INTESTINAL OBSTRUCTION

Presented to the Clinical Instructor of

Notre Dame of Tacurong College
College of Nursing

SHANGRILA JOY V. ANCHETA, RN MN

In Partial Fulfilment of the

Course Requirement in
Intensive Nursing Practice

Submitted by:
ELOSO, QUEZALYN PASCUAL

January 2, 2012

I INTRODUCTION
This is a case of Mr. Ben a 50 years old male patient of Barangay Lamfugon Lake Sebu,
South Cotabato admitted at South Cotabato Provincial Hospital at 6:25 in the evening on
December 4, 2011 with an admitting diagnosis of Intestinal Obstruction and undergone an
operation of Exploratory Laparotomy, Appendectomy under the service of Dr. Enrique Pascasio
and Dr. Jose Ferrante Solano.
Intestinal Obstruction is a blockage of your small intestine or colon that prevents food
and fluid passing through. Appendicitis is an inflammation of the appendix; early sign is pain
around the umbilicus, later pain localized in the right lower quadrant of the abdomen.
Small intestine obstruction accounts for about 5% of acute surgical admission. One large
study found an incidence of 16% and approximately 1 in 146 or 0.13% or 364,563 people in
USA, in the Philippines over 115,590 cases to the total population of 862,416,972. The cases of
fatality rate of appendicitis jumps from less than 1% in non perforated cases to 5% or higher
when perforation occurs. In 1997 more than 260,000 new cases occurred at US, the over all life
time occurrence is approximately 12% in women and 25% in men. In the Philippines there are
45,604 has acute appendicitis. For mortality rate, the top 1 is Brazil for about 450 deaths
followed by US with 371 deaths with the total of 44.8% deaths worldwide.
I choose this case, for me to gain knowledge and develop positive attitude and skills in
handling patient with the same condition.

II OBJECTIVES
General objectives:
After a thorough reading of this case study, the readers and the future researchers will
be able to acquire knowledge, improve the skills and develop positive attitude in dealing to
patient with intestinal obstruction and undergone an operation.
Specific objectives
After 2-6 hours of reading this case, the readers and future researchers will be able to
understand the content of this study that will help them determine the disease process by:
1. Presenting the introduction analytically.
2. Presenting the patients data which includes vital information, family background, history
of past and present illness, the effect and expectation to self and family towards
condition, the genogram which shows familial / hereditary disease and developmental
data where patient is classified according to individual task theory.
3. Present accordingly the physical assessment and review of system in line in the general
condition of the patient systematically.
4. Discuss comprehensively the textbook discussion which includes the complete diagnosis
of the disease, related Anatomy and Physiology of the systems.
5. Trace schematically the pathophysiology.
6. Interpret the diagnostic and laboratory examinations which the patient underwent to help
in diagnosis and treatment of this case.
7. Present the doctors order completely and rationalized.
8. Present the list all the drugs to be administered to the patient completely.
9. Present all the drugs administered with intervention.
10. List all prioritize problem according to actual problem manifest by the patient.
11. Prioritize correctly the possible nursing diagnosis and intervention being applied.
12. Interpret accordingly the prognosis of the disease after medical and nursing intervention.
13. Enumerate all the references used through its bibliography completely.

III PATIENTS DATA

I.

Vital Information

Patients Name: Mr. Ben

Age: 50 years old
Address: Barangay Lamfugon, Lake Sebu South Cotabato
Civil Status: Married
Sex: Male
Religion: Roman Catholic
Race: Asian
Birthplace: Lake Sebu South Cotabato
Birthdate: June 26, 1961
Occupation: Farmer
Educational Attainment: Elementary Level (grade III)
Chief Complaint: Abdominal pain
Admitting Diagnosis: Intestinal Obstruction
Attending Physician: Enrique Pascasio, MD
Anaesthesiologist: Jose Ferrante Solano, MD
Pre-op Diagnosis: Intestinal Obstruction
Post-op Diagnosis: Small Bowel Obstruction 2 Ruptured Appendicitis
Operation Done: Exploratory Laparotomy, Appendectomy
Date & Time of Admission: December 4, 2011 @ 6:25 in the evening
Health Care Finance: Income from farming
: Philhealth
Father: deceased
Mother: deceased

Name of Spouse: Mrs. Anni Han

Deceased due to gun shot wound.

Children:
Susi Han

28 years old

Tobi Han
Maki Han

Married

25 years old

Farmer/
housewife
Farmer

20 years old

Farmer

Married

Sources of Information:
-

II.

Patient
Patients chart
Patients daughter & son

Family Background

Single

high school
graduate
elementary
graduate
high school
level

Mr. Ben is the youngest son of Mr. A and Mrs. B, Mr. Ben didnt know how many are
they as a son and daughter of Mr. A because Mrs. B is a third wife of Mr. A. His father died
due to lung disease, a severe coughing because his father is a chain smoker, and his mother
died due to old age. His Grandpa and Grandma, he didnt remember or even know them
because when his father got married they stay away from their parents.
Mr. Ben verbalized that they have no history of hypertension, diabetes, or any other
complicated disease because it is not recognize by their time, they only say that the illness is
cause of bad spirit. No report of any diseases present in the family.
Mr. Ben is married to Mrs. Anni Han and they are blessed with three children, they only
reaches high school and the second child is on elementary. Mrs. Anni Han died due to gun
shoot wound, she didnt reach the hospital. Now Mr. Ben has second wife, they have no child
but his second wife has five children to her first husband. Three of them have already their
own family, and the remaining two is living with them. Their work is farming, they also have
a garden beside their house and also at the back, and they planted camote, squash, string
beans and eggplant. They are not gaining money monthly on their farm, only when here is a
harvest they have money and they estimated it as 10,000 each harvest. For their daily needs,
they are selling vegetables coming from their backyard. They eat regular meals. They always
serve rice and vegetables; meat is served three to four times a week as well as fish.
The common illness present in the family is common colds, fever, cough, diarrhea. They
are doing self medication like paracetamol for fever, mefinamic and amoxicillin for
toothache and neosep for common colds. They are also using herbal plants such as lagundi,
lampunaya, and oregano. When the family member got sick, they are consulting to an
albularyo, health center, hilot and if it is not treated they are going to the hospital. Health
Center was utilized during the prenatal of her eldest daughter. His children were normal
delivery at their home. Mr. Ben verbalized that maybe he is normal delivery and also at their
home he was born.

III.

