World Citi Colleges

960 Aurora Blvd. Quezon City

Case Presentation

In

NCM 103

Gastric Outlet Obstruction (Status post-Jejunostomy)

Submitted by:

Boncato, Ronnie Jay Salazar, James Tabieros, Kristine Joy

Fernando, Christian Sanosa, Jasmin Taclas, Josid

Flaminiano, Chris Saquitan, RJ Tobari, Dianne

Flores, Eunice Faith Saring, Marie Ungos, Abby

Reyes, Daniel Victor Sherman, Myrna

Reyes, Ella Mae Solatre, Carlo

Submitted to:

Mr. Dominic Bautista

Ms. Myla Lim

Mr. Sherwin Villegas

Date of Submission:

September 2010
I. Introduction

Our group chose this case as interesting to us because it is a rare case that is usually
underestimated as a cause of mortality and morbidity to patients. We would like to make an
outlook of what this case is and gather information that can help us to expand our
knowledge and learn how it occurs, manifest, develop and cause a disease.

Gastric outlet obstruction (GOO), also known as pyloric obstruction) is not a single
entity; it is the clinical and pathophysiological consequence of any disease process that
produces a mechanical impediment to gastric emptying.

The major benign causes of gastric outlet obstruction (GOO) are PUD, gastric polyps,
ingestion of caustics, pyloric stenosis, congenital duodenal webs, gallstone obstruction
(Bouveret syndrome), pancreatic pseudocysts, and bezoars.

PUD manifests in approximately 5% of all patients with GOO. Ulcers within the pyloric
channel and first portion of the duodenum usually are responsible for outlet obstruction.
Obstruction can occur in an acute setting secondary to acute inflammation and edema or,
more commonly, in a chronic setting secondary to scarring and fibrosis. Helicobacter
pylori has been implicated as a frequent associated finding in patients with GOO, but its
exact incidence has not been defined precisely. The incidence of gastric outlet obstruction
(GOO) has been reported to be less than 2- 4 % in patients with PUD, which is the leading
benign cause of the problem. Five percent to 5% of ulcer-related complications result in an
estimated 950 operations per year in the Philippines. The incidence of GOO in patients with
peripancreatic malignancy, the most common malignant etiology, has been reported as 10-
12%.

Nausea and vomiting are the cardinal symptoms of gastric outlet obstruction. Vomiting
usually is described as nonbilious, and it characteristically contains undigested food
particles. In the early stages of obstruction, vomiting may be intermittent and usually occurs
within 1 hour of a meal. Patients with gastric outlet obstruction resulting from a duodenal
ulcer or incomplete obstruction typically present with symptoms of gastric retention,
including bloating or epigastric fullness, indigestion, anorexia, nausea, vomiting, epigastric
pain, and weight loss. They are frequently malnourished and dehydrated and have a
metabolic insufficiency. Weight loss is frequent when the condition approaches chronicity
and is most significant in patients with malignant disease.
II. Objectives

After successful accomplishment of this case presentation, the students will be able to:

General:
• To make the students of third year BSN capable of understanding the case about Gastric Outlet
Obstruction (GOO).

Specific:
• Select the appropriate nursing theory and apply its principles in rendering nursing care to a
patient who is currently suffering Gastric Outlet Obstruction (GOO).
• Understand the Anatomy and Physiology of both the Digestive system that are directly affected
in Gastric Outlet Obstruction (GOO) and relate the concepts to the actual situation of the
patient.
• Explain in detail the Pathophysiology of Gastric Outlet Obstruction (GOO) and relate it with the
patient’s case. 
• Establish the nursing priorities and nursing management applicable to patients with Gastric
Outlet Obstruction (GOO) and incorporate these in the formulation of an essential nursing care
plan. 
• Differentiate the different pharmacologic actions of the drugs involved in the treatment of
Gastric Outlet Obstruction (GOO).
 
• Formulate relevant health teachings for a patient with Gastric Outlet Obstruction (GOO).
 III. Theoretical Framework

FAYE ABDELLAH- 21 Nursing Problems

Abdellah's Typology of 21 Nursing Problems are as follows:

1. To promote good hygiene and physical comfort.

2. To promote optimal activity, exercise, rest, and sleep.

3. To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection.

4. To maintain good body mechanics and prevent and correct deformities

5. To facilitate the maintenance of a supply of oxygen to all body cells

6. To facilitate the maintenance of nutrition of all body cells

7. To facilitate the maintenance of elimination

8. To facilitate the maintenance of fluid and electrolyte balance

9. To recognize the physiologic responses of the body to disease conditions

10. To facilitate the maintenance of regulatory mechanisms and functions

11. To facilitate the maintenance of sensory function

12. To identify and accept positive and negative expressions, feelings, and reactions

13. To identify and accept the interrelatedness of emotions and organic illness

14. To facilitate the maintenance of effective verbal and nonverbal communication

15. To promote the development of productive interpersonal relationships

16. To facilitate progress toward achievement of personal spiritual goals

17. To create and maintain a therapeutic environment

18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs

19. To accept the optimum possible goals in light of physical and emotional limitations

20. To use community resources as an aid in resolving problems arising from illness

21. To understand the role of social problems as influencing factors in the cause of illness
IV. Nursing Assessment

A. Personal Data

Name: A. M.

Age: 62 years old

Birthday: November 11, 1947

Nationality: Filipino

Gender: Male

Civil Status: Married

Address: San Mateo, Rizal

Occupation: Driver

Adm. Date: August 9, 2010

Adm. Time: 5:30 pm

Chief complaint: Abdominal pain (6/10) and vomiting

Clinical Impression: Gastric outlet obstruction

B. History of Present illness:

Few weeks prior to admission, the patient experienced general body weakness,
constipation, and abdominal bloatedness. Persistence of the signs and symptoms mentioned
prompted the patient to consult medical help. Upon admission, patient’s vital signs were
documented as follows: BP- 140/80 mm Hg, T- 36.0°C, RR-18bpm PR- 82bpm. The patient has
symptoms of nausea, vomiting. He complains of abdominal pain. Patient had undergone
jejunostomy insertion on August 16, 2010. Patient is a diagnosed case of seminoma S/P
orchidectomy (R), Gastric Outlet Obstruction, S/P jejunostomy tube insertion.

