Chapter VII MEDICAL AND NURSING MANAGEMENT

A. Ideal Diagnostic Tests

i.

Abdominal CT scan - combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. These cross-sectional images of the area being studied can then be examined on a computer monitor, printed or transferred to a CD.

ii.

Abdominal X-Ray - An abdominal X-ray is a picture of structures and organs in the belly (abdomen). This includes the stomach, liver, spleen, large and small intestines, and the diaphragm, which is the muscle that separates the chest and belly areas. Often two Xrays will be taken from different positions. An abdominal X-ray may be one of the first tests done to find a cause of belly pain, swelling, nausea, or vomiting.

iii.

Abdominal Ultrasonography - An ideal clinical tool for determining the source of abdominal pain. It can simplify the differential diagnosis of abdominal pain, especially when pain and tenderness are present over the site of disease.

iv.

Barium Enema - X-ray examination of the large intestine (colon and rectum). The test is used to help diagnose diseases and other problems that affect the large intestine. To make the intestine visible on an X-ray picture, the colon is filled with a contrast material containing barium. This is done by pouring the contrast material through a tube inserted into the anus.

v.

Laboratory studies (e.g., electrolyte studies and a complete blood cell count) reveal a picture of dehydration, loss of plasma volume, and possible infection.

B. Ideal Medical Management

Decompression of the bowel through a nasogastric or small bowel tube is successful in most cases. When the bowel is completely obstructed, the possibility of strangulation warrants surgical intervention. Before surgery, intravenous therapy is necessary to replace the depleted water, sodium, chloride, and potassium. The surgical treatment of intestinal obstruction depends largely on the cause of the obstruction. In the most common causes of obstruction, such as hernia and adhesions, the surgical procedure involves repairing the hernia or dividing the adhesion to which the intestine is attached. In
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some instances, the portion of affected bowel may be removed and an anastomosis performed. The complexity of the surgical procedure for intestinal obstruction depends on the duration of the obstruction and the condition of the intestine. A colonoscopy may be performed to untwist and decompress the bowel. A cecostomy, in which a surgical opening is made into the cecum, may be performed for patients who are poor surgical risks and urgently need relief from the obstruction. The procedure provides an outlet for releasing gas and a small amount of drainage. A rectal tube may be used to decompress an area that is lower in the bowel. The usual treatment, however, is surgical resection to remove the obstructing lesion. A temporary or permanent colostomy may be necessary. An ileoanal anastomosis may be performed if it is necessary to remove the entire large colon.

C. Ideal Nursing Management

Nursing management of the nonsurgical patient with a small bowel obstruction includes maintaining the function of the nasogastric tube, assessing and measuring the nasogastric output, assessing for fluid and electrolyte imbalance, monitoring nutritional status, and assessing improvement (eg, return of normal bowel sounds, decreased abdominal
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distention, subjective improvement in abdominal pain and tenderness, passage of flatus or stool). The nurse reports discrepancies in intake and output, worsening of pain or abdominal distention, and increased nasogastric output. If the patients condition does not improve, the nurse prepares him or her for surgery. The exact nature of the surgery depends on the cause of the obstruction. Nursing care of the patient after surgical repair of a small bowel obstruction is similar to that for other abdominal surgeries

D. Actual Diagnostic Tests

Fluid Serum December 8, 2010

Electrolytes exist in the blood as acids, bases, and salts (such as sodium, calcium, potassium, chloride, magnesium, and bicarbonate). They control such things as cardiac function and muscle contraction and are routinely measured by laboratory studies of the serum. Fluid Serum is the cell-free fluid of the bloodstream. It appears in a test tube after the blood clots and is often used in expressions relating to the levels of certain compounds in the blood stream.

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A Blood chemistry test is a procedure to examine the general health of a patient especially to assess the functioning of certain organs.

Test Creatinine Sodium Potassium Amylase

Result 0.8 mg/dl 137 mmol/L 3.4 mmol/L 37 u/L

Reference value 0.7-1.2 137-145 3.5-5.0 30-110

Interpretation Normal Normal Low Normal

Interpretation: The table shows that Potassium is slightly decreased. This decrease in potassium may be due to patients vomiting, deficient potassium intake, or dehydration.

Nursing Responsibilities: define and explain the test state the specific purpose of the test explain the procedure discuss test preparation, procedure, and posttest care some blood chemistry tests will have specific requirements such as dietary restrictions or medication restrictions.

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Complete Blood Count December 8, 2010

The complete blood count (CBC) is one of the most commonly ordered blood tests. The complete blood count is the calculation of the cellular (formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood in less than a minute. This test may be a part of a routine check-up or screening, or as a follow-up test to monitor certain treatments. It can also be done as a part of an evaluation based on a patient's symptoms.