History of Past and Present Illness

History of Past Illness

According to Mr. Ben he experienced cough, common colds, fever, diarrhea and other
common illnesses when he is young, he is only doing self medication as the illness come (stated
above). He didnt remember if he completed any immunization.
Mr. Ben loves to smoke, he can consume one pack a day. And he is drinking liquor
almost every afternoon after working at farm together with his friends. Mr. Ben verbalized that
he didnt remember having hypertension or diabetes mellitus.
History of Present illness
According to Mr. Ben two months prior to hospitalization, he experienced abdominal
pain but he didnt mind it because he thought that this is common illness and only pass by. Five
days prior to admission he experienced vomiting, dizziness and abdominal pain, bowel changes
(constipation) and he also experienced loss of appetite. When it got worse they decided to go to
hospital and he diagnosed with Intestinal Obstruction.

IV.

Effects and Expectation to Self and Family

EFFECTS
To Self:
The effect of this illness to Mr. Ben was it refrain him from doing his usual activities and
he become financially burden to his family.
To Family:
According to his daughter they are so much worried to the condition of Mr. Ben even
they can spend money, just to make sure that Mr. Ben will be okay. The illness of Mr. Ben
become the cause that Susi Han have less supervision to her own child because she is the one
taking care of Mr. Ben in the entire hospitalization

EXPECTATION
To Self:
According to Mr. Ben, he is expecting that his illness will be healed and will not come
again. He is also expecting that the medical team will do their job great for his fast recovery.
To Family:
They are expecting that even Mr. Ben got an operation he can do his usual activities and
back to his normal living pattern, as well as his strength. They are also expecting that they
can go home immediately and will not stay for a long period of time in the hospital.

GENOGRAM

_ ______

______

__________________________________________

50yo

LEGEND:
Male
Female
related to blood
___

not related to blood

deceased

LD

lung disease

OA

old age

patient
yo

years old

NOTE:
The genogram is not good to show
familial/hereditary disease because the patient
didnt know their grandparents even the sister
and brothers of his father and mother. And
also he didnt know how many they are as son
and daughter of Mr. A because his father has
three wives. Other info are reflected on family
background.

DEVELOPMENTAL DATA

Name of the Patient: Mr. Ben

Age of the Patient: 50 years old
Stage of the Patient: Generativity vs. stagnation/self-absorption stage (45-65 years)
Theory: Psychosocial developmental theory
Theorist: Erik Erikson
Description of the theory:
-

Erik Erikson described stages of psychosocial development, each stage with both
positive and negative aspects. According to him, the adaptation is based on the
resolution of a conflict between two opposing qualities.
He also stated that the crisis of each stage is resolved when the person achieves a
new level of functioning at the end of the stage and a successful outcome of each
stage results in specific lasting outcomes.

His psychosocial developmental theory involves the: Trust vs. mistrust, which occurs
during infancy; the Autonomy vs. shame and doubt, which occurs on the early childhood
of a person; Initiative vs. guilt, which occurs on the late childhood; the Industry vs.
inferiority, which occurs during school age; the Identity vs. role confusion, for the
adolescence; Intimacy/ solidarity vs. isolation, for young adulthood; the Generativity vs.
stagnation/ self-absorption, in middle adulthood; and the Ego integrity vs. despair, in the
late adulthood.
My patient, Mr. Israel belong to the Generativity vs. stagnation/self-absorption stage,
because she is already in her 33rd year of life, for this stage includes the persons
belonging to the middle adulthood aging from 25-60 years old.

STAGE

JUSTIFICATION

REMARKS
T
A
S
K

-The patient can perform different activities in

a creative way; he is the one who makes
decision for the good of his family together
with his wife.

P
A
R
T
I
A
L
L
Y

GENERATIVITY VS.
STAGNATION/ SELFABSORPTION STAGE
-In this stage the person is now
starting to learn to look beyond
oneself, community and world
needs; successful achievement
of identity is a pre requisite to
parental
attainment
of
Generativity.
- the attainment of Generativity
is also characterized by; the
feeling of concern for others,
beyond family, and moving
away from oneself to become
involved with the world or
community; and by having an
interest in establishing and
guiding the next generation.
- This is also the period of role
transition as an individual.

-He thinks for the betterment for his own

family and showing concern for them, for
himself and for other people by showing
respect to each other but Mr. Ben didnt totally
fulfil his duty to become a good father
because his children didnt finish their
schooling and two of them got married in a
younger age.

A
C
H
I
E
V
E
D

PSYCHOSEXUAL DEVELOPMENT
By: Freuds theory
Sigmund Freuds theory of psychosexual development the personality develops in five
overlapping stages from birth to adulthood. The libido changes its location of emphasis with in
the body from one stage to another. Therefore, a particular body area has especial significance to
a client at a particular stage. The first 3 stages are oral, anal, and phallic which called as
pregenital stages. The culminating stage is the genital stage in which the patient belongs.
Freuds Five Stages of Development; Genital (puberty and after)
TASK

REMARKS

JUSTIFICATION

Genital:
Puberty and After
Energy is directed toward full

TASK

The patient is married and

sexual maturity and function

PARTIALLY

blessed three children. They

and development of skills

ACHIEVED

separated to their parents and

needed to cope with the

live independently, together

environment.

with his wife they are helping

each other to solve problem
arises to their family. He is
also sending their children to
school but they didnt make it
to step on college and his two
children got married with
young age.

HAVIGHURST DEVELOPMENTAL THEORY

Robert Havighurst believed that learning is a basic to life and that people continue to
learn throughout life. He believes that ones a person learns to task it is mastered for life.
Mr. Ben belongs to middle age which ranges the age of 45-84 years old.
Havighursts Age Periods and Developmental Task
TASK

REMARKS

1. Achieving adult civic

TASK ACHIEVED

and social responsibility.

JUSTIFICATION
The patient is participating in local
and national votation and for the
community he is participating in
every meeting held in their barangay.

2. Establishing and

TASK ACHIEVED

The patients family eats regular

maintaining an

meals and together with her husband

economic standard of

they are sending their children to

living.
3. Assisting teenage
children to become

school.
TASK PARTIALLY
ACHIEVED

responsible and happy

His children married with a younger

age but they are maintaining an
economic standard of living by

adults.

making sure that their siblings are

going to school and they eat regular
meals.

4. Relating oneself to ones

spouse as a person
5. Developing adult leisure
time activities

TASK ACHIEVED

They are living with a happy life,

together with his new love one.