C. Past Health history:

The patient was diagnosed to have a Gouty Arthritis way back 1990. He also had a
Diabetes Mellitus for 6 years but has been controlled through medication and proper diet as
well as exercise. Further, he also had a Pulmonary Tuberculosis last 2007 and was treated using
short course therapy for 6 months.
The patient was previously admitted on July, 2010 due to abdominal mass and pain on
his testes that started last June, 2010. It is when the patient was diagnosed to have seminoma
and had undergone orchidectomy. Since then, he had experienced different signs and symptoms
that lead to his present admission at WCC.
 D. Family history:
Both his parents have a history of Diabetes Mellitus. His mother had a breast cancer that
contributed to her death.

E. Social History:
He works as a government driver. He has three children; all of them are already
graduated from school. He was a hard drinker. Also a chain smoker, he can consume 6 packs a
day but has stopped for one month before hospitalization.

F. Physical Assessment:

Day 1

HAIR

The patient is bald at the upper portion of the head. Has gray thin hair on the back and on his side of his
head

SCALP

White, oily clean scalp

FACE

Symmetrical facial movement, he looks worried and sad

EYES

The outer cantus of the patient eyes were symmetrical to the pinna of his ears. The eyebrows were thin
but evenly distributed and have short eyelashes. Patient’s was observed to have yellowish sclera, pale
conjunctivas, and black equally rounded pupils. Constriction were observed when light stimulation done
at varying distance.

NOSE

The patient has pointed nose, with dry mucus membranes. NGT tube is attached to the left nostril

EARS

Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed when exposed to pen light.
He is able to hear from both ears because he was able to respond to the questions that was asked to
him.

MOUTH

He is able to open and close with ease.

TEETH

He has two missing molar tooth on his upper and lower teeth. Yellowish in color.

TONGUE

The patient has moist with white patches over the tongue.

LIPS

Dry and pale in color.

NECK

The patient’s neck has dry skin complexion. Muscle tone was fairly good and able to move his head. No
masses palpated along lymph nodes. There’s a presence of wrinkles. The carotid pulse is palpable.

CHEST

Chest is symmetrical during respiration, fair skin in color and smooth with respiratory rate of 18 bpm.
Torso- ribs are visible and palpable

ABDOMEN

There is an incision at the right side of his abdomen, with no discharge. There is jejunostomy tube attach
to the left lower quadrant of his abdomen, tender to touch.

UPPER EXTREMITIES

The patient’s left and right upper extremities were symmetrical to each other; has brown complexion
but pale. Patient’s arms and palms were dry, warm to touch with dry and good skin turgor. Capillary
refill was within 3 seconds.

LOWER EXTREMETIES

The patient’s right and left lower extremities has brown complexion and both were symmetrical
compared to each other. Patient’s legs and feet were dry and warm to touch. Capillary refill was within
3 seconds and skin turgor was good.

Day 2

HAIR

The patient is bald at the upper portion of the head. Has gray thin hair on the back and on his side of his
head

SCALP

White, oily clean scalp

FACE

Symmetrical facial movement, he looks worried and sad

EYES

The outer cantus of the patient eyes were symmetrical to the pinna of his ears. The eyebrows were thin
but evenly distributed and have short eyelashes. Patient’s was observed to have yellowish sclera, pale
conjunctivas, and black equally rounded pupils. Constriction were observed when light stimulation done
at varying distance.

NOSE

The patient has pointed nose, with dry mucus membranes. NGT tube is attached to the left nostril

EARS

Tip of the ear is aligned with the outer canthus of the eye. Ear wax observed when exposed to pen light.
He is not able to hear from both ears because he was having a hard time to hear the questions that was
asked to him.

MOUTH

He is able to open and close with ease.

TEETH

He has two missing molar tooth on his upper and lower teeth. Yellowish in color.

TONGUE

The patient has moist with white patches over the tongue.

LIPS

Dry and pale in color.

NECK

The patient’s neck has dry skin complexion. Muscle tone was fairly good and able to move his head. No
masses palpated along lymph nodes. There’s a presence of wrinkles. The carotid pulse is palpable.

CHEST

Chest is symmetrical during respiration, fair skin in color and smooth with respiratory rate of 18 bpm. /
Torso- ribs are visible and palpable
ABDOMEN

There is an incision at the right side of his abdomen, with no discharge. There is jejunostomy tube attach
to the left lower quadrant of his abdomen, tender to touch.

UPPER EXTREMITIES

The patient’s left and right upper extremities were symmetrical to each other; has brown complexion
but pale. Patient’s arms and palms are dry, warm to touch with dry and good skin turgor. Capillary refill
was within 3 seconds.

LOWER EXTREMETIES

The patient’s right and left lower extremities has brown complexion and both were symmetrical
compared to each other. Patient’s legs and feet are dry and warm to touch. Capillary refill was within 3
seconds and skin turgor was good.

V. Usual Patterns of Daily Living

AREA BEFORE DURING DURING

HOSPITALIZATION HOSPITALIZATION HOSPITALIZATION
(DAY1) (DAY2)

1. Social history He works as a He is always on the He is awake but stays on

government driver. He bed sleeping and he the bed. He had his two
has three children; all of has only one companions throughout
them are already companion. the day.
graduated from school.

2. Mental Conscious and aware of The patient is The patient is conscious

time, date and reality conscious and and ambulatory but
ambulatory but limited ROM
limited ROM

3. Emotional The patient is reacts He is approachable He is irritated because

depending on the of the room ambiance.
situation.

4. Sensory His sensory were all The patient is He can’t hear the person
perception working, able to answering whenever he is talking to clearly.
perceive stimuli. asked by the
interviewer.

5. Motor Able to move his body The patient is able to He is able to stand and
Capabilities
 stand and walk alone. walk alone.

