Case Presentation

Surgical Ward

I. Introduction:

Colorectal cancer (also known as colon cancer, rectal cancer or bowel cancer) is when cancer
develops in the colon or rectum (parts of the large intestine).
[1]
It is due to the abnormal growth
of cells that have the ability to invade or spread to other parts of the body.Symptoms may include
blood in the stool, a change in bowel movements, weight loss, and feeling tired all the time.
Most colorectal cancers are due to lifestyle factors and increasing age, with only a small number
of cases due to underlying genetic disorders.Risk factors include: diet, obesity, smoking and not
enough physical activity.Dietary factors that increase the risk include: red and processed meat as
well as alcohol.
[4]
Another risk factor is inflammatory bowel disease, which includes Crohn's
disease and ulcerative colitis.Some of the inherited conditions that can cause colorectal cancer
include: familial adenomatous polyposis and hereditary non-polyposis colon cancer; however,
these represent less than 5% of cases.It typically starts as a benign tumor which over time
becomes cancerous.Bowel cancer may be diagnosed by biopsy during a sigmoidoscopy or
colonoscopy. This is then followed by medical imaging to determine if the disease has spread.
Screening is effective at decreasing the chance of dying from colorectal cancer and is
recommended starting at the age of 50 and continuing until the age of 75. Aspirin and other non-
steroidal anti-inflammatory drugs decrease the riskTheir general use is not recommended for this
Globally, colorectal cancer is the third most common type of cancer making up about 10% of all
cases. In 2012 it resulted in 1.4 million new cases and caused 694,000 deaths. It is more common
in developed countries where more than 65% of occur. It is less common in women than men.

II. Purpose/ Objective:
Learning Goal Student Centered Client Centered
Skills To put into action the skills that
we have learned in RLE into real
life situation in handling the
patient.
To be able to perform the skills
needed for the patient
effectively.
Knowledge To gain knowledge about the
disease chosen.
For the patient and her relatives
to gain knowledge about the
disease
Attitude To be able to practice our
communication technique in
dealing with patient and her
relatives.
To give the patient the
immediate care needed that will
help in the alleviation of her
condition through providing
rapport.


I. Biography :
a. Name: Patient A
b. Age: 39 years old
c. Sex: male
d. Birthdate: September 9, 1974
e. Address: Bagong Flores,Lupao Nueva Ecija
f. Marital Status: Married
g. Address: Sta. Rosa Nueva Ecija
h. Occupation: Housewife
i. Religion: Roman Catholic
j. Room/Ward: Female surgical Ward, Bed 1
k. Date and time of Admission: June 21, 2013/ 3:45pm
l. Admitting Diagnosis:
m. Final diagnosis: ascending colon adeno CA
n. Chief Complaint:
The patient is complaining of abdominal distention few days prior to consultation.

IV. History of Present Illness:
The patient complained of abdominal distention few days prior to consultation. The
condition started several weeks prior to admission as gradual abdominal distention. She had
undergone explore lap on July 2009.

V. Past Medical History:
Last July 17, 2009, the patient was admitted at Eduardo L. Joson Memorial Medical
Hospital due to a mass of the right lower quadrant of the abdomen. She was diagnosed of
having an ileocecal mass and an operation was done which is explore laparotomy right
hemicolectomy and total abdominal bilateral hysterosalphingo-ooperectomy last July 24,
2009(10am)
VI. Past Surgical History:
She had undergone explore laparotomy right hemocolectomy and total abdominal
bilateral hysterosalphingo-ooperectomy last July 24, 2009(10am)

III. Allergies/ Medications:
She has no allergies to any food and medication given to her upon hospitalization. The
following are the medications given to her during the course of treatment:
Metronidazole 500mg q8 IV
Metoclopramide 10mg/2ml TID
Omeprazole 20mg 1tab OD per orem


Cefuroxime 500mg 1tab TID per orem
Iberet Folic tab OD per orem
Ranitidine 50mg q8 IV
Ceftriaxone 1GM q8 IVP
Catapres 75mcg q8 w/n NPO SL
Ketorolac amp for pain IVP
Nubain amp every 6 hours PRN for severe pain IVP



IV. Smoking, Alcohol, Substance Abuse :
The patient is not a smoker and a drunker. She has never been engaged in taking any
abusive substance.

