In Partial Fulfillment Of The Requirements In RELATED LEARNING EXPERIENCE

Case Study:

Inguinal Hernia

Submitted to: Ms. Rose Elan Bundac, R.N. Clinical Instructor

By: Kristine Claire S. Quicho-Salvador BSN-4 Ma. Adelene Lagrada BSN-3

July 27, 2005

Department of Nursing HOLY TRINITY COLLEGE Puerto Princesa City

TABLE OF CONTENTS Title Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 .2 .3 .5 .6 .7 .8 .8 .8 .9 .10 .11 .13 .14 .15 .16 .21 .22 .28 .29 .30

Table of Contents Introduction .

Approval Sheet

Significance of the Study Statement of the Problem Personal Information . Family History .

Past Medical History . Present Condition .

Physical Assessment . Laboratory Examinations

Review of Anatomy & Physiology Pathophysiology Treatments . . . . . . . . . . .

Pharmacological Studies Summary of Findings . Nursing Care Plans Conclusions . . . . .

Discharge Plans References .

INTRODUCTION A hernia is the abnormal protrusion of an organ, tissue, or part of an organ through the structure that normally contains it. Hernias frequently occur in the abdominal cavity as a result of a congenital or acquired weakness of abdominal musculature. Hernias can occur at any age and in either sex. Indirect Inguinal hernias are the most common type and typically occur in men. Direct hernias are found more commonly in older adults. Incisional or ventral hernias occur most often in clients who had poor wound healing after surgery. Obese or pregnant clients are more likely to develop umbilical hernias. Two factors must be present for hernia to occur: (1) a defect in the integrity of the muscular wall and (2) increased intra-abdominal pressure. Congenital muscle weakness is one risk factor combined with the factors that increase intra-abdominal pressure. The muscle weakness cannot be prevented, but exercise can strengthen the weak muscles. Because obesity is one cause of increased intra-abdominal pressure, it can be prevented by weight control. Avoiding heavy lifting and straining also reduces intra-abdominal pressure. Early diagnosis is important to prevent incarceration and strangulation. Defects in the muscular wall may be congenital owing to weakened tissue or a wide space at the inguinal ligament, or may be caused by trauma. Intra-abdominal pressure most commonly increases as a result of pregnancy or obesity. Heavy lifting also causes increased intra-abdominal pressure, as do coughing and traumatic injuries from blunt pressure. When two of these factors coexist, with some tissue weakness, the person may develop hernia. Increased pressure without a weakness is not likely to cause hernia. Weakness, in addition to being present from birth, is acquired as part of the aging process. As clients age, muscular tissues become infiltrated and are replaced by adipose and connective tissues. When the contents of the hernia sac can be replaced into the abdominal cavity by manipulation, the hernia is said to be reducible. Irreducible and incarcerated are terms that refer to a hernia that cannot be reduced or replaced by manipulation. When pressure from the hernia ring (in the case of Rolando, the inguinal ring) cuts off the blood supply to the herniated segment of the bowel, the bowel becomes strangulated. Incarcerated hernias often become strangulated. This situation is an emergency procedure because unless the bowel is released, it soon becomes gangrenous owing to a lack of blood supply.

APPROVAL SHEET

Kristine Claire Q. Salvador and Ma. Adelene LAgrada, a 4th year and third year BSN students respectively, assigned in the Surgical Ward of Ospital ng Palawan has prepared this case study entitled, Inguinal Hernia. This serves as a partial fulfillment of the Requirements in Related Learning Experience (RLE). It was examined and approved with the grade of ________%.

Ms. Rose Elan Bundac, R.N. Clinical Instructress

SIGNIFICANCE OF THE STUDY

This case study, entitled Inguinal Hernia is aimed not only to finish a requirement in Related Learning Experience with clinical exposure at the Surgical Ward of Ospital ng Palawan, it serves:

a. The client and his family, because the making of nursing care plans considers his immediate needs;

b. The medical staff of Ospital ng Palawan and other members of the health team, because they would have a reference in the course of their assessment and health care of clients with hernia;

c. The ordinary people, because they would have a guide to aid them should such symptoms of illness occur to them; and,

d. The student-nurses/researchers, to broaden their understanding, knowledge and experience to render effective, accurate and prompt nursing care to such clients.

