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ST.

PAUL UNIVERSITY MANILA


St. Paul University System

College of Nursing and Allied Health Sciences

NURSING CARE STUDY


(Application of Nursing Process)

Name: Christine Mae H. Siervo BSN ______Date:_____________

I. ASSESSMENT
A. General Information

Client’s initials: R.A.M Age: 50 y/o Sex: Female CS: Single Nationality: Filipino
Religion: Catholic Educ. Attainment: High School Graduate Occupation:
Unemployed
Admission complaint/s: Abdominal pain
Final Diagnosis (if applicable): Intestinal Obstruction
______________________________________________________________________

Admitting VS: T: 36.9 P: 112 R: 22


BP: 110/80 Weight: ________ Height:_____ __ Arrived on unit by: Ambulatory
Accompanied by: Son Allergies: None Medications: _____________

Brief description of the diagnosis/ surgery performed:


Intestinal obstruction refers to a lack of movement of the intestinal contents through
the intestine. Because of its smaller lumen, obstructions are more common and
occur more rapidly in the small intestine, but they can occur in the large intestine
as well. Depending on the cause and location, obstruction may manifest as an
acute problem or a gradually developing situation.

B. Nursing History (Based on the Functional Health Pattern by Gordon)


1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
1.1 Client’s description of her/his health:
The patient verbalized that she don’t often experience health problems.

1.2 Health Management:


Self:
The patient verbalized that don’t have a particular regimen for her health.

Family and Children:


The patient verbalized that her sons are old enough to care for themselves.

1.3 History of present illness:


5 days prior to confinement, patient complained of abdominal pain on
epigastric area with a pain scale of 8/10 with 10 being the highest and 1
being the lowest and with associated vomiting (non-billus; non-bloody).
Patient also has reported loss of appetite.

1 day prior to confinement, there was persistence of abdominal pain with


associated vomiting. Patient was afebrile and with generalized body
malaise. Still with loss of appetite which leads the patient to seek consult
at EAMC.

1.4 Past illness:


Back in 2016 the patient experienced severe abdominal pain and difficulty
defecating. The patient sought consult at EAMC and was diagnosed with
ulcerative colitis. Prior to that the patient verbalized that she was perfectly
healthy.

1.5 History of hospitalization (when, where and why):


Patient had undergone hemicolectomy back in the year 2016 at EAMC

1.6 History of illness in the family:


Patient has no known history of family illness

1.7 Expectations of hospitalization:


The patient expects that she be nursed back to health as soon as possible.

1.8 Anticipation of problem with caring for self upon discharge:


The patient is concerned about having another complication following her
surgery.

1.9 Knowledge of treatment or practices prescribed:


The patient is aware of the medications that she is taking is taking.

1.10 Reaction to above prescriptions:


The patient understands her need of the medication she is taking.
2. NUTRITION AND METABOLIC PATTERN
2.1 Usual food intake (before admission)
Breakfast: Hotdog, daing, rice
Lunch: Meat (pork), fish, rice
Supper: Corned beef, pork, fish, rice
Snacks: Biscuits, Kakanin
Preferences: None

2.2 Usual fluid intake (type, amounts):


Before admission the client usually drinks 2 liters of water per day.

Preferences:
Coffee

2.3 Any food/fluid restrictions:


None

2.4 Any problems with ability to eat:


None

2.5 Any supplements (vitamins, feedings):


None

3. ELIMINATION PATTERN
3.1 Bladder:
Usual frequency/day, color and consistency:
The patient stated that she usually voids around 6-8 times a day and that
the usual color of her urine is amber yellow.

Complaints the usual pattern of urination:


None

Home remedies:
None

3.2 Bowel:
Usual pattern/day (time, frequency, color and consistency):
Once every two or three days

Complaints of usual pattern of bowel movement:


Often constipated

Home remedies:
None

3.3 Any assertive device:


None
3.4 Skin: (condition)
Pallor noted. Poor skin turgor in both upper and lower extremities; Warm
to touch, no active dermatoses.