6. Respiratory With in the normal RR: 17 (4pm) RR: 18 (4pm)

range (16-20bpm).
18 (8pm) 20 (8pm)

7. Circulatory Within normal range PR: 110bpm (4pm) PR: 118bpm (4pm)

(PR: 60-100 bpm; BP: 117 bpm (8pm) 118 bpm (8pm)
150/90 mmHg)
BP:120/80 mmhg BP:120/80 mmhg (4pm)
(4pm)
110/80 mmhg (8pm)
120/80 mmhg (8pm)

8. Body Within normal range Temp: 36.5'C (4pm) Temp: 36.5'C (4pm)
temperature
(Temp: 36.5-37.5'C) 36.5’C (8pm) 36.7’C (8pm)

9. Nutritional He eats well at least 3-4 Jejunostomy tube Jejunostomy tube

times a day. He always feeding (1800kcal). He feeding (1800kcal). He
eat with fish and take liquid substances take liquid substances
vegetables by mouth by mouth

10. Elimination She urinates and Urine: 2 Urine: 1

defacates regularly.
Stool: 2 Stool: 1

11. State of She was able to sleep 7- He is always sleeping He is awake but stays
physical rest & 8 hours on the bed for the
comfort whole day

12. State of skin Good skin turgor, skin He has dry skin He still has dry skin
and especially on the especially on the mouth.
appendices mouth

VI. Anatomy and Physiology

Small Intestine

If the small intestine were not looped back and forth upon itself, it could not fit into
the abdominal space it occupies. It is held in place by tissues which are attached to the abdominal wall
and measures eighteen to twenty-three feet in the average adult, which makes it about four times
longer than the person is tall. It is a three-part tube of about one and one-half to two inches in diameter
and is divided into three sections: (1) the duodenum, a receiving area for chemicals and partially
digested food from the stomach; (2) the jejunum, where most of the nutrients are absorbed into the
blood and (3) the ileum, where the remaining nutrients are absorbed before moving into the large
intestine. The intestines process about 2.5 gallons of food, liquids and bodily waste every day. In order
for enough nutrients to be absorbed into the body, it must come in contact with large numbers of
intestinal cells which are folded like gathered skirts. Each of these cells contain thousands of tiny finger-
like projections called "villi," and each villus contains microscopic "microvilli". In one square inch of small
intestine, there are about 20,000 villi and ten billion microvilli. Each villus brings in fresh, oxygenated
blood and sends out nutrient-enriched blood. The villi sway constantly to stir up liquefied food and
remove the nutrients which can be absorbed and then passed through the membranes of the villi into
the blood and lymph vessels. The fatty nutrients go to the lymph vessels, and glucose and amino acids
go to the blood and on to the liver. The muscles which encircle this tube constrict about seven to twelve
times a minute to move the food back and forth, to churn it, knead it, and to mix it with gastric juices.
The small intestine also makes waves which move the food forward, but these are usually weak and
infrequent to allow the food to stay in one place until the nutrients can be absorbed. If a toxic substance
enters the small intestine, these movements may be strong and rapid to expel the poisons quickly.

VII. Pathophysiology Risk factors:

Sedentary lifestyle, gender, obstruction of the

pyloric channel or duodenum
 Organ Affected:

Small Intestine

Disease Process:
Patient
Mechanical impediment to gastric emptying

BOOK

Clinical Manifestations:
Clinical Manifestations:
General Body Weakness
-Nausea and vomiting is the cardinal symptom.
Constipation
-Tolerance to liquids than solid food.
Feeling of bloatness
-May develop significant weight loss due to poor
caloric intake ( Malnutrition). Nausea

-In the acute or chronic phase of obstruction,

continuous vomiting may lead to dehydration
and electrolyte abnormalities. Diagnostic Evaluation:

Hemoglucotest

Uric acid
Diagnostic Evaluation:
Albumin test
-Obtain a CBC. Check the hemoglobin and
Creatinine
hematocrit
Glycosylated Hemoglobin
-Upper endoscopy
Calcium Ionized
-Sodium chloride load test
Medical Management: Medical
Sodium, Management:
Routine Urinalysis
-Barium upper GI studies
- Sodium chloride IV fluid solution Blood typing
- Jejunostomy tube insertion
-CT scans
- Jejonostomy tube insertion - Osteurized Feeding: Jejunostomy tube feeding
1800 kcal
- Place a NGT to decompress the stomach.
- Meds: Allopurinol, Conzace, Dolcet, Etoricoxib
-Potassium deficits are corrected after repletion
of volume status
VIII. Laboratory
Date ordered Laboratory exams Results Normal values significant

August 11, 2010 Glycosylated Hemoglobin 8.8 4.50-6.30% Increase- found in

people with
persistent
elevated blood
sugar.

August 11, 2010 Calcium Ionized 1.21 1.00-1.20 mmol/L

August 12, 2010 Phosphorus 1.00 0.80-1.50 mmol/L Increase- kidney

failure, hypo para-
thyroidism, iabetic
keto acidosis.

Decrease- Hyper
calcemia,
malnutrition,
alcoholism,
osteomalasia.

August 11, 2010 LDH 368 144.00-225.00 U/L Increase- CVA,

hemolytic
anemias, kidney,
liver disease,
pancreatitis,
lymphoma.

Date ordered Laboratory exams results Normal values Significant

August 19, 2010 Uric Acid 236 208.30-428.40 umol/L Increased- gout,
cardiovascular
disease.

Decrease- multiple
sclerosis

August 21, 2010 Chloride 88.60 98.00-107.00 mmol/L Decreased-

metabolic alkalosis,
respiratory
acidosis, prolonged
vomiting.

August 11, 2010 Albumin 25.64 35.00-52.00 G/L Decreased- liver

disease, shock,
malnutrition,

August 23, 2010 Creatinine 102.9 72.00-127.00 umol/L Increase- mascular

 dystrophy, fever,
carcinoma of liver

Decrease-
decreased muscle
mass

August 23, 2010 Potassium 4.96 3.50-5.50 mmol/L Increased-

hemolysis, chronic
renal failure,
acidosis, cushing’s
diease, corpus
luteum cysts.

Decrease –
diarrhea,
adrenocortical
insuffiency.

August 23, 2010 Sodium 135.7 135.00-148.00 mmol/L Increased- useful in

detecting gross
changes in water
and salt balanced

Decrease-
Diarrhea, excessive
sweating, kidney
disease,

Date ordered Laboratory exams results Normal values Significant

August 11, 2010 Uric Acid 581 208.30-428.40 umol/L The results shows
that the uric acid is
above normal
which can cause
gout,
cardiovascular
disease.

August 17, 2010 Chloride 91.4 98.00-107.00 mmol/L Decreased-

metabolic alkalosis,
respiratory
acidosis, prolonged
vomiting.