STATEMENT OF THE PROBLEM

This case study aims to answer the following questions:

a. What is the nature and dynamics of Inguinal hernia? b. What are the diagnostic and laboratory tests needed to diagnose inguinal hernia? c. What nursing problems are identified and corresponding nursing care plans are appropriate for patients with Inguinal hernia? d. What possible discharge plan and home care is indicated for patients with inguinal hernia?

PERSONAL INFORMATION Name: Age: Sex: Address: Civil Status: Religion: Educational Attainment: Occupation: Date and Time Admitted: Chief Complaint/s: Informant: Physician: ROLDAN JESORO 23 years old Male Bgy. Inagawan, Puerto Princesa City, Palawan Live-in Roman Catholic High school level Farming July 24, 2005 at 3:01pm Abdominal pain Rolando Baldo, son Dra. Nufuar FAMILY HISTORY Name of Father: Name of Mother: Name of Spouse: Number of children in the family: Position in the family: Number of offsprings: Presence of Hereditary diseases: a. Diabetes b. Cardiovascular diseases c. Bronchial Asthma d. Others Deaths in the family: Cause/s: Leonardo Flores (Deceased) Ignacia Flores (Deceased) Rodolfo Baldo (Deceased) 10 2nd 4 (-) (-) (-) No history of hereditary diseases Husband/Spouse Undiagnosed and untreated illness, said to have been caused by supernatural forces such as nuno sa punso and others.

PAST MEDICAL HISTORY a. Type of delivery b. Childhood diseases c. Immunization status d. Previous sickness/hospitalization Normal Unknown Unknown Bicycle accident where she reportedly sustained a head trauma that caused her hearing impairment when she was 10 years old. She, however, was not brought to the hospital and received only home remedy.

PRESENT CONDITION a. Perceptions and Expectations of Illness/Hospitalization The patient does not answer regarding this because her attention is focused on her abdominal pain. Her children, however, verbalized that they expect her to get well enough soon but are uncertain due to their financial status. b. Specific Basic Needs 1. Comfort/Rest Needs The patient shows physical signs of abdominal pain that interferes with her normal sleeping pattern. Her naps are usually short (often only lasting about 3-5 minutes) and interrupted by sudden pain episodes. She also is not able to do her usual daily activities such as bathing, brushing her teeth, etc. as well as leisure activities which include listening to radio and reading short stories due to her attention being focused on her discomfort and pain. 2. Safety Needs Nanay Elena has hearing impairment that interferes with her ability to express her needs and desires. This impairment also predisposes her to hazards such as traffic and household accidents as well. Her old age also predisposes her to a lot of other illness such as colds and flu. Added to this, the family is insecure about medical bills and costs of drugs because they are not financially capable of supporting a sick member of the family. 3. Fluids and Nutrition She has not been able to retain any food or fluid for at least a week prior to admission because she vomits every time she eats or drinks even a tablespoon of rice or a few sips of water. She is however, placed on DAT during admission and IV fluids has been administered to replace lost fluids, counteract any fluid and electrolyte imbalance, and as a route for administration of medications. 1. Elimination The client has not moved her bowel for approximately 1 week. Although she does not have any difficulty urinating, she has less frequent voiding and U/A shows a slightly hazy urine transparency of urine. 2. Oxygen RR=33/minute. When she was brought to the ward, she became apneic and was given O2 inhalation via nasal cannula @ 3-4LPM. Prior to her illness, she is a kaingin farmer who is always exposed to a lot of smoke. 3. Others: a. Sexuality She is feminine and has had 4 sons with her husband who is now deceased. b. Allergies No known allergies to food and drugs. c. Communication She cannot hear very well and cannot express her feelings verbally. She only gestures and her pain is evident only through her facial expressions and movements such as grimacing,

crying or softly groaning in pain episodes and waving to her sons if she needs to do anything.. PHYSICAL ASSESSMENT a. EENT Eyes Ears Nose Throat Pale conjunctiva, white sclera, gray pupils, tearful. Ears are long and symmetrical. Nose is small, centrally-located. Unremarkable.

