat plate and volvulus upright 14 | P a g e
  15. 15. Case Presentation: Intestinal Obstruction o Foreign body visualization Contrast studies Treatment o Barium enema may diagnose With oxygen inhalation at 2- colon obstruction or 3L/min intussusception. NGT removed o Ileus may be identified by oral Drainage of transudate fluid with barium or Gastrografin. suction Laboratory tests Fluid taken for cell block, cell o May show decreased sodium, count potassium, and chloride levels due Vital signs monitoring every hour to vomiting Intake and output monitoring o Elevated WBC counts due to every shift inflammation; marked increase Refer if urine output is less than with necrosis, strangulation, or 30mL/hr peritonitis On general liquids diet o Serum amylase may be elevated from irritation of the pancreas by Medication the bowel loop Tramadol 50mgIVTTq8h Flexible sigmoidoscopy or colonoscopy may identify the source of the obstruction Ketorolac 30mgIVTTq6h RTC such as tumor or stricture Cefuroxime 750mgIVTTq8h Metronidazole 500mgIVTTq8hNonsurgical Management Paracetamol 300mgIVTT for Correction of fluid and electrolyte temp>38°C imbalances with normal saline or Ringers Azithromycin solution with potassium as required. Telmisortan NG suction to decompress bowel. Simvastatin Treatment of shock and peritonitis. Furosemide 20mgIVTT now TPN may be necessary to correct protein deficiency from chronic obstruction, IVF paralytic ileus, or infection. D5LR Analgesics and sedatives, avoiding D5NM opiates due to GI motility inhibition. Antibiotics to prevent or treat infection. Ambulation for patients with paralytic ileus to encourage return of peristalsis.SURGICAL MANAGEMENT IDEAL ACTUALSurgery Exploratory LaparotomyConsists of relieving obstruction. Options include: Ileal Resection and Anastomosis Closed bowel procedures: lysis of adhesions, reduction of volvulus,  Surgical preparation done. intussusception, or incarcerated hernia  Postoperative care done. Enterotomy for removal of foreign bodies or bezoars Resection of bowel for obstructing lesions, or strangulated bowel with end-to-end anastomosis Intestinal bypass around obstruction Temporary ostomy may be indicated Surgical preparation is often lengthy, taking as long as 6 to 8 hours. It includes correction of fluid and electrolyte imbalances; decompression of the bowel to relieve vomiting and distention; treatment of shock and peritonitis; and administration of broad-spectrum antibiotics. 15 | P a g e
  16. 16. Case Presentation: Intestinal Obstruction 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.Nursing Management IDEAL ACTUALNursing Assessment Prioritized Nursing Diagnoses Assess the nature and location of the Ineffective Airway Clearance patients pain, the presence or absence of Ineffective Breathing Pattern distention, flatus, defecation, emesis, Decreased Cardiac Output obstipation. Deficient Fluid Volume Listen for high-pitched bowel sounds, Acute Pain peristaltic rushes, or absence of bowel Impaired Skin Integrity sounds. Risk for Secondary Infection Assess vital signs. Hyperthermia Watch for air-fluid lock syndrome in elderly Activity Intolerance patients, who typically remain in the Risk for Injury recumbent position for extended periods. o Fluid collects in dependent bowel loops. Nursing Interventions o Peristalsis is too weak to push fluid Vital signs monitored q hr. ―uphill‖.• Regulated IVF to prescribed rate. o Obstruction primarily occurs in the large Monitored intake and output as bowel. ordered. Conduct frequent checks of the patients level Prescribed meds given. of responsiveness; decreasing Assessed patient. responsiveness may offer a clue to an Provided therapeutic increasing electrolyte imbalance or impending environment. shock. Measured abdominal girth daily. Encouraged pt to perform deepNursing Diagnoses breathing and coughing Ineffective Breathing Pattern related to exercises. abdominal distention, interfering with normal Health teachings done to patient lung expansion and SO. Ineffective tissue perfusion: GI Acute Pain related to obstruction, distention, Instructed patient on active ROM. and strangulation Assessed bowel sounds. Imbalanced nutrition: Less than body Assessed breath sounds. requirements Elevated patient’s feet to lessen Risk for Deficient Fluid Volume related to edema. impaired fluid intake, vomiting, and diarrhea Assisted patient in assuming a from intestinal obstruction semi-Fowler’s position. Risk for Injury related to complications and Assisted patient in ambulation severity of illness and promoted patient safety Constipation Instructed SO on proper skin Diarrhea related to obstruction care. Fear related to life-threatening symptoms of 16 | P a g e
