CASE STUDY

WILT SKYNYRD S. DAGUIO

PATIENTS PROFILE
 The patient is a 62 year old female residing at Zone 4, Maliwalo, Tarlac City
and was admitted to a private hospital due to abdominal bloatedness.
CHIEF COMPLAINT
 Abdominal bloatedness
HISTORY OF PRESENT ILLNESS
 Two months prior to admission, the patient felt abdominal pain associated
with bloatedness. She then took Omeprazole for relief. For two months,
she was relieved of the medication.
 One month prior to admission, the patient was no longer relieved by the
medication. Abdominal bloatedness persisted but with associated nausea
and vomiting. Hence, she sought consult to a private physician. She then
was requested and undergone esophageagastroduodenoscopy, abdominal
ultrasound and CT scan. These tests revealed a gastric adenocarcinoma and
gallbladder hydrops. The patient was advised for total gastrectomy. Hence,
the patient was admitted.
PAST MEDICAL HISTORY
 She had no known hospitalizations in the past except when her first baby
was aborted. Other than that, there were no injuries, blood transfusions or
other medical conditions.

LEGEND:
FAMILY HISTORY History of CA

History of Hypertension

Father Mother
 63 60 58 55 43 40 39
Eldest Patient 3rd eldest 4th eldest

OB HISTORY
 The patient’s GTPALM is (100100). Her menarche is when she was 14 years
old with regular intervals of menstruation. She consumes 2-3 soaked pads
per day. Her menopause is when she was 53 years old.

NUTRITIONAL AND LIFESTYLE STATUS

 The patient appears to be fairly nourished with an ectomorph body built.
She claims that she is a herbalist. She is more on the herbal products for
anti-oxidants and maintaining optimum health status.
Everyday meal of the patient. For breakfast, she usually drinks coffee and
eats bread. Her meal for lunch mostly consist of processed foods. The
patient does not eat dinner often. She does not have like smoking or
drinking alcoholic beverages. When the patient’s symptoms begin to
worsen, she vomits whatever she eats.

SOCIO-ECONOMIC BACKGROUND
 The patient worked for more than 20 years at an insurance company as an
advisor. Her income is more than enough to aid in her daily expenses.

 FUNCTIONAL HEALTH PATTERNS

SLEEP-REST PATTERN
 The patient sleeps at around 9 in the evening and wakes up at around 5 in
the morning. Sleep disturbance began when she experienced bloatedness
and pain.
ACTIVITY-EXECISE PATTERN
 The patient considers “Zumba” and walking as her exercise

ELIMINATION PATTERN
 She urinates 5-6 times a day depending on her fluid intake and defecates
once a day.

REVIEW OF SYSTEMS

CARDIOVASCULAR INTEGUMENTARY
 None None
GENITOURINARY REPRODUCTIVE
 None None
MUSCULOSKELETAL NEUROLOGIC

 None Occasional headache

RESPIRATORY METABOLIC

 None None
GASTROINTESTINAL
 Epigastric pain
GENERAL APPEARANCE
 Patient is awake, appears to be weak and conscious.

PHYSICAL EXAMINATION
BODY PARTS ACTUAL FINDINGS
HEAD/NECK Head and face is symmetric, no
presence of lesions.
EYES pupils are round, equal and
reactive to light.
NOSE No nasal flaring or discharged
observed.
EARS No discharges.
MOUTH Pinkish and sooth lips
Presence of dental carries
SKIN No presence of lesion
Presence of few scars
No edema
CHEST/THORAX AND LUNGS No noted use of accessory
muscles while breathing.
Bilateral chest expansion
HEART Normal heart rate and rhythm
ABDOMEN Presence of cholecystostomy tube
on the right hypochondriac region
Presence of jejunostomy tube on
the left lumbar region

UPON ADMISSION UPON ASSESSMENT

BP: 120/80mmHg BP: 100/70mmHg
PR: 80 bpm PR: 91 bpm
RR: 21 cpm RR: 22 cpm
T: 36.5 ‘C T: 36.4 ‘C
 Not able to percuss and palpate
due to certain conditions of the
patient .
UPPER EXTREMITIES Arms are equal in size and
symmetric bilaterally
Presence of few scars
No edema
LOWER EXTREMITIES Legs are bilaterally symmetric
Presence of few scars, no edema
 LABORATORY RESULTS
PRO-TIME DATE: OCT. 02,2016 @
3:14pm
PARAMETERS RESULTS
Patient NV: 10-14 seconds Patient’s time: 10.5 seconds
Control NV: 10.4-13.2 seconds Control: 11.0 seconds
% Activity: 79-100% % Activity: 115.9%
INR: 0.01

