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In Partial Fulfillment

Of The Requirements In

RELATED LEARNING EXPERIENCE

Case Study:

Inguinal Hernia

Submitted to:

Ms. Rose Elan Bundac, R.N.

Clinical Instructor

By:

Kristine Claire S. Quicho-SalvadorBSN-4Ma. Adelene Lagrada

BSN-3

July 27, 2005

Department of Nursing

HOLY TRINITY COLLEGE

Puerto Princesa City

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TABLE OF CONTENTS

Title Page . . . . . . . . . .1

Table of Contents . . . . . . . . .2

Introduction . . . . . . . . . .3

Approval Sheet . . . . . . . . .5

Significance of the Study . . . . . . . .6

Statement of the Problem . . . . . . . .7

Personal Information . . . . . . . . .8

Family History . . . . . . . . .8

Past Medical History . . . . . . . . .8

Present Condition . . . . . . . . .9

Physical Assessment . . . . . . . . .10

Laboratory Examinations . . . . . . . .11

Review of Anatomy & Physiology . . . . . . .13

Pathophysiology . . . . . . . . .14

Treatments . . . . . . . . . .15

Pharmacological Studies . . . . . . . .16

Summary of Findings . . . . . . . . .21

Nursing Care Plans . . . . . . . . .22

Conclusions . . . . . . . . . .28

Discharge Plans . . . . . . . . .29

References . . . . . . . . . .30

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INTRODUCTION

A hernia is the abnormal protrusion of an organ, tissue, or part of an organ

through the structure that normally contains it. Hernias frequently occur in the abdominal

cavity as a result of a congenital or acquired weakness of abdominal musculature.Hernias can occur at any age and in either sex. Indirect Inguinal hernias are the

most common type and typically occur in men. Direct hernias are found more commonly

in older adults. Incisional or ventral hernias occur most often in clients who had poorwound healing after surgery. Obese or pregnant clients are more likely to develop

umbilical hernias.

Two factors must be present for hernia to occur: (1) a defect in the integrity of the

muscular wall and (2) increased intra-abdominal pressure.Congenital muscle weakness is one risk factor combined with the factors that

increase intra-abdominal pressure. The muscle weakness cannot be prevented, but

exercise can strengthen the weak muscles. Because obesity is one cause of increased

intra-abdominal pressure, it can be prevented by weight control. Avoiding heavy liftingand straining also reduces intra-abdominal pressure. Early diagnosis is important to

prevent incarceration and strangulation.Defects in the muscular wall may be congenital owing to weakened tissue or a

wide space at the inguinal ligament, or may be caused by trauma. Intra-abdominal

pressure most commonly increases as a result of pregnancy or obesity. Heavy lifting also

causes increased intra-abdominal pressure, as do coughing and traumatic injuries fromblunt pressure. When two of these factors coexist, with some tissue weakness, the person

may develop hernia. Increased pressure without a weakness is not likely to cause hernia.

Weakness, in addition to being present from birth, is acquired as part of the agingprocess. As clients age, muscular tissues become infiltrated and are replaced by adipose

and connective tissues.

When the contents of the hernia sac can be replaced into the abdominal cavity bymanipulation, the hernia is said to be reducible. Irreducible and incarcerated are terms

that refer to a hernia that cannot be reduced or replaced by manipulation. When pressure

from the hernia ring (in the case of Rolando, the inguinal ring) cuts off the blood supplyto the herniated segment of the bowel, the bowel becomes strangulated. Incarcerated

hernias often become strangulated. This situation is an emergency procedure because

unless the bowel is released, it soon becomes gangrenous owing to a lack of blood

supply.

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APPROVAL SHEET

Kristine Claire Q. Salvador and Ma. Adelene LAgrada, a 4 th year and third year

BSN students respectively, assigned in the Surgical Ward of Ospital ng Palawan has

prepared this case study entitled, Inguinal Hernia. This serves as a partial fulfillment

of the Requirements in Related Learning Experience (RLE). It was examined and

approved with the grade of ________%.

Ms. Rose Elan Bundac, R.N.