  17. 17. Case Presentation: Intestinal Obstruction intestinal obstructionNursing Interventions Allow the patient nothing by mouth, as ordered, but make sure to provide frequent mouth care to help keep mucous membranes moist. Look for signs of dehydration (thick, swollen tongue; dry, cracked lips; dry oral mucous membranes). If surgery wont be performed, the patient may be allowed a few ice chips. Avoid using lemon-glycerin swabs, which can increase mouth dryness. Insert an NG tube to decompress the bowel as ordered. Attach the tube to low-pressure, intermittent suction. Monitor drainage for color, consistency, and amount. Irrigate the tube, if necessary, with normal saline solution to maintain patency. Begin and maintain I.V. therapy as ordered. Monitor intake and output. Maintain fluid and electrolyte balance by monitoring electrolyte, blood urea nitrogen, and creatinine levels. Provide I.V. fluids to keep levels within normal ranges. Administer analgesics, broad-spectrum antibiotics, and other medications as ordered. Monitor the patient for the desired effects and for adverse reactions. To ease discomfort, help the patient change positions frequently. Continually assess his pain. Remember, colicky pain that suddenly becomes constant could signal perforation. Watch for signs of metabolic alkalosis (changes in sensorium; slow, shallow respirations; hypertonic muscles; tetany) or acidosis (shortness of breath on exertion; disorientation; and later, deep, rapid breathing, weakness, and malaise). Watch for signs and symptoms of secondary infection, such as fever and chills. Monitor urine output carefully to assess renal function, circulating blood volume, and possible urine retention due to bladder compression by the distended intestine. If you suspect bladder compression, catheterize the patient for residual urine immediately after he has voided. Measure abdominal girth frequently to detect progressive distention. Keep the patient in semi-Fowlers or Fowlers position as much as possible. These positions help to promote pulmonary ventilation and ease respiratory distress from abdominal distention. Listen for bowel sounds, and watch for other signs of resuming peristalsis (passage of flatus and mucus through the rectum). If surgery is scheduled, prepare the patient as required. After surgery, provide all necessary postoperative care. Care for the surgical site, 17 | P a g e
  18. 18. Case Presentation: Intestinal Obstruction maintain fluid and electrolyte balance, relieve pain and discomfort, maintain respiratory status, and monitor intake and output.Patient Teaching Teach the patient about his disorder, focusing on his type of intestinal obstruction, its cause, and signs and symptoms. Listen to his questions and take time to answer them. Explain the rationale for NG suction, NPO status, and I.V. fluids initially. Advice patient to progress diet slowly as tolerated once home. Explain necessary diagnostic tests and treatments. Make sure the patient understands that these procedures are necessary to relieve the obstruction and reduce pain. Prepare the patient and family members for the possibility of surgery. Provide preoperative teaching, and reinforce the physicians explanation of the surgery. Demonstrate techniques for coughing and deep breathing, and teach the patient how to use incentive spirometry. Tell the patient what to expect postoperatively. After surgery, review incisional care. Provide emotional support and positive reinforcement before and after surgery. Discuss postoperative activity limitations and point out why these restrictions are necessary.Health Maintenance Review the proper use of prescribed medications, focusing on their correct administration, desired effects, and possible adverse reactions. Advise plenty of rest and slow progression of activity as directed by surgeon or other health care provider. Teach wound care if indicated. Encourage patient to follow-up as directed and to call surgeon or health care provider if increasing abdominal pain, abdominal distention, nausea, vomiting, or fever occur prior to follow-up.Evaluation: Expected Outcomes 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 18 | P a g e
