CASE PRESENTATION

GROUP 9

INTRODUCTION
Intestinal Tuberculosis

Is the 6th most frequent form of extra-pulmonary site. After lymphatic, genitourinary, bone and joint, miliary and meningeal tuberculosis. The postualted mechanism by which the tubercule bacilli reach the gastrointestinal tract are:

Hematogenous spread from the primary lung, with later reactivation Ingetsion of the bacilli In sputum from active pulmonary focus. Direct spread from adjacent organs. Through lymph channels from infected nodes.

the most common site of involvement is the ileocaecal region, possibly because of the increased physiological statis, increased rate of fluid and electrolyte absorption, minimal digestive activity and abundance of lymphoid tissue at this site.

Signs and symptoms

Chills

and fever, Weakness, Malaise, Progressive dyspnea.

Diagnostic tests
Tuberculin

test Intradermal PPD (mantoux) test Multiple puncture (tint) test Polymerase chain reaction permiots rapid detection of DNA from M. tuberculosis. Chest x-ray

Medications
Rifampin Isoniazid

Pyrazinamide
Ethambutol Streptomycin

Nursing management
Assesment

(with suspected TB) Health history: complaints of fatigue, weight loss, night sweats, DOB, cough, bloody sputum, chest pain, alcohol and other recreational drug use. Physical examination: vital signs, general appearance, respiratory rate, and lung sounds.

Nursing care:
Discuss

the reason for and importance of respiratory isolation procedure during initial hospitalization. Place mask on the client when transporting to other parts of the facility for diagnostic or treatment procedure. Inform all personnel having contact with the client of the diagnosis. Teach the client how to limit transmitting disease to others: Always cough and expectorate into tissues Dispose of tissues properly, placing them in closed bag. Wear mask if you are sneezing or unable to control secretions. Teach the importance of complying with prescribed treatment for the entire course of therapy.

Colonic tumor
A colon tumor is an abnormal growth of cells found
in the colon and can be an indication of colon cancer. If the colon tumor spreads to the bottom part of the colon, also known as the rectum, it can be an indication of colorectal cancer. Some colon tumors are non-cancerous and are called benign polyps. Since benign polyps do not cause colon cancer, they are not dangerous, but if they are not identified and removed, they can change into cancerous tumors.

.It is common in the Western world and is rare in Asia and Africa. In countries where the people have adopted western diets, the incidence of colon cancer is increasing.

Factors that increase a person's risk of coloncancer include:

high fat intake, a family history of colorectal cancer and polyps, the presence of polyps in the large intestine, and chronic ulcerative colitis.

Signs and symptoms

The symptoms are greatly determined by the location of the cancer, the stage of disease, and the function of the intestinal segment in which it is located. The most common presenting symptom is a change in bowel habits. The passage of blood in stool is the 2nd most common symptom. Unexplained anemia Anorexia Fatigue

Right sided lesion : dull abdominal pain and melena Left-sided lesion: obstruction ( abdominal pain and cramping, narrowing stools, constipation)

Diagnostic test
Barium

enema Colonoscopy Fecal occult blood testing

Complications

Tumor growth may cause partial or complete bowel obstruction. Extension of the tumor and ulceration into the surrounding blood vessel result in hemorrhage. Perforation Abscess formation Peritonitis Sepsis Shock

Patients Biographic Data

Mr. C.E, is a 41 y/o male married, with three children. Hes presently residing at San Pablo City Laguna. He works as a salesman in Zesto. He was admitted last September 18, 2010 with chief complaint of Abdominal Pain and diagnosis of Intraabdominal Mass right lower quadrant T/C appendicitis.

Past Health History

The client was never been hospitalized during his childhood. He had complete immunizations. He had cough, colds, fever and self medicates with any OTC drugs like paracetamol. He has no known allergies in both foods and drugs. His 1st hospitalization was when he had 2nd degree burn due to oven explosion when he was still working in a bakery. He was confined for several days and was given medication such as analgesics , NSAIDs and topical antibiotics. His 2nd confinement was due to anemia.

He was diagnosed with PTB year 2003, he was then treated with Rimstar-4 for 9mos. at their Brgy. Health Center The present confinement was his third.

History of present illness

The present illness started one month prior to admission when Mr. CE experienced right lower quadrant intermittent pain with the scale of 5/10. He neither take any medications nor sought consult according to him. His pain was tolerable. Three weeks prior to admission, the client noticed that there was a change of character in his bowel movement. That was the time when he sought consult. One day prior to admission, he palpated a mass at his right lower quadrant of abdomen but has no fever and vomiting. The patient sought consult at ER and was then recommended for admission.

GORDONS FUNCTIONAL HEALTH PATTERN

HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN According to Mr. C.E , health is very important. Being healthy makes him do everything he has to. He defined health as being free from any disease. Like any other man, he always wanted to stay healthy both physically and mentally for his family. Hes neither smoking nor taking alcohol. He doesnt take any medication when experiencing pain as long as he can tolerate it. When hes not feeling well, he usually self-medicate with OTC drugs.

NUTRITIONAL METABOLLIC PATTERN

According to the client the right nutrition is attained by eating a proper diet and the right choice of food. Before confinement, the client has a good appetite. He eats three times a day, consists of meat or fish, rice, vegetables, water or sometimes juice. They dont eat meat daily Salit salitan kain naming ng baboy, hindi araw-araw. During confinement, the client had slight decrease of appetite in which he doesnt consume everything that was served because of fear that might disturb his bowel movement further.