TASK ACHIEVED

The patient leisure time is in the

farm, after working he is chatting
with his friend, and drinking liquor

6. Accepting and adjusting

to death of spouse.

with them.
TASK ACHIEVED

The patient accepts the death of his

spouse and found a new love of his

life.
PHYSICAL EXAMINATION
Date: december 9, 2011
Time: 9:00 am
Vital signs:
BP: 100/ 90 mmHg
PR: 80 bpm
RR: 32 cpm
Temp.: 36.6 C

General appearance:
The patient is male, lying on bed with IVF D5NSS 1liter @ 40 drops per minute hooked
@ left dorsal venous arc patent and infusing well, with O2 inhalation @ 3 l/min via nasal
cannula and with NGT @ left nostrils. The patient is wearing loose orange T-shirt and cotton
short, patient appeared sleepy, a frequent yawning noted, untidy looking and slightly restless.
Patients cough with whitish discharge.
Head/ Hair/ Scalp:
Inspection: skull is rounded (normocephalic and symmetric, with frontal, parietal, and,
occipital prominences) with symmetric facial movement, no dandruff as well as lice noted. The
hair is curly black and short, it is eventually distributed.
Palpation: smooth, uniform consistency; absence of nodules or masses noted upon
palpation.

Eyes and Vision:

Inspection: the skin around the orbit of the eye is darken, eyeball appear sunken because
of the decrease in orbital fat. The conjunctiva of the eye is pinkish in color. Pupil reaction to light
and accommodation is normally symmetrically equal.
Ears and Hearing:
Inspection: auricle is in the same color as facial skin color, symmetrical. No lesions or
deformities noted impacted cerumen and no discharges noted. No sensorineural hearing loss
noted. Patient able to hear a whisper word on a distance of 18inchs.
Palpation: mobile, firm, and not tender; pinna recoils after is folded.
Nose and Sinuses:
Inspection: external nose are symmetric and straight, uniform in color, nasal septum
intact and in middle. O2 inhalation of 3 Lpm via nasal cannula noted and NGT on the left
nostrils.
Palpation: not tender; no lesions or tenderness noted upon palpation.
Mouth and Throat: lips are pale, tongue in central position; uvula located at the midline and
appears red. Gums are intact and pinkish in color. Patient has 8 teeth in the upper part and 12 at
the lower part. No dentures noted.
Neck:
Inspection: neck muscles are equal in size; head centered, no lesions noted. She can able
to move her neck but with slightly discomfort.
Palpation: no tenderness noted.
Chest and Respiratory:

Inspection: normal chest wall, patient is a diaphragmatic breather. Patient is coughing

with a whitish discharges.
Palpation: chest wall intact; no tenderness; no masses. Full and symmetric chest wall
expansion.
Auscultation: crackles noted upon auscultation on both lungs.
Cardiovascular:
Inspection: no irregularities noted on pulsation of the heart, normal capillary noted, no
cyanosis noted. Patient Blood pressure upon assessment is 100/90 mmHg and in ECG reading is
normal sinus rhythm.
Breast:
Inspection: breast is equal in size and shape which is slightly flat on chest, skin uniform
in color, smooth and intact, both nipples is point in same direction. No discharge noted.
Abdomen:
Inspection: uniform in color, round abdomen, no evidence of enlargement of liver or
spleen, symmetric contour. Symmetric movements caused by respiration. With incision at mid
abdominal area and with a dry and intact dressing. 18 stitches noted with a dry wound, no
discharges noted.
Musculoskeletal:
Inspection: equal size on sides of body, no contractures, and no tremors noted with slow
range of motion. Weakness noted upon moving.
Genitourinary:
Inspection: pubic skin intact, no lesions noted oliguria noted with 10cc/hr.
Extremities:

Inspection; both feet are symmetrical, pitting edema noted on both feet with 4-5sec. Joints move
smoothly but with discomfort.

Skin and Hair;

Inspection: skin is dry, thumb nails are long and dirty, the rest is short and also dirty. Hair
is evenly distributed.
Palpation: clammy skin with capillary refill of >2-3 seconds.

REVIEW OF SYSTEMS
Date: december 9, 2011
Time: 9:00 am
Vital signs:
BP: 100/ 90 mmhg
PR: 80 bpm
RR: 32 cpm
Temp.: 36.6 C

General:
Prior to admission, patient verbalized that, two months prior to hospitalization, he
experienced abdominal pain but he didnt mind it because he thought that this is common illness
and only pass by. Five days prior to admission he experienced vomiting, dizziness and abdominal
pain, bowel changes (constipation) and he also experienced loss of appetite. During the time of
assessment 5 days post operative, patient verbalized that he feels dizzy the time he sit on bed and
blurring of vision experienced.
Skin, Hair, Nails:
The patient verbalized wala man ko biskan ano nga allergy sa pagkaon o bulong, saho
ko man tanan. Wala man ga hurot buhok ko kun magsudlay kag pagkatapos ko ligo. Aring kuko
ko di ko ginautdan kay ginagamit ko ni pangkusi, wala man ko makaagi nga nabaog kuko ko.
Head:

The patient denies of previous head injury. And admit experiencing light headedness.
Eyes:
The patient experiencing blurring of vision and denies having eye injury and surgery.
Ears:
The patient denies of having infection and discharges in the ear.
Nose & Sinuses:
The patient denies of having colds and watery discharges from the nose and denies of
having nosebleeds and sinus troubles.
Mouth, Throat & Pharynx:
The patient denies of having gingival bleeding, dental difficulties and hoarseness of
voice. And he verbalized ginaubo ako subong, tung pagsulod ko di wala pa ko gina ubo, subong
lang gid. Di man ko gina budlayan magginhawa pero ginahapo lang ko, sa ubo ko man guro ni.
Neck:
The patient denies of having lumps, goiter and neck stiffness.
Breast:
The patient denies of having lumps, swelling, and nipple discharges.
Cardiovascular:
The patient denies of having heart murmurs, visible varicosities, phlebitis, and heart
surgery. Patient verbalized hindi man ko high blood.
Respiratory:
The patient verbalized ginaubo ako subong, tung pagsulod ko di wala pa ko gina
ubo, subong lang gid. Di man ko gina budlayan magginhawa pero ginahapo lang ko, sa ubo ko
man guro ni.

Gastrointestinal:
The patient admits of having poor appetite and bowel changes. He experienced
constipation and abdominal pain 5 days prior to admission. And he experienced vomiting.
Genitourinary:
The patient denies of having UTI and unusual color of urine.
Musculoskeletal:
The patient verbalizes weaknesses and limit movements because he feels dizzy during
changing of position.
Neurologic:
The patient is awake and he is oriented to the place where he is and the person around
him.
Hematologic:
The patient denies of having blood transfusion and any disease related to hematologic
system.

