Download - Liver Cirrhosis
INTRODUCTION
Liver Cirrhosis is derived from Greek word kirrhos, meaning "tawny" (the
orange-yellow colour of the diseased liver). It is a consequence of chronic liver disease
characterized by replacement of liver tissue by fibrous scar tissue as well as regenerative
nodules (lumps that occur as a result of a process in which damaged tissue is
regenerated), leading to progressive loss of liver function. Cirrhosis is most commonly
caused by alcoholism, hepatitis B and C and fatty liver disease but has many other
possible causes. Some cases are idiopathic, i.e., of unknown cause. It is the 11th most
common cause of death in the United States and is most common among people ages 45
– 75. Most cases are a result of alcoholism, but toxins, biliary destruction, hepatitis, and a
number of metabolic conditions may stimulate the destruction process. In the
Philippines, this disease ranks as the 13th leading cause of death and has affected 126, 826
Filipinos in the year 2005. Locally, liver cirrhosis is the 17th leading cause of death.
Gastroenteritis (also known as gastro, gastric flu and stomach flu, although
unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the
stomach and the small intestine resulting in acute diarrhea. The inflammation is caused
most often by infection with certain viruses, less often by bacteria or their toxins,
parasites, or adverse reaction to something in the diet or medication. Worldwide,
inadequate treatment of gastroenteritis kills 5 to 8 million people per year, and is a
leading cause of death among infants and children under 5.
At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another
20% of cases, and the majority of severe cases in children, are due to rotavirus.
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Risk factors include consumption of improperly prepared foods or contaminated water
and travel or residence in areas of poor sanitation. It is also common for river swimmers
to become infected during times of rain as a result of contaminated runoff water. The
incidence is 1 in 1,000 people. It can also be classified as either viral or bacterial. A
major cause of morbidity and mortality in developing nations, gastroenteritis occurs in
people of all ages. In the United States, this disorder ranks second to the common colds
as a cause of lost work time and fifth as the cause of death among young children. It can
also be life-threatening in elderly and debilitated patients. This disorder belongs to one of
the ten causes of morbidity and mortality in the Philippines. Locally, it ranks 14 th among
the leading causes of death.
Our patient, given the name “T2”, was chosen as the subject for this case study
because of his condition. He acquired schistosomiasis which led to the removal of his
spleen and then resulted to liver cirrhosis.
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OBJECTIVES
General Objectives:
To conduct a thorough and comprehensive study about the Mr. T2’s disease
according to the data that was gathered by conducting a series of interviews and through
the use of data gathered from extensive research.
Specific Objectives:
To organize our patient’s data for the establishment of good background
information
To show the family health history as well as the history of past and present illness
for the knowledge of what could be the predisposing factors that might contribute
to the patient's illness
To present the family’s genogram containing information that will help out in
tracing any hereditary risk factors
To trace the psychological development of our patient through analysis of different
developmental theories with comparison to the patient’s data
To give different definitions of the complete diagnosis of our patient for better
understanding of unfamiliar terms
To present the data from the physical assessment performed on our patient using
the cephalocaudal approach for a good overview of her over-all health
To discuss the human anatomy and physiology of the systems involved in the
disease process of our patient
To identify the symptoms, predisposing and precipitating factors that contribute to
the present illness of the patient
To organize a flow chart showing the pathophysiology of liver cirrhosis as well as
its relation to acute gastroenteritis for a clear visualization of how this condition
affects a person
To list the different orders of the physicians assigned to our patient together with
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their rationale for a general knowledge of what consists of the medical
management for liver cirrhosis
To present the different results of our patient’s diagnostic exams together with
comparisons of normal values for the understanding of what changes during the
disease
To list the different drugs used by our patient to have a better understanding of its
actions and indications
To analyze the different nursing theories applicable to our patient
To formulate specific, measurable, attainable, realistic and time-bounded nursing
care plans
To impart appropriate health teachings specifically for the patient to promote
wellness
To present an appropriate discharge plan for our patient
To have an over-all conclusion and recommendation about the case study
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PATIENT’S DATA
Patient’s Code name: Mr. T2
Age: 24 years old
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Occupation: Technician
Ward: Med CP Ward
Hospital No: 1091204
Date of Admission: April 15, 2009
Time of Admission: 12:35 am
Vital Signs on Admission:
BP – 110/ 80mmHg
RR –21 bpm
Temp: 36.7ºC
PR: 76bpm
Mode of Arrival: Stretcher
Admitting Doctor: Dr. Carl Hill N. Florida
Admitting Diagnosis: Liver Cirrhosis: A.G.E. with moderate Dehydration
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FAMILY BACKGROUND
Mr. T2, a 24-year old male, was born in Davao City on September 15, 1984. He is
currently residing at Estores Village, Davao City. They are 7 in the family including his
parents. He is the third child among the five children. Our patient was completely
immunized since he received the needed immunizations before he reached 1 year old.
He enrolled in elementary at B.F. Coucuera Elementary School at Malagamot,
Panacan, Davao City. He finished high school at University of Mindanao at Ilang,
Tibungco, Davao City. Our patient was not able to study in college because of financial
constraints. Our patient used to work in Ateneo College as a technician in the
Engineering Department. At present, he is working at Notre Dame of Marbel as a
technician.
Upon interview, Mr. T2 said that no one in his family had the same disease.
LIFESTYLE
Mr. T2 described his workplace as having a stressful environment as well as his
job. He works six days a week and verbalized that he was always assigned to different
departments and mostly he works more than his hours of duty. He reported that when he
is not working, he usually stays at his boarding house sleeping and eating.
When asked about how he usually spends his days, Mr. T2 was able to formulate
a schedule that would describe his activities of daily living. He would wake up at 6:00
am. The first thing he would do is to take a bath, change to his working clothes then takes
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his breakfast. He arrives at his workplace at around 7:30 am. It is in there where he does
his work. His duty ends at 5:00 pm but he usually goes home at 9:00 or 10:00 pm because
of overtime. When he arrives at home, he sometimes skips his meals and goes directly to
bed.
DIET
Mr. T2 verbalized that he is fond of eating chicken, egg, hotdog, meat and he
seldom eats vegetables. He admits that he is an occasional drinker but does not smoke.
He said that he only drinks alcoholic beverages whenever there are occasions such as
birthdays and fiestas.
HISTORY OF PATIENT’S PAST ILLNESS
According to Mr. T2, he was hospitalized four times. His first hospitalization was
on 2005 due to melena. He then underwent endoscopy and was diagnosed with ulcer.
When asked about the medicines he took, he immediately said that he cannot recall the
names of those medicines.
His second hospitalization was on 2006 due to schistosomiasis. His chief
complaints were abdominal pain and fatigue and he was not able to determine the real
cause why he acquired such disease. In addition, his diagnostic exam showed that he has
enlarged spleen which needed immediate attention. Due to this, he had undergone
splenectomy on the same year. After the said procedure, he was not able to have follow-
up check-ups.
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His third hospitalization was on March 15, 2009. His chief complaint was melena
and had an admitting diagnosis of Upper Gastrointestinal Bleeding. During this
hospitalization, he was also diagnosed with Liver Cirrhosis. Among complaints were
yellowish discoloration of skin, insomnia, recurrent fever, fatigue, abdominal pain,
weight loss, nosebleed and nausea.
HISTORY OF PRESENT ILLNESS
Mr. T2’s fourth hospitalization was on April 15, 2009 due to his present illness
which is Acute Gastroenterisits. He verbalized that he experienced diarrhea since
March19, 2009. Three days prior to his admission, he experienced an onset of
undocumented fever associated with diarrhea. Then a day prior to his admission, he had
five episodes of loose bowel movement with blood streaked stools thus prompted the
consult.
EFFECTS OF ILLNESS TO THE FAMILY
During the interview, Mr. T2 was asked regarding the effects of his illness to him
and to his family. He directly said that it greatly affected their family especially on
financial and emotional matters. He said that it is understandable why it affected them
financially because of his hospitalizations. Emotionally they are affected because of the
emotional stress they encounter everytime Mr. T2 is hospitalized.
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DEVELOPMENTAL DATA
Theorist Theory Stage Result and Justification
Erik Erikson’s
Psychosocial
Theory of
Development
Source:
Fundamentals of Nursing, 3rd EditionBy:Sue C. DelaunePatricia K. Ladner
Fundamentals of Nursing, 7th
EditionBy:Barbara Kozier, Glenora Erb, Audrey Berman, Sherlee Snyder
Erik Erikson
theorized that
development is a
lifelong process and
does not end with
the cessation of
adolescence. Just as
physical growth
patterns can be
predicted, certain
psychosocial tasks
must be mastered in
each developmental
stage. The greater
the task
achievement, the
healthier the
personality of the
person. However,
failure to achieve a
Intimacy Vs. Isolation
(18 to 25 years old)
Individuals feel
established as adults and
autonomous from their
families. A person
develops closeness and
committed meaningful
relationships with other
people. They see
themselves as well-
defined but still feel the
need to prove themselves
to their parents. They see
this as the time for
growing and building time
for the future.
A person with a poor
sense of self tend to have
less committed
The patient has
positively achieved
this stage of
development. He
has the ability to
keep a good
relationship with
other people
especially to the
other sex. He said
that he is very
much happy and
contented with his
current girlfriend
because they were
able to establish an
intimate
relationship for
almost 4 years now.
He is thankful
because they both
help each other’s
needs and wants
since they both
matured together.
Also, he said that
he is one lucky guy
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task influences the
person’s ability to
achieve the next
task. The resolution
of the conflicts at
each stage enables
the person to
function effectively
in society.
relationships and are more
likely to suffer emotional
isolation, loneliness, and
depression.
A positive outcome in this
stage is achieved if the
person establishes an
intimate relationship to
another person, accepts
sexual behavior as
desirable, and makes a
commitment to a
relationship even at times
of stress and sacrifice.
for having a family
who cares for him
so much and
supports whatever
his decisions will
be. Without doubt
T2 did not have any
regrets in all his
decisions and
things he made
whether it be bad or
good for as long as
it’ll serve as a
lesson for him.