ELIMINATION PATTERN
Before experiencing abdominal pain, Mr. C.E used to have normal BM in which he defecates once a day. Then 3 weeks prior to admission the client had change in BM. Hindi na siya katulad ng dati, putol putol na kapag nalabas as stated. He also experienced difficulty in defecating

ACTIVITY EXERCISE PATTERN Client doesnt have a routine exercise, but in his free time he does some walking, jogging and stretching.
SLEEP-REST PATTERN Before confinement, Mr. CE, sleeps for 5-8 hours per day without interruption. During confinement , he had the same sleep pattern. wala naman akong problema sa pagtulog. As stated.

COGNITIVE-PERCEPTION The client knows how to read and write. He have no hearing or visual impairment. Awa naman ng dIyos, malinaw pa naman ang mata ko at pandinig. as stated. ROLE-RELATIONSHIP PATTERN Mr. C.E has a very good family relationship. He is happily married and blessed with three beautiful children. He also has a good relationship with the people around his community. madali naman akong pakisamahan as stated.

COPING STRESS PATTERN Before confinement the usual things that give him stress are his works and when his children were arguing and he is tired from work. During confinement his condition gives him stress, he just hold on to his family and thinks of them to cope it. VALUE-BELIEF PATTERN Being a roman catholic he always feels close to God. During Sundays they went to church together. He has a very strong faith. alam kong hindi niya kami pababayaan

Physical Assessment
Area of Assessment Normal Findings Abnormal Findings Interpretation

Hair

Does not fall out easily Even hairline distribution Black with gray in color
Free of lesions No pest inhabitants

Oily

Due to not shampooing of hair.

Scalp

Minimal flakes

Due to not shampooing of hair.

Skull

No unusual contours or bulges Symmetrical No swelling or edema No bruise

No abnormal findings

No abnormal findings Face

Eyes

Eyelid margins are moist & No abnormal findings pink with short lashes Eyelashes evenly spaced out & curled upward No sores at corners of eyelids Eyebrows present Bilaterally No discharge of any type Can tolerate normal light Normal visual acuity

Pupils

Uniform in color Equal in size Reactive to light Equal in sizes bilaterally No pain, swelling, redness, discharges, lumps, and lesions Ability to hear on both ears

No abnormal findings

Ears

No abnormal findings

Nose

Smooth No abnormal findings Tender Proportion to other facial features Can breathe freely through both sides of the nose No lesions, and pain No lesions present Fixed to the gum No darkening No abnormal findings With dentures on upper central and lateral incisors No abnormal findings

Lips Teeth

Thorax

Symmetric expansion Ability to support own weight Symmetrical

Abdomen

With abdominal binder With Jackson Pratt drainage With paramedian surgical incision Distended abdomen

Upper/Lower Extremeties Genitalia

Symmetrical, No lesions, No lesions, & discharge Urethral meatus is positioned centrally Asymmetric scrotum

With IVF on right hand, With scars on left arm. With indwelling foley Catheter

Skin

No lesions, tenderness, scaly, swelling & inflammation

Skin color is not fairly Uniform With scars on the upper extremities specifically on the arms, chest, and abdomen

Muscles

Free of pain

Normal

Bones

Free of pain No stiffness Has proper alignment

No abnormal findings

Nails

Transparent, smooth Pink nail beds Uniform in texture Firm

No abnormal findings

Mental Status

Pleasant Cooperative Follows command oriented to time, place, person, and event

No abnormal findings

LYDIA HALLS THEORY OF NURSING

Lydia Hall presented her theory of nursing visually by drawing three interlocking circles, each circle presenting a particular aspect of nursing . The circle represent the Care, Core and Cure.

The Care Circle

Representing nurturing component of nursing and exclusive to nursing Using factors the concept of mothering ( care and comfort of the person) Professional nurse provide bodily care, biological needs as eating, bathing, elimination and dressing.

presents the nurse and patient with an opportunity for closeness, the patient can share and explore feelings with the nurse. a strong theory base allows the nurse to maintain a professional status, rather than a mothering status. . The patient views the nurse as a potential comforter, one who provides care and comfort.

The Body Natural and Biological sciences Intimate bodily care aspect of nursing The Care

The Core Circle The core circle of patient care is base on the social sciences, involves the therapeutic use of self, and shared with others members of the health team. The professional nurse, by developing an interpersonal relationship with the patient verbally discuss feeling regarding the disease process and its effect expression the patient gain self-identity and further develop maturity The professional nurse, by use of the reflective technique (acting as a mirror for the patient)

Patient bringing into awareness to make conscious decision base on understood and accepted feelings and motivation.

The Person Social sciences therapeutic use of self aspect in nursing The Core

The Cure Circle Based pathological and therapeutic sciences and is shared with other member of health team. Nurse helps the patient and family through the medical, surgical and rehabilitative prescriptions made by the physician. The nurse role during the cure aspect is different from the care circle because many of the nurse actions take on negative quality of avoidance of pain rather than a positive quality of comforting.
The disease Pathological and therapeutic science Seeing the family and patient through the medical care of aspect of nursing.