Clinical Instructress

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SIGNIFICANCE OF THE STUDY

This case study, entitled Inguinal Hernia is aimed not only to finish a

requirement in Related Learning Experience with clinical exposure at the Surgical Ward

of Ospital ng Palawan, it serves:

a. The client and his family, because the making of nursing care plans

considers his immediate needs;

b. The medical staff of Ospital ng Palawan and other members of the health

team, because they would have a reference in the course of their

assessment and health care of clients with hernia;

c. The ordinary people, because they would have a guide to aid them should

such symptoms of illness occur to them; and,

d. The student-nurses/researchers, to broaden their understanding, knowledge

and experience to render effective, accurate and prompt nursing care to

such clients.

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STATEMENT OF THE PROBLEM

This case study aims to answer the following questions:

a. What is the nature and dynamics of Inguinal hernia?

b. What are the diagnostic and laboratory tests needed to diagnose inguinal

hernia?

c. What nursing problems are identified and corresponding nursing care

plans are appropriate for patients with Inguinal hernia?

d. What possible discharge plan and home care is indicated for patients with

inguinal hernia?

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PERSONAL INFORMATION

Name: ROLDAN JESOROAge: 23 years old

Sex: Male

Address: Bgy. Inagawan, Puerto Princesa City, PalawanCivil Status: Live-in

Religion: Roman Catholic

Educational Attainment: High school levelOccupation: Farming

Date and Time Admitted: July 24, 2005 at 3:01pm

Chief Complaint/s: Abdominal pain

Informant: Rolando Baldo, sonPhysician: Dra. Nufuar

FAMILY HISTORY

Name of Father: Leonardo Flores (Deceased)Name of Mother: Ignacia Flores (Deceased)

Name of Spouse: Rodolfo Baldo (Deceased)

Number of children in the family: 10

Position in the family: 2ndNumber of offsprings: 4

Presence of Hereditary diseases:

a. Diabetes (-)b. Cardiovascular diseases (-)

c. Bronchial Asthma (-)

d. Others No history of hereditary diseasesDeaths in the family: Husband/Spouse

Cause/s: Undiagnosed and untreated illness, said to have

been caused by supernatural forces such as nuno sapunso and others.

PAST MEDICAL HISTORY

a. Type of delivery Normal

b. Childhood diseases Unknownc. Immunization status Unknown

d. Previous sickness/hospitalization Bicycle accident where she reportedly sustained a

head trauma that caused her hearing impairmentwhen she was 10 years old. She, however, was not

brought to the hospital and received only home

remedy.

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PRESENT CONDITION

a. Perceptions and Expectations of Illness/HospitalizationThe patient does not answer regarding this because her attention is focused on her

abdominal pain. Her children, however, verbalized that they expect her to get well

enough soon but are uncertain due to their financial status.b. Specific Basic Needs

1. Comfort/Rest Needs

The patient shows physical signs of abdominal pain that interfereswith her normal sleeping pattern. Her naps are usually short (often only

lasting about 3-5 minutes) and interrupted by sudden pain episodes. She

also is not able to do her usual daily activities such as bathing, brushing

her teeth, etc. as well as leisure activities which include listening to radioand reading short stories due to her attention being focused on her

discomfort and pain.

2. Safety Needs

Nanay Elena has hearing impairment that interferes with her abilityto express her needs and desires. This impairment also predisposes her to

hazards such as traffic and household accidents as well. Her old age alsopredisposes her to a lot of other illness such as colds and flu. Added to

this, the family is insecure about medical bills and costs of drugs because

they are not financially capable of supporting a sick member of the family.

3. Fluids and NutritionShe has not been able to retain any food or fluid for at least a week

prior to admission because she vomits every time she eats or drinks even a

tablespoon of rice or a few sips of water. She is however, placed on DATduring admission and IV fluids has been administered to replace lost

fluids, counteract any fluid and electrolyte imbalance, and as a route for

administration of medications.1. Elimination

The client has not moved her bowel for approximately 1 week.

Although she does not have any difficulty urinating, she has less frequentvoiding and U/A shows a slightly hazy urine transparency of urine.

2. Oxygen

RR=33/minute. When she was brought to the ward, she became

apneic and was given O2 inhalation via nasal cannula @ 3-4LPM. Prior toher illness, she is a kaingin farmer who is always exposed to a lot of

smoke.