T2 said that even
though he is stress
from his
workloads, he has
his inspiration and
is still loved by
many. He added
that he is also ready
to marry his current
girlfriend as soon
as he is able.
Lawrence
Kohlberg’s
Lawrence
Kohlberg’s theory
Level II: Conventional
In this level, the person is
T2 is a nice and
considerate person
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Stages of
Moral
Development
Source:
Fundamentals
of Nursing,
3rd Edition
By:
Sue C. Delaune
Patricia K.
Ladner
Fundamentals
of Nursing, 7th
Edition
By:
Barbara Kozier,
Glenora Erb,
Audrey
Berman,
Sherlee Snyder
specifically
addresses moral
development in
children and adults.
The morality of an
individual’s
decision was not
Kohlberg’s concern;
rather, he focused
on the reasons the
individual makes a
decision. His model
states that a
person’s ability to
make moral
judgments and
behave in a morally
correct manner
develops over a
period of time.
concerned with
maintaining expectations
and rules of the family,
group, nation, or society.
The person values
conformity, loyalty, and
active maintenance of
social order and control.
Stages:
Interpersonal
Concordance
Orientation:
Decisions and behavior
are based on concerns
about others’ reaction; the
person wants others’
approval or a reward.
Law-and-Order
Orientation:
The person wants
established rules and the
reason for decisions and
behavior is that social and
sexual rules and traditions
demand the response.
according to his
older brother. He
prefers to cater to
the needs of his
family before
tending to his own.
Whenever
problems or
decisions come
along, he puts
himself to the shoes
of the others. Thus,
understanding the
feelings and
concerns of others
like his family and
friends. He abides
and maintains law
and order by
following the rules,
doing one’s duty,
and respecting
authority.
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Robert
Havighurst’s
Developmental
Milestones
Theory
Source:
Fundamentals of Nursing, 3rd EditionBy:Sue C. DelaunePatricia K. Ladner
Fundamentals of Nursing, 7th
EditionBy:Barbara Kozier, Glenora Erb, Audrey Berman, Sherlee Snyder
Havighurst
theorized that there
are six
developmental
stages of life, each
with essential tasks
to be achieved.
Mastery of a task in
one developmental
stage is essential for
mastery of tasks in
subsequent stages.
A successful
achievement of a
task leads to
happiness and to
success with later
tasks. However,
failure leads to
unhappiness in the
individual and
difficulty with later
tasks.
Early Adulthood (19 to 29 years)
This stage in a person’s
life is concerned with the
achievement of the
following tasks:
Selecting a
mate
Learning to live
with a partner
X Starting a
family
X Rearing
children
Managing a
home
Getting started
in an
occupation
Taking on
civic
responsibility
Finding a
congenial
T2 is not yet
married but he has
plans on marrying
his girlfriend as
soon as he can save
enough money.
He was not able to
achieve the third
and fourth task
since he is still
single with no
children to attend
to. Though he is
busy, he still finds
time to help his
parents in
maintaining the
cleanliness of the
house. He is
currently working
as a technician at
Notre Dame of
Marbel in order to
attend to the wants
and needs of his
family. He is also
aware of his
responsibilities as a
Filipino citizen. For
one, he is a
registered voter,
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social group second, pays his
taxes and abides
the laws. He
claimed that he
doesn’t find it hard
to interact with his
neighbors because
they are
approachable and
helpful every time
they may have
some problems.
Thus, in return, he
and his family also
render help when
needed. “It’s a give
and take
relationship”, T2
added. He is not a
member of any
social institution,
since he is more
focused with his
job.
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DEFINITION OF COMPLETE DIAGNOSIS
Liver Cirrhosis
A chronic hepatic disease, cirrhosis is characterized by diffuse destruction and
fibrotic regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease
alters liver structure and normal vasculature, impairs blood and lymph flow, and
ultimately causes hepatic insufficiency.
Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse
Liver Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement
of liver tissue by fibrous scar tissue as well as regenerative nodules (lumps that occur as a
result of a process in which damaged tissue is regenerated) leading to progressive loss of
liver function.
Source: Blackwell’s Dictionary of Nursing 5th Edition
Liver Cirrhosis
Cirrhosis is a chronic, degenerative disease in which normal liver cells are
damaged and are then replaced by scar tissue.
Source: http://www.answers.com/topic/cirrhosis
AGE with Mild Dehydration
A self-limiting disorder, gastroenteritis is an inflammation of the stomach and
small intestine. The bowel reacts to any of the varied causes of gastroenteritis with
hypermotility, producing severe diarrhea and secondary depletion of intracellular fluid. is
the loss of water from the body. With mild dehydration, a related disorder where both
fluids and salts are depleted in the cells or volume depletion.
Source: http://www.answers.com/topic/cirrhosis
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AGE with Mild Dehydration
Gastroenteritis is inflammation of the gastrointestinal tract, involving both the
stomach and the small intestine and resulting in acute diarrhea. With a relative
deficiency of water molecules in relation to other dissolved solutes.
Source: http://en.wikipedia.org/wiki/Gastroenteritis
Gastroenteritis
A self- limiting disorder, gastroenteritis is an inflammation of the stomach and
small intestine.
Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse
Liver Cirrhosis; AGE with mild dehydration
A chronic hepatic disease, cirrhosis is characterized by diffuse destruction and
fibrotic regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease
alters liver structure and normal vasculature, impairs blood and lymph flow, and
ultimately causes hepatic insufficiency.
A self-limiting disorder, gastroenteritis is an inflammation of the stomach and
small intestine. The bowel reacts to any of the varied causes of gastroenteritis with
hypermotility, producing severe diarrhea and secondary depletion of intracellular fluid. is
the loss of water from the body. With mild dehydration, a related disorder where both
fluids and salts are depleted in the cells or volume depletion.
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PHYSICAL ASSESSMENT
Patient’s Name: Mr. T2
Age: 24 y.o.
Sex: Male
Ward: Med Cp (DMC)
General Survey:
Our patient, Mr. T2 was assessed on April 17, 2009 at 5:00pm. He was received
lying on bed awake, conscious and coherent. He has an ongoing IVF of D5.3 NaCl 1 liter
regulated @120cc/hr infusing well at L metacarpal vein at 400cc level. He weighs 46
kilograms and he has an ectomorphic body structure. He was responsive and cooperative
when asked.
Vital signs
4:00 pm
BP- 110/60 mmHg
PR- 78 bpm
RR- 24 bpm
Temp.- 37.6 °C
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Skin
Mild jaundice was noted on his skin. He has good skin turgor as skin goes back to
its previous state after being pinched and with a capillary refill of 2 seconds. He has dry
skin with a rough texture. Nails were not properly trimmed and traces of dirt were noted.
Upon palpation, the skin on his forearm is warm.
Head
Our patient’s head is normocephalic. Presence of hair was noted in the head and
in the upper and lower extremities. Lesions, bleeding and bruises were not seen upon
inspection.
Eyes
The sclera is moist and yellowish in color. The iris appears to be black on both
eyes. He has an isocuric pupil reaction of 2mm; round and reactive to light and
accommodation. He verbalized that he can see both near and far objects. Both eyes move
in unison, no signs of scratches and discharges on both eyes noted. Sunken eyeballs are
also noted.
Ears
The shape of the pinnaes are oval and with no discharges noted. Upper margin of
the pinnaes are in line with the outer canthi of the eyes. Ears are firm and non-tender.
Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was
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able to repeat a sentence when it was softly said behind his ears, which reveals that he
does not have any hearing problems.
Nose
External surface of the nose is smooth and oily. Nasolabial folds are symmetrical.
Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are
present upon inspection. Nasal septum is not deviated. Both nostrils are patent. No signs
of tenderness were noted. Patient was able to distinguish the smell of rubbing alcohol and
female perfume while eyes were closed.
Mouth
Gums and buccal mucosa are pinkish in color. Tongue is in the midline of the
mouth. Tonsils are not inflamed. No signs of inflammation and laceration on the uvula.
Bleeding, ulceration and swelling were not seen upon inspection. Patient was on diet as
tolerated and does not have any difficulty eating and swallowing.
Neck
The neck of our patient can move easily without any difficulty, which includes
right and left lateral, right and left rotation, flexion and hyperextension. Neck can
properly support the head. No signs of enlargement and masses on the thyroid. Carotid
pulse is palpable. No signs of swelling or enlargement of the lymph nodes. No
deformities noted.
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Chest and Lungs
Chest muscle expansion during inspiration and relaxation during expiration are
symmetrical and painless. There were no presence of scars and lesions. He was not in
respiratory distress. Respiratory rate is 24 cycles per minute and rhythm was regular.
Breath sounds were clear on both lungs but upon observing he coughs and whitish
sputum was noted upon coughing.
Abdomen
Patient’s abdomen is flat upon inspection. Palpation was contraindicated due to
his disease. But according to him, he feels a stabbing pain in the hypogastric region on
his abdomen because of presence of dyspepsia. A scar was noted starting in the xyphoid
process until above the mons pubis. Hyperactive bowel movements were noted at 16
sounds in one full minute.
Genito-Urinary
Patient refused to be assessed on his genital area. However, patient verbalized no
pain or difficulty upon urination and defecation. His total urine output for 8 hours was
about 640cc and was able to defecate six times with an output of approximately 1500cc.
Upper extremities
Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted
on the bones of the wrist and fingers. No deformities and swelling noted. He could freely
move his shoulders. The patient has a weak grip when he was asked to squeeze one of the
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student nurse’s hands. No structural deviations noted. T2 was undergoing venoclysis with
IVF of D5.3NaCl 1 liter regulated @120cc/hr infusing well at L metacarpal vein at 400cc
level.