August 9, 2010 Albumin 30.82 35.00-52.00 G/L Increased-

 dehydration

Decreased- liver
disease, shock,
malnutrition,

August 17, 2010 Creatinine 121.3 72.00-127.00 umol/L Increase- mascular

dystrophy, fever,
carcinoma of liver

Decrease-
decreased muscle
mass

August 21, 2010 Potassium 4.74 3.50-5.50 mmol/L Increased-

hemolysis, chronic
renal failure,
acidosis, cushing’s
diease, corpus
luteum cysts.

Decrease –
diarrhea,
adrenocortical
insuffiency.

August 22, 2010 Sodium 129.2 135.00-148.00 mmol/L Increased- useful in

detecting gross
changes in water
and salt balanced

Decrease-
Diarrhea, excessive
sweating, kidney
disease,

Date ordered Laboratory exams results Normal values Significant

August 14, 2010 Chloride 84.80 98.00-107.00 mmol/L Decreased-

metabolic alkalosis,
respiratory
acidosis, prolonged
vomiting.

August 15, 2010 Creatinine 93.6 72.00-127.00 umol/L Increase- mascular

dystrophy, fever,
carcinoma of liver
 Decrease-
decreased muscle
mass

August 17, 2010 Potassium 4.76 3.50-5.50 mmol/L Increased-

hemolysis, chronic
renal failure,
acidosis, cushing’s
diease, corpus
luteum cysts.

Decrease –
diarrhea,
adrenocortical
insuffiency.

August 21, 2010 Sodium 125.60 135.00-148.00 mmol/L Increased- useful in

detecting gross
changes in water
and salt balanced

Decrease-
Diarrhea, excessive
sweating, kidney
disease,

Date ordered Laboratory exams results Normal values Significant

August 14, 2010 Creatinine 94,3 72.00-127.00 umol/L Increase- mascular

dystrophy, fever,
carcinoma of liver

Decrease-
decreased muscle
mass

August 15, 2010 Potassium 3.91 3.50-5.50 mmol/L Increased-

hemolysis, chronic
renal failure,
acidosis, cushing’s
diease, corpus
luteum cysts.

Decrease –
diarrhea,
adrenocortical
 insuffiency.

August 17, 2010 Sodium 130.4 135.00-148.00 mmol/L Increased- useful in

detecting gross
changes in water
and salt balanced

Decrease-
Diarrhea, excessive
sweating, kidney
disease,

Date ordered Laboratory exams results Normal values Significant

August 11, 2010 Creatinine 125.5 72.00-127.00 umol/L Increase- mascular

dystrophy, fever,
carcinoma of liver

Decrease-
decreased muscle
mass

August 14, 2010 Potassium 3.72 3.50-5.50 mmol/L Increased-

hemolysis, chronic
renal failure,
acidosis, cushing’s
diease, corpus
luteum cysts.

Decrease –
diarrhea,
adrenocortical
insuffiency.

August 15, 2010 Sodium 130.1 135.00-148.00 mmol/L Increased- useful in

detecting gross
changes in water
and salt balanced

Decrease-
Diarrhea, excessive
sweating, kidney
disease,

Date ordered Laboratory exams results Normal values Significant

August 9, 2010 Creatinine 163.4 72.00-127.00 umol/L Increase- mascular
dystrophy, fever,
carcinoma of liver

Decrease-
decreased muscle
mass

August 14, 2010 Potassium 3.72 3.50-5.50 mmol/L Increased-

hemolysis, chronic
renal failure,
acidosis, cushing’s
diease, corpus
luteum cysts.

Decrease –
diarrhea,
adrenocortical
insuffiency.

August 13, 2010 Sodium 125.20 135.00-148.00 mmol/L Increased- useful in

detecting gross
changes in water
and salt balanced

Decrease-
Diarrhea, excessive
sweating, kidney
disease,

Date ordered Laboratory exams results Normal values Significant

August 9, 2010 Potassium 4.98 3.50-5.50 mmol/L Increased-

hemolysis, chronic
renal failure,
acidosis, cushing’s
diease, corpus
luteum cysts.

Decrease –
diarrhea,
adrenocortical
insuffiency.

August 9, 2010 Sodium 136.1 135.00-148.00 mmol/L Increased- useful in

detecting gross
changes in water
 and salt balanced

Decrease-
Diarrhea, excessive
sweating, kidney
disease,

Date ordered Laboratory exams results Normal values Significant

August 23, 2010 Total Bilirubin 65.28 5.00-21 umol/L Increase-

hemolytic, sickle
August 23, 2010 Direct Bilirubin 25.42 0.00-3.40 umol/L
cell or pernicious
August 23, 2010 Indirect Bilirubin 39.86 5.00-17.60 umol/L anemia.

Date ordered Laboratory exams results Normal values Significant

August 14, 2010 Total Bilirubin 10.42 3.42-17.10 mmol/L Increase-

hemolytic, sickle
August 14, 2010 Direct Bilirubin 3.88 0.00-8.55 mmol/L
cell or pernicious
August 14, 2010 Indirect Bilirubin 6.54 2.60-12.00 mmol/L anemia.

Date ordered Laboratory exams results Normal values Significant

August 24, 2010 140 Increase- found in

people with
August 23, 2010 154
persistent elevated
August 23, 2010 107 blood sugar

August 22, 2010 153 Decrease- sickle

Hemoglucotest 70.00-140.00mgs/dl
cell disease, Vit-
August 21, 2010 163 B12 or folate
deficiency.
August 18, 2010 146

August 15, 2010 144

August 9, 2010 143

Routine Urinalyis

Macroscopic Results:
 Date Ordered Result Interpretation
August 10, 2010 Color Light Yellow Healthy and normal urine
August 10, 2010 Character Slightly Turbid May be caused by normal or abnormal
processes.
Normal= precipitation crystals or mucus.
Abnormal= presence of blood cells, yeast or
bacteria.
August 10, 2010 Reaction 5.0
August 10, 2010 Specific Gravity 1.025 The specific gravity is in range of the normal of
1.020-1.030 g/ml, hence the urine’s
concentration is normal
August 10, 2010 Protein Trace Protein is present in the urine that may indicate
kidney damage/disease.
August 10, 2010 Sugar Negative Sugar is not present in the urine.
Microscopic Results:

Date Ordered Result Interpretation

August 10, 2010 Red Blood Cells 0-2/ HPF Normal presence of RBCs in the
urine
August 10, 2010 Pus Cells 0-2/HPF Normal presence of Pus cells in the
urine
August 10, 2010 Epithelial Cells FEW Normal
August 10, 2010 Amorphus Urates FEW
August 10, 2010 Amorphous Phosphates N/A
August 10, 2010 Bacteria N/A
August 10, 2010 Mucus Threads FEW Normal presence of mucus which
causes the slight turbidity of the
client’s urine
August 10, 2010 Yeast Cells

Complete Blood Count ( August 21, 2010)

Date ordered Laboratory exams results Normal values significant

August 21, 2010 WBC 8.4 4.00-10.00 10^9/L Increased-

neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.