Interaction of the Three Aspects of Nursing

Because Hall emphasizes the importance of a total person approach, it is important that the three aspect of nursing not be viewed as functioning independently but interrelated. The three aspects interacts, and the circle representing them change size, depending on the patients total course of progress. The professional nurse functions most therapeutically when patient entered the second stage of hospital stay This recuperation stage, the care and the core aspects, are the most prominent, and the cure aspect is less prominent.

The

size of the circles represent the degree to which the patient is progressing in each of the three areas,

the core

The care

The cure

COURSE IN THE WARD

Day 1 September 18,2010,10:30pm, A 41 year old male accompanied by his wife was admitted to E.R. with a chief complaint of abdominal pain. Initial vital signs were taken:BP-100/70,CR-76,RR-20,T-36.8 and Wt-76kgs. Dr. Bonagua the ROD ordered to have laboratory test for CBC with platelet, Urinalysis, Fecalysis , EIA and abdominal CT scan. At 12:00 mn, after the laboratory results, Mr. C.E. was transferred at room 313F with his wife via wheelchair. He was confined under the service of Dr.Alcantara. He was received with IVF PNSS1L at KVO and no medications were given. His diet was DAT except dark colored foods. He was ordered to have input and output monitoring every shift. He was diagnosed with Intra-abdominal mass at Right Lower Quadrant T/C Appendicitis.

Laboratory Results
Sept.18, 2010
PARAMETER Color Transparency Reaction Specific Gravity Albumin Sugar

URINALYSIS
RESULT Yellow Clear 5.5 1.025 Negative Negative (+) DM (increase) nephrotic syndrome INTERPRETATION color change may be due to drugs, diet or a disease. turbidity may be having a kidney infection

PARAMETER

RESULT

INTERPRETATION Pyuria refers to abnormal numbers WBC that may appear with infection in either the upper or lower urinary tract or with acute glomerulonephritis Hematuria is the presence of abnormal numbers of red cells in urine due to any of several possible causes,(glomerular damage, tumors)

WBC

24

RBC

03

Amorphous Mucous

Few Few

CBC with PLATELET sept.18, 2010

PARAMETER Hemoglobin Hematocrit NORMAL VALUE 12 15 RESULT 12.90 INTERPRETATION (increase) dehydration hemoconcentratio n infection acute infection hepatitis (Decrease) hemorrhage

4.6 5.2

4.31

hemodillution infectius hepatitis viral infection aplastic anemia

RBC WBC Neutriphils

5 10 .55 .65 .25 .35

8.33 0.57 0.29

Parameter

Normal values 0.02 0.1 02 .04

Result

Indication (increase) parasitic dieases parasitic infection acute leukemia hemorrha ge

Decrease

Lymphocytes

0 .08

HIV infection

Eosinophils Basophils

0 0.05

parasitic disease acute leukemia

Platelet

140 340

348

Sept.19,2010

Fecalysis
Color yellow Consistency soft Parasite no parasite seen

Fecalysis (implication)
Possitive

result of: Aeromonas Hydrophila gastroenteritis Bacillus Cereus food poisoning Campylobacter Jejumi gastroenteritis Clostridium Botolinum food poisoning & infant botulism Clostridium difficle pseudomonas enterocolitis E.coli gaastroenteritis

Sept.19,2010

Entameoba histolytica
Positive

(+) Indication (+)a pathogenic species of amoeba that causes amebic dysentery and hepatic amoebiasis in humans

Day2
September 19,2010,6:00pm. Mr. C.E was still complaining his pain at Right Lower Quadrant of his abdomen. He had ongoing IVF PNSS1L at KVO. Dr. Alcantara ordered Metronidazole 500 mg TIV every eight hours.

Metronidazole
Brand

Name: Flagyl Classification: Antibiotic/ Anti-protozoal Action: Direct- acting amebicide/ trichomonacide. It binds to bacterial and protozoal DNA to cause loss of helical structure, strand breakage, inhibition of nucleic acid synthesis and cell death. Indication: Infections in the intra-abdominal, skin and skin structure, bone and joint, gynecologic, bacterial septicemia, CNS, lower respiratory system and endocarditis. Treatment of susceptible protozoal infections and in the treatment and prophylaxis of anaerobic bacterial infection.

 Contraindication:

Blood dyscrasias. Active CNS diseases. Hypersensitivity to imidazole. Tuberculosis of mucous membranes and certain viral conditions. First trimester of pregnancy. Lactation. Children. Side Effects: convulsive seizures; peripheral neuropathy; rash; pruritus; GI discomfort, anorexia; nausea; furred tongue; dry mouth and unpleasant metallic taste, headache, less frequently vomiting, diarrhea, weakness, dizziness and darkening of the urine. Leucopenia.

Nursing Considerations: Obtain C&S before beginning drug therapy to identify if correct treatment has been initiated. Assess for allergic reactions: rash, urticaria, pruritus. Monitor renal function: urine output, inputoutput ratio, polyuria, dysuria, pyuria, BUN and creatinine. Decreasing output and increased BUN, creatinine may indicate nephrotoxicity. Assess for overgrowth of infection: perineal itching, fever, malaise, redness, swelling, drainage, rash, diarrhea and change in cough and sputum. Monitor bowel pattern, discontinue if severe diarrhea occurs.

September 20,2010, seen by AP and was ordered for explore-lap the following day at 1pm. NPO except meds and enema was done every six hours as ordered. Lactulose 50 cc was given , Erythromycin 500mg 1 tablet, and Metronidazole(Flagyl) 500mg 1 tab every 8 hours. He was requested for CP Clearance , ECG,and chest X-ray.

