ANGELES UNIVERSITY FOUNDATION McArthur Hi-Way, Angeles City College of Nursing

CASE STUDY on

INTESTINAL OBSTRUCTION SECONDARY TO COLON CANCER

Surgery Ward, Jose B. Lingad Memorial General Hospital

In Partial Fulfillment of the Requirements for Nursing Care Management 104 Related Learning Experiences

Presented By: Basilio, Mary A. Gonzales, Irene Lacanlale, Justin Nichole Legaspi, Marilei Villanueva, Elaine BSN III 2, Group 5

Presented To: Sammy B. David, RN, MN

Presented On: December 6, 2012

I.

Introduction

An intestinal obstruction is a partial or complete blockage of the small or large intestine. Surgery is sometimes necessary to relieve the obstruction. The large intestine is composed of the colon, where stool is formed; and the rectum, which empties to the outside of the body through the anal canal. A blockage that occurs in the colon is a colonic obstruction. Intestinal obstruction is significant mechanical impairment or complete arrest of the passage of contents through the intestine. Symptoms include cramping pain, vomiting, constipation, and lack of flatus. Diagnosis is clinical, confirmed by abdominal x-rays. Treatment is fluid resuscitation, nasogastric suction, and, in most cases of complete obstruction, surgery. Blockage of the intestine may be caused by a tumor growth in the intestines or outside the intestines but causes pressure to the intestines. Symptoms can include crampy abdominal pain, lack of ability to eliminate normal feces, and eventually shock. On examining the abdomen, the doctor may feel a mass. Abdominal X-rays may suggest intestinal obstruction, but a barium enema may be needed to show the actual cause. Treatment depends on the cause of the obstruction. One of the numerous conditions that may lead to an intestinal obstruction is brought about by cancerous tumors. Surgical intervention is necessary in approximately 25% of patients with a partial obstruction, and 50%65% of patients with a complete obstruction. An obstruction of the large intestine is less common than blockages of the small intestine. Blockages of the large bowel are usually caused by colon cancer. As in the case of small bowel obstruction, most patients with a blockage of the large intestine can be treated with IV fluids and bowel decompression. Approximately 300,000 intestinal obstruction repairs are performed in the United States each year. Among patients who are admitted to the hospital for severe abdominal pain, 20% have an intestinal obstruction. While bowel obstruction can affect individuals of any age, different conditions occur at higher rates in certain age groups. Elderly patients, on the other hand, have a higher rate of colon cancer. To diagnose an intestinal obstruction, the physician first gives a physical examination to determine the severity of the patient's condition. The abdomen is examined for evidence of scars, hernias, distension, or pain. The patient's medical history is also taken, as certain factors increase a person's risk of developing a bowel obstruction (including previous surgery, older age, and a history of constipation). A series of x rays may be taken of the abdomen, as a definitive diagnosis of obstruction can be made by x ray in 5060% of patients. Computed tomography (CT; an imaging technique that uses x rays to produce two-dimensional cross-sections on a viewing screen) or ultrasonography (an imaging technique that uses high-frequency sounds waves to visualize structures inside the body) may also be used to diagnosis intestinal obstruction.