COMPLETE DOCTORS ORDER

DATE/TIME
12-4-11
6:25pm

ORDER
Admit

TPR q6hours

NPO

Laboratory:
CBC

BT STAT

X-ray abdomen
upright include
diaphragm STAT

ECG STAT

Medication:
Cefuroxime 750
mg IVTT now
then q8hours
ANST

RATIONALE
The patient is admitted because she
needs to be evaluated and needs to
undergo series of assessment and
examination to diagnose condition.
Taking VS is important to find out
current status of the patient and to
monitor for any significant changes
and to have baseline date.
To prepare patient with the
operation, and to prevent aspiration
during operation.

REMARKS
Done/the
patient is
admitted

Complete blood count this will

determine the blood components
level and its abnormalities.
Blood typing is needed to prepare
blood prior the operation in order to
be ready for any abnormalities may
happen inside the operating room.
X-ray is used to visualize the
abdominal content and abnormalities
in the abdomen.
To assess cardiac rhythm of the
patient and to know the presence of
dysrhythmias or any heart problem.

Done/result
attached to
the chart
Done and
result
attached to
the chart.

Second-generation cephalosphorin
that inhibits cell-wall synthesis,
promoting osmotic instability:
usually bactericidal. Given to the
patient to fight for infection.
Prevention of post operative
Metronidazole
500mg IVTT now infection in contaminated or
potential contaminated colorectal
then q8hours
surgery
ANST
To decrease gastric acid secretion.

Monitored
and
Recorded

Instructed

Done, result
not attached
to chart
Done/result
attached to
the chart
Given

Given

Given

Ranitidine 50mg
IVTT now then
q8hours
For Exlap STAT
IVF:
D5LR1L @ 30gtts/min
PlainNSS1L @
40gtts/min
Inform OR/
anaesthesiologist

Consent

Insert NGT now

To secure 1 unit of whole
blood type O; x-match
For CP evaluation to start
surgery

Refer accordingly

12-4-11
7:10pm
ROS

PHx

PE

Patient referral for CP

evaluation
( ) vomiting
( ) dizziness
( ) chest pain
( ) DM
( ) HPN
( - ) chest pain
-conscious

To assess, correct and determine any

damage inside the abdomen.

Done

To maintain hydration, provide TPN,

for fluid and electrolyte balance,
serve as portal of IVTT medication
and serve as BT line.
For them to be aware and to allow
OR staff and anesthesiologist to
prepare materials, instruments and
medications that will be used in the
procedure.
For legal bases and to know if
patient is willing to undergone the
operation
To know if there is an abdominal
bleeding
To be ready if blood transfusion is
needed during operation.
For legal bases and purposes, to
insure that patient has no heart and
lung problem and to insure safety
during operation
Referring is necessary for it facilities
collaboration between nurse and
doctors to ensure better management
arrangement of the patient.

Inserted and
Regulated

For legal bases and purposes, to

insure that patient has no heart and
lung problem and to insure safety
during operation

Informed

Signed and
attached to
chart
Inserted
Secured
Done

Done
Referred

Done

Labs

12-4-11
7:35pm
Conscious
Coherent
(-) BT

-coherent
-pinkish sclera
-extremities (-) edema
Hgb 171
RBS 166
ECG NSR
NPO

V/S in route to OR

IVF as ordered

Will proceed with the

plan of surgery
Refer

To prepare patient with the

operation, and to prevent aspiration
during operation.
To know if there is any significant
changes in the vital signs of the
patient.

Instructed

To maintain hydration, provide TPN,

for fluid and electrolyte balance,
serve as portal of IVTT medication
and serve as BT line.
To treat the underlying condition of
the patient
Referring is necessary for it facilities
collaboration between nurse and
doctors to ensure better management
arrangement of the patient.

Hooked and
Regulated

For close monitoring

Done

Taken and
Recorded

Done

Referred

10:50pm
POST OP
To RR then to surgery
ward once stable
V/S q15min till stable
then q4hours

To monitor patients condition after

the procedure and to know any
significant changes happen
To prevent aspiration. Gag reflex
NPO
was relaxed due to anesthesia.
To know if there is a presence of
NGT as drain, keep open blood that indicates further
always
complication.
To maintain hydration, provide TPN,
Continue IVF with D5LR for fluid and electrolyte balance, and
@ 40gtts/min
it serve as portal of IVTT
medication
To maintain hydration, provide TPN,
IVF TF with D5LR2L @ for fluid and electrolyte balance, and

Monitored
and
Recorded
Instructed
Keep it open

Regulated

Followed up
and

30gtts/min and D5NM2L

@ SR

it serve as portal of IVTT

medication

Regulated

Laboratory:
Serum potassium

To monitor renal function, glucose

metabolism and evaluate clinical
sings of hyper or hypokalemia
To evaluate fluid and electrolyte and
acid base balance, related to neuro
muscular, renal and adrenal function

Done/ result
attach to
chart
Done/ result
attach to
chart

An analgesic for moderate to severe

pain.
Analgesic given to the patient for
moderate to severe pain.
To decrease gastric acid secretion.

Given

Serum sodium

Medication:
Ketorolac 30mg IVTT
q8hours
Tramadol 50mg IVTT
q8hours
Ranitidine 50mg IVTT
q8hours

Prevention of post operative

infection in contaminated or
potential contaminated colorectal
surgery
Second-generation cephalosphorin
Cefuroxime 750mg IVTT that inhibits cell-wall synthesis,
q8hours
promoting osmotic instability:
usually bactericidal. Given to the
patient to fight for infection.
To monitor the renal status of the
I & O q hourly
patient and the fluid in the body.
12hours then q 6hours
To maintain normal O2 saturation in
O2 inhalation @ 3the body
4L/min till awake
To refer accordingly and give
Watch out for any
immediate interventions to the
unusualities
problem arise.
Referring is necessary for it facilities
Refer accordingly
collaboration between nurse and
doctors to ensure better management
arrangement of the patient.

Given
Given

Given

Metronidazole 500mg
IVTT q8hours

Given

Monitored
& Recorded
Given
Watched out

Referred

12-5-11
8:30am

Turn patient side to side

IVF:
D5LR
1L
D5NSS
@
D5LR
30gtts/min
Continue medication

To prevent accumulation of fluid in

the lungs, promote peristaltic
movement and prevent pressure
ulcer.
To maintain hydration, provide TPN,
for fluid and electrolyte balance, and
it serve as portal of IVTT
medication
For continuity of treatment &
management of the patient

Instructed

Done &
Regulated

Continued

12-6-11
9:36am
Conscious &
coherent
Afebrile
Able to flex
Dehydrated
body

Moderate fast drip

remaining fluid 400ml
D5LR then TF with
D5LR1L @ 40 gtts/min
Continue IV analgesics
Refer

To maintain hydration, provide TPN,

for fluid and electrolyte balance, and
it serve as portal of IVTT
medication
Analgesic is given for pain
Referring is necessary for it facilities
collaboration between nurse and
doctors to ensure better management
arrangement of the patient.