Day 3

CP CLEARANCE
Sept.21,2010

Cp evaluation (+)PTB (-)DM

System review pertinent symptoms

(-)cough (-)chest pain (-) dob (-)edema (-)alcohol intake (-)smoking

Erythromycin
Brand Name: Pharex Erythromycin Classification: Anti- Infectives Action: inhibits bacterial protein synthesis by binding to 50s ribosomal subunit of susceptible bacteria. Bacteriostatic. Indication: treatment of infectons of respiratory tract, skin and skin structure and sexually transmitted disease caused by susceptible organisms.

Contraindication: hypersensitivity to erythromycin or any macrolide antibiotic; pre-exisiting liver disease; epithelial herpes simplex. Lactation. Side Effects: rash, photosensitivity, erythema and peeling. Diarrhea, nausea, vomiting, abdominal cramping, vaginitis, hepatotoxicity. Nursing Responsibility: Assess for previous sensitivity reaction. Monitor for any drug side effects.

Lactulose
Brand Name: Duphalac Classification: GI/ Hepatobiliary Drug Action: causes an influx of fluid in the intestinal tract by increasing the osmotic pressure within the intestinal lumen. Bacterial metabolism of the drug to lactate and other acids which are only partially absorbed in the distal ileum and colon augments the osmotic effect. It also lowers intestinal absorption of ammonia presumably due to increased utilization of ammonia by intestinal bacteria. Indication: constipation, salmonellosis. Treatment of hepatic encephalopathy.

Contraindication: patients who require a low

lactose diet. Galactosemia or disaccharide deficiency. Intestinal obstruction.

Side Effects: abdominal discomfort associated with

flatulence and intestinal cramps. Nausea, vomiting, diarrhea on prolonged use.

Nursing Considerations:

Monitor possible side effects. For patients with hepatic encephalopathy, regularly assess mental condition (clearing of confusion, lethargy, restlessness, irritability) and ammonia level (30-70 mg/100 mL.) Monitor fluid and electrolyte status,urine output, input- output ratio to identify fluid loss, hypokalemia and hypernatremia.

Day4 September 21,2010 ABG done before the surgery to evaluate his acid-based balance and oxygenation. Mr. C.E was positive for Right Lower Quadrant mass which is 2.10 in size as a result of abdominal CT Scan. It was tender to touch on palpation. His operation was rescheduled at 11:30 am.

ABG
PARAMETER NORMAL VALUE RESULT INTERPRETATION pH 7.35 7.45 7.38 Normal Respiratory Acidosis Normal

PCO2

35 -45 mmHg

79

HCO3

22 26 mmol/L

24.4

BE

+/- 2

-1

normal

O2 Sat

95 100%

96%

normal

Chest X ray
no evident pneumothorax or pleural effusion pulmonary vascularity is within normal limits hila are unremarkable trachea is midline diaphragm and sulci are intact osseous structures and soft tissue planes are intact Findings: normal chest x ray

CTscan (whole abdomen)

Sept.18, 2010 Suboptimal study due to lack of intravenous and oral contrast. Large fairly imaginated heterogeneous mass, (R) lower hem abdomen near the ileocecal region, as described. Considerations include: primary bowel neoplasm and inflammatory bowel pathology such as an organizing periapendical abscess formation. Tissue characterization is recommended for better evaluation Findings: Fecal retention small bowel and coloni ileus

At 10:00 am, Mr. C.E was brought in the operating room via stretcher. Before the operation, the pre op medications were given, Nubain 10mg and Benadryl 50 mg cocktail through IM and Omeprazole 40 mg through IV. The operation started at exactly 11:30am,during the operation the appendix and mass in the intestine was removed. The intestinal mass was sent to the laboratory for biopsy. The operation ended at 4:05pm.

Nalbuphine
Brand

Name: Nubain Classification: Analgesic Action: Treating and preventing moderate to severe pain. It can also be used for pain relief before and after surgery and during childbirth. It may also be used for other conditions as determined by your doctor.

 Indication:

relief of moderate to severe pain. Pre- op analgesia, as a supplement to balanced anesth, surgical anesth, for obstet analgesia during labor and relief of pain following MI. Contraindication: impaired renal or hepatic function, biliary tract surgery, impaired respiration, MI. Labour and delivery. Side Effects: sedation, infrequently sweating, GI upsets, vertigo, dizziness, dry mouth, headache, allergic reactions.

 Nursing

Responsibility:

Assess the clients history before administering drug. Check if: having asthma or other breathing problems, high blood pressure,liver and kidney problems.

Dipenhydramine HCl
Brand Name: Benadryl Classification: Antihistamine Action:acts on blood vessels, GI, respiratory system by antagonizing the effects of histamine for H1 receptor site; decreases allergic response by blocking histamine; causes increased heart rate; vasodilation; secretions;and anticholinergic properties. Indication: hay fever, urticaria, vasomotor rhinitis, angio- neurotic edema, drug sensitization, serum and penicillin reaction, contact dermatitis, atopic eczema. Contraindication: premature and newborn infants; asthma attack.Lactation.

Side Effects: CV and CNS effects. Blood disorders.