b. Chest and Lungs Clear breath sounds on both lung fields, bones prominent on chest. Symmetrical lung expansion observed. c. Abdomen Flat abdomen with minimal stretch marks seen. Hyperactive bowel sounds on the hypogastric region heard upon auscultation. Epigastric, hypogastric and RLQ pain upon palpation. Unable to palpate for mass or systolic bruit due to the intense pain she expresses with facial expression during palpation. d. Genito-Urinary With gray pubic hair, no BM and less frequent urination as reported by patients sons. e. Skin/Extremities Hand and foot digits are complete (20 in all), nails are short but with dirt underneath and pale in color, poor skin turgor noted. White spots seen which the sons claim is an-an. f. General Conditions The patient is conscious, alert but in severe abdominal pain. Her attention is focused on this pain. She does not respond when asked if she comprehends orientation to 4 spheres such as asking the date, time, place or her identity due to her attention being focused in her pain.

LABORATORY EXAMINATIONS Diagnostic Procedure: June 27, 2005 CBC Hemoglobin DIFFERENTIAL COUNT Neutrophils Results: Normal Values 120-160 g/L Interpretation: Rationale: CBC with differential, WBC, platelet count and BSMP is ordered for Nanay Elena to rule out presence of any infections due to the inconclusive nature of interview and assessment.

120 g/L

84

60-70%

Eosinophils Lymphocytes

3 13 18.10 x 109/L 250 x 10 9/L Negative

1-4% 20-30 4-9 x 109/L 150-450 x 109/L Negative

Not yet indicative of anemia; borderline. Indicates presence of bacterial or parasitic infectious process. No allergic reaction or anemia Indicative of trauma Coagulation mechanism intact Malaria is ruled out. (-) Sediments present Average of pH range (-) (-) (-) (-) (-)

WBC Count Platelet Count BSMP June 28, 2005 Urinalysis Color Transparency Albumin pH Glucose sg Microscopic Exam Pus cells RBC Epithelial cells Squamous Bacteria Amorphous urates June 28, 2005 Ultrasound

Pale yellow Sl. Hazy ++ - 6 ++++ - 1.00 1-4/hpf 8-12/hpf Few Moderate Moderate

Pale yellow Clear ++ - 4.6-8 ++++ - 1.011.025 No reference No reference No reference No reference No reference

Urinalysis is important to determine whether there is infection in the body.

Abdominal Aortic

Normal pattern

Abdominal Aortic Aneurism

Ultrasonography was ordered due to the

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Aneurism

images of structures being studied (abdominal aorta)

seen that therefore changes the medical impressions to a definite medical diagnosis.

inconclusive nature of interview and assessment. This study creates sound waves that allow visualization of organs inside the abdomen. Ordered to assess for hypovolemia or shock.

June 28, 2005 Hemoglobin (Hgb)