Lower Extremities
Both legs of the patient are symmetrical and can stretch, flex, rotate, extend and
bend without any difficulty. No signs of deformities, lesions, lacerations, bruises and
bleeding were seen upon inspection. Patient has difficulty ambulating because of fatigue,
he needs assistance when he goes to the comfort room.
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ANATOMY AND PHYSIOLOGY
Gastrointestinal Tract[image from: http://www.lessonsonthelake.com/_images//j0438737.jpg]
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from
the oral cavity, where food enters the mouth, continuing through the pharynx,
oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There
are various accessory organs that assist the tract by secreting enzymes to help break down
food into its component nutrients. Thus the salivary glands, liver, pancreas and gall
bladder have important functions in the digestive system. Food is propelled along the
length of the GIT by peristaltic movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break down food into
nutrients, which can be absorbed into the body to provide energy. First food must be
ingested into the mouth to be mechanically processed and moistened. Secondly, digestion
occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates
are chemically broken down into their basic building blocks. Smaller molecules are then
absorbed across the epithelium of the small intestine and subsequently enter the
circulation. The large intestine plays a key role in reabsorbing excess water. Finally,
undigested material and secreted waste products are excreted from the body via
defecation (passing of faeces).
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Cross-section of the small intestine[image from: http://z.about.com/d/coloncancer/1/0/Y/3/Overview.png]
The digestive tract, from the esophagus to the anus, is characterized by a wall
with four layers, or tunics. Here are the layers, from the inside of the tract to the outside:
The mucosa is a mucous membrane that lines the inside of the digestive tract from
mouth to anus. Depending upon the section of the digestive tract, it protects the
GI tract wall, secretes substances, and absorbs the end products of digestion. It is
composed of three layers:
o The epithelium is the innermost layer of the mucosa. It is composed of
simple columnar epithelium or stratified squamous epithelium. Also
present are goblet cells that secrete mucus that protects the epithelium
from digestion and endocrine cells that secrete hormones into the blood.
o The lamina propria lies outside the epithelium. It is composed of areolar
connective tissue. Blood vessels and lymphatic vessels present in this
layer provide nutrients to the epithelial layer, distribute hormones
produced in the epithelium, and absorb end products of digestion from the
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lumen. The lamina propria also contains the mucosa-associated lymphoid
tissue (MALT), nodules of lymphatic tissue bearing lymphocytes and
macrophages that protect the GI tract wall from bacteria and other
pathogens that may be mixed with food.
o The muscularis mucosae, the outer layer of the mucosa, is a thin layer of
smooth muscle responsible for generating local movements. In the
stomach and small intestine, the smooth muscle generates folds that
increase the absorptive surface area of the mucosa.
The submucosa lies outside the mucosa. It consists of areolar connective tissue
containing blood vessels, lymphatic vessels, and nerve fibers.
The muscularis (muscularis externa) is a layer of muscle. In the mouth and
pharynx, it consists of skeletal muscle that aids in swallowing. In the rest of the
GI tract, it consists of smooth muscle (three layers in the stomach, two layers in
the small and large intestines) and associated nerve fibers. The smooth muscle is
responsible for movement of food by peristalsis and mechanical digestion by
segmentation. In some regions, the circular layer of smooth muscle enlarges to
form sphincters, circular muscles that control the opening and closing of the
lumen (such as between the stomach and small intestine).
The serosa is a serous membrane that lines the outside of an organ. The following
serosae are associated with the digestive tract:
o The adventitia is the serous membrane that lines the esophagus.
o The visceral peritoneum is the serous membrane that lines the stomach,
large intestine, and small intestine.
o The mesentery is an extension of the visceral peritoneum that attaches the
small intestine to the rear abdominal wall.
o The mesocolon is an extension of the visceral peritoneum that attaches the
large intestine to the rear of the abdominal wall.
o The parietal peritoneum lines the abdominopelvic cavity (abdominal and
pelvic cavities). The abdominal cavity contains the stomach, small
intestine, large intestine, liver, spleen, and pancreas. The pelvic cavity
contains the urinary bladder, rectum, and internal reproductive organs.
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Motility
The gastrointestinal tract generates motility using smooth muscle subunits linked by gap
junctions. These subunits fire spontaneously in either a tonic or a phasic fashion. Tonic
contractions are those contractions that are maintained from several minutes up to hours
at a time. These occur in the sphincters of the tract, as well as in the anterior stomach.
The other type of contractions, called phasic contractions, consist of brief periods of both
relaxation and contraction, occurring in the posterior stomach and the small intestine, and
are carried out by the muscularis externa.
Stimulation
The stimulation for these contractions likely originates in modified smooth muscle cells
called interstitial cells of Cajal. These cells cause spontaneous cycles of slow wave
potentials that can cause action potentials in smooth muscle cells. They are associated
with the contractile smooth muscle via gap junctions. These slow wave potentials must
reach a threshold level for the action potential to occur, whereupon Ca2+ channels on the
smooth muscle open and an action potential occurs. As the contraction is graded based
upon how much Ca2+ enters the cell, the longer the duration of slow wave, the more
action potentials occur. This in turn results in greater contraction force from the smooth
muscle. Both amplitude and duration of the slow waves can be modified based upon the
presence of neurotransmitters, hormones or other paracrine signaling. The number of
slow wave potentials per minute varies based upon the location in the digestive tract. This
number ranges from 3 waves/min in the stomach to 12 waves/min in the intestines.
Contraction Patterns
The patterns of gastrointestinal contraction as a whole can be divided into two distinct
patterns, peristalsis and segmentation. Occurring between meals, the migrating motor
complex is a series of peristaltic wave’s cycles in distinct phases starting with relaxation
followed by an increasing level of activity to a peak level of peristaltic activity lasting for
5-15 minutes. This cycle repeats ever 1.5-2 hours but is interrupted by food ingestion.
The role of this process is likely to clean excess bacteria and food from the digestive
system.
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Peristalsis
Peristalsis is the second of the three patterns and is one of the patterns that occur during
and shortly after a meal. The contractions occur in wave patterns traveling down short
lengths of the GI tract from one section to the next. The contractions occur directly
behind the bolus of food that is in the system, forcing it toward the anus into the next
relaxed section of smooth muscle. This relaxed section then contracts, generating smooth
forward movement of the bolus at between 2-25 cm per second. This contraction pattern
depends upon hormones, paracrine signals, and the autonomic nervous system for proper
regulation.
Segmentation
The third contraction pattern is segmentation, which also occurs during and shortly after a
meal within short lengths in segmented or random patterns along the intestine. This
process is carried out by longitudinal muscles relaxing while circular muscles contract at
alternating sections thereby mixing the food. This mixing allows food and digestive
enzymes to maintain a uniform composition, as well as to ensure contact with the
epithelium for proper absorption.
Secretion
Every day, seven liters of fluid are secreted by the digestive system. This fluid is
composed of four primary components: ions, digestive enzymes, mucus, and bile. About
half of these fluids are secreted by the salivary glands, pancreas, and liver, which
compose the accessory organs and glands of the digestive system. The rest of the fluid is
secreted by the GI epithelial cells.
25
Ions
The largest component of secreted fluids is ions and water, which are first secreted and
then reabsorbed along the tract. The ions secreted primarily consist of H+, K+, Cl-,
HCO3- and Na+. Water follows the movement of these ions. The GI tract accomplishes
this ion pumping using a system of proteins that are capable of active transport,
facilitated diffusion and open channel ion movement. The arrangement of these proteins
on the apical and basolateral sides of the epithelium determines the net movement of ions
and water in the tract.
H+ and Cl- are secreted by the parietal cells into the lumen of the stomach creating acidic
conditions with a low pH of 1. H+ is pumped into the stomach by exchanging it with K+.
This process also requires ATP as a source of energy; however, Cl- then follows the
positive charge in the H+ through an open apical channel protein.
HCO3- secretion occurs to neutralize the acid secretions that make their way into the
duodenum of the small intestine. Most of the HCO3- comes from pancreatic acinar cells
in the form of NaHCO3 in a watery solution. This is the result of the high concentration
of both HCO3- and Na+ present in the duct creating an osmotic gradient to which the
water follows.
Digestive Enzymes
The second vital secretion of the GI tract is that of digestive enzymes that are secreted in
the mouth, stomach and intestines. Some of these enzymes are secreted by accessory
digestive organs, while others are secreted by the epithelial cells of the stomach and
intestine. While some of these enzymes remain embedded in the wall of the GI tract,
others are secreted in an inactive proenzyme form. When these proenzymes reach the
lumen of the tract, a factor specific to a particular proenzyme will activate it. A prime
example of this is pepsin, which is secreted in the stomach by chief cells. Pepsin in its
secreted form is inactive (pepsinogen). However, once it reaches the gastic lumen it
becomes activated into pepsin by the high H+ concentration, becoming a enzyme vital to
digestion. The release of the enzymes is regulated by neural, hormonal, or paracrine
signals. However, in general, parasympathtic stimulation increases secretion of all
digestive enzmes.
26
Mucus
Mucus is released in the stomach and intestine, and serves to lubricate and protect the
inner mucosa of the tract. It is composed of a specific family of glycoproteins termed
mucins and is generally very viscous. Mucus is made by two types of specialized cells
termed mucus cells in the stomach and goblet cells in the intestines. Signals for increased
mucus release include parasympathetic innervations, immune system response and
enteric nervous system messengers.
Bile
Bile is secreted into the duodenum of the small intestine via the common bile duct. It is
produced in liver cells and stored in the gall bladder until release during a meal. Bile is
formed of three elements: bile salts, bilirubin and cholesterol. Bilirubin is a waste product
of the breakdown of hemoglobin. The cholesterol present is secreted with the feces. The
bile salt component is an active non-enzymatic substance that facilitates fat absorption by
helping it to form an emulsion with water due to its amphoteric nature. These salts are
formed in the hepatocytes from bile acids combined with an amino acid. Other
compounds such as the waste products of drug degradation are also present in the bile.