GI disturbances. Allergic reactions. Nursing Considerations: Advise to increase fluid intake of 2L a day to decrease secretion thickness. Monitor I&O. watch out for urinary retention, frequency, dysuria. Assess cough characteristics including type, frequency, thickness of secretions and evaluate response to medication. Assess for possible side effects. Assess degree of itching, skin rash and inflammation.

Omeprazole
Brand Name: Pantoloc Classification: GI/ Hepatobiliary Drugs Action: inhibits both basal and stimulated gastric acid
secretion by suppressing the final step in acids production, through the inhibition of the proton pump by binding to and inhibiting, hydrogen potassium adenosine triphosphatase, the enzyme system located at the secretory surface of the gastric parietal cell.

Indication: Duodenal and gastric ulcer, moderate

and severe reflux esophagitis. Eradication of H. Pylori in patients with peptic ulcers. Prevention of gastroduodenal ulcers induced by NSAID in patients at risk with a need for continous NSAID treatment.

Contraindication: Hypersensitivity, moderate to severe hepatic or renal dysfunction. Side Effects: Headache, insomnia, diarrhea, abdominal pain, flatulence, rash, hyperglycemia. Nursing Considerations: Monitor for possible adverse effects. Monitor for hepatic enzymes: AST, ALT, alkaline phosphates during treatment.

At 4:30pm Mr. C.E was transferred to Recovery room. He had an IVF at 30gtts/min. and ordered to have IVF to follow D5LR 1 L and D5NM 1 L each run for 8hrs. He was placed flat on bed until 6:30 pm. The vital signs were taken and recorded every 15 min until stable. BP 100/70 ,CR- 120.RR-9 ,T-36.5 ,O2 Sat- 91%. His RR decreased to 9 /min dyspnea and cyanosis was noted and Naloxone (Narcan) 4 mg was administered. His RR was monitored every 30 min for the first 12 hours(12mn-12pm) and closed watch between 8pm-10pm, and he was turned to side lying after 12 hours.

administered O2 2L/min. Metronidazole 500mg TIV every 8 hours and Zeptrigen 1 gm TIV every 8 hours were ordered as a post op meds after negative skin test. Had Jackson pratt drainage at his right lower abdomen which maintained at negative pressure and indwelling catheter for bladder irrigation. At exactly 2:30 am the patient vital signs was stable and was transferred back to his room 313F via stretcher . He was diagnosed S/P Ex Lap Appendectomy Bulking of Intraabdominal mass.

Naloxone
Brand Name: Narcan Classification: Antidote Action: may displace opioid analgesics from their receptors ( competitive antagonism) to reverse its effects. Indication: Narcotic overdose. Post-op narcotic depression. Contraindication: respiratory depression due to non- opioid drugs. Side Effects: tachycardia, increase BP, seizures, cardiac arrest, pulmonary edema.

Nursing Considerations: Assess patients opioid use before starting therapy, and reassess regularly to monitor drugs effectiveness. Duration of opioid may exceed that of naloxone, causing relapse of depression. Assess cardiac status and monitor vital signs. Watch out for ECG abnormalities, tachycardia and hypertension. Assess for pain: duration;intensity;location before and after administration. Assess respiration to identify depression: character, rate and rhythm. Respiration<10/min is most probably due to opioid overdose.

Ceftazidime
Brand

Name: Zeptrigen Classification: Antibiotic, Cephalosporin (3rd Generation) Action: Interfere with a final step formation of the bacterial cell wall (inhibition of mucopeptide biosynthesis), resulting in unstable cell membranes that undergo lysis. Also cell division and growth are inhibited. More activity against gramnegative organisms and resistant organisms and les activity against grampositive organisms than first generation drugs.

 Indication:

Treatment of infections of the lower respiratory tract, skin and skin structure, UTI, bacterial septicemia, bone and joint infections, intra- abdominal infections, CNS infections. Contraindication: Patients with allergies to penicillins, cephalosporins. Side Effects: Phlebitis and inflammation at injection site, allergic reactions, GI disturbances.

Nursing Considerations:

1. Assess for liver and renal dysfunction. 2. Obtain CBC, renal function studies; reduce dose with dysfunction. 3. Culture infection, and arrange sensitivity tests before and during therapy if expected response is not seen. 4. Watch out for the adverse effects.

Day 5
September 22,2010.Mr. C.E was negative flatus. He was maintained on NPO temporarily. His vital signs were monitored and recorded every 1 hour. He was instructed flat on bed with moderate high back rest. Dr. Alcantara seen and examined his paramedian incision and demonstrated to his wife the proper drainage of Jackson pratt every 2 hours. It was drained at 100cc level with serosanguineous drainage and indwelling foley catheter at 500 cc level with tea colored urine.

Day 6
September 23,2010,Mr. C.Es flatus was still negative, postive nausea and vomiting and postive epigastric pain. At 3:00 pm he was inserted with NGT connected to bedside bottle. Dr. Alcantara ordered esomeprazole 40mg, nubain 5mg PRN for epigastric pain and metoclopramide for severe vomiting.

Metoclopramide
Brand

Name: Dormicum Classification: Hypnotics/ Sedatives Action: Depresses the limbic system and reticular formation (subcortical levels of CNS) by increasing or facilitating the inhibitory neurotransmitter activity of GABA. Indication: Sedation in pre- medication before surgical or diagnostic procedures, induction and maintenance of anesthesia. Contraindication: Acute narrow angle glaucoma. Premature infants. Hypersensitivity. Side Effects: Amnesic episodes

Nursing Considerations:
Monitor blood pressure, heart rate and rhythm, respiration, airway integrity, arterial oxygen saturation( during procedures in patients premedicated with opioids). Emergency equipment should be nearby. Assess for apnea, respiratory depression which may increased in elderly. Assess vital signs during recovery period in obese patient because half- life may be extended. Assess injection site.