52 g/L

120-160 g/L

Indicative of anemia

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REVIEW OF ANATOMY & PHYSIOLOGY OF CARDIOVASCULAR SYSTEM: BLOOD VESSELS Except for the microscopic capillaries, the walls of blood vessels have three coats or tunics: Tunica Intima, which lines the lumen or interior of the vessels, is a thin layer of endothelium resting on a scanty layer of loose connective tissue, Its cells fit closely together and form a slick surface that decreases friction as blood flows through the lumen. The Tunica Media is the bulky middle coat. It is mostly smooth muscle and elastic tissue. The smooth muscle, which is controlled by the sympathetic nervous system, is active in changing the diameter of the blood vessels. As the vessels constrict or dilate, blood pressure increases or decreases, respectively. The Tunica Externa, is the outermost tunic, it is composed largely of fibrous connective tissue. Its function is basically to support and protect the blood vessels. The aorta is the largest artery of the body. In adults, the aorta is about the size of a garden hose where it issues from the left ventricle of the heart. It decreases in size as it runs to its terminus. Different parts of the aorta are named for their location or shape. The aorta curves upward from the left ventricle of the heart as the ascending aorta, arches to the left as the aortic arch and then plunges downward through the thorax following the spine (Thoracic aorta) to finally pass through the diaphragm into the abominopelvic cavity where it becomes the abdominal aorta. Blood circulates inside the blood vessels, which form a closed transport system, the so-called vascular system. Like a system of roads, the vascular system has its freeways, secondary roads, and alleys. As the heart beats, blood is propelled into the large arteries leaving the heart. It then moves into successively smaller and smaller arteries, then into the arterioles, which feed the capillary beds in the tissues. Capillary beds are drained by venules, which in turn empty into the veins that finally empty into the great veins entering the heart. Thus arteries, which carry blood away from the heart, and veins, which drain the tissues and return blood to the heart, are simply conducting vessels the freeway sand secondary roads.

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PATHOPHYSIOLOGY OF ABDOMINAL AORTIC ANEURISM (AAA)

PREDISPOSING FACTORS: Age: 50-80 y/o Genetic

PRECIPITATING FACTORS: Focal weakness in the muscular Layer of the aorta

CONTRIBUTING FACTORS: - Trauma

Inner layer (Tunica intima) & outer layer (tunica adventitia) stretches outward

Aneurism

Palpable mass in the periumbilical area

Tenderness Blood pressure in the aorta weakens the vessel walls Aneurism is enlarged Pressure on lumbar nerve Lumbar pain Aneurism ruptures

Systolic bruit over the aorta

Peritoneal cavity Severe, persistent abdominal and back pain

Retroperitoneal space Tamponade

Subtle weakness, sweating, tachycardia, hypotension Shock Death

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TREATMENTS Treatment/Special Procedures/Surgery Rationale Pharmacotherapy Pharmacotherapy is done to the patient which is aimed at managing gastric acid secretions and pain, as well as constipation. IV therapy IV therapy is given to the patient to replace lost fluids and manage fluid and electrolyte imbalance as well as a route for administration of medication. O2 therapy O2 therapy is given the patient to aid in her oxygenation. She is experiencing apnea in the ward which may be due to her pathologic condition.

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Generic/ Dosage/Freq/ Brand Name Route Ranitidine/ 1 amp, ANST Inhibits histamine Zantac then q8, IV at H2-receptor site in parietal cells, which inhibits gastric acid secretion.

DRUG STUDY Action

Indication
Duodenal ulcer, Zollinger-Ellison Syndrome, gastric ulcers, hypersecretory conditions, gastroesophageal reflux disease, stress ulcers, erosive esophagitis (maintenance), active duodenal ulcers with Helicobacter pylori in combination with clarithromycin. Ranitidine is indicated to Elena Baldo to alleviate pain episodes due to gastritis where there is too much gastric acid secretions and to protect the mucosa of the stomach. Since there has yet to be a conclusive diagnostic/lab exam, in the incidence that she may have gastric ulcerations, coating and protecting the mucosa of her stomach will also aid in the healing of the ulcers.

Nursing Responsibilities Assess gastric pH Assess I&O ratio Assess GI complaints : nausea, vomiting, diarrhea, cramps Provide storage at room temperatur e Evaluate therapeuti c response: decreased abdominal pain Teach pt/family to avoid black pepper, caffeine, alcohol, harsh spices, extremes in temperatur e of food and that drug must be continued for prescribed time to be effective. 15

Nalbuphine/ Nubain

1 amp q8 IV Depresses pain prn for severe impulse abdominal pain transmission at the spinal cord level by interacting opioid receptors.