Unless a patient presents with symptoms that indicate immediate surgery may be necessary (high fever, severe pain, a rapid heart beat, etc.), a course of IV fluids, NG decompression, and antibiotic therapy is usually prescribed in an effort to avoid surgery. Complications associated with intestinal obstruction repair include excessive bleeding; infection; formation of abscesses (pockets of pus); leakage of stool from an anastomosis; adhesion formation; paralytic ileus (temporary paralysis of the intestines); and reoccurrence of the obstruction. Most patients who undergo surgical repair of an intestinal obstruction have an uneventful recovery and do not experience a recurrence of the obstruction. Large bowel obstruction carries a mortality rate of 2% for volvulus to 40% if part of the bowel is gangrenous. Billroth Surgery is a partial resection of the stomach with anastomosis to the duodenum (Billroth I) or to the jejunum (Billroth II). It is a standard treatment for ulcer disease, stomach cancer, injury and other diseases of the stomach. This was first described by Theodor Billroth, the pioneer in modern surgery. Billroth I is also called gastroduodenostomy. It involves the partial gastrectomy or removal of the antrum and pylorus of stomach) with anastomosis of the gastric stump to the duodenum. Billroth I, more formally Billroth's operation I, is an operation in which the pylorus is removed and the distal stomach is anastomosed directly to the duodenum. Billroth II is also called gastrojejunostomy. It involves the partial gastrectomy or removal of the antrum and pylorus of stomach) with anastomosis of the gastric stump to the jejunum. Billroth II, more formally Billroth's operation II, is an operation in which the greater curvature of the stomach is connected to the first part of the jejunum in a sideto-side manner. This often follows resection of the lower part of the stomach (antrum). The antrectomy (resection of the stomach antrum) is not part of the originally described procedure. The surgical procedure is called gastrojejunostomy. In the majority of gastric surgical units across Japan, Billroth 1 is the preferred method of anastomosis following subtotal distal gastrectomy for gastric cancer. However, across Europe and North America, reconstruction using a Roux-en-Y anastomosis is more common. There is a lack of comparative studies of the two methods focusing on long-term outcome. This study evaluated patient outcome, in terms of adverse gastrointestinal complaints and quality of life, at 5 years following surgery. A total of 652 patients had a subtotal distal gastrectomy for early gastric cancer between January 1993 and December 1999. We studied 229 patients with reconstruction by the Billroth 1 procedure and 214 patients with the Roux-en-Y procedure. All patients had an abdominal ultrasound and endoscopy as part of their follow-up. Quality of life was assessed by questionnaire. We had an 87% response rate from the questionnaire assessment. The results demonstrated that patients were less likely to experience symptoms of either early or late dumping after Roux-en-Y anastomosis than after Billroth 1. In addition, there were significantly fewer patients with gastritis on endoscopy in the Roux-en-Y group. There was no significant

difference in the average relative body weight between the groups. However, patients were more likely to develop gallstones after a Roux-en-Y than after a Billroth 1 reconstruction. The results from this study show that, at 5 years, both symptomatically and functionally, Roux-en-Y reconstruction was superior to the Billroth I method after subtotal distal gastrectomy for gastric cancer. However, the overall outcome in both groups was good, with patient satisfaction scores of around 75% in each group. A current study was made about trends in imaging utilization and their influence in its rising hospital bill for patients diagnosed with intestinal obstruction. The purpose of the study was to evaluate trends in the utilization of different imaging modalities and review how imaging utilization practices affect hospital charges for patients with intestinal obstruction. CT utilization for intestinal obstruction increased from 1999 to 2004 without modality substitution. While hospital and imaging charges have significantly increased, the fraction represented by imaging has remained constant, suggesting that imaging is an unlikely cause for the increase in hospital charges.

IV. Patient and His Illness Pathophysiology a. Schematic Diagram

a. Definition In a bowel obstruction (intestinal obstruction), a blockage prevents the contents of the intestines from passing normally through the digestive tract. The problem causing the blockage can be inside or outside the intestine. Inside the intestine, a tumor or swelling can fill and block the inside passageway of the intestine. Outside the intestine, it is possible for an adjacent organ or area of tissue to pinch, compress or twist a segment of bowel. A bowel obstruction can occur in the small bowel (small intestine) or large bowel (large intestine or colon). Also, a bowel obstruction can be total or partial, depending on whether any intestinal contents can pass through the obstructed area. Cancerous tumors or colon cancer can cause small-bowel obstruction either by pressing on the outside of the bowel and pinching it closed, or by growing within the wall of the intestine and slowly blocking its inner passageway. Cancers account for a small percentage of all small-bowel obstructions. The blockage prevents food, fluids, and gas from moving through the intestines in the normal way. The blockage may cause severe pain that comes and goes. b. Risk factors for colon cancer Non-modifiable Factors

