Case presentation volvulus in geriatric patient

Misamis University
Ozamiz City

Graduate School

CASE PRESENTATION:
Intestinal Obstruction (Volvulus)
In Geriatric Patient

In partial fulfillment of the requirements in ADM 212

Submitted to:

Prof. Maricar M. Mutia, RN, MN-MAN
Faculty, Graduate School

Submitted by:

Reynel Dan L. Galicinao, RN
Student, Master in Nursing
Major in Nursing Educational Administration

October 15, 2011

Case Presentation: Intestinal Obstruction

OBJECTIVES
General Objectives:
Within the case presentation session, the audience will be able to discuss the etiology,
pathophysiology, and medical, surgical, and nursing interventions of intestinal obstruction.

Specific Objectives:
Within the case presentation session, the audience will be able to:
1. Describe intestinal obstruction
2. List the risk factors of intestinal obstruction
3. Trace the pathophysiology of intestinal obstruction
4. Determine the signs and symptoms associated with intestinal obstruction
5. Identify diagnostic and laboratory procedures for intestinal obstruction and their
corresponding nursing responsibilities
6. Enumerate possible medical and surgical interventions for intestinal obstruction
7. List the medications to be given for intestinal obstruction
8. Identify possible nursing diagnoses for intestinal obstruction
9. Plan appropriate independent and interdependent nursing interventions for intestinal
obstruction
10. Write a discharge plan for intestinal obstruction

OVERVIEW OF INTESTINAL OBSTRUCTION

Intestinal obstruction is an interruption in the normal flow of intestinal contents along the
intestinal tract. The block may occur in the small or large intestine, may be complete or
incomplete, may be mechanical or paralytic, and may or may not compromise the vascular
supply. Obstruction most frequently occurs in the young and the old.

Pathophysiology and Etiology

Types and Causes

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Three causes of intestinal obstruction. (A) Intussusception. Note
shortening of the colon by the movement of one segment of bowel into
another. (B) Volvulus of the sigmoid colon. The twist is counter
clockwise in most cases of sigmoid volvulus. (C) Hernia (inguinal). Note
that the sac of the hernia is a continuation of the peritoneum of the
abdomen and that the hernial contents are intestine, omentum, or other
abdominal contents that pass through the hernial opening into the
hernial sac.

Mechanical obstruction—a physical block to passage of intestinal contents without
disturbing blood supply of bowel. High small-bowel (jejunal) or low small-bowel (ileal)
obstruction occurs four times more frequently than colonic obstruction. Causes
include:
o Extrinsic—adhesions from surgery, hernia, wound dehiscence, masses,
volvulus (twisted loop of intestine). Up to 70% of small bowel obstructions are
caused by adhesions.
o Intrinsic—hematoma, tumor, intussusception (telescoping of intestinal wall into
itself), stricture or stenosis, congenital (atresia, imperforate anus), trauma,
inflammatory diseases (Crohn's, diverticulitis, ulcerative colitis).
o Intraluminal—foreign body, fecal or barium impaction, polyp, gallstones,
meconium in infants.
o In postoperative patients, approximately 90% of mechanical obstructions are
due to adhesions. In nonsurgical patients, hernia (most often inguinal) is the
most common cause of mechanical obstruction.
Paralytic (adynamic, neurogenic) ileus
o Peristalsis is ineffective (diminished motor activity perhaps because of toxic or
traumatic disturbance of the autonomic nervous system).
o There is no physical obstruction and no interrupted blood supply.
o Disappears spontaneously after 2 to 3 days.
o Causes include:
 Spinal cord injuries; vertebral fractures.
 Postoperatively after any abdominal surgery.
 Peritonitis, pneumonia.
 Wound dehiscence (breakdown).
 GI tract surgery.
Strangulation—obstruction compromises blood supply, leading to gangrene of the
intestinal wall. Caused by prolonged mechanical obstruction.

Altered Physiology
Increased peristalsis, distention by fluid and gas, and increased bacterial growth
proximal to obstruction. The intestine empties distally.
Increased secretions into the intestine are associated with diminution in the bowel's
absorptive capacity.
The accumulation of gases, secretions, and oral intake above the obstruction causes
increasing intraluminal pressure.
Venous pressure in the affected area increases, and circulatory stasis and edema
result.
Bowel necrosis may occur because of anoxia and compression of the terminal
branches of the mesenteric artery.
Bacteria and toxins pass across the intestinal membranes into the abdominal cavity,
thereby leading to peritonitis.
―Closed-loop‖ obstruction is a condition in which the intestinal segment is occluded at
both ends, preventing either the downward passage or the regurgitation of intestinal
contents.

Clinical Manifestations

Fever, peritoneal irritation, increased WBC count, toxicity, and shock may develop with all
types of intestinal obstruction.

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Simple mechanical—high small-bowel: colic (cramps), mid- to upper abdomen, some
distention, early bilious vomiting, increased bowel sounds (high-pitched tinkling heard
at brief intervals), minimal diffuse tenderness.
Simple mechanical—low small-bowel: significant colic (cramps), midabdominal,
considerable distention, vomiting slight or absent, later feculent, increased bowel
sounds and ―hush‖ sounds, minimal diffuse tenderness.
Simple mechanical—colon: cramps (mid- to lower abdomen), later-appearing
distention, then vomiting may develop (feculent), increase in bowel sounds, minimal
diffuse tenderness.
Partial chronic mechanical obstruction—may occur with granulomatous bowel in
Crohn's disease. Symptoms are cramping, abdominal pain, mild distention, and
diarrhea.
Strangulation symptoms are initially those of mechanical obstruction, but progress
rapidly—pain is severe, continuous, and localized. There is moderate distention,
persistent vomiting, usually decreased bowel sounds and marked localized
tenderness. Stools or vomitus become bloody or contain occult blood.

Complications

Dehydration due to loss of water, sodium, and chloride
Peritonitis
Shock due to loss of electrolytes and dehydration
Death due to shock

Nursing Assessment

Assess the nature and location of the patient's pain, the presence or absence of
distention, flatus, defecation, emesis, obstipation.
Listen for high-pitched bowel sounds, peristaltic rushes, or absence of bowel sounds.
Assess vital signs.

GERONTOLOGIC ALERT

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Watch for air-fluid lock syndrome in elderly patients, who typically remain in the recumbent
position for extended periods.

Fluid collects in dependent bowel loops.
Peristalsis is too weak to push fluid ―uphill.‖
Obstruction primarily occurs in the large bowel.
Conduct frequent checks of the patient's level of responsiveness; decreasing
responsiveness may offer a clue to an increasing electrolyte imbalance or impending
shock.

Nursing Diagnoses

Acute Pain related to obstruction, distention, and strangulation
Risk for Deficient Fluid Volume related to impaired fluid intake, vomiting, and diarrhea
from intestinal obstruction
Diarrhea related to obstruction
Ineffective Breathing Pattern related to abdominal distention, interfering with normal
lung expansion
Risk for Injury related to complications and severity of illness
Fear related to life-threatening symptoms of intestinal obstruction

Nursing Interventions

Achieving Pain Relief
Administer prescribed analgesics.
Provide supportive care during NG intubation to assist with discomfort.
To relieve air-fluid lock syndrome, turn the patient from supine to prone position every
10 minutes until enough flatus is passed to decompress the abdomen. A rectal tube
may be indicated.