Moderate to severe pain. In Elena Baldos case, she is experiencing severe epigastric, hypogastric and RLQ pain and this drug was given to her to help manage that pain.

Ephedrine/Ep 1 amp x 2 doses Causes increased hedrine IV contractility and sulfate heart rate by acting on receptors in the heart; also acts on

Shock; increased perfusion,; hypotension, bronchodilation. In this case ephedrine was given to

Assess I&O ratio. Assess for allergic reactions. Check for respiratory dysfunctio n. Administe r IV route undiluted over 3-5 minutes. Provide storage in lightresistant area at room temperatur e. Provide assistance with ambulatio n. Evaluate therapeuti c response: decrease in pain. Teach that physical dependenc y may result from longterm use. Assess I&O ratio. Assess for paresthesi as and coldness 16

-receptors, causing vasoconstriction in blood vessels.

counteract the possibility of an impending hypovolemic shock.

Metronidazol e/Flagyl

500 mg q8 IV Direct acting ANST (-) amebicide/ trichomonacide binds, degrades DNA in organism.

Intestinal amebiasis, amebic abscess, trichomoniasis, refractory trichomoniasis, bacterial anaerobic infections, giardiasis, septicemia,

of extremitie s. Administe r IV direct route through Y-tube or 3-way stop-cock; give 1025mg slowly, may repeat in 5-10 minutes. Storage of reconstitut ed solution refrigerate d no longer than 24 hours. Do not use discolored solution. Evaluate therapeuti c response: increased BP with stabilizatio n. Assess for infections. Assess stools during entire treatment. Assess vision by 17

endocarditis, bone, joint infections, lower respiratory tract infections. In Nanay Elenas case, she was prescribed metronidazole at the ER because there was yet to be a conclusive evaluation of her disease due to the fact that she cannot verbalize her feelings at the time.

Bisacodyl/Du 1 Suppository Acts directly on lcolax stat intestine by increasing motor activity; thought to irritate colonic

Short-term treatment of constipation, bowel or rectal preparation for

ophthalmi c exam. Assess I&O ratio. Assess for allergic reactions. Administe r IV route prediluted. Provide storage in lightresistant container; do not refrigerate . Evaluate therapeuti c response: decreased symptoms of infection. Teach patient/fa mily that urine may turn darkreddish brown, drug may cause metallic taste. Teach proper hygiene after BM Assess blood, urine electrolyte s if drug is 18

intramural plexus. surgery,

examination. In Mrs. Baldos case, her sons reported that she has not moved her bowel for more than a week before seeking medical attention. Dulcolax would help her be able to move her bowel due to the direct increase in peristalsis that is its action.

used often by patient. Assess I&O ratio. Assess cause for constipatio n. Assess for cramping. Evaluate therapeuti c response: decrease in constipatio n. Teach not to use for long-term use. Teach that normal BM do not always occur daily.

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SUMMARY OF FINDINGS THAT ARE RELEVANT TO NURSING CARE After assessment of physical, past medical history, family history, perceptions, specific and basic needs, I conclude that the following should be the focus of nursing care: ER assessment: 1. Severe pain r/t disease process 2. Constipation r/t inability to retain ingested food 2 to disease process 3. Impaired verbal communication r/t childhood accident/trauma Ward Assessment: 4. Fluid volume deficit r/t disease process 5. Ineffective breathing pattern r/t disease process In prioritizing these problems, I have the following list of nursing problems: 1. 2. 3. 4. 5. Severe pain r/t disease process Ineffective breathing pattern r/t disease process Fluid volume deficit r/t disease process Constipation r/t inability to retain ingested food 2 to disease process Impaired verbal communication r/t childhood accident/trauma

Due to the fact that assessment in ER is most essential for this case study because this is the area of assignment and owing to time constriction, the 1st three problems assessed in ER are given priority although some of the last three are more important in nature.