4. ACTIVITY EXERCISE PATTERN


4.1 Usual daily/weekly activities:
Exercise:
Patient goes for walks when she is feeling like it.

Leisure:
Watching television

4.2 Any limitations of physical ability:


None

4.3 History of dyspnea or fatigue:


None

5. SLEEP-REST PATTERN
5.1 Usual sleep pattern:
Bedtime and Hours slept:
11:00 PM – 7 hours

No. of pillows and Sleep routines:


2 pillows and always prays before sleeping

5.2 Any problems regarding sleep:


None

5.3 Usual remedies:


None

6. COGNITIVE-PERCEPTUAL PATTERN
6.1 Any deficits in sensory perception (hearing, sight, touch)
None

6.2 Ability to read and write. Any difficulty in learning?


The client does not have any difficulty in reading, in writing and in learning.

6.3 Any complaints? (e.g. pain)


Pain on surgical wound site.

7. SELF-PERCEPTION PATTERN
7.1 What the client is most concerned about?
The patient is worried about continuing her activities of daily living.

7.2 Present health goals:


For surgical wound to heal without any complications.

7.3 Effect of present illness to self:


Patient verbalized that she is often in pain and it affects her daily activities.

7.4 How does the client see/feel about self?


The client feels weak.

8. ROLE-RELATIONSHIP PATTERN
8.1 Language spoken:
Tagalog and Bisaya.

8.2 Manner of Speaking:


The client speaks on a normal pace, well-modulated and soft toned voice.

8.3 Significant person to client:


Her two sons.

8.4 Complaints regarding family:


None

8.5 Living with (members of family):


Patient is living with her two sons

9. SEXUALITY-SEXUAL FUNCTION
9.1 Anticipated change in sexual relations because of illness:
None

9.2 Knowledge of sexual functioning:


The client is aware of her sexual functioning.

10. COPING-STRESS MANAGEMENT PATTERN


10.1 Decision making ability:
The patient makes decision by first discussing the problem with her
family then proceeding to analyze the situation and then prays for
guidance.

10.2 Any significant stress in the past year?


None

10.3 Management of stress?


The patient verbalized that she would pray and go for walks

10.4 Expectations from nurses to provide comfort and security


during hospitalization:
To facilitate faster the healing

11. VALUE BELIEF SYSTEM


11.1 Source of strength or meaning:
God and her children.

11.2 Importance of God to client:


Patient verbalized that she put her relationship with God above all

11.3 Religious practices (type and frequency):


Prays the rosary every day and goes to mass every Sunday.

11.4 Request for religious person/practice:


None
C. PHYSICAL ASSESSMENT Date performed: _01/31/2018____

1. Head-to-Toe Examination
1.1 General Survey
The client was awake and oriented to time and date, has an IV line site on
her right hand and was not in difficulty during the assessment. She has
pale conjunctiva and dry lips. Body movements are voluntary and not
limited at that time.

1.2 Vital Signs


T: 37.1 PR: 87
BP: 110/70 RR: 20

1.3 Head and Face


a. Cranium
The hair of the client is color black and evenly distributed. Absence
of head lice and dandruff, no lesions and mass found, is
symmetrical with no deformities.

b. Temporal arteries
The temporal arteries of the client are slightly felt upon palpation.

c. Face
The client’s face is round in shape; color of the face is brown similar
with the color of the whole body. Face is symmetrical from left to
right. No abnormal movements noted. Presence of wrinkles, no
signs of edema and hollowness.
d. Cranial nerves V and VII
There are no involuntary movements. There are no problems in
facial sensation and expression.

e. Nose and cranial nerve I


Nose is symmetric and straight. No external lesions, no discharge
present when assessed upon the interview and color is similar with
facial skin.

1.4 Eyes and vision


a. External eye structure
The client’s external eye structure is symmetrical, has pale conjunctiva,
has eye bags, no skin lesions and deformities.

b. Visual acuity
The patient has no problem with her vision.