Done and
followed up

12-7-11
1:00pm

May sit on bed

To prevent accumulation of fluid in

the lungs, promote peristaltic
movement and prevent pressure
ulcer.
To maintain hydration, provide TPN,
for fluid and electrolyte balance, and
it serve as portal of IVTT
medication
For continuity of treatment &
management of the patient

Instructed

IVF:
D5LR
1L
D5NSS
@
D5LR
Same Rate
Continue medication

Continued
Referred

Done &
Regulated

Continued

TEXT BOOK DISCUSSION

Intestinal obstruction is a blockage of your small intestine or colon that prevents food and fluid
from passing through. Intestinal obstruction can be caused by many conditions, including fibrous
bands of tissue in the abdomen (adhesions), hernias and tumors.
Intestinal obstruction can result in an array of uncomfortable signs and symptoms, including
abdominal pain and swelling, nausea, and vomiting. If left untreated, intestinal obstruction can
cause the blocked parts of your intestine to die. This tissue death can lead to perforation of the
intestine, severe infection and shock. However, with prompt medical care, intestinal obstruction
can often be successfully treated.
Current Medical Diagnosis and Treatment
30th Edition A Lange Medical Book
By: Schloeder, Krupp, Tierney & Mc Phee

Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of
the intestinal contents to pass through. An intestinal obstruction occurs when food or stool cannot
move through the intestines. The obstruction can be complete or partial. There are many causes.
The most common are adhesions, hernias, cancers, and certain medicines. All abdominal
surgeries carry the risk of adhesion formation. Abdominal adhesions are rare in people who have
not had abdominal surgery and very common in people who have had multiple abdominal
surgeries. Adhesions are more common following procedures involving the intestines, colon,
appendix, or uterus. They are less common following surgeries involving the stomach, gall
bladder, or pancreas. Although most abdominal adhesions do not cause problems, they can be
painful when stretched or pulled because the scar tissue is not elastic.

Modern Guide to Health

By: Clifford R. Anderson, MD

The term ileus has changed in meaning over the years. It is now most frequently used to imply
non-mechanical intestinal obstruction. The term paralytic ileus is sometimes used when the
problem is inactivity of the bowel.
N.B. Obstruction to free passage of contents can occur at any level of the gut but only
obstruction of beyond the duodenum will be considered here. For conditions causing obstruction
at a higher level, see the articles on Oesophageal Strictures, Webs and Rings, Carcinoma of the
Oesophagus, Gastric Carcinoma, and Pyloric Stenosis.
EpidemiologySmall intestinal obstruction accounts for about 5% of acute surgical admissions. A
significant number of colo-rectal malignancies present with obstruction. One large study found
an incidence of 16%. And approx 1 in 746 or 0.13% or 364,563 people in USA, in the
Philippines over 115,590 cases to the total population of 86,241,6972
Risk factors

Small intestinal obstruction is caused by adhesions in 60%, strangulated hernia in 20%,

malignancy in 5% and volvulus in 5%. Malignancy usually means a tumour of the
caecum as small bowel malignancies are very rare.

Large intestinal obstruction is most often the result of colo-rectal malignancies. Patients
are often over 70 years old. The risk of obstruction increases the further down the bowel
the lesion is sited, as the contents become more solid. Tumours are often advanced with
25% having distant metastases. Perforation can occur at the site of the tumour or in a
dilated caecum.

Sigmoid and caecal volvulus describes rotation of the gut on its mesenteric axis. The
sigmoid colon is the commonest site of volvulus and accounts for 5% of large bowel
obstruction. It is usually seen in the elderly or those with psychiatric illness. It is the
commonest cause of intestinal obstruction in Africa and Asia where the incidence is 10
times higher than in Europe or North America.

Paralytic ileus describes the condition in which the bowel ceases to function and there is
no peristalsis. Intestinal pseudo-obstruction is also called Ogilvies syndrome. It results
from massive dilatation of the colon but possibly small intestine too. It may occur in
association with a number of medical conditions including
o Chest infection
o Acute myocardial infarction
o Stroke
o Acute renal failure
o Puerperium
o Trauma
o Severe hypothyroidism
o Electrolyte disturbance
o Diabetic ketoacidosis
http://www.rightdiagnosis.com/i/intestinal_obstruction/stats-country.htm

Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of
the intestinal contents to pass through. Intestinal obstruction is significant mechanical

impairment or complete arrest of the passage of contents through the intestine. Symptoms
include cramping pain, vomiting, obstipation, 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.
Mechanical obstruction is divided into obstruction of the small bowel (including the duodenum)
and obstruction of the large bowel. Obstruction may be partial or complete. About 85% of partial
small-bowel obstructions resolve with nonoperative treatment, whereas about 85% of complete
small-bowel obstructions require operation.
Etiology
Paralytic ileus; Intestinal volvulus; Bowel obstruction; Ileus; Pseudo-obstruction - intestinal;
Colonic ileus
Obstruction of the bowel may due to:

A mechanical cause, which simply means something is in the way

Ileus, a condition in which the bowel doesn't work correctly but there is no structural
problem

Paralytic ileus, also called pseudo-obstruction, is one of the major causes of intestinal obstruction
in infants and children. Causes of paralytic ileus may include:

Chemical, electrolyte, or mineral disturbances (such as decreased potassium levels)

Complications of intra-abdominal surgery

Decreased blood supply to the abdominal area (mesenteric artery ischemia)

Injury to the abdominal blood supply

Intra-abdominal infection

Kidney or lung disease

Use of certain medications, especially narcotics

In older children, paralytic ileus may be due to bacterial, viral, or food poisoning
(gastroenteritis), which is sometimes associated with secondary peritonitis and appendicitis.
Mechanical causes of intestinal obstruction may include:

Abnormal tissue growth

Adhesions or scar tissue that form after surgery

Foreign bodies (ingested materials that obstruct the intestines)

Gallstones

Hernias

Impacted feces (stool)

Intussusception

Tumors blocking the intestines

Volvulus (twisted intestine)