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NURSING CARE PLANS

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ASSESSMENT Subjective/Objective Cues

STATEMENT OF THE PROBLEM Nursing Diagnosis

PLANNING Long Term Goal/ Short Term Goal

NURSING ACTION Nursing Interventions with Rationale Independent, Dependent, & Interdependent Independent: 1. Monitor and record V/S. R: For baseline data and because V/S are usually altered during pain episodes. 2. Instruct patient to relax and breathe rhythmically. R: Anxiety and too much pain cause clients to breathe rapidly and has more difficulty managing the pain. 3. Encourage client to do deep breathing exercises. R: Helps promote comfort and relaxation. 4. Do and instruct SO about comfort measures such as backrubbing, soft massage of extremities, etc. R: Promotes patients comfort and deviates attention from pain experience. 5. Establish a form of communication such as writing or nodding in agreement or shaking head in disagreement. R: Gives the client a way to communicate desires and needs. Dependent: 1. Administer IV fluid therapy. R: To replace lost fluids and as a route for parenteral medications. 2. Administer medications, Ranitidine(Zantac). R: Inhibits histamine at H2-receptor site in parietal cells, which inhibits gastric acid secretion.

OUTCOME Evaluation/ Revision

Subjective Cue: None Objective Cues: Pale conjunctiva Teary eyes noted Sweaty forehead Grimaced face noted Groaning Guarding behavior noted Assuming fetal position Seeking SO often RR=30/minute BP=90/70mmHg Pain scale = 10/10

Severe pain r/t disease process BACKGROUND KNOWLEDGE: Pain is defined in NANDA as a state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation. In Elena Baldos case, the pain is severe enough for her to try and get medical treatment as she can possibly be able to do so. Pharmacotherapy. IV therapy, medical and nursing management is focused on alleviating this condition.

LTG: At the end of 3 days nursing intervention, the client will be able to demonstrate relaxed body posture and able to sleep/rest appropriately. STG: At the end of 1 days nursing intervention, the client should be able to express through written communication reduction of pain from a scale of 10/10 to 8/10.

Evaluation of effectivity of care plan is through the clients communicati on of pain reduction/ and appear relaxed and well-rested.

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ASSESSMENT Subjective/Objective Cues

STATEMENT OF THE PROBLEM Nursing Diagnosis

PLANNING Long Term Goal/ Short Term Goal

NURSING ACTION Nursing Interventions with Rationale Independent, Dependent, & Interdependent Independent: 1. Monitor and record V/S to pay particular attention to respiratory rate, rhythm and depth. R: For baseline data and because shallow breathing, splinting with respirations, holding breath may result to hypoventilation or atelectasis. 2Auscultate breath sounds. R: To assess for any signs of respiratory problems. 3. Assist patient to turn, cough and breath deeply periodically. R: Promotes ventilation of all lung segments. Dependent: 1. Administer O2 therapy.

OUTCOME Evaluation/ Revision

Subjective Cue: None Objective Cues: Pale conjunctiva Seeking SO often Episodes of apnea (ward) Hooked to O2 tank via nasal cannula @ 3-4 LPM

Ineffective breathing pattern r/t disease process BACKGROUND KNOWLEDGE: Ineffective breathing pattern is a NANDAaccepted nursing diagnosis of an inhalation or exhalation pattern that does not enable adequate pulmonary inflation or emptying. Such is Nanay Elenas case who experienced apneic episodes in the Medical ward.

LTG: At the end of 3 days nursing intervention, the client will be able to establish effective breathing pattern.

STG: At the end of 1 days nursing intervention, the client should be able to R: Assists in oxygenation by regulating O2 experience no volume. signs of respiratory compromise/ complications.

Evaluation of effectivity of care plan is through the clients establishment of effective breathing pattern and show no signs of respiratory compromise or complication s.