1.5 Ears & Hearing


a. External ear
The client’s external ear is symmetrical, no skin lesions and
deformities, auricles have the same color with the facial skin. Auricles
are firm with no tenderness.

b. Hearing
The patient has no difficulty in hearing.

1.6 Neck
a. Muscoloskeletal structures
Muscles equal in size; head centered. Color is the same as the
facial skin, no mass and tenderness.

b. Lymph nodes
Not palpable

c. Thyroid glands
Not palpable

d. Musculoskeletal function and cranial nerve XI


The client has no difficulty in moving her head. Has coordinated
muscle movement and there is no pain in moving.

1.7 Upper Extremities


a. Musculoskeletal structures, skin, nails
The client has brown skin, good capillary refill; long dirty nails, dry skin
and has no lesions.

b. Musculoskeletal functions
The client is able to move hands and shoulders without difficulty.

c. Brachial and radial arteries


Brachial and radial pulses can be felt.

1.8 Anterior Chest


a. Breasts and axillae
Breasts are symmetrical in size; color is the same as with the
abdomen. No discharges noted. No tenderness, masses, and nodules
noted upon palpation.

b. Thorax
Symmetrical, has no lesions and no deformities.

1.9 Back
a. Musculoskeletal structure
The client’s back has no deformities, and no skin lesion. Skin is
intact; spine is vertically aligned.
b. Posterior thorax
Symmetrical, has no lesion, and no deformities.

1.10 Neck veins


There is no tenderness upon palpation.

1.11 Abdomen
With tenderness upon palpation, no distention.

1.12 Lower Extremities


a. Musculoskeletal structures, skin, and toe nails
All toes are normal in size and symmetric with long dirty toe nails,
without tenderness, no swelling, no deformity and no skin
discoloration.

b. Musculoskeletal function
Normal gait, no tenderness, no instability, no atrophy or abnormal
muscle tone.

1.13 Genitals and pelvis


Not assessed; patient refused

1.14 Rectum
Not assessed; patient refused

Summary of abnormal findings:


Face, Upper extremities, Lower Extremities: No abnormal findings
Nose and Cranial Nerve I: No abnormal findings
External ear: No abnormal findings
Lymph Nodes: No abnormal findings
Lower extremities: No abnormal findings

2. REVIEW OF RECORDS
1. Pertinent Data from the Doctor’s Order
January 23, 2018
 Thank you for this referral
 Patient seen and examined
 History reviewed, labs noted
o Multiple electrolyte imbalance secondary to GI loses secondary to
intestinal obstruction
o Intestinal obstruction probably secondary to post op adhesion s/p
exploratory laparotomy, right hemicolectomy, colostomy (2017) s/p
takedown of colostomy (January 2018, EAMC)
 To shift IVF to
o D5NSS 1L + 40 meqs KCl at 80 cc/hr
 Diagnostic
o BUN, Creatinine, Sodium, Potassium to include Calcium,
Magnesium, Albumin, Phosphate
o Suggest to do 12L ECG
o Chest X-ray done
 Therapeutics
o Adequate pain relief care of main service
o Continue omeprazole 40 mg IV OD
 WOF: chest pain, dysphagia, altered sensory
 Inform IM service once with lab results
 Refer accordingly
 Suggested to include I&O monitoring Q2

Krizia Ramos Daguman, MD


2. Pertinent Data from the Nurse’s Notes
F – Risk for fluid volume deficit
D – (+) vomiting of previously eaten food
A - Advised NPO temporarily
- kept comfortable
- watched out for any untoward signs and symptoms
- provided adequate rest period
R – (+) 2x vomiting
- (-) BM
3. DATA FROM TEXTBOOK
3.1 Definition of Diagnosis / Surgery Performed

Intestinal obstruction is significant mechanical impairment or complete arrest of the


passage of contents through the intestine. Symptoms include cramping pain, vomiting,
constipation, and lack of flatus. Diagnosis is clinical, confirmed by abdominal x-rays.
Treatment is fluid resuscitation, nasogastric suction, and, in most cases of complete
obstruction, surgery.