Maintaining Electrolyte and Fluid Balance
Measure and record all intake and output.
Administer I.V. fluids and parenteral nutrition as prescribed.
Monitor electrolytes, urinalysis, hemoglobin, and blood cell counts, and report any
abnormalities.
Monitor urine output to assess renal function and to detect urine retention due to
bladder compressions by the distended intestine.
Monitor vital signs; a drop in BP may indicate decreased circulatory volume due to
blood loss from strangulated hernia.

Maintaining Normal Bowel Elimination
Collect stool samples to test for occult blood if ordered.
Maintain adequate fluid balance.
Record amount and consistency of stools.
Maintain NG tube as prescribed to decompress bowel.

Maintaining Proper Lung Ventilation
Keep the patient in Fowler's position to promote ventilation and relieve abdominal
distention.
Monitor ABG levels for oxygenation levels if ordered.

Preventing Injury Due to Complications
Prevent infarction by carefully assessing the patient's status; pain that increases in
intensity or becomes localized or continuous may herald strangulation.
Detect early signs of peritonitis, such as rigidity and tenderness, in an effort to
minimize this complication.
Avoid enemas, which may distort an X-ray or make a partial obstruction worse.
Observe for signs of shock—pallor, tachycardia, hypotension.
Watch for signs of:
o Metabolic alkalosis (slow, shallow respirations; changes in sensorium; tetany).

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o Metabolic acidosis (disorientation; deep, rapid breathing; weakness; and
shortness of breath on exertion).

Relieving Fears
Recognize the patient's concerns, and initiate measures to provide emotional support.
Encourage presence of support person.

NURSING HEALTH ASSESSMENT
Demographic Data

Name: ―Mr. William Lippincott‖
Address: Poblacion, Midsalip, Zamboanga del Sur
Age: 77 years old
Sex: Male
Status: Widower
Religion: Roman Catholic
Occupation: Bookkeeper

Health History

A. Chief Complaint/s:
Abdominal pain

B. Impression/Admitting Diagnosis:
Acute abdominal problem secondary to volvulus; gangrenous ileum 35 cm from
ileocecal valve with ileoileal anastomoses.

C. History of Present Illness:
One month prior to admission, patient had complaints of epigastric pain, described as
crampy, graded at 8/10, intermittent, aggravated by eating solid foods, patient can only
tolerate to eat porridge with flaked fish sprinkled on it, alleviated by application of Efficascent
oil to abdomen, and rest. Patient had a feeling of strong urge to fart or expel flatus but was
unable to do.
Patient had loose bowel movement for 3 days prior to admission, intermittent, brown-
colored, unformed stool.
Few hours prior to admission, pain became generalized and unrelieved with oral
medications thus prompted admission; no fever, no vomiting, no tarry stool. Last bowel
movement was the morning before admission (September 26, 2011) with mucoid stool.
Patient is a bookkeeper and a regular member of parish church.

D. History of Past Illness/es:
Patient was hospitalizedfor 1 week last July 2008 due to Pneumonia. Patient reported he
had ―complete immunization‖. Patient takes Centrum 500 mg 1 tablet, once a day. Patient
had blood transfusion (1989) but he could not recall the details. No known allergies. Born via
NSVD.

E. Health Habits
Frequency Amount Period
Tobacco None None None
Alcohol None None None
OTC drugs/non-prescription drugs
Specify: Centrum OD 500 mg Tab 1 year

F. Family History with Genogram
History of Heredo-familial diseases:
Cancer X
_____
DM /
_____
Asthma X
_____
Hypertension X
_____
Cardiac Disease _____
X
X
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Mental Disorder _____
Others _____
X

G. Patient’s Perception of
Present Illness: Pt reported, ―Nawala naman ang sakit sa akong tiyan karon, bag-o
paman gud ko gitagaan ug tambal para mawala ang sakit.‖
Hospital Environment: Pt reported, ―Ok raman ang kwarto dire aircon, komportable
ra man.‖

H. Summary of Interaction
Patient was sleeping upon nurse’s arrival. During physical assessment, patient woke
up and nurse continued assessment. Patient appears weak but still answered the nurse’s
interview questions and cooperated in the assessment.

GORDON’S ASSESSMENT
Normal Pattern Before Hospitalization Clinical Appraisal
1. Activities – Rest Pt usually sleeps at 9pm, Pt has been lying on bed the
a. Activities and then wakes up at 6am. whole day. Moves/ changes
b. Sleeping pattern Pt takes a bath every day position with assistance. Pt
c. Rest except for Tuesdays and was not able to sleep in the
Fridays r/t his cultural belief. morning due to pain, but was
Pt goes to work as a able to sleep for 2 hours in
bookkeeper, and then goes the evening. Pt appeared
to city hall, BIR, and then very weak and sleepy.
church. Few weeks PTA, pt
usually takes naps in the
afternoon.
2. Nutrition – Metabolic Few days PTA, pt only eats Pt is on NGT early this
a. Typical intake (food or quaker oats, drinks water, morning, but was removed
fluid) coffee, and flaked fish on later in the morning then diet
b. Diet porridge. No diet restriction. changed to clear liquids
c. Diet restriction Weight not taken, unknown. limited to 15 ml/ hr Pt is
d. Weight Takes Centrum 500 mg tab taking Paracetamol 500 mg
e. Medication/Supplement once a day. 1 tab every 4 hours, prn;
food Telmisartan (Micardis) 40
mg tab OD every HS.
3. Elimination Pt was able to urinate Pt was able urinate once on
a. Urine (frequency, color, approximately 1-2 times per his diaper, with clear and
transparency) day, with clear and yellow yellow urine, had changed
b. Bowel (frequency, urine. Pt defecated > 3x for diaper once. Pt has not been
color) LBM with color brown, able to defecate this day.
unformed, intermittent LBM
for 3 days.
4. Ego Integrity Pt reported, ―ok Pt reported ―ok koron‖. Pt
a. Perception of Self rabayaakongkinabuhi‖. Pt has 8 children, with his
b. Coping Mechanism has 8 children, has been whole family visiting him