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ASSESSMENT Subjective/Objective Cues

STATEMENT OF THE PROBLEM Nursing Diagnosis

PLANNING Long Term Goal/ Short Term Goal

NURSING ACTION Nursing Interventions with Rationale Independent, Dependent, & Interdependent Independent: 1. Monitor and record V/S I&O. R: Provides information about overall fluid balance. 2. Assess V/S: BP, PR, and T. R: Hypotension, tachycardia, fever can indicate response to fluid loss. 3. Observe for excessively dry skin and mucus membranes, decreased skin turgor, slowed capillary refill. R: Indicates excessive fluid loss. 4. Monitor lab studies (electrolytes, and ABGs). R: Determines replacement needs and effectiveness of therapy. Dependent: 1. Administer parenteral fluids as indicated.

OUTCOME Evaluation/ Revision

Subjective Cue: None Objective Cues: Pale conjunctiva Poor skin turgor Anorexia Hgb=52g/L

Fluid volume deficit LTG: At the end r/t disease process of 3 days nursing intervention, the BACKGROUND client will be able KNOWLEDGE: to maintain NANDA defines this adequate fluid as the state in which volume as an individual evidenced by experiences vascular, moist mucus cellular, or membranes and intracellular good skin turgor. dehydration. In Nanay Elenas case, this is STG: At the end evident in her dry skin of 1 days and poor skin turgor nursing as well as her intervention, the R: To help in rehydration of client. generalized weakness. client should be able to demonstrate behaviors to monitor and correct deficit.

Evaluation of effectivity of care plan is through the clients maintenance of adequate fluid volume as evidenced by moist mucus membranes and good skin turgor.

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ASSESSMENT Subjective/Objective Cues

STATEMENT OF THE PROBLEM Nursing Diagnosis

PLANNING Long Term Goal/ Short Term Goal

NURSING ACTION Nursing Interventions with Rationale Independent, Dependent, & Interdependent
Independent: 1. Review dietary regimen. R: To assess direct cause of constipation. 2. Record fluid intake. R: Dehydration aggravates constipation. 3. Auscultate bowel sounds. R: Bowel sounds are decreased in constipation. 4. Encourage fluid intake if not contraindicated. R: Assists in improving stool consistence. Interdependent: 1. Consult with dietician to provide wellbalanced diet high in fiber and bulk. R: Fiber resists enzymatic digestion and absorbs liquids in its passage along the intestinal tract and thereby produces bulk, which acts as a stimulant to defacation. Dependent: 1. Administer IV fluid therapy. R: To facilitate rehydration and as a route for parenteral medications. 2. Administer medications, Bisacodyl (Dulcolax) R: Acts directly on intestine by increasing motor activity; thought to irritate colonic intramural plexus.

OUTCOME Evaluation/Revision

Subjective Cue: None Objective Cues: Guarding behavior noted Irritability Assuming fetal position Seeking SO often Decreased activity level noted Vomiting ingested food or fluid. RR=30/minute

Constipation r/t inability to retain ingested food 2 to disease process BACKGROUND KNOWLEDGE: Constipation, according to Billings and Stokes for Medical Surgical Nursing, is the retention of fecal material, delay in excretion or delay from usual elimination habits. In Elena Baldos case, although not yet conclusive, it may have been brought about by her inability to retain food and fluid intake due to her pathologic condition.

LTG: At the end of 3 days nursing intervention, the client will be able to establish/return to normal patterns of bowel functioning. STG: At the end of 1 hours nursing intervention, the client should be able to cooperate in procedures that will enhance bowel pattern.

Evaluation of effectivity of care plan is through the clients ability to return to normal bowel patterns.

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ASSESSMENT Subjective/Objective Cues Subjective Cue: None Objective Cues: Silent crying Guarding behavior noted Soft groaning noted Irritability Assuming fetal position Signaling SO with hand waves No oral/ written communication expressed No verbal responses to questions and enquiries SOs verbalization of a childhood head trauma

STATEMENT OF THE PROBLEM Nursing Diagnosis Impaired verbal communication r/t childhood accident/trauma BACKGROUND KNOWLEDGE