August 21, 2010 RBC 3.92 4.50-6.50 10^12/L Decreased-

iron deficiency, vit.

B6, b12 or/ and
folic acid
deficiency, chronic
 disease, hereditary
anemia, free radical
pathology, toxic
metals, catabolic
methabolism.

August 21, 2010 HGB 116.00 130.00-170.00 g/L Decreased in

various anemias,
pregnancy, severe
of prolonged
hemorrhage, and
with excessive fluid
intake.

August 21, 2010 HCT 0.35 0.40-0.54 Decrease in severe

anemias, anemia in
pregnancy, acute
massive blood loss.

August 21, 2010 MCV

August 21, 2010 MCH

August 21, 2010 MCHC

August 21, 2010 PLT Slight Increase 150.00-350.00 10^9/L Increased in

malignancy,
myeloproliferative
disease,
rheumatoid
arthritis, and
postoperativerly;
about 50% of
patients with
unexpected
increase of platelet
count will be found
to have a
malignancy;

August 21, 2010 Lymphocytes 0.19 0.25-0.50 Increase with

infectious
mononucleosis,
 viral and some
bacterial infections,
hepatitis;
decreased with
aplastic anemia,
SLE,
immunodeficiency
including AIDS.

August 21, 2010 Monocytes 0.05 0.02-0.10 Increase with viral

infections, parasitic
disease, collagen
and hemolytic
disorder; decreased
with use of
corticosteroids, RA,
HIV infection.

August 21, 2010 Neutrophils 0.75 0.50-0.80 Increase with acute

infection, trauma or
surgery, leukemia,
malignant disease,
necrosis; decrease
with viral
infections, bone
marrow
suppression,
primary bone
marrow disease.

August 21, 2010 Eosinophils 0.01 0.00-0.05 Increase in allergy,

parasitic disease,
collagen disease,
subacute
infections;
decrease with
stress, use of some
medications(ACTH,
epinephrine,
thyroxin

Complete Blood Count ( August 17, 2010)

Date ordered Laboratory exams results Normal values significant

August 17, 2010 WBC 8.7 4.00-10.00 10^9/L Increased-

 neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.

Decreased-
leukemia, bone
marrow failure,
collagen vascular
disease, liver and
spleen disease,
radiation therapy
or exposure.

August 17, 2010 RBC 3.25 4.50-6.50 10^12/L Decreased-

iron deficiency, vit.

B6, b12 or/ and
folic acid
deficiency, chronic
disease, hereditary
anemia, free radical
pathology, toxic
metals, catabolic
methabolism.
Increased-

chronic respiratory
insufficiency,
emphysema,
respiratory distress,
living at a high
altitudes, cystic
fibrosis (non-
respiratory)

August 17, 2010 HGB 93.00 130.00-170.00 g/L Decreased in

various anemias,
pregnancy, severe
of prolonged
hemorrhage, and
with excessive fluid
intake.

Increased in
polycythemia,
chronic obstructive
 pulmonary disease,
failure of
oxygenation
because of
congestive heart
failure, and
normally in people
living at high
altitudes

August 17, 2010 HCT 0.30 0.40-0.54 Decrease in severe

anemias, anemia in
pregnancy, acute
massive blood loss.

Increased in
erythrocytosis of
any cause, and in
dehydration or
hemoconcentration
associated with
shocks.

August 17, 2010 MCV

August 17, 2010 MCH

August 17, 2010 MCHC

August 17, 2010 PLT Increase 150.00-350.00 10^9/L Increased in

malignancy,
myeloproliferative
disease,
rheumatoid
arthritis, and
postoperativerly;
about 50% of
patients with
unexpected
increase of platelet
count will be found
to have a
malignancy;
decreased in
thrombocytopenic
 purpura, acute
leukemia, aplastic
anemia, and during
cancer
chemotherapy

August 17, 2010 Lymphocytes 0.18 0.25-0.50 Increase with

infectious
mononucleosis,
viral and some
bacterial infections,
hepatitis;
decreased with
aplastic anemia,
SLE,
immunodeficiency
including AIDS.

August 17, 2010 Monocytes 0.01 0.02-0.10 Increase with viral

infections, parasitic
disease, collagen
and hemolytic
disorder; decreased
with use of
corticosteroids, RA,
HIV infection.

August 17, 2010 Neutrophils 0.79 0.50-0.80 Increase with acute

infection, trauma or
surgery, leukemia,
malignant disease,
necrosis; decrease
with viral
infections, bone
marrow
suppression,
primary bone
marrow disease.

August 17, 2010 Eosinophils 0.02 0.00-0.05 Increase in allergy,

parasitic disease,
collagen disease,
subacute
infections;
decrease with
stress, use of some
medications(ACTH,
 epinephrine,
thyroxin

Complete Blood Count ( August 14, 2010)

Date ordered Laboratory exams results Normal values significant

August 14, 2010 WBC 9.2 4.00-10.00 10^9/L Increased-

neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.

Decreased-
leukemia, bone
marrow failure,
collagen vascular
disease, liver and
spleen disease,
radiation therapy
or exposure.

August 14, 2010 RBC 3.69 4.50-6.50 10^12/L Decreased-

iron deficiency, vit.