1. Age: Colon cancer is more common in people over the age of 50 and the chance of developing colon cancer increases as age increases. This doesn't mean that colon cancer does not occur at younger age. More than 90% of people who develop colon cancer are older than 50 years. 2. Family history of colon cancer: Close relatives (parents, siblings, children) of colon cancer patients are at higher risk of developing this disease. This increased risk is higher if the relative had the cancer at a young age. If several family members have had colon cancer, the chances increase even more. 3. Race and ethnic background: Risk of developing colon cancer is higer in Jews of Eastern European descent (Ashkenazi Jews). Recent findings suggest a genetic abnormality in this group of people that is casing an increased risk of developing colon cancer. 4. Genetic or Family Predisposition: As mentioned above people whose close relatives have had colon cancer have a higher risk of developing colon

cancer. There are many inherited disorders, which may increase a persons risk of developing colon cancer. There are mainly two genetic disorders associated with increased risk of colon cancer 1. Familial Adenomatosis Polyposis (FAP) 2. Hereditary Non-Polyposis Colon Cancer (HNPCC) Modifiable Factors: 1. Diet: The development of colon cancer appears to be associated with diets that contain high amount of fat and calories and subsequently is low in fiber. High intake of meat may be associated with colon cancer. The exact role of dietary factors in causation of colon cancer is not clear at this time. Ongoing research is expected to increase our understanding of this critical issue. 2. Large intestinal polyps: Polyps are non-cancerous growths, which may develop on the inner wall of the colon and rectum. This may occur in many people especially after age 50. Polyps may be of different types, and some of these may be associated with increased risk of development of colon cancer. In a rare, inherited condition called familial adenomatosis polyposis (FAP), hundreds or even thousands of polyps may develop in the large intestine , causing almost 100 percent risk of developing colon cancer in these individuals if left untreated. 3. Medical conditions: Ulcerative colitis is a medical condition in which the inner lining of the colon becomes ulcerated in multiple places. If someone develops ulcerative colitis the chance of developing colon cancer is increased. Having this condition increases a person's chance of developing colon cancer. Colon cancer risk may also be slightly increase in another disease called Crohn's disease. This disease has some similarity to ulcerative colitis but is more often associated with scarring and obstruction of the intestine than ulceration. 4. Personal cancer history: Women with a past history of developing breast cancer, ovarian cancer and uterine cancer may have increased risk of developing colon cancer. The risk of developing second colon cancer 5. Lack of exercise: People who leads sedentary life, with not much of physical activity may have a higher risk of developing colon cancer. 6. Obesity: Overweight by itself may be risk factor for colon cancer, the chance of dying from colon cancer is higher in obese individuals. 7. Diabetes: Diabetes may increase the chance of developing colon cancer by as much as 40%. 8. Smoking: Smoking may increase the risk of developing colon cancer by as much as 40%. Smokers may swallow some of the cancer-causing chemicals and this may be an explanation for the increased risk of colon

cancer in smokers. Some of these substances are also absorbed into the bloodstream thus causing increased risk of many cancers. 9. Alcohol consumption: Heavy alcohol consumption may be associated with increased risk of colon cancer. Depletion of body vitamins including folic acid may play in the development of colon cancer but the direct effect of alcohol on the colon may also be responsible for the increased risk. 10. Familial Adenomatous Polyposis: Familial Adenomatous Polyposis. This is a rare type of inherited disorder that may affect 1 in 8000 people. In this genetic disorder, hundreds or even thousands of polyps may develop in the large intestine, causing almost 100 percent risk of developing colon cancer in these individuals if left untreated The polyps are not present at birth but develop over time. 11. Gardner's Syndrome: This is a subtype of FAP, in which a type of benign tumor called adenoma may affect the entire large and small bowel. These patients may have other associated abnormalities as well which include, desmoid tumors, lipomas and sebaceous cysts. 12. Hereditary Non-polyposis Colon Cancer (HNPCC) Syndromes: This is another form of genetic disorder with increase risk of developing colon cancer. In this genetic condition there are no increased incidence of polyp development. Patients are included in this diagnosis if there is a history of developing colon cancer at an early age in the family. The diagnosis can only be confirmed by genetic testing. The following are the clinical criteria for diagnosing HNPCC. These are called the Amsterdam criteria

a. At least one family member who has developed colon cancer by age 50. b. Colon cancer involving at least two successive generations. c. Proven colon cancer in three or more relatives, one of whom is a first degree relative of the other two. Symptoms of large-bowel obstruction can include:

A bloated abdomen Abdominal pain, which can be either vague and mild, or sharp and severe, depending on the cause of the obstruction Constipation at the time of obstruction, and possibly intermittent bouts of constipation for several months beforehand If a colon tumor is the cause of the problem, a history of rectal bleeding (such as streaks of blood on the stool)

Diarrhea resulting from liquid stool leaking around a partial obstruction Dehydration caused by severe diarrhea that leads to loss of fluids and electrolytes

MEDICAL MANAGEMENT: Date Ordered Medical Management/ Treatment Date Performed Date Changed General Description Indication(s) Or Purpose(s) Clients Response to the Treatment

D5 LRS 1L x 30 gtts/min

Date ordered: December 16, 2011

Date Performed: December 16, 2011

Date Changed:

Lactated Ringers and 5% Dextrose Injection, has value as a source of water, electrolytes, and calories. It is capable of inducing diuresis depending on the clinical condition of the patient. Lactated Ringers and 5% Dextrose Injection.

Volume expanders with osmolarity almost the same as serum, thus they stay inside the intravascular compartment.

There were no side effects noted upon administration (pain, swelling and tenderness, at the insertion site) patient did not manifest signs and symptoms of fluid overload. Patients hydration was good.

Nursing Responsibilities:

Before o Explain the procedure, importance and its benefits to the patient. o Secure all materials for IV insertion. o Clean the site for insertion.

During o Regulate the flow rate as ordered. o Assess patient carefully for signs of hypervolemia such as bounding pulse and shortness of breath. o Always check if the infusion site is intact and in place. o Monitor I & O ratios. o Monitor client for fluid overload. o Check for signs of phlebitis and infiltration and intervene accordingly. o Be sure that IV line is free from any links and bubbles.

After: o Monitor hydration status of patient. o Refer as needed.

Generic and Brand name

General Description Indication (s) /Purpose (s)

Nursing Responsibilities

Clients Response to the Treatment

GN: Metronidazole

BN: Flagyl

Disturbs DNA synthesis in susceptible bacterial organisms. It is converted to reduction products that interact with DNA to cause destruction of helical DNA structure and strand leading to a protein synthesis inhibition and cell death in susceptible organisms.

It is prescribed in the treatment of a variety of infections such as bacterial infections.

>Compute the ordered dosage of the drug twice.

The patient responded well with no signs of infection.

Initially, 15 mg/kg I.V., followed by 7.5 mg/kg I.V. q 6 hours, not to exceed 4 g/day for 7 to 10 days

> Monitor I.V. site. Avoid prolonged use of indwelling catheter.

> Evaluate hematologic studies, especially in patients with history of blood dyscrasias.

>Advise patient to

report fever, sore throat, bleeding, or bruising.

>Inform patient that prolonged use may result in fungal or bacterial superinfection.

> document and sign for the time of administration.

Generic and Brand name

General Description

Indication (s) /Purpose (s)

Nursing Responsibilities

Clients Response to the Treatment The patients pain scale decreased from 6 to 3.

GN: Celecoxib

BN: Celebrex

Exhibits antiinflammatory, analgesic, and antipyretic action due to inhibition of COX-2 enzyme

It is prescribed for the treatment of acute pain.

200 mg b.i.d

. >Advise patient to immediately report bloody stools, vomiting of blood, or signs or symptoms of liver damage (nausea, fatigue, lethargy, pruritus, yellowing of eyes or skin, tenderness in upper right abdomen, or flulike symptoms).

>Instruct patient to take drug with food or milk.

>Tell patient to avoid aspirin and other NSAIDs (such as

ibuprofen and naproxen) during therapy.

> document and sign for the time of administration.

Generic and Brand name

General Description

Indication (s) /Purpose (s)

Nursing Responsibilities Clients Response to the Treatment > Monitor I.V. site. Avoid prolonged use of indwelling catheter. The patients pain scale decreased from 6 to 3.

GN: Morphine sulfate BN: Roxanol

Interacts with opioid receptor sites, primarily in limbic system, thalamus, and spinal cord. This interaction alters neurotransmitter release, altering perception of and tolerance for pain

Indicated for severe to moderate pain

> For best response, give at pain onset.

2 to 10 mg/70 kg I.V. p.r.n. given slowly over 4 to 5 minutes.