HEMATOLOGY DATE: OCT. 02, 2016 @ 3:13pm

Blood count Normal value Results Indication
WBC 3.98 – 10.04 x 6.40 Normal
10^3/Ul
NEUTRO% 34.0 – 71.1 70.6 Normal
LYMPHO% 19.3 – 51.7 17.2 Decreased
MONO% 4.7 – 12.5 9.4 Normal
EO 0.7 – 5.8 2.3 Normal
BASO% 0.1 – 1.2 0.5 Normal
 NEUTRO# 1.56 – 6.13 x 4.52 Normal
10^3/uL
LYMPHO# 1.18 – 3. 74 x 1.10 Normal
10^3/Ul
MONO# 0.24 – 0.36 x 0.33 Normal
10^3/Ul
EO# 0.04 – 0.36 x 0.15 Normal
10^3/Ul
BASO# 0.01 – 0.08 x 0.03 Normal
10^3/uL

Blood count Normal value Results Indication

RBC 3.39 – 5.22 x 4.35 Normal
10^3/uL
HGB 11.2 – 15.7 g/dL 11.9 Normal
HCT 34.1 – 44.9 % 37.6 Normal
MCV 79.4 – 94.8 fl 86.4 Normal
MCH 25.6 – 32.2 pg 27.4 Normal
MCHC 32.2 – 35.5 g/dL 31.6 Decreased
RDW-CV 11.7 – 14.4 % 12.3 Normal
RDW-SD 36.4 – 46.3 fl 37.8 Normal
PLT 150 – 400 x 360 Normal
10^3/uL

ELECTROLYTES DATE: OCT. 02, 2016 @ 4:40pm

Test Result Normal value
SODIUM 114 mmol/L 137 – 145 mmol/L
POTASSIUM 4.3 mmol/L 3.6 – 5.0 mmol/L
CREATININE 90 mmol/L 62 – 106 mmol/L
APTT DATE: OCT. 02, 2016 @ 4:37pm
Parameters Result
NORMAL VALUE: 26.1 – 36.3 27.2 seconds
SECONDS
CONTROL: 27.7 – 34.0 SECONDS 27.7seconds

HEMATOLOGY DATE: OCT. 04,2016 @ 8:30pm

Blood count Normal value Results Indication
WBC 3.98 – 10.04 x 19.20 Increased
10^3/Ul
NEUTRO% 34.0 – 71.1 86.9 Increased
LYMPHO% 19.3 – 51.7 6.5 Decreased
MONO% 4.7 – 12.5 6.5 Normal
EO 0.7 – 5.8 0.0 Normal
BASO% 0.1 – 1.2 0.1 Normal
NEUTRO# 1.56 – 6.13 x 16.71 Normal
10^3/uL
LYMPHO# 1.18 – 3. 74 x 1.24 Normal
10^3/Ul
MONO# 0.24 – 0.36 x 1.24 Increased
10^3/Ul
EO# 0.04 – 0.36 x 0.00 Normal
10^3/Ul
BASO# 0.01 – 0.08 x 0.01 Normal
10^3/uL

Blood count Normal value Results Indication

RBC 3.39 – 5.22 x 4.35 Normal
10^3/uL
 HGB 11.2 – 15.7 g/dL 11.9 Normal
HCT 34.1 – 44.9 % 37.6 Normal
MCV 79.4 – 94.8 fl 86.4 Normal
MCH 25.6 – 32.2 pg 27.4 Normal
MCHC 32.2 – 35.5 g/dL 31.6 Decreased
RDW-CV 11.7 – 14.4 % 12.3 Normal
RDW-SD 36.4 – 46.3 fl 37.8 Normal
PLT 150 – 400 x 360 Normal
10^3/uL
 CHEST PA DATE: 0CT.02,2016
FINDINGS:
Lungs are clear.
Heart is normal in size.
Diaphragm and both costophrenic sulci are intact.
The visualized bony structures are unremarkable.

IMPRESSION:
NORMAL CHEST RADIOGPRAPHIC FINDINGS.