Causes of Intestinal Obstruction

Location

Cause

Colon

Tumors (usually in left

colon), diverticulitis
(usually in sigmoid),
volvulus of sigmoid or
cecum, fecal impaction,
Hirschsprung's disease

Duodenum
Adults

Cancer of the duodenum

or head of pancreas, ulcer
disease

Neonates

Atresia, volvulus, bands,

annular pancreas

Jejunum and
ileum
Adults

Hernias, adhesions
(common), tumors,
foreign body, Meckel's
diverticulum, Crohn's
disease (uncommon),
Ascaris infestation,
midgut volvulus,
intussusception by tumor
(rare)

Neonates

Meconium ileus,
volvulus of a malrotated
gut, atresia,
intussusception

Pathophysiology
In simple mechanical obstruction, blockage occurs without vascular compromise. Ingested fluid
and food, digestive secretions, and gas accumulate above the obstruction. The proximal bowel
distends, and the distal segment collapses. The normal secretory and absorptive functions of the
mucosa are depressed, and the bowel wall becomes edematous and congested. Severe intestinal
distention is self-perpetuating and progressive, intensifying the peristaltic and secretory
derangements and increasing the risks of dehydration and progression to strangulating
obstruction.
Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly 25%
of patients with small-bowel obstruction. It is usually associated with hernia, volvulus, and
intussusception. Strangulating obstruction can progress to infarction and gangrene in as little as 6
h. Venous obstruction occurs first, followed by arterial occlusion, resulting in rapid ischemia of
the bowel wall. The ischemic bowel becomes edematous and infarcts, leading to gangrene and
perforation. In large-bowel obstruction, strangulation is rare (except with volvulus).
Perforation may occur in an ischemic segment (typically small bowel) or when marked dilation
occurs. The risk is high if the cecum is dilated to a diameter 13 cm. Perforation of a tumor or a
diverticulum may also occur at the obstruction site.
Symptoms and Signs

Obstruction of the small bowel causes symptoms shortly after onset: abdominal cramps centered
around the umbilicus or in the epigastrium, vomiting, andin patients with complete obstruction
obstipation. Patients with partial obstruction may develop diarrhea. Severe, steady pain
suggests that strangulation has occurred. In the absence of strangulation, the abdomen is not
tender. Hyperactive, high-pitched peristalsis with rushes coinciding with cramps is typical.
Sometimes, dilated loops of bowel are palpable. With infarction, the abdomen becomes tender
and auscultation reveals a silent abdomen or minimal peristalsis. Shock and oliguria are serious
signs that indicate either late simple obstruction or strangulation.

Appendicitis is initiated by obstruction of the appendiceal lumen by a fecalith,

inflammation, foreign body, or neoplasm. Obstruction is followed by infection, edema and
frequently by infaction of the appendiceal wall. Intraluminal tension develops rapidly by tends to
cause early neural necrosis and perforation. All ages and both sexes are affected, but appendicitis
is more common in males than women at 10 and 50 years of age.
Appendicitis is one of the most frequent causes of acute surgical abdomen. The
symptoms and signs usually follow a fairly stereotyped pattern, but appendicitis is capable of
such protean manifestation that is should be considered in the differential diagnosis of every
obscure case of intraabdominal sepsis and pain.

Current Medical Diagnosis and Treatment

30th Edition A Lange Medical Book
By: Schloeder, Krupp, Tierney & Mc Phee
Page: 439-441
Appendicitis is an inflammation of the appendix, which is the worm-shaped pouch
attached to the cecum, the beginning of the large intestine. The appendix has no known function
in the body, but it can become diseased. Appendicitis is a medical emergency, and if it is left
untreated the appendix may rupture and cause a potentially fatal infection. Appendicitis is the
most common abdominal emergency found in children and young adults. One person in 15
develops appendicitis in his or her lifetime. The incidence is highest among males aged 10-14,
and among females aged 15-19. More males than females develop appendicitis between puberty
and age 25. It is rare in the elderly and in children under the age of two.
The hallmark symptom of appendicitis is increasingly severe abdominal pain. Since many
different conditions can cause abdominal pain, an accurate diagnosis of appendicitis can be
difficult. A timely diagnosis is important, however, because a delay can result in perforation, or
rupture, of the appendix. When this happens, the infected contents of the appendix spill into the
abdomen, potentially causing a serious infection of the abdomen called peritonitis. Other
conditions can have similar symptoms, especially in women. These include pelvic inflammatory
disease, ruptured ovarian follicles, ruptured ovarian cysts, tubal pregnancies, and endometriosis.
Various forms of stomach upset and bowel inflammation may also mimic appendicitis.
The treatment for acute (sudden, severe) appendicitis is an appendectomy, surgery to
remove the appendix. Because of the potential for a life-threatening ruptured appendix, persons
suspected of having appendicitis are often taken to surgery before the diagnosis is certain.
http://medical-dictionary.thefreedictionary.com/Ruptured+appendix

DIGESTIVE SYSTEM

Mouth
The mouth is the first part of the digestive tract. The tongue and the teeth are found in the mouth.
The inside of the mouth is lubricated with saliva that comes from the salivary glands. The
strongest muscles are found in each side of the mouth. They help move the lower jaw and give it
a biting force. There are four types of teeth in the mouth. The incisors are used in cutting food.
The canines are used for grasping, piercing and tearing. The premolars and molars are used for
crushing and grinding. Aside from tasting food, the tongue is used for moving the food as the
saliva softens it. We have three pairs of salivary glands. Saliva from these glands lubricates the
food and makes it soft. Saliva also contains an enzyme that breaks down starch.