>Tell patient and caregiver that drug may cause respiratory depression. Instruct them to immediately report respiratory rate of 10 breaths/minute or less.

> Inform patient that drug may cause constipation or urinary retention. Encourage high-fiber diet

and high fluid intake. >Stress importance of taking drug only as prescribed. Point out that drug may cause psychological or physical dependence.

>Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, vision, and alertness. >Teach patient and caregiver about appropriate safety measures to prevent injury.

> Caution patient to avoid alcohol and other CNS depressants during and for 24 hours after

therapy.

> Advise patient to avoid herbs, which may worsen adverse CNS effects.

> As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.

> document and sign for the time of administration.

Drug Name

General description

Indication / Purpose

Nursing Responsibilities

Clients Response to the Treatment The patient responded well with no signs of infection.

GN: Promethazine Hcl

BN: Phenergan

25 to 50 mg I.V. at bedtime

Blocks effects but not release of histamine and exerts strong alpha-adrenergic effect. Also inhibits chemoreceptor trigger zone in medulla and alters dopamine effects by indirectly reducing reticular stimulation in CNS

Used as an adjunct to postoperative analgesia and provide sedation.

>Monitor I.V. site. Avoid prolonged use of indwelling catheter.

>Monitor neurologic status. Stay alert for signs and symptoms of neuroleptic malignant syndrome (high fever, sweating, unstable blood pressure, stupor, muscle rigidity, and autonomic dysfunction).

> In long-term therapy, assess for other adverse CNS effects, including extrapyramidal reactions. >Monitor CBC and liver function tests.

>Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, vision, alertness, and motor skills.

Drug Name

Date Ordered Date Performed Date Changed General Description

Indication(s) Or Purpose(s) Clients Response to the Treatment

GN: Ampicillin sodium and Sulbactam sodium

BN: Unasyn

1.5 to 3 g I.V. q 6 hours

Destroys bacteria by inhibiting bacterial cellwall synthesis during microbial multiplication. Addition of sulbactam enhances drug's resistance to betalactamase, an enzyme that can inactivate ampicillin

To treat intra-abdominal, and skin-structure infections caused by susceptible betalactamase-producing strains.

Instruct patient to immediately report signs and symptoms of hypersensitivity reaction, such as rash, fever, or chills.

The patient responded well with no signs of infection.

>Tell patient to report signs and symptoms of infection or other problems at injection site.

>Inform patient that drug lowers resistance to certain infections. Instruct him to report new signs or symptoms of infection, especially in mouth or

rectum.

>Tell patient to promptly report unusual bleeding or bruising. >Instruct patient to avoid activities that can cause injury. Advise him to use soft toothbrush and electric razor to avoid gum and skin injury.

>Inform patient that he may need to undergo regular blood testing during therapy.

>As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs

and tests mentioned above.

B. Surgical Management a. Billroth Surgery is a partial resection of the stomach with anastomosis to the duodenum (Billroth I) or to the jejunum (Billroth II). It is a standard treatment for ulcer disease, stomach cancer, injury and other diseases of the stomach. This was first described by Theodor Billroth, the pioneer in modern surgery. Billroth I & Billroth II Billroth I is also called gastroduodenostomy. It involves the partial gastrectomy or removal of the antrum and pylorus of stomach) with anastomosis of the gastric stump to the duodenum. Billroth II is also called gastrojejunostomy. It involves the partial gastrectomy or removal of the antrum and pylorus of stomach) with anastomosis of the gastric stump to the jejunum.

Pre-operative Provide calm, efficient, knowledgeable care, and explain what is being done. Note and respond to the clients nonverbal behavior. Listen to the client carefully; respond to cues, and offer support and understanding. Provide pre-operative teachings such as explanation of the surgery. Explain that the client will have either an NG tube or a gastrostomy tube with suction. Intravenous fluids as prescribed to maintain fluid and electrolyte balance Instruct client to take nothing by mouth prior to surgery. Record allergies and medications as well. Thoroughly demonstrate and discuss the importance of deep-breathing exercises or use of an incentive spirometer or both.

During operation Monitor and record vital signs every 15 mins.