Test WBC Segmenters Lymphocyte Monocyte Eosinophil Hemoglobin Hematocrit Platelet

Results 12.1 0.76 0.15 0.08 0.01 96 0.29 291

Reference Value 5-10 x 10^9/L 0.55-0.65 0.25-0.35 0.03-0.06 0.02-0.04 140-170 9/L 0.40-0.50 volume 150-350x10^9/L

Interpretation High High Low High Low Low Low Normal

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Interpretation: CBC is a combination report of a series of test of the peripheral blood. White blood cells (leukocytes) are bodys defense against infective organisms and foreign substances. The table shows that there is elevated number of WBC which indicates that there is possible infection or immunosuppression happening inside. Segmenters are above the normal range which indicates infection. Low lymphocyte, Eosinophil and Monocyte count indicates that the body's resistance to fight infection has been substantially lost and one may become more susceptible to certain types of infection, namely cancer and tumor. As lymphocyte cells make up fifteen to forty percent of the total white blood cells that circulate in the bloodstream, a low count can cause damage to organs. Hemoglobin is the oxygen carrying protein within the RBCs. The table shows that there is decreased hemoglobin concentration in the blood, which indicates that there is less oxygen being transported throughout the body, because of the less oxygen being transported. With this, the patient is likely experiencing difficulty of breathing that leads patient to have impaired gas exchange. Hematocrit is the percentage of RBC mass to original blood volume. The table shows that hematocrit volume is decreased which
57

indicates that there is over expansion of extra cellular fluid volume, since the patient has a decreased RBC she also have a decreased hematocrit level.

Nursing Responsibilities: Explain that the tests are done to detect any hematologic disorders as well as infection and inflammation. Tell the patient that a blood sample will be taken and that she may feel slight discomfort from the tourniquet and needle puncture. Use gloves when collecting and handling all specimens. Transport the specimen to the laboratory as soon as possible after the collection. Do not allow the blood sample to clot, of the results will be invalid. Place the specimen in a biohazard bag.

Abdomen Supine and upright December 8, 2010

Abdominal x-rays may be performed to diagnose causes of abdominal pain, such as masses, perforations, or obstruction. Abdominal x-rays may be performed prior to other procedures that evaluate the

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gastrointestinal (GI) tract or urinary tract, such as an abdominal CT scan and renal procedures. Result: Lung bases are clear. Free subphrenic air is noted. There are gas containing loops of small and large bowel in all quadrants with no definite pattern. An ovoid soft tissue density is seen in the right lower quadrant area overlying pattern of the right superior iliac crest. This is seen in the supine view only and may be in the soft tissues. Reacted gas is present. There are advance degenerative changes in lumbar spine characterized by osteophytes/ spurs formation. Asymmetrical narrowing of L4-L5 intervertebral joint space, left is seen with linear lucencies within. Mild levoseoliosis is noted. Impression: Essentially (-) study of the abdomen save for degenerative changed of the lumbar spine. Abdomen Supine and upright December 9, 2010

Re-examination no longer shows the ovoid soft tissue density in the right lower quadrant area or seen in the abdominal supine view. Gas containing loops of predominantly small bowel segments are still seen in
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all quadrants with no definite pattern. Rectal gas is present. Properitoneal flank stripes are intact, abdomen are not displaced laterally.

Nursing Management: Remove any clothing, jewelry, or other objects that might interfere with the procedure. Given a gown to wear. Position in a manner that carefully places the part of the abdomen that is to be observed. The patient may be asked to stand erect, to lie flat on a table, or to lie on the side on a table, depending on the x-ray view the physician has requested. Body parts not being imaged may be covered with a lead apron (shield) to avoid exposure to the x-rays. Once positioned, ask the patient to hold still for a few moments while the x-ray exposure is made. Also, ask the patient to hold his/her breath at various times during the procedure. It is extremely important to remain completely still while the exposure is made, as any movement may distort the image and even require another x-ray to be done to obtain a clear image of the body part in question. The x-ray beam is then focused on the area to be photographed.

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Urinalysis December 9, 2010

Routine urinalysis is performed for general health screening to detect renal and metabolic diseases; to diagnose diseases or disorders of the kidneys or urinary tract. In addition, it is performed to help diagnose specific disorders such as endocrine diseases.

Physical properties: Color Light yellow Reaction 6.0 Transparency Clear Specific gravity 1.003

Chemical reaction: Sugar Negative Albumin Negative

Microscopic examination: Pus cell 0.1/ HPF RBC 0.1/ HPF

Interpretation: The physical and chemical properties of the patients urine show normal results. Normally, blood must be absent in the urine. Presence of blood may indicate acute kidney infections, chronic infections, and stone formation in the kidneys.
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Nursing Responsibilities: Explain how to collect a clean catch specimen of at least 15 mL. Explain that there is no food or fluids restriction. Obtain a first voided morning specimen if possible. Medications may be restricted for it may affect laboratory results.

Fecalysis December 9, 2010

It refers to a series of laboratory tests done on fecal samples to analyze the condition of a person's digestive tract in general. Among other things, a fecalysis is performed to check for the presence of any reducing substances such as white blood cells (WBCs), sugars, or bile and signs of poor absorption as well as screen for colon cancer.

Color Black

Chemical and occult blood Positive

Result No intestinal parasite

62

seen

Interpretation: Black stool may be a result of possible internal bleeding, particularly somewhere in the digestive tract.

Nursing Responsibilities:

Discourage patient from taking aspirin, alcohol, vitamin C, ibuprofen, and certain types of food if fecal sample will be checked for any sign of blood.

The patient must urinate first to prevent any urine from mixing with feces.