Esophagus

From the mouth, food goes down the esophagus through the pharynx or throat. The esophagus is
a muscular tube that can open and close at the pharynx. It can also open and close to the
stomach. The walls of the esophagus consist of smooth muscles. The wavelike movement of
these muscles, called peristalsis, pushes the food down to the stomach.
Stomach
The stomach is a hollow muscular organ shaped like a bag. Its upper end is connected to the
esophagus while the lower end is connected to the small intestine. The upper and lower ends of
the stomach have smooth circular muscles called sphincter muscles. When the upper end muscle
relaxes, the stomach opens and food gets in. when the lower end muscles relaxes, partially
digested food moves out of the stomach. The sphincter muscles keep the food in the stomach.
The stomach is flexible and can expand when you eat. It can hold from 1 to 3 liters of food. The
stomach acts as a storage bag of food. If the stomach could not store food, you would have to eat
every twenty minutes or so instead of just three times a day. The stomach contains three layers of
smooth muscles which also produce peristaltic movements to continue breaking down the food.
Intestines
The intestines are found below the stomach and liver. They form the major part of the digestive
tract. The small intestine is about 2.5 centimeter in diameter and 6 meters long. Its wall are made
of smooth muscles. The inner lining of the small intestines is folded into tiny fingerlike
projections called villi (singular, villus). Each villus contains blood vessels. The work of the
small intestines is to digest food, which can then be absorbed by the blood. The villi act much
like the same as the folded towels. Because the wall of the intestine is folded into millions of
villi, the surface area through which nutrients pass to the bloodstream is greatly increased. If the
villi on the inner lining of the small intestine are flattened out, they would cover about 4500
square meters.
The large intestine is about 5 centimeters in diameter and about 1.8 meters long. Its main part if
the colon. At the end of the colon is the rectum which opens to the anus. The work of the large
intestine is to absorb water from the undigested food, hold the undigested food for a while and
then excrete it as feces.
Accessory Parts of the Digestive System and their functions
The liver, pancreas and gall bladder are not part of the alimentary canal but they have important
functions in the digestive process. They are called accessory parts of the digestive system.
Liver

The liver lies under the diaphragm and near the stomach. It is the largest organ inside the body
and one of the most important. Among the functions of the liver that are related to digestion are
the following.
1. It produces bile, a substance that helps in the digestion of fats.
2. It stores glycogen, vitamins and some minerals, such as iron and copper, which are
released when needed by the body.
Gall bladder
The gall bladder is a small muscular sac that is attached beneath the liver. Bile produced by the
liver passes through a small tube and is stored in the gall bladder. From the gall bladder, bile is
released to the small intestine digestion.
Pancreas
The pancreas is an organ that lies behind the stomach. Its function related to digestion is to
produce pancreatic juice. Pancreatic juice helps in neutralizing or weakening the acid in food
inside the stomach before it moves onto the small intestine. Pancreatic juice also contains
different enzymes that are needed to further break down starch, proteins and fats in the small
intestine.
Appendix
According to a recent study just released (as I understand it) one of the functions of the
appendix is storing and protection of the good bacteria that aids in the digestion of food.
The appendix - has no known physiological function but probably
represents a degenerated portion of the cecum that, in ancestral forms, aided in cellulose
digestion. It is believed that the appendix will gradually disappear in human beings as our diet no
longer utilizes cellulose.
"For years, the appendix was credited with very little physiological function. We now
know, however, that the appendix serves an important role in the fetus and in young adults.
Endocrine cells appear in the appendix of the human fetus at around the 11th week of
development. These endocrine cells of the fetal appendix have been shown to produce various
biogenic amines and peptide hormones, compounds that assist with various biological control
(homeostatic) mechanisms. There had been little prior evidence of this or any other role of the
appendix in animal research, because the appendix does not exist in domestic mammals.
"Among adult humans, the appendix is now thought to be involved primarily in immune
functions. Lymphoid tissue begins to accumulate in the appendix shortly after birth and reaches a

peak between the second and third decades of life, decreasing rapidly thereafter and practically
disappearing after the age of 60. During the early years of development, however, the appendix
has been shown to function as a lymphoid organ, assisting with the maturation of B lymphocytes
(one variety of white blood cell) and in the production of the class of antibodies known as
immunoglobulin A (IgA) antibodies. Researchers have also shown that the appendix is involved
in the production of molecules that help to direct the movement of lymphocytes to various other
locations in the body.
"In this context, the function of the appendix appears to be to expose white blood cells to
the wide variety of antigens, or foreign substances, present in the gastrointestinal tract. Thus, the
appendix probably helps to suppress potentially destructive humoral (blood- and lymph-borne)
antibody responses while promoting local immunity. The appendix--like the tiny structures called
Peyer's patches in other areas of the gastrointestinal tract--takes up antigens from the contents of
the intestines and reacts to these contents. This local immune system plays a vital role in the
physiological immune response and in the control of food, drug, microbial or viral antigens. The
connection between these local immune reactions and inflammatory bowel diseases, as well as
autoimmune reactions in which the individual's own tissues are attacked by the immune system,
is currently under investigation.
"In the past, the appendix was often routinely removed and discarded during other
abdominal surgeries to prevent any possibility of a later attack of appendicitis; the appendix is
now spared in case it is needed later for reconstructive surgery if the urinary bladder is removed.
In such surgery, a section of the intestine is formed into a replacement bladder, and the appendix
is used to re-create a 'sphincter muscle' so that the patient remains continent (able to retain urine).
In addition, the appendix has been successfully fashioned into a makeshift replacement for a
diseased ureter, allowing urine to flow from the kidneys to the bladder. As a result, the appendix,
once regarded as a nonfunctional tissue, is now regarded as an important 'back-up' that can be
used in a variety of reconstructive surgical techniques. It is no longer routinely removed and
discarded if it is healthy.

List of Drugs

1.
2.
3.
4.
5.

Cefuroxime Sodium 750mg.IVTT q8hrs

Ketorolac Trometamine 15mg IVTT q8hrs
Ranitidine 50mg IVTT q8hrs
Tramadol 500mg IVTT q8hrs
Metronidazole 500mg IVTT q8hrs

PRIORITIZED PROBLEM
1. Ineffective Airway Clearance r/t Retained Secretion as evidenced by productive cough and crackles noted on both lungs upon
auscultation.
2. Impaired Skin Integrity r/t Surgical Incision 2 post exploratory laparotomy, appendectomy.
3. Sleep Pattern Disturbance r/t Physical Condition 2 cough as evidenced by patients verbalization.
4. Self Care Deficit r/t lack of motivation and physical condition.
5. Risk for infection r/t surgical incision 2 post exploratory laparotomy, appendectomy.

NURSING CARE PLAN

ASSESSMENT

NEEDS

NSG.

GOALS

NSG. INTERVENTION

RATIONALE

EVALUATION

Subjective:

DIAGNOSIS
Ineffective airway

General:

Teach the patient in proper

To provide knowledge

12-9-11

12-9-11

clearance r/t

After

coughing technique.

and information to the

@ 2pm

@ 9am

retained secretion

rendering

as evidenced by

nursing care

Instruct the patient to

To prevent wound

Goal partially

Gina ubo ko

productive cough

the patient

splint the wound when

complication and give

met as

subong, di man

and crackles noted will be able

coughing with a pillow or

knowledge to the patient.

evidenced by

ko gina budlayan

upon auscultation.

to maintain

placing his hand on the

magginhawa

airway

incision site.

To motivate the patient

verbalization

patency.