WHOLE ABDOMEN(CONTRAST) TRI-PHASIC

Multiple axial images of the abdomen and pelvis were obtained with
oral intravenous contrast. Dynamic multiple axial images of the upper
abdomen were obtained with intravenous contrast.
The liver is normal in size and shape. The density if the liver is normal.
The liver parenchyma is homogenous. There is no focal mass lesion or
dilated intrahepatic ducts. The gallbladder is dilated measuring 10.5 x
5.4 cm (APxW) with lamellated focus near the neck region measuring
1.3cm. Free fluid is seen at the perihepatic, perisplenic, both gutter on
the pelvic region
The pancreas, kidneys, spleen, and adrenal glands are normal in size,
shape and location. There is no free air in the peritoneal cavity. The
visualized bowel loops are unremarkable.
There are no focal masses or enlarged lymph nodes in the peritoneal or
retroperitoneal areas. There is no focal mass in the pelvis. The urinary
bladder is well-distended.
The visualized osseous structure are unremarkable. Intimal
calcifications are seen in the abdominal aorta and iliac arteries

IMPRESSION:
• Consider gallbladder hydrops with lithiasis
• Ascites
• Atherosclerotic disease of the abdominal aorta and iliac arteries.
PATHOPHYSIOLOGY
Abdominal Bloatedness

Hepatobiliary tree Gastrointestinal

(+) gallbladder hydrops as (+) history of gastric CA

Evidenced by the CT Scan (+) excessive intake of
processed foods
Gallbladder distention

Abdominal pain possible inheritance

of CDH1 gene

EGD & CTscan

result formation of adenocarcinoma
(+) gastric
adenocarcinoma

formation of mass
 abdominal epigastric regurgitation
r bloatedness pain of acids

nausea and vomiting

NURSING DIAGNOSES
 Pain related to tumor mass
 Anxiety related to disease and anticipated treatment
 Imbalance nutrition less than body requirement
 NURSING MANAGEMENT
Pain related to tumor mass
• Assess frequency, intensity and duration for pain .
• Suggest pain relief measures such as position changes.
• Advise diversional activities
 Dependent
• Administer analgesics as prescribed
Anxiety related to disease and anticipated treatment
• Establish therapeutic rapport
• Explore patients feelings about current condition.
• Encourage family in efforts to support the patient/
 Dependent
• Administer anti-anxiety drugs as administered
Imbalance nutrition less than body requirements related to anorexia
• Monitor daily intake of fluids
 • Advise the patient to comply with the prescribed nutrition.
• Collaborative
• Refer the client to a Dietician
 Dependent
• Administer anti-emetic drugs
• Administer PPI
PRE-OPERATIVE MANAGEMENT
• Established therapeutic relationship
• Obtain baseline vital signs.
• Determine history of allergy.
• Emphasize deep breathing exercises and ambulation or movement of
extremities post-op.
• Remove jewelries and dentures.
• Gown the patient accordingly.
• Provide nutritional support as ordered to correct any nutrient deficiency.

INTRA-OPERATIVE MANAGEMENT
• Maintain asepsis and infection control.
• Aid the surgeon in performing the procedure.
• Ensure that all instrument used are counted and correct.
• Ensure that therapeutic communication is established.
• Monitor vital signs during the procedure.

POST-OPERATIVE MANAGEMENT
• Secure PACU parameters before transferring the patient into the room.
• Maintain patient flat on bed until anesthesia wears off
• Apply pre-op (ambulation)

DISCHARGE PLAN
 MEDICATIONS:
 Teach the client about the importance of the discharge medications and
their indication and possible side effects (Kefox 750mg q8 for 3 days,
Omeprazole 40mg OD for 3 days,c Ketesse 50g q8 for 2 days)
 Teach the client on how to take the medications properly.
 EXERCISE:
• Promote ambulation.
• Advise client to do non-strenuous activities to reduce pain
• Advise client to resume ADL when tolerated
 TREATMENT
• Educate the client about pain relief measures such as positioning,
distraction
• Educate patient about the use of PPI’s and analgesics
 HEALTH TEACHINGS
• Teach the client importance of treatment
• Teach the client of care of the jejunostomy tube, proper cleaning of tube,
and proper feeding
• Emphasize the importance of follow up check-ups.
 DIET
• Advise SO on how to properly feed the client via jejunostomy tube, amount
of feeding and frequency
• Advise oral intake of fluids to be minimized to prevent bloatedness.