Esomeprazole
Brand

Name: Nexium Classification: Antacids/ Anti- ulcerants Action: Inhibit the H+-K+-ATP pump (proton pump) in gastric parietal cells effectively blocking the final step in acid production, thereby reducing gastric acidity. Indication: Erosive reflux esophagitis. Prevents relapse of healed esophagitis, symptomatic treatment of gastroesophageal reflux disease(GERD). Helicobacter pylori associated ulcer disease.

 Contraindication:

Known hypersensitiviy to esomeprazole, substituted benzimidazoles or any other constituents of the formulation. Children. Side Effects: headache, abdominal pain, diarrhea, flatulence, nausea and vomiting, constipation, dermatitis, pruritus, urticaria, dizziness, dry mouth, blurred vision. Hypersensitivity to reactions. Nursing Considerations: Assess patients condition before and during drug therapy, (previous gastric ulcer, aged 60 and above, NSAID therapy). Assesss GI system: anorexia and abdominal pain.

 Assess

hepatic function because drug is extensibly metabolized in the liver: AST, ALT, alkaline phospahate. Monitor for side effects like headache, diarrhea, abdominal pain, nausea and vomiting, constipation and dry mouth. Long term use with omeprazole has caused atrophic gastritis.

Day7
September 24,2010,Mr. C.E had hyperactive bowel sounds. Dr. Alcantara required him to have a clear liquid diet then soft diet for continuous progression. Bladder training was ordered.

Day 8

September 25, 2010,Nursing care was done. Vital signs were monitored and recorded every 4 hours. Intravenous fluid to follow was D5NM to run for 8 hours . Mr. C.E was on bladder training. He was ambulatory but needs assistance. Dr. Alcantara did not visit the patient and no new orders were made on that day.

Day 9 September 26,2010,4;30pm. Indwelling foley catheter was removed. Metronidazole 500mg TIV and Zeptrigen 1 gm TIV every 8 hours were given.

Metronidazole
Brand Name: Flagyl Classification: Antibiotic/ Antiprotozoal Action: Direct- acting amebicide/ trichomonacide. It binds to bacterial and protozoal DNA to cause loss of helical structure, strand breakage, inhibition of nucleic acid synthesis and cell death.

 Indication:

Infections in the intra-abdominal, skin and skin structure, bone and joint, gynecologic, bacterial septicemia, CNS, lower respiratory system and endocarditis. Treatment of susceptible protozoal infections and in the treatment and prophylaxis of anaerobic bacterial infection Contraindication: Blood dyscrasias. Active CNS diseases. Hypersensitivity to imidazole. Tuberculosis of mucous membranes and certain viral conditions. First trimester of pregnancy. Lactation. Children.

 Side

Effects: convulsive seizures; peripheral neuropathy; rash; pruritus; GI discomfort, anorexia; nausea; furred tongue; dry mouth and unpleasant metallic taste, headache, less frequently vomiting, diarrhea, weakness, dizziness and darkening of the urine. Leucopenia.

 Nursing

Considerations: Obtain C&S before beginning drug therapy to identify if correct treatment has been initiated. Assess for allergic reactions: rash, urticaria, pruritus. Monitor renal function: urine output, input- output ratio, polyuria, dysuria, pyuria, BUN and creatinine. Decreasing output and increased BUN, creatinine may indicate nephrotoxicity.

Assess for overgrowth of infection: perineal itching, fever, malaise, redness, swelling, drainage, rash, diarrhea and change in cough and sputum. Monitor bowel pattern, discontinue if severe diarrhea occurs.

Day 10

September 27,2010, Mr. C.E may have his soft diet, above intravenous fluid consumed and followed up the same IVF1 liter regulated at the same rate. For possible discharge on the next day.

Day 11 September 28,2010 7:00 pm, intravenous fluid was terminated. Home medications instructed and patient may go home with jackson pratt drainage . After the clearance of his bill for hospitalization patient was discharged accompanied by his wife and eldest daughter via the wheelchair with a final diagnosis of Intraabdominal mass RLQ T/C Appendicitis R/O Colonic mass VS Intraabdominal GITB. His diagnosis has not been identified because of the awaiting result of the biopsy.

His home medications were Clindamycin and Unasyn. His follow-up check-up was scheduled last October 5, 2010.

CLINDAMYCIN
Brand

Name: Clindal Classification: Antibiotics Action: Inhibits bacterial protein synthesis by binding to the 50s sub unit of the ribosomes. Indication: serious anaerobic infections especially those caused by Bacteroides fragilis. Alternative to penicillin in some severe staphylococcal and streptococcal infections.

 Contraindication:

Hypersensitivity to lincosamides. Patients with colitis and diarrhea. Severe renal and hepatic impairment. Newborn and premature infants. Pregnancy and lactation. Side Effects: nausea, vomiting, abdominal cramps, rash, urticaria, pruritus, erythema, ulcers in the esophageal mucosa, pseudomembranous colitis.