Encourage patient to do

expectorate properly the

di na ko

coughing exercise.

secretion.

nabudlayan

To open the airway and

magginhawa

pero ginahapo

patient.

patients

lang ko, kag di

Rationale:

ko ka tulog sa

Inability to clear

Specific:

akon ubo. As

secretions or

After eight

Elevate the head of bed or

prevent aspiration during

pero gina ubo

verbalized by the

obstruction from

hours of

place the patient in semi

coughing

lang gihapon

patient

the respiratory

rendering

fowlers position

To take advantage of

ko patients RR

tract to maintain a

nursing care

Instruct the patient to

gravity, decreasing

is 26cpm

clear airway. The

the patient

change position every two

pressure on diaphragm,

Productive cough

plem of the

will be able

hours.

also help to loosen the

noted with

patient is the

to:

whitish discharge

cause of cough

Expectorate

Objective:

secretion.
Do back tapping and back

It helps to loosen the

Crackles noted

and obstruction on secretion

rubbing

secretion.

upon

the airway.

readily

Instruct the patient to

To prevent worsening of
condition.

auscultation on

By:

Demonstrate

change his clothes when it

both lungs

Gordons

behaviour to

is wet.

Restlessness

Functional

improve or

Instruct the patient not to

To prevent further

noted

Health

maintain

let the wet clothes dry on

complication and severity

Difficulty in

Pattern

clear airway

his body.

of cough.

falling asleep

Follow

Instruct the patient to

To give appropriate

V/S:

therapeutic

verbalize concerns

intervention to the

BP:100/90mmH

regimen

management

problem address
Give medication as

Medication may help in

RR:32cpm

ordered (expectorant or

improving his condition

PR:80bpm

bronchodilator).

Temp:36.6C

Give oxygen as ordered.

It helps in improving his

condition and help to
supply oxygen in the
body.

Encourage patient to

To give appropriate

report any changes or

intervention to the

unusualities happen

problem arise.

ASSESSMEN

NEEDS

T
Subjective:

12-9-11

@ 9am

NSG. DIAGNOSIS

GOALS

NSG. INTERVENTION

RATIONALE

EVALUATION

Impaired Skin

General:

Teach the patient in proper

To provide knowledge

12-9-11

Integrity r/t Surgical

After

coughing technique.

and information to the

@ 2pm

Incision 2 to post

rendering

Exploratory

nursing care

Instruct the patient to

To prevent infection and

Goal met,

May tahi akon

Laparotomy,

the patient

participate in daily

for hygienic purposes.

patient able to

tiyan, wala

Appendectomy

will be able

dressing.

naman ga sakit

to manifest

Instruct the patient to

To prevent wound

of wound

pilas ko As

no sign of

splint the wound when

complication and give

complication as

verbalized by

Rationale:

wound

coughing with a pillow or

knowledge to the patient.

evidenced by

the patient

Altered epidermis

complication

placing his hand on the

dry and intact

incision site.

wound and no

and/or dermis (the

Objective:

patient.

manifest no sign

integumentary

Specific:

Encourage patient to do

To motivate the patient

discharges,

coughing exercise.

expectorate properly the

redness or

secretion.

edema noted.

Surgical

system is the largest

After eight

incision at mid

multifunctional

hours of

abdominal area

organ of the body).

rendering

Explain the importance of

To give knowledge and

noted

The patient has

nursing care

daily dressing and good

information to the patient.

With dry and

wound due to

the patient

hygiene.

intact dressing

surgical procedure

will be able

Instruct the patient not to

To prevent wound

With sutures

performed.

to:

touch his wound with bare

infection.

Identify

hands.

noted on the

incision

prevention

Enumerate foods that will

To give knowledge and

With 18 stitches

measures for

help for fast wound

information to the patient

No presence of

wound

healing such as rich in

as well as to motivate

discharge noted

complication

vitamin C (calamansi,

him eat foods that will

Dry wound

By:

tomato, orange) and rich in help in his fast recovery.

noted

Gordons

Participate in

protein (meat, egg, green

Functional

prevention

leafy vegetables).

Health

measures and Instruct the patient to

To give appropriate

Pattern

treatment

intervention to the

verbalize concerns

programs

problem address

Follow

Explain the importance of

To provide knowledge

therapeutic

hand hygiene.

and information to the

regimen
management

patient
Give antibiotic as ordered

Medication will help to

(cefuroxime sodium).

fight for infection

Encourage patient to

To give appropriate

report any changes or

interventions to the

unusualities happen

problem arise.

ASSESSMENT
Subjective:

NEEDS
S

NSG. DIAGNOSIS
Sleep Pattern

GOALS
General:

NSG. INTERVENTION
Assess the cause and factors

RATIONALE
For properly manage the

12-9-11

Disturbance r/t Physical

After rendering

that disturbed sleep pattern

cause and factors affecting

@ 9am

Condition 2 cough as

nursing care the

Instruct the patient to remove

sleep pattern

evidenced by patients

patient will be

crumples at bed linen.

Crumple linen may be the

verbalization.

able to verbalize

Instruct patient to practice

factor affecting sleep

rested feeling

hygienic activity before

Wala ko katulog
maayo kagab-e kay
sige ubo ko kag gin

sleeping.

Hygiene is also a factor

Specific:

Instruct patient to do deep

affecting sleep pattern

hilanat pa ko As

verbalized by the

Rationale:

After eight hours

breathing exercise and proper

patient

Time limited disruption

of rendering

coughing technique

For properly expectorate the

of sleep (natural,

nursing care the

Instruct patient to have a good

plem disturbing sleep

Objective:

periodic suspension of

patient will be

hygiene always

Weakness noted

consciousness) amount

able to:

Infection may be the cause of

Frequent yawning

and quality.

Identify factors

Instruct patient to listen soft

elevated temperature

noted

Sleep disruption due to

affecting sleep

music

It may help falling asleep

Restlessness noted

physical condition being

and rest

Provide quit environment if

Productive cough

felt.

Demonstate

possible

noted with whitish

behaviour to

secretion

improve

Instruct patient to limit visitors To provide rest and limit

condition

and provide rest

and help to facilitate asleep

Able to report
V/S:

improvement in

For convenient environment

factors that disturbed asleep

To provide knowledge and

Explain the importance of

motivate patient to have

BP:100/90mmHg

sleep pattern

having enough sleep for at

enough sleep.

RR:32cpm

By:

least 8 hours

Medication help for

PR:80bpm

Gordons

Give medication as ordered

providing good sleep and rest

Temp:36.6C

Functional

To properly intervene the

Health

Encourage patient to verbalize

Pattern

concerns

problem arise