Regulation
The digestive system has a complex system of motility and secretion regulation which is
vital for proper function. This task is accomplished via a system of long reflexes from the
central nervous system (CNS), short reflexes from the enteric nervous system (ENS) and
reflexes from GI peptides working in harmony with each other.
27
ETIOLOGY
Predisposing Factors
Factor Rationale Present or Absent JustificationExtremes of age Extremes of age can
increase the susceptibility of getting ill with AGE
Absent Patient is an adult and does not belong to the pediatric or geriatric classification.
Location – Philippines
The Philippines is considered as one of the South-East Asian countries that have high numbers of E. histolytica.
Present Patient has lived in the Philippines for a long period of time.
Race - Filipino The Filipino culture is fond of eating without utensils
Present Patient is a Filipino, and has lived in the Philippines his entire life so far.
28
Precipitating Factors
Factor Rationale Present or Absent JustificationNegligence to observe proper hand washing
Failure to do proper hand washing leads to increased risk of ingesting bacteria
Present Patient verbalized that he does not wash his hands as often as needed.
Facial contact with surfaces containing bacteria.
Facial contact, especially with the mouth, can lead to increased risk of ingesting bacteria
Present Patient verbalized that for a few days, he stayed in a ward where he got ill with Acute Gastroenteritis.
Ingestion poisonous plants
Poisonous plants can cause disturbances in the GI tract leading to AGE and other GI disturbances.
Absent Patient did not ingest any known poisonous plant.
Food allergens Food allergies can also cause GI disturbances
Absent Patient does not have any food allergies.
Drug reactions from antibiotics
Antibiotic-associated diarrhea (AAD)can be related to AGE
Absent Patient has not been examined for AAD. Assumption of the presence of this risk factor cannot be done.
29
SYMPTOMATOLOGY
Symptom Rationale Present or Absent JustificationAbdominal Pain Pain is felt from the
gas that accumulates in the GI tract.
Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.
Nausea and Vomiting
Nausea and Vomiting is caused by the increased motility of the GI tract.
Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.
Fatigue Fatigue is caused by the rapid losing of electrolytes.
Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.
Diarrhea Diarrhea is caused by the increased peristalsis of the intestines.
Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.
Dehydration Dehydration is also caused by rapid loss of body fluids.
Present Intake and output documents revealed that this symptom is present.
Malaise Malaise is the result of the lack of fluids in the brain and muscles of the body.
Present Patient verbalized a confirmatory remark that he indeed experienced the symptom.
30
31
Ingestion of bacteria
Direct invasion of the bowel wall
Stimulation and destruction of mucosal lining of the bowel wall
ulceration
Attempted defecation (tenesmus)
Digestive & absorptive malfunction
Pain
GI bleeding
melena
hematochezia
hematemesis
Excessive gas formation
GI distention
Nausea & vomiting
Flatus
Endotoxins are released
Predisposing factor:
Extremes of ageLocation – PhilippinesRace - Filipino
Precipitating factor:
-Negligence to observe proper hand washing-Facial contact with surfaces containing bacteria.-Ingestion poisonous plants-Food allergens-Drug reactions from antibiotics
PATHOPHYSIOLOGY
32
Secretion of F&E in the
intestinal lumen
Increase peristaltic movement
Increase secretionof Cl & HCO3
ions in the bowel
Hyperactive bowel sound (borborygmi)
Mild diarrhea (2-3 stools)
F&E imbalance
hypernatremiaIncrease protein in
the lumen
Large intestine is overwhelmed & unable to
reabsorb the lost fluid
Intense diarrhea (>10x) (watery stool)
Serious fluid volume deficit
Hypovolemic shock
Death
Hypotension
Acute gastroenteritis is usually caused by bacteria and protozoan. In the Philippines, one
of the most common causes of acute gastroenteritis is E. histolytica. The pathologic process starts
with ingestion of fecally contaminated food and water. The organism affects the body through
direct invasion and by endotoxin being released by the organism. Through these two processes
the bowel mucosal lining is stimulated and destroyed the eventually lead to attempted defecation
or tenesmus as the body tries to get rid of the foreign organism in the stomach.
The client with acute gastroenteritis may also report excessive gas formation that may
leads to abdominal distention and passing of flatus due to digestive and absorptive malfunction in
the system. Feeling of fullness and the increase motility of the gastrointestinal tract may progress
to nausea and vomiting and increasing frequency of defecation. Abdominal pain and feeling of
fullness maybe relieved only when the patient is able to pass a flatus.
As the destruction of the bowel continues the mucosal lining erodes due to toxin, direct
invasion of the organism and the action of the hydrochloric acid of the stomach. As the protective
coating of the stomach erodes the digestive capabilities of the acid helps in destroying the
stomach lining. Pain or tenderness of the abdomen is then felt by the patient. When the burrows
or ulceration reaches the blood vessels in the stomach bleeding will be induced. Dysentery may
be characterized by melena or hematochezia depending on the site and quantity of bleeding that
may ensue. Signs of bleeding may be observed also through hematemesis.
As the bowel is stimulated by the organism and its toxin, the intestinal tract secretes
water and electrolytes in the intestinal lumen. The body secretes and therefore lost Chloride and
bicarbonate ions in the bowel as the body try to get rid of the organism by increasing peristalsis
and number of defecation. Sodium and water reabsorption in the bowel is inhibited with the lost
of the two electrolytes.
Mild diarrhea is characterized by 2-3 stool, borborygmi (hyperactive bowel sound),fluid
and electrolyte imbalance and hypernatremia. When the condition continue to progress, protein in
the body is excreted to the lumen that further decreases the reabsorption and the body become
overwhelmed that leads to intense diarrhea with more than 10 watery stool. Serious fluid volume
deficit may lead to hypovolemic shock and eventually death.
33
DOCTOR’S ORDER
DATE DOCTOR'S ORDER RATIONALE REMARKS
April 15, 20092:45 pm
Pls. admit under the white service at med main level II
The patient is in need of medical attention so she is admitted in Davao Medical Center Hospital
DONE
Secure consent for care For legal purposes and to ensure that the client understands the nature of the treatment
DONE
TPRq4˚ Vital signs are recorded to obtain patients baseline data and are useful for further management. A temperature higher than normal may indicate the development of infection. Pulse & respiration is taken to watch out for tachycardia - a sign of hemorrhage & dehydration.
DONE
Labs:CBC with pc, Blood typing, PT with INR, Urinalysis, Creatine, Potassium, Sodium, ECG- 12 leads, Fecalysis
These entire lab tests are performed to screen for alteration and to serve as a baseline data for future comparison.
DONE
Start venoclysis with D5 0.3 NaCl to run for 8 hours fast drip 200 cc now
Serves as a route for IVTT medications and replaces fluid and electrolyte losses due to frequent loose bowel movement
DONE
Meds:1. Essentiale forte tab 1 tab Indicated for liver disorders
DONE
34
2. Ranitidine 50 mg IVTT now every 8 hours
3. Hyoscine amp 1 amp IVTT now then every 8 hours
4. Metronidazole 500 mg per amp 1 amp every 8 hours ANST
Short term treatment for gastric ulcer
Treatment for abdominal pain
Treatment for bacterial infection
I & O every shift To determine if the patient’s intake is closely equal to his output
DONE
Refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.
DONE
April 15, 20092:45 pm
Transfer to blue service, please inform service
To render specific treatment for gastro cases
DONE
April 16, 20096:15 pm
Dx: stool culture To ensure that the needed specimen will be obtained for early examination and diagnosis
DONE
For colonoscopy scheduling To aware the NOD and to schedule for the endoscopic examination of the colon
DONE
Transfer to blue service ( gastro)
To render specific treatment for gastro cases
DONE
April 16, 200910:25 am
Dx for CT scan of the whole abdomen
To test the amount of glucose in the blood. An abnormal may signify further management.
DONE
For HBsAg, Anti- HAV To establish a diagnosis of hepatits B infection and to assess immune status in naturally infected and experimentally vaccinated individuals
Continue all meds To continue medication therapy and avoid further complications
Refer Referral is done to correct DONE
35
unusualities as soon as possible and to inform the attending physician of the patient’s condition
April 16, 2009
Admit to CP- Gym (level II) For further specialization of management
DONE
April 17, 2009
(+) BM 7x
3:55 am
Still for colonoscopy scheduling
To follow up previous order DONE
Follow up stool culture To ensure that the needed specimen will be obtained for early examination
DONE
Continue meds. To continue medication therapy and avoid further complications
DONE
DONERefer Referral is done to correct
unusualities as soon as possible and to inform the attending physician of the patient’s condition
DONE
36
Diagnostic Exams
Ultrasound ReportDate: March 19, 2009
Result Findings:The right hepatic lobe is small relative to the left lobe. The liver exhibits a
diffusely coarsened parenchyma with a slightly irregular external outline. No focal mass lesion seen. There are no dilated intrahepatic ducts.
The gall bladder is normal in size and configuration. The walls are not thickened. There are no intraluminal echoes nor calculus seen.
There are no abnormal intraluminal masses seen within the common bile duct. It’s largest antero-posterior diameter is 0.25 cm.
There are no abnormal masses or enlarged lymph nodes in the vicinity of the abdominal aorta.
The pancreas is normal in size with the following dimensions: head = 1.55 cm, neck = 0.83 cm, body/tall = 1.35 cm. it exhibits a homogenous parenchymal echopattern and a regular outline, no focal mass lesions seen.
The spleen is surgically absent.
Length (cm) Width (cm) Thickness (cm) Cortical Thickness (cm)Right Kidney 11.75 5.87 5.82 1.88Left Kidney 11.43 5.65 5.50 1.74
There is no significant disparity in the size, shape and location of both kidneys. They exhibit a isoechoic parenchymal echopattern relative to that of the liver and spleen. The pelvocalyceal systems as well as the ureters are not dilated no evident mass nor calculus in one scans obtained.
The urinary bladder is adequately distended showing regular contours and smooth walls. There are no abnormal intraluminal masses seen within.