The patient must wear gloves when it's time to handle stool and transfer it to a safer container. This will prevent any possibilities of being contaminated or infected by bacteria found within the stool.

Solid and liquid fecal samples are both acceptable as long as they do not have urine or other foreign substances like soap, water, and toilet paper mixed in them.

If the patient is suffering from diarrhea, placing a plastic wrap and securing it under the toilet seat could facilitate the collection process.

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Collected samples must be brought to the doctor's office or laboratory as soon as possible. Delays could compromise the quality of the sample.

Volume or amount is also important so the patient must be sure he has collected an adequate amount of stool.

Potassium Test December 10, 2010

This test measures the amount of potassium in the blood. Potassium (K+) helps nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells.

Test Potassium

Result 4.1

Reference value 3.6-5.0 mmol/L

Interpretation Normal

Interpretation: The potassium level of the patient is normal.

Ultrasound in the Whole Abdomen December 10, 2010

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It is an ideal clinical tool for determining the source of abdominal pain. It can simplify the differential diagnosis of abdominal pain, especially when pain and tenderness are present over the site of disease.

Result:

Liver is normal in size and contour. It shows normal homogenous echo pattern. No mass lesion is noted. Intrahepatic bile ducts and CBD are not dilated. Hepatic vessels are unremarkable. Gallbladder is physiologically distended. It shows normal wall thickness. No internal echoes are noted. No pevicholecystic fluid collection is seen. Pancreas and spleen are normal. Right kidney measures 9.6 x 4.2 cm with cortical thickness of 1.2 cm. Left kidney measures 9.5 x 4.0 cm with cortical thickness of 1.5 cm. Both are normal in size showing homogenous corticomedullary parenchymal echogenecity. No echogenic focus or mass lesion is noted. There is no separation of the central echo complexes. Proximal uterus is not dilated. Uterus is atrophic and is compatible with the age of the patient. No abnormal masses are seen in both advexac. Moderately dilated, fecal-filled segment of large bowel are noted in both paracolic gutters, iliac regions and pelvis. No evident mass lesion is appreciated.
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Impression: Considers ileus; Partial obstruction Fecal stasis

Nursing Responsibilities: Before procedure, instruct patient to be on NPO 8-12 hrs since air or gas can reduce quality of image Assess abdominal distention because it may affect quality of image During procedure, keep the patient in a supine position

E. Actual Medical Management

Date Ordered

Doctors order

Rationale
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December 8, 2010 (8:39 PM) c/c: pain T-370C PR-92bpm RR-24cpm BP122/76mmHg O2-95 HG-145 abdominal

Please admit room of choice under the service of Dr. Albano

For admission and to

provide quality care.

NPO

In preparation for diagnostic tests.

CBC, serum Amylase blood type

To diagnose a disease and evaluate the stages of the particular disease.

U/A

General health screening to detect renal and metabolic disease.

Na, K, Creatinine

To examine the general health of a patient especially to assess the functioning of certain organs.

Req. X-ray of abdomen flat

To view the obstruction in the

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intestine.

PLR 1 L x 12o

To replenish fluid loss and electrolyte imbalance.

TPR monitor and record Decrease IVF to 60cc/hr

For baseline data.

Fecalysis and stool for occult

To check for the presence of blood.

Prosec IV now

For antacids and antiulcer function.

December 2010 PM)

8,

Incorporate 30 mEq KCl to present IVF

To provide a direct replacement of potassium in the body.

(10:40

December 2010 Soft abdomen (-) flatus

9,

Soft diet

To prevent further obstruction.

kalium durule TID x 6 doses

To provide a direct replacement of potassium in the body.

D5NM x 16o

To replenish fluid loss and electrolyte

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imbalance.

Nexium p.o OD

To reduce gastric acid secretion.

Motilium tab TID

To increase the movements or contractions of the stomach and bowel. It is also used to treat nausea and vomiting.

December 2010

10,

Senokot Forte 2 tabs now

To stimulate peristalsis and increase intestinal motility.

For Serum test (1:45)

To examine the general health of a patient especially to assess the functioning of certain organs.

Ultrasound of whole abdomen

For determining the source of abdominal pain.

Cleansing enema

To alleviate symptoms of poor

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digestive health.

Colonoscopy tomorrow 12 noon

To examine colon internally.

December 2010 Tympanic abdomen 11,

Dulcolax 2 tabs tonight Senokot Forte 2 tabs BID x 3 doses

It stimulates bowel movements.

To stimulate peristalsis and increase intestinal motility.

Soft diet

To prevent further obstruction.

D5LR 1 L x 16o D5LR 1 L x 16o (10:35) Lactulose 30 cc

For maintenance of nutritional balance.

December 2010 Partial obstruction

12,

To increase water content in colon and enhances peristalsis and for the breakdown of products in colon that lead to acidification of colonic contents, softening of feces, and decreased ammonia absorption from colon to
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Discussed with patient/ relative (+) BM

systemic circulation.

D5NM 1 L x 16o Continue soft diet NPO Refer to Dr. Mercado for co- management

December 2010 (-) BM

13,

D5NM 1 L x 12o

11:25 AM NPO Vomit (3x)

Give Metoclopramide 1 amp IVTT now

To reduce nausea and vomiting.