  19. 19. Case Presentation: Intestinal ObstructionSUMMARY OF MEDICATIONS 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 Administered10/1-10/4 Telmisartan 40 mg tab PO OD and tolerated Simvastatin 40 mg tab PO q HS well10/5 Metronidazole 500 mg IV PUSH q 8 hrs 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 hrsDRUG STUDYMedication Drug Side Mecha- Contraindica- Classi- Effects/ Nursing Indication nismof tionsand ficatio Adverse Responsibilities Action Cautions n Effects Antiulc -Duodenal Competitiv Vertigo, - Assess patient for -ContraindicatedRanitidine er drug and ely inhibits malaise, abdominal pain. in patients gastric action of headache, - Instruct patient on hypersensitive to ulcer histamine blurred proper use of OTC drug. -heartburn on the H2 vision, preparation as -Use cautiously in at receptor anaphylaxis, indicated. patients with sites of angioedema - Remind patient to hepatic parietal take once daily. dysfunction. cells, - Instruct patient to decreasing take without regards gastric acid to meals because secretion. absorption is not affected. - Urge patient to avoid cigarette smoking because this may increase gastric acid secretion. 19 | P a g e
  20. 20. Case Presentation: Intestinal ObstructionMedication Drug Mecha- Side Contraindica- Classi- Effects/ Nursing Indication nismof tionsand ficatio Adverse Responsibilities Action Cautions n Effects Nonopi -Mild pain Unknown. Hemolytic - Advise patient that -ContraindicatedParacetamol oid -Feer Thought to anemia, drug is only for short- in patients analge produce neutropenia, term use. hypersensitive to sic and analgesia pancytopeni - Tell patient not to use drug. antipyr by blocking a, jaundice, for marked fever of etic pain hypoglycemi 103.1°F. impulses a, rash - Warn patient that by long-term use can synthesis cause liver damage. of the prostaglan din in the CNS or other substances that synthesize pain receptors to stimulation. Opioid -moderate Unknown. -dizziness, - tell patient to take -ContraindicatedTramadol analge or A centrally- vertigo, drug as prescribed and in patients sic moderatel acting headache, not to increase dose or hypersensitive to y severe synthetic somnolence, dosage. drug. pain analgesic seizures, - Caution ambulatory -Use cautiously in compound nausea, patient to be careful patients at risk for not constipation, rising and walking. seizures and chemically vomiting, - Advise patient to respiratory related to respiratory check with prescriber depression. opioids. depression before taking OTC Thought to drugs because drug bind to reactions can occur. opioid - Warn patient not to receptors stop drug abruptly. and inhibit reuptake of norepineph rine and serotonin. 20 | P a g e
  21. 21. Case Presentation: Intestinal Obstruction Medication Drug Mecha- Side Contraindica- Classi- Effects/ Nursing Indication nismof tionsand ficatio Adverse Responsibilities Action Cautions n Effects Diuretic -acute A potent -vertigo, - To prevent nocturia, Contraindicated Furosemide pulmonary loop headache, give medication in the in patients edema diuretic that dizziness, morning. hypersensitive to -edema inhibits pancreatitis, - Monitor weight, blood drug and in those - sodium and agranulocyt pressure, and pulse with anuria. hypertensi chloride osis, rate routinely with long- - Use on reabsorptio leucopenia, term use and during cautiously in n at the thrombocyto rapid dieresis. patients with proximal penia, - Watch for signs of hepatic and distal aplastic hypokalemia such as cirrhosis and tubules and anemia, muscle weakness and in those the hepatic cramps. allergic with ascending dysfunction, - Monitor fluid intake sulfonamides loop of volume and output and . Henle. depletion electrolyte and BUN, and and carbon dioxide dehydration, levels frequently. hypokalemia - Consult prescriber , about a high-potassium hyperglycem diet. ia, dilutional hyponatremi a, muscle spasm, dermatitis, purpura, photosensiti vity reactions and gout Non- Short-term Inhibits CNS: Correct first In those who areKetorolac tromethamine steroid managem prostaglan headache, hypovolemia. at risk for al anti- ent of din dizziness, bleeding. inflam moderatel synthesis, drowsiness, In patients less than 2 matory y severe, to produce sedation years of age, use single As prophylactic drug acute pain anti- dose only. analgesic before for single inflammato CV: major surgery or and ry, arrhythmias, Tell patient to notify intraoperatively multiple- analgesic, edema, prescriber if there is when hemostasis dose and hypertensio blood in the vomit, is critical. treatment. antipyretic n, urine, or stool; coffee- effects. palpitations ground vomit and In those who are black-tarry stool. elderly, with GI: renal/hepatic dyspepsia, impairment GI pain, nausea, vomiting, diarrhea, constipation SKIN: diaphoresis, pruritus, rash 21 | P a g e