 Nursing

Considerations: Assess patient for sins and symptoms of infection including characterstics of wounds, sputum, urine, stool, WBC >10,000/mm3, fever; obtain baseline information before and during treatment. Assess complete culture and sensitivity testing before start of drug therapy; to identify correct treatment to be initiated.

 Assess

patient with poor renal function; drug is excreted slowly in poor renal system function toxicity may occur rapidly. Assess for allergic reactions. Monitor urine output if decrease notify physician this may indicate nephrotoxicity. Assess bowel pattern daily; if severe diarrhea occurs, discontinue drug; may indicate pseudomembranous colitis.

Sultamicillin tosylate
BRAND

NAME: UNASYN Classification: Antibiotic Action: upper and lower respiratory tract infections, UTI, and pyelonephritis, skin and soft tissue and gonococcal infection. Contraindication: history of allergic reaction to any penicillins. Side Effects: GI disturbances, phlebitis, skin rashes, itching, blood disorders, anaphylaxis and superinfection.

ANATOMY AND PHYSIOLOGY

Small Intestine
Small

Intestine is about 6 meters long and consists of 3 parts: the duodenum (25 cm long), jejunum (2.5m long and makes up two fifths of the total length of the small intestine), and the ileum (3.5 m long and makes up three fifths of the small intestine. Small Intestine is the major site of digestion and absorption of food which are accomplished by the presence of a large surface area.

 The

duodenum, jejunum, and ileum are similar in structure except that there is a gradual decrease in diameter of the small intestine, in the thickness of the intestinal wall, and in the number of circular folds and in the number of villi as one progresses through the small intestine.

 Lymph

nodules are common along the entire length of the digestive tract. Cluster of lymph nodules called Peyers patches are numerous in the ileum. These lympathic tissues in the intestines help protect the intestinal tract from harmful microorganisms.

FUNCTION (ILEUM): o The function of the ileum is mainly to absorb Vitamin B12 and bile salts and whatever products of digestion that were not absorbed in the jejunum. o The DNES (diffuse neuroendocrine system) cells of the ileum secrete various hormones (gastrin, secretin, cholecystokinin) into the blood. o Cells in the lining of the ileum secrete the protease and carbohydrase enzyme responsible for the final stages of protein and carbohydarte digestion into the lumen of the intestine.

Pathophysiology

NURSING CARE PLAN

Assessment
Objective:
With

IVF D5 NM on right hand With Jackson Pratt drainage intact with serosanguineous drain. Draining an amount of 100 cc With IFC intact and draining dark yellow colored urine (100cc) With post-op surgical incision

Diagnosis
Risk for Infection (risk factors: inadequate primary defenses due to presence of surgical incision, prolonged use of IFC, and presence of jackson pratt drainage.)

Planning
After nursing Interventions the client remains free from infection AEB normal VS, absence of purulent discharge from incision site, drainage, tubes throughout the hospitalization.

Interventions/Rationale
Assessed

vital signs frequently, noting unresolved or progressing hypotension, decreased pulse pressure, tachycardia, fever and tachypnea. /Signs of impending septic shock, circulating endotoxins eventually produce vasodilation, shift of fluid from circulation and a low cardiac output. Noted skin color, temperature, moisture. / Warm flushed dry skin is an early sign of septicemia. Later manifestations include cool clammy pale skin and cyanosis.

 Maintained

aseptic technique in care of abdominal drains, and incision. Use appropriate solution to cleanse./ Prevents access or limits spread of infecting organisms. Cleansed hands between client contacts, after touching body substances and before performing procedures or touching incision site./ Hand cleansing is an important means of controlling and preventing the transmission of microorganisms. Educated client and support persons about appropriate methods to clean, disinfect and or sterilize articles./ Knowledge of ways to reduce or eliminate microorganisms reduces the number of organisms present and the likelihood of transmission.

 Performed

and modelled good hand washing technique./ Reduces risk of cross contamination, spread of infection. It is considered one of the most effective infection control measures. Emptied drainage and IFC at the end of each shift or before they become full./ Drainage harbors microorganisms that if left for long periods, proliferate and can be transmitted to others. Reference: Kozier & Erbs Fundamentals of Nursing 8th edition Nursing care plan 11th edition

Evaluation
Goal Met. Client was free from infection throughout the hospitalization AEB normal VS, absence of purulent discharge from incision site, drainage, tubes.

Assessment
Subjective:
masakit yung tahi ko, makirot siya. Pain scale of 5-6 out of 10.

Objective:
facial grimace Guarding behavior Minimal range of motion Weak in appearance

Diagnosis:
Acute Pain r/t post operative surgery (incision site)

Definition:
Unpleasant

sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage ;sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.

Planning:
After nursing intervention will be able to relive pain from pain scale of 5-6 to pain scale of 0 out of 10.

Intervention/Rationale
Performed a comprehensive assessment of pain (location, characteristics onset, duration, frequency, quality, intensity, and precipitating factors of pain)./Pain is subjective experience and be described by the client in order to plan effective treatment Closed monitoring of skin color, temperature, and vitalsigns. /Because it usually altered in acute pain

 Provided

comfort measures, quiet environment and calm activities./To promote non-pharmacologic pain management Encouraged use of relaxation techniques, divertional activities (deep breathing, watching TV, listening to music, etc.)./To divert attention

 Considered

willingness and ability to participate preference, post experiences and contraindications before selecting a specific relaxation strategy./The client must feel comfortable trying a different approach to pain management to avoid ineffective strategies, the client should be involve in planning.