(-) BM (-) flatus x 2 days (+) vomiting

Assessment: For surgical management - Bowel obstruction

To treat large bowel obstruction.

For emergency exlap 5PM today once cleared

To know the real cause of obstruction.

AP Homez for anesthesia

To assist during surgery.

For Na+ K+- refer to Dr. A Rosete for CP clearance

In preparation for surgery.

No absolute contraindication for

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surgery (ex-lap) (-) HPN, (-) DM

Re: acute abdomenintestinal obstruction Nebulize with combivent 1 ampule before transport to OR To assist respiration.

Transderm 5mg patch to Left Anterior Chest now OD To replace blood loss.

Secure 2 u of FWB/ packed RBC for OR use

11:20 PM

Transderm patch- defer if BP 90 systolic Post-op orders

To RR x 2o then back to room if stable

For respiration. To promote circulation.

O2 at 2-3 LPM Flat on bed until fully awake

For monitoring.

VS q 15, q 10 NPO- NGT tip (opened) attached to BTB

IVF right- KVO rate BT #1 of packed RBC at

To replace blood loss.

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20-25 gtts/min. To follow BT as packed RBC BT #2

IVF left- LR at 30 gtts/min.

TF D5LR 1 L x 8o Sidedrip- NSS 500 cc + voltaren 2 ampules at 20 cc/hr post-op meds

11:20 PM

1. cefuroxime 750 mg q8o IVTT

2. metronidazole left IVF 500 mg q8o at AM

3. Omepron 8 AM OD 40 mg IVTT OD

4. Voltaren 20 cc/hr 5. Nebulize with Combivent now then q8o with volume/ volume

6. nalbuphine 5 mg q6o x 12 doses IVTT (6AM-126-12AM)

Replace NGT loss q4o (volume/ volume replacement)

11:55 PM

To assist the patient

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SPO2 95-96%

O2 via face mask at 2-3 LPM RTC

for enhanced airway. For monitoring.

Attach to pulse oximeter at bedside

11:57 PM

Specimen for pathologic exam To assist her respiration

Continue nebulization every 8

o

December 14, 2010 10:45 AM Patient comfortable Clear breath sounds Surgery

D/c O2 supplement

An exploratory laparotomy is done especially when a person

complains of abdominal pain. The operation allowed the surgeon to examine the internal organs. Disease or damage can be uncovered. In some cases, the problem can be corrected during the surgery. A colostomy is when the colon is cut in half and the end leading to

the stomach is brought through the wall of the abdomen and attached to the skin. The end of the colon that leads to the rectum is closed off
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and becomes dormant. Usually a colostomy is performed for infection, blockage, or in rare instances, severe trauma of the colon. This is not an operation to be taken lightly. It is truly quite serious and demands the close attention of both patient and doctor. A colostomy is often performed so that an infection can be stopped and/or the affected colon tissues can heal.

F. Actual Nursing Management Assess and measure the nasogastric output Assess fluid and electrolyte balance and administer IV as prescribed Monitor nutritional status Assess improvement such as return of normal bowel sounds, decreased abdominal distention, abdominal pain and

tenderness, passage of flatus or stool Prepare patient for surgery which includes preoperative teaching After surgery, provide wound care and post-operative nursing care

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 Place ice chips on the same day of surgery to ease the

patients thirst. By the next day, the patient may be allowed to drink clear liquids.
Slowly add thicker fluids and then soft foods as the bowels

begin to work again.

Patient may eat normally within 2 days after the surgery. The colostomy drains stool (feces) from the colon into the

colostomy bag. Most colostomy stool is softer and more liquid than stool that is passed normally. The texture of stool depends on the location of the segment of intestine used to form the colostomy.

G. Actual Pharmacologic Management (Drug Study)

Drug # 1 Date Ordered: Dec. 09, 2010 Generic Name: esomeprazole magnesium Brand Name: Nexium Classification: Antiulcer drugs Dosage: 40 mg 1 tab OD P.O

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Mechanism of Action: Proton pump inhibitor that reduces gastric acid secretion and decreases gastric acidity. Indications:

Indicated to Gastroesophageal reflux disease (GERD) Healing erosive esophagitis Reduce the risk of gastric ulcers in patients receiving continuous NSAID therapy.

Contraindications: Contraindicated to patients hypersensitive to drug or components of esoprazole or omeprazole.

Patients receiving continuous NSAID therapy who are at increased risk for gastric ulcers include those age 60 and older or those with a history of gastric ulcers.

Adverse Reactions: CNS: headache GI: dry mouth, diarrhea, abdominal pain, nausea, flatulence, vomiting, constipation Nursing Responsibilities: Give drug at least 1 hour before meals. Antacids can be used while taking drug, unless otherwise directed by prescriber.

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Monitor patient for rash or signs and symptoms of hypersensitivity or worsening.

Monitor GI symptoms for improvement or worsening. Instruct patient to take drug exactly as prescribed.

Health Teachings: Tell patient to take drug at least 1 hour before a meal. Advise patient that antacids can be used while taking drug unless otherwise directed by prescriber. Warn patient not to chew or crush drug pellets because this makes the drug ineffective. Tell patient to inform prescriber of worsening signs and symptoms or pain. Rationale: To reduce gastric acid secretion.