  22. 22. Case Presentation: Intestinal Obstruction Medication Drug Mecha- Side Contraindica- Classi- Effects/ Nursing Indication nismof tionsand ficatio Adverse Responsibilities Action Cautions n Effects HMG- To reduce Inhibits CNS: Patient should follow a In those withSimvastatin CoA risk of HMG-CoA asthenia, standard low- active liver reducta death reductase, headache cholesterol diet during disease. se from CV an early therapy. inhibito diseases (and rate- GI: Caution on those r and CV limiting)ste abdominal Instruct patient to take who consume events in p in pain, drug with the evening large amounts of patients at cholesterol constipation, meal because this alcohol. high risk biosynthesi diarrhea, enhances absorption for s dyspepsia, and increases coronary nausea, cholesterol events. vomiting biosynthesis. To reduce MUSCULOS total and KELETAL: LDL myalgia cholestero l levels in RESPI: patients URTI with homozygo us familial hyperchol esterolemi a. Macroli Acute Binds to CNS: Give Zmax 1 hour In patientsAzithromycin de bacterial 50S dizziness, before or 2 hours after hypersensitive to worsening subunit of fatigue, a meal; can be taken erythromycin. of COPD bacterial headache, with or without food; do ribosome, vertigo not give with antacids. Caution in Communit blocking patients with y acquired protein CV: chest Tell patient to avoid impaired hepatic pneumoni synthesis; pain, excessive sunlight and function. a bacteriostat palpitations to wear protective ic or clothing and use Single bactericidal GI: sunscreen when dose , abdominal outside. treatment depending pain, for mild to on diarrhea, moderate concentrati nausea, acute on. vomiting, bacterial melena sinusitis GU: Urethritis candidiasis, and nephritis, cervicitis vaginitis Pelvic SKIN: inflammat photosensiti ory vity, rash disease Chlamydia l infections 22 | P a g e
  23. 23. Case Presentation: Intestinal Obstruction Medication Drug Mecha- Side Contraindica- Classi- Effects/ Nursing Indication nismof tionsand ficatio Adverse Responsibilities Action Cautions n Effects Angiote Hypertensi Blocks CNS: Monitor for hypotension Caution for thoseTelmisartan nsin II on (used vasoconstri dizziness, after starting drug. who have recepto alone or cting and pain, Place patient supine if patients with r with other aldosteron fatigue, hypotension occurs, biliary obstruction antago antihypert e-secreting headache and give IV normal disorders or renal nist ensives) effects of saline, if needed. and hepatic angiotensin CV: chest insufficiency II by pain, Closely monitor BP. selectively hypertensio blocking n, peripheral Can be taken without the binding edema regard to meals. of angiotensin EENT: Remove drug from II to the pharyngitis, blister-sealed packet angiotensin sinusitis until immediately before I, or AT1, use. receptor in GI: nausea, many abdominal tissues, pain, such as diarrhea, vascular dyspepsia smooth muscle and GU: UTI the adrenal gland RESPI: cough, URTI NURSING CARE PLAN Identified Problem: ineffective coughing Nursing Diagnosis: Ineffective Airway Clearance r/t ineffective cough reflex 2° pain at incision site CUES OBJECTIVES INTERVENTIONS RATIONALE Subjective: Short Term Objective: 1. Auscultate breath 1. To ascertain ―Pungaiginhawa,‖ Within 8 hours of sounds and assess air status and note as verbalized by the providing nursing care, movement. progress. patient. patient will expectorate 2. Monitor vital signs, 2. To assess secretions readily and noting BP and pulse changes and note maintain a patent changes. for possible airway. complications. Objective: 3. Observe for sign and 3. To identify Ineffective symptoms of infection infectious process weak such as dyspnea with and promote coughing Long Term Objective: onset of fever, and timely Adventitious Within 3 days of sputum color changes. intervention. sounds providing nursing care, 4. To open or (stridor patient will demonstrate 4. Position head midline maintain open heard) and maintain absence of with flexion appropriate airway in at-rest Confused congestion as for age/condition. or compromised dyspneic evidenced by clear individual. decreased breath sounds, 5. To decrease breath noiseless respirations, 5. Elevate head of pressure on the sounds on and vital signs within bed/change position diaphragm and lower fields normal range, and will every two hours and enhance drainage CXR: be free from any when necessary. /ventilation to pneumonitis complications. different lung UTZ: segments. Moderate 6. Encourage deep 6. To mobilize ascites breathing and coughing secretions for exercises; splinted better V/S: incision. expectoration. 23 | P a g e