B6, b12 or/ and
folic acid
deficiency, chronic
disease, hereditary
anemia, free radical
pathology, toxic
metals, catabolic
methabolism.
Increased-

chronic respiratory
insufficiency,
emphysema,
respiratory distress,
living at a high
altitudes, cystic
fibrosis (non-
respiratory)
August 14, 2010 HGB 110.00 130.00-170.00 g/L Decreased in
various anemias,
pregnancy, severe
of prolonged
hemorrhage, and
with excessive fluid
intake.

Increased in
polycythemia,
chronic obstructive
pulmonary disease,
failure of
oxygenation
because of
congestive heart
failure, and
normally in people
living at high
altitudes

August 14, 2010 HCT 0.33 0.40-0.54 Decrease in severe

anemias, anemia in
pregnancy, acute
massive blood loss.

Increased in
erythrocytosis of
any cause, and in
dehydration or
hemoconcentration
associated with
shocks.

August 14, 2010 MCV

August 14, 2010 MCH

August 14, 2010 MCHC

August 14, 2010 PLT Adequate 150.00-350.00 10^9/L Increased in
malignancy,
myeloproliferative
disease,
rheumatoid
arthritis, and
postoperativerly;
about 50% of
patients with
unexpected
increase of platelet
count will be found
to have a
malignancy;
decreased in
thrombocytopenic
purpura, acute
leukemia, aplastic
anemia, and during
cancer
chemotherapy

August 14, 2010 Lymphocytes 0.17 0.25-0.50 Increase with

infectious
mononucleosis,
viral and some
bacterial infections,
hepatitis;
decreased with
aplastic anemia,
SLE,
immunodeficiency
including AIDS.

August 14, 2010 Monocytes 0.04 0.02-0.10 Increase with viral

infections, parasitic
disease, collagen
and hemolytic
disorder; decreased
with use of
corticosteroids, RA,
HIV infection.
 August 14, 2010 Neutrophils 0.78 0.50-0.80 Increase with acute
infection, trauma or
surgery, leukemia,
malignant disease,
necrosis; decrease
with viral
infections, bone
marrow
suppression,
primary bone
marrow disease.

August 14, 2010 Eosinophils 0.01 0.00-0.05 Increase in allergy,

parasitic disease,
collagen disease,
subacute
infections;
decrease with
stress, use of some
medications(ACTH,
epinephrine,
thyroxin

Complete Blood Count ( August 9, 2010)

Date ordered Laboratory exams results Normal values significant

August 9, 2010 WBC 10.10 4.00-10.00 10^9/L Increased-

neurosyphilis,
anterior
poliomyelitis,
encephalitis
lethargic.

Decreased-
leukemia, bone
marrow failure,
collagen vascular
disease, liver and
spleen disease,
radiation therapy
or exposure.

August 9, 2010 RBC 4.50 4.50-6.50 10^12/L Decreased-

iron deficiency, vit.

 B6, b12 or/ and
folic acid
deficiency, chronic
disease, hereditary
anemia, free radical
pathology, toxic
metals, catabolic
methabolism.
Increased-

chronic respiratory
insufficiency,
emphysema,
respiratory distress,
living at a high
altitudes, cystic
fibrosis (non-
respiratory)

August 9, 2010 HGB 129.00 130.00-170.00 g/L Decreased in

various anemias,
pregnancy, severe
of prolonged
hemorrhage, and
with excessive fluid
intake.

Increased in
polycythemia,
chronic obstructive
pulmonary disease,
failure of
oxygenation
because of
congestive heart
failure, and
normally in people
living at high
altitudes

August 9, 2010 HCT 0.42 0.40-0.54 Decrease in severe

anemias, anemia in
pregnancy, acute
 massive blood loss.

Increased in
erythrocytosis of
any cause, and in
dehydration or
hemoconcentration
associated with
shocks.

August 9, 2010 MCV 94.00 80.00-100.00 fl Increase in

macrocytic
anemias;

decrease in
microcytic anemia

August 9, 2010 MCH 28.70 27.00-32.00 pg Increase in

macrocytic
anemias;

decrease in
microcytic anemia

August 9, 2010 MCHC 305.00 320.00-360.00 g/L Decreased in

severe hypocromic
anemia.

Increased and
decreased is same
with MCV two
exceptions in
spherocytosis, the
MCHC is elevated
but not in
pernicious anemia

August 9, 2010 PLT Increase 150.00-350.00 10^9/L Increased in

malignancy,
myeloproliferative
disease,
rheumatoid
arthritis, and
postoperativerly;
about 50% of
patients with
unexpected
increase of platelet
count will be found
 to have a
malignancy;
decreased in
thrombocytopenic
purpura, acute
leukemia, aplastic
anemia, and during
cancer
chemotherapy

August 9, 2010 Lymphocytes 0.23 0.25-0.50 Increase with

infectious
mononucleosis,
viral and some
bacterial infections,
hepatitis;
decreased with
aplastic anemia,
SLE,
immunodeficiency
including AIDS.

August 9, 2010 Monocytes 0.02 0.02-0.10 Increase with viral

infections, parasitic
disease, collagen
and hemolytic
disorder; decreased
with use of
corticosteroids, RA,
HIV infection.

August 9, 2010 Neutrophils 0.75 0.50-0.80 Increase with acute

infection, trauma or
surgery, leukemia,
malignant disease,
necrosis; decrease
with viral
infections, bone
marrow
suppression,
primary bone
marrow disease.

August 9, 2010 Eosinophils 0.00 0.00-0.05 Increase in allergy,

parasitic disease,
collagen disease,
subacute
 infections;
decrease with
stress, use of some
medications(ACTH,
epinephrine,
thyroxin

August 18, 2010

BLOOD TYPING

Specimen: Blood

Result: “AB” Positive

August 15, 2010

ELECTROCARDIOGRAM

Interpretation: Non-specific ST-T wave changes

August 15, 2010

X-RAY

Interpretation:

-There is unchanged appearance of the fibrosis on the right upper lobe since 7/11/10.

-Suspicious thin walled lucency is seen in the left apex w/c may represent a bulla.

-Suggest apicolordotic view

-Heart is not Enlarged

-Diaphragm & costophrenic sulci are intact.

August 10, 2010

CT SCAN SECTION
Interpretation: CT KUB Stonogram

-Follow up to 07.12.10 shows increase in size of the previously noted

right supra renal mass now measuring 4x6 cm w/ previous

measurement of 3.2x4.7cm. There is likewise increase in size of the

previously noted mass

in the perivical & right psoas region now measuring

7x10 cm w/ previous measurement of 5.6x5 cm now showing signs

of central necrosis.