Monitor IV fluids. Post Operation Monitor Vital Signs Accurately

Monitor Operative Site and assess for any signs of infection such as fever, redness or swelling around the incision, drainage, and worsening pain. Administer pain Medication as indicated or as ordered. Assist patient in turning, coughing and deep breathing to promote expansion of the lungs. Assess the operative site for excessive drainage, too much fluid n the remaining gastric stump may caused increased pressure and injury. Assess drainage from the NG tube and document. Maintain NG tube patency with saline irrigation, as ordered.

b. Colectomy is a surgical procedure to remove all or part of your colon. Your colon, also called your large intestine, is a long tube-like organ at the end of your digestive system. Colectomy may be necessary to treat or prevent diseases and conditions that affect your colon. There are various types of colectomy operations. Colectomy that involves removing the entire colon is called total colectomy. Colectomy to remove part of the colon may be called subtotal colectomy or partial colectomy. Removing the right or left portion of the colon is called hemicolectomy. Surgery to remove both the colon and rectum is called proctocolectomy Pre-operative Provide calm, efficient, knowledgeable care, and explain what is being done. Note and respond to the clients nonverbal behavior. Listen to the client carefully; respond to cues, and offer support and understanding. Provide pre-operative teachings such as explanation of the surgery. Explain that the client will have either an NG tube or a gastrostomy tube with suction. Intravenous fluids as prescribed to maintain fluid and electrolyte balance Instruct client to take nothing by mouth prior to surgery. Record allergies and medications as well. Thoroughly demonstrate and discuss the importance of deep-breathing exercises or use of an incentive spirometer or both.

During operation Monitor and record vital signs every 15 mins.

Monitor IV fluids. Post Operation Monitor Vital Signs Accurately Monitor Operative Site and assess for any signs of infection such as fever, redness or swelling around the incision, drainage, and worsening pain. Administer pain Medication as indicated or as ordered. Assist patient in turning, coughing and deep breathing to promote expansion of the lungs. For patients who do not have any oral intake for several days, nutrition may be provided intravenously or through a tube in the stomach or bowel as ordered. The function of the bowel is monitored closely to await the passage of gas and stool after surgery. Instruct the patient that he/she can gradually begins to take liquids by mouth and solid food later on, following which they will be discharged home.

ACUTE PAIN Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Interventions Rationale Expected Outcome

S> O>: The patient manifested: Abdominal Pain Appears weak Limited range of motion Restlessness Verbalization of pain with a pain scale of 8/10. Guarding behaviour on the incision site The pt. may manifest: Facial grimaces Irritability

Acute Pain

One of the manifestations of intestinal obstruction secondary to colon cancer is abdominal pain due to surgical procedure of billroth I and ll. During the course of inflammation, the bodys immune response, causing the release of cytokine and prostaglandin causing an increase in vascular permeability and causes pain, which

Short term: 1. Monitor and After 3 hrs of record vital nursing signs. interventions 2. Review factor the pt. will that aggravate report pain is or alleviate relieved from pain a pain scale of 3. Encourage 8/10 to 2/10. pain reduction techniques 4. Provide adequate rest Long Term: 5. Provide After 2 days of diversional nursing activities like interventions socialization the pt will be 6. Administer free from pain analgesics to as evidence maintain by acceptable demonstration level of pain if of relaxation not skills and contraindicate diversional d activities with 7. Instruct client the help of the to perform SO. deep breathing

1. To provide baseline data and note deviations from normal. 2. Helpful in establishing diagnosis and treatment needs 3. To reduce pain and promote relief/comfort 4. To promote healing 5. For clients comfort and relief from pain 6. To decrease pain. 7. Deep breathing exercises may reduce pain sensation/ used in pain

Short term: The pt. shall have reported pain is relived from a pain scale of 8/10 to 2/10

Long Term: The patient shall be free from pain as evidenced by demonstration of relaxation skills and diversional activities with the help of the SO.

Impaired thought process Reduced interaction with people sleep disturbances diaphoresis

felt by the patient in the abdomen.

exercises (DBE) 8. Monitor effectiveness of pain medications

management 8. To promote timely intervention/ revision of plan of care

ASSESSMENT

NURSING DIAGNOSI S

SCIENTIFIC EXPLANATIO N

OBJECTIVE S

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOME

IMPAIRED SKIN INTEGRITY

s>

o> the patient manifested: Surgical incision on the abdomen.