Elicited behavior that are conditioned to produced relaxation such deep breathing, yawning, abdominal breathing or peaceful environment./Relaxation techniques help reduce skeletal muscle tension which will reduce the intensity of the pain Taught the use of non-pharmacologic techniques before and after if possible during pain activities, before pain occurs or increases and along w/ other pain relief measures./The use of non invasive pain relief measures can increased the release of endorphin and enhance the therapeutic effect.

Evaluation:
Goal

partially met, hindi na gaanong masakit, pain scale of 2 out of 10. as stated.

Assessment
Subjective:
hindi ako masyadong makakilos ngayon, as stated

Objective:
o o o o o o

Weak in appearance Limited activities With abdominal binder With Jackson Pratt draining serosanganous drainage With indwelling foley catheter draining tea colored urine in urine bag Remain on bed at times

Diagnosis
Activity Intolerance R/T surgical incision, body weakness (Definition) insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Planning
After two days of nursing intervention able to report measurable increase in activity within level of tolerance

Interventions/Rationale
o

Assessed ability to perform usual task such as walking, going to bathroom./Influence choice of intervention needed assistance Provided quiet atmosphere; bed rest if indicated./Enhances rest to lower body oxygenation requirement and reduce strain in the heart and lungs

Elevated head of the bed as tolerated./ Enhances by expulsion to maximize oxygen need. Instructed change position slowly, monitor for dizziness./ Postural hypotension or cerebral hypoxia may cause dizziness Encouraged assistance in activities / ambulation assistance./Self esteem is enhanced when client does something things for self.

Assisted in learning and demonstrating appropriate safety measures./ To prevent injury

Implemented energy-saving techniques; e.g sitting, rather than standing use of shower chair ./ Maximizes available energy for self-care tasks.
Demonstrated proper performance of ADLs, ambulation or position changes./Protects from injury during activities.

EVALUATION Goal met: Verbalized he was able to walk in his own, without any assistance from his significant others.

JOURNAL
ABDOMINAL LOCALISATION OF TUBERCULOSIS AND THE ROLE OF SURGERY (Department of Surgery, Clinical Centre Ni, Republic of Serbia :Department of Hematology, Clinical Centre Ni, Republic of Serbia )2008

In conclusion, abdominal tuberculosis is a disease presented by non-specific symptoms, laboratory and radiography findings that make it difficult to diagnose. Only histopathological diagnosis is correct in 100% of cases. Most patients had severe, progressed forms with developed complications, such as stenosis, hemorrhages, fistulas, perforations with peritonitis, demanding not only diagnostic, but therapeutic surgical intervention as well.

great number of death outcomes were also recorded. In minor number of cases with less extensive complications, surgical laparoscopic interventions would be a gold standard, because they make complete exploration of abdominal cavity possible, with precise biopsy of tuberculosis changes.

DIAGNOSIS OF GASTROINTESTINAL TUBERCULOSIS: USING CYTOMORPHOLOGICAL, MICROBIOLOGICAL, IMMUNOLOGICAL AND MOLECULAR TECHNIQUES. (Departments of Research, *Microbiology, **Pathology and ***Surgical Gastroenterology, Bhopal Memorial Hospital & Research Centre, Bhopal, India) 2010

The present study included three groups: (A) age and gender matched control (n=24) with no previous signs of M. tuberculosis complex (MTBC) infection, (B) patients (n=28) diagnosed with gastro-intestinal TB (GITB), (C) patients (n=50) with clinical and histo-pathological signs of GITB, but were culture and AFB negative. Real time assay performed using fluorescence resonance energy transfer hybridization probes showed a positivity index of 36 % in group C, i.e. 18 were found reactive from the total 50 cases studied

In addition, immune characterization of these 18 cases showed depleted CD4 + count and increased levels of IFN- and TNF- cytokines. No positive case was found in group A, while in group B, out of total 28 cases studied 27 were found positive. A combinatorial diagnostic approach for rapid detection and characterization of GITB might provide specific therapeutic strategies for prevention and treatment of the infection in future.

Reflection
Doing

a case presentation is a very challenging work. We admire our group mates for their skills and commitment on the tasks that were given to them. There are many qualities that each one of us possess, we feel that we have already developed some of these qualities given the time and experience that we have spent together

 When

it comes to the care of the patient, the assigned student nurse collaborates with the patient, family, and others in the conduct of nursing practice. In our own reflection, we are aware that we have done this during our student practice. We communicate to the patient, family, and other health care professionals regarding the care of the patient and our role in the provision of that care. Especially when it comes to creating a documented plan, and with the case presentation of our patient, our role becomes more difficult.

 Weve

used different kinds of strategies to promote positive relationships, cooperation, and meaningful learning experiences in our group. We recognized the importance of nonverbal as well as verbal communication, but there are times that we are not thoughtful and responsive listener. The best thing that we are very thankful to this group is that we still understand each others difference.

 Our

deepest thanks to our advisers, Ms. Dean Alpay,and Mr.Isip who are always teaching and sharing their ideas, they always checks and monitors the progress of our presentation. We are thankful for much knowledge to make this presentation positive, thank you also for providing us long, long, long, long patience. Also Mr. Inandan and Ms. Daquis sthank you.

END.. THANK YOU PO