-Right perirenal fat stranding, pelvocalectasis & proximal ureterectasis

is also noted.

The inferior vena cava, right psoas & right ureter appear is

is to be encased by the mass. Subcentimeter mesenteric adenopathies

are likewise noted.

-The stomach is distended w. no intraluminal mass.

-The liver, gall bladder, pancreas. Left adrenal, left kidney & spleen

are unremarkable.

- Negative for pelvic mass nor adenopathies.

- No other finding of note.

 IX. Drug Study

Date Medication Action Indication Nursing Considerations

Ordered Generic
Brand
08-09-10 Ketorolac NSAID. Acts on Short-term (≤ 5 - Treatment should not
tromethamin cyclooxigenase route, days) management exceed 5 days
e inhibits of moderate and - Food decreases the
Remopain prostaglandins severe acute pain absorption rate
30 mg synthesis that requires
Q8° analgesia at the
PRN opioid level.
08-12-10 Tramadol Analgesic. Binds to Relief of moderate - Control environment
Tramal mu-opiod receptors to severe pain; (temperature, lighting) if
50 mg and inhibits the Patient sweating or CNS effects
STAT reuptake of experienced occur
PO norepinephrine and surgery-related - Report severe nausea,
serotonin pain. dizziness, sever constipation
08-16-10 Cefuroxime Antibiotic. 2nd Perioperative - Given 30-60 minutes prior
Zinacef generation prophylaxis. to initial incision
750 mg cephalosporin. Surgery – - May experience stomach
IV Inhibits synthesis of Jejunostomy tube upset or diarrhea
ANST (-) bacterial cell wall, insertion on
causing cell death. August 16
08-21-10 Metformin Antidiabetic. Exact Adjunct to diet to - Monitor for blood glucose
hydrochloride. mechanism not lower blood and ketones as prescribed
Metformin understood. Perhaps glucose with type 2 - Report fever, sore throat,
500 mg increases peripheral DM. Patient has unusual bleeding or bruising,
½ tab utilization of glucose, had DM for six rash, dark urine, light-
BID decreases hepatic years. colored stools,
PO glucose production, hypo/hyperglycemia
and alters intestinal reactions
absorption of glucose
08-23-10 Conzace Multivitamin. Extra vitamins A, C, - Assess for nutritional
1 cap Vitamin supplement E, and zinc to fight deficiencies
OD of vitamins A, C, E, infection and
PO and zinc. promote wound
healing post-op.
08-24-10 Etoricoxib cyclooxygenase-2 Relief of acute - Swallow them with a glass
Arcoxia (COX-2) specific pain. Treatment of of water. Do not cut the
1 tab inhibitors aka Coxibs. acute gouty tablet in half
STAT Reduces pain and arthritis. Relieves - Take the same time daily
PO inflammation by pain and - It does not matter if taken
blocking COX-2. inflammation with before or after food
less risk of
 stomach ulcers
compared to
NSAIDS.

Date Medication Action Indication Nursing Consideration

Ordered
8/09/10 Generic Name: -Binds to an enzyme on GERD/maintenance of -Assess patient
omeprazole gastric parietal cels in healing in erosive routinely for epigastric
Brand Name: the presence of acidic esophagitis. Duodenal or abdominal pain and
Omepron gastric pH, preventing ulcers. Short-term frank or occult blood,
40mg/IV the final transport of treatment of active stool, emesis,
STAT hydrogen ions to the benign gastric ulcer.
gastric lumen. Reduction of risk of GI
- THERAPEUTIC EFFECT: bleeding in critically ill
anti ulcer agents. patients
-PHARMACOLOGIC
ACTION: proton-pump
inhibitors
8/09/10 Generic Name: -Block dopamine Treatment of -Assess patient for N/V,
metoclopramide receptors in postsurgical and diabetic abdominal distention,
Brand Name: chemoreceptor trigger gastric stasis. Facilitation and bowel sounds
Plasil zone of the CNS. of small bowel before and after
1amp Stimulates motility of intubation in administration.
q8 the upper GI tract and radiographic
PRN accelerates gastric procedures.
emptying. Management of
-THERAPEUTIC gastroesophageal reflux.
EFFECT: antiemetics Treatment and
prevention of post
operative N/V when
nasogastric suctioning is
undesirable.
8/09/10 Generic Name: -Stimulates peristalsis. Treatment of -Assess patient for
bisacodyl Alters fluid and constipation. abdominal distention,
Brand Name: electrolyte transport, presence of bowel
Dulcolax supp producing fluid sounds, and usual
1supp accumulation in the pattern if bowel
STAT colon. function.
-THERAPEUTIC EFFECT: -Assess color,
Laxatives consistency, and
-PHARMACOLOGIC amount of stool
ACTION: stimulant production.
laxatives
8/11/10 Generic Name: -Inhibits the production Prevention of attack of -Monitor I/O ratios.
allopurinol of uric acid by inhibiting gouty arthritis and Decreased kidney
Brand Name: the action of xanthine nephropathy. function can cause drug
 N/A oxidase. accumulation and toxic
1tab -THERAPEUTICE EFFECT: effects.
OD antigout agents -Assess patient for rash
-PHARMACOLOGIC and more severe
ACTION: xanthine hypersensitivity
oxidase inhibitors. reaction. Discontinue
allopurinol if rash
occurs.
8/11/10 Generic Name: - Itopride Itopride hydrochloride is - Watch out for some
itopride increases acetylcholine  used in the treatment of common side-effects of
Brand Name: concentrations by gastrointestinal itopride; rash, diarrhea,
Ganaton Tab inhibiting dopamine D2 symptoms of functional, giddiness, exhaustion,
1tab receptors and acetylcholi nonulcer dyspepsia back or chest pain,
TID nesterase. Higher (chronic gastritis) i.e., increased
acetylcholine increases sensation of bloating, salivation, constipation,
GI peristalsis, increases early satiety, upper abdominal
the lower esophageal abdominal pain or pain, headache, sleeping
sphincter pressure, discomfort, anorexia, disorders,
stimulates gastric heartburn, nausea and dizziness, galactorrhea,
motility, accelerates vomiting. and gynecomastia.
gastric emptying, and
improves gastro-
duodenal coordination.
-THERAPEUTIC EFFECT:
antiemetic
8/11/10 Generic Name: Pharmacological: Vasodilation; dizziness, -Assess pt’s pain
tramadol + -Analgesic, Muscle vertigo, H.A, stimulation, (location, type and
paracetamol Relaxants and anxiety confusion character) before
Brand Name: Dolcet Uricosurics nervousness, sleep therapy,and regularly
MOA: disorders, seizures, N&V, thereafter to monitor
-Centrally acting Diarrhea drug effectiveness.
analgesic not chemically -Assess for
related to mu-opioids hypersensitivity
receptors a inhibits reactions: pruritus,
reuptake of rash, urticaria
norepinephrine and -Monitor for CNS
serotonin. changes: dizziness,
INDICATIONS: drowsiness
Moderate to Severe pain -Monitor I&O ratio and
check for decreasing
output w/c may
indicate retention.
Nursing Care Plans