V. Social/ Work History:
She is a full housewife she only uses to work inside their house in doing their household
chores and in taking care of her children.

VI. Family History:
Upon taking the interview, she stated that her family has a history of hypertension only.

VII. Review Of System:




PATHOPHYSIOLOGY
Modifiable Non-modifiable
-High fat, low fiber -Age
-Gender


Ingestion of Food Presence of recurrent tumor
in ileocecal junction

Digested through mouth and stomach Immune response

Absorption of nutrients in WBC
small intestine


Intestinal obstruction

Accumulation of fluid, gas and stomach content

Inability to excrete waste products Unable to defecate for 18 days

Extreme vigorous increased pressure
peristaltic wave in the intestinal lumen

Reverse peristaltic
Movement in venous and arterial inability to absorb compression of
capillary pressure water by the large right ureter
Fecal excretion through NGT intestine middle 3rd
Impaired blood circulation
Dehydration Impaired filtration
-Edema of right kidney
-Congestion
-necrosis slight kidney
enlargement
Perforation
Peritonitis




VIII. Physical Examination
I. Vital Signs
Temperature
Pulse Rate
Respiratory Rate
Blood Pressure
Actual Findings
36.6 degrees Celsius
75 bpm
22 cbm
150/100 mmhg
II. Level of Consciousness Conscious and Coherent

III. BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS Scientific Explanation
A. GENERAL
APPEARANCE
With normal weight,
afebrile,
proportionality and
symmetry
The patients weight is
normal at her age
with proportional
body.
Normal
B. SKIN The color depends on
race, ethnic
background,
complexion, sun
exposure, and
pigmentation
tendencies.
Poor skin turgor Due to dehydration
C. HAIR Grows well, properly
tied, no hair loss, with
proper hair
distribution
With proper hair
distribution
Normal
D. NAILS Clean and pink in
appearance.
Clean and Pink in
appearance
Normal
E. SKULL AND
HEAD
Normal cephalic,
symmetrical facial
structure, absence of
tenderness over the
maxillary sinuses.
With symmetrical
facial structure.
Normal
F. EYES Normal vision of
20/20
With normal vision Normal
G. EARS Hears clearly
H. NOSE AND
SINUSES
Straight Nasal septum,
no discharge present,
airway is patent,
mucous membranes
are pink, no swelling.
No discharge present. Normal
I. MOUTH Lips are moist and
pink, no masses, gums
are pink and smooth,
The tongue is midline
and without any
hoarseness of voice.
Lips are dry Due to dehydration
J. NECK With normal range of
motion, can turn the
head against force of
the hand, no swelling.
Can turn head against
force of the hand and
no swelling noted.
Normal
K. THORAX AND There is no Normal Normal
LUNGS tenderness, chest
movement should be
symmetric and
without lag or
impairment. With
normal lung sounds
L. HEART No palpitations,
normal PR should be
60- 100 in adult
Without palpitations
and the PR is within
normal value
Normal
M. BREAST AND
AXILLA
Absence of pain,
lumps, discharge, or
any surgery.
No pain or any
discharge
Normal
N. UPPER
EXTREMETIES
Extremities should be
symmetrical and the
skin is warm without
any fracture.
Both upper
extremities are
symmetrical and
without fracture

Normal
O. LOWER
EXTREMRTIES
Hair covers the legs,
the venous pattern is
normally visible, both
legs are symmetrical
and without any
swelling.
Normal Normal
P. GROSS MOTOR
FUNCTIONS
Gross motor skills
involve the large
muscles of the body
that enable such
functions as sitting
upright, lifting, and
throwing a ball.
Normal Normal
Q. FINE MOTOR
TEST
Fine motor skills
involve the small
muscles of the body
that enable such
functions as writing,
grasping small objects,
and fastening
clothing.
Normal Normal
R. SENSORY
FUNCTION
With normal senses.
Can see clearly, can
hear accurately, no
altered taste, can
smell normally.
Can see clearly , hear
accurately, smell and
feel normally and
there is no altered
taste
Normal
S. ABDOMEN The contour of the
abdomen is usually
flat and rounded, the
skin surface is smooth,
and even with
homogenous color
and good skin turgor.
With distention Due to the presence of her
disease