The prostate gland measures 3.22 x 3.55 x 2.89 cm (IWT). It exhibits a homogenous parenchymal echopattern. Approximate weight 17 grams. No calcifications seen within.
Minimal to moderate amount of fluid collection is present within the abdomen.
37
Impression/Remarks: Consider liver cirrhosis correlation with the liver function tests suggested Minimal to moderate ascites Isoechoic renal parenchymal echopattern, bilateral cannot entirely rule out renal
parenchymal disease based on echogenicity. Serum creatinine correlation suggested
Sonographically normal gall bladder, biliary ducts, pancreas, urinary bladder and prostate glands
S/P splenectomy
38
IPD HEMATOLOGYDate: April 02, 2009 @ 09:32
Test Result Flag Limit Reference RangeWBC
- To determine infection or inflammation in the body and monitor its responses to specific therapies. Explain to the patient the necessity of undergoing the test that it helps detect occurrence of anemia and polycythemia.
15.0 (10E 9/L) H 4.6-10.2 (10E 9/L)
LYM
- to identify if there is an abnormal amount of lymphocyte that may indicate viral infection such as HIV. A decreased number of lymphocytes in the peripheral circulation, occurring as a primary hematologic disorder or in association with the nutritional deficiency, malignancy or infection mononucleosis.
4.8 (RM 32.1 %L) H 0.6-3.4 (10.0-50.0 %L)
MID 1.4 (9.2 %M) 0.0-1.8 (0.1-21.5 %M)GRAN
- An elevated level of granulocytes is indicative of an underlying bacterial infection.
8.8 (R4 58.7 %G H 2.0-6.9 (37.0-80.0 %G)
RBC
- to know the amount of RBC in the blood. Rule out anemia due to nutritional deficiencies,
3.15 (10E 12/L) L 4.69-6.13 (10E 12/L)
39
blood loss.HGB
-to identify the amount of O2 carrying protein contained within the RBC.
107 (g/L) L 141.0-181.0 (g/L)
HCT
- To identify the percentage of the blood volume occupied by red blood cells.- decreased hematocrit indicates blood los, anemia, blood replacement therapy, and fluid balance, and screens red blood cells status.
28.9 (%) L 43.5-53.7 (%)
MCV
- Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs (red blood cells). The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic), such as is seen in iron deficiency anemia or thalassemias.
91.7 (fL) 80.0-97.0 (fL)
MCH
- Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of
34.0 (pg) H 27.0-31.2 (pg)
40
oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value.
MCHC- Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin is abnormally concentrated inside the red cells, such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder.
370 (g/L) H 318-354 (g/L)
RDW
- Red cell distribution width (RDW) is a calculation of the variation in the size of your RBCs. In some anemias, such as pernicious anemia, the amount of variation (anisocytosis) in RBC size (along with
20.5 (%) H 11.6-14.8 (%)
41
variation in shape – poikilocytosis) causes an increase in the RDW.
PLT
- The platelet count is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting.
262 (10E 9/L) 142.0-424.0 (10E 9/L)
MPV
- Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow.
10.3 (fL) 0.0-99.8 (fL)
42
Clinical Chemistry
Patient name: Rambo Physician: Dr. Otero
Sex:M Age: 24 yrs old Analyzer: VITROS 250
Test initial date: April 02, 2009 Fluid: SERUM
Report print date: 04/02/09 Priority: Routine
TEST RESULT UNIT NORMAL RANGE
ALTthe most sensitive indicators of liver cell irritation or damage. The activity of this enzyme is measured in blood plasma. Elevated levels of this enzyme can be an indication of viral hepatitis and other forms of liver disease.
H 157 U/L 21 - 72
ALP
Alkaline phosphatase are a family of enzymes that are present throughout the body. Elevated levels of ALP are associated with liver and bile duct disorders, and bone diseases.
H 225 U/L 38 - 126
TOTAL PROTEIN
Measurement of the total protein concentration in plasma. Elevated concentrations reflect dehydration, which might be attributable to vomiting, diarrhea, Addison's disease, diabetic acidosis, and other conditions.
81 g/L 63 - 82
ALBUMIN L 21 g/L 35 - 50
43
Albumin is the most abundant protein found in blood plasma, representing 40 to 60% of the total protein. Reduced levels of albumin may reflect a variety of conditions, including primary liver disease, increased breakdown of macromolecules resulting from tissue damage or inflammation, malabsorption syndromes, malnutrition, and renal diseases.
GLOBULIN
Globulins are a diverse group of proteins in the blood, and together represent the second most common proteins in the bloodstream. An elevation in the level of serum globulin can indicate the presence of cirrhosis of the liver.
H 60 g/L 23 - 35
A/G RATIO L .4 1.5 - 2.5
TOTAL BILIRUBIN H 384.0 umol/L 3.0 – 22.0
Unconcentrated BILIRUBIN
H 31.1 umol/L 0.0 - 19.0
Direct BILIRUBIN H 352.9 umol/L 0.0 - 7.0
DATE: 04/02/09PROTHROMBIN TIMEPatient: 23.7 secondsControl: 13.5 secondsINR: 1.8% Activity: 57.0%
44
Clinical Microscopy
Name: T2 Date: April 15, 2009Age/ Sex: 24 M Hospital #: 1091204Requesting Physician: Dr. Florida Specimen: Urine
Findings:
A. Physical Examination: B. Chemical Reaction:Color: Dark yellow Albumin: negativeApperance: cloudy Sugar: negativeReaction: 6.0Specific Gravity: 1.010
C. Microscopic Examination:
Epithelial cells: Cast:Squamos: + Hyaline: _______/lpfRenal: ______/ lpf Fine Granular:_____/ lpfPus Cells: _____/ hpf Coarse granular:____/ lpfMusous Threads Crystal:Bacteria Uric AcidYeast cells Calcium OxalateOil globules UratesSpermatozoa Triple Phosphate
Amorphous PhosphateOthers
45
Lab no.: 11712
Name: T2 Age: 24 Sex: M Log#: 65592 Index date: .4/15/09Physician: Walk in Reference #: 59560 Print date: 04/15/09
Test Normal Value Result Units
Hepatitis above 2.0 considered 0.712 (NR) COIas reactive
Meds:
D5.3 NaCl FD 200 cc now then x8 hour
Essentiale forte 1 tab BID
Ranitidine 50 mg IVTT (NOW) then q 8 hour
Hyoscine amp 1 Amp(now) then q 8 hour
Metronidazole 500 mg q 8 hours
46
Generic Name: Essentiale Forte
Brand Name:
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
Responsibilities- Cholagogues,
Cholelitholytics
& Hepatic
Protectors
-Essentiale 1-2
cap tds.
Essentiale
Forte Intiailly 2
cap tds.
Maintenance: 2
cap once-bd.
- increase
functional
status of the
liver,
improvemen
t in the
lipids
metabolism
caused by
accelerated
synthesis of
lipoproteins
in the liver,
activation of
the
phospholipi
d-depending
ferments,
- cirrhosis
- Hepatic
steatosis
(also in cases
of diabetes)
- Acute and
chronic
hepatitis
- Necrosis of
the liver cells
- Hepatic
coma and
precoma
- Toxic liver
damage
(including
- Contraindicated
in patients
hypersensitive to
drug
-in newborn
children
-in pregnant
women
Drug-drug. abdominal
pain, nausea,
diarrhea and
allergic
reaction(skin
rash).
1. Instruct patient on
proper use of the drug
2. Urge patient to avoid
cigarette smoking because
this may increase gastric
acid secretion and worsen
disease
3. Inform patient to take
drug once daily
prescription at bedtime for
best results.
4. Tell the physician what
medicines you are taking,
including those bought
without a prescription and
herbal medicines, before
you start treatment with
47
increased
synthesis of
glycogen in
the liver,
decreased
the fatty
infiltration
of the
hepatocytes
pregnancy
toxicosis)
-
Essentiale.
5. Tell the physician
before taking any new
medication while taking
this one, to ensure that the
combination is safe.
6. Do not use the medicine
for other health
conditions.
http://en.wikipedia.org/wiki/Essentiale, http://www.drugs-pro.com/liver-disease/essentiale%20forte.html
Generic Name: hyoscine butylbromide Brand Name: Buscopan
Suggested Mode of Contra DrugSide Effects/
Adverse Nursing
48
Classifications Dose Actions Indications
indications Interactions Reactions Responsibilities
- antispasmodic - 0.4 to 0.8 mg P.O.
daily
- used to
relieve
bladder or
intestinal
spasms.
-relaxing the
muscle that
is found in
the walls of
the stomach,
intestines
and bile
duct
(gastrointest
inal tract)
and the
reproductive
organs and
urinary tract
(genitourina
ry tract)
-Spasms
of the
stomach,
intestines
or bile
duct
(gastrointe
stinal
tract),
including
those
associated
with
irritable
bowel
syndrome
)
-Spasms
of the
reproducti
ve or
-
Hypersensitivi
ty
-Abnormal
muscle
weakness
(myasthenia
gravis).
-Abnormally
large or
dilated large
intestine
(megacolon).
-Hereditary
blood
disorders
known as
porphyrias.
-Closed angle
glaucoma.
-Buscopan
Drug-drug. Antidepressants, antihistamines, disopyramide, quinidine: additive anticholinergic effects
Antidepressants, antihistamines, opioid analgesics, sedative-hypnotics: additive CNS depression
Oral drugs: altered absorption of these drugs
Wax-matrix potassium tablets: increased GI mucosal lesions
Drug-herbs. Angel's trumpet, jimsonweed, scopolia: increased
Adverse reactions
CNS: drowsiness, dizziness, confusion, restlessness, fatigue
CV: tachycardia, palpitations, hypotension, transient heart rate changes
EENT: blurred vision, mydriasis, photophobia, conjunctivitis
GI: constipation, dry mouth
GU: urinary hesitancy or
1.Assess vital signs and
neurologic,
cardiovascular, and
respiratory status.
