INTESTINAL OBSTRUCTION

Group 4, n-407

INTESTINAL OBSTRUCTION
y

is a blockage of your small intestine or colon that prevents food and fluid from passing through. can be caused by many conditions, including fibrous bands of tissue in the abdomen (adhesions), hernias and tumors. Alternative names: Paralytic ileus; Intestinal volvulus; Bowel obstruction; Ileus; Pseudo-obstruction intestinal; Colonic ileus. Etiology of bowel obstruction is pathological prevention of passage of gastrointestinal luminal content from passing distally.

The signs and symptoms of intestinal obstruction are Abdominal swelling, Constipation, Severe abdominal cramps, Intermittent abdominal cramps, nausea and Vomiting, Green vomit, Fecal vomiting (vomit that looks like feces) Blood-stained mucus passed, Passing jellylike mucus Diseases and conditions that can increase your risk of intestinal obstruction include: Abdominal or pelvic surgery, which often causes adhesions a common cause of intestinal obstruction. Crohn's disease an inflammatory condition that can cause the intestine's walls to thicken, narrowing its passageway. Cancer within your abdomen, especially if you've had surgery to remove an abdominal tumor or radiation therapy

OBJECTIVES (NURSE-CENTERED)
Upon completion of this case study, the student nurse should be able to: COGNITIVE

Recognize and understand the disease condition. Identify predisposing and precipitating factors that could possibly contribute to the occurrence of the disease. Understand the normal anatomy and physiology of the organs that are affected by the underlying disease condition. Review literature and background of the signs and symptoms manifested by the client. Identify specific theoretical and/or research-based causes and clinical manifestations of the disease, and trace the pathophysiology of the disease condition.

AFFECTIVE

Establish rapport with the client and SO. Maintain sound communication by making use of self as a therapeutic agent.

PSYCHOMOTOR

Assess the following such as: Personal history such as demographic data Pertinent family health and history by making use of a diagram History of past and present illness Formulate nursing diagnosis that address the needs of the patient and plan nursing interventions to meet those needs. Conduct physical assessment (cephalo-caudal approach, review of systems) Review and monitor diagnostic and laboratory results Construct individualized nursing care plans. Do discharge planning

II NURSING HISTORY

Personal History Demographic Data Mr. P, is a 39 year old male, he was born on December 1, 1971. He is married and blessed with 3 children. He is a Filipino citizen, currently living at Lubao, Pampanga together with his wife and children. His religious view is Roman Catholic. He is a college undergraduate of Bachelor of Science in Education, in Don Honorio Ventura College of Arts and Trades. b.Socio-Economic and Cultural Factors Mr. Ps family source of daily expenses comes from the money he earns as a tricycle driver and from her wifes mini grocery at home. They are earning a total of P10,000. Mr.Ps weekly expenses are: Food 2000x( 4) = 8000/month Monthly Income = 10000 Electric Bill 1000/month Monthly Expenses = 9400 Water Bill 400/month 600

He wakes up at 5:00 a.m. to take a bath and eat breakfast. By 6:00 am he will drop by and pick up the 3 elementary students at their house and he will send them to school. From 8:00 am to 3:00 pm he will stay at the terminal and pick up passengers. Then at 4:00 p.m he will fetch the students from school and bring them back home. At 5:00 pm onwards he will watch t.v., eat, or sometimes go to his neighbors. He usually sleeps at 10:00 in the evening. He smokes 1 pack per day of Philips since he was 27 y/o, but he stopped smoking 3 years ago. And he drinks 1 1/2 bottle a day of Red Horse. Pack years = # of packs/day x # of years smoked = 1 pack/day x 5 = 9 pack years He only self-medicate when he has headache and fever by taking Biogesic every 4 hours until the symptoms subside. They also seek help to a manghihilot if they have fever. They also utilize herbal medicines like oregano and guava whenever one of their family members is having cough and colds and stomach ache respectively, in which they boil the leaves for 5 to 10 minutes and drinks 1 glass 3x/day until it subsides.

II. Family Health Illness History It was revealed in the diagram that on father side, Mr. Ts grandfather is hypertensive and has Diabetes mellitus, and his grandmother died because of old age. On the other hand, on his mother side, Mr. Ps grandparents are both alive, his grandmother has heart disease while his grandfather is living healthy. His father was also hypertensive and his mom has heart disease. In addition his eldest sister is hypertensive and she was diagnosed of Diabetes mellitus Type II. Lastly, our client was currently diagnosed of Partial Intestinal Obstruction secondary to ileocecal tumor. Patient claimed that aside from those, there are no significant hereditary familial disease like asthma, bone disease and etc.

III. History of Past Illness

The patient has been hypertensive for the past 2 years, according to him he was taking Norvasc 5mg once a day. He has also irregular bowel habits for the past 3 months. The patient has also experienced minor illness such as cough and colds and drinks 2 tablespoon of oregano 3x/day until symptoms subside. He also experienced having fever once in a while in which he self medicates by taking Biogesic every four hours until fever is gone.

History of Present Illness One month prior to admission patient had generalized abdominal pain associated with 2 episodes of watery diarrhea and 2-3 episodes of vomiting and he noticed abdominal distention. Patient consulted to the nearest hospital and was admitted with a chief complaint of abdominal pain. NGT inserted to relieve his abdominal distention. After 9 days he decided to be discharged when his abdominal distention was relieved, he signed a refusal form and was advised by the doctor just to come back once pain persists. Patient had on and off pain after 2 days of being discharged followed by abdominal distention, with a pain scale of 7/10. He went back to the said hospital, thus, admitted again to have his operation, Explore Laparatomy, Right Hemicolectomy.

PHYSICAL ASSESSMENT

III. DIAGNOSTICS AND LABORATORY PROCEDURES

Diagnostic / Laboratory Indications or Purpose Procedure

Date Results Ordered Date Results were released

Normal Values

Analysis and Interpretation of the Results

Hematology

To aid in diagnosing anemia and to monitor blood loss and infection

Hct (%)

This represents the 9-7-10 percentage of total blood volume composed of RBC

.23

.40-.52

Hematocrit is below the normal range. This may be due to the intestinal obstruction which leads to digestive inflammation.

Hgb (g/dL)

This indicates the 9-7-10 amount of hemoglobin in a given blood volume. Hemoglobin is the component of the blood that gives its red color.

120

125-175 g/L

Hemoglobin is slightly decreased. This may be due to the intestinal obstruction which leads to digestive inflammation.

Diagnostic Laboratory Procedure

/ Indications Purpose

or Date Ordered Results Date Results were released

Normal Values

Analysis and Interpretation of the Results

WBC (x10 9/L)

Neutrophils(%)

The patient has a 9-7-10 bacterial infection so it is important that the WBC be determined which is responsible to fight against infection. Neutrophils are the 9-7-10 most common type of white blood cell, comprising about 5070% of all white blood cells. They are phagocytic, meaning that they can ingest microorganism. Neutrophils are the first immune cells to arrive at a site of infection.

12.4

5-10 x 109/L

White Blood Cell is Increased which may indicate infection.

.88

.45-.65

Neutrophils is increased which may indicate bacterial infection.

Diagnostic Laboratory Procedure

/ Indications Purpose

or Date Ordered Results Date Results were released

Normal Values

Analysis and Interpretation of the Results

Lymphocytes

A small white blood 9-7-10 cell (leukocyte) that plays a large role in defending the body against disease.

.12

.20-.35

The infection is caused by bacteria. However, the lymphocytes are low since this is indicated for viral infections

Platelet

(x10 9/L)

Indicates the amount of platelets present in a given amount of blood, the platelets are the ones responsible for blood clotting and stop bleeding.

9-7-10

.387

150-400 x 109/L

Platelet count is within the normal range.

NURSING RESPONSIBILITIES

Prior Administration:
y y y

Check the doctors order. Prepare the needed materials for laboratory test. Explain the purpose and indication of laboratory test to the patient.

During Administration:
y y y

Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movements. If the patient has a history of severe allergic reaction to latex, care should be taken to avoid the use of equipment containing latex. Remove the needle and apply pressure dressing on the puncture site.

After Administration:
y y y y

Label the blood specimen with the name, age and diagnosis of the patient. Bring the blood specimen immediately to the laboratory Document the laboratory test performed. Attach the laboratory test result in the patients chart.

Diagnostic Laboratory Procedure

/ Indications or Purpose

Date Ordered Results Date Results were released

Normal Values

Analysis and Interpretation of the Results

Blood Chemistry

Blood chemistry tests are often ordered prior to surgery or a procedure to examine the general health of a patient.

RBS

Random glucose test is a blood sugar test taken from a non-fasting subject. This is ordered 9-7-10 since the patient manifests some signs and symptoms of diabetes mellitus such as polydipsia, polyuria, and weight loss.

10.26

3.85 mmol/L

9.0 There is an increased blood sugar which could indicate diabetes mellitus. This could also be attributed to stress brought by the disease condition.

Diagnostic Laboratory Procedure

/ Indications or Purpose

Date Ordered Results Date Results were released

Normal Values

Analysis and Interpretation of the Results

BUN

The blood urea 9-7-10 nitrogen test is a measure of the amount of nitrogen in the blood in the form of urea, and a measurement of renal function. It may be ordered to 9-7-10 determine if a disease or condition involving the brain, lungs, liver, heart, kidney, thyroid, or adrenal glands is causing or being exacerbated by a sodium deficiency or excess.

12.8

1.7-8.3 mmol/L

A high level may indicate that the

kidneys are functioning less than normal.

Sodium

125.1

136-145 mmol/L

Sodium electrolyte is below the normal range. This may be due to diarrhea, excessive urination, and vomiting prior to admission.

Diagnostic Laboratory Procedure

/ Indications or Purpose

Date Ordered Results Date Results were released

Normal Values

Analysis and Interpretation of the Results

Potassium

Essential to regulate 9-7-10 heartbeat, facilitate normal muscle contraction, regulate the transfer of nutrients to cells, and regulate kidney function and stomach juice secretion,

3.16

3.5-5 mmol/L

Potassium electrolyte is below the normal range. This may also be due to diarrhea, excessive urination, and vomiting prior to admission.

Chloride

This test shows the level 9-7-10 of chloride in the blood. Chloride binds with electrolytes including potassium and sodium in the blood and plays a role in maintaining the proper pH of the blood. Chloride levels can vary widely if the patient is dehydrated or overly hydrated, if the kidneys are not functioning properly.

76.7

101-111 mmol/L

Serum Chloride is below the normal range. This may also be due to diarrhea, excessive urination, and vomiting prior to admission.

Diagnostic Laboratory Procedure

/ Indications or Purpose

Date Ordered Results Date Results were released

Normal Values

Analysis and Interpretation of the Results

Alkaline Phosphatase

Alkaline phosphatase 9-7-10 (ALP, ALKP) is a hydrolase enzyme responsible for removing phosphate groups from many types of molecules, including nucleotides, proteins, and alkaloids.

119.7

64-306 IU/L

The alkaline phosphatase is within the normal range.

SGOT/AST

SGOT: Serum glutamic 9-7-10 oxaloacetic transaminase, an enzyme that is normally present in liver and heart cells. SGOT is released into blood when the liver or heart is damaged.

48

10-40 IU/L

The SGOT is elevated which may indicate a liver or heart problem.

Diagnostic Laboratory Procedure

/ Indications or Purpose

Date Ordered Results Date Results were released

Normal Values

Analysis and Interpretation of the Results

SGPT/ALT

Alanine transaminase 9-7-10 or ALT is a transaminase enzyme (EC 2.6.1.2). It is also called serum glutamic pyruvic transaminase (SGPT) specific test for liver function. Since the patient is taking anti-TB drugs, it is important to check for liver function since one of its side effects is hepatotoxicity.

25.8

0-39 IU/L

The SGPT is within normal range.

NURSING RESPONSIBILITIES

Prior Administration:
y y y

Check the doctors order. Prepare the needed materials for laboratory test. Explain the purpose and indication of laboratory test to the patient.

During Administration:
Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movements. y If the patient has a history of severe allergic reaction to latex, care should be taken to avoid the use of equipment containing latex. y Remove the needle and apply pressure dressing on the puncture site.
y

After Administration:
y y y y

Label the blood specimen with the name, age and diagnosis of the patient. Bring the blood specimen immediately to the laboratory Document the laboratory test performed. Attach the laboratory test result in the patients chart.

Diagnostic Laboratory Procedure

/ Indications or Purpose

Date Results Ordered Date Results were released

Color: yellow

Normal Values

Analysis and Interpretation of the Results

Urinalysis

To check components of the D.O: 09-07-10 urine D.R: 09-07-10

Usual colors are colorless, straw, yellow, amber; less commonly Transparency: pink, red, brown. Turbid Usual appearances (opacity) are clear or hazy; less commonly turbid, cloudy and opaque

This indicates that the urine is concentrated.

Urine normally is clear. Mucus and lipid may cause turbidity in normal urine. Increased numbers of cells, crystals, casts, or organisms can increase the turbidity of urine in disease conditions.

Albumin: (-) Sugar: (-) Specific gravity: 1.005 Puss cells: 1216/ HPF 3-6/HPF 1.010 1.025 The specific gravity is lower than the normal range which indicates that the urine is concentrated. This may be due to problem in the urine concentration of the kidneys.

NURSING RESPONSIBILITIES
Prior Administration: Check the doctors order. Prepare the needed materials for laboratory test. Explain the purpose and indication of laboratory test to the patient. During Administration: A urine sample is collected in an unused disposable plastic cup with a tight-fitting lid. A randomly voided sample is suitable for routine urinalysis although the first-voided morning urine is most concentrated and therefore, preferred. After Administration: Label the urine specimen with the name, age and diagnosis of the patient. Bring the urine specimen immediately to the laboratory Document the laboratory test performed. Attach the laboratory test result in the patients chart.

Diagnostic Laboratory Procedure

/ Indications or Purpose

Chest X-Ray

Date Ordered Date Results were To evaluate the lungs, as released

Results

Normal Values

Analysis and Interpretation of the Results

well as the chest cage, for the presence of abnormalities. 9-7-10 To evaluate the size of the heart. To establish the size and 9-7-10 location of an abnormality prior to performing other tests, such as a biopsy.

(+) The lungs look cardiomegaly normal in size and shape, and the lung tissue looks normal. No growths or other masses can be seen within the lungs. The pleural spaces also look normal. The heart looks normal in size, shape, and the heart tissue looks normal. The blood vessels leading to and from the heart also are normal in size, shape, and appearance. The bones including the spine and ribs look normal. The diaphragm looks normal in shape and location.

Results show cardiomegaly or enlargement of the heart which may indicate that the patient has a heart problem.

Diagnostic / Laboratory Indications Procedure Purpose

or Date Ordered Results Date Results were released

Normal Values

Analysis and Interpretation of the Results

Electrocardiography

Symptoms generally indicating use of electrocardiography include: y Cardiac murmurs

y

Sinus tachycardi a 9-7-10

Syncope or collapse Seizures Perceived dysrhythmia] Symptoms of myocardial infarction

9-7-10

y y

Normal sinus rhythm: each P wave is followed by a QRS; P wave rate is not more than 150 bpm

Results show a fast heartbeat which is attributed to the heart enlargement since the heart needs to compensate in order to pump enough blood.

NURSING RESPONSIBILITIES

Instruct client that hospital gown will replace all clothing on the upper body. All jewelry must be removed. Pregnant women and should use protective lead aprons during the procedure because there is minimal exposure to radiation. Ask client to take a deep breath and hold it without moving while an X-ray picture is taken.

NURSING RESPONSIBILITIES
Clean the skin and clip hair in the area where the electrode tabs will be placed to ensure adherence and reduce discomfort during removal Attach the adhesive electrode tabs to the skin where the electrode wires will be fastened. Avoid touching the adhesive tabs over bones, scars, and breast tissues. After the procedure, wipe the area or the electrode tabs especially when lubricant is used.

SURGICAL MANAGEMENT

Surgical Management

General Description

Indications/ Purpose

Date Ordered, Date Performed

Clients response to treatment

Exploratory Laparotomy with Hemicolectomy

A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside of the abdominal cavity.

Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure may be recommended for a patient who has abdominal pain of unknown origin or who has sustained an injury to the abdomen.

Date ordered: September 8, 2010 Date Performed: September 9, 2010

The patient complains of pain on the incision site.

Hemicolectomy (also

The procedure is relatively common for treating referred to as right or left diverticulitis, inflammatory hemicolectomy) is a partial bowel disease, benign or colon-removal procedure in malignant polyps of the colon, and colon cancer. which surgeons excise the The hemicolectomy right (ascending) part of the procedure traditionally begins with an incision in the colon or the left abdomen, opening the area for access to the (descending) side of the colon. Thereafter, the colon. surgeon cuts away the infected or injured portions of the colon and reattaches the remaining tissue.

NURSING RESPONSIBILITIES
Prior

Explain to the patient how the procedure will be done or what the results will mean. Ask him Ask her to sign the inform consent. Make sure that the patient should understand the nature and purpose of the diagnostic procedure or treatment, its risks and benefits, and alternatives, including the option of not proceeding with the test or treatment. Ask him to fill out the medical test information form to understand the importance of the surgery.

Ask the patient if :

y y

Are allergic to any medications, including anesthetics. Have had bleeding problems or take blood thinners, such as aspirin or warfarin (Coumadin).

Get the complete blood count (CBC) and bleeding factors. NPO post-midnight before surgery. Ask the patient to remove dentures, eyeglasses or contact lenses, hearing aids, wigs, makeup, and jewelry before the biopsy. Ask him to empty bladder

NURSING RESPONSIBILITIES
During Maintain aseptic technique. After He may be required to lie flat for two hours following the procedure to prevent the risk of bleeding. Checks the patient's status at two-hour intervals. Monitor vital signs. Inform the patient that he should report immediately if the he experiences extreme pain, light-headedness, or difficulty breathing after the procedure. Advise to keep the incision site covered and dry for 48 hours.

PATHOPHYSIOLOGY

MEDICAL MANAGEMENT

POST-OP

DRUGS

Generic and Brand name

General Description

Indication (s) /Purpose (s) It is prescribed in the treatment of a variety of infections such as bacterial infections.

Nursing Responsibilities >Compute the ordered dosage of the drug twice. > Monitor I.V. site. Avoid prolonged use of indwelling catheter. > Evaluate hematologic studies, especially in patients with history of blood dyscrasias. >Advise patient to report fever, sore throat, bleeding, or bruising. >Inform patient that prolonged use may result in fungal or bacterial superinfection. > document and sign for the time of administration.

GN: Disturbs DNA Metronidazo synthesis in le susceptible bacterial BN: Flagyl organisms. It is converted to Initially, 15 reduction products that mg/kg I.V., followed by interact with DNA to cause 7.5 mg/kg I.V. q 6 destruction of hours, not to helical DNA exceed 4 structure and g/day for 7 to strand leading to a protein synthesis 10 days inhibition and cell death in susceptible organisms.

Clients Response to treatment The patient responded well with no signs of infection.

Generic and Brand name GN: Celecoxib

General Description

Indication (s) /Purpose (s) It is prescribed for the treatment of acute pain.

Nursing Responsibilities >Advise patient to immediately report bloody stools, vomiting of blood, or signs or symptoms of liver damage (nausea, fatigue, lethargy, pruritus, yellowing of eyes or skin, tenderness in upper right abdomen, or flulike symptoms). >Instruct patient to take drug with food or milk. >Tell patient to avoid aspirin and other NSAIDs (such as ibuprofen and naproxen) during therapy. > document and sign for the time of administration.

Clients Response to treatment The patients pain scale decreased from 6 to 3.

Exhibits antiinflammatory, analgesic, and BN: Celebrex antipyretic action due to inhibition 200 mg b.i.d. of COX-2 enzyme

Generic and Brand name GN: Morphine sulfate BN: Roxanol

General Description

Indication (s) /Purpose (s)

Nursing Responsibilities

2 to 10 mg/70 kg I.V. p.r.n. given slowly over 4 to 5 minutes.

Interacts with opioid Indicated for >Compute the ordered receptor sites, primarily in severe to dosage of the drug twice. limbic system, thalamus, moderate pain. and spinal cord. This > Monitor I.V. site. Avoid prolonged use of indwelling interaction alters catheter. neurotransmitter release, altering perception of and > For best response, give at pain onset. tolerance for pain. >Tell patient and caregiver that drug may cause respiratory depression. Instruct them to immediately report respiratory rate of 10 breaths/minute or less. > Inform patient that drug may cause constipation or urinary retention. Encourage high-fiber diet and high fluid intake. >Stress importance of taking drug only as prescribed. Point out that drug may cause psychological or physical dependence. >Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, vision, and alertness. >Teach patient and caregiver about appropriate safety measures to prevent injury. > Caution patient to avoid alcohol and other CNS depressants during and for 24 hours after therapy. > Advise patient to avoid herbs, which may worsen adverse CNS effects. > As appropriate, review all other significant and lifethreatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above. > document and sign for the time of administration.

Clients Response to treatment The patients pain scale decreased from 6 to 3.

Generic and Brand name

General Description

Indication (s) Nursing Responsibilities /Purpose (s)

Clients Response to treatment

GN: Promethazine Hcl

Blocks effects but not release of histamine and exerts strong alphaBN: Phenergan adrenergic effect. Also inhibits 25 to 50 mg chemoreceptor I.V. at bedtime trigger zone in medulla and alters dopamine effects by indirectly reducing reticular stimulation in CNS.

Used as an adjunct to postoperativ e analgesia and provide sedation.

>Compute the ordered dosage of the drug twice. >Monitor I.V. site. Avoid prolonged use of indwelling catheter. >Monitor neurologic status. Stay alert for signs and symptoms of neuroleptic malignant syndrome (high fever, sweating, unstable blood pressure, stupor, muscle rigidity, and autonomic dysfunction). > In long-term therapy, assess for other adverse CNS effects, including extrapyramidal reactions. >Monitor CBC and liver function tests. >Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, vision, alertness, and motor skills. >As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above. > document and sign for the time of administration.

The patient responded well with no signs of infection.

Generic and Brand name

GN: Ampicillin sodium and Sulbactam sodium BN: Unasyn 1.5 to 3 g I.V. q 6 hours

General Description
Destroys bacteria by inhibiting bacterial cell-wall synthesis during microbial multiplication. Addition of sulbactam enhances drug's resistance to beta-lactamase, an enzyme that can inactivate ampicillin.

Indication (s) /Purpose (s)

To treat intraabdominal, and skinstructure infections caused by susceptible betalactamaseproducing strains.

Nursing Responsibilities
>Compute the ordered dosage of the drug twice.

Clients Response to treatment

The patient responded well with no signs of > Monitor I.V. site. Avoid prolonged use of indwelling catheter. infection. >Instruct patient to immediately report signs and symptoms of hypersensitivity reaction, such as rash, fever, or chills. >Tell patient to report signs and symptoms of infection or other problems at injection site. >Inform patient that drug lowers resistance to certain infections. Instruct him to report new signs or symptoms of infection, especially in mouth or rectum. >Tell patient to promptly report unusual bleeding or bruising. >Instruct patient to avoid activities that can cause injury. Advise him to use soft toothbrush and electric razor to avoid gum and skin injury. >Inform patient that he may need to undergo regular blood testing during therapy. >As appropriate, review all other significant and lifethreatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above. > document and sign for the time of administration.

VI. CLIENTS DAILY PROGRESS

NURSING CARE PLAN

THANK
Godbless

YOU