  24. 24. Case Presentation: Intestinal Obstruction T- 36- 7. Increase fluid intake to 7. To help liquefy 36.7°C at least 2L/day within secretions. PR- 70-83 level of cardiac BPM tolerance. RR- 14-20 8. Assist with postural 8. To mobilize CPM drainage and secretions. BP- 110/60- percussion as indicated 140/70 if not contraindicated by condition. 9. Demonstrate pursed-lip 9. To promote or diaphragmatic wellness. breathing technique with splinting on the operative site. Dependent: 10. Administer O2 via 10. To provide nasal canula @ 2-3 supplemental O2 L/min.Identified Problem: Difficulty of breathing with nasal flaring.Nursing Diagnosis: ineffective breathing pattern r/t restricted lung expansion 2° to moderateascites CUES OBJECTIVES INTERVENTIONS RATIONALESubjective: Short Term Objective: independent―Pungaiginhawa,‖ pt After 8 hrs of nursing >auscultated chest, >to identify anyverbalized. intervention, pt. will be noting presence/ unusual findings. able to establish a character of breath normal/effective sounds, presence ofObjective: respiratory pattern, secretion. >it may restrict orV/S: verbalize awareness of >assessed for limit respiratoryBP- 130/80 mmHg causative factors, and concomitant effort.PR- 86 bpm demonstrate behavior pain/discomfort >to limit level ofRR- 22 cpm that improves breathing >maintained calm attitude anxietyT- 37.5 °C pattern. in dealing with client>nasal flaring or SO >to limit level of>use of abdominal, and >assisted client in use of anxietyinternal intercostal Long Term Objective: relaxation technique >to facilitateaccessory muscles to After 3 days of nursing >provided cool, clean, bronchialbreathe with effort intervention, pt. will be and comfortable relaxation, and>restricted able to demonstrate environment facilitate restdiaphragmatic excursion effective breathing >to provide>respiratory rate greater pattern, breathing with >assisted client to learn maximum chestthan normal: 14-20 cpm ease, with no further different breathing expansion.>UTZ: moderate ascites pulmonary exercises esp. DBE>UTZ: Incidental small complications. and Balloon maneuverpleural fluid, right q 2 hrs while awake. >to prevent>dyspnea noted >encouraged position of atelectasis> decreased breath comfort. Repositionedsounds on lower fields client every 2-3 hours. >to prevent further >encouraged ambulation complication as individually indicated. >to limit fatigue > encouraged adequate rest periods between activities dependent >for underlying > administered oxygen at pulmonary lowest concentration condition, indicated respiratory depress, or cyanosis.Identified Problem: Pale skin, Bipedal Edema, Cardiomegaly, Cool and Dry skinNursing Diagnosis: Decreased Cardiac Output r/t Impaired Heart Contractility 2º toCardiomegaly 24 | P a g e
  25. 25. Case Presentation: Intestinal Obstruction CUES OBJECTIVE INTERVENTION RATIONALESubjective STO  Assess mentation  Restlessness is noted―Enlarged man dawiya Within 8 hours of in the early stages;heartana ang doctor,‖ total nursing care, severe anxiety andverbalized by S.O. patient will be able confusion are seen in to participate in  Assess V/S later stages activities that  Sinus tachycardia andObjective improve condition, increased arterial blood  +1 Bipedal Edema such as stress pressure are seen in  Pallor management and the early stages; BP  Dry skin will adhere to both drops as the condition  Weakness, Fatigue pharmacologic and deteriorates. Pulses are  Decreased non-pharmacologic weak with reduced Peripheral Pulses: course of therapy.  Assess fluid cardiac output. Brachial –1+ balance and weight  Compromised Radial –1+ gain regulatory mechanisms Ulnar –1+ LTO may result in fluid and Popliteal – 1+ Within 3 days of sodium retention. Body Dorsalis Pedis –1+ total nursing care, weight is a more Posterior Tibialis – patient will have a sensitive indicator of 1+ reduction of edema fluid or sodium Weak, and thready on both extremities,  Assess lung retention than intake pulse regular cardiac sounds. Determine and output. rhythm, V/S within any occurrence of  Crackles reflect  Confusion, Change in Mental Status normal range, paroxysmal accumulation of fluid  Decreased Urine improvement in nocturnal dyspnea secondary to impaired Output – mentation, reduced (PND) or left ventricular  Anxiety, problems in orthopnea. emptying. They are Restlessness ventilation, and more evident in the  Orthopnea absence of dependent areas of the  V/S: complication lung. Orthopnea is brought by difficulty breathing T –70-83 bpm problems with when supine. PND is P-70-83 bpm cardiac function.  