XV. Laboratory/Diagnostic Tests:

Hematology Result NORMAL VALUES
6/22/13
Hemoglobin 122 M- 130-180g/L
F- 120-160g/L
Hematocrit 0.35 M- 0.40-0.54
F- 0.37-0.47
WBC 11.8 5-10x10
9
/L
Segmenters 0.53 0.45-0.65
Lymphocytes 0.47 0.20-0.35
Platelets 258
BT 2 mins,10 sec 2-5 minutes
CT 5mins,15 sec 5-15 minutes
7/6/13
Hemoglobin 122 M- 130-180g/L
F- 120-160g/L
Hematocrit 0.36 M- 0.40-0.54
F- 0.37-0.47
WBC 12.3 5-10x10
9
/L
Segmenters 0.49 0.45-0.65
Lymphocyte 0.51 0.20-0.35
7/5/13
ERC count 3.52 4.05-5.5 x 10 12/1
ERC hematocrit 0.30 0.37-0.47
Hemoglobin 97.0 120-150g/L
Leukocytes 6.29 5-10x10g/L
Segmenters 0.70 0.50-0.7
Eosinophils 0.02 0-0.05
Lymphocytes 0.21 0.10-0.40
Platelet count 280 150-450 x 10g/L

Interpretation: The WBC count of the patient is increased that may indicate infection.


Urinalysis Result NORMAL VALUES
Color Yellow Yellow
Specific Gravity 1.030 1.002-1.030
PH 5.0 5-7
Sugar Negative Negative
Epithelial Cells Moderate Moderate
Amorphous urates Moderate Moderate
WBC 3-4 0-2/HPF
RBC 1-2 0-2/HPF
Mucus Threads Moderate Moderate

Clinical Chemistry Result NORMAL VALUES
6/27/13
Sodium 137.7 137-145 mEq/L
Potassium 3.84 3.6-5.0 mEq/L
Chloride 101.9 98-110 mEq/L


Blood Screening
Type of Component Whole blood
Blood Serial # B-13-1080
Blood type A
Rh Postive
Collection Date 6-24-2013
Expiration Date 7-29-2013
Amount 500cc


Chest X-ray
Findings
Lungs are clear
Heart is not enlarged
Diaphragms are intact
Evaluation
Normal chest

June 23,2013 Abdominal ultrasound
Findings
The abdomen is globular and hazy
Distended bowels at the left upper abdomen with thickened
interserousal linings and air fluid levels
No significant gas in the colon and rectosigmoid
Evaluation
Consider intestinal obstruction
Plain abdominal ultrasound
Findings
The abdomen is globular and hazy.
Distended bowels at the upper abdomen, with air-fluid levels
No significant gas in the lower abdomen
No calcifications
Evaluation
Consider intestinal obstruction and ascites
May suggest ultrasound of the abdomen
June 28,2013 Abdominal Ultrasound
Findings
Distended loops of bowels at the left upper abdomen with thickened
interserousal linings, air-fluid levels and generalized haziness of the
abdomen. Minimal gas and feces in the colon.
Evaluation
Consider Partial intestinal obstruction. Consider also bowel wall edema
and or intraperitoneal fluid.

Plain abdomen Upright Supine (follow-up)
Findings
Distended bowels with air fluid levels at the upper abdomen.
The abdomen is globular and hazy with thickened interserousal linings
No calcification
No significant gas in the lower abdomen and rectosigmoid areas
Evaluation
Intestinal obstruction with bowel wall edema and/or intraperitoneal
fluid.
No significant change as compared to the previous x-rays dated 06-23-
2013




COURSE IN THE WARD

06/21/13 Please admit to Female surgical Ward
Secure consent for admission
TPR every shift and record
NPO
Dx: CBC,BT
CTBT
Urinalysis
FBS
IVF of D5LRS 1L for 8hrs
Metronidazole 500mg IV every 8 hours
Ranitidine 50mg IV every 8 hours
For plain abdomen supine upright requested
Intake and Output every shift and record
Refer accordingly
06/21/13 Please insert NGT
Maintain NPO
Ketorolac amp IVP every 8 hours
Dulcolax suppository: rectum STAT
IVF to follow
D5LRS for 8hours
D5NM for 8hours
D5LRS for 8hours
For plain abdominal ultrasound
6-26-13 Dulcolax suppository per rectum now- Dr. Galang
For plain abdomen supine upright requested
Maintain NPO and NGT
Reinsert NGT and connect to beds bottle
6-27-13 Ambulate
Serum electrolyte NaKCl
Sched for E/L tom 6-28-13 at 10pm
Notify OR and AOD
Secure consent please
Maintain NPO
IVF to follow D5NM for 8 hours
D5LRS for 8 hours
Refer
6-29-13 BP 150/100 compress 75mg
Please give ketorolac IVP
O2 at 2-3
The husband refused oxygen
7-1-13 Dx was explained the need to undergo surgical intervention but was informed by Dr.
Panella that surgery will be scheduled on thursday
7-3-13 Schedule for E/L tomorrow 7/4/13 at 10am
Secure consent please
Notify OR and AOD please
Maintain NPO
(+) abdominal pain
Give ketorolac amp IVP STAT then every 8 hours for pain
(+) vomiting
Metoclopramide(Plasil) amp STAT IVP then TID
7-5-13
8:40am
Fast drip 300cc of present IVF
For repeat CBC
7-5-13 Please transfuse 1 u of PNBC
Diphenhydramine 1amp to BT

7-10-13 Pull out FC,NGT
Maintain NPO
Same IVF cycle
Refer
7-12-13 Clean to general liquid diet
Lower the dosage of ranitidine
7-13-13 May have soft diet
On Monday for follow up check up with OPD
7-14-13 DAT in small amount
7-16-13 Total removal of sutures
Continue IVF
MGH tomorrow
Change dressing

PHARMACOLOGIC TREATMENT
Date Generic/ Trade
name
Dosage/
Frequency
/ Route
Classification Indication Contraindic
ation
Side
Effects
Nursing
Responsi
bility
7-14-
13
Omeprazole
(Mefracid)

20mg 1tab
OD PO
Belongs to the
class of proton
pump inhibitor
It is used in
the
treatment
of
Duodenal
ulcer,
Gastric
ulcer, reflux
oesophagiti
s,
Indigestion
It is
contraindic
ated in
persons
with
hypersensiti
vity to the
drug,
neonates
and during
lactation.
Possible
side
effects:
breathing
difficulty,
nausea,
fever,
weakness,
and
diarrhea.
Instruct
the
patient
to take
the
medicati
on using
the rights
of
medicati
on
and
stomach
discomfort
administr
ation
such as
right
time,
right
dose,
right
route.
6-21-
13
Metoclopramide 10mg/2ml
TID
It belongs to a
group of
medicines
called
dopaminergic
blockers.
Metoclopra
mide is
used short-
term to
treat
heartburn
caused by
gastroesop
hageal
reflux.
It is also
used to
treat slow
gastric
emptying in
people with
diabetes
(also called
diabetic
gastropares
is), which
can cause
nausea,
vomiting,
heartburn,
loss of
appetite,
and a
feeling of
fullness
after meals.
Metoclopra
mide is
contraindic
ated
in pheochro
mocytoma.
Patients
who
take antipsy
chotics are
recommend
ed not to
take
metoclopra
mide.

Possible
Side
effects:
drowsines
s,
excessive
tiredness,
weakness,
headache,
dizziness,
diarrhea,
nausea
and
vomiting.
akathisia,
and focal
dystonia
.
Instruct
the
patient
to take
the
medicati
on using
the rights
of
medicati
on
administr
ation
such as
right
time,
right
dose,
right
route.
7-14-
13
Cefuroxime

500mg 1tab
TID PO
Cefuroxime is a
semisynthetic
cephalosporin
antibiotic(2
nd

generation),
chemically
similar to
penicillin

For
respiratory
tract
infections,
meningitis,
gonorrhea,
surgical
prophylaxis
and for
susceptible
infections
Hypersensit
ivity to
cephalospor
ins.

Possible
side
effects:
Large
doses can
cause
cerebral
irritation
and
convulsio
ns;
Instruct
the
patient
to take
the
medicati
on using
the rights
of
medicati
on
nausea,
vomiting,
diarrhea,
GI
disturbanc
es;
erythema
multiform
e,
epidermal
necrolysis.
administr
ation
such as
right
time,
right
dose,
right
route.
Iberet Folic

tab OD OP

iron and
multivitamins;
belongs to the
class of iron in
other
combinations.

Prevention
&
treatment
of Fe-
deficiency
anemia &
prevention
of folate
deficiency.
Thalassemia
,
sideroblasti
c anemia,
hemochrom
atosis
&hemoside
rosis
Possible
side
effects:
GI effects,
hyperbilir
ubinemia,
acneform
vulgarisde
terioratio
n or
acneform
exanthem
a
eruption,
bright
yellow
urine
discolorati
on,
flushing, d
izziness
or faintne
ss,
peripheral
sensory
neuropath
ies,
stone for
mation,
crystalluri
a
& oxalosis
, black
discolorati
on of
stool
Instruct
the
patient
to take
the
medicati
on using
the rights
of
medicati
on
administr
ation
such as
right
time,
right
dose,
right
route.
06-20-
13
Metronidazole

500mg q8
IV
Antiprotozoal
agent-
Nitroimidazole
group.

Metronidaz
ole is given
for
treatment
of
Metronidaz
ole is
contraindic
ated in
blood
Possible
side
effects:
nausea,
diarrhea,
Instruct
the
patient
to take
the
protozoal
infections
like
amoebiasis,
giardiasis
and
trichomona
s vaginitis.
It is also
used in the
treatment
of
anaerobic
infection,
ulcerative
gingivitis,
trench
mouth,
guinea
worm
infestation.
dyscrasias,
hypersensiti
vity, certain
serious
neurological
diseases,
alcohol,
severe
hepatic
failure,
pregnancy
especially
during the
first
trimester
and
lactation.
and/or
metallic
taste in
the
mouth.
Intraveno
us
administr
ation is
commonly
associated
with
thrombop
hlebitis.
Infrequen
t adverse
effects
include:
hypersens
itivity
reactions
(rash, itch,
flushing,
fever),
headache,
dizziness,
vomiting,
glossitis,
stomatitis,
dark
urine,
and/or
paraesthe
sia.
medicati
on using
the rights
of
medicati
on
administr
ation
such as
right
time,
right
dose,
right
route.
6-21-
13
Ranitidine

50mg q8
IV
It belongs to a
class of drugs
called H2
(histamine-2)
blockers

Ranitidine
tablets are
indicated
for the
treatment
of
duodenal
ulcers and
benign
gastric
ulcers,
including
that
associated
with non-
steroidal
anti-
inflammato
Ranitidine
tablets are
contraindic
ated in
patients
known to
have
hypersensiti
vity to the
drug
Possible
side
effects:
Headache
s,
tiredness,
dizziness
and mild
gastrointe
stinal
disturbanc
e (e.g.
diarrhoea,
constipati
on and
nausea)
are
among
Instruct
the
patient
to take
the
medicati
on using
the rights
of
medicati
on
administr
ation
such as
right
time,
right
dose,
ry agents..
This
medication
is also used
to treat
certain
stomach
and throat
problems
caused by
too much
acid
the most
frequent
complaint
s
right
route.
7-4-13 Ceftriaxone 1GM/IVP
STAT then
every 8
hours IVP

Third-
generation
cephalosporin
Therapeutic
class: Anti-
infective
Bacteremia,
Benign
gastric,
duodenal
or NSAID-
associated
ulceration,
Bone and
joint
infection,
Enteric
fever,
Gonococcal
infections,
Lower
respiratory
tract
infections,
Meningitis,
Pneumonia,
Pophylaxis
of cardiac
transplant
rejection,
Pophylaxis
of hepatic
transplant
rejection, ,
Skin
infections,
Soft tissue
infections,
Surgical
prophylaxis
,
Documente
d
hypersensiti
vity;
hyperbilirub
inemic
neonates,
particularly
those who
are
premature;
neonates
28 d if they
receive
calcium-
containing
IV products
Possible
side
effects:
nausea,
vomiting,
upset
stomach,
headache,
dizziness,
overactive
reflexes,
pain or
swelling in
your
tongue,
sweating
or
vaginal
itching or
discharge

Instruct
the
patient
to take
the
medicati
on using
the rights
of
medicati
on
administr
ation
such as
right
time,
right
dose,
right
route.
6-29-
13
Catapres

75mcg q8
w/n NPO
SL
Belongs to the
class of
imidazoline
receptor
agonists
indicated in
the
treatment
of
hypertensio
Catapres
(clonidine)
tablets
should not
be used in
Possible
side
effects:
drowsines
s,
Instruct
the
patient
to take
the
n. Catapres
(clonidine)
tablets may
be
employed
alone or
concomitan
tly with
other
antihyperte
nsive
agents.
patients
with known
hypersensiti
vity to
clonidine
dizziness,
feeling
tired or
irritable,
cold
symptoms
such as
runny or
stuffy
nose,
sneezing,
cough,
sore
throat,
sleep
problems
(insomnia)
,
nightmare
,
headache,
ear pain,
mild
fever,
feeling
hot

medicati
on using
the rights
of
medicati
on
administr
ation
such as
right
time,
right
dose,
right
route.
6-22-
13
Ketorolac amp q8
IV
Ketorolac is a
member of a
class of drugs
called
nonsteroidal
antiinflammato
ry drugs
(NSAIDs) that is
used for
treating
inflammation
and pain
Short-term
manageme
nt of
moderately
severe,
acute pain
requiring
opioid-level
analgesia.
Aspirin
allergy.
Peptic
ulcer. GI
bleed or
perforation.
As
prophylacti
c analgesic
before any
major
surgery.
Treatment
of peri-op
pain in
CABG
setting.
Advanced
renal
impairment
Hypovolemi
a.
Cerebrovas
cular
bleeding.
Possible
side
effects:
mild
heartburn
,stomach
pain,
bloating,
gas,dizzin
ess,
headache,
drowsines
s,
sweating,r
inging in
your ears,
swelling
or rapid
weight
gain,
fever,
sore
throat,
and
headache
Instruct
the
patient
to take
the
medicati
on using
the rights
of
medicati
on
administr
ation
such as
right
time,
right
dose,
right
route.
Hemorrhagi
c diathesis.
Incomplete
hemostasis.
Bleeding
disorders or
high risk of
bleeding.
Concomitan
t
probenecid,
salicylates,
pentoxifylli
ne, other
NSAIDs.
Epidural or
intrathecal
inj. Labor &
delivery.

Nubain amp for
severe pain

Opioid agonist-
antagonist
Therapeutic
class:
Analgesic,
adjunct to
anesthesia

Nubain is
indicated
for the
relief of
moderate
to severe
pain.
Nubain can
also be
used as a
supplement
to balanced
anesthesia,
for
preoperativ
e and
postoperati
ve
analgesia,
and for
obstetrical
analgesia
during
labor and
delivery.
Nubain
should not
be
administere
d to
patients
who are
hypersensiti
ve to
nalbuphine
hydrochlori
de, or to
any of the
other
ingredients
in Nubain.
Possible
side
effects:
feeling
nervous
or
restless,
depressio
n, strange
dreams,
bitter
taste in
your
mouth,
skin
itching or
burning,
mild rash,
blurred
vision,
slurred
speech, or
flushing
(warmth,
redness,
or tingly
feeling).
Instruct
the
patient
to take
the
medicati
on using
the rights
of
medicati
on
administr
ation
such as
right
time,
right
dose,
right
route.




XVII. Nursing Care Plan



Assessment Nsg. Dx Planning Intervention Rationale Evaluation
Subjective:

As verbalized
by the patient


Objective:
Poor skin
turgor
Dry skin
Dry lips

Deficient fluid
volume related
to impaired
water
absorption as
manifested by
poor skin
turgor
After 8 hours
of nursing
intervention
the patient will
show
improvement
on the
objective
assessment
Independent:
Monitor
vital signs

Assess color
and amount
of urine

Monitor
temperatur
e


Collaborative:
Administer
parenteral
fluids as
ordered by
the
physician
Fast drip of
IVF as
ordered by
the
physician

To evaluate
patients
current status










To aid in
dehydration




To aid in
dehydration


After 8 hours
of nursing
interventions,
the patient
was able to
meet the goal
as evidence of
improved
objective cues




Assessment Nsg. Dx Planning Intervention Rationale Evaluation
Subjective:
sumasakit
ang tiyan ko
As verbalized
by the patient


Pain scale
5/10
As 0 is the
lowest and 10
is the highest
With the pain
characteristics
of moderate
pain

Acute pain
related to post
surgical
procedure as
manifested by
facial grimace
and verbal
report of acute
pain
After 8 hours
of nursing
intervention
the patient will
manifest a
decrease in the
pain scale of
5/10 to a
manageable
level of 0/10
Independent:
Assess
clients pain
scale and
perception


Encourage
verbal
report
during and
after the
nursing
intervention

Monitor
vital signs

To identify the
intensity,
onset,
duration, and
quality of pain

Pain is highly
subjective and
to identify the
effectiveness
of the
intervention


Obtain vital
signs, v/s

After 8 hours
of nursing
interventions,
goals are met
as evident of
the clients
decreased in
pain scale from
5/10 to 0/10

Objective:
With facial
grimace
Verbal
report of
acute pain
and pain
scale





Teach client
divertional
activities


Advice
breathing
exercise




Collaborative:
Administer
medicine as
ordered by
the
physician
changes during
onset of pain,
for future
comparison of
the
interventions

To divert
clients
attention from
pain

To allow
proper O2
supply on the
body. Clients
tend to stop
breathing
during pain

Relieve clients
pain using
pharmacologic
intervention


Assessment Nsg. Dx Planning Intervention Rationale Evaluation
Subjective:
Kaoopera
lang sakin
As verbalized
by the patient


Objective:
Temp -36.3
c
Weak in
appearance
Clean and
intact
abdominal
dressing
Risk for
infection
related to post
operative
incision
After 8 hours
of nursing
intervention
the patient will
be able to
identify the
risk factors
that are
present and be
free from any
signs and
symptoms of
infection
Independent:
Assess signs
and
symptoms
of infection
especially
temperatur
e
Emphasize
the
importance
of
handwashin
g technique

Maintain
aseptic
technique
when
changing
dressing/car
ing wound

Fever may
indicate
infection




It serves as
first line
defense
against
infection


Regular wound
dressing
promotes fast
healing and
drying of
wound


After 8 hours
of nursing
interventions,
the patient
was able to
meet the goal
as evidence of
able to identify
the risk factors
that are
present and
with the
absence of the
signs and
symptoms
related to
infection

Keep area
around the
wound
clean and
dry

Collaborative:
Administer
antibiotics
as ordered
by the
physician

Wet area can
be an area for
bacteria




Antibiotics will
help kill and
stop the
growth of the
bacteria which
can cause
infection


XVIII. Discharge Planning
Medication:
The take home meds are as follows:
Iberet Folic tab OD per orem
Abound sachet + 100cc cold water 2times for 2 weeks
Instruct the patient to take the medication using the rights of medication
administration such as the right time, right dose, right route.
Exercise:
Have an adequate rest.
Avoid having strenuous activities.
Ambulate to improve blood flow and speeds wound healing and it can lead to a quicker
return of bowel function
Treatment:
Emphasize adequate rest and sleep pattern.
Teach her how and when to take her prescribed medications.
Emphasize the importance of frequent hand washing
Emphasize the importance of hygiene.
Emphasize the importance of wound care

Out- Patient:
Have a follow up check- up as scheduled on Monday after discharge.

Diet:
Instructed to eat foods that are high in fiber and low in fat.
Instructed to eat foods that are rich in proteins.
Instructed to eat foods that are rich in vitamin C