3. Others:a. Sexuality She is feminine and has had 4 sons with her husband who

is now deceased.

b. Allergies No known allergies to food and drugs.c. Communication She cannot hear very well and cannot express her

feelings verbally. She only gestures and her pain is evident only

through her facial expressions and movements such as grimacing,

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crying or softly groaning in pain episodes and waving to her sons if

she needs to do anything..

PHYSICAL ASSESSMENT

a. EENTEyes Pale conjunctiva, white sclera, gray pupils, tearful.

Ears Ears are long and symmetrical.

Nose Nose is small, centrally-located.Throat Unremarkable.

b. Chest and Lungs

Clear breath sounds on both lung fields, bones prominent on chest.Symmetrical lung expansion observed.

c. Abdomen

Flat abdomen with minimal stretch marks seen. Hyperactive bowel soundson the hypogastric region heard upon auscultation. Epigastric, hypogastric and

RLQ pain upon palpation. Unable to palpate for mass or systolic bruit due to theintense pain she expresses with facial expression during palpation.

d. Genito-Urinary

With gray pubic hair, no BM and less frequent urination as reported bypatients sons.

e. Skin/ExtremitiesHand and foot digits are complete (20 in all), nails are short but with dirt

underneath and pale in color, poor skin turgor noted. White spots seen which the

sons claim is an-an.

f. General Conditions

The patient is conscious, alert but in severe abdominal pain. Her attentionis focused on this pain. She does not respond when asked if she comprehends

orientation to 4 spheres such as asking the date, time, place or her identity due to

her attention being focused in her pain.

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LABORATORY EXAMINATIONS

Diagnostic

Procedure:

Results: Normal

Values

Interpretation: Rationale:

June 27, 2005

CBC Hemoglobin

DIFFERENTIAL

COUNT

Neutrophils

Eosinophils

Lymphocytes

WBC Count

Platelet Count

BSMP

120 g/L

84

3

13

18.10 x

109/L

250 x 10 9/L

Negative

120-160 g/L

60-70%

1-4%

20-30

4-9 x 109/L

150-450 x109/L

Negative

Not yetindicative of

anemia;

borderline.

Indicatespresence of

bacterial or

parasiticinfectious

process.

No allergicreaction or

anemia

Indicative of

trauma

Coagulationmechanism

intact

Malaria is ruled

out.

CBC with

differential,WBC, plateletcount and

BSMP is

ordered for

Nanay Elena torule out

presence of

any infectionsdue to the

inconclusive

nature ofinterview and

assessment.

June 28, 2005Urinalysis

Color

Transparency

Albumin pH

Glucose sg

Microscopic Exam

Pus cells

RBC

Epithelial cells Squamous

Bacteria

Amorphous

urates

Pale yellow

Sl. Hazy

++ - 6++++ - 1.00

1-4/hpf

8-12/hpf

Few

Moderate

Moderate

Pale yellow

Clear

++ - 4.6-8++++ - 1.01-

1.025

No reference

No reference

No reference

No reference

No reference

(-)

Sediments

presentAverage of pH

range

(-)

(-)

(-)

(-)

(-)

Urinalysis isimportant to

determine

whether there

is infection inthe body.

June 28, 2005Ultrasound Abdominal

Aortic

Normal

pattern

Abdominal

Aortic Aneurism

Ultrasonography

was ordered due

to the

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Aneurism images of

structuresbeing

studied

(abdominal

aorta)

seen that

thereforechanges the

medical

impressions to a

definite medicaldiagnosis.

inconclusive

nature of

interview and

assessment. This

study creates

sound waves that

allowvisualization of

organs inside the

abdomen.

June 28, 2005Hemoglobin (Hgb) 52 g/L 120-160 g/L Indicative of

anemia

Ordered to assess

for hypovolemia

or shock.

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REVIEW OF ANATOMY & PHYSIOLOGY

OF

CARDIOVASCULAR SYSTEM: BLOOD VESSELS

Except for the microscopic capillaries, the walls of blood vessels have three coats

or tunics: Tunica Intima, which lines the lumen or interior of the vessels, is a thin layerof endothelium resting on a scanty layer of loose connective tissue, Its cells fit closely

together and form a slick surface that decreases friction as blood flows through the

lumen.

The Tunica Media is the bulky middle coat. It is mostly smooth muscle and

elastic tissue. The smooth muscle, which is controlled by the sympathetic nervous

system, is active in changing the diameter of the blood vessels. As the vessels constrict ordilate, blood pressure increases or decreases, respectively.