Drug # 2 Date Ordered: Dec. 09, 2010 Generic Name: potassium chloride Brand Name: Kalium Durule Classification: Electrolytes and minerals Dosage: 1 tab tid x 6 doses

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Mechanism of Action: Supplemental potassium in the form of high potassium food or potassium chloride may be able to restore normal potassium levels. Indications:

For hypokalemia As prophylaxis during treatment with diuretics Indicated when potassium is depleted by severe vomiting, and prolonged diuresis

Contraindications:

Severe renal impairment Severe hemolytic reactions Acute dehydration Heat cramps Hyperkalemia Cautious use in: cardiac or renal disease; systematic acidosis

Adverse Reactions:

Renal insufficiency Hyperkalemia Nausea and Vomiting Irritability and Muscle Weakness Difficulty in swallowing
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Nursing Responsibilities: Some patients find it difficult to swallow the large sized KCl tablet. Administer while patient is sitting up or standing (never in recumbent position) to prevent drug- induced esophagus. Dont crush sustained-release potassium products. Monitor ECG and electrolyte levels during therapy. Monitor for adverse effect that may reflect by perkalemia.

Health Teachings:

Tell patient to take with or after meals with full glass of water or fruit juice to lessen GI distress.

Teach patient signs and symptoms of hyperkalemia, and tell patient to notify prescriber if they occur.

Warn patient not to use salt substitutes concurrently, except with prescribers permission.

Rationale: To provide a direct replacement of potassium in the body. Drug # 3 Date Ordered: Dec. 09, 2010 Generic Name: domperidone Brand Name: Motilium Classification: Antidiarrheal and Antiemetic Dosage: 10 mg 1 tab tid

80

Mechanism of Action: Gastrointestinal emptying (delayed) adjunct; peristaltic stimulant: The gastroprokinetic properties of domperidone are related to its peripheral dopamine receptor blocking properties. Motilium facilitates gastric emptying and decreases small bowel transit time by increasing esophageal and gastric peristalsis and by lowering esophageal sphincter pressure. Antiemetic: The antiemetic properties of domperidone are related to its dopamine receptor blocking activity at both the chemoreceptor trigger zone and at the gastric level. Indication: For management of dyspepsia, heartburn, epigastric pain, nausea, and vomiting Contraindications: Known hypersensitivity to domperidone or any of the excipients Prolactin-releasing pituitary tumour (prolactinoma). Motilium should not be used when stimulation of the gastric motility could be harmful: Gastro-intestinal perforation. Adverse Reactions: Immune System Disorder: Very rare; Allergic reaction Endocrine disorder: Rare; increased prolactin levels
81

haemorrhage,

mechanical

obstruction

or

Nervous system disorders: Very rare; extrapyramidal side effects Gastrointestinal disorders: Rare; gastro-intestinal disorders,

including very rare transient intestinal cramps Skin and subcutaneous tissue disorders:Very rare; urticaria Reproductive system and breast disorders: Rare; galactorrhoea, gynaecomastia, amenorrhoea Nursing Responsibilities:

If clinical symptoms dont improve within 48 hours, stop therapy and consider other alternatives.

Drug produces antidiarrheal action similar to that of diphenoxylate but without as many adverse CNS effects.

Know the patients sensitivity to domperidone before giving it.

Health Teachings: Advise patient not to exceed recommended dosage. Tell patient with acute diarrhea to stop drug and seek medical attention if no improvement occurs within 48 hours. In chronic diarrhea, tell patient to notify prescriber and to stop drug if no improvement occurs after taking 16 mg daily for at least 10 days. Advise patient with acute colitis to stop drug immediately and notify prescriber about abdominal distention.
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Warn patient to avoid activities that require mental alertness until CNS effects of drug are known.

Rationale: To increase the movements or contractions of the stomach and bowel. It is also used to treat nausea and vomiting.

Drug # 4 Date Ordered: Dec. 10, 2010 Generic Name: senna

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Brand Name: Senokot Forte Classification: Laxatives Dosage: 2 tabs bid x3 doses Mechanism of action: Unknown. Stimulant laxative that increases peristalsis, probably by direct effect on smooth muscle of the intestine. Its thought to either irritate the musculature or stimulate the colonic intramural plexus. Drug also promotes fluid accumulation in colon and small intestine. Indication: Acute constipation, preparation for bowel examination. Contraindications: Contraindicated in patients with ulcerative bowel lesions, fecal impaction, intestinal obstruction, intestinal perforation, or signs and symptoms of acute surgical abdomen, such as nausea, vomiting, and abdominal pain. Adverse reactions: GI: nausea, vomiting, diarrhea, loss of normal bowel function with excessive use, abdominal cramps, especially in severe

constipation, malabsorption of nutrients, yellow or yellow-green cast to feces, darkened pigmentation of rectal mucosa with long-term use, protein losing enteropathy.

GU:

red-pink

discoloration

in

alkaline

urine,

yellow-brown

discoloration in acidic urine. Metabolic: electrolyte imbalance such as hypokalemia. Other: laxative dependence with long-term or excessive use.
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Nursing Responsibilities: Before giving drug for constipation, determine whether patient has adequate fluid intake, exercise and diet. Limit diet to clear liquids after X-prep liquid is taken. Avoid exposing product to excessive heat or light. Drug is for short-term use.