Impaired skin integrity r/t mechanical trauma 2 surgery

The patient may manifest: Risk for infection due to wound Hypertherm ia caused by an inflammator y response due to possible infection of

After mechanical injury, keratinocytes release interleukin-1 (IL-1), which activates them and signal alerts the surrounding tissues. The keratinocyte activation cycle is characterized by changes in expression of keratin proteins, enabling them to proliferate and migrate to repair the damage.

Short term: After 3 hours of NI, the patient will verbalize understandin g of condition and identify interventions appropriate for specific condition.

1. Monitor VS

2. Assessed skin, noticed color, turgor and sensation 3. Emphasize importance of adequate nutrition and fluid intake 4. Instructed to provide proper wound dressings carefully 5. Inspect wound daily or as appropriate for changes

1. To obtain Short term: baseline data The patient shall 2. Establish have comparative verbalized baseline understandin g of condition 3. Improved and identify nutrition and interventions hydration will appropriate improve skin for specific condition condition 4. Wound dressing protect the wound and the Long term: surrounding tissues The patient shall 5. Promotes have timely displayed intervention/re timely wound vision plan of healing of care skin wound AEB

Long term: After 1 week of NI, the patient will display timely wound healing of skin wound AEB

the wound May acquire sepsis due to possible infection of the wound

participating in prevention measures and treatment program.

6. Encourage adequate periods of rest and sleep.

7. Ascertain attitude of individual/S O (s) about condition

6. To limit metabolic demands, maximize energy available for healing and meet comfort needs 7. Identifies areas to be addressed in teaching plan and potential referral needs

participating in prevention measures and treatment program.

8. Encourage early ambulation

8. Promotes circulation and reduce risks associated with immobility

9. Provide

optimum nutrition, including vitamins

9. To provide a positive nitrogen balance to aid in skin healing and to maintain general good health

10. Assist the patient/ SO (s) in understandi ng and following medical regimen and developing program of preventive care and daily maintenance

10. Enhances commitment to plan, optimizing outcomes

ANXIETY ASSESSMENT NURSING DIAGNOSI S Anxiety r/t stress SCIENTIFIC EXPLANATIO N Anxiety is a complex feeling of apprehension, fear and worry often accompanied by pulmonary, cardiac and other physical sensations. It is a common condition that OBJECTIVE NURSING S INTERVENTIONS RATIONALE EXPECTE D OUTCOME Short term: 1. Monitor VS 1. To obtain baseline data 2. This may indicate an interferenc e with ability to deal with problem The patient shall have verbalized awareness of feelings of anxiety

s> o> the patient manifested: Expressed feeling of sadness Not sociable to others Teary eyes during nursepatient

Short term: After 2 hours of NI, the patient will verbalize awareness of feelings of anxiety.

2. Be aware of emotional defense mechanisms used 3. Review patients

interaction Appears worried. tachycardia

Patient may manifest: Risk for suicide Dyspnea restlessness

can be selflimited physiologic response to a stressor. It is a heightened physiologic response and elevated catecholamine levels play an important role in the normal physiologic response of the body to stress and anxiety.

Long term: After 3 days of NI, the patient will appear relaxed and report anxiety is reduced to a manageable level AEB demonstrate healthy ways to deal with and express anxiety.

coping skills used in the past

Long term: 3. To determine those that might be helpful in current circumstan ces The patient shall have appeared relaxed and report anxiety is reduced 4. To provide AEB therapeutic demonstrat care for the e healthy ways to patient deal with and express anxiety.

4. Be available to client for listening and talking

5. Provide patient with accurate information about the situation

6. Administer medications as ordered 7. Provide comfort measures

5. Helps patient identify what is reality

based 8. Encourage adequate rest periods 9. Encourage patient to acknowledg e and to express feelings

6. To provide a pharmacol ogical treatment 7. To relieve/red uce patients tension 8. To prevent fatigue

9. To be relieved from emotional burdens

Progress Notes:

Management D5 LRS 1L x 30 gtts/min

Dosage or Indication Volume expanders with osmolarity almost the same as serum, thus they stay inside the intravascular compartment. It is prescribed in the treatment of a variety of infections such as bacterial infections. Initially, 15 mg/kg I.V., followed by 7.5 mg/kg I.V. q 6 hours, not to exceed 4 g/day for 7 to 10 days It is prescribed for the treatment of acute pain. 200 mg b.i.d Indicated for severe to moderate pain. 2 to 10 mg/70 kg I.V. p.r.n. given slowly over 4 to 5 minutes. Used as an adjunct to postoperative analgesia and provide sedation. 25 to 50 mg I.V. at bedtime To treat intra-abdominal, and skin-structure infections caused by susceptible beta-

December 16, 2011

Metronidazole

Celecoxib

Morphine sulfate

Promethazine Hcl

Ampicillin sodium and Sulbactam sodium

lactamase-producing strains. 1.5 to 3 g I.V. q 6 hours

Discharge planning:

M- Diamorphine - This blocks the transmission of pain signals sent by the nerves to
the brain. Therefore even though the cause of the pain may remain, less pain is actually felt. Hyoscine butylbromide - used to relieve bladder or intestinal spasms Methotrimeprazine- medication has calming, sedating and pain relieving actions. It is used for a variety of reasons which may include treatment of anxiety Corticosteroids- Are anti-inflammatory drug useful in treating any condition which swelling occurs.

E- Bed rest T-Treatment involves placing a tube through the nose into the stomach or intestine to
help relieve abdominal distention and vomiting.

H- Nasogastric tube to suction out the contents of the stomach and the intestines.
Intravenous fluid will be infused to prevent dehydration and to correct electrolyte imbalances that may already occurred. Small frequent feeding Sips of fluids Avoid gas forming foods such as: cabbage Avoid heavy lifting for about 4 weeks or until the physician say so. Oral and nose care Keep semi fowlers position as possible

O- After 2 3 weeks go back to the hospitals OPD ward for the check up.

D- Sufficient fiber to help encourage stool formation and regular elimination. Highfiber foods include whole grain breads and cereals, apples and other fresh fruits, dried fruits such as prunes, pumpkin and squash, fresh raw vegetables, beans and nuts. Conclusion

The researchers were able to accomplish the task given to them. They were able to gain needed information for the completion of the study. Also, they were able to identify the diagnosis of the patient and the respective complications. They were also able to recognized and identified actual potential problem and the prognosis in the course of the disease. They were able to show patients data with the information gathered and interpret the data. The workload is properly distributed with the patient. The work tasks are completed on time. The researchers were able to: Identify and differentiate risks for Intestinal obstruction secondary to Colon Cancer. Be updated with the latest trends and in the treatment of the colon cancer Perform a comprehensive assessment of intestinal obstruction and colon cancer. Enumerate the different signs and symptoms of intestinal obstruction secondary to colon cancer. List down the different diagnostic procedures that would help in the diagnosis of intestinal obstruction secondary to colon cancer including the normal values, indications, and results of the patients laboratory test. Identify and understand different types of medical treatment necessary for the treatment of patients with intestinal obstruction secondary to colon cancer Formulate nursing care plans utilizing the nursing process. Formulate conclusions based on the findings Have critical thinking necessary for providing safe and effective nursing care. Have a comprehensive assessment and implement care based on our knowledge and skills of the condition. Have familiarized with effective inter-personal skills to emphasized health promotion and illness prevention.

Identify measures that could minimize the risk of occurrences of the disease/condition. Identify possible risk factors that may have contributed to the development of intestinal obstruction secondary to colon cancer Increased awareness on the risk factors of intestinal obstruction secondary to colon cancer Develop the familys support system and distinguish their respective roles in improving the patients health status and involved them in promoting the health care of the patient.

Bibliography

Joyce M. Black, J. H. (2008). Medical-Surgical Nursing: Clinical Management for Positive Outcomes. Winsland House I: Elsevier. Karch, A. M. (2009). 2009 Lippincotts Nursing Drug Guide. Ambler City: Lippincott Williams & Wilkins. Marilyn E. Doenges, M. F. (2007). Nurses Pocket Guide, Diagnoses, Prioritized Interventions, and Rationales (2007) Edition 11 . Bangkok: iGroup Press Co, Ltd. . Joyce M. Black, J. H. (2008). Medical-Surgical