The Tunica Externa, is the outermost tunic, it is composed largely of fibrous

connective tissue. Its function is basically to support and protect the blood vessels.

The aorta is the largest artery of the body. In adults, the aorta is about the size of agarden hose where it issues from the left ventricle of the heart. It decreases in size as it

runs to its terminus. Different parts of the aorta are named for their location or shape. The

aorta curves upward from the left ventricle of the heart as the ascending aorta, arches to

the left as the aortic arch and then plunges downward through the thorax following thespine (Thoracic aorta) to finally pass through the diaphragm into the abominopelvic

cavity where it becomes the abdominal aorta.

Blood circulates inside the blood vessels, which form a closed transport system,

the so-called vascular system. Like a system of roads, the vascular system has its

freeways, secondary roads, and alleys. As the heart beats, blood is propelled into the largearteries leaving the heart. It then moves into successively smaller and smaller arteries,

then into the arterioles, which feed the capillary beds in the tissues. Capillary beds are

drained by venules, which in turn empty into the veins that finally empty into the greatveins entering the heart.

Thus arteries, which carry blood away from the heart, and veins, which drain the

tissues and return blood to the heart, are simply conducting vessels the freeway sandsecondary roads.

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PATHOPHYSIOLOGY OF

ABDOMINAL AORTIC ANEURISM (AAA)

PREDISPOSING PRECIPITATING FACTORS: CONTRIBUTING FACTORS:FACTORS: Focal weakness in the muscular - Trauma

Age: 50-80 y/o Layer of the aorta

Genetic

Inner layer (Tunica intima) & outer layer (tunica adventitia) stretches outward

Aneurism Palpable mass in the periumbilical

area

Tenderness Systolic bruit over

the aorta

Blood pressure in the aorta

weakens the vessel walls

Aneurism is enlarged

Pressure on lumbar nerve

Lumbar pain Aneurism ruptures

Peritoneal cavity Retroperitoneal space

Severe, persistent abdominal Tamponade

and back pain

Subtle weakness, sweating, tachycardia, hypotension

Shock

Death

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TREATMENTS

Treatment/Special Procedures/Surgery Rationale

Pharmacotherapy

IV therapy

O2 therapy

Pharmacotherapy is done to the

patient which is aimed at managinggastric acid secretions and pain, as

well as constipation. IV therapy is given to the patient to

replace lost fluids and manage fluid

and electrolyte imbalance as well as

a route for administration of

medication.

O2 therapy is given the patient to aid

in her oxygenation. She isexperiencing apnea in the ward

which may be due to her pathologic

condition.

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DRUG STUDY

Generic/

Brand Name

Dosage/Freq/

Route

Action Indication Nursing

Responsibilities

Ranitidine/Zantac

1 amp, ANSTthen q8, IV

Inhibits histamineat H2-receptor site

in parietal cells,which inhibitsgastric acid

secretion.

Duodenal ulcer,

Zollinger-Ellison

Syndrome, gastriculcers,

hypersecretory

conditions,

gastroesophageal

reflux disease,

stress ulcers,

erosive esophagitis

(maintenance),

active duodenal

ulcers with

Helicobacter pylori

in combination

with

clarithromycin.

Ranitidine is

indicated to Elena

Baldo to alleviate

pain episodes due

to gastritis where

there is too much

gastric acid

secretions and to

protect the mucosa

of the stomach.

Since there has yet

to be a conclusive

diagnostic/lab

exam, in the

incidence that she

may have gastric

ulcerations,

coating and

protecting the

mucosa of her

stomach will also

aid in the healing

of the ulcers.

Assessgastric pH

AssessI&O ratio

Assess GI

complaints

: nausea,vomiting,

diarrhea,

cramps

Providestorage at

room

temperature

Evaluate

therapeutic

response:

decreasedabdominal

pain

Teach

pt/family

to avoidblack

pepper,caffeine,

alcohol,

harshspices,

extremes

intemperatur

e of food

and thatdrug mustbe

continued

forprescribed

time to be

effective.

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Nalbuphine/

Nubain

1 amp q8 IV

prn for severeabdominal pain

Depresses pain

impulsetransmission at

the spinal cord

level by

interacting opioidreceptors.

Moderate to severe

pain. In ElenaBaldos case, she isexperiencing

severe epigastric,hypogastric and

RLQ pain and thisdrug was given to

her to help managethat pain.

AssessI&O ratio.

Assess for

allergic

reactions.

Check forrespiratory

dysfunction.

Administe

r IV routeundiluted

over 3-5

minutes.

Provide

storage in

light-resistant

area at

room

temperature.

Provide

assistancewith

ambulatio

n.

Evaluatetherapeuti

cresponse:

decrease

in pain.

Teach thatphysical

dependenc

y mayresult

from long-term use.

Ephedrine/Ep

hedrine

sulfate

1 amp x 2 doses

IV

Causes increased

contractility and

heart rate byacting on -

receptors in the

heart; also acts on

Shock; increased

perfusion,;

hypotension,

bronchodilation. Inthis case ephedrinewas given to

Assess

I&O ratio.

Assess forparesthesi

as and

coldness

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-receptors,

causingvasoconstriction

in blood vessels.

counteract the possibility of animpendinghypovolemic shock.

of

extremities.

Administe

r IV direct

routethrough

Y-tube or3-way

stop-cock;

give 10-25mg

slowly,

mayrepeat in

5-10

minutes. Storage of

reconstitut

ed

solutionrefrigerate

d no

longer

than 24hours.

Do not use

discoloredsolution.

Evaluate

therapeutic

response:

increasedBP with

stabilizatio

n.

Metronidazol

e/Flagyl

500 mg q8 IV

ANST (-)

Direct acting

amebicide/trichomonacidebinds, degrades

DNA in

organism.

Intestinal

amebiasis, amebicabscess,

trichomoniasis,

refractorytrichomoniasis,

bacterial anaerobic

infections,

giardiasis,septicemia,

Assess for

infections. Assess

stools

during

entiretreatment.

Assess

vision by

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endocarditis, bone,

joint infections,

lower respiratory

tract infections. In

Nanay Elenascase, she was

prescribedmetronidazole at

the ER becausethere was yet to bea conclusiveevaluation of her

disease due to thefact that she cannotverbalize her feelings at the time.

ophthalmi

c exam.

Assess

I&O ratio.

Assess for

allergicreactions.

Administer IV route

prediluted.

Providestorage in

light-

resistant

container;do not

refrigerate.

Evaluate

therapeuti

cresponse:

decreased

symptomsof

infection.

Teach

patient/family that

urine may

turn dark-reddish

brown,

drug maycause

metallic

taste.

Teach

properhygieneafter BM

Bisacodyl/Du

lcolax

1 Suppository

stat

Acts directly on

intestine byincreasing motor

activity; thought

to irritate colonic

Short-term

treatment of

constipation, bowel

or rectal preparation for

Assess

blood,urine

electrolyte

s if drug is

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intramural plexus. surgery,examination. InMrs. Baldos case,her sons reported

that she has notmoved her bowel

for more than aweek before

seeking medicalattention. Dulcolaxwould help her beable to move her

bowel due to thedirect increase in peristalsis that isits action.

used often

by patient.

Assess

I&O ratio.

Assess

cause forconstipatio

n.

Assess for

cramping.

Evaluatetherapeuti

c

response:

decreasein

constipation.

Teach not

to use for

long-termuse.

Teach that

normalBM do not

always

occur

daily.

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SUMMARY OF FINDINGS THAT ARE RELEVANT TO NURSING CARE

After assessment of physical, past medical history, family history, perceptions,specific and basic needs, I conclude that the following should be the focus of nursing

care:

ER assessment:

1. Severe pain r/t disease process2. Constipation r/t inability to retain ingested food 2 to disease process

3. Impaired verbal communication r/t childhood accident/trauma

Ward Assessment:

4. Fluid volume deficit r/t disease process

5. Ineffective breathing pattern r/t disease process

In prioritizing these problems, I have the following list of nursing problems:

1. Severe pain r/t disease process

2. Ineffective breathing pattern r/t disease process

3. Fluid volume deficit r/t disease process

4. Constipation r/t inability to retain ingested food 2 to disease process5. Impaired verbal communication r/t childhood accident/trauma

Due to the fact that assessment in ER is most essential for this case study becausethis is the area of assignment and owing to time constriction, the 1 st three problems

assessed in ER are given priority although some of the last three are more important in

nature.

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NURSING CARE PLANS

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ASSESSMENT STATEMENT OF

THE PROBLEM

PLANNING NURSING ACTION OUTCOME

Subjective/Objective

Cues

Nursing Diagnosis Long Term Goal/

Short Term Goal

Nursing Interventions with Rationale

Independent, Dependent, & Interdependent

Evaluation/

Revision

Subjective Cue:

None

Objective Cues:

Pale conjunctiva

Teary eyes noted

Sweaty forehead

Grimaced facenoted

Groaning

Guarding

behavior noted

Assuming fetalposition

Seeking SOoften

RR=30/minute

BP=90/70mmHg

Pain scale =10/10

Severe pain r/t disease

processBACKGROUND

KNOWLEDGE:Pain is defined in

NANDA as a state in

which an individualexperiences and

reports the presence ofsevere discomfort or

an uncomfortablesensation. In Elena

Baldos case, the painis severe enough for

her to try and getmedical treatment as

she can possibly be

able to do so.

Pharmacotherapy. IVtherapy, medical andnursing management

is focused on

alleviating thiscondition.

LTG: At the end

of 3 days nursingintervention, the

client will be ableto demonstrate

relaxed body

posture and ableto sleep/rest

appropriately.

STG: At the endof 1 days

nursing

intervention, theclient should be

able to expressthrough written

communication

reduction of painfrom a scale of

10/10 to 8/10.

Independent:

1. Monitor and record V/S.R: For baseline data and because V/S are usuallyaltered during pain episodes.

2. Instruct patient to relax and breatherhythmically.R: Anxiety and too much pain cause clients to

breathe rapidly and has more difficulty managingthe pain.3. Encourage client to do deep breathingexercises.R: Helps promote comfort and relaxation.4. Do and instruct SO about comfort measuressuch as backrubbing, soft massage of extremities,etc.R: Promotes patients comfort and deviatesattention from pain experience.5. Establish a form of communication such aswriting or nodding in agreement or shaking head

in disagreement.R: Gives the client a way to communicate desiresand needs.Dependent:

1. Administer IV fluid therapy.

R: To replace lost fluids and as a route forparenteral medications.

2. Administer medications, Ranitidine(Zantac).R: Inhibits histamine at H2-receptor site in parietal

cells, which inhibits gastric acid secretion.

Evaluation of

effectivity ofcare plan is

through theclients

communicati

on of painreduction/

and appearrelaxed and

well-rested.

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THE PROBLEM



Cues


Short Term Goal



Evaluation/

Revision

Subjective Cue:

None

Objective Cues:

Pale conjunctiva

Seeking SO

often

Episodes of apnea (ward)

Hooked to O2tank via nasal

cannula @ 3-4LPM

Ineffective breathing

pattern r/t diseaseprocess

BACKGROUNDKNOWLEDGE:

Ineffective breathing

pattern is a NANDA-accepted nursing

diagnosis of aninhalation or

exhalation pattern thatdoes not enable

adequate pulmonary

inflation or emptying.Such is Nanay Elenascase who experienced

apneic episodes in the

Medical ward.

LTG: At the end

of 3 days nursingintervention, the

client will be ableto establish

effective

breathing pattern.


nursingintervention, the

client should be

able toexperience no

signs of respiratory

compromise/

complications.

Independent:

1. Monitor and record V/S to pay particularattention to respiratory rate, rhythm and depth.R: For baseline data and because shallow

breathing, splinting with respirations, holdingbreath may result to hypoventilation or atelectasis.2Auscultate breath sounds.R: To assess for any signs of respiratory

problems.3. Assist patient to turn, cough and breath deeply

periodically.R: Promotes ventilation of all lung segments.Dependent:

1. Administer O2 therapy.

R: Assists in oxygenation by regulating O2volume.

Evaluation of

effectivity ofcare plan is

through theclients

establishment

of effectivebreathing

pattern andshow no

signs ofrespiratory

compromise

orcomplication

s.

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THE PROBLEM



Cues


Short Term Goal



Evaluation/

Revision

Subjective Cue:

None

Objective Cues: Pale conjunctiva

Poor skin turgor

Anorexia

Hgb=52g/L

Fluid volume deficitr/t disease process

BACKGROUND

KNOWLEDGE:

NANDA defines thisas the state in which

an individualexperiences vascular,

cellular, or intracellular

dehydration. In Nanay Elenas case, this is

evident in her dry skinand poor skin turgor

as well as her

generalized weakness.

LTG: At the endof 3 days nursing

intervention, theclient will be able

to maintain

adequate fluidvolume as

evidenced bymoist mucus

membranes andgood skin turgor.


nursingintervention, the

client should be

able todemonstrate

behaviors tomonitor and

correct deficit.

Independent:

1. Monitor and record V/S I&O.R: Provides information about overall fluid

balance.2. Assess V/S: BP, PR, and T.R: Hypotension, tachycardia, fever can indicate

response to fluid loss.3. Observe for excessively dry skin and mucus

membranes, decreased skin turgor, slowedcapillary refill.

R: Indicates excessive fluid loss.4. Monitor lab studies (electrolytes, and ABGs).R: Determines replacement needs andeffectiveness of therapy.Dependent:

1. Administer parenteral fluids as indicated.

R: To help in rehydration of client.

Evaluation ofeffectivity of

care plan isthrough the

clients

maintenanceof adequate

fluid volumeas evidenced

by moistmucus

membranes

and goodskin turgor.

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THE PROBLEM



Cues


Short Term Goal


Independent, Dependent, &

Interdependent

Evaluation/Revision

Subjective Cue:

NoneObjective Cues:

Guardingbehavior

noted

Irritability

Assuming

fetal position

Seeking SOoften

Decreasedactivity level

noted

Vomiting

ingested foodor fluid.

RR=30/minute

Constipation r/tinability to retain

ingested food 2 to

disease processBACKGROUND

KNOWLEDGE:

Constipation,

according to Billings

and Stokes for MedicalSurgical Nursing, is

the retention of fecalmaterial, delay in

excretion or delayfrom usual elimination

habits. In ElenaBaldos case, although

not yet conclusive, itmay have been

brought about by her

inability to retain foodand fluid intake due to

her pathologiccondition.

LTG: At the end of 3days nursing

intervention, the client

will be able toestablish/return to

normal patterns ofbowel functioning.

STG: At the end of 1hours nursing

intervention, the clientshould be able to

cooperate in procedures that will

enhance bowel

pattern.

Independent:

1. Review dietary regimen.

R: To assess direct cause of constipation.2. Record fluid intake.

R: Dehydration aggravates constipation.

3. Auscultate bowel sounds.

R: Bowel sounds are decreased in

constipation.

4. Encourage fluid intake if not

contraindicated.

R: Assists in improving stool consistence.

Interdependent:

1. Consult with dietician to provide well-

balanced diet high in fiber and bulk.

R: Fiber resists enzymatic digestion and

absorbs liquids in its passage along the

intestinal tract and thereby produces bulk,

which acts as a stimulant to defacation.

Dependent:

1. Administer IV fluid therapy.R: To facilitate rehydration and as a route

for parenteral medications.

2. Administer medications, Bisacodyl

(Dulcolax)

R: Acts directly on intestine by increasing

motor activity; thought to irritate colonic

intramural plexus.

Evaluation ofeffectivity of care

plan is through the

clients ability toreturn to normal

bowel patterns.

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THE PROBLEM



Cues

Nursing Diagnosis Long Term Goal/ Short

Term Goal


Independent, Dependent, &

Interdependent

Evaluation/Revision

Subjective Cue:

NoneObjective Cues:

Silent crying

Guardingbehavior noted

Soft groaningnoted

Irritability

Assuming fetalposition

Signaling SOwith handwaves

No oral/

writtencommunica-

tion expressed

No verbalresponses toquestions andenquiries

SOs verbalizationof a childhoodhead trauma

Impaired verbalcommunication r/tchildhood

accident/traumaBACKGROUND

KNOWLEDGE:

Nursing Care Plans byMarilyn Doenges statesthat impaired verbalcommunication may berelated to impairedcerebral circulation,neuromuscularimpairment, and loss oforal/facial/muscle tone /control or generalizedweakness. In Elena

Baldos case, her

childhood head traumacould be the cause ofthis impairment due butdue to the fact that shedid not have and seekmedical attention at thattime and she does notexpress this in her ownwords, this summary is

not yet conclusive.

LTG: At the end of 1

days nursingintervention, the client

will be able to

establish a method ofcommunication which

needs can beexpressed.

STG: At the end of 1hours nursing

intervention, the clientshould be able to

indicate anunderstanding of the

communication

problems.

Independent:

1. Assess type/degree of dysfunction.R: Helps determine difficulty that patient

has with any or all steps ofcommunication process.2. Provide alternative methods ofcommunication.R: Provides for communication ofneeds/desires based on individualsituation.3. Anticipate and provide for patientsneed.R: Helps in decreasing frustration whendependent on others and unable tocommunicate desires.4. Encourage SO/visitors to persist inefforts to communicate with patient.R: To reduce patients isolation and

promotes establishment of effectivecommunication pattern.Interdependent:

1. Consult with or refer to speechtherapist.

R: Assesses individual verbalcapabilities and sensory, motor, and

cognitive functioning to identifydeficits/therapy needs.

Evaluation of

effectivity of careplan is through the

clients

establishment of ameans to

communicate needsand desires.

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CONCLUSION

The study of Abdominal Aortic Aneurism (AAA) was a real challenge to me forseveral reasons:

1. It is the first time I have ever encountered this disease in the ER or in any

ward for that matter;2. It was a very time-constricted research for me;

3. I was alone in my research;

4. The interaction with the client was very fast-paced; and,5. My client died.

But through all these challenges, I have learned and experienced so much. In

dealing with AAA, I conclude the following:1. To render effective nursing care to an AAA patient must be done promptly

and with compassion.

2. That we should not only think of nursing as a job to do, especially in AAA

clients whose needs and concerns are immediate.3. That AAA is a very serious illness that comes rarely but gravely.

4. It is essential that we do not wait for an AAA to rupture because thiswould have very austere repercussions, most of the time such as in the

case of my client, death is a real possibility.

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DISCHARGE PLAN

M Instruct patient on medication the proper medicine, route, dosage, and duration.

E Instruct about proper financial and social assistance for economic needs.

T Treatments should be continued for prescribed time for continued effectivity.

H Health teachings should focus on maintaining optimum lood pressure to avoidcontinues enlargement and subsequent rupture of aneurism.

O Out-patient or home care should be continued for check-ups and diagnosticprocedures (ultrasound every 6 months)

D Diet should restrict salty and cholesterol-rich food.

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REFERENCES

Anderson, Kenneth N. et. al., 1990, Mosbys Pocket Dictionary, 3rd ed., St. Louis,

Missouri, The CV Mosby Company, pp. 52, 66, and 135.

Black, Joyce M. et. al., 1993, Luckmann and Sorensens Medical-Surgical Nursing

4th ed. Vol. 2, United States of America, W.B. Saunders Company, pp. 1295-1297.

Charnogursky, Gerald A. et.al., 1999, Handbook of Diseases 2nd ed.,Pennsylvania,

Springhouse Corporation, pp. 44-46.

Doenges, Marilynn E. et. al., 1993 Nurses Pocket Guide, 4th ed., Philadelphia, F.A.

Davis Company, pp. 105-108, 109-115, 126-134, 193-196, and 306-309.

Doenges, Marilynn E. et. al., 2002, Nursing Care Plans 6

th

ed.,Thailand, F.A. davisCompany, pp. 65-67, 234-236, 506-507, 595-596, and 654-655.

Lemone, Priscilla et. al., 2004, Medical-Surgical Nursing 3rd ed. Vol. 2, New Jersey,

Pearson Education, Ltd., pp. 994-996.

Marieb, Elaine N., 2002, Essentials of Human Anatomy & Physiology 6th ed.,Singapore, Addison Wesley Longman, pp. 313-330.

McFarland, Mary B. et. al., 1991, Nursing Implications of Laboratory Test 6th ed,New York, Delmar Publishers, pp. 19-38 and 166-177.

Roth, Linda S. et. al., 2004, Mosbys Nursing Drug Refernce, 2004 ed., Missouri,Mosby Inc., pp. 174-175, 400-403, 665-667, 702-704, and 871-873.

Smeltzer, Suzanne C. et. al., 1996, Medical-Surgical Nursing 8thed. Vol 1,Philadephia, Lippincott, pp. 738-741.

aortic aneurism

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