Administer difficulty breathing that R-14-20 cpm medication as occurs at night. BP-110/60-140/70 prescribed, noting  To regain normal organ response and function, aid in watching for side rehabilitation; minimize effects and toxicity. symptoms of adverse Clarify with reactions and to prompt physician interventions when parameters for complications arise. withholding medications  Place patient in semi- to high-  To aid in ventilation by Fowler’s position.  Administer reducing pressure over humidified oxygen the diaphragm  The failing heart may as ordered  Schedule planned not be able to respond activities and to increased oxygen provide adequate demands.  To minimize oxygen rest periods  Provide quiet, demands relaxed  Emotional stress environment. increases cardiac  Elevate both feet demands. with 2 pillows for 2  To relieve edema on hours 3 to 4 times both lower extremities a day by preventing pooling of blood and increase  Assist in changing blood flow back to the position within bed- heart. from lying to sitting  This maintains muscle position every 2 tone, prevents pressure hours several times sores and increase a day; and when intestinal peristalsis 25 | P a g e
  26. 26. Case Presentation: Intestinal Obstruction ambulating-from thus preventing bed to comfort complications from room and back to immobility. bedIdentified Problem: DehydrationNursing Diagnosis: Deficient Fluid Volume (isotonic) r/t active fluid volume loss 2° to ascitesfluid, and fluid drainage CUES OBJECTIVES INTERVENTIONS RATIONALESubjective: Short Term Independent:  Elderly are @―Uhawkaayo, pero dili Objective:  Note client’s age and higher riskpamankopwedekainom‖, Within 8 hours of degree of hydration. because ofas verbalized by the providing appropriate decreasingpatient. nursing intervention, response of patient will compensatory demonstrate behaviors  Monitor V/S, regulate mechanisms.Objective: in monitoring and IVF.  For base line Skin dry and rough to correcting deficit, and  Measure abdominal data. touch manifestation of girth; monitor wound Oral mucosa dry, lips balanced intake and drainage.  To evaluate cracked output.  Provide supplemental ascites. Pale nail beds, oral fluids, regulate IVF @ mucosa prescribed rate.  For fluid balance. Patient is very weak Long Term  Provide frequent oral U/O: 40 cc/7 hours Objective: care. Wound drainage: Within 3 days of  Bathe lips with water  To prevent injury app. 420 cc in 8 hours providing appropriate using cotton buds. from dryness. Non-pitting edema on nursing intervention,  Encourage slow  To prevent both foot noted patient will change in position cracking of lips. Moderate ascites: demonstrate, maintain every 2 hours.  To promote UTZ fluid volume @ a  Provide/control comfort and Weak, thread pulse functional level as humidity of rooms (air safety. Sharp decrease in BP evidenced by conditioning). from 140/90-110/60 individually adequate  Provide meticulous  To prevent further Light contusion noted urine output, stable oral skin care. loss of fluid early in the morning V/S, moist mucous through membrane, good skin evaporation. turgor, and prompt  Provide adequate rest  To prevent further capillary refill, and periods. injury to dry skin resolution of edema.  Administer Lasix as and edematous ordered. foot.  For comfort and promote safety.  To help in relieving edema and ascites, by mobilizing fluid in the inaccessible compartments of body.Identified problem: Pain on mid-abdominal area/ incision siteNursing Diagnosis: Acute Pain r/t abdominal incision 2° to surgical procedure ASSESSMENT PLANNING INTERVENTIONS RATIONALESubjective: STO: 1. Perform a  To assess etiology―Sakitkaayoakong Within 8 hours of comprehensiveopera, ― as verbalized rendering nursing assessment ofby the patient. care, pt. will be able pain. to participate in the  This can influenceP-moving, Valsalva use of relaxation 2. Note location of the amount of post-maneuver skills & diversional surgical procedure operative painQ-gnawing pain activities asR-mid-abdominal area indicated for experiencedS-7/10 individual situation. 3. Perform pain  To rule outT-intermittent assessment each worsening of 26 | P a g e

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