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c. Support Mechanism living with his daughter. He regularly, with friends also
d. Mood/Affect goes to work, and a part of visiting him regularly. He
lay ministerof parish church, prays for his health
he goes to church regularly. condition. Pt appears very
Pt has normal affect weak but with normal affect
congruent to behavior c calm congruent to behavior, with
mood. calm mood.
5. Neuro-Sensory Pt is in well mental being. Pt Pt is in well mental being,
a. Mental State speaks clearly and logically speaks clearly and logically
b. Condition of 5 senses with normal pace. Pt has within normal pace. Pt has
(sight, hearing, smell, intact senses: Able to read intact senses as tested: Able
taste, touch) with aid, hear, feel, touch to read with aid, hear, feel,
and discriminate, smell and touch and discriminate, smell
taste. and taste.
6. Oxygenation and Vital VS not taken but has history RR: 22 cpm
Signs of Pneumonia and was PR: 86 bpm
a. Respiratory rate hospitalized for a week last HR: 86 bpm
b. Pulse rate 2007. BP: 130/80 mmHg
c. Heart Rate Pt has decreased breath
d. Blood pressure sounds on lower lobes.
e. Lung sounds Pt has history of pneumonia
f. History of respiratory and was hospitalized for a
problems week last July 2008.
7. Pain – Comfort Epigastric pain, graded Pain – 0/10 upon
a. Pain (location, onset, 8/10, for 2 weeks already, assessment since pt has just
intensity, duration, with LBM for 3 days but been given an analgesic.
associated intermittent with brown
symptoms, unformed stool, aggravated
aggravation) with solid foods; alleviated
b. Comfort with Efficascent oil and rest.
measures/alleviation
c. Medication/s
8. Hygiene and activities of Pt takes a bath everyday Pt has not taken a bath since
daily living upon waking up except for admission. Pt changes
Tuesdays and Fridays. Pt position with assistance lies
goes to work as bookkeeper, on bed the whole day. Sleep
goes to City Hall, BIR, and is disturbed due to pain; was
church. He sleeps at 9pm- only able to sleep for 2 hours
6pm this evening for this day.
9. Sexuality Patient is a male, 77 years Patient is a male, 77 years
a. Male (circumcision, civil old, widower, with 8 children, old, widower, with 8 children,
status, number of circumcised at 6 years old. circumcised at 6 years old.
children)

PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS
General
Patient is male, 77 y/o, lying semi-fowler’s position in bed, sleeping, but later was awakened.
Patient has mild body and breath odor. Patient is conscious, and oriented to person, and
place. Patient is calm and with normal affect congruent to behavior, speaks clearly, logically,
and with normal pace. Patient appears very weak and sleepy. Patient has #17 D5 LR 1L with
650 cc left, hooked at right arm, regulatedat 30 gtts/min, patent and infusing well.

HEENT
H-Patient has wavy, white-streaked hair, equally distributed, no infestations, facial features
are symmetric, slightly oval in shape. Skin is wrinkled at the forehead and cheeks.
E-Patient has moist, pink conjunctiva, anicteric sclera, able to read with aid, pupils are black,
constricts 2mm when lighted, 4mm when not, PERRLA.
E-Patient is able to hear adequately; ears have dry, brown cerumen, level with eyebrows

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N- Patient is able to smell adequately, patent and equal nostrils, no nasal flaring, nasal
septum at midline, with dried up mucus.
T- Patient’s oral mucosa is pale and dry, lips are parched. Tongue is pink, dry, and parched.
With dental carries, tonsils are not enlarged/flat. Has slight breath odor, able to swallow, and
gag reflex present.

Integumentary System
Patient’s skin is dry, warm, rough in some parts, and brownish in color. Skin in feet is dry,
scaly, and pale. Patient has body hairs equally distributed on contralateral parts of the body.
Patient has good skin turgor, with nonpitting edema on dorsal part of both feet, but with a
grade 1+ pitting edema on the ankles. Patient has median incision on abdomen. Patient has
an open wound below the umbilicus, with length of 9cm and width of 6cm, yielding yellow-
greenish drainage with foul odor. Patient’s nails are long, no clubbing, CRT 2-3 sec.
Temperature is 37.8 ˚C. Patient’s nails are in normal angle and shape/ curvature, but with
pale nail beds.

Respiratory System
Patient has chest shape 1:2 anteroposterior to transverse. Chest movement is symmetric,
diaphragmatic exursion is equal and symmetric, but restricted. Spine is vertically aligned.
Chest expansion is slightly restricted. Tactile fremitus is palpated, symmetrical bilaterally.
Patient’s breath sounds on the upper lung fields are clear, but decreased breath sounds on
the lower fields. RR-22 cpm, and with effort. Patient uses abdominal accessory muscles and
internal intercostal muscles when breathing. Flaring nostrils noted. Pt breathes with open
mouth. Pt’s respiration is rhythmic, with regular pattern and normal depth. No adventitious
breath sounds. Pt has moderate ascites that pushes the diaphragm upwards, thus restricting
lung expansion, as reflected on UTZ, and physical assessment.

Cardiovascular System
Patient is pale, with pale extremities. Anterior chest has symmetrical features. Neck veins are
flat on semi-fowler’s position. Skin is warm to touch. PMI is at fifth intercostal space, left
midclavicular line. Pulse is graded 1+ on all extremities, equal bilaterally, weak, and thready
as palpated. Nonpitting edema on both feet. CRT is 2-3 sec. HR-86 bpm, PR-86 bpm,
resonant to dull at midclavicular line. S1 is heard best on apex, S2 at base. No murmurs.
Heart sounds have irregular pattern, with S4.

Digestive System
Abdomen is flabby/globular, light brown, uniform all over. Umbilicus is at midline, with median
incision on abdomen. Landmarks are palpated in appropriate places, liver borders, xiphoid
process, and bladder. No signs of enlargement. Chest rises on inspiration and deflates on
expiration. Hypoactive bowel sounds of 3/min. dull on liver, tympany on intestine, flat on ribs
upon percussion. No pulsations or masses with thickness only on deep palpation. Abdominal
girth is 107cm. Oral mucosa is pale and dry; tongue is pink, dry, and parched. With dental
carries, has slight breath odor, able to swallow, and gag reflex present. On clear liquid diet.
Pt has moderate ascites.

Excretory System
Patient has urinated on diaper, which was changed once for the whole day, with clear, yellow
urine. No burning sensation upon urination. Bladder is slightly palpable. Patient has not been
able to defecate for 2 days already.

Musculoskeletal System
Patient’s muscles on upper extremities are equal in size bilaterally, measures 24.5cm thigh
23.5cm on right and 27.5cm on left, calf is 35cm on right and 31.5cm on left. Has firm tone,
smooth and coordinated in movement graded 4+on extremities. PROM and AROM
performed. Patient is able to change position with assistance. Patient is able to move toes. Pt
has nonpitting edema on both feet, pitting on the ankles grading 1++. Pt has moderate
ascites.

Nervous System
Patient is conscious, and oriented to person, place, but confusion noted at times. Patient is
calm and with normal affect congruent to behavior, speaks clearly, logically, and with normal
pace. Cranial nerves tested and found functioning. Patient’s reflexes are 2+ bilaterally,

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superficial reflexes present. Patient is able to contrast pain, temperature appropriately and
able to differentiate temperatures. Patient is able to move but slowly and with assistance.
GCS=14, muscle strength 4+ on all extremities.

Endocrine System
Patient has no history of hormonal/endocrine problems, thyroid is not enlarged, skin is dry
and warm to touch. Patient has no known allergies.

Reproductive System
Patient is a widower, with eight children, was circumcised at age 6 y/o. no pain upon
urination, no abnormal masses on his reproductive organ reported by patient.

PATHOPHYSIOLOGY

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LABORATORY AND DIAGNOSTIC TESTS
HEMATOLOGY
NORMAL Sep Sep Sep Sep Sep Oct 1 IMPLICATIONS
VALUE 26 27 28 29 30
135- Anemia, decreased 2°
Hgb 133 136 105 103 116 110
160g/L to blood loss 3° surgery
Decreased, anemia 2°
Hct 0.40-0.48 0.4 0.4 0.31 0.21 0.34 0.32
blood loss 3° surgery
Increased, indicates
5- infection 2° current
WBC 11.3 12.8 13.1 12.8
10x10/L abdominal problem and
surgical procedures
Increased, indicates
Neutrophil 0.55-.65 0.79 0.84 0.88 0.8
bacterial infection
Decreased, indicates
bacterial infection,
Lymphocyte 0.25-0.4 0.21 0.14 0.1 0.2 decreased because
outnumbered by
neutrophils
Monocyte 0.02-0.06 0.01 Indicates infection
Eosinophil 0.01-0.05 0.01 0.02 Normal

Indication
Basic screening test determines altered hematologic functioning.

Nursing Responsibilities
PRE-TEST
1. Explain test purpose and procedure.
2. Ensure consent is secured.
3. Assess patient for bleeding disorder.
4. Instruct patient that slight discomfort maybe felt when skin is punctured.
5. Instruct pt to avoid stress and dehydration.
POST-TEST
1. Apply manual pressure on punctured site.
2. Monitor vital signs.
3. Monitor puncture site for bruising, bleeding.

URINALYSIS (Oct 2, 2011)

NORMAL VALUE RESULT IMPLICATIONS
Color yellow/amber dark yellow normal
pH 4.5-8.0 6 normal
Sp. Gravity 1.005-1.030 1.015 normal
Sugar negative ++ normal
Protein negative 8-10/hpf Indicates proteinuria
Pus negative 8-10/hpf Indicates bacteriuria
RBC negative 2.4/hpf Indicates hematuria
Epithelial cells rare few normal
Indicates dehydration, or
Crystals negative moderate improper hydration
Bacteria negative moderate indicates bacteriuria, UTI
Granular cast
(coarse) 2-4/hpf 8-10/hpf indicates ineffective GRF

Indication
Determines altered urine properties.

PRE-TEST

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1. Explain test procedure and purpose.
2. Avoid excessive water and sodium intake.
3. Eliminate caffeine and alcohol in the diet.
POST-TEST
1. Patient can resume normal fluid and dietary intake and medications.

BLOOD CHEMISTRY

NORMAL VALUE Sep 28 Oct 2 Oct 3 IMPLICATIONS
SODIUM 135-148 mmol/L 143.4 mmol/L Normal
POTASSIUM 3.5-5.3 mmol/L 4.88 mmol/L 5.19 mmol/L 4.83 mmol/L Normal

Indication
Identify chemical blood constituents, to establish a pattern of abnormalities/ balance.

PRETEST
2. Ensure legal consent is secured
3. Assess Patient for bleeding disorder
4. Instruct pt that slight discomfort maybe felt when skin is punctured
5. Instruct pt to avoid stress, DHN
POSTTEST
1. Apply manual pressure.
2. Monitor V/S.
3. Monitor puncture site for bruising, bleeding

CHEST X-RAY AP View (Sep 30, 2011)

INDICATION NORMAL VALUE RESULT IMPLICATIONS
Used to diagnose Normally appearing Hazy densities at the right - cardiomegaly
pulmonary and positioned chest, paracardiac aorta and left - calcified aorta
diseases and bony thorax (all lung base suggestive of - pneumonitis
disorder of bones present, PNEUMONITIS. There is - pneumo-
mediastinum, aligned, symmetrical, suspicious free-peritoneal air peritoneum
and bony thorax, and normally below the hemi- diaphragm
to evaluate heart shaped), soft tissues, suggestive of:
condition. mediastinum, lungs, pneumo-peritoneum
pleura, heart, and cardiomegaly AP view
aortic arch. Calcified aorta

PRETEST
2. Remove all jewelry and other ornamentation in the chest area before X-ray.
3. Remind pt should remain motionless and follow breathing instructions.
POSTTEST
1. Provide and return pt to comfortable room environment and inform result later.

ULTRASOUND- LIVER (Oct 5, 2011)

Valuable in The size and shape of Normal in size exhibiting Ultrasonically
detecting a the abdominal organs homoenous parenchymal normal size
variety of appear normal. The Echo pattern in relation to the liver
pathologies, liver, spleen, and system Moderate
including pancreas appear It has smooth outline ascites
fluid normal in size and No definite focal nor diffuse mass Incidental small
collections, texture. No abnormal lesions pleural fluid,
masses, growths are seen. No No dilated intrahepatic vessels right
infections fluid is found in the There is moderate amount of
and abdomen. free- intraperitoneal fluid

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obstruction. collection

PRETEST
1. Explain test purpose, benefits, and procedure.
2. Instruct patient to remain NPO for a minimum of 8 hours before the examination to
improve anatomic visualization of all structures.
3. Assure the patient that there is no pain involved. However, the patient may feel
uncomfortable lying quietly for a long period.
4. Explain that a liberal coating of coupling agent must be applied to the skin that there
is no air between the skin and the transducer and to allow for easy movement of the
transducer over the skin.
5. Explain that the patient will be instructed to control breathing patterns while the
images are being made.
POSTTEST
1. Normal diet and fluids are resumed.
2. Interpret test outcomes and counsel appropriately.

FASTING BLOOD SUGAR (Sep 29, 2011)

To monitor the blood Increased, possible for
glucose level of a patient DM
72-125 mg/dL 131 mg/dL
and is vital component of And advanced liver
diabetes management. disease

PRETEST
2. Tell patient that the test requires at least one overnight fast; water is permitted.
Instruct the patient to defer insulin or oral hypoglycemics until after blood is drawn,
unless specifically instructed to do otherwise.
3. Note the last time the patient ate in the record and on the laboratory requisition.

POSTTEST
1. Tell patient that he or she may eat and drink after blood is drawn.
2. Interpret test results and monitor appropriately for hyperglycemia and hypoglycemia.
Counsel regarding necessary lifestyle changes
3. Give the patient the following checklist:
a. Take special care of the feet
b. Use a lubricant or unscented hand cream on dry, scaly skin.
c. Look for calluses on your soles. Rub them gently with pumice stone.
d. Make sure new shoes fit properly; wear freshly washed socks or stockings.
e. Never go barefoot
f. Avoid using hot water bottles, tubs of hot water, or heating pads on your feet.
g. Trim your toe nails straight across
4. Persons with glucose levels >200mg/dl should be placed on a strict intake and output
program.

MEDICAL MANAGEMENT

IDEAL ACTUAL
Diagnostic Evaluation Diagnostic Evaluation
Fecal material aspiration from NG tube Hematology
Abdominal and chest X-rays Chest X-ray -AP view
o May show presence and location Blood Chemistry
of small or large intestinal Abdominal Ultrasound
distention, gas or fluid Urinalysis
o ―Bird beak‖ lesion in colonic Abdominal X-ray flat plate and
volvulus upright

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o Foreign body visualization
Contrast studies Treatment
o Barium enema may diagnose With oxygen inhalation at 2-
colon obstruction or 3L/min
intussusception. NGT removed
o Ileus may be identified by oral Drainage of transudate fluid with
barium or Gastrografin. suction
Laboratory tests Fluid taken for cell block, cell
o May show decreased sodium, count
potassium, and chloride levels due Vital signs monitoring every hour
to vomiting Intake and output monitoring
o Elevated WBC counts due to every shift
inflammation; marked increase Refer if urine output is less than
with necrosis, strangulation, or 30mL/hr
peritonitis
On general liquids diet
o Serum amylase may be elevated
from irritation of the pancreas by
Medication
the bowel loop
Tramadol 50mgIVTTq8h
Flexible sigmoidoscopy or colonoscopy
may identify the source of the obstruction Ketorolac 30mgIVTTq6h RTC
such as tumor or stricture Cefuroxime 750mgIVTTq8h
Metronidazole 500mgIVTTq8h
Nonsurgical Management Paracetamol 300mgIVTT for
Correction of fluid and electrolyte temp>38°C
imbalances with normal saline or Ringer's Azithromycin
solution with potassium as required. Telmisortan
NG suction to decompress bowel. Simvastatin
Treatment of shock and peritonitis. Furosemide 20mgIVTT now
TPN may be necessary to correct protein
deficiency from chronic obstruction, IVF
paralytic ileus, or infection. D5LR
Analgesics and sedatives, avoiding D5NM
opiates due to GI motility inhibition.
Antibiotics to prevent or treat infection.
Ambulation for patients with paralytic ileus
to encourage return of peristalsis.

SURGICAL MANAGEMENT

IDEAL ACTUAL
Surgery Exploratory Laparotomy
Consists of relieving obstruction. Options include: Ileal Resection and Anastomosis
Closed bowel procedures: lysis of
adhesions, reduction of volvulus,  Surgical preparation done.
intussusception, or incarcerated hernia  Postoperative care done.
Enterotomy for removal of foreign bodies
or bezoars
Resection of bowel for obstructing lesions,
or strangulated bowel with end-to-end
anastomosis
Intestinal bypass around obstruction
Temporary ostomy may be indicated

 Surgical preparation is often lengthy, taking
as long as 6 to 8 hours.
 It includes correction of fluid and electrolyte
imbalances; decompression of the bowel to
relieve vomiting and distention; treatment of
shock and peritonitis; and administration of
broad-spectrum antibiotics.

15 | P a g e


 Often, decompression is begun
preoperatively with passage of a nasogastric
(NG) tube attached to continuous suction.
This tube relieves vomiting, reduces
abdominal distention, and prevents
aspiration.
 In strangulating obstruction, preoperative
therapy also usually requires blood
replacement and I.V. fluids.
 Postoperative care involves careful patient
monitoring and interventions geared to the
type of surgery.
 Total parenteral nutrition may be ordered if
the patient has a protein deficit from chronic
obstruction, postoperative or paralytic ileus,
or infection.

Nursing Management

IDEAL ACTUAL
Nursing Assessment Prioritized Nursing Diagnoses
Assess the nature and location of the Ineffective Airway Clearance
patient's pain, the presence or absence of Ineffective Breathing Pattern
distention, flatus, defecation, emesis, Decreased Cardiac Output
obstipation. Deficient Fluid Volume
Listen for high-pitched bowel sounds, Acute Pain
peristaltic rushes, or absence of bowel Impaired Skin Integrity
sounds. Risk for Secondary Infection
Assess vital signs. Hyperthermia
Watch for air-fluid lock syndrome in elderly Activity Intolerance
patients, who typically remain in the Risk for Injury
recumbent position for extended periods.
o Fluid collects in dependent bowel loops. Nursing Interventions
o Peristalsis is too weak to push fluid Vital signs monitored q hr.
―uphill‖.• Regulated IVF to prescribed rate.
o Obstruction primarily occurs in the large Monitored intake and output as
bowel. ordered.
Conduct frequent checks of the patient's level Prescribed meds given.
of responsiveness; decreasing Assessed patient.
responsiveness may offer a clue to an Provided therapeutic
increasing electrolyte imbalance or impending environment.
shock. Measured abdominal girth daily.
Encouraged pt to perform deep
Nursing Diagnoses
breathing and coughing
Ineffective Breathing Pattern related to
exercises.
abdominal distention, interfering with normal
Health teachings done to patient
lung expansion
and SO.
Ineffective tissue perfusion: GI
Acute Pain related to obstruction, distention, Instructed patient on active ROM.
and strangulation Assessed bowel sounds.
Imbalanced nutrition: Less than body Assessed breath sounds.
requirements Elevated patient’s feet to lessen
Risk for Deficient Fluid Volume related to edema.
impaired fluid intake, vomiting, and diarrhea Assisted patient in assuming a
from intestinal obstruction semi-Fowler’s position.
Risk for Injury related to complications and Assisted patient in ambulation
severity of illness and promoted patient safety
Constipation Instructed SO on proper skin
Diarrhea related to obstruction care.
Fear related to life-threatening symptoms of

16 | P a g e


intestinal obstruction

Nursing Interventions
Allow the patient nothing by mouth, as
ordered, but make sure to provide frequent
mouth care to help keep mucous membranes
moist.
Look for signs of dehydration (thick, swollen
tongue; dry, cracked lips; dry oral mucous
membranes). If surgery won't be performed,
the patient may be allowed a few ice chips.
Avoid using lemon-glycerin swabs, which can
increase mouth dryness.
Insert an NG tube to decompress the bowel
as ordered. Attach the tube to low-pressure,
intermittent suction. Monitor drainage for
color, consistency, and amount. Irrigate the
tube, if necessary, with normal saline solution
to maintain patency.
Begin and maintain I.V. therapy as ordered.
Monitor intake and output.
Maintain fluid and electrolyte balance by
monitoring electrolyte, blood urea nitrogen,
and creatinine levels. Provide I.V. fluids to
keep levels within normal ranges.
Administer analgesics, broad-spectrum
antibiotics, and other medications as ordered.
Monitor the patient for the desired effects and
for adverse reactions.
To ease discomfort, help the patient change
positions frequently. Continually assess his
pain. Remember, colicky pain that suddenly
becomes constant could signal perforation.
Watch for signs of metabolic alkalosis
(changes in sensorium; slow, shallow
respirations; hypertonic muscles; tetany) or
acidosis (shortness of breath on exertion;
disorientation; and later, deep, rapid
breathing, weakness, and malaise).
Watch for signs and symptoms of secondary
infection, such as fever and chills.
Monitor urine output carefully to assess renal
function, circulating blood volume, and
possible urine retention due to bladder
compression by the distended intestine. If you
suspect bladder compression, catheterize the
patient for residual urine immediately after he
has voided.
Measure abdominal girth frequently to detect
progressive distention.
Keep the patient in semi-Fowler's or Fowler's
position as much as possible. These positions
help to promote pulmonary ventilation and
ease respiratory distress from abdominal
distention.
Listen for bowel sounds, and watch for other
signs of resuming peristalsis (passage of
flatus and mucus through the rectum).
If surgery is scheduled, prepare the patient as
required.
After surgery, provide all necessary
postoperative care. Care for the surgical site,

17 | P a g e


maintain fluid and electrolyte balance, relieve
pain and discomfort, maintain respiratory
status, and monitor intake and output.

Patient Teaching
Teach the patient about his disorder, focusing
on his type of intestinal obstruction, its cause,
and signs and symptoms. Listen to his
questions and take time to answer them.
Explain the rationale for NG suction, NPO
status, and I.V. fluids initially. Advice patient
to progress diet slowly as tolerated once
home.
Explain necessary diagnostic tests and
treatments. Make sure the patient
understands that these procedures are
necessary to relieve the obstruction and
reduce pain.
Prepare the patient and family members for
the possibility of surgery. Provide
preoperative teaching, and reinforce the
physician's explanation of the surgery.
Demonstrate techniques for coughing and
deep breathing, and teach the patient how to
use incentive spirometry.
Tell the patient what to expect
postoperatively. After surgery, review
incisional care. Provide emotional support
and positive reinforcement before and after
surgery.
Discuss postoperative activity limitations and
point out why these restrictions are
necessary.

Health Maintenance
Review the proper use of prescribed
medications, focusing on their correct
administration, desired effects, and possible
adverse reactions.
Advise plenty of rest and slow progression of
activity as directed by surgeon or other health
care provider.
Teach wound care if indicated.
Encourage patient to follow-up as directed
and to call surgeon or health care provider if
increasing abdominal pain, abdominal
distention, nausea, vomiting, or fever occur
prior to follow-up.

Evaluation: Expected Outcomes
Maintains position of comfort, states pain
decreased to 3 or 4 level on 0-to-10 scale
Urine output greater than 30 mL/hour; vital
signs stable
Passed flatus and small, formed brown stool,
negative occult blood
Respirations 24 breaths per minute and
unlabored with head of bed elevated 45
degrees
Alert, lucid, vital signs stable, abdomen firm,
not rigid
Appears relaxed and reports feeling better

18 | P a g e


SUMMARY OF MEDICATIONS

DATE MEDICATION DOSAGE ROUTE FREQUENCY REMARKS

09/27-10/2 Tramadol 100 mg IV PUSH q 8 hrs
Ketorolac 30 mg IV PUSH q 6 hrs RTC
09/27-10/4 Cefuroxime 750 mg IV PUSH q 8 hrs
Metronidazole 500 mg IV PUSH q 8 hrs
Paracetamol 500 mg tab PO q 4 hrs, PRN
10/1-10/3 Azithromycin 50 mg tab PO OD Administered
10/1-10/4 Telmisartan 40 mg tab PO OD and tolerated
Simvastatin 40 mg tab PO q HS well
10/5 Metronidazole 500 mg IV PUSH q 8 hrs
Cefuroxime 750 mg IV PUSH q 8 hrs
Tramadol 50 mg IV PUSH q 8 hrs
Ranitidine 50 mg IV PUSH q 8 hrs
Ketorolac 30 mg IV PUSH q 6 hrs

DRUG STUDY
Medication

Drug Side
Mecha- Contraindica-
Classi- Effects/ Nursing
Indication nismof tionsand
ficatio Adverse Responsibilities
Action Cautions
n Effects

Antiulc -Duodenal Competitiv Vertigo, - Assess patient for -Contraindicated
Ranitidine

er drug and ely inhibits malaise, abdominal pain. in patients
gastric action of headache, - Instruct patient on hypersensitive to
ulcer histamine blurred proper use of OTC drug.
-heartburn on the H2 vision, preparation as -Use cautiously in
at receptor anaphylaxis, indicated. patients with
sites of angioedema - Remind patient to hepatic
parietal take once daily. dysfunction.
cells, - Instruct patient to
decreasing take without regards
gastric acid to meals because
secretion. absorption is not
affected.
- Urge patient to avoid
cigarette smoking
because this may
increase gastric acid
secretion.

19 | P a g e


Medication Drug
Mecha-
Side
Contraindica-
Action Cautions
n Effects

Nonopi -Mild pain Unknown. Hemolytic - Advise patient that -Contraindicated
Paracetamol

oid -Feer Thought to anemia, drug is only for short- in patients
analge produce neutropenia, term use. hypersensitive to
sic and analgesia pancytopeni - Tell patient not to use drug.
antipyr by blocking a, jaundice, for marked fever of
etic pain hypoglycemi 103.1°F.
impulses a, rash - Warn patient that
by long-term use can
synthesis cause liver damage.
of the
prostaglan
din in the
CNS or
other
substances
that
synthesize
pain
receptors
to
stimulation.
Opioid -moderate Unknown. -dizziness, - tell patient to take -Contraindicated
Tramadol

analge or A centrally- vertigo, drug as prescribed and in patients
sic moderatel acting headache, not to increase dose or hypersensitive to
y severe synthetic somnolence, dosage. drug.
pain analgesic seizures, - Caution ambulatory -Use cautiously in
compound nausea, patient to be careful patients at risk for
not constipation, rising and walking. seizures and
chemically vomiting, - Advise patient to respiratory
related to respiratory check with prescriber depression.
opioids. depression before taking OTC
Thought to drugs because drug
bind to reactions can occur.
opioid - Warn patient not to
receptors stop drug abruptly.
and inhibit
reuptake of
norepineph
rine and
serotonin.

20 | P a g e


Medication Drug
Mecha-
Side
Contraindica-
Action Cautions
n Effects

Diuretic -acute A potent -vertigo, - To prevent nocturia, Contraindicated
Furosemide

pulmonary loop headache, give medication in the in patients
edema diuretic that dizziness, morning. hypersensitive to
-edema inhibits pancreatitis, - Monitor weight, blood drug and in those
- sodium and agranulocyt pressure, and pulse with anuria.
hypertensi chloride osis, rate routinely with long- - Use
on reabsorptio leucopenia, term use and during cautiously in
n at the thrombocyto rapid dieresis. patients with
proximal penia, - Watch for signs of hepatic
and distal aplastic hypokalemia such as cirrhosis and
tubules and anemia, muscle weakness and in those
the hepatic cramps. allergic with
ascending dysfunction, - Monitor fluid intake sulfonamides
loop of volume and output and .
Henle. depletion electrolyte and BUN,
and and carbon dioxide
dehydration, levels frequently.
hypokalemia - Consult prescriber
, about a high-potassium
hyperglycem diet.
ia, dilutional
hyponatremi
a, muscle
spasm,
dermatitis,
purpura,
photosensiti
vity
reactions
and gout
Non- Short-term Inhibits CNS: Correct first In those who are
Ketorolac tromethamine

steroid managem prostaglan headache, hypovolemia. at risk for
al anti- ent of din dizziness, bleeding.
inflam moderatel synthesis, drowsiness, In patients less than 2
matory y severe, to produce sedation years of age, use single As prophylactic
drug acute pain anti- dose only. analgesic before
for single inflammato CV: major surgery or
and ry, arrhythmias, Tell patient to notify intraoperatively
multiple- analgesic, edema, prescriber if there is when hemostasis
dose and hypertensio blood in the vomit, is critical.
treatment. antipyretic n, urine, or stool; coffee-
effects. palpitations ground vomit and In those who are
black-tarry stool. elderly, with
GI: renal/hepatic
dyspepsia, impairment
GI pain,
nausea,
vomiting,
diarrhea,
constipation

SKIN:
diaphoresis,
pruritus,
rash

21 | P a g e


Medication Drug
Mecha-
Side
Contraindica-
Action Cautions
n Effects

HMG- To reduce Inhibits CNS: Patient should follow a In those with
Simvastatin

CoA risk of HMG-CoA asthenia, standard low- active liver
reducta death reductase, headache cholesterol diet during disease.
se from CV an early therapy.
inhibito diseases (and rate- GI: Caution on those
r and CV limiting)ste abdominal Instruct patient to take who consume
events in p in pain, drug with the evening large amounts of
patients at cholesterol constipation, meal because this alcohol.
high risk biosynthesi diarrhea, enhances absorption
for s dyspepsia, and increases
coronary nausea, cholesterol
events. vomiting biosynthesis.

To reduce MUSCULOS
total and KELETAL:
LDL myalgia
cholestero
l levels in RESPI:
patients URTI
with
homozygo
us familial
hyperchol
esterolemi
a.
Macroli Acute Binds to CNS: Give Zmax 1 hour In patients
Azithromycin

de bacterial 50S dizziness, before or 2 hours after hypersensitive to
worsening subunit of fatigue, a meal; can be taken erythromycin.
of COPD bacterial headache, with or without food; do
ribosome, vertigo not give with antacids. Caution in
Communit blocking patients with
y acquired protein CV: chest Tell patient to avoid impaired hepatic
pneumoni synthesis; pain, excessive sunlight and function.
a bacteriostat palpitations to wear protective
ic or clothing and use
Single bactericidal GI: sunscreen when
dose , abdominal outside.
treatment depending pain,
for mild to on diarrhea,
moderate concentrati nausea,
acute on. vomiting,
bacterial melena
sinusitis
GU:
Urethritis candidiasis,
and nephritis,
cervicitis vaginitis

Pelvic SKIN:
inflammat photosensiti
ory vity, rash
disease

Chlamydia
l infections

22 | P a g e


Medication Drug
Mecha-
Side
Contraindica-
Action Cautions
n Effects

Angiote Hypertensi Blocks CNS: Monitor for hypotension Caution for those
Telmisartan

nsin II on (used vasoconstri dizziness, after starting drug. who have
recepto alone or cting and pain, Place patient supine if patients with
r with other aldosteron fatigue, hypotension occurs, biliary obstruction
antago antihypert e-secreting headache and give IV normal disorders or renal
nist ensives) effects of saline, if needed. and hepatic
angiotensin CV: chest insufficiency
II by pain, Closely monitor BP.
selectively hypertensio
blocking n, peripheral Can be taken without
the binding edema regard to meals.
of
angiotensin EENT: Remove drug from
II to the pharyngitis, blister-sealed packet
angiotensin sinusitis until immediately before
I, or AT1, use.
receptor in GI: nausea,
many abdominal
tissues, pain,
such as diarrhea,
vascular dyspepsia
smooth
muscle and GU: UTI
the adrenal
gland RESPI:
cough, URTI

NURSING CARE PLAN

Identified Problem: ineffective coughing
Nursing Diagnosis: Ineffective Airway Clearance r/t ineffective cough reflex 2° pain at incision
site
CUES OBJECTIVES INTERVENTIONS RATIONALE
Subjective: Short Term Objective: 1. Auscultate breath 1. To ascertain
―Pungaiginhawa,‖ Within 8 hours of sounds and assess air status and note
as verbalized by the providing nursing care, movement. progress.
patient. patient will expectorate 2. Monitor vital signs, 2. To assess
secretions readily and noting BP and pulse changes and note
maintain a patent changes. for possible
airway. complications.
Objective: 3. Observe for sign and 3. To identify
Ineffective symptoms of infection infectious process
weak such as dyspnea with and promote
coughing Long Term Objective: onset of fever, and timely
Adventitious Within 3 days of sputum color changes. intervention.
sounds providing nursing care, 4. To open or
(stridor patient will demonstrate 4. Position head midline maintain open
heard) and maintain absence of with flexion appropriate airway in at-rest
Confused congestion as for age/condition. or compromised
dyspneic evidenced by clear individual.
decreased breath sounds, 5. To decrease
breath noiseless respirations, 5. Elevate head of pressure on the
sounds on and vital signs within bed/change position diaphragm and
lower fields normal range, and will every two hours and enhance drainage
CXR: be free from any when necessary. /ventilation to
pneumonitis complications. different lung
UTZ: segments.
Moderate 6. Encourage deep 6. To mobilize
ascites breathing and coughing secretions for
exercises; splinted better
V/S:
incision. expectoration.

23 | P a g e


T- 36- 7. Increase fluid intake to 7. To help liquefy
36.7°C at least 2L/day within secretions.
PR- 70-83 level of cardiac
BPM tolerance.
RR- 14-20 8. Assist with postural 8. To mobilize
CPM drainage and secretions.
BP- 110/60- percussion as indicated
140/70 if not contraindicated by
condition.
9. Demonstrate pursed-lip 9. To promote
or diaphragmatic wellness.
breathing technique with
splinting on the
operative site.
Dependent:
10. Administer O2 via 10. To provide
nasal canula @ 2-3 supplemental O2
L/min.

Identified Problem: Difficulty of breathing with nasal flaring.
Nursing Diagnosis: ineffective breathing pattern r/t restricted lung expansion 2° to moderate
ascites
Subjective: Short Term Objective: independent
―Pungaiginhawa,‖ pt After 8 hrs of nursing >auscultated chest, >to identify any
verbalized. intervention, pt. will be noting presence/ unusual findings.
able to establish a character of breath
normal/effective sounds, presence of
Objective: respiratory pattern, secretion. >it may restrict or
V/S: verbalize awareness of >assessed for limit respiratory
BP- 130/80 mmHg causative factors, and concomitant effort.
PR- 86 bpm demonstrate behavior pain/discomfort >to limit level of
RR- 22 cpm that improves breathing >maintained calm attitude anxiety
T- 37.5 °C pattern. in dealing with client
>nasal flaring or SO >to limit level of
>use of abdominal, and >assisted client in use of anxiety
internal intercostal Long Term Objective: relaxation technique >to facilitate
accessory muscles to After 3 days of nursing >provided cool, clean, bronchial
breathe with effort intervention, pt. will be and comfortable relaxation, and
>restricted able to demonstrate environment facilitate rest
diaphragmatic excursion effective breathing >to provide
>respiratory rate greater pattern, breathing with >assisted client to learn maximum chest
than normal: 14-20 cpm ease, with no further different breathing expansion.
>UTZ: moderate ascites pulmonary exercises esp. DBE
>UTZ: Incidental small complications. and Balloon maneuver
pleural fluid, right q 2 hrs while awake. >to prevent
>dyspnea noted >encouraged position of atelectasis
> decreased breath comfort. Repositioned
sounds on lower fields client every 2-3 hours. >to prevent further
>encouraged ambulation complication
as individually
indicated. >to limit fatigue
> encouraged adequate
rest periods between
activities
dependent >for underlying
> administered oxygen at pulmonary
lowest concentration condition,
indicated respiratory
depress, or
cyanosis.

Identified Problem: Pale skin, Bipedal Edema, Cardiomegaly, Cool and Dry skin
Nursing Diagnosis: Decreased Cardiac Output r/t Impaired Heart Contractility 2º to
Cardiomegaly

24 | P a g e


CUES OBJECTIVE INTERVENTION RATIONALE
Subjective STO  Assess mentation  Restlessness is noted
―Enlarged man dawiya Within 8 hours of in the early stages;
heartana ang doctor,‖ total nursing care, severe anxiety and
verbalized by S.O. patient will be able confusion are seen in
to participate in  Assess V/S later stages
activities that  Sinus tachycardia and
Objective improve condition, increased arterial blood
 +1 Bipedal Edema such as stress pressure are seen in
 Pallor management and the early stages; BP
 Dry skin will adhere to both drops as the condition
 Weakness, Fatigue pharmacologic and deteriorates. Pulses are
 Decreased non-pharmacologic weak with reduced
Peripheral Pulses: course of therapy.  Assess fluid cardiac output.
Brachial –1+ balance and weight  Compromised
Radial –1+ gain regulatory mechanisms
Ulnar –1+ LTO may result in fluid and
Popliteal – 1+ Within 3 days of sodium retention. Body
Dorsalis Pedis –1+ total nursing care, weight is a more
Posterior Tibialis – patient will have a sensitive indicator of
1+ reduction of edema fluid or sodium
Weak, and thready on both extremities,  Assess lung retention than intake
pulse regular cardiac sounds. Determine and output.
rhythm, V/S within any occurrence of  Crackles reflect
 Confusion, Change
in Mental Status normal range, paroxysmal accumulation of fluid
 Decreased Urine improvement in nocturnal dyspnea secondary to impaired
Output – mentation, reduced (PND) or left ventricular
 Anxiety, problems in orthopnea. emptying. They are
Restlessness ventilation, and more evident in the
 Orthopnea absence of dependent areas of the
 V/S: complication lung. Orthopnea is
brought by difficulty breathing
T –70-83 bpm
problems with when supine. PND is
P-70-83 bpm
cardiac function.  Administer difficulty breathing that
R-14-20 cpm medication as occurs at night.
BP-110/60-140/70 prescribed, noting  To regain normal organ
response and function, aid in
watching for side rehabilitation; minimize
effects and toxicity. symptoms of adverse
Clarify with reactions and to prompt
physician interventions when
parameters for complications arise.
withholding
medications
 Place patient in
semi- to high-
 To aid in ventilation by
Fowler’s position.
 Administer reducing pressure over
humidified oxygen the diaphragm
 The failing heart may
as ordered
 Schedule planned not be able to respond
activities and to increased oxygen
provide adequate demands.
 To minimize oxygen
rest periods
 Provide quiet, demands
relaxed
 Emotional stress
environment.
increases cardiac
 Elevate both feet
demands.
with 2 pillows for 2
 To relieve edema on
hours 3 to 4 times
both lower extremities
a day
by preventing pooling of
blood and increase
 Assist in changing
blood flow back to the
position within bed-
heart.
from lying to sitting
 This maintains muscle
position every 2
tone, prevents pressure
hours several times
sores and increase
a day; and when
intestinal peristalsis

25 | P a g e


ambulating-from thus preventing
bed to comfort complications from
room and back to immobility.
bed

Identified Problem: Dehydration
Nursing Diagnosis: Deficient Fluid Volume (isotonic) r/t active fluid volume loss 2° to ascites
fluid, and fluid drainage
Subjective: Short Term Independent:  Elderly are @
―Uhawkaayo, pero dili Objective:  Note client’s age and higher risk
pamankopwedekainom‖, Within 8 hours of degree of hydration. because of
as verbalized by the providing appropriate decreasing
patient. nursing intervention, response of
patient will compensatory
demonstrate behaviors  Monitor V/S, regulate mechanisms.
Objective: in monitoring and IVF.  For base line
 Skin dry and rough to correcting deficit, and  Measure abdominal data.
touch manifestation of girth; monitor wound
 Oral mucosa dry, lips balanced intake and drainage.  To evaluate
cracked output.  Provide supplemental ascites.
 Pale nail beds, oral fluids, regulate IVF @
mucosa prescribed rate.  For fluid balance.
 Patient is very weak Long Term  Provide frequent oral
 U/O: 40 cc/7 hours Objective: care.
 Wound drainage: Within 3 days of  Bathe lips with water  To prevent injury
app. 420 cc in 8 hours providing appropriate using cotton buds. from dryness.
 Non-pitting edema on nursing intervention,  Encourage slow  To prevent
both foot noted patient will change in position cracking of lips.
 Moderate ascites: demonstrate, maintain every 2 hours.  To promote
UTZ fluid volume @ a  Provide/control comfort and
 Weak, thread pulse functional level as humidity of rooms (air safety.
 Sharp decrease in BP evidenced by conditioning).
from 140/90-110/60 individually adequate  Provide meticulous  To prevent further
 Light contusion noted urine output, stable oral skin care. loss of fluid
early in the morning V/S, moist mucous through
membrane, good skin evaporation.
turgor, and prompt  Provide adequate rest  To prevent further
capillary refill, and periods. injury to dry skin
resolution of edema.  Administer Lasix as and edematous
ordered. foot.
 For comfort and
promote safety.
 To help in
relieving edema
and ascites, by
mobilizing fluid in
the inaccessible
compartments of
body.

Identified problem: Pain on mid-abdominal area/ incision site
Nursing Diagnosis: Acute Pain r/t abdominal incision 2° to surgical procedure
ASSESSMENT PLANNING INTERVENTIONS RATIONALE
Subjective: STO: 1. Perform a  To assess etiology
―Sakitkaayoakong Within 8 hours of comprehensive
opera, ― as verbalized rendering nursing assessment of
by the patient. care, pt. will be able
pain.
to participate in the  This can influence
P-moving, Valsalva use of relaxation 2. Note location of
the amount of post-
maneuver skills & diversional surgical procedure
operative pain
Q-gnawing pain activities as
R-mid-abdominal area indicated for experienced
S-7/10 individual situation. 3. Perform pain  To rule out
T-intermittent assessment each worsening of

26 | P a g e

Case presentation volvulus in geriatric patient

Case presentation volvulus in geriatric patient

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