According to Bordeianou and Yeh of Wolters Kluwers, Bowel obstruction occurs when the
normal flow of intraluminal contents is interrupted. Obstruction can be functional (due to
abnormal intestinal physiology) or due to a mechanical obstruction, which can be acute or
chronic. Advanced small bowel obstruction leads to bowel dilation and retention of fluid
within the lumen proximal to the obstruction, while distal to the obstruction, as luminal
contents pass, the bowel decompresses. If bowel dilation is excessive, or strangulation
occurs, perfusion to the intestine can be compromised leading to necrosis or perforation,
complications, which increase the mortality, associated with small bowel obstruction.

The most common causes of mechanical small bowel obstruction are postoperative
adhesions and hernias. Other etiologies of small bowel obstruction include disease
intrinsic to the wall of the small intestine (eg, tumors, stricture, intramural hematoma) and
processes that cause intraluminal obstruction (eg, intussusception, gallstones, foreign
bodies).

3.2 Brief description of the Anatomy and Physiology

The GI System

The gastro-intestinal system is essentially a long tube running right through the
body, with specialised sections that are capable of digesting material put in at the
top end and extracting any useful components from it, then expelling the waste
products at the bottom end. The whole system is under hormonal control, with the
presence of food in the mouth triggering off a cascade of hormonal actions; when
there is food in the stomach, different hormones activate acid secretion, increased
gut motility, enzyme release etc. etc.

Nutrients from the GI tract are not processed on-site; they are taken to the liver to
be broken down further, stored, or distributed.

The digestive system is made up of the alimentary canal (also called


the digestive tract) and the other abdominal organs that play a part in digestion,
such as the liver and pancreas. The alimentary canal is the long tube of organs
— including the esophagus, stomach, and intestines — that runs from the mouth
to the anus. An adult's digestive tract is about 30 feet (about 9 meters) long.
The peritoneal cavity refers to the potential space between the parietal and
visceral peritoneum. A small amount of serous fluid is present in the cavity to
facilitate the necessary movement of structures such as the stomach.

The mesentery is a double layer of peritoneum that supports the


intestines and conveys blood vessels and nerves to supply the wall of the
intestine. The mesentery attaches the jejunum and ileum to the posterior (dorsal)
abdominal wall. This arrangement provides a balance between the need for
support of the intestines and the need for considerable flexibility to accommodate
peristalsis and varying amounts of content.

The greater omentum is a layer of fatty peritoneum that hangs from the
stomach like an apron over the anterior surface of the transverse colon and the
small intestine. The lesser omen-tum is part of the peritoneum that suspends the
stomach and duodenum from the liver. When inflammation develops in the
intestinal wall, the greater omentum, with its many lymph nodes, tends to adhere
to the site, walling off the inflammation and temporarily localizing the source of
the problem. Inflammation of the omentum and peritoneum may lead to scar
tissue and the formation of adhesions between structures in the abdominal
cavity, such as loops of intestine, restricting motility and perhaps leading to
obstruction.
Signs & Symptoms found in the book Signs and Symptoms manifested by the
client
Abdominal cramps √
Loss of appetite √
Constipation √
Vomiting √
Inability to defecate √
Swelling of the abdomen X

Reference:

II. PLANNING
1. Problem List

Date Identified Nursing Diagnosis Prioritization


Day 1 Day 2
January 29, 2018 Activity Intolerance
Impaired skin
integrity
Risk for infection

2. Nursing Care Plan

Assessment Nursing Goals/Objective Nursing Rationale


Diagnosis Intervention

Subjective: Activity After 2 hours of  Note patient’s  Symptoms may


“Nanghihina intolerance intervention, the response of be result of/or
ang buong patient will weakness, contribute to
katawan ko.” appear more fatigue, pain, activity
as verbalized comfortable and difficulty intolerance.
by the patient. be able to accomplishing  To determine
ambulate. tasks and/or current status
Objective: insomnia. and needs
 Patient  Ascertain ability associated with
appears to stand and participation in
weak. move about and needed/desired
 Dry lips degree of activities.
and skin. assistance  Enhance ability
 Restricted necessary/use of to participate in
mobility equipment. activities.
 Provide comfort
measures and
provide for relief
for pain.
 Encourage  To promote
patient to normal
ambulate. functioning of
the body
systems to
facilitate
healing.