2.Monitor patient for
urinary hesitancy or
retention.
3.Swallow tablets whole
with a glass of water.
Take at least one hour
before antacids or certain
anti-diarrhea drugs.
4. Do not share this
medication with others.
3. Inform your doctor or
pharmacist if you have
previously experienced
such an allergy. If you
feel you have
experienced an allergic
reaction, stop using this
49
urinary
systems
(genitouri
nary
tract), for
example
period
pain
cramps.
tablets are not
recommended
for children
under six
years of age.
anticholinergic effects
Drug-behaviors. Alcohol use: increased CNS depression
retention
Skin: decreased sweating, rash
medicine.
4. Tell your doctor or
pharmacist what
medicines you are
already taking, including
those bought without a
prescription and herbal
medicines, before you
start treatment with this
medicine.
5. This medicine should
be used with caution
during pregnancy, and
only if the expected
benefit to the mother is
greater than the possible
risk to the fetus,
particularly in the first
trimester. Seek medical
advice from your doctor.
6. It is not known if this
medicine passes into
50
breast milk. It should be
used with caution in
nursing mothers, and
only if the benefits to the
mother outweigh any
risks to the nursing
infant.
7. This medicine may
cause blurred vision and
so may affect your ability
to drive or operate
machinery safely. If
affected do not drive or
operate machinery.
http://www.medicinenet.com/hyoscine_butylbromide-oral/article.htm, http://medical-dictionary.thefreedictionary.com/hyoscine
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
ResponsibilitiesAnti-infectives,
antiprotozoals,
1 amp q 8° Disrupts
DNA and
PO, IV:
Treatment
Contraindicated
in:
Drug-drug:
Cimetidine may
CNS:
Seizures, 1. Adiminister on empty
51
Generic Name: Metronidazole
Brand Name: Flagyl
antiulcer agents protein
synthesis
susceptible
organisms.
Therapeutic
effects:
Bactericidal,
trichomonaci
dal or
amebicidal
action.
Spectrum:
Most notable
for avtivity
against
anaerobic
bacteria
including:
Bacteroides,
clostridium.
In addition is
active
of the
following
anaerobic
infections:
Intra-
abdominal
infections,
gynecologic
infections,
skin and
skin
structure
infections
lower
respiratory
tract
infections,
CNS
infections,
septicemia,
and
endocarditis
Hypersensitivit
y.
Use cautiously
in: history in
blood
dyscrasias,
History of
seizures or
neurologic
problems and
severe hepatic
impairement.
decrease
metabolism of
metronidazole.
Phenobarbital and
rifampin
increases
metabolism and
may decrease
effectiveness.
Metronidazole
increases the
effects of
phenytoin,
lithium, and
warfarin.
Disulfiram-like
reaction may
occur with
alcohol ingestion.
May cause acute
psychosis and
confusion with
dizziness,
headache.
EENT:
Tearing
(topical only).
GI:
Abdominal
pain,
anorexia,
nausea,
diarrhea, dry
mouth, furry
tongue,
glossitis,
unpleasant
taste and
vomiting.
Hemat:
Leukopenia
Neuro:
Peripheral
neuropathy
stomach or may
administer with food or
milk to minimize GI
irritation.
2.Instruct patient to take
medication exactly as
directed with evenly
spaced times between
doses, even if feeling
better.
3.Advised patient to not
skip doses or double up
on missed doses.
4.Inform patient that
medication can cause
metallic taste.
5.Advise patient that
frequent mouth rinses,
good oral hygiene and
sugarless gum or candy
may minimize dry
mouth.
52
against:
Trichomonas
vaginalis,
entamoeba
histolytica,
giardia
lamdia, H.
pylori and
clostridium
difficile.
.
IV:
Perioperativ
e
prophylacti
c agent in
colorectal
surgery.
PO:
Amebecide
in the
managemen
t of amebic
dysentery,
amebic
liver
abscess and
trichomonia
sis:
treatment of
peptic ulcer
disease
disulfiram.
Increased risk of
leucopenia with
fluorourousel or
azathioprine.
6.Inform patient that
medication may cause
urine to turn dark.
7.Advise patient to
consult health care
professional if no
improvement in a few
days or if signs and
symptoms of
superinfection (black
furry overgrowth on
tongue or foul-smelling
stools) develop.
53
caused by
Helicobacte
r pylori.
ClassificationsSuggested
DoseMode ofActions Indications
Contraindications
DrugInteractions
Side Effects/Adverse
ReactionsNursing
ResponsibilitiesTherapeutic:
Antiulcer agents
Pharmacologic:
Histamine H2
antagonist
50 mg IVTT
now q 8°
Inhibits the
action of
histamine at
the H2-
receptor site
located
primarily in
Short term
treatment of
active
duodenal
ulcers and
benign
gastric
Contraindicated
in:
Hypersensitivit
y. Cross
sensitivity may
occur. Some
products
Drug-drug:
Cimetidine
inhibits drug
metabolizing
enzymes in the
liver; may lead to
increase levels
CNS:
confusion,
dizziness,
drowsiness,
hallucinations
, headache.
CV:
1. Assess for
epigastric or
abdominal pain
and frank or
occult blood in
the stool, emesis
or gastric
54
Generic Name: Ranitidine Bismuth CitrateBrand Name: Tritec
gastric
parietal
cells,
resulting in
inhibition of
gastric acid
secretion. In
addition,rani
tidine
bismuth
citrate has
some
antibacterial
action
against H.
Pylori.
Therapeutic
effects:
Healing and
prevention
of ulcers.
Decrease
ulcers.
Prophylaxis
of duodenal
ulcers (at
lower
doses).
Manageme
nt GERD
treatment
and
prevention
of
heartburn,
acid
indigestion
and sour
stomach
(OTC use).
Cimetidine,
famotidine,
ranitidine:
managemen
contained
alcohol and
should be
avoided in
patients with
known
intolerance.
Porphyria
(ranitidine
bimuth citrate
only). Some
products
contain
aspartame and
should be
avoided in
patients with
phenylketonuria
.
Use cautiously
in: Renal
impairement.
and toxicity in the
following- some
benzodiazepines,
beta blockers,
caffeine, calcium
channel blockers,
carbamazepine,
chloroquine,
lidocaine,
metronidazole,
moricizine,valpor
ic acid and
warfarin.
arrythmias
GI: Altered
taste, black
tongue,consti
pation, dark
stools,diarrhe
a and drug-
induced
hepatitis,
nausea.
GU:
Decreased
sperm count,
impotence.
Hemat:
Agranulocyto
sis, aplastic
anemia,
anemia,
neutropemnia,
thrombocytop
enia.
aspirate.
2. Administer with
meals or
immediate
afterward and at
bedtime to
prolong effect.
3. Doses administer
once daily at
bedtime to
prolong effect.
4. Instruct patient to
take medication
as directed for the
full course of
therapy, even if
feeling better.
5. Inform patient
that increased
fluid and fiber
intake and
exercise may
55
symptoms of
gastroesopha
geal reflux.
Decreased
secretion of
gastric acid.
t of gastric
hypersecret
ory states
(Zollinger-
Ellison
syndrome).
Unlabeled
uses:
Manageme
nt of GI
symptoms
associated
with the use
of NSAIDs.
Prevention
of stress
ulceration
or
aspiration
pneumoniti
s.
Prevention
Misc:
Hypersensitivi
ty reactions,
vaculitis
minimize
constipation.
6. Advise patient to
report onset of
fever, sorethroat,
diarrhea,
dizziness, rash,
confusion, or
hallucinations.
7. Inform patient
that medication
may temporarily
cause stools and
tongue to appear
gray-lack.
56
of acid
inactivation
of
supplement
al
pancreatic
enzymes in
patients
with
pancreatic
insufficienc
y.
57
Nursing Theories
Theorist: Faye Glenn Abdella
Theory: 21 Nursing Problems
Abdellah's theory of nursing stated that it was the “determination of the nature and extent
of nursing problem presented by the individual patients or families receiving nursing care”. She
says a nursing problem presented by a client is a condition faced by the client or client's family
that the nurse, through the performance of professional functions, can assist them to meet.
Abdellah's use of term “nursing problems” is more consistent with nursing functions or nursing
goals than with those client-centered problems. The apparent contradiction can be explained by
her desire to move away from the disease-centered orientation. In her attempt to bring nursing
practice into its proper relationship with restorative and preventive measures for meeting total
client needs, her model seems to swing the pendulum to the opposite pole, from the disease
orientation to nursing orientation, while leaving the client somewhere in the middle.
The student nurses are instruments by which certain nursing problems which are faced
by the client and the client's family are addressed and met. Quality professional nursing care
requires the nurses to identify and solve overt and covert nursing problems. This theory
emphasizes a client-centered approach because it is the primary role of the nurse to alleviate the
patient from whatever suffering she is in and help her meet her needs. Her framework is efficient
enough to address and meet the different requirements of the three major aspects of her
“pendulum model” which consists of client-oriented, nursing-centered and disease-centered
approach.
58
Theorist: Lydia Hall
Theory: Core, Care and Cure Theory
Hall's theory emphasizes the importance of individuals as unique, capable of growth and
learning, and requiring a total person approach. Her definition of health can be inferred to a state
of self-awareness with conscious selection of behaviors that are optimal for that individual. Hall
stresses the need to help the person explore the meaning of his or her behavior to identify and
overcome problems through developing self-identity and maturity. The concept of society or
environment is dealt with in relation to the individual. Hall's theory of nursing involves three
interlocking circles, each one of it represents one aspect of nursing. The same aspect represents
intimate bodily care of the patient. The core aspect deals with the innermost feeling and
motivations of the patient and family through the medical aspects of care.
Care is the sole function of nurses, where as core and cure are shared with other
members of the health care team. The major purpose of care is to achieve interpersonal
relationship with the individual. The nurse plans and prepares a series of independent nursing
interventions that can aid from its condition. These interventions are designed to provide good
and conducive atmosphere, administering drugs to the right patient, right drug and right time.