Risk for impaired skin integrity

Subjective: After 3-4 hours of I: Record the patient’s The patient’s family
nursing weight regularly. members or relatives
“Medyo nanghihina ako” intervention the are able to
as verbalized by the family members understand what
patient and other relatives R: This ensures would be the
will be able to accurate record of appropriate diet,
recognize the foods weight changes. behavior and lifestyle
Objective: or the type of diet that could regain
that will regain the patient’s appetite.
Before hospitalization
patient’s appetite
I: conduct nutritional
Weight: 60kg and demonstrate
assessment.
behaviors, lifestyle
Height: 167.6 changes to regain
and/or maintain
BMI: 20.8
appropriate R: It’s critical that the
weight. health care provider
openly discuss and
During hospitalization have an
understanding on
(OF: 1800kcal/day)
complex food and
Weight: 50kg weight related to
behaviors of the
Height: 167.6 patient so that
appropriate supports
BMI: <18.5 or 17.3
can be integrated into
the treatment plan.

Nursing Diagnosis:

Imbalanced Nutrition: I: Asses

cardiovascular
Less than body metabolic, renal,
requirement related to gastric hematological
weight loss. and endocrine
system.

R: This assessment
provides data on the
severity of
 malnutrition

Imbalanced Nutrition
Fluid volume deficit

Assessment Planning Intervention Evaluation

Subjective After 1-2 hours of Monitor and record After 1-2 hours of
nursing intervention vital sign nursing intervention
“Nanunuyo ang labi the patient will the patient shall have
ko , nararamdaman demonstrate R: to obtain baseline reported
ko makapal ang labi data
adequate fluid understanding of
ko at uhaw” as balance and will show causative factors for
verbalized by the Assess patient’s
moist mucus condition fluid volume deficit
patient membrane.
R: to be aware of the
patient’s condition
Objective and feeling

Weakness Monitor input and

output balance
Dehydration
R: to ensure accurate
Decreased skin turgor fluid status
Decreased urine Maintain adequate
output hydration increase
Weight loss fluid intake.

Diagnosis: R: to prevent
dehydration and
Fluid volume deficit maintain hydration
related to status
dehydration
Provide oral care

R: to prevent from
dryness

Restrict solid food

intake as indicated

R: to allow for bowel

rest and to reduce
intestinal workload

Discuss individual risk

 factors or potential
and specific
interventions

R: to prevent or limit
occurrence of fluid
deficit

RISK FOR INFECTION

Assessment Planning Intervention Evaluation

Subjective After 2-3 hours of Independent After 2-3 hours of
none nursing intervention Monitor vital signs and nursing intervention
the patient and his records the patient and his
Objective relatives will have relatives had enough
*T- 36.5 enough knowledge on R: To provide baseline knowledge on how to
*P- 110bpm how to prevent data for comparison. prevent infection.
*R- 18bpm infection. Elevation in rates may
*BP- 120/80 mmHg signal infection

*With NGT and Assess insertion site for

Jejunostomy tube. signs of infection

R: To check for skin

Diagnosis: integrity and identify
Risk for infection need for further
related to post surgical management
incision.
Provide regular wound
dressing and tube care

R: To promote comfort
and hygiene. To prevent
growth of
microorganisms in
dressings, tube

Change linens and pt’s

robes

R: To promote comfort
and hygiene. To prevent
growth of
microorganisms in linens
and robes

Encourage patient to
verbalize any untoward
feelings esp. discomfort
or pain on
operative/insertion site

R: To allow continuous
monitoring and
assessment of patient
condition

Dependent
Administer antibacterial
antibiotics as ordered

R: Inhibits bacterial wall

synthesis making the
pathogen vulnerable to
changing osmotic
pressures thereby
rendering
microorganism weak
until it dies.
 X. Evaluation

Medication: Continue prescribed medications for PULMONARY TUBERCULOSOS, and be aware of their
complications.

These include:

- Allopurinol 300mg/ tab 1 tab once a day

- Conzace 1 cap once a day
- Dolcet 1 tab every 8 hours
- Etoricoxib (arcoxia)

Exercise: Avoid strenuous activities, such as heavy lifting and any other extreme sports or activities that
may trigger an increase in heart rate. After recovery if the patient discharged the patient should start
with short slow walks for about 10-15 minutes and with time gradually increase the duration and
intensity of the walk. Patient should also be advised to “take it easy” to do activates that their body can
handle.

Treatment: Educate the patient how to properly take the medications and explain the action of it and
the considerations to be taken during medication intake.

Hygiene: Educate patient to practice proper hygiene to prevent any further complications and avoid any
further infections.

Out Patient: Remind patient about upcoming check ups needed to increase the patients health. Also
advice patient about any further appointments that need to be made. Educate the patient about
physical limitations and the time needed to make a full recovery before resuming normal activates
before hospitalization.

Diet: Avoid foods that will cause constipation and strain during bowel movements. Stick to a soft diet
such as pureed diet to ease the digestion process to avoid any further complications with the patient’s
condition.

Spiritualism – joining to some activities like bible studies and attending events to further develop the
client’s condition after being discharged from the hospital.

Prognosis

The client’s prognosis is not good because it shows in his body that he looks weak and tired