Health Teachings: Teach patient about dietary sources of bulk, including bran and other cereals, fresh fruit, and vegetables. Tell patient to report persistent or severe reactions.

Rationale: To stimulate peristalsis and increase intestinal motility.

Drug # 5 Date Ordered: Dec. 12, 2010 Generic Name: lactulose

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Brand Name: Duphalac Classification: Laxatives Dosage: 30 cc now Mechanism of Action: Produces an osmotic effect in colon; resulting distention promotes peristalsis. Also decreases ammonia, probably as a result of bacterial degradation, which lowers the pH of colon contents. Indication: Constipation Contraindications: Contraindicated in patients on a low galactose diet and in those with diabetes mellitus. Adverse Reactions: GI: abdominal cramps, belching, diarrhea, gaseous distention, flatulence, nausea, vomiting. Nursing Responsibilities: To minimize sweet taste, dilute with water or fruit juice or give with food. Prepare enema by adding 200 g (300 ml) to 700 ml of water or normal saline solution. The diluted solution is given as retention enema for 30 to 60 minutes. Use a rectal balloon. If enema isnt retained for at least 30 minutes, be prepared to repeat dose. Monitor sodium level for hypernatremia, especially when giving to patients with hepatic encephalopathy.

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Monitor mental status and potassium level when giving to patients with hepatic encephalopathy.

Be prepared to replace fluid loss.

Health Teachings:

Show home care patient how to mix and use drug. Inform patient about adverse reactions and tell him to notify prescriber if reactions become bothersome or if diarrhea occurs.

Instruct patient not to take other laxatives during lactulose therapy.

Rationale: To increase water content in colon and enhances peristalsis and for the breakdown of products in colon that lead to acidification of colonic contents, softening of feces, and decreased ammonia absorption from colon to systemic circulation.

Drug # 6 Date Ordered: Dec. 13, 2010 Generic Name: cefuroxime

87

Brand Name: Zegen Classification: Antibiotic Cephalosporin ( 2nd generation) Dosage: 750 mg q8 IVTT Mechanism of Action: Cefuroxime is a bactericidal antibiotic, which exerts antibacterial activity by inhibition of bacterial cell wall synthesis in susceptible species. Cefuroxime has good stability to several bacterial beta-lactamase enzymes and, consequently, is active against many penicillin-resistant and amoxicillin-resistant strains of susceptible species. Indications: Lower respiratory tract infections caused by S. pneumoniae, S. aureus, E. coli, Klebsiella, H. influenzae, S. pyogenes Dermatologic infections caused by S. aureus, S. pyogenes, E. coli, Klebsiella, Enterobacter UTIs caused by E. coli, Klebsiella Uncomplicated gonorrhoea Septicemia caused by S. pneumoniae, S. aureus, E. coli, Klebsiella, H. influenzae Meningitis caused by S. pneumoniae, H. influenzae, S. aureus, N. meningitidis Bone and joint infections caused by S. aureus
Perioperative prophylaxis 88

and

disseminated

gonorrhea

caused

by

N.

Contraindications: Allergy to cephalosporins or penicillins Renal failure Adverse Reactions:

CNS: Headache, dizziness, lethargy, paresthesias GI:

Nausea,

vomiting,

diarrhea,

anorexia,

abdominal

pain,

flatulence, pseudomembranous colitis, liver toxicity

Hematologic:

Bone

marrow

depression:

decreased

WBC,

decreased platelets, decreased Hct

GU: Nephrotoxicity Hypersensitivity: Ranging from rash to fever to anaphylaxis, serum

sickness reaction
Local: Pain, abscess at injection site; phlebitis, inflammation at IV

site
Other: Superinfections, disulfiram-like reaction with alcohol

Nursing Responsibilities: Assess for history of hepatic and renal impairment Observe the 12 rights when administering the drug Have vitamin K available in case hypoprothrombinemia occurs
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Discontinue if hypersensitivity occurs Observe for adverse reactions Do not mix with aminoglycosides Inject slowly over 3-5min

Health Teachings:

Avoid alcohol while taking this drug and 3 days after because severe reactions often occurs

May experience side effects Report diarrhea, difficulty in breathing, unusual tiredness or fatigue, pain at injection site

Rationale: To treat the existing acute infection.

Drug # 7 Date Ordered: Dec. 13, 2010 Generic Name: metronidazole

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Brand Name: Rosex Classification: Amebicide; Antibacterial; Antibiotic; Antiprotozoal Dosage: 500mg q8 IVF @ am Mechanism of Action: Metronidazole exerts rapid bactericidal effects against anaerobic bacteria. It inhibits DNA synthesis, causing cell death. Indications: Acute infection with susceptible anaerobic bacteria Acute intestinal amebiasis Amebic liver abscess Trichomonias ( acute and partners of patients with acute infection) Bacterial vaginosis Preoperative, intraoperative, postoperative prophylaxis for patients undergoing colorectal surgery Prophylaxis for patients undergoing abdominal surgery Contraindications: Hypersensitivity to metronidazole Used cautiously with CNS, hepatic diseases, candidiasis, blood dyscrasias Adverse Reactions:

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 CNS:

Headache,

dizziness,

ataxia,

vertigo,

incoordination,

insomnia, seizures, peripheral neuropathy, fatigue

GI : unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea,

GI upset, cramps
GU:dysuria, incontinence, darkening of the urine Local: thrombophlebitis Other: Superinfections , disulfiram-like reaction with alcohol

Nursing Responsibilities: Assess for history of CNS or hepatic disease, candidiasis, blood dyscrasias Reduce dosage with hepatic disease Observe the 12 rights when administering the drug Discontinue if hypersensitivity occurs Observe for adverse reactions Do not refrigerate neutralized solution Do not administer solution that has not been neutralized Infuse over 1hr Discontinue other solutions while running metronidazole Protect medication from sunlight Health Teachings: Take full course of drug therapy
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Avoid alcohol while taking this drug and 3 days after because severe reactions often occurs

May experience side effects Expect dark colored urine Report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills

Rationale: To treat the existing acute infection.

Drug # 8 Date Ordered: Dec. 13, 2010 Generic Name: diclofenac sodium Brand Name: Voltaren

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Classification: Analgesic (non-opioid); Anti-inflammatory (NSAID); Antipyretic Dosage: 20cc/hr IV Mechanism of Action: Inhibits prostaglandin synthetase to cause antipyretic and anti-inflammatory effects; the exact mechanism of action is not known. Indications: Acute or long-term treatment of mild to moderate pain Rheumatoid arthritis Osteoarthritis Ankylating spondylitis Contraindications: Contraindicated in the presence of significant renal impairment, and allergies to NSAIDs Use caution in the presence of impaired hearing, allergies, hepatic, cardiovascular, and GI conditions and in elderly patients

Adverse Reactions:

CNS: Headache, dizziness, somnolence, insomnia, fatigue, tiredness, dizziness, tinnitus, ophthamologic effects
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GI: Nausea, dyspepsia, GI pain, vomiting, constipation, flatulence, diarrhea, GI bleed

Hematologic: Bleeding, platelet inhibition with higher doses GU: Dysuria, renal impairment Dermatologic: Rash, pruritus, sweating, dry mucous membranes, stomatitis

Other: Peripheral edema, anaphylactoid reactions to fatal anaphylactic shock Nursing Responsibilities: Assess for history of hepatic and renal impairment, CV and GI conditions, impaired hearing Observe the 12 rights when administering the drug Administer drug with food Institute emergency procedures if overdose occurs Observe for adverse reactions Monitor with use of anticoagulants ( increased risk of bleeding)

Health Teachings: Take drug with food

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 Take only the prescribed dosage May experience side effects

Report sore throat, fever, rash, itching, weight gain, swelling in

ankles or fingers, changes in vision, black, tarry stools Rationale: This drug is given to alleviate the pain perceived and experienced.

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Drug # 9 Date Ordered: Dec. 13, 2010 Generic Name: omeprazole Brand Name: Omepron Classification: Antisecretory drug; Proton pump inhibitor Dosage: 40mg IVTT OD Mechanism of Action: Gastric acid pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the spinal step of acid production Indications: Short-term treatment of active duodenal ulcer Treatment of heartburn or symptoms of GERD Short-term treatment of active benign gastric ulcer GERD Eradication of H. Pylori Reduction of risk of upper GI bleeding in critically ill patients Contraindications: Hypersensitivity to omeprazole or its components

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Adverse Reactions:

CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesia, dream abnormalities

GI: Nausea, vomiting, constipation, diarrhea, abdominal pain, dry mouth, tongue atrophy

Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin

Respiratory : cough, epistaxis Other: back pain, fever Nursing Responsibilities: Assess for hypersensitivity to omeprazole or its components Observe the 12 rights when administering the drug
Administer with antacids if needed administer before meals

Observe for adverse reactions Health Teachings:

Take drug before meals and take only the prescribed dosage May

experience side effects and report severe headache,

worsening of symptoms, fever, chills Rationale: This is given to suppress the gastric secretion and thus, reduce the pain perceived.
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Drug # 10 Date Ordered: Dec. 13, 2010 Generic name: nalbuphine Brand name: Nubain Classification: Opioid agonist-antagonist analgesic Dosage: 5mg q6 x 12 doses IVTT Mechanism of Action: Nalbuphine acts as an agonist at specific opioid receptors in the CNS to produce analgesia and sedation. It inhibits the ascending pain pathways, altering the perception of and response to pain by binding to opiate receptors in the CNS but also acts to cause hallucinations and is an antagonist at mu receptors.

Indications: Relief to moderate to severe pain Preoperative analgesia, as a supplement to surgical anesthesia Prevention and treatment of intrathecal morphine-induced pruritus after CS Contraindications: Hypersensitivity to nalbuphine, sulfites

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 Use cautiously with emotionally unstable patients or those with history of opioid abuse, bronchial asthma, COPD, respiratory depression, anoxia, increased ICP,acute MI Adverse Reactions:

CNS: sedation, clamminess, sweating, headache, nervousness, restlessness, depression, crying, confusion, faintness, unusual dreams, hallucinations, dizziness, vertigo, floating feeling, feeling of heaviness, numbness, tingling, flushing, warmth, blurred vision

GI: Nausea, vomiting, cramps, dyspepsia, bitter taste dry mouth GU: urinary urgency Respiratory : respiratory depression, dyspnea, asthma

Nursing Responsibilities: Assess for hypersensitivity to nalbuphine, sulfites, emotional instability or history of opioid abuse, bronchial asthma, COPD, respiratory depression, anoxia, increased ICP, and MI Observe the 12 rights when administering the drug Taper dosage when discontinuing after prolonged use to avoid withdrawal symptoms Reassure patient about addiction liability Discontinue if hypersensitivity occurs Observe for adverse reactions
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Health Teachings: May experience side effects Avoid performing tasks that require alertness For loss of appetite, lying quietly and eating small frequent meals may help Report severe nausea, vomiting, palpitations, shortness of breath, or difficulty in breathing Rationale: It is given to alleviate the pain experienced by the patient.

H. Prognosis
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Poor (1) Duration of Illness

Fair (2)

Good (3)

Justification She has already a 1 year background of Fair Poor intermittent pain on her abdomen and lately, she 2.5- 1.6 difficulty and inability to defecate. is having 1- 1.5 The physician believes that symptoms develop gradually in time. She was not diagnosed immediately since she doesnt have regular check-ups. It is not clear when was obstruction started and how she acquired the tumor causing obstruction and such manifestations. It is fair since she practices healthy lifestyle by eating fruits and vegetables. She doesnt have any vices like smoking and drinking alcohol. However, the real factors arent clear of what aids in developing obstruction caused by the tumor. When she found out what her condition is, all she desires is for her cure and recovery. She gives her trust to the health care providers and is willing to cooperate with every procedure and follows what the physician is saying. She is also complying with the medications prescribed for her. She is at higher risk because age is a predisposing factor that may lead in having intestinal obstruction. She wants a clean environment especially at their house. With that, she does household chores to maintain neat and organized surroundings. She is well loved and supported by her husband, children, and grandchildren. She has a close relationship among them.

Good

3- 2.7

Onset

Precipitating Factors

Willingness to Compliance of Treatment

Age

Environment

Family Support Scoring:

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The patients score is 2.14 which is a fair prognosis. The patient wasnt diagnosed immediately since she already had a one year background of abdominal pain. She only then decided to have her checkup after having difficulty in defecating. She was admitted and the physician advised her o undergo surgery.

I. Discharge Planning When client is to be discharged from the hospital, nursing care is still continued. With sufficient support at home, most client recover gradually. During home visits, the clients physical status and progress
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towards recovery is assessed. The clients understanding of therapeutic regimen is also assessed, and previous teaching is reinforced.

Method
Instruct the significant others to take the following home medication

as ordered by the physician.

Explain to the significant others the drug names as well as the right

route and dosage.

Inform the significant others about the side effects that may occur

brought by the medication.

Encourage the significant others to comply and follow religiously the

right timing in taking the medication. Confer with the patients family the need take precautions regarding medication therapy, activity, and dietary restriction. Discuss with the patients family ways to cope with stressful situations in positive manner. Instruct patients family to report for immediate occurrence of signs and symptoms to a health care professional. Reinforce and supplement patients family knowledge about diagnosis, prognosis, and expected level of function. Provide patients family with specific directions about when to call the physician and what complications require prompt attention.
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 Peer support and psychological counseling may be helpful for some families.

Exercise/ Environment Once at home, patient may resume much of the normal activity short of aggressive physical exercise. Walk short distances everyday and gradually increase activity.
No lifting of a weight greater than 20 lbs (9kg) for 6 weeks. Exercise

should be started cautiously. Encouraged to practice deep breathing exercise and range of motion exercises up to the level of capability. Explain the need for rest periods both before and after certain activities. Teach client the importance of stress management through relaxation technique, and regular appropriate exercise. Help improve patients self-concept by providing positive feedback, emphasizing strengths and encouraging social interaction and pursuit of interests.

Treatment
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 Explain to the significant others the need to continue drug therapy Provide patients family with a list of medications, with information on action, purpose and possible side effects.
Advise significant others to always comply with the medications. Call

the physician if there is a problem taking them. If the result of biopsy showed chemotherapy must be followed up. malignancy of the tumor,

Hygiene Keep proper hygiene. Teach clients family the importance of hygiene like daily oral care, bathing and changing clothes. Proper Wound care must be observed.

Outpatient
Advise to visit or have her follow up check-up with her attending

physician. Advise to call and notify the attending physician for any unusualities that may occur

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 Routinely, follow up check up with patients within two weeks. If there are staples that require removal, postoperative problems, or wound issues, a follow-up appointment will be scheduled sooner. Diet Emphasize to the clients family the importance of proper nutrition, its need for early recovery. This can aid in restoring body functioning.
Provide dietary instructions to help patients family identify and

eliminate foods that is needed by the patient. Soft or low residue diet upon discharge; this should be continued at home for approximately 2 weeks (this includes breads, cereals, chicken, fish, and soup). Avoid large quantities of raw fruits and vegetables. After 2 weeks, gradually reintroduce regular diet. Encourage to drink plenty of fluids. Take nutrition supplements

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