The nurse also provides health teachings to his client who it can be based on medication
management and independent actions such as advising the client to have complete bed rest.
59
Theorist: Ida Jean Orlando
Theory: Nursing Process Theory
Orlando’s theory was developed in the late 1950s from observations she recorded
between a nurse and patient. Despite her efforts she was able to categorize the records as “good”
or “bad” nursing. It then dawned on her that both formulations of “good” and “bad” nursing were
contained in the records. From these observations she formulated the deliberative nursing
process. The role of the nurse is to find out and meet the patient’s immediate needs for help. The
patient’s presenting behavior maybe a plea for help, however, the help needed may not be what it
appears to be. Therefore, nurses need to use their perception, thoughts about the perception or the
feelings engendered from their thoughts to explore with patients the meaning of their behavior.
This process helps the nurse finds out the nature of the distress and what help the patient needs.
Orlando ’s theory remains one of the most effective practice theories available. The use of her
theory keeps the nurses to focus on their patients. The strength of the theory is that it is clear,
concise and easy to use. While providing the overall framework for nursing, the use of her theory
does not exclude nurses from using other theories while caring for the patient.
Student nurse is finding out the problem and meeting the patient’s immediate needs. This
is possible due to the fact that the nurse seeks out the nature of the problems using her perception
based on her cognitive and motor skills thus having a better understanding of how to address the
needs of the patient with the east possible effort alongside with the greatest and maximal result
and efficiency. The theory is presented with fewer complications thus time and energy is
conserved. This provides the nurse to have more time to focus more on her patient and this
serves as an opportunity to furthermore look for underlying complaints and problems.
60
Date / Time
Cues Needs Nursing Diagnosisw/ Rationale
Objective of Care
Nursing Interventionw/ Rationale
Evaluation
April 17, 2009
4:00pm
Subjective:
“Dugay-dugay na ang sakit sa akoang tiyan.”“Murag naa’y hangin.”“4.” [pain scale: 0=none;1-3=mild;4-6=moderate;7-10=severe]
Objective:
-occasional guarding behavior toward the abdominal area noted.-mild grimacing noted.
Vital Signs:
BP- 110/60 mmHg
PR- 78 bpm
RR- 24 bpm
TEMP. - 37.6 °C
COGNITIVE-PERCEPTUAL
PATTERN
Acute pain [abdominal] related to flatulence secondary to increase in gastrointestinal motility.
R: Increased gastrointestinal motility increases the amount of abdominal gas which exerts pressure on the gastrointestinal tract walls resulting in pain.
Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania
Within the remaining 7 hours of our shift, the patient will be able to experience less pain as evidenced by verbalization of decreased pain [pain scale < 4] and less guarding behavior toward the abdomen.
1.) Perform pain assessment each time pain occurs; Note and compare previous reports.
®To identify possible factors that worsen the pain; to help out
in further pain control. 2.) Monitor vital signs.
®Usually elevated during occurences of pain.
3.) Instruct patient to report pain as soon as it occurs.®For non-delayed interventions
to be performed.4.) Provide non-pharmacological pain management such as therapeutic touch®To promote cost-free comfort
5.) Identify ways to alleviate/minimize pain®To promote independent self-
care6.) Note specific time and activity when pain occurs.®To administer medications as
prophylaxis appropriately.7.) Review ways to minimize pain regularly
®To maintain and promote ability to care for self
8.) Obtain laboratory results
Goal Met:
Patient was able to experience less pain, as evidenced by verbalization of a pain scale of 1 and lessened guarding behavior toward the abdomen.
61
from laboratory technician®To determine possible causes
of pain in the abdomen.9.) Assist in treating AGE®To treat the underlying cause
of the pain.10.) Educate watcher(s) on how they can help alleviate the pain.®For continuous cost-free pain
management.11.) Administer analgesics as ordered.
®Medications that are ordered for pain will greatly help in
alleviating pain.12.) Administer oxygen as ordered.
®Oxygen therapy can help alleviate pain.
Date / Time
Cues Needs Nursing Diagnosisw/ Rationale
Objective of Care
Nursing Interventionw/ Rationale
Evaluation
62
April 17, 2009
4:00pm
Subjective:
“Gina-uhaw ko pirminti”“Mga unom ka beses na ko sige ug balik-balik sa CR.”“Basa akong mga tae.”
Objective:
-ectomorphic body structure-imbalanced intake and output [output is greater than intake]
Vital Signs:BP- 110/60
mmHg
PR- 78 bpm
RR- 24 bpm
TEMP. - 37.6
NUTRITIONAL-
METABOLIC
PATTERN
Deficient fluid volume related to excessive fluid loss secondary to increased peristaltic movement in the gastrointestinal tract
R: Increased peristaltic movement in the gastrointestinal tract overwhelms the large intestine and hinders it from absorbing much needed water, causing excessive amounts of fluid to be lost through the stool
Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania
Within our remaining 7 hours span of care, patient will be able to perform activities and self-treatments for correction of deficient fluid volume and show fluid intake grater than output.
1.) Assess level of understanding®Helps out in determining how to
proceed with patient education and instruction.
2.) Monitor Vital Signs; note strength of peripheral pulses.
®Deficient fluid volume results in poor perfusion; perfusion can be
assessed by strength of pulse.3.) Establish 24-hour fluid replacement needs and routes to be used
®Prevents peaks/valleys in fluid level4.) Note client’s preferences regarding food and fluids that have high fluid content
®Prevents refusal in offered food and drinks
5.) Keep fluids within arms reach®Promotes independent self-care
6.) Encourage to increase oral fluid intake
®Increases hydration rate7.) Provide adequate hygiene to entire body, especially the eyes and mouth.
®Prevents damage from dryness8.) Weigh patient daily® indicates overall fluid and nutritional status
9.) Administer intravenous fluids as ordered.
®Increases hydration rate10.) Educate watchers on how to
Goal Met:
Patient was able to increase oral fluid intake and was able to show fluid intake being greater than fluid output.
63
°C monitor intake and output.®Promotes continuous care.
11.) Administer medications as prescribed.
®Proper medication will ensure good recovery.
12.) Give Oral Rehydration Solution, if not contraindicated.
®Helps out in replacing lost fluids
Date / Time
Cues Needs Nursing Diagnosisw/ Rationale
Objective of Care
Nursing Interventionw/ Rationale
Evaluation
64
April 17, 2009
4:00pm
Subjective
“Mga unom ka beses na ko sige ug balik-balik sa CR.”“Basa akong mga tae.”
Objective-decreased level of sodium
Vital Signs:
BP- 110/60
mmHg
PR- 78 bpm
RR- 24 bpm
TEMP. - 37.6
°C
NUTRITIONAL-
METABOLIC
PATTERN
Imbalanced nutrition: less than body requirements related to inability to absorb nutrients secondary to increased peristalsis of gastrointestinal tract
R: Increased peristalsis of the gastrointestinal tract hinders the small intestine to absorb much needed nutrients resulting in decreased nutrition.
Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania
Within our remaining 7 hours span of care, our patient will be able to maintain or develop current nutritional status by increasing oral food intake and showing increased appetite.
1.) Determine ability to chew, swallow and taste.
®Ensures success in future interventions
2.) Discuss eating habits, food preferences, allergies and dislikes
®To appeal to preference and to prevent ingestion of non-preferred
food/fluid.3.) Assess weight, body build, strength and activity level.
®Provides a baseline data for comparison.
4.) Encourage to have of food and fluids rich in nutrients like preferred and non-preferred fruits and vegetables.
®Presents a wide-range of food for variety
5.) Use flavoring agents (e.g., lemon, herbs, salt)
®Enhances appetite; promotes intake of food
6.) Limit fiber/bulk food and carbonated beverages
®May lead to early satiety7.) Encourage to restrict self from unpleasant sights or odors
®May decrease appetite8.) Consult dietitian/nutritional advisor as indicated.
®Promotes further wellness and nutrition
Goal Met:
Patient was able to increase oral food intake with good over-all appetite.
65
9.) Obtain repeated laboratory results from laboratory technician
®To determine effectiveness of diet therapy
10.)Educate watcher(s) to watch out for factors that induce vomiting and/or regurgitation of food
®Ensures prevention of future complications
11.) Administer medications as ordered
®Medications ensure good over-all recovery
12.) Monitor Intake and Output as ordered.® To determine water retention.
Date / Time
Cues Needs Nursing Diagnosisw/ Rationale
Objective of Care
Nursing Interventionw/ Rationale
Evaluation
66
April 17, 2009
4:00pm
Subjective
“Gitanggal akoang spleen katong ni-aging 2005”“Nadiagnose ko ug liver cirrhosis katong 2006.”
Objective
-status: post splenectomy-Admitting diagnosis: “Liver cirrhosis…”-location: DMC Communicable Pavillion
Vital Signs:
BP- 110/60
HEALTH
PERCEPTION
–
HEALTH
MANA
Risk for infection related to decreased immune system efficiency 2° post splenectomy and liver cirrhosis.
R: Complications with the liver and spleen decrease the body’s capability to maintain an optimal defense against infectious bacteria
Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania
Within our remaining 7 hours span of care, our patient will be able to have a decreased risk of infection as evidenced by a clean environment, hygienic practices, and general asepsis.
1.) Stress proper hand washing to all individuals involved in patient’s care
®Ensures control of the spread of bacteria and prevention of
nosocomial infections 2.) Monitor care givers and watchers
®To ensure patient will remain free from contact with suspected bacteria-
filled surfaces3.) Provide frequent proper general and oral hygiene
®Reduces surfaces having multiplying bacteria
4.) Instruct not to wander around too much or too far
®May lead to contact with bacteria-filled surface
5.) Explain importance of wearing face mask
®Face masks are effective in preventing infection by air-borne
bacteria6.)Provide isolation as indicated
®Prevents cross contamination7.) Emphasize necessity of taking antibiotics as directed
®Premature discontinuation of treatment may lead to an infection
8.) Occasionally obtain clean linens for the patient to change into
®Linens may serve to be a good place for bacteria to proliferate
9.) Advise watchers to change unable
Goal Met:
Patient was able to have a clean environment, good hygienic practices, and over-all bacteria free surfaces.