Assessment Nursing Goals/Objective Nursing Rationale
Diagnosis Intervention

Subjective: Impaired After 6 hours of  Asses for  To note for


“Kumikirot skin integrity intervention, the redness, the classic
yung related to patient will have swelling, signs of
inoperahan sa surgical reduced risk of increased pain, infection.
akin.” wound on further purulent
abdomen impairment of discharge from  Decreases
Objective: skin integrity. wound. the chances
 Maintain or teach of
 Presence
asepsis for transmitting
of surgical
dressing changes or spreading
wound on
and wound care. pathogens to
the
the wound of
abdomen the patient.
 Guarding  A third
behavior  Administer generation
 Restricted ceftriaxone 1gm cephalosporin
mobility via IV. for treatment
of intra-
abdominal
tract infection.
 Administer  Treatment for
metronidazole anaerobic
500gm via IV. infection in
inr-abdominal
tract as well
as
inflammatory
bowel
disease

Assessment Diagnosis Planning Intervention Rationale


Subjective: Risk for After 6 hours  Assess  Increased body
infection of changes in may indicate the
related intervention, body presence of
Objective: surgical patient temperature. infection.
 Presence wound on remains free  Asses for  To note for the
of surgical the of infection, redness, classic signs of
wound on abdomen as evidenced swelling, infection.
the absence increased
abdomen swelling, pain, purulent
redness of discharge
the wound from wound.
and elevated  Maintain or  Decreases the
temperature. teach asepsis chances of
for dressing transmitting or
changes and spreading
wound care pathogens to the
wound of the
patient.
 Administer  A third
ceftriaxone generation
1gm via IV. cephalosporin for
treatment of
intra-abdominal
tract infection.
 Administer  Treatment for
metronidazole anaerobic
500gm via IV. infection in inr-
abdominal tract
as well as
inflammatory
bowel disease.

DISCHARGE PLANS FOLLOW-UP EVALUATION

M: instructed the patient to take the following


Omeprazole
Cefuroxime
Metronidazole
E: Instructed the client to have adequate bed rest
T: Instructed the client on strict compliance to medication and therapy
H: Instructed patient to always have adequate rest periods in a comfortable position
 Instructed patient to avoid high fat and high sodium content food
 Instructed patient to schedule regular follow-up check-up appointments with
physician to monitor progress
O: Instructed client to continue therapy
D: Instructed client on low fat low salt diet

Health Teaching Guide


Topic: Diet as tolerated

Objectives Content Teaching Strategy Evaluation

After 10 minutes of -Discussion of the - Oral questioning The patient and her
health teaching, the importance of - Lecture son were able to
patient and her family increase intake of - Discussion verbalize fully their
will be able to fiber-rich food understanding of the
verbalize clearly their recommended diet
-Lecture about the
understanding about ordered.
recommended food
her recommended
for the patient
diet.
-Discussion about
food to avoid (high-fat
food)

Topic: Compliance of Medication

Objectives Content Teaching Strategy Evaluation

After 5 minutes of -Explain the possible - Oral questioning The patient and her
health teaching, the effects of not taking - Lecture son were able to
patient and her family drug on time - Discussion verbalize their
-Explanation
will be able to understanding of the
verbalize clearly their -Discuss the importance of taking
understanding about importance of taking the prescribed
the importance of medications on time medications on time.
taking the prescribed -Impart the things to
medications on time. remember when
taking medications

-Emphasize to strictly
follow the dosage
ordered and do not
exceed provision
beyond the
prescribed dosage
and interval.