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BACKGROUND ....................................................................................................................... 5
GENERAL OBJECTIVES ............................................................................................................ 6
SPECIFIC OBJECTIVES ......................................................................................................................6

PATIENTS PROFILE ................................................................................................................ 7

CHIEF COMPLAIN: .................................................................................................................. 8
HISTORY TAKING ................................................................................................................... 9
HISTORY OF PRESENT ILLNESS: .......................................................................................................9
PAST HEALTH HISTORY: ................................................................................................................ 10
FAMILY TREE ................................................................................................................................ 11
PERSONAL HEALTH HISTORY: ....................................................................................................... 12
ENVIRONMENTAL HISTORY .......................................................................................................... 13

PHYSICAL ASSESSMENT........................................................................................................ 14
DEVELOPMENTAL TASK OF ADOLESCENT ............................................................................. 19
DISEASE PROCESS ................................................................................................................ 23
ANATOMY AND PHYSIOLOGY (DIGESTIVE SYSTEM) ....................................................................... 23
DIGESTIVE ORGANS...................................................................................................................... 24
ACCESSORY GLANDS/ ORGANS ..................................................................................................... 27
ANATOMY AND PHYSIOLOGY (Peritoneal Anatomy) ..................................................................... 27
TYPES OF PERITONEUM................................................................................................................ 28
ABDOMINAL TUBERCULOSIS WITH PERFORATION PERITONITIS .................................................... 29
PERFORATION PERITONITIS ...............................................................................................................................29
ABDOMINAL TUBERCULOSIS ..............................................................................................................................30

PATHOPHYISIOLOGY .................................................................................................................... 32
SIGN AND SYMPTOMS ................................................................................................................. 35
DIAGNOSIS AND INVETIGATIONS .................................................................................................. 37
LABORATORY EXAMS .........................................................................................................................................41

TREATMENT................................................................................................................................. 44
(MEDICAL MANAGEMENT) ................................................................................................................................44
SURGICAL MANAGEMENT ..................................................................................................................................45
MANAGEMENT AFTER PERIOTISNIS: ..................................................................................................................45
OPERATIVE PROCEDURE NOTE ..........................................................................................................................46

HISTOPATHOLOGICAL EXAMINATION REPORT: .................................................................................................47

FECAL DIVERSION PROCEDURE .........................................................................................................................47

NURSING MANAGEMENT: ............................................................................................................ 48

APPLICATION OF NURSING THEORY ..................................................................................... 48

NURSING PROCESS: ...................................................................................................................... 51
Nursing Care Plan......................................................................................................................... 53

DRUG STUDY ....................................................................................................................... 67

DAILY PROGRESS NOTE: ....................................................................................................... 88
DIVERSIONAL THERAPY USED IN MY PATIENT TO MINIMIZE STRESS: .................................... 91
DISCHARGE TEACHING: ........................................................................................................ 93
WHAT I LEARNED FROM MY CASE STUDY: ............................................................................ 95
SUMMARY OF MY CASE STUDY ............................................................................................ 96
CONCLUSION ....................................................................................................................... 97
BIBLIOGRAPHY .................................................................................................................... 98

This Nursing concept hospital based case report on Abdominal tuberculosis with Perforation
Peritonitis" has been completed within 8 weeks period in Bir Hospital, Mahaboudha in Male
Surgical Ward. This is a great opportunity for me to perform a case study in National Academy
Of Medical Sciences, Bir Hospital through which I was able to gain a lot of knowledge as well as
skills of nursing care. I would like to express my sincere thanks and appreciation to all those
people whose voluntary efforts helped me complete this case study.
I would like to thank my respected teachers, Madam Pramila Shakya, Coordinator Madam
Jayalaxmi Shakya, Madam Bandana Thapa, Madam Nibaran Joshi and other associated teachers
for their continuous supervision, direction, guidance, support and encouragement throughout the
case study period.
I would like to express my gratitude to the director, matron and ward in-charge of Bir hospital
for granting me permission to conduct case study. I am also grateful to all the staffs and doctors
concerned to the care of my patients for their help and kind cooperation, without whom, this case
study would not have been completed.
My sincere thanks go to my colleagues, seniors and juniors for their valuable suggestions and
help and to the library staffs of NAMS, BHNC for providing me necessary books and materials
as well as staffs of Central Library Bir Hospital for providing me valuable time and books.

Finally, I express my genuine gratitude to the patient Mr. Yubraj Patamagar and his family for
providing me valuable information, time and cooperation that helped me to successfully study
the case, thus providing me a better insight on Abdominal Tuberculosis.

Throughout the world tuberculosis is associated with poverty, deprivation, and human
immunodeficiency virus infection. Abdominal tuberculosis is usually of insidious onset with
diverse symptoms and signs. A few present with acute complications of perforation, obstruction,
or bleeding. The diagnosis is difficult, especially in areas where the disease is less common, as
many patients do not have evidence of pulmonary tuberculosis or a positive skin test. However,
in developing countries like Nepal where Tuberculosis is still prevalent ,the diagnosis of
abdominal tuberculosis or even its complication like perforations is not that tricky.
Peritoneum is one of the most common extra-pulmonary sites of tuberculoses infection and due
to perforation of bowel in the people having intestinal tuberculosis, peritoneum is infected
without doubt. The diagnosis of this disease, however, remains a challenge because of its
insidious nature, the variability of its presentation and the limitations of available diagnostic
tests. A high index of suspicion is needed whenever confronted with unexplained ascites,
particularly in high-risk patients.
Laparoscopy combined with peritoneal biopsy is effective for the diagnosis of tuberculous
causing perforation peritonitis in 75 to 85% of cases. Peritoneal tuberculosis is treated with
antituberculous drugs for a period of eight to nine months or according to the case.
In my case study, the above proclamation still remaining true, one more aspect can be added to
the cause where complication of pulmonary tuberculosis spreading in other areas (eg intestine)
has remained undetected until complications (perforation peritonitis )occurred , and this may not
be solely due to poverty or lack of diagnostic facilities but partly due to modernization in sociocultural side as well. This is further illustrated in my study here.

To provide holistic care to patient through nursing process using proper nursing theories and
practices considering the socio cultural background and traditional philosophy of the patient with
the help of basic science and fundamental nursing knowledge.

1. To gain specific knowledge about specific disease.
2. To identify the cause, pathophysiology, clinical features and diagnostic evaluation of
abdominal tuberculosis and perforation peritonitis.
3. To prevent patient from complication of the disease.
4. To gain new facts and ideas about the disease.
5. To gain better and clearer understanding on the nature, course, physical and emotional
changes and signs and symptoms related to abdominal tuberculosis.
6. To establish rapport and gain the trust and co-operation of the patient and immediate
family members.
7. To gather factual health assessment of the patient and perform proper assessment of the
8. To disseminate information to the patient as well as her relative about the illness and
ways of caring the patient.
9. To evaluate daily progress of patient health and effectiveness of treatment.
10. To minimize the stress of the patient and her family by providing adequate information
and using appropriate diversional therapy.
11. To be able to formulate related nursing diagnosis from the patients health data and to the
current problems the patient experiences and to come out with different nursing
interventions effective for the patient to improve and progress on the most possible time.
12. To encourage patient and his family members to be involved in discharge planning and
follow up visits.

Biographic data:
Name of the patient:

Yub Raj Patamagar

Age /sex:

17 years/ male


Ason, Kathmandu , Nepal

Marital status:


Date of birth:






Educational status:


Hospital data:

Bir Hospital

Date of admission:


In Patient no:



Male Surgical Ward

Bed no:



Surgery Unit III ( Dr. Yawan Chandra Shivakoti)

Provisional Diagnosis:

Kochs abdomen with obstruction

Final Diagnosis:

Abdominal tuberculosis with Perforation peritonitis

Date of surgery:



Exploratory Laparotomy with anstomosis with proximal

Ileostomy done for multiple perforation viscera.

(On admission, 2070/02/25)

Distention of abdomen x 3 days

Pain abdomen x 3 days
No passage of stool x 3 days
Vomiting x 3 days
Poor scanty micturation


Underweight = <18.5
Normal weight = 18.5 24.9
Overweight = 25 29.9
Obesity = BMI of 30 or greater

Patients value:
Weight: 32 kg.
Height: 5 ft. 1inch
Formula: BMI=

mass (lb.) x 703___

[height (inches)] squared

703 = (constant value in BMI)
32 kg. = (2.20 lb/ 1 kg) =70.4lb.
5 ft. = (12 inches/ 1 ft.) =60 inches + 1 inch = 61 inches
BM I= ___70.4 lb. x 703__ = 49491.2 lb. = 13.30
BMI= 13.3 Patient is Underweight

Patient had been experiencing low grade fever and cough on and off since one month (since
Baisakh, 2070). He had weakness and had episodes of blood in stool occasionally. He took some
Ayurved medication (powder form, no name identified) which made him feel better. He also
took some medications and antibiotics for fever from nearby medical clinic. He had also been
losing weight (approximately 42 kgs before 2 mths of admission, and 32 kgs 1 week after
On 2070/02/19 he was taken to Samudayik Sahari Swastha Clinic,in Jyatha Kathmandu by her
aunt, as no progress was seen in his health and he seemed more deteriorating. The clinician
suggested that it might be Tuberculosis and advised Laboratory tests like Sputum for AFB, stool
R/E, and also widal test. Since Tuberculosis was suggested, the family took him to Sukraraj
Tropical & Infectious Disease Hospital Teku where the Sputum AFB was done and ATT was
started (2070/02/24).
On 2070/02/25 patient came in emergency ward with distention of whole abdomen, severe
abdomen pain increasing on movement and difficulty to swallow food or medications.
In emergency, His GCS was 15/15.
His vital signs were:
Temperature: 980 F
Respiration: 24/ min

Pulse: 70 bpm
Blood Pressure: 110/70 mm of Hg

On Examination:

Distention of whole abdomen.

Bowel sound absent
Umbilicus central, hernia orifices intact
Board rigidity (+)
Normal anal tone, empty anal canal

ER diagnosis: ? Kochs abdomen with obstruction

After investigations: Perfotaion Peritonitis/ PTB
Investigations: CBC,LFT,PT, INR, Blood grouping, Blood sugar, Urea , Cretenine, Na, K,
Serum amaylase, Urine R/E , HIV I and II, HBsAG, HCV, X-ray abdomen (erect and
supine),USG abdomen and pelvis were done.
Emergency Exploratory Laparotomy surgery was performed and later admitted to Male
Surgical Ward, Bed number 91.


Childhood Illness:
Patient was weak health wise since childhood. He used to have diarrhea and indigestion
problems on and off several times in a year. According to his fathers information, he was
born at home and it was normal delivery without any complication. His mother died
when he was 8 years old who was diagnosed of PTB (refused treatment).
He did not have any major disease but he is wearing glasses for shortsightedness since

Childhood immunization:
Patients father claims that he has his son immunized completely according to EPI
schedule. Patient confirms that he also had three doses of Hepatitis B vaccine taken at

History of hospitalization or surgery:

No history of hospitalization or any kind of surgery.

Accidents and injuries:

He was involved in an incident when he was hit hard on head with a football when he
was 14 years old. He used to work part time as a ball boy in football games in Dasrath
Rangashala. He was unconscious for a moment and regained consciousness but dint seeks
any medical treatment.

Patient used over the counter drugs for headache, fever and cough occasionally.

Family history:
Patient is the second child and has a brother 2 years older than him. He lives with his
father who is good in health but has hypotension ( checks Blood pressure in nearby clinic
sometimes) maintained by diet. His mother died when he was 8 years old who had
Pulmonary Tuberculosis. She was being treated in Bir hospital but she refused treatment
several times and used to discontinue medications or hospital visits.





1st sibling






He in non- alcoholic, non- smoker, no drug user.
He is non- vegetarian. He describes that his diet pattern is not as normal. He drinks a
glass of milk or tea every morning with biscuits or puff pastry. Then he eats rice and
curry around 2 or 3pm in the afternoon. Most of the time he eats noodles or some light
snacks for dinner and takes rice hardly ever.
On Saturdays, he eats restaurant foods/ fast foods like pizza, momo, and carbonated
drink*----s with friends and doesnot eat at home. Since a month or two, he has been
eating lesser, and has stopped eating out with friends even on staurdays.
Sleep and rest pattern:
Before hospitalization, he usually slept between 10:30 to 11 pm and woke up around 7 to
8 am. However, since hospitalization he claims that his sleep has been disturbed as he has
leaking ileostomy bags sometimes and also gets disturbed in a hospital environment. He
is unable to take nap during day time.
Elimination pattern:
Before hospitalization he used to urinate 7-8 times a day and had a bowel movement
every day. He frequently had diarrhea so some days he used to pass stool 4-5 times a day.
Few episodes of blood in stool were seen one month back. He also had scanty urine 3-4
days prior to admission.
During hospital--ization he had difficulty passing urine on the day when Foleys catheter
was removed, but later urinated normally.
Activities with daily living:
He did not have problems in daily activities like bathing, eating, dressing or locomotion
but he experienced some weakness and left his part time job after 1 year of working as a
ball boy.
However, he is now dependent for his daily activities as he cannot walk or sit for a long
time due to weakness post surgery.
Recreational activities and hobbies:
He loves video games and has craze over online gaming. He participates in online
tournaments and spends hours in cyber house with his friends. He agrees that he saves his
pocket money given for lunch and spends it playing video games /computer games
instead. Sometimes he loses track of time and ignores lunch or breakfast.

Social data
Family relationship/ friendship:
In regards to his family relationship, he has strong family ties. He is loved by his father
and supported greatly by his elder brother. He has also very close relationship with his
paternal relations i.e. his aunts, uncles. He shares friends with his brother and has a close
relationship with them too.
Ethnic affiliation:
Although he is open minded, he respects his values and cultures. He is Hindu by religion
and visits temple occasionally.
Educational history:
He is an average student and took morning classes in school. He attended SLC but could
not pass all the subjects.
Economic history:
His family is able to afford the necessities of household and has been able to support his
studies till date.

According to the patient, he lives in a rented house. There are two rooms and a flower
shop in next house. His father, brother and himself share a single room as their bedroom
and kitchen. They use the other room as storage of flower shop.
The toilet is water sealed type. But they have scarcity of water so they buy water jars for
drinking water and use Boring-underground water for washing and cleaning purposes.

Patterns of health care

According to patient and his family the first choice for their health problems is modern
medicine. They visit nearby clinic or seek doctors help in need. However, they also take
medicines from Ayurveda sometimes.

Date of assessment: 2070/03/04 (Tuesday)
Assessed lying in the bed (in supine position).
Temperature: 980F

Pulse: 84/ min

Respiration: 26/min

Blood Pressure: 100/70 mm of Hg

General Condition: Patient was weak and tired in appearance.
Gait: unstable, could not support own body on standing or sitting position
Nutritional Status: Very thin body structure, looked mal nourished.
Hygiene: skin surface seemed unclean. But clean clothes.
Speech and behavior: Clear and understandable speech. Gives appropriate reaction to the

Fair complexion without cyanosis, uniform distribution of colour.

1st degree bedsore noted on sacral region.
No rashes or skin abrasions around Ileostomy region (Ileostomy post surgery)

Warm and soft skin with even temperature all over her body.
No sign of edema or dehydration on examination.
Good skin turgor.




Even distribution of hair over the scalp.

No dandruff or lice present.
Symmetric facial features.

No swelling, lump or injury over scalp or forehead.

No tenderness over the sinuses.

No any palpable lymph nodes present over the body nderness over the sinuses.

Both eyes were symmetrical in shape, size and location with equal movements.
No bulging of eyes.
No redness or discharge from the eyes.
Patient has shortsightedness and wears glasses.(power: -2), discontinues during
Eye Brows: symmetrical, well distributed. No eye brows fall.
Eye Lids: No redness, edema, lesion or dropping.
Eye Lashes: outward and upward curled.
Conjunctiva: transparent
Pupil: Bi lateral equal (approx 2mm) and responsive to light.
Lens: transparent
Sclera: No any signs of anemia or jaundice.



Normal shape, size and symmetry.

Top of pinna meets eyes at the line of outer canthus of the eyes.
No lump, lesion or discharge.
No redness, mass or foreign body present on the external auditory canal.


No any tenderness or swelling present on the mastoid bone.

Hearing activity: normal and can hear the sound of normal conversation.


Medially located. Nostrils uniform in size& do not flare on respiration. Nasal septum is
not deviated.
No lesion, redness, tenderness or blockage of nasal pathways.
Intact smelling sense.


Lips: Looks dry. No cracks or angular stomatitis.

Gums: pink without bleeding or swelling.
Teeth: 28 teeth are present in total number. No dental caries.
Tongue: positioned centrally, free movement. Moist, no tongue tie present. Can identify
the sense of taste. No signs of injury. But slight dryness of tongue.
Palate and uvula: dry and pink. No any signs of injury in palate and uvula located in
midline of the throat.
Throat: tonsils are not inflamed. Positive gag reflex upon touching the posterior part of
the tongue with the use of tongue depressor.


Neck muscles are equal with the head positioned at the centre
Able to flex, extend and hyperextend his head when asked to do so.


No visible or palpable thyroid, salivary glands and lymph nodes.


Trachea and sternum are vertically aligned.

Equal expansion of chest bilaterally during inspiration and expiration.
Diameters of chest not measured but none deformity of chest was visible.
No respiratory distress observed.


No tenderness, lumps or depression present along the ribs.


Resonant sound heard over the lungs.

Dull sound over the heart.


Clear breathe sounds present over all areas of lungs with no added breathe sounds
(wheezes, crepitation, rhonchus).
Bronchial breathe sounds over trachea heard where inspiration was shorter than
Broncho vesicular breathe sounds lateral to the trachea heard where inspiration and
expiration both are equal.
Vesicular sound was present over peripheral areas of the lungs over entire lungs field
where expiration was shorter than inspiration.


Palms of hands appear pink.


Capillary refill time is less than 2 sec.

Peripheral pulses (brachial, radial, femoral, posterior tibial and dorsalis pedis) were


Regular heart beat with rate of 86/min.

S1S2 (lub/ dup) present with no other added sounds or heart murmer.
Apex beat heart on fifth intercostals space mid clavicular line.
Apex beat is symmetrical with other peripheral pulses i.e. 86 per minute


Cylindrical in shape.
Vertical incision sutured post Laparotomy. No soakage and sign of infection over
the wound surface. Dressing has been applied and changed daily.

Inspection /subjective data:

Is on normal diet but eats soft food in very little amount3/4 times a day.
Diarrhea on ileostomy.
Nausea, vomiting, heart burn was absent.

Gurgling peristalsis movement audible on all the four quadrants. 10 per minute.

Pain on touch due to surgical wound.

Abdomen soft and tender.
Liver: no tenderness or palpable per abdomen.
Spleen: no tenderness or palpable per abdomen.


Not perfomed due to surgical wound and ileostomy presence.


History of painful micturation but at present normal urination.

Costo-vertebral tenderness absent.
Clear urine drains more than 2500 ml per day (self voiding)


No any deformity on the back is seen (Kyphosis, scoliosis or lordosis).

1st degree bedsore on sacral region.


Bilateral equal expansion of back during respiration.

No tenderness.


Resonance sound present over the back.


Breath sounds are heard in all areas of the lungs.

Inspiration longer than aspiration.


Both upper and lower extremities are of equal size, shape and symmetrical
without any deformity.
No redness, swelling or any tenderness.
Difficulty to Full range of motion of left extremities due to weakness and pain.
Capillary refill: less than 2 sec
Color of nail bed: pink
Peripheral pulses: present
Normal temperature of extremities on palpation.
No bone or joint deformity


GCS 15/15
Level of consciousness: conscious and oriented to time, place and person
Equal strength & co-ordination on right and left sides of extremities.
Sensory and motor functions are intact.
Bicep and triceps, brachioradialis, abdominal reflex, knee-jerk, Achilles and
plantar reflexes are present.
Patient shows normal response to stimuli.


(13-20 YEARS OF AGE)

Developmental Tasks:
Developmental tasks is defined as the task which arises at certain periods during the life span of
an individual, the successful accomplishment of which leads to satisfaction and success with
later life while the failure leads to dissatisfaction and difficulty with later life.
Growth and development during adolescent period.

Biologic growth

Physical growth:
During adolescent a tremendous increase in physical size occurs in short period.
Growth spurs begins early in girls than in boys
Start from 10-14 years in girls, in boys starts from 12-16 years.
Growth in height stops around 16-17 years on girls (epiphyseal closure)
Growth in height stops around 21-25 years in boys.
Increased shoulder width in boys and broader hip development in girls.
The muscle growth both in quantity and quality are greater in boys than in girls.
Oestrogen brings soft skin, increase vascularity in girls.
Androgenic hormone produce increased thickening and darkening of skin, increased
active sebaceous and sweat glands (apocrine gland)
Effect of gonadal hormone makes hair coarse and dark.

Physiologic changes:

Size of the heart, blood volume and BP increases to supply blood to increase body size.
Boys have higher blood volume that girls due to more muscle mass.
Pulse rate, respiration rate decreases, but BMR increases similar like adult.

Hormonal changes:

Pubertal events are caused by hormonal influences and controlled by anterior pituitary
It causes stimulation of the gonads which has dual function:
Production and release of gametes (sperms in the male and ova on the female)
Secretion of the sex appropriate hormone.
In female: estrogen and progesterone (ovaries)
In male: testosterone (testes)

Sexual maturation:

Includes primary sex characteristics.

Related to development of external and internal organs that carry out reproductive
Voice alteration, development of facial and pubertal hair, fat deposition.

Sequence of maturation in boys:

The first pubescent changes in boys are testicular enlargement with thinning, reddening
and increased looseness of the scrotum during 9.5- 14 years.
Growth of pubic hair, auxiliary hair, facial hair after 2 years of pubic hair.
Rapid increase in health.

Muscular development, changes in larynx and voice along with grown of penis.
Nocturnal emission: the beginning of nocturnal emission seminal fluid at periodical
interval is the signal to reveal the onset of spermatogenesis.
Abrupt declaration of linear growth.

Puberty delay in boys considered when there is no enlargement of the testes or scrotal changes
by 13.5- 14 years of age or genital growth is not complete 4 years after the testicle to begin
Boys reaction to puberty
Increase in height and weight is usually a welcome event to adolescent boys who had been
embarrassed for several months due to lag in their physical growth in comparison to their girl
mates. The development of secondary sex characteristic especially the growth of facial and body
hair has psychological and social meaning of masculine sex role. The enlargement of
reproductive organs in boys may produce embarrassment

Psychological Development

According to Erickson , the psychological crisis that adolescents face between age 13 and
18 is identity versus role confusion
See themselves as distinct individuals unique and separate from other individual.
Adolescents strains to attain autonomy from the family and develop a sense of personal
identity as opposed to role diffusion.
Sense of group identity appears to be essential to the development of a sense of personal
They achieve a sense of group identity and individual identity.

Emotional development

Uncertain in their emotional state between childlike behavior and considerable maturity.
Unpredictable mood swings.

Better control their emotions in later adolescence.

Social development

They have feeling of immortality and exemption from the consequence of risk behavior,
which can be an important developmental function toward independence although viewed
as negative.
Acceptance by peers, close friends and secure love of family are essential for inter
personal maturation.
They resist parental control. And frequent conflicts can occur.

Peers become important source of advice and support and also provide them strength
power and belongingness.
They spend their leisure time in group, music, movies and other fun.

Development tasks during adolescence.

The task is to achieve some degree of intimacy, as opposed to remaining in isolation. Intimacy is
the ability to be close to others, as a lover, a friend and as a participant in society. It includes not
only the love between two lover/ husband and wife, the love between friends/ co-workers and the
love of ones neighbor as well.

Developing more mature relations with the same sex age mates and learning new
relationship with members of the opposite sex.
Accepting the changing body size, shape and function and understanding the
Achieving a satisfying and socially acceptable feminine or masculine role.
Achieving emotional independence from parents and other adults.
Preparing for economic career to be economically independent.
Acquiring a set of values and ethical system as a guide to his/her ideology and behavior.
Achieving socially responsible behavior.
Developing the intellectual and work skills and social sensitivities of competent citizens.
Preparing for marriage and family life.

Developmental tasks in relation to my patients:

Yubraj Patamagar seems to have achieved social maturity, he has moved from the
parental environment to outside peer group environment.
He spends most of the time with the same sex age mates.
He has also tried to achieve economical independence from his family by trying to work
part time jobs.
Emotional changes like unpredictable mood swings , has been noticed during hospital
He also verbalizes and expresses that he has enthusiasm to gain new experiences.
Sometimes he gets depressed and withdrawn because of the crisis situation he is facing in
his disease process, but he also demonstrates mature emotions later on.
He is positive about life.

My patient has the Diagnosis of abdominal tuberculosis that caused perforation of peritonitis.
First, the anatomy and physiology of the related system in illustrated and then follows the entire
disease process.


The digestive tract, also called the alimentary canal or gastrointestinal (GI) tract, consists of a
long continuous tube that extends from the mouth to the anus. It includes the mouth, pharynx,
esophagus, stomach, small intestine, and large intestine. The tongue and teeth are accessory
structures located in the mouth. The salivary glands, liver, gallbladder, and pancreas are major
accessory organs that have a role in digestion. Food undergoes three types of processes in the
Digestion and absorption occur in the digestive tract. After the nutrients are absorbed, they are
available to all cells in the body and are utilized by the body cells in metabolism. The digestive
system prepares nutrients for utilization by body cells through six activities, or functions.
Ingestion: The first activity of the digestive system is to take in food through the mouth. This
process, called ingestion, has to take place before anything else can happen.
Mechanical Digestion: The large pieces of food that are ingested have to be broken into smaller
particles that can be acted upon by various enzymes.
Chemical Digestion: Through a process called hydrolysis, uses water and digestive enzymes to
break down the complex molecules. Digestive enzymes speed up the hydrolysis process, which
is otherwise very slow.
Movements: After ingestion and mastication, the food particles move from the mouth into the
pharynx, then into the esophagus. This movement is deglutition, or swallowing. Mixing
movements occur in the stomach as a result of smooth muscle contraction
Absorption: The simple molecules that result from chemical digestion pass through cell
membranes of the lining in the small intestine into the blood or lymph capillaries. This process is
called absorption
Elimination: The food molecules that cannot be digested or absorbed need to be eliminated from
the body. The removal of indigestible wastes through the anus, in the form of feces, is defecation
or elimination.

The digestive system is a group of organs (Buccal cavity (mouth), pharynx, esophagus, stomach,
liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components of food,
with digestive juices, into tiny nutrients which can be absorbed to generate energy for the body.

The Buccal Cavity: Food enters the mouth and is chewed by the teeth, turned over and mixed
with saliva by the tongue. The sensations of smell and taste from the food sets up reflexes which
stimulate the salivary glands.
The Salivary glands: Saliva lubricates the food enabling it to be swallowed and contains the
enzyme ptyalin which serves to begin to break down starch.
The Pharynx: Situated at the back of the nose and oral cavity receives the softened food mass or
bolus by the tongue pushing it against the palate which initiates the swallowing action.

The Esophagus: The esophagus travels through the neck and thorax, behind the trachea and in
front of the aorta. The food is moved by rhythmical muscular contractions known as peristalsis
(wave-like motions) caused by contractions in longitudinal and circular bands of muscle.
The Stomach: The stomach lies below the diaphragm and to the left of the liver. It is the widest
part of the alimentary canal and acts as a reservoir for the food where it may remain for between
2 and 6 hours. Here the food is churned over and mixed with various hormones, enzymes including
pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of which are
also secreted further down the digestive tract.

Anatomy of Small Intestine (related to disease process): The small intestine measures about
7m and is continuous from pyloric sphincter to large intestine at illeocecal valve. The small
intestine, because of its structure, provides a vast lining through which further absorption takes
Mobility of small intestine:

Rhythmic segmentation (mixing movement): it mixes the chyme to digestive juices and
exposes it to absorptive surface.
Peristalsis (wave of rhythmic contraction and relaxation) of longitudinal and circular
smooth muscles. It makes propelling force that moves digested food down the length of
the tract.

Parts of small intestine

Duodenum : It is C shaped, proximal part of small intestine which is widest and shortest.
It is curved around the head of pancreas .it contains glands which secrete the mucous.
Neuroendocrine cells present on duodenal mucosa secrete secretin and cholestokin.
Jejunum : It is middle part of the small intestine and has a thick wall, wide lumen and is
more vascular than other parts of the small intestine. It has villi, which are more
abundant. It also contains intestinal gland which produce water, electrolytes and mucous.
Largest amount of absorption occur through this part.
Ileum : It is the distal largest part of the small intestine. It has thin wall, and it is the
narrowest lumen which is less vascular among the parts of small intestine. It has short
and thin villi. It contains the payers patches (lymphoid follicles) which is responsible for
local intestinal immunity.

Digestive enzyme of small intestine.: the enzymes are sucrose , maltose , lipase which helps
is final digestion of fat , carbohydrate, and protein. Digested form of food in small intestine is

Note: The ileocecal junction is a sphincter or valve connecting the end of the small intestine (the
ileum) with the beginning of the large intestine (the cecum).
Function of small intestine

Complete the digestion of food with the help of intestinal juices, pancreatic juices, and
Complete absorption of nutrients.
Local intestinal immunity by payers patches against various ingested bacteria and virus.

The Large Intestine: The large intestine averages about 1.5m long and comprises the cecum,
appendix, colon, and rectum. After food is passed into the cecum a reflex action in response to
the pressure causes the contraction of the ileo-colic valve preventing any food returning to the
ileum. Here most of the water is absorbed, much of which was not ingested, but secreted by
digestive glands further up the digestive tract.
Vermiform appendix: Blind tube arising from the posterior wall of the cecum. About 2 cm,
below the ileo-cecal valve. Its sub-mucosa contains numerous lymphoid follicles so it is called
the abdominal tonsils. It helps in immune response due to presence of lymphoid tissue.
Rectum: Distal portion of the large intestine, between the sigmoid colon and anus. Desire of
defecation occurs when the feces reaches the rectum.
Anus: Extends from rectum, about 3.8 cm in length.


The Pancreas: The Pancreas is connected to the duodenum via two ducts and has two main

To produce enzymes to aid the process of digestion

To release insulin directly into the blood stream for the purpose of controlling blood
sugar levels

The Liver: The liver, which acts as a large reservoir and filter for blood, occupies the upper right
portion of abdomen and has several important functions:
1. Secretion of bile to the gall bladder
2. Carbohydrate, protein and fat metabolism.
3. The storage of glycogen ready for conversion into glucose when energy is required.
4. Storage of vitamins (A, D, E, K)
5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria.
6. Reservoir of blood. 30% of blood is reserved here.
The Gall Bladder: The gall bladder stores and concentrates bile which emulsifies fats making
them easier to break down by the pancreatic juices.
Spleen: It acts as a reservoir, functions as phagocytosis. It is also called graveyard of RBCs.


The peritoneum is the serous membrane that lines the abdominal cavity. It lies directly beneath
the abdominal musculature (rectus abdominis and transverse abdominis). Peritoneum is made up
of layers of mesothelial cells. Mesothelial cells are simple squamous and of mesodermal origin,
they have microvilli on their surface and are very fragile but regenerate very quickly.
There are two layers of peritoneum lining the abdomen.
1. The outer layer, called the parietal peritoneum, is attached to the abdominal wall and
the pelvic walls.
2. The inner layer, the visceral peritoneum, is wrapped around the internal organs that are
located inside the intra-peritoneal space. It is thinner than the parietal peritoneum.
The potential space between these two layers is the peritoneal cavity; it is filled with a small
amount (about 50 ml) of slippery serous fluid that allows the two layers to slide freely over each

Peritoneal Fluid:
A small quantity of peritoneal fluid is produced by mesothelial cells. It fills the potential space
formed by the two layers of peritoneum and allows the two layers to slide over each other freely.
Peritoneal fluid is also produced as a transudate which coats the serosal surface of viscera to
facilitate frictionless movement e.g. during peristalsis. It is in equilibrium with plasma but
doesn't contain high molecular weight molecules like fibrinogen. The fluid is constantly being
produced and resorbed through the large surface area of the peritoneum, for this reason drugs are
sometimes administered by intraperitoneal injection. Bacterial toxins are also absorbed readily
and can cause inflammation of the peritoneum; peritonitis.
Organs are described as retroperitoneal if they are located behind the parietal peritoneum.
Retroperitoneal organs include: the kidneys, adrenal glands, ureters, urinary bladder, part of
the oesophagus, rectum, ovaries, uterus, aorta and caudal Vena Cava. Organs are intraperitoneal
if they are enclosed by a fold of visceral peritoneum. Intraperitoneal organs include: small
intestine, large intestine, liver, gall bladder, pancreas and spleen.

The peritoneum doubles up to form the following suspensory structures: Mesentery, from viscera
to the dorsal abdominal wall. Omentum from the stomach to other viscera and ligament, from
viscera not involved in digestion to the abdominal wall or to other viscera that are not involved
in digestion (e.g.ligaments of the liver).

A mesentery suspends the small and large bowel from the posterior peritoneal cavity by
way of a double layer of peritoneum. It acts as a channel for neurovascular and lymphatic
structures between the organ and posterior abdominal wall.
A ligament is also formed by two layers of the peritoneum; it supports a structure within
the peritoneal cavity and is named according to the structures it connects.
An omentum refers to a double-layered extension of ligaments of the peritoneum joining
the stomach and proximal duodenum to other adjacent structures, the greater and lesser
omentum extending from the greater and lesser curvatures of the stomach respectively.

Fig.: Sagittal CT peritoneogram with diagram.


Perforation Peritonitis is inflammation of the peritoneum, the serous membrane lining the
abdominal cavity and covering the viscera due to infections from certain organisms followed by
gastrointestinal perforation. Perforation is said to occur once a pathology which extends through
the full thickness of the hollow viscus leading to peritoneal contamination with intraluminal
contents. Perforation can occur anywhere in the gastrointestinal tract starting from oesophagus to
the rectum.

Usually, it is a result of bacterial infection; the organisms come from diseases of the GI
tract or, in women, from the internal reproductive organs.
Peritonitis can also result from external sources such as injury or trauma (eg, gunshot
wound, stab wound) or an inflammation that extends from an organ outside the peritoneal
area, such as the kidney.

The most common bacteria implicated are Escherichia coli, Klebsiella, Proteus, and
Other common causes of peritonitis are appendicitis, perforated ulcer, diverticulitis, and
bowel perforation.
Peritonitis may also be associated with abdominal surgical procedures and peritoneal

Perforation peritonitis is one of the most common surgical conditions encountered in surgical
practice and is a common cause of morbidity and mortality and warrants early surgical
intervention. Adequate resuscitation along with baseline investigations and broad spectrum
antibiotics are imperative in all cases. Further management depends upon the cause of peritonitis.

In regards to my patient
According to study I have done in my case, perforation peritonitis resulted due to abdominal
tuberculosis which leaded to bowel perforation resulting in peritonitis. It is further discussed

Abdominal tuberculosis is a most common type of extra-pulmonary tuberculosis, comprising of
tuberculosis of gastrointestinal tract, peritoneum, omentum, mysentery and its lymph nodes and
other abdominal organs such as liver, spleen and pancreas. The extrapulmonary tuberculosis
involves 11-16% of all patients of tuberculosis out of which 3 to 4% belong to abdominal
tuberculosis. The gastrointestinal tract is involved in more than 60% of cases of abdominal
Extra pulmonary tuberculosis is common amongst HIV-infected patients.
Abdominal tuberculosis can mimic a variety of other abdominal conditions/diseases and only a
high degree of suspicion can help in the diagnosis otherwise it is likely to be missed or delayed
resulting in high morbidity and mortality.
Abdominal tuberculosis can occur primarily or it can be secondary to a tubercular focus
elsewhere in the body. Gastrointestinal tuberculosis occurring due to ingestion of milk or food
infected with Mycobacterium bovis can result in primary intestinal tuberculosis, but it is
nowadays rare. Secondarily, Infection by Mycobacterium tuberculosis causing abdominal
tuberculosis is acquired in following ways:
1. Dissemination of primary pulmonary tuberculosis in childhood.

2. Swallowing of infected sputum in active pulmonary tuberculosis.

3. Hematogenous dissemination from a focus of active pulmonary tuberculosis or military
4. Mycobacteria can spread from infected adjacent organs like fallopian tubes.
5. Intestinal infection can occur by lymphatic spread from infected mesenteric lymph
6. Mycobacteria can also get disseminated through bile from tubercular granulomas of the

ETIOLOGY in my patient
It could not be confirmed what was the real cause of abdominal tuberculosis but it is highly
possible that it was due to swallowing of infected sputum as he was in an active stage of
pulmonary tuberculosis. According to my analysis, the pulmonary tuberculosis might have
resulted from the transmission of organisms through his mother (who had incompletely treated
Pulmonary Tuberculosis that lead to death) during his childhood.
Sites of Involvement in Abdominal Tuberculosis
1. Gastrointestinal tract
2. Peritoneum, e.g. ascites
3. Lymph nodes
4. Solid organs, e.g. liver, spleen and pancreas
The most common site is the terminal ileum and ileocaecal region due to increased physiological
stasis, increased fluid and electrolyte absorption, minimal digestive activity, and an abundance of
lymphoid tissue (Peyers patches) at this site.
The other sites, in order of frequency, include the colon and jejunum. Peritoneal involvement
occurs in 4-10% patients of extrapulmonary tuberculosis (EPTB).Tubercular peritonitis follows
either the direct spread of tuberculosis from ruptured lymph nodes and intra-abdominal organs or
hematogenous seeding. Peritoneal involvement may be in the form of peritoneal adhesions or
exudative fluid in the peritoneal cavity (ascites). Rarely, tuberculosis may involve other areas
such as the perianal region, appendix, duodenum, stomach, and oesophagus.
The nodal involvement due to tuberculosis is commonly mesenteric or retroperitoneal. The
abdominal solid organs (liver, spleen, and pancreas) may also be affected with tuberculosis, but

Precipitating factor
Previous contact with
the case of TB (mother)

Predisposing factor:
-malnutrition associated with decrease in
immunity activates inactivated organisms.
Low Nutrition = low immunity= high
tubercle bacillus

Pulmonary tuberculosis

Primary infection due to

ingestion of milk or food
infected with Mycobacterium

Secondary infection due to Swallowing of infected sputum in

active pulmonary tuberculosis


Ileum; ielocecal area and lymph

nodes involved (80-90%)
Rarely tuberculosis may also involve
Stomach, duodenum and esophagus.

Mycobacterium cannot continue to grow in the

acidic extracellular environment, and thus most
infections are controlled, but TB can persist
within the tubercles for extended periods.

Although many activated macrophages surround the

tubercles, many other macrophages are inactivated or
poorly activated. TB uses these macrophages to
replicate causing the tubercle to grow and invade the
intestinal wall/abdominal structure.

Cell-mediated immune response

terminates the unimpeded growth of M.
tuberculosis within 2 to 3 weeks after the
initial infection.

(CD4) helper T cells activate the macrophages to kill the

intracellular bacteria with resultant epithelioid granuloma
formation. Tuberculous granulomas of variable size are
initially formed in the submucosa or the Peyers patches.

Tuberculin test
become positive
around this time.

CD8 suppressor T cells lyse the macrophages

infected with the mycobacteria, resulting in
the formation of caseating granulomas.

Caseating granulomas
in histopathological
examination indicates
infection of

Under immunosuprresed conditions

Secondary lesions occurs. The caseous centres of the tubercles

liquefy .this liquid is very crucial for the growth of TB, and
therefore multiplies rapidly (extracellularly)

These later becomes a large antigen load causing

the walls of intestine become necrotic and rupture.

Perforation (formation of a hole in an organ), fecal materials exits to

peritoneal cavity causing formation of abscess. Infection spreads throughout
the abdomen (peritoneal cavity)

Bacteria invasion of peritoneal cavity causing inflammation

of the membrane that lines the abdomen peritoneum

Septic shocks:
1. Decrease bloodpressure
2. Decrease blood volume



-Prescribed antibiotics and /or

surgical repair.
-Treatment of Tuberculosis with

Fluid volume replacement



In order of frequency, abdominal tuberculosis manifests as tubercular lymphadenitis, peritonitis
and hepato-splenic or pancreatic tuberculosis. The disease may present at any age but commonly
seen in young adults. In children, peritoneal and nodal form of tuberculosis is more common
than intestinal tuberculosis. The modes of presentation may vary from asymptomatic disease (an
incidental finding on laparotomy) to acute, acute on chronic or chronic symptomatic disease. The
clinical manifestations depend on the site and type of involvement. The symptomatology mainly
(i) Constitutional symptoms in about one-third of patients

night sweats
loss of weight
(ii) Local symptoms and signs referable to the site involved.



Stricturous /


Liver and spleen


Lymph node

Clinical presentations
Chronic diarrhea, malabsorption, intestinal perforation (occasional).
Rectal bleeding is rare but reported occasionally in colonic
Intestinal obstruction or an abdominal (ileocaecal) lump
Recurrent subacute intestinal obstruction (e.g. vomiting,
constipation, distention, colicky pain). There may be associated
gurgling sounds or feeling of moving ball of wind in the abdomen
and visible distended intestinal loops with visible peristalsis.These
symptoms get relieved with passage of flatus / stool. Sometimes,
acute intestinal obstruction may develop.
Stricture or fistula-in-ano
Peptic ulcer with or without gastric outlet obstruction or perforation
Hepatosplenomegaly usually a part and parcel of disseminated
tuberculosis is accompanied with fever, night sweats and decreased
or loss of appetite Microscopic involvement shows granulomatous
Abdominal distention and ascites, sometimes there may be a soft
cystic lump due to loculated ascites
As a mass or lump of matted lymph nodes in the central abdomen
or as
vague abdominal pain. There is associated fever, night sweats and

A physical examination of abdomen may show signs of ascites, lump in the abdomen or visible
peristalsis with dilated loops of gut. However, abdominal examination may be unrewarding in a
large number of cases. Because of varied clinical manifestations, one or the other form of
abdominal tuberculosis may mimic any one of the followings:

Malignant neoplasms, e.g. lymphoma, carcinoma

Inflammatory bowel disease
Cirrhosis of the liver especially peritoneal tuberculosis
Ileocaecal mass may mimic appendicular lump or malignancy caecum or other

A high degree of suspicion combined with proper use of diagnostic modalities will help in the
timely diagnosis of the disease

Symptoms after peritonitis:

Symptoms depend on the location and extent of the inflammation. The early clinical
manifestations of peritonitis frequently are the symptoms of the disorder causing the condition.
At first, a diffuse type of pain is felt. The pain tends to become constant, localized, and more
intense near the site of the inflammation. Movement usually aggravates it. The affected area of
the abdomen becomes extremely tender and distended, and the muscles become rigid. Rebound
tenderness and paralytic ileus may be present. Usually, nausea and vomiting occur and peristalsis
is diminished. The temperature and pulse rate increase, and there is almost always an elevation
of the leukocyte count.

Sign and symptoms in my patient.

As my patient had abdominal tuberculosis, the sign and symptoms he developed one and half
months were:

Low grade fever

Weight loss
Blood in stool ,sometimes

Later on few days before admission with peritonitis he had:

Abdominal distention
No passage of stool or flatus for 3 days.
Severe pain on abdomen, increasing on movement.
Rigidity of abdominal muscle due to pain


1. History taking
2. Physical examination
Blood examination may show varying degree of anemia, leucopenia and raised
Serum biochemistry: Serum albumin level may be low. Serum transaminases are
Mantoux test: This gives supportive evidence to the diagnosis of abdominal
tuberculosis in 55 to 70% patients if positive, however, a negative tuberculin test
may also be observed in one-third of patients. Negative mantoux test in patients
of tuberculosis could be due either to (a) immunosuppression or malnutrition
producing energy or (b) recent overwhelming tuberculosis or military tuberculosis
or (c) rarely circulating mononuclear adherent cells suppressing the sensitized Tlymphocytes in peripheral blood or (d) suppression of PPD-reactive Tlymphocytes.
4. Imaging Techniques:
Plain X-ray abdomen and chest: It may show presence of multiple air fluid levels and
dilated loops of gut in case there is sub acute or acute intestinal obstruction. Calcification
in the abdominal lymph nodes also indicates tuberculosis.
5. Barium Studies: It has been documented that barium studies are useful in 75% patients
with suspected intestinal tuberculosis. Barium meal follow through is the best diagnostic
test for intestinal lesions. The bowel lesions highly suggestive of tuberculosis include
multiple strictures, distended caecum or terminal ileum.
6. Ultrasound: The USG of abdomen may show a mass of matted loops of small bowel
with thickened walls, rolled up or diseased omentum, and loculated ascites. Peritoneal
thickening and nodularity are the other ultrasonographic findings of peritoneal
Tubercular lymphadenitis usually involves mesenteric, peri-pancreatic, periportal
and para-aortic groups of lymph nodes. These lymph nodes are seen as conglomerate
mass and/or as scattered enlarged nodes with hypoechoic center because of necrosis
(Fig.). This necrosis within lymph nodes may also be seen in metastatic
lymphadenopathy. However, caseation with calcification is highly suggestive of
tubercular lymphadenitis rather than malignant. The nodes maytransiently increase in size
once the treatment is started and then gradually diminish in size.


Fig.: Abdominal ultrasonography showing enlarged mesenteric lymph nodes (Note

the hypoechoic centers due to caseation.

Computed Tomography (CT): Abdominal CT scan is better than ultrasound detecting

high density ascites, lymphadenopathy with caseation ,bowel wall thickening and
irregularsoft tissue densities in the omental area. Abdominal lymphadenopathy is the
commonest manifestation of tuberculosis on CT.
Loculated fluid collections in the presence of omental infiltration, peritoneal
enhancement, transperitoneal reaction, i.e. septal, and mesenteric (macronodules >5 mm
in diameter) or bowel involvement are important features of abdominal tuberculosis on
The other CT findings reported to be highly suggestive of abdominal tuberculosis are
irregular soft tissue densities in omental area, low density masses and a disorganized
appearance of soft tissue densities, fluid and bowel forming an ill-defined mass.

Fig. : Tubercular peritonitis. Contrast enhanced CT (CECT) abdomen showing

peritoneal reaction with ascites and mesenteric streaking.
8. Endoscopy: Terminal ileoscopy is the easiest and direct method of establishing the
diagnosis of ileocolic tuberculosis. The findings on endoscopy of ileum include
submucosal granulomas in all cases from which biopsy may be taken for confirmation of
the diagnosis.
9. Laparoscopy: Laparoscopy examination is an effective method of diagnosing tubercular
peritonitis because (i) it directly visualizes the inflamed thickened peritoneum studded
with whitish-yellow miliary tubercles and (ii) biopsy of the peritoneum confirms the
diagnosis. Laparoscopy facilitates an accurate diagnosis in 80-90% of patients.
Laparoscopic biopsy specimens may reveal AFB in 75% patients and caseating
granulomas in 85-90% patients. The finding of adhesions or fibrotic strands within turbid
ascites is virtually diagnostic of tuberculosis. The liver, spleen and omentum can also be
examined on laparoscopy, are also studded with tubercles in hepatosplenic tuberculosis.
Laparoscopy through open exposure of the peritoneum may be employed in patients with
fibroadhesive peritoneal tuberculosis so as to avoid chances of perforation.

Flow chart 1: Algorithmic approach to diagnosis of abdominal tuberculosis

For Peritonitis:

The leukocyte count is elevated.

The hemoglobin and hematocrit levels may be low if blood loss has occurred.
Serum electrolyte studies may reveal altered levels of potassium, sodium, and
An abdominal x-ray is obtained, and findings may show air and fluid levels as well
as distended bowel loops.
A CT scan of the abdomen may show abscess formation.
Peritoneal aspiration and culture and sensitivity studies of the aspirated fluid may
reveal infection and identify the causative organisms.

Diagnosis and assessment done in my patient:

1. History taking revealed that his mother was a PTB patient who had refused treatment and
passed away. Information received also suggested that the patient did not have healthy
life style as he did not give much care for his nutritional requirements.

2. Physical examination: done before surgery also had findings of distended abdomen, and
other signs and symptoms related to peritonitis which has been discussed above.
3. Blood examination:
4. Chest x-ray
5. Ultrasound
6. Laparosopy and histopathological examination of specimen collected.




Hb (hemoglobin)

2070/02/25 13.4%
2070/02/25 26,800 mm3
2070/02/27 21,300 mm3





Iron containing Oxygen
transport in the blood

Within normal range

(4,000 11,000)/ mm3

WBC fights infection.

Increase in WBC
signifies bacterial

Indicates presence of

Important factor for

2070/02/25 6,41,000mm3 (150,0003
3 blood to clot
2070/02/27 1,88,000mm 450,000)/mm


Lymphocytes 2070/02/25



Lymphocytes B and T
are the natural cell killers


Indicates infection


2070/02/25 01%





Sugar pp




2070/02/25 0.8mg/dl
2070/02/26 0.7mg/dl

















Total Protein



2070/02/27 6.5
2070/02/25 14.9 sec



Usually elevated
when pancreatitis is

5-42 IU/l

5.0-35 IU/l

97- 279 IU/l

4.5- 8.0 gm/dl May be decreased

2.5- 5.5 gm/dl because of fluid

shifts, lack of food

intake, and nothing
by mouth (NPO)

Control 12

HIV I and II
Anti HCV





Colour Deep yellow
Appearance- s. turbid
Sugar- Negative
Albumin- +
Crystal- nil
RBCs- plenty/phf
Pus cells- 1-3/phf
Epithelial cells -1 2/phf
DATE: 2070/02/25

Bowel loops appear to be loaded with fecal matter.

No intra bowel free fluid is noted
No area of hyper peristalsis noted
No lymphadenopathy noted
Large bowel noted to be loaded with feaces with no areas of hyperperistalis.
Intestinal onstruction (? subacute type)

Date: 2070/02/21

AFB found
AFB found
AFB found


The treatment of abdominal tuberculosis is on the same lines as for pulmonary tuberculosis.
Conventional antitubercular therapy for at least 6 months including initial 2 months of HREZ
(e.g. isoniazid, rifampicin, ethambutol and pyrazinamide) followed by 4 month HR is
recommended in all patients with abdominal tuberculosis. However, previously, the
antitubercular therapy was extended upto 8 to 12 months, but recently, a 6 month short course
chemotherapy regimen has been found as effective as standard 12 months regimen. However,
many physicians still extend the duration of treatment to 12 to 18 months. Corticosteroids have
been employed to decrease fibrosis during healing so as to prevent development of obstruction
but now-a-days, not preferred as they may delay healing and predispose to perforation or further
obstruction. Studies have now shown that even obstructing intestinal lesions can be successfully
treated with antitubercular drugs without the need for surgery and complete resolution
radiological abnormalities may occur.
The goals for treatment of TB are to cure the individual and to minimize transmission to other
persons. It is essential that treatment be tailored and supervision be based on each clients
clinical and social circumstances. DOT may be the most effective way to maximize the
completion of therapy.
Administer anti-infective agents, as indicated, for example:
Primary drugs: isoniazid (INH, Liniazid), rifampin (RIF, Rifadin, Rimactane),
pyrazinamide (PZA, Tebrazid), and ethambutol (Etbi, Myambutol):
These four drugs should not be given in divided doses; all four drugs should be
given together. Evidence shows this promotes the therapys effectiveness (CDC,
2005). INH is usually drug of choice for those exposed and who are at risk for
developing TB. Extended therapy for up to 24 months is indicated for
reactivation cases, extrapulmonary reactivated TB, or in the presence of other
medical problems, such as diabetes mellitus or silicosis.
Rufabutin (Mucobutin): Therapeutic agent for atypical mycobacterium. May be
used in client with advanced HIV disease with TB
Second-line drugs, such as ethionamide (Trecator-SC), paraaminosalicylate (PAS),
cycloserine (Seromycin), amikacin (Amikin), and levofloxacin (Levoquin): These
second-line drugs may be required when infection is resistant to or intolerant of primary
drugs or may be used concurrently with primary antitubercular drugs. Note: MDR-TB
requires minimum of 18 to 24 months therapy with at least three drugs in the regimen
known to be effective against the specific infective organism and that client has not
previously taken. Treatment is often extended to 24 months in clients with severe
symptoms or HIV infection.
Monitor laboratory studies, such as the following:
Sputum smear results: Client who has three consecutive negative sputum smears over a
3- to 5-month period is adhering to drug regimen and who is asymptomatic will be
classified as a nontransmitter.
Liver function studies, such as aspartate aminotransferase (AST), alinine
aminotransferase (ALT): The most common serious adverse effect of drug therapy
particularly RIF, but possibly others as wellis drug-induced hepatitis.

Surgical treatment is done to manage the complications such as obstruction, perforation (free or
with access or fistula) and massive hemorrhage not responding to conservative therapy.
Strictures are managed by strict uroplasty or resection of the involved segment of the bowel. The
perforation is managed by resection and anastomosis rather than by simple closure so as to avoid
fistula formation. Bypass surgery such as enteroenterostomy, ileotransverse colostomy is not
recommended for obstructive lesions as they may cause formation of blind loops leading to
obstruction, fistulation, malabsorption etc.


Fluid, colloid, and electrolyte replacement is the major focus of medical management. The
administration of several liters of an isotonic solution is prescribed. Hypovolemia occurs because
massive amounts of fluid and electrolytes move from the intestinal lumen into the peritoneal
cavity and deplete the fluid in the vascular space.
Analgesics are prescribed for pain. Antiemetics are administered as prescribed for nausea and
vomiting. Intestinal intubation and suction assist in relieving abdominal distention and in
promoting intestinal function. Fluid in the abdominal cavity can cause pressure that restricts
expansion of the lungs and causes respiratory distress. Oxygen therapy by nasal cannula or mask
can promote adequate oxygenation, but airway intubation and ventilator assistance occasionally
are required.
Massive antibiotic therapy is usually initiated early in the treatment of peritonitis. Large doses of
a broad-spectrum antibiotic are administered intravenously until the specific organism causing
the infection is identified and the appropriate antibiotic therapy can be initiated.
Surgical objectives include removing the infected material and correcting the cause. Surgical
treatment is directed toward excision (ie, appendix), resection with or without anastomosis (ie,
intestine), repair (ie, perforation), and drainage (ie, abscess). With extensive sepsis, a fecal
diversion may need to be created.
MANAGEMENT FOR MY PATIENT (Both intestinal tuberculosis and perforation
As my patient came with perforation peritonitis, emergency operation was the first treatment
protocol. Then, medical management and Nursing management were carried out accordingly.


Date: 2070/02/25
Exploratory Laparotomy with anstomosis with proximal ileostomy done for multiple
perforation viscera.
Provisional diagnosis: Peritonitis due to hollow viscous perforation
Post-op diagnosis: Multiple lleal perforation
PROCEDURE: Exploratory laparotomy with resection of perforated ileal part, anastomosis of
ileum , repair of perforation with proximal loop, ileostomy and tension wire suturing.
Anaesthesia: general anesthesia
Surgeon: Dr Ghanashyam
Anesthesia: Dr. Hem
Assistant surgeon: Dr. Ranjan, Dr. Udita

Multiple perforation at ileum

2 perforation at 60 cm proximal to Ielocecal Junction(IC Junction)
1 perforation at 75cms proximal to IC junction
1 perforation at 120 cm proximal to IC junction
Tubercles at bowel, proximal bowel edematous and dilated enlarged , mesenteric lymph
nodes, some are caseating.
About 150 ml of dirty contaminated fluid in peritoneal cavity.


Resection of terminal ileum, 60 cms proximal to IC junction including 2 perforation sites

done and anstomosis done in 2 layers.
Primary repair of perforation at 75 cm proximal t o IC junction done, loop ileostomy
made out of perforation at 120 cms proximal to IC junction.
Peritoneal wash done , haemostasis maintained
Tension wire suturing done
Abdomen closed in wires.

Resected ielal part with perforation site sent for Histopathological examination.
Mesenteric Lymph Node sent for Histopathological examination.


Specimen: Resected ielal part with perforation
490- two tubular structure . one measures 3.3x4.5 cm with perforation measuring 3.0x0.2 cm
and another tunbular tissue measures 2.7x 1.0cm , P/E-5B
Microscopy :
490- sections from the submitted tissue show ulceration of mucosa and infiltration by chronic
inflammatory cells in stoma. There is caseous necrosis along with well formed granuloma
consisting of lymphocytes, plasma cells, epithelloid cells and multineucleated giant cells.
Fibrosis, vascular congestion are also noted in section examined.
491- sections from lymph node show caseous necrosis and multiple well formed granulomas
consisting of epithelloid cells, langhans type cells.
490- consistent with variable villous abnormality showing specific diagnostic changes;
Tubercular ileits
491- Tubercular lymphadenitis


Ileostomy (perfomed in my case during surgery)
Performed when the entire colon, rectum, and anus must be removed, in which case the
ileostomy is permanent; or, a temporary ileostomy can be done to provide complete
bowel rest in conditions, such as with chronic colitis and in some trauma cases.

Most frequently performed for complications of inflammatory bowel diseaseCrohns

disease and ulcerative colitisincluding intestinal perforation or intestinal stricture
causing obstruction, abscess, or massive hemorrhage (Clark, 2005; Boehmke, 2006)
May also be done because of intestinal trauma, polyps, cancer, or complications from
cancer (Clark, 2005).

Etiology: dependent on underlying pathology requiring procedure

Nursing management was carried out following the Nursing theory and Nursing Process along
with it.


Nursing Theory is a conceptualization of some aspects of nursing communicated for the purpose
of describing, explaining, predicting or prescribing nursing care .In other words, a Nursing
Theroy is a set of concepts , definitions, relationships, and assumptions or propositions derived
from nursing models or from other disciplines and project purposive systematic view of
phenomena by designing specific inter-realtionships among concepts for the purposes of
describing, explaining, predicting, and/or prescribing.
There are numbers of Nursing theories and one of those theory is the Problem Solving Theory
by Faye Glenn Abdellah, which I have applied for my case study patient during my nursing
According to Abdellah, Nursing is based on an art and science that molds the attitudes,
intellectual competencies and technical skills of individual nurse into the desire and ability to
help people, sick or well, cope with their health needs. Applying her theory I have tried to
provide my patient with complete patient centered care and at the same time enhance my
knowledge on problem solving methods.
Nursinng may be carried out under general or specific medical direction. As per Abdellah,
nursing as a comprehensive service includes:
1. Recognizing the nursing problems of t he patient
2. Deciding the appropriate course of action to take in terms of rel evant
nursing principles
3. Providing continuous care of the individuals total needs
4. Providing continuous care to relieve pain and discom fort and provide
immediate security for the individual
5. Adjusting the total nursing care plan to meet the patients individual needs
6. Helping the individual to become more self directing in attaining or
maintaining a healthy state of mind & body
7. Instructing nursing personnel and family to help the individual do for himself
that which he can within his limitations
8. Helping the individual to adjust to his limitations and emotional problems

9. Working with allied health professions in planning for optimum health on

local, state, national and international levels
10. Carrying out continuous evaluation and research to improve nursing techniques and to
develop new techniques to meet the health needs of people.
Abdellahs patient-centred approach to nursing was developed inductively from her
practice and is considered a human needs theory.
The theory was created to assist with nursing education and is most applicable to the
education of nurses.
Although it was intended to guide care of those in the hospital, it also has relevance for
nursing care in community settings.
Abdellah and colleagues developed a list of 21 nursing problems. They also identified 10steps to
identify the clients problems. 11 nursing skills to be used in developing a treatment typology10
steps to identify the clients problems.
1. Learn to know the patient
2. Sort out relevant and significant data
3. Make generalizations about available data in relation to similar nursing
problems presented by other patients
4. Identify the therapeutic plan
5. Test generalizations with the patient and make additional generalizations
6. Validate the patients conclusions about his nursing problems
7. Continue to observe and evaluate the patient over a period of time to identify any
attitudes and clues affecting his behavior
8. Explore the patients and familys reaction to the therapeutic plan and involve them in the
9. Identify how the nurses feels about the patients nursing problems
10. Discuss and develop a comprehensive nursing care plan
11 nursing skills
1. Observation of health status
2. Skills of communication
3. Application of knowledge
4. Teaching of patients and families
5. Planning and organization of work
6. Use of resource materials
7. Use of personnel resources
8. Problem-solving
9. Direction of work of others
10. Therapeutic use of the self
11. Nursing procedure
Abdellahs 21 nursing problem
1. To maintain good hygiene and physical comfort.

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

3. To promote safety through prevention of accident, injury, or other trauma and through
the prevention of the spread of infection.
4. To maintain good body mechanics and prevent and correct deformity.
5. To facilitate the maintenance of a supply of oxygen to all body cells.
6. To facilitate the maintenance of nutrition of all body cells.
7. To facilitate the maintenance of elimination.
8. To facilitate the maintenance of fluid and electrolyte balance.
9. To recognize the physiological responses of the body to disease conditions
pathological, physiological, and compensatory.
10. To facilitate the maintenance of regulatory mechanisms and functions.
11. To facilitate the maintenance of sensory function.
12. To identify and accept positive and negative expressions, feelings, and reactions.
13. To identify and accept interrelatedness of emotions and organic illness.
14. To facilitate the maintenance of effective verbal and nonverbal communication.
15. To promote the development of productive interpersonal relationships.
16. To facilitate progress toward achievement of personal spiritual goals .
17. To create and/or maintain a therapeutic environment.
18. To facilitate awareness of self as an individual with varying physical, emotional, and
developmental needs.
19. To accept the optimum possible goals in the light of limitations, physical, and emotional.
20. To use community resources as an aid in resolving problems arising from illness.
21. To understand the role of social problems as influencing factors in the cause of illness

Subjective data `
Generalized weakness and fatigue.
Shortness of breath with exertion.
Difficulty sleeping.

Objective data
Anxiety, apprehension,
Presence of dark circles under the eye.

Feelings of helplessness and hopelessness.
Loss of appetite
Nausea, vomiting
Weight loss

Poor skin turgor.

Muscle wasting and loss of subcutaneous

Abdominal pain on movement, on incision
Facial expression of pain.
Feelings of isolation and rejection because
of communicable disease.
Assistance need with dietary concerns
Information need on management of
Teaching need on disease(Tubeculosis)
Occasional diarrhea

poor perforamance of ostomy care

Fecal Diversion, presence of ileostomy.

Nursing Problems:
Actual problems

Verbalization of change in body image

Not touching or looking at stoma, refusal to participate in care
Reports of pain and restlessness.
Disruption of skin and tissuepresence of incision and sutures, drains
Verbalizations of interrupted sleep, not feeling well-rested
Changes in behaviorirritability and lethargy
statement of misconception, misinformation
Inaccurate performance of ostomy care
Unfamiliarity with information resources
Expressing or exhibiting feelings of being overwhelmed

Potential problems.

Tissue destruction, extension of infection due to Tuberculosis.

Environmental exposure related to active stage of TB.
Insufficient knowledge to avoid exposure to pathogens.
Improper fitting or care of appliance/skin.
Excessive losses through normal routesemesis or diarrhea.
Prolonged anorexia, altered intake
Restriction of bulk and residue-containing foods

Nursing Priorities:
1. Relieve from pain
2. Prevent complications, septicemia.
3. Prevent spread of infection.
4. Maintain skin integrity.
5. Support behaviors and tasks to maintain health.
6. Achieve and maintain adequate ventilation and oxygenation.
7. Attainment of adequate fluid balance.
8. Achievement of optimal nutritional status.
9. Promote rest and relaxation.
10. Promote effective coping strategies.
11. Assist client and family in psychosocial adjustment.
12. Support independence in self-care.
13. Provide information about procedure, prognosis, treatment needs, potential
complications, and community resources

Nursing Care Plan

Drug used in my patient:
2070/02/25 to 2070/03/06
Inj Gentamycin
Inj Pantaprazole
Inj Tramadol
Inj Ondem
Inj Pethidine
Inj Phenargan

40 mg






2070/02/26 to 2070/03/06
Inj Metron
Inj Cipro
2070/03/01 to 2070/03/06
Inj. Normal saline
IV pint
Inj. Dextrose 5%
I pint
Inj. KCl 60meq/24hr increased to 120meq/24hr since 2070/03/02
2070/02/24 and continued till date
ATT (Anti Tubercular Treatment)

Parenteral, intrathecal: Alcomicin (CAN), Pediatric: Gentamicin Sulfate Topical
dermatologic cream, ointment: Garamycin Ophthalmic: Garamycin, Gentak, Genoptic
Drug class: Aminoglycoside
Therapeutic actions: Bactericidal: Inhibits protein synthesis in susceptible strains of gramnegative bacteria; appears to disrupt functional integrity of bacterial cell membrane,
causing cell death.
Indications: Parenteral: Serious infections caused by susceptible strains of Pseudomonas
aeruginosa, roteus species, Escherichia coli, Klebsiella- Enterobacter-Serratia species,
Citrobacter, Staphylococcus species. Serious infections when causative organisms are not
known (often in conjunction with a penicillin or cephalosporin)
Unlabeled use: With clindamycin as alternative regimen in PID
Contraindications and cautions
Contraindicated with allergy to any amino glycosides.Use cautiously with renal or hepatic
disease; sulfite sensitivity; preexisting hearing loss; active infection with herpes, vaccinia,
varicella, fungal infections, mycobacterial infections (ophthalmic preparations);
myasthenia gravis; parkinsonism; infant botulism; burn patients; lactation, pregnancy.
Dosages: Dosage should be based on estimated lean body mass.
Parenteral: Adults: 3 mg/kg/day in three equal doses every 8 hr IM or IV. Up to 5
mg/kg/day in three to four equal doses in severe infections, usually for 710 days. For IV
use, a loading dose of 12 mg/kg may be infused over 3060 min.
PID: 2 mg/kg IV followed by 1.5 mg/kg tid plus clindamycin 600 mg IV qid. Continue for at
least 4 days and at least 48 hr after patient improves, then continue clindamycin 450 mg
orally qid for 1014 days total therapy.
Surgical prophylaxis regimens: Several complex, multidrug prophylaxis regimens are
available for preoperative use; consult manufacturers instructions.
Adverse effects

CNS: Ototoxicitytinnitus, dizziness, vertigo, deafness (partially reversible to

irreversible), vestibular paralysis, confusion, disorientation, depression, lethargy,
nystagmus, visual disturbances, headache, numbness, tingling, tremor, paresthesias,
muscle twitching, seizures, muscular weakness, neuromuscular blockade
CV: Palpitations, hypotension, hypertension

GI: Hepatic toxicity, nausea, vomiting, anorexia, weight loss, stomatitis, increased
GU: Nephrotoxicity
Hematologic: Leukemoid reaction, agranulocytosis, granulocytosis, leukopenia,
leukocytosis, thrombocytopenia, eosinophelia, pancytopenia, anemia, hemolytic anemia,
increased or decreased reticulocyte count, electrolyte disturbances
Hypersensitivity: Purpura, rash, urticaria, exfoliative dermatitis, itching Local: Pain,
irritation, arachnoiditis at IM injection sites
Other: Fever, apnea, splenomegaly, joint pain, superinfections

Nursing considerations
History: Allergy to any aminoglycosides; renal or hepatic disease; preexisting hearing loss;
active infection with herpes, vaccinia, varicella, fungal infections, mycobacterial infections
(ophthalmic preparations); myasthenia gravis; parkinsonism; infant botulism; lactation,
Physical: Site of infection; skin color, lesions; orientation, reflexes, eighth cranial nerve
function; P, BP; R, adventitious sounds; bowel sounds, liver evaluation; urinalysis, BUN,
serum creatinine, serum electrolytes, LFTs, CBC.

Monitor serum concentrations when feasible to avoid potentially toxic levels. Peak levels
should not exceed 12 mcg/mL (68 mcg/mL is usually adequate for most infections).
Trough levels should not exceed 2 mcg/mL.
Give by IM route if at all possible; give by deep IM injection.
Culture infected area before therapy.
Use 2 mg/mL intrathecal preparation without preservatives, for intrathecal use.
Avoid long-term therapies because of increased risk of toxicities. Reduction in dose may
be clinically indicated.
Patients with edema or ascites may have lower peak concentrations due to expanded
extracellular fluid volume.
Cleanse area before application of dermatologic preparations.
Ensure adequate hydration of patient before and during therapy.
Monitor hearing with long-term therapy; ototoxicity can occur.
Monitor renal function tests, CBC, and serum drug levels during long-term therapy.
Consult with prescriber to adjust dosage as needed.

Generic Name: pantoprazole
Functional Class: Antiulcer, Proton-pump inhibitor/Antisecretory compound
Chemical Class: Benzimidazole
Mechanism of action: Suppresses gastric secretion by inhibiting hydrogen/potassium ATpase
enzyme system in gastric parietal cell, characterized by gastric acid pump inhibitor, since it
blocks final step of acid production
Uses: Gastroesophgeal reflux disease, severe erosive esophagitis, pathologic hypersecretory
conditions, heartburn, and treatment of active duodenal ulcer with or without anti-infective for H.
Oral: Short-term (8 wk or less) and longterm treatment of GERD
Maintenance healing of erosive esophagitis
Long-term treatment of pathological hypersecretory conditions
IV: Short-term (710 days) treatment of GERD in patients unable to continue oral therapy
Adults: 40 mg PO daily for maintenance healing of erosive esophagitis for 8 wk or less. The 8wk course may be repeated if healing has not occurred; give continually for hypersecretory
disorders; 40 mg/day IV for 710 days. Up to 240 mg/day PO or IV has been used for severe
hypersecretory syndromes.
Side Effects: headache, dizziness, chest pain, angina, tachycardia, palpitation, tinnitus, diarrhea,
abdominal pain, vomiting, nausea, constipation, rash, back pain, cough
Contraindications: Hypersensitivity
Precautions: Pregnancy, breast feeding, children
Adverse effects
CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream
Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal
pain, nausea, vomiting, constipation, dry mouth, tongue atrophy
Respiratory: URI symptoms, cough, epistaxis, pneumonia
Other: Cancer in preclinical studies, back pain, fever, vitamin B12 deficiency, loss of bone
density, bone fractures.
Nursing considerations:
GI system: bowel sounds q8h, abdominal for pain, swelling, anorexia Hepatic studies:
AST,ALT, alk phos during treatment
Administer: Do not break, crush, or chew del rel tab After breakfast daily

Therapeutic response: absence of epigastric pain, swelling, fullness
Teach patient/ family:
To report severe diarrhea, product may have to be discontinued.
That diabetic patient should know hypoglycemia may occur.
To avoid hazardous activities, dizziness may occur.
To avoid alcohol, salicylates, NSAIDs; may cause GI irritation.
To wear sunscreen, protective clothing to prevent burns.
Drug name: Tramadol
Functional class: central analgesic
Action: not completely understood, binds to opioid receptors, inhibits reuptake of norepinephrine, serotonin; does not cause histamine release or affect heart rate.
Relief of moderate to moderately severe pain
Relief of moderate to severe chronic pain in adults who need around-the-clock treatment
for extended periods (ER tablets)
Unlabeled uses: Premature ejaculation; restless leg syndrome
Contraindications and cautions
Contraindicated with allergy to tramadol or opioids or acute intoxication with alcohol,
opioids, or psychoactive drugs.
Use cautiously with pregnancy, lactation; seizures; concomitant use of CNS depressants,
MAOIs, SSRIs, TCAs; renal impairment; hepatic impairment.
Dosage and routes:
Patients who require rapid analgesic effect: 50100 mg PO every 46 hr; do not exceed400
Patients with moderate to moderately severe chronic pain: Initiate at 25 mg/day in the morning,
and titrate in 25-mg increments every 3 days to reach 100 mg/day. Then, increase in 50-mg
increments every 3 days to reach 200 mg/day. After titration, 50100 mg every 46 hr; do not
exceed 400 mg/day. Alternatively, 100-mg ER tablet once daily, titrated by 100-mg increments
every 5 days; do not exceed 300 mg/day. For orally disintegrating tablets, do not exceed 200 mg/
Available forms: tabs50 mg, Inj. 50mg/ml
Side effects/ adverse reactions:
CNS: dizziness, CNS stimulation, somnolence, headache, anxiety, confusion, euphoria, seizure,

GI: nausea, constipation, vomiting, dry mouth, diarrhea, abdominal pain, anorexia, flatulence, GI
CV: vasodilation, orthostatic hypotension, tachycardia, hypertension, abnormal ECG.
INTEG: pruritus, rash, urticaria, vesicles.
GU: urinary retention/frequency, menopausal symptoms, dysuria, menstrual disorder.
Interactions: decreased level of tramadol: carbamazepine. inhibition of norepinephrine and
serotonin reuptake: MAO inhibitors, use together with caution.
Lab test interference: increases creatinine, liver enzymes, decrease Hgb.
Contraindications: Hypersensitivity, acute intoxication with any CNS depressents.
Precautions: Seizure disorder, pregnancy(C), lactation, children, elderly, renal or hepatic
disease, respiratory depression, head trauma, increased intracranial pressure, acute abdominal
condition, drug abuse.
Pharmacokinetics: rapidly and almost completely absorbed, steady state 2 days, may cross
blood-brain barrier, extensively metabolized, 30% excreted in the urine as unchanged drug.
Pain: location, type, character, give before pain becomes extreme.
I/O ratio: check for decreasing output; may indicate urinary retention.
Need for drug.
For constipation: increase fluids, bulk in diet.
CNS changes: dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction.
Allergic reactions: rash, urticaria.
Administer: with antiemetic for nausea, vomiting. When pain is beginning to return;
determine dosage interval by patient response.
Perform/provide: Storage in cool environment, protected from sunlight. Assistance with
ambulation. Safety measures: side rails, night light, call bell within easy reach.
Therapeutic response, decrease in pain.
Teach patient/ family:
To report any symptoms of CNS changes, allergic reactions that drowsiness, dizziness
and confusion may occur, to call for assistance.
To make position changes slowly, orthostatic hypotension may occur.
To avoid OTC medications and alcohol unless approved by prescriber.

Zofran, Zofran ODT, Zuplenz
Drug class: Antiemetic
Therapeutic actions
Blocks specific receptor sites (5-HT3), which are associated with nausea and vomiting in the
chemoreceptor trigger zone, centrally and at specific sites peripherally. It is not known whether
its antiemetic actions are from actions at the central, peripheral, or combined sites.

Parenteral and oral: Prevention of nausea and vomiting associated with emetogenic cancer
chemotherapy in patients older than6 month.
Prevention of postoperative nausea and vomiting to prevent further episodes or, when
postoperative nausea and vomiting must be avoided (oral), prophylactically (parenteral) in
patients older than 1 mo
Prevention of nausea and vomiting associated with radiotherapy
Unlabeled uses: Treatment of nausea and vomiting associated with acetaminophen poisoning,
prostacyclin therapy
Contraindications and cautions
Contraindicated with allergy to ondansetron.
Use cautiously with pregnancy, lactation, hepatic impairment.
Parenteral :Prevention of chemotherapy-inducednausea and vomiting: Three 0.15 mg/kg
doses IV: First dose is given over 15 min,beginning 30 min before chemotherapy; subsequent
doses are given at 4 and 8 hr, or a single 32-mg dose is infused over 15 min beginning 30 min
before the start of the chemotherapy.
Adverse effects
CNS: Headache, dizziness, drowsiness, shivers, malaise, fatigue, weakness, myalgia
CV: Chest pain, hypotension Dermatologic: Pruritus
GI: Abdominal pain, constipation, liver impairment, diarrhea
GU: Urinary retention
Local: Pain at injection site
Drug-food Increased extent of absorption if taken orally with food
Nursing considerations
History: Allergy to ondansetron, pregnancy, lactation, nausea and vomiting
Physical: Skin color and texture; orientation, reflexes, bilateral grip strength, affect; P, BP;
abdominal examination; urinary output; ECG
Ensure that the timing of drug doses corresponds to that of the chemotherapy or radiation.
Administer oral drug for 12 days following completion of chemotherapy or radiation.
For Zofran ODT, peel foil backing of one blister and remove tablet gently. Do not push tablet
through the foil backing. Immediately place tablet on tongue , where it will dissolve in seconds,
and have patient swallow it with saliva.

Drug class: Opioid agonist analgesic
Therapeutic actions: Acts as agonist at specific opioid receptors inthe CNS to produce
analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same as
those mediating the effects of endogenous opioids (enkephalins, endorphins).
Oral, parenteral: Relief of moderate to severe acute pain
Parenteral: Preoperative medication, support of anesthesia, and obstetric analgesic.
Contraindications and cautions
Contraindicated with hypersensitivity to opioids, diarrhea caused by poisoning (before toxins
are eliminated), bronchial asthma, COPD, cor pulmonale, respiratory depression, anoxia,
kyphoscoliosis, acute alcoholism, increased intracranial pressure, pregnancy, seizure disorder,
renal impairment. Contraindicated in premature infants.
Use cautiously with acute abdominal conditions, CV disease, supraventricular tachycardias,
myxedema, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, Addisons
disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis,
labor or delivery (opioids given to the mother can cause respiratory depression of neonate;
premature infants are especially at risk), renal or hepatic impairment, lactation.
Relief of pain: Individualize dosage; 50 150 mg IM, subcutaneously, or PO every 3 4
hr as needed. Diluted solution may be given by slow IV injection. IM route is preferred
for repeated injections.
Preoperative medication: 50100 mg IM or subcutaneously, 3090 min before beginning
Support of anesthesia: Dilute to 10 mg/ml and give repeated doses by slow IV injection,
or dilute to 1 mg/mL and infuse continuously. Individualize dosage.
Obstetric analgesia: When contractions become regular, 50100 mg IM or
subcutaneously; repeat every 13 hr.
Adverse effects
CNS: Light-headedness, dizziness, sedation,euphoria, dysphoria, delirium, insomnia, agitation,
anxiety, fear, hallucinations, disorientation, drowsiness, lethargy, impaired mental and physical
performance, coma, mood changes, weakness, headache, tremor, seizures, miosis, visual
disturbances, suppression of cough reflex
CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia,
palpitations, chest wall rigidity, hypertension, hypotension, orthostatic hypotension, syncope
Dermatologic: Pruritus, urticaria, laryngospasm, bronchospasm, edema

GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm, increased colonic
motility in patients with chronic ulcerative colitis
GU: Ureteral spasm, spasm of vesical sphincters, urine retention or hesitancy, oliguria,
antidiuretic effect, reduced libido or potency
Local: Tissue irritation and induration (subcutaneous injection)
Major hazards: Respiratory depression, apnea, circulatory depression respiratory arrest, shock,
cardiac arrest
Other: Sweating, physical tolerance and dependence, psychological dependence.
Nursing Interventions
Administer to lactating women 46 hr before the next feeding to minimize the amount in
Reduce dosage of meperidine by 25%50% in patients receiving phenothiazines or other
Give each dose of the oral syrup in half glass of water. If taken undiluted, it may exert a
slight local anesthetic effect on mucous membranes.
Reassure patient that addiction is unlikely; most patients who receive opiates for medical
reasons do not develop dependence syndromes.

Phenadoz, Phenergan, Promethegan
Drug classes
Antiemetic, Antihistamine, Antimotion-sickness drug, Dopaminergic blocker, Phenothiazine,
Therapeutic actions
Selectively blocks histamine-1 receptors, diminishing the effects of histamine on cells of the
upper respiratory tract and eyes and decreasing the sneezing, mucus production, itching, and
tearing that accompany allergic reactions in sensitized people exposed to antigens; blocks
cholinergic receptors in the vomiting center that are believed to mediate the nausea and vomiting
caused by gastric irritation, by input from the vestibular apparatus (motion sickness, nausea
associated with vestibular neuritis), and by input from the chemoreceptor trigger zone (drug- and
radiation-induced emesis); depresses the RAS, including the parts of the brain involved with
Symptomatic relief of perennial and seasonal allergic rhinitis, vasomotor rhinitis, allergic
conjunctivitis; mild, uncomplicated urticaria and angioedema; amelioration of allergic
reactions to blood or plasma; dermatographism, adjunctive therapy (with epinephrine and
other measures) in anaphylactic reactions
Treatment and prevention of motion sickness; prevention and control of nausea and
vomiting associated with anesthesia and surgery

Preoperative, postoperative, or obstetric sedation

Adjunct to analgesics to control postoperative pain

Contraindications :
Contraindicated with hypersensitivity to antihistamines or phenothiazines, coma or severe CNS
depression, bone marrow depression, vomiting of unknown cause, concomitant therapy with
MAOIs, lactation (lactation may be inhibited)
Allergy: Average dose is 25 mg PO or by rectal suppository, preferably at bedtime. If
needed, 12.5 mg PO before meals and at bedtime; 25 mg IM or IV for serious reactions.
May repeat within 2 hr if needed.
Motion sickness: 25 mg PO bid. Initial dose should be scheduled 3060 min before
travel; repeat in 812 hr if needed. Thereafter, give 25 mg on arising and before evening
Nausea and vomiting: 25 mg PO; repeat doses of 12.525 mg as needed, every 4 6 hr.
Give rectally or parenterally if oral dosage is not tolerated. 12.525 mg IM or IV, not to
be repeated more frequently than every 46 hr.
Sedation: 2550 mg PO, IM, or IV.
Preoperative use: 50 mg PO the night before, or 50 mg with an appropriately reduced
dose of meperidine and the required amount of belladonna alkaloid.
Postoperative sedation and adjunctive use with analgesics: 2550 mg PO, IM, or IV
Adverse effects:
Same as Pethidine
Nursing Interventions
Do not give to children younger than 2 yr because of risk of fatal respiratory depression;
use lowest effective dose and caution in children 2 yr and older.
Give IM injections deep into muscle.
Do not administer subcutaneously; tissue necrosis may occur.
Do not administer intra-arterially; arteriospasm and gangrene of the limb may result.
Do not administer subcutaneously into an artery or under the skin; drug may leach into
tissue and cause serious injury.
If IV route is used, limit drug concentration and rate of administration and ensure open
IV line.

(me troe nida zole) Apo-Metronidazole (CAN), Flagyl, Flagyl 375, Flagyl ER, MetroGel,
MetroGel-Vaginal, NidaGel (CAN), Noritate, Protostat, Vandazole
Drug classes
Amebicide, Antibacterial , Antibiotic, Antiprotozoal

Therapeutic actions
Bactericidal: Inhibits DNA synthesis in specif-ic (obligate) anaerobes, causing cell death;
antiprotozoal-trichomonacidal, amebicidal
Biochemical mechanism of action is not known.
Acute infection with susceptible anaerobic bacteria
Acute intestinal amebiasis
Amebic liver abscess
Trichomoniasis (acute and partners of pa-tients with acute infection)
Bacterial vaginosis
Preoperative, intraoperative, postoperative prophylaxis for patients undergoing colo-rectal
Topical application: Treatment of inflam-matory papules, pustules, and erythema of rosacea
Unlabeled uses: Prophylaxis for patients undergoing gynecologic, abdominal sur-gery; hepatic
encephalopathy; Crohns dis-ease; antibiotic-associated pseudomem-branous colitis; treatment of
Gardnerella vaginalis, giardiasis (use recommended by the CDC); infected decubitus ulcers; perioral dermatitis
Contraindications and cautions
Contraindicated with hypersensitivity to metronidazole; pregnancy (do not use for
trichomoniasis in first trimester).
Use cautiously with CNS diseases, hepatic disease, candidiasis (moniliasis), blood dyscrasias,
Adults: IV
Anaerobic bacterial infection: 15 mg/kg IV infused over 1 hr; then 7.5 mg/kg infused over 1 hr
every 6 hr for 710 days, not to exceed 4 g/day.
Prophylaxis: 15 mg/kg infused IV over 3060 min and completed about 1 hr be-fore surgery.
Then 7.5 mg/kg infused over 3060 min at 6- to 12-hr intervals after initial dose during the day
of surgery only.
Adverse effects
CNS: Headache, dizziness, ataxia,vertigo, incoordination, insomnia, seizures, peripheral
neuropathy, fatigue
GI: Unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, cramps
GU: Dysuria, incontinence, darkening of the urine
Local: Thrombophlebitis (IV); redness, burning, dryness, and skin irritation (topical)
Other: Severe, disulfiram-like interaction with alcohol, candidiasis (superinfection)
Decreased effectiveness with barbiturates
Disulfiram-like reaction (flush-ing, tachycardia, nausea, vomiting) with alcohol
Psychosis if taken with disulfiram

Increased bleeding tendencies with oral anticoagulants

Nursing considerations
History: CNS or hepatic disease, candidiasis (moniliasis), blood dyscrasias, preg-nancy,
Physical: Reflexes, affect; skin lesions, color (with topical application); abdominal
examination, liver palpation; urinalysis, CBC, LFTs
Administer oral doses with food.
Apply topically (MetroGel) after cleansing the area. Advise patient that cosmetics may be used
over the area after application.
Reduce dosage in hepatic disease

Drug classes: Antibacterial, Fluoroquinolone
Therapeutic actions
Bactericidal; interferes with DNA replication in susceptible bacteria preventing cell
For the treatment of infections caused by susceptible gram-negative bacteria, including
Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter cloa-cae, Proteus
vulgaris, Proteus rettgeri, Morganella morganii, Pseudomonas aeruginosa, Citrobacter freundii,
Staphy-lococcus aureus, Staphylococcus epider-midis, group D streptococci, Serratia marcescens
Treatment of uncomplicated UTIs caused by E. coli, K. pneumoniaeas a one-time dose in
patients at low risk of nausea, diarrhea (Proquin XR)
Otic: Treatment of acute otitis externa
Treatment of chronic bacterial prostatitis
IV: Treatment of nosocomial pneumonia caused by Haemophilus influenzae, K. pneumoniae
Oral: Typhoid fever
Oral: STDs caused by Neisseria gonorrheae
Prevention of anthrax following exposure to anthrax bacilla (prophylactic use in regions
suspected of using germ warfare)
Acute sinusitis: Caused by H. influenzae, Streptococcus pneumoniae,or Moraxella catarrhalis
Lower respiratory tract infections: Caused by E. coli, Klebsiella, Enterobacter species, P.
mirabilis, P. aeruginosa, H. influenzae, Haemophilus parainfluenzae, S. pneumoniae
Unlabeled use: Cystic fibrosis in patients who have pulmonary exacerbations, gastroen-teritis
in children, mycobacterial infection, travelers diarrhea

Contraindications and cautions

Contraindicated with allergy to ciprofloxacin, norfloxacin or other fluoroquinolones,
pregnancy, lactation.
Use cautiously with renal impairment, seizures, tendinitis or tendon rupture asso-ciated with
fluoroquinolone use.
Uncomplicated UTIs: 250 mg PO every 12 hr for 3 days or 500 mg PO daily (ER tablets) for 3
days. Proquin XR500 mg PO once a day for 3 days.
Mild to moderate UTIs:250 mg every 12 hr PO for 714 days or 200 mg IV every 12 hr for 7
14 days.
Complicated UTIs:500 mg every 12 hr PO for 714 days or 400 mg IV every 12 hr or 1,000
mg (ER tablets) PO daily every 714 days.
Chronic bacterial prostatitis:500 mg PO every 12 hr for 28 days or 400 mg IV every 12 hr for
28 days.
Infectious diarrhea:500 mg every 12 hr PO for 57 days..
Respiratory infections:500750 mg PO every 12 hr or 400 mg IV every 812 hr for 714 days.
Adverse effects
CNS: Headache,dizziness, insomnia, fatigue, somnolence, depression, blurred vision,
hallucinations, ataxia, nightmares
CV: Arrhythmias, hypotension, angina
EENT: Dry eye, eye pain, keratopathy
GI: Nausea,vomiting, dry mouth, diarrhea,abdominal pain
GU: Renal failure
Hematologic: Elevated BUN, AST, ALT, serum creatinine and alkaline phosphatase;
decreased WBC count, neutrophil count, Hct
Other: Fever, rash
Nursing considerations
Arrange for culture and sensitivity tests be-fore beginning therapy.
Continue therapy for 2 days after signs and symptoms of infection are gone.
Be aware that Proquin XRis not inter-changeable with other forms.
Ensure that patient swallows ER tablets whole; do not cut, crush, or chew.
Ensure that patient is well hydrated.
Give antacids at least 2 hr after dosing.
Monitor clinical response; if no improvement is seen or a relapse occurs, repeat culture and
Encourage patient to complete full course of therapy.

(isonicotinic acid hydrazide, INH) (eye soe nyea zid) Isotamine (CAN), Nydrazid
Drug class: Antituberculotic
Therapeutic actions:
Bactericidal: Interferes with lipid and nucleic acid biosynthesis in actively growing tubercle
TB, all forms in which organisms are susceptible
Prophylaxis in specific patients who are tuberculin reactors or household members of
recently diagnosed tuberculars or who are considered to be high risk (patients with HIV, IV drug
users, recent converters [5 mm or more increase on skin test within 2 yr in patients younger than
35 yr or 15 mm or more increase in patients older than 35 yr] and children younger than 4 yr
with 10 mm or more induration on purified protein derivative tuberculin skin test)
Unlabeled use of 300400 mg/day, increased over 2 wk to 20 mg/kg/day, for improvement of
severe tremor in patients with MS
Contraindications and cautions
Contraindicated with allergy to isoniazid, isoniazid-associated hepatic injury or other severe
adverse reactions to isoniazid, acute hepatic disease.
Use cautiously with renal impairment, lactation, pregnancy
Treatment of active TB:5 mg/kg/day (up to 300 mg) PO in a single dose, with other effective
drugs or 15 mg/kg (up to 900 mg) PO two or three times per week. First-line treatment is
considered to be 300 mg INH plus 600 mg rifampin, each given in a single daily oral dose.
Consult manufacturers guidelines for other possible combinations.
Prophylaxis for TB: 300 mg/day PO in a single dose.
Concomitant administration of 1050 mg/ day of pyridoxine is recommended for those who
are malnourished or predisposed to neuropathy (alcoholics, diabetics)
Adverse effects
CNS: Peripheral neuropathy,seizures, tox-ic encephalopathy, optic neuritis and atrophy,
memory impairment, toxic psychosis
GI: Nausea, vomiting, epigastric distress, bilirubinemia, bilirubinuria, elevated AST, ALT
levels, jaundice, hepatitis
Hematologic: Agranulocytosis, hemolytic or aplastic anemia, thrombocytopenia, eosinophilia,
pyridoxine deficiency, pel-lagra, hyperglycemia, metabolic acidosis, hypocalcemia,
hypophosphatemia due to altered vitamin D metabolism
Hypersensitivity: Fever, skin eruptions, lymphadenopathy, vasculitis
Local: Local irritation at IM injection site
Other: Gynecomastia, rheumatic syndrome, SLE syndrome

Increased incidence of isoniazid-related hepatitis with alcohol and possibly if taken in high
doses with rifampin
Increased serum levels of phenytoin In-creased effectiveness and risk of toxicity of
carbamazepine Risk of high output renal fail-ure in fast INH acetylators with enflurane
Increased risk of hepatotoxicity with aceta-minophen, rifampin
Risk of sympathetic-type re-actions with tyramine-containing foods and exaggerated response
(headache, palpitations, sweating, hypotension, flushing, diarrhea, itch-ing) to histamine
containing food (fish [skip-jack, tuna] sauerkraut juice, yeast extracts)
Nursing considerations
History: Allergy to isoniazid, isoniazid-associated adverse reactions; acute hepatic disease;
renal impairment; lactation, pregnancy
Physical: Skin color, lesions; T; orientation, reflexes, peripheral sensitivity, bilateral grip
strength; ophthalmologic examina-tion; R, adventitious sounds; liver evaluation; CBC, LFTs,
renal function tests, blood glu-cose
Give on an empty stomach, 1 hr before or 2 hr after meals; may be given with food if GI upset
Give in a single daily dose. Reserve parenteral dose for patients unable to take oral
Decrease foods containing tyramine or histamine in patients diet.
Consult with physician and arrange for daily pyridoxine in diabetic, alcoholic, or mal
nourished patients; also for patients who develop peripheral neuritis, and those with HIV.
(rifam pin) Rifadin, Rimactane, Rofact (CAN)
Drug classes: Antibiotic, Antituberculotic (first-line)
Therapeutic actions
Inhibits DNA dependent RNA polymerase activity in susceptible bacterial cells.
Treatment of pulmonary TB in conjunction with at least one other effective antituber-culotic
Neisseria meningitidiscarriers, for asymp-tomatic carriers to eliminate meningococ-ci from
nasopharynx; not for treatment of meningitis
Unlabeled uses: Infections caused by Staphy-lococcus aureus and Staphylococcus epi-dermis,
usually in combination therapy gram-negative bacteremia in infancy; Le-gionella (Legionella
pneumophila) not re-sponsive to erythromycin; leprosy (in com-bination with dapsone);
prophylaxis of meningitis caused by Haemophilus in-fluenza
Contraindications and cautions

Contraindicated with allergy to any ri-famycin, acute hepatic disease, lactation.

Use cautiously with pregnancy (teratogenic effects have been reported in preclinical stud-ies;
safest antituberculous regimen for use in pregnancy is considered to be rifampin, isoniazid, and
Pulmonary TB: 10 mg/kg/day; not to ex-ceed 600 mg in a single daily dose PO or IV(used in
conjunction with other antituber-culotics). Continue therapy until bacterial conversion and
maximal improvement occur.
Meningococcal carriers:600 mg PO or IV once daily for 4 consecutive days or 600 mg every
12 hr for 2 days.
Adverse effects
CNS: Headache, drowsiness, fatigue, dizzi-ness,inability to concentrate, mental con-fusion,
generalized numbness, ataxia, mus-cle weakness, visual disturbances, exudative conjunctivitis
Dermatologic: Rash,pruritus, urticaria, pemphigoid reaction, flushing, reddish-orange
discoloration of body fluidstears, saliva, urine, sweat, sputum
GI: Heartburn, epigastric distress,anorex-ia, nausea, vomiting, gas, cramps, diarrhea,
pseudomembranous colitis, pancreatitis, el-evations of liver enzymes,hepatitis GU:
Hemoglobinuria, hematuria, renal in-sufficiency, acute renal failure,men-strual disturbances
Hematologic: Eosinophilia, thrombocy-topenia, transient leukopenia,hemolytic anemia,
decreased Hgb, hemolysis
Other: Pain in extremities, osteomalacia, myopathy, fever, flulike symptoms
Nursing considerations:
Administer on an empty stomach, 1 hr be-fore or 2 hr after meals.
Administer in a single daily dose.
Consult pharmacist for rifampin suspension for patients unable to swallow capsules.
Prepare patient for the reddish-orange col-oring of body fluids (urine, sweat, sputum, tears,
feces, saliva); soft contact lenses may be permanently stained; advise patients not
to wear them during therapy.

(peer a zina myde) Tebrazid (CAN)
Drug class: Antituberculotic
Therapeutic actions
Bacteriostatic or bacteriocidal against My-cobacterium tuberculosis;mechanism of ac-tion is

Initial treatment of active TB in adults and children when combined with other
Treatment of active TB after treatment fail-ure with primary drugs
Treatment of drug-resistant TB as part of an individualized regimen
Contraindications and cautions
Contraindicated with allergy to pyrazinamide, acute hepatic disease, lactation, acute gout.
Use cautiously with diabetes mellitus, acute intermittent porphyria, pregnancy
Adults and pediatric patients: 1530 mg/kg/day PO, given once a day; donot exceed 2 g/day.
Always use with up to four other antituberculotics; administer for the first 2 mo of a 6-mo
treatment program. 5070 mg/ kg PO twice weekly may increase compliance and is being
studied as an alternative dosing schedule. Patients with HIV infection may re-quire a longer
course of therapy.
Adverse effects
Dermatologic: Rashes, photosensitivity
GI: Hepatotoxicity, nausea, vomiting, diarrhea, anorexia
Hematologic: Sideroblastic anemia, thrombocytopenia, adverse effects on clot-ting mechanism
or vascular integrity
Other: Active gout
Nursing considerations
Administer only in conjunction with other antituberculotics.
Administer once a day.
Arrange for follow-up of LFTs (AST, ALT) pri-or to and every 24 wk during therapy.

(e thambyoo tole) Etibi (CAN), Myambutol
Drug class: Antituberculotic (second line)
Therapeutic actions
Inhibits the synthesis of metabolites in grow-ing mycobacterium cells, impairing cell
metabolism, arresting cell multiplication, and causing cell death.
Treatment of pulmonary TB in conjunction with at least one other antituberculotic
Contraindications and cautions
Contraindicated with allergy to ethambutol; optic neuritis.

Use cautiously with impaired renal function, lactation, pregnancy (use other antituberculotics),
visual problems (cataracts, dia-betic retinopathy).
Ethambutol is not administered alone; use in conjunction with other antituberculotics.
Initial treatment: 15 mg/kg/day PO as a single daily oral dose. Continue therapy until
bacteriologic conversion has become per-manent and maximal clinical improvement has
Retreatment:25 mg/kg/day as a single daily oral dose. After 60 days, reduce dose to 15
mg/kg/day as a single daily dose.
Adverse effects
CNS: Optic neuritis(loss of visual acuity, changes in color perception), fever, malaise,
headache, dizziness, mental confusion, dis-orientation, hallucinations, peripheral neu-ritis
GI: Anorexia, nausea, vomiting,GI up-set, abdominal pain, transient liver impair-ment
Hypersensitivity: Allergic reactions dermatitis, pruritus, anaphylactoid reaction
Other: Toxic epidermal necrolysis, thrombocytopenia,joint pain, acute gout
Decreased absorption with aluminum salts
Nursing considerations
Administer with food if GI upset occurs.
Administer in a single daily dose; must be used in combination with other antituber-culotics.
Arrange for follow-up of LFTs, renal func-tion tests, CBC, ophthalmologic examina-tions


Drug class: Electrolyte
Therapeutic actions: Principal intracellular cation of most body tissues, participates in a
number of physiologic processesmaintaining intracellular tonicity; transmission of nerve
impulses; contraction of cardiac, skeletal, and smooth muscle; maintenance of normal renal
function; also plays a role in carbohydrate metabolism and various enzymatic reactions.
Prevention and correction of potassium deficiency; when associated with alkalosis, use
potassium chloride; when associated with acidosis, use potassium acetate, bicarbonate, citrate, or
IV: Treatment of cardiac arrhythmias due to cardiac glycosides
Contraindications and cautions
Contraindicated with allergy to tartrazine, aspirin (tartrazine is found in some preparations

marketed as Kaon-Cl, Klor-Con); therapy with potassium-sparing diuretics or aldosteroneinhibiting agents; severe renal impairment with oliguria, anuria, azotemia; untreated Addisons
disease; hyperkalemia; adynamia episodica hereditaria; acute dehydration; heat cramps; GI
disorders that delay passage in the GI tract.
Individualize dosage based on patient response using serial ECG and electrolyte determinations
in severe cases.
Adults : Oral Prevention of hypokalemia: 1624 mEq/
day PO. Treatment of potassium depletion: 40 100 mEq/day PO.
IV : Do not administer undiluted. Dilute in dextrose solution to 4080 mEq/L.
Adverse effects
Dermatologic: Rash
GI: Nausea, vomiting, diarrhea, abdominal discomfort, GI obstruction, GI bleeding,
GI ulceration or perforation
Hematologic: Hyperkalemiaincreased serum potassium, ECG changes (peaking of
T waves, loss of P waves, depression of ST segment, prolongation of QTc interval)
Local: Tissue sloughing, local necrosis, local phlebitis, and venospasm with injection.
Nursing Intervention:
Arrange for serial serum potassium levels before and during therapy.
Administer liquid form to any patient with delayed GI emptying.
Administer oral drug after meals or with food and a full glass of water to decrease GI
Caution patient not to chew or crush tablets;
have patient swallow tablet whole.
Mix or dissolve oral liquids, soluble powders, and effervescent tablets completely in 38
oz of cold water, juice, or other suitable beverage, and have patient drink it slowly
Arrange for further dilution or dose reduction if GI effects are severe.
Agitate prepared IV solution to prevent layering of potassium; do not add potassiumto
an IV bag in the hanging position.
Monitor IV injection sites regularly for necrosis tissue sloughing, and phlebitis.
Monitor cardiac rhythm carefully during IV administration.
Caution patient that expended wax matrix capsules will be found in the stool.
Caution patient not to use salt substitutes
It is the commonly-used phrase for a solution of 0.90% w/v of NaCl, about 300 mOsm/L or 9.0 g
per liter. Less commonly, this solution is referred to as physiological saline or isotonic saline,
neither of which is technically accurate. NS is used frequently in intravenous drips (IVs) for
patients who cannot take fluids orally and have developed or are in danger of
developing dehydration or hypovolemia. NS is typically the first fluid used when hypovolemia is
severe enough to threaten the adequacy of blood circulation, and has long been believed to be the

safest fluid to give quickly in large volumes. However, it is now known that rapid infusion of NS
can cause metabolic acidosis.
For medical uses, saline is often used to flush wounds and skin abrasions. Normal saline will not
burn or sting when applied.
Saline is also used in I.V. therapy, intraveno supplying extra water to rehydrate patients or
supplying the daily water and salt needs ("maintenance" needs) of a patient who is unable to take
them by mouth. Because infusing a solution of low osmolality can cause problems, intravenous
solutions with reduced saline concentrations typically have dextrose (glucose) added to maintain
a safe osmolality while providing less sodium chloride. As the molecular weight (MW) of
dextrose is greater, this has the same osmolality as normal saline despite having less sodium.
The amount of normal saline infused depends largely on the needs of the patient (e.g.
ongoing diarrhea or heart failure) but is typically between 1.5 and 3 litres a day for an adult.
Saline is also often used for nasal washes to relieve some of the symptoms of the common
cold. The solution exerts a softening and loosening influence on the mucus to make it easier to
wash out and clear the nasal passages for both babies and adults.

It is a solution is sterile and nonpyrogenic. It is a parenteral solution containing dextrose in water
for injection intended for intravenous administration. Each 100 mL of 5% Dextrose Injection,
USP, contains dextrose, hydrous 5 g in water for injection. The caloric value is 170 kcal/L. The
osmolarity is 252 mOsmol/L (calc.), which is slightly hypotonic. The solution pH is 4.3 (3.2 to
6.5). This solution contains no bacteriostat, antimicrobial agent or added buffer and is intended
only as a single-dose injection. When smaller doses are required the unused portion should be
discarded. 5% Dextrose Injection, USP is a parenteral fluid and nutrient replenisher.
Indications and usage
Intravenous solutions containing dextrose are indicated for parenteral replenishment of fluid and
minimal carbohydrate calories as required by the clinical condition of the patient.
5% Dextrose Injection, USP without electrolytes should not be administered simultaneously with
blood through the same infusion set because of the possibility that pseudoagglutination of red
cells may occur.
Clinical evaluation and periodic laboratory determinations are necessary to monitor changes in
fluid balance, electrolyte concentrations and acid-base balance during prolonged parenteral
therapy or whenever the condition of the patient warrants such evaluation.
Solutions containing dextrose should be used with caution in patients with known subclinical or
overt diabetes mellitus.
Do not administer unless solution is clear and container is undamaged. Discard unused portion
Adverse reactions

Reactions which may occur because of the solution or the technique of administration include
febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from
the site of injection, extravasation and hypervolemia.
If an adverse reaction does occur, discontinue the infusion, evaluate the patient, institute
appropriate therapeutic countermeasures and save the remainder of the fluid for examination if
deemed necessary
Dosage and administration
The dose is dependent upon the age, weight and clinical condition of the patient.
As reported in the literature, the dosage and constant infusion rate of intravenous dextrose must
be selected with caution in pediatric patients, particularly neonates and low birth weight infants,
because of the increased risk of hyperglycemia/hypoglycemia.
Drug Interactions
Additives may be incompatible. Consult with pharmacist, if available. When introducing
additives, use aseptic technique, mix thoroughly and do not store.
Parenteral drug products should be inspected visually for particulate matter and discoloration
prior to administration, whenever solution and container permit.


Date: 2070/03/03
Day: Monday
6 am

Blood pressure
100/80 mm of Hg
110/70 mm of Hg

97 oF
99.2 oF



2750 ml
2200 ml
Over 24 hours

Patients General condition seems weak. Patient is awake and well oriented but looks tierd and
lethargic. It is the 8th post operative day (patient undergone Exploratory Laparotomy with
resection and anstomosis). Pateint has fecal diversion after the surgery i.e. ileostomy present.
Central Line present for Parenteral medication and nutrition. Abdominal incision present post
surgery.patient also has 1st degree bedsore on sacral region.
Chest Bi-lateral equal air entry, soft and tender Per abdomen.No wound soakage but gaps
between two sutures present on distal portion. Dressing done. CVP was 9mm of H20 , CVP care
Patients blood Potassium value was 3.0 meq/l so and had been on very lowered side for a long
time so Inj KCL 120meq/l over 24 hours in IV pint of NS being administered.
Patient had complain of slight pain so nursing care was provided along with medical
management. Deep breathing excersise was taught.
Patient is in active stage of Tuberculosis under ATT for 9 days now.
Health teaching about risk of infection, risk of tuberculosis transmission to others was given.

Date: 2070/03/04
Day: Tuesday
6 am

Blood pressure
100/70 mm of Hg
110/70 mm of Hg

2800 ml
2400 ml
Over 24 hours

97.8 oF
98.8 oF



Patient is wide awake and well oriented to time, place and person. However looks irritated and
restless. Chest Bi-lateral equal air entry, soft and tender Per abdomen. No wound soakage. CVP
line in-situ, Dressing done on abdominal wound and CVP site. Bedsore dressing done and left
open and is healing. Colostomy bag changed and colostomy care provided with teaching given to
Lab values of blood sodium = 125 meq/l and potassium= 3.0 meq/l. Health teaching about
nutrition and fluid management provided. Patient instructed to change position frequently at least
every 2 hours. ATT, antibiotic and other medications carried out.
Date: 2070/03/05
Day: Wednesday
6 am

Blood pressure
100/80 mm of Hg
90/70 mm of Hg

97.4 oF
98.4 oF



4900 ml
3930 ml
Over 24 hours
Pateint is well oriented and awake. Patient seems fresh and has become open to conversation.
Appetite has been increased and patient is eating soft diet. Chest and abdomen examination done
and are normal.CVP care and wound dressing done. Bedsore Dressing done.
Ileosomy bag had leakage so bag changed and care done with assistance provided to visitor.
Patient complained that he had disturbed sleep due to leakage of ielostomy bag at night.
Necessary interventions carried out. (refer careplan). Besore seems to be healing with no need
for dressing.
Date: 2070/03/06
Day: Thursday
6 am

Blood pressure
100/70 mm of Hg
110/70 mm of Hg

97.8 oF
98.0 oF



3900 ml

Patient General condition seems fair. He is awake and oriented. Abdomen tender and soft and
bowel sound present. Chest clear. Abdominal wound seems to be healing but still the gap
netween stures has not joined completely.
Lab values of Blood sodium was= 134 meq/l and Potassium was 4meq/l.

Antibiotic and I/V fluids has been stopped and Inj KCl supplement has been stopped too.
Patinet now has Tab Tramadol, Tab Pantop , Syrp Potklor and ATT as medication.
Patient is eating well. Patient complained of back pain so patient was assisted to change position
, sit upright with support and oil massage done by visitor.

Date: 2070/03/07
Day: Friday
6 am

Blood pressure
100/70 mm of Hg
90/70 mm of Hg

97.8 oF
98.0 oF



3900 ml

Patient General condition seems fair. Vital s have been stable. Patient has normal finding on
chest and abdomen examination. Pateint seems well rested and cheerful. He has been eating well
and increased movements during the day. Colostomy care, back care, Wound dressing provided.
Patient in tolerating normal diet. No specific complain. Discharged has been planned but patient
party does not seem ready . Counselling done and Information and health teaching provided
regarding nutrition, continuity of care, medication, tuberculosis treatment, follow up visits,
colostomy care and so on.

Date:, 2070/03/010
Day: Monday
Patient seems well. Looks fresh and cheerful. Patient seemed to be coping well with the
situation.Discharge has been planned for today. Patient party looked more convinced. Queries
were raised about further care at home. Information provided including home adjustments for
dressing continuation and colostomy care. Patient party consulted a known health personnel, for
homevisit who could carry out dressing and other needed care once a day.
Patient father informed that necessary adjustment to room setting has been done at home.
Patient was discharged around 1pm today with follow up visit scheduled for Thursdaya they live
in a walking distance from Bir Hospital.


Diversional Therapy is a client centered practice that recognizes that leisure and recreational
experiences are the right of all individuals. Diversional Therapists promote the involvement in
leisure, recreation and play by reducing barriers to their client's participation and providing
opportunities where the individual may choose to participate. Ideally these recreational activities
promote self-esteem and personal fulfillment, through an emphasis on holistic care; providing
physical, psychological, social, intellectual and spiritual/cultural support.
It is not just about passing the time, about being entertainers or babysitters. Stress threshold
depends on individual. Different people have different experiences, some has lower grade and
some has higher grade. Divertional therapy is used in parallel with medicines for the treatment of
sick person because during illness a person has more concern about his body and illness. This
concern may cause severe depression and emotional upsets. I used following divertional therapy
to minimize stress of my patient:

Stress management strategy:

1. Talk therapy:
I made conversation with my patient and his family timely through which I found out his
views and expectation towards the disease condition, hospital surroundings, policies,
hospital staffs and rules and regulations. I also explained her about treatment methods. I
was always patient and open to their queries. Through the talk therapy, I was able to
minimize stress and divert patients mind.
2. Autogenic training:
It is the method of replacing pain and unpleasant event or situation with pleasant ones
through self readiness and action. I taught my patient about the method and provided him
sufficient rest and adequate sleep as it helps to reduce pain and induce sleep which can
minimize the stress easily.
3. Imaginary:
It is the imagination and concentration to take mental vacation. I encouraged my patient
to prevent the stressful thought from his mind. I encouraged him to imagine pleasant
sceneries and peaceful environment which helped to divert mind and reduce stressful

4. Distraction:
This is the method of diverting mind in another pleasant situation. I suggested him to
distract his mind by listening to music, singing or watching Television program at home
after discharge, and allow friends visits.(keeping in mind the risk of infections)

5. Deep breathing and relaxation:

During the time of mild pain, I advised him to take deep breath and relax the body.

Result of diversional therapy:

I found myself succeed to meet the goal towards minimizing the patient stress as
evidenced by patient verbalization of feelings and anxiety and demonstration of behavior


Health teaching during hospitalization play important role for the timely recovery of patient.
Health education is important in preventing disease; promoting health and to cure disease
without any complication. I have provided following teaching to the patient and his family.
The objectives of health education:

To promote health by using locally available resources.

To prevent illness and infection.
To recover from illness and achieve normal health.
To prevent complications.
To maintain and fulfill the nutritional status of the patient.
To provide good family environment.

Health education provided to achieve above objectives:

Nutrition: Providing healthy and well balanced diet is most for the quick recovery of the patient.
As food is the good source of energy, it helps to cope with the disease and live healthy.

Personal hygiene: Maintain personal hygiene of client regarding bed bath, oral care, nail
care, changing clean clothes, food hygiene and perineal hygiene to prevent infection.
Encourage the visitors to keep the patient with proper bladder care and ostomy care.
Bladder and Bowel Care: Encourage the patient to drink about 2 to 3 liters water per
day. Encourage the patient to take diet according to the disease condition for example
high protein diet for timely healing and tissue repair, carbohydrate for energy and
limiting fibers due to risk of high effluent in ostomy.
Respiratory care: Encourage the patient to take deep breath and exhale to avoid pooling
of secretions and prevent pulmonary complications like cough, hypostatic pneumonia but
at the same time take precautions so as to prevent tubercular infections to caregivers.
Rest and sleep: Encourage the patient to take adequate rest and sleep well because rest
and sleep reduces fatigue and need for oxygen consumption and provided with ideas and
knowledge to enhance un-interrupted sleep.
Reporting: Encourage the patient and his visitors to report any unusual signs and
symptoms that may indicate complications like fever, redness/blister/injury in the skin,
cough, problem in urination etc.
Medicines: Provide health teaching to the visitors not to take self medications. If they see
any unusual symptoms, report promptly. Encourage the visitors to ask questions if they
have any queries regarding the medicines.
About Tuberculosis: Provide family and patient with health teaching about the care of
tuberculosis patient and the nearest care givers to prevent cross infections, complications,
or reactivations.
About Ileostomy care: Provide teaching about the ostomy care and assured that re
demonstration was acceptable.

Health teaching during discharge and hospitalization are important for preventing complications,
promoting health and restoring the sound health, maintaining normal and actual living style.
Objectives of discharge teaching plan:
To promote and maintain health and prevent from illness in home after discharge.
To consider primary health care concept in health teaching.
To provide holistic care to the patient.
To provide need based health education.

I provided teaching on the following topics:Medicines:

Anti Tuberculosis Treatment: I explained medication dosage, frequency of

administration, expected action and the reason for long treatment period emphasizing on
necessity of continuous drug treatment and following of DOT regimen.
Reviewed potential side effects of Tuberculosis treatment such as dry mouth,
gastrointestinal (GI) upset, constipation, visual disturbances, headache, and orthostatic
hypertension may occur as side effects but it is important that ant tuberculosis drugs not
be discontinued because of nuisance side effects. Problem solving could be done; as
taking medication with food and changing the hour of dosing, may reduce discomfort
associated with therapy. However, severe reactions must be reported to physician.
Reviewed that TB is transmitted primarily by inhalation of airborne organisms, but may
also spread through stools or urine if infection is present in these systems; also reviewed
hazards of reactivation as providing knowledge may reduce risk of transmission or
Take your medicine as directed: I informed my patients to keep a list of the medicines
including TB medications and other vitamins, painkillers, and include the amounts, when
and why you take them. Carry your medicine list with you in case of an emergency.


I emphasized the importance of maintaining high-protein and carbohydrate diet and

adequate fluid intake.
Discussed need for periodic evaluation and administration of supplemental vitamins and
minerals, as appropriate during follow up visits.
Stressed importance of chewing food well, adequate intake of fluids with and following
meals, only moderate use of high-fiber foods, and avoidance of cellulose.
Reviewed foods that are, or may be, a source of flatus, such as carbonated drinks, beer,
beans, cabbage, onions, fish, and highly seasoned foods; or odor, such as onions,
cabbage, eggs, fish, and beans.
Patient party to identify foods associated with diarrhea, such as green beans, broccoli, and
highly seasoned foods.
Recommend foods used to manage constipation, such as bran, celery, and raw fruits, and
discuss importance of increased fluid intake.

Rest as needed
Drink liquids as directed
Take part in ileostomy care and personal hygiene.
Eat nutritious small frequent meals rather than three large meals.
Encouraged for follow-up visits with the health care
Seek care immediately when:
Dizzy or feel confused.

Arm or leg feels warm, tender, and painful. It may look swollen and red.
Suddenly feel lightheaded and short of breath.
Pulling below skin
Blood in cough.
Often leaking ileostomy bag or doenot fit well as before.
Skin around stoma is buldging out.
Any sore on skin around.
Persistent diarrhea
Identification of problems:
Identify symptoms of electrolyte depletion, such as anorexia, abdominal muscle cramps,
feelings of faintness or cold in arms and legs, general fatigue or weakness, bloating, and
decreased sensations in extremities as it may indicate loss of colon function.
Identify signs and symptoms requiring medical evaluation, such as recurrent abdominal
pain or distention, vomiting, fever, chills, or presence of purulent drainage, swelling, and
erythema of surgical incision.


1. About the disease:
I studied about the disease condition, causes, sign and symptoms, treatment, management
through the different resources like library, net, researches, literature, etc. Also I received
information from staffs, doctors and other medical staffs.
2. About the patient.
I got a chance to know about the history of patient, his personal habits, ways of living,
thinking and its influences on health and illness.
3. About the environment, family and age factor.
I also got information about my patient's family background, socio-cultural and education
background, concept about health and illness, nutrition, economic status, traditional
beliefs and attitude towards disease. I could presume that how this age groups
(adolescent) are more prone to diseases nowadays by studying about patients lifestyle. I
found out that avoidance of nutrition, health care by this age group could be related to
advancement of technologies like children are now addicted on playing video games,
online games, going to cybe , spending more and more time with friend in comparison to
older days where children were busy playing physical games with peer groups and stayed
under parents supervision most of the time. There may also be problems of choosing a
wrong path like drug addiction, alcoholism, smoking, crimes or simply leading to
malnutrition, avoidance of education e.t.c as parents are more and busier in earning
money for their daily living and spending less time with their children. Though, this
could be just a personal assumption of mine, which cannot be concluded through a single





case study, nevertheless, I received more inspiration and encouragement to look into the
depths of situations that may lead to deterioration of ones health
About nursing care:
I applied holistic approach while providing nursing care to the patient. I also applied
Abdellahs theory while caring my patient by using nursing process. I gained lot of
knowledge about the care plan while planning and implementing the nursing care.
About the documentation:
Documentation is also an important skill which I developed by the case study. I could
learn this skill by my observation, activities, findings and conclusion. I developed this
skill so that I formulate the case study systematically and deeply.
About stress and management:
I got the chance to solve my patient's emotional worries, tensions by providing different
techniques of reducing stress, divertional therapy and psychotherapy. I also provided him
emotional and psychological support which was really helpful to reduce stress.
About the hospital policy:
During my case study I involved in every sector of activities like reporting, recording,
admission, discharge procedures. So I could understand the rules and policy about Bir
hospital, which is very useful.


During my 8 weeks hospital major practicum of NAMS Bir Hospital Nursing Campus BN1st
year curriculum, I chose the case of Abdominal tuberculosis with perforation peritonitis for my
case study, patient name Yubraj Patamagar, 17 years of female admitted in Male surgical ward.
He is from Ashon. He was admitted to ward with the complain of abdominal pain and distension
, and inability to pass stool , and after necessary investigations, he was diagnosed with Perfotaion
Peritonitis due to Intestinal Tuberculosis.
I provided holistic nursing care to the patient according to his need by considering the physical,
mental, socio-cultural, spiritual and economic aspect. I provided nursing care based on
Abdellahs Problem Solving Theory. During hospitalization I also provided necessary health
education regarding health promotion, maintenance, prevention from infection,post surgey care,
nutrition and discharge teaching that he needed to cope with his disease condition.
During interaction with my patient, he and his family members were very co-operative with me
so there was no difficulty providing care and collecting information. The immense help of
patient and his family inspired me to study the case thoroughly and become able to provide better

Case study is one of the most important aspect of Nursing practice in the hospital setting.It
provides us an opportunity for l comprehensive study of one selected case in comparision with
book and helps to provide holistic nursing care to the patient according to developmental
Abdominal Tuberculosis and Peritonitis can be important experiences for all learning personnel
for getting clear and up to date knowledge about disease condition. This will not only help us to
promote safe and healthy living in the family and the community but also it will help to reduce
morbidity and mortality rates. Such detailed case study gives knowledge about what are
problems, its causes, sign and symptoms and nursing consideration. Case study also helps us to
do research.
During hospitalization, I provided my patient with holistic nursing care in every aspects like
physical, emotional, economical and socio-cultural ways. I also gained knowledge about nursing
theory and its application in real situation. So, the case study not only gives the cognitive domain
but also provide us the opportunity to develop psychomotor domain, which is very important in
nursing field. So, the patient is main source of converting knowledge in practice.
I also got opportunity to know about my patient, family, socio-cultural, economic status,
religious background which helped me in providing care effectively. I could also find out some
socio-cultural factors affecting the health of adolescent age group In this way, this case study
provided me a good opportunity to gain deep knowledge on Abdomial Tuberculosis and
Peritonitis, so I am completely satisfied with my case study.


Smeltzer Suzanne C., Bare Brenda G., Hinkle Janice L., Cheever Kerry H., 2008 Brunner
& Suddharths Textbook of Medical-Surgical Nursing, Eleventh Edition Lippincott
Williams & Wilkins.
Davidson Sir Stanely, Davidsons Principle and Practice of Medicine,20th edition, (2012),
Churchill Livingstone Elsevier.
Porth Carol Mattson, sixth edition,(2002),Pathophysiology , Concepts of Altered Health
States, Lippincott Williams & Wilkins.
Doenges Marilynn.E, Moorhouse MF, Murr A.C, Nursing Care Plans, 8th edition,
2010,F. A. Davis Company,1915 Arch Street, Philadelphia
B.T Baswantathappa, medical surgical nursing.1st eddition,2003Jaypee brothers private
Rai Lalita, Nursing Concepts Theories And Principles, 2nd edition (2011), Publisher Mr,
Nabin Kumar Rai, Basaha-1, Udaypur.
Shrestha Tumla, Essential Child Health Nursing, 1st edition (2012), Medhavi Publication
New Baneshwar, Kathmandu.
Karch.A.M, 2012 Lippincots Nursing Drug Guide, Lippincott Williams & Wilkins
Skidmore Linda, Mosbys 2013 Nursing Drug Reference.
www.jkscience.org Vol. 12 No.3, July- September 2010
http://www.biomedcentral.com/1471-2482/10/12, Jain et al. BMC Surgery 2010, 10:12
Terms: Abdomen, Acute/microbiology*; Adult; Anthrax/complications*
www.docstoc.com/docs/70193806/Abdominal-Tuberculosis-Current...600 Medicine
Update Abdominal Tuberculosis 102 Current Concept
www. myESR.org