67
mmHg
PR- 78 bpm
RR- 24 bpm
TEMP. - 37.6
°C
GEMENT
PATTERN
person to change clothes®Clothes can be a place for bacteria
to reside10.)Educate watchers on how to identify infections
®Ensures immediate care to be gathersd
11.) Administer antibiotics as ordered®Antibiotics serve as prophylaxis
12.) Monitor intake and output as ordered® to determine water retention.
Date / Time
Cues Needs Nursing Diagnosisw/ Rationale
Objective of Care
Nursing Interventionw/ Rationale
Evaluation
68
April 17, 2009
4:00pm
S/O:- with
jaundice noted in the skin upon inspection.
- (+)body malaise
- sunken eyeballs
- dry lips
Vital Signs:BP- 110/60
mmHg
PR- 78 bpm
RR- 24 bpm
TEMP. -
37.6 °C
NUTRITIONAL
METABOLIC
PATTERN
Risk for impaired skin integrity r/t accumulation of bile salts in skin secondary to Liver Cirrhosis.
R: At risk for skin being adversely altered.
Source: Marilynn E. Doenges, APRN, BC, et. al. Nurse’s Pocket Guide, 10th ed. © 2006. F.A. Davis Company, Philadelphia, Pennsylvania
Within our 8 hours span of care, our patient will be able to:Demonstrate behaviors/ techniques to prevent skin breakdown.
1.) VS checked and recorded.® to have a baseline data.2.) Check and regulate IVF @ ordered rate.® to prevent further dehydration.3.) Assess for any changes in skin.® to determine the causative factors4. Encourage continuation of regular exercise.®: to enhance circulation.5.) Maintain strict skin hygiene.® to prevent the spread of bacteria and prevent infection6.) Provide adequate clothing/covers.®to prevent vasoconstriction.7.) Observe for reddened/blanched areas and institute treatment immediately.®: Reduces likelihood of progression to skin breakdown.8.) Emphasize importance of adequate nutritional/fluid intake.®: to maintain general good health and skin turgor.9.) Note laboratory results pertinent to causative factors.® to determine the needed treatment to
be given.10.) Assist the client in understanding and following medical regimen and preventive care and daily maintenance.®: Enhances commitment to plan, optimizing outcomes.
Goal Met:
Patient was able to demonstrate behaviors and techniques that prevents skin breakdownlike skin care, proper nutrition intake, exercise and comply with medications.
69
11.) Administer medications as ordered.® to treat any underlying cause 12.) Monitor intake and output as ordered® to determine fluid and electrolyte intake and loses
70
Discharge Plan
MEDICATION
Instruct the patient and family to follow the home medications as prescribed by the
physician.
R: Treatment regimen is important to have faster recovery.
Explain each purpose of the medication
R: Knowledge about what medications will make the client become aware of what he is
taking and for the family to participate more in the client’s treatment.
Instruct client not to take over-the-counter drugs without doctor’s knowledge.
R: Non-prescribed drugs may have an antagonistic effect or synergistic effect in any
drug therapy.
Explain the side effects or adverse reactions of each medication. Instruct the client and
family to watch out for it and to report it immediately as soon as possible to the
physician.
R: Explaining the side effects will let the client and family identify what harmful effects
to expect and for them to distinguish the adverse reaction to medication for them to report
it to their physician immediately.
Inculcate to the client to comply all the medications prescribed at the ordered dosage,
route and at the ordered time.
R: Taking the drugs at the ordered dose, route and time limits the chance for toxicity and
ensure its effectiveness.
71
Advice client to take medications with food if not contraindicated or to take medicine one
hour before meals or one hour after meals.
R: Some medications are irritating to the gastric mucosa.
Let patient complete the whole course of the drug therapy.
R: This can help the patient alleviate the problem and be able to experience the full
therapeutic effect of the medication.
EXERCISE
Encourage early ambulation.
R: Walking is good exercise and could promote circulation, hence, proper healing.
Promote exercise to the client especially ROM.
R: This will promote good physical health.
Instruct client to avoid strenuous activities for at least a week or a month until fully
recovered.
R: Activities that require great muscle strength should be avoided to prevent injury and
muscle strain.
Advise patient to have adequate rest and sleep.
R: To gain back the lost strength and be able to return to its normal state thus allow ample
time for healing.
Practice deep breathing exercise.
R: This will help alleviate any pain or discomfort that patient will encounter
72
TREATMENT
Explain the need of treatment after discharge and must take it seriously so as to prevent
such complications to the patient
R: To make the client and family aware that the treatment does not only end at hospital but
needs to be continued at home to make the client responsible towards medication.
Explain to the family the condition of the patient and give them factual information about
the illness.
R: To have better understanding of the patient’s condition and to be able to know what
intervention they should give that could not alter the effect of the therapy.
HYGIENE
Encourage having proper hygiene like taking a bath, meticulous hand washing, and
brushing of teeth every after meal.
R: Hygiene promotes comfort and cleanliness to the patient. It also increases the sense of
wellness, which is very much needed in the therapeutic process.
Encourage patient to continue hygienic measures practiced at present such as changing
clothes everyday and changing of underwear as often as necessary, keeping the nails
neatly trimmed, maintaining own supplies/items for personal necessities.
R: Keeping all practiced measures is necessary in consistent maintenance of proper hygiene.
Owning personal accessories for hygiene purposes keep client away from contamination and
infectious diseases.
Provide a calm, clean, and accepting environment.
73
R: Calm, clean and non threatening environment may lessen the occurrence of possible
infection and would be a good place for healing.
OUTPATIENT ORDER
Inform the patient that follow-up check-up is important to have continuous monitoring
and care even after attainment of the course medical therapy.
R: Through constant visits as out patient, the physician would still monitor the progress of
the therapeutic intervention availed by the patient.
Advice the client and the family to carry out follow-up diagnostic examinations
R: This is to evaluate the therapeutic response of the patient to the treatment.
Instruct the family to report any unusual signs and symptoms experienced by the patient.
R: This will help detect early signs and symptoms of recurrence of the disease.
DIET
Encourage client to eat a variety of nutritious foods like fruits and vegetables once
instructed by the physician.
R: To maintain and promote a healthy body.
Instruct client to take vitamins as ordered.
R: To boost the body’s defense mechanism.
Encourage patient to increase oral fluid intake.
R: This hydrates the body for normal functioning and maintain acid-base balance.
Advise client not to skip meals and have a regular eating pattern/schedule.
R: Regular interval of meals is the basic principle of a good dietary plan.
74
Tell patient not to eat foods contraindicated by the physician.
R: To prevent the occurrence of complications.
Instruct patient to avoid drinking liquors and smoking
R: To also avoid illness to be triggered.
75
Prognosis
CategoryPoor
(1)
Fair
(2)
Good
(3)Justification
1. Duration
of Illness
It has been one month since he
has been having diarrhea.
2. Onset of
Illness
Getting infected and contracting
AGE could have been avoided by
good hygiene.
3.
Predisposing
Factors
Race and location predispose T2
to getting AGE
4.
Precipitating
Factors
2 out of 5 precipitating factors are
present. However, these factors
could have been avoided by very
simple hygiene and prevention
methods.
5.
Willingness
to take the
medications
or
compliance
to treatment
regimen
T2 is very willing to take his
medications. He knows the good
effects of the drug and
intravenous therapy.
6.
environment
T2 was admitted to the
Communicable Pavilion in DMC.
76
7. family
support
The most number of family
members that were present in the
ward was 5. This number included
every member of his immediate
family except the father.
Calculation
s
4x1 =
4
1x2 =
22x3 = 6
4 + 2 + 6 = 12
12/7 = 1.7
Ranges:
1.0 – 1.5 = Poor
1.5 – 2.5 Fair
2.5 – 3.0 = Good
T2 has a FAIR prognosis.
His condition has been with him for about a month before he chose to seek treatment. He
took for granted the worsening of his condition. He could have possibly prevented the
complications brought about by his condition if he had only consulted a health care professional
immediately. Also, simple observance of good hygiene could have been a means to prevent him
from contracting the infection of AGE. On the other hand, upon seeking medical care, his family
support and good compliance of medicines were observed. Through this, our prognosis has come
up to the fair category.
77
Recommendation
To the Student Nurses:
We have also evaluated ourselves and have agreed that we have to heed the
recommendations of our clinical instructor. Patient care is our ultimate goal and continuous
monitoring and application of nursing interventions is compulsory for the patient’s recovery.
Data gathering skills should also be honed for accurate presentation of cases.
To the Patient and his family:
Religious taking of medicine was promoted as well as good general and oral hygiene.
Good family support can boost the morale of the patient and continuous holistic care will
improved his over-all health. He must also accept his condition and be aware of it, so that he
could disciplined himself and follow the necessary interventions given.
To the Ateneo de Davao University – College of Nursing
The group is proud to belong to such a prestigious school. We recommend that the
Ateneo de Davao University’s College of Nursing keep up, or improve their inculcation of
morals and values to their student nurses. Aside from that, continuous teaching and evaluating
our skills will lead us to aim a higher standard of education.
78
To the readers:
The group recommends that you, the reader, broaden your knowledge and continue
reading other sources and not base anything on this case presentation alone. A variety of sources
make a good over-all understanding of a subject.
Liver Cirrhosis is not always preventable for those at risk, however, steps can be taken to
lower the chance to develop and to delay the possible outcome. That’s why we recommend that
everybody must take care of themselves in preparing or eating foods. They must also establish
new patterns of eating, drinking, and lifestyle in order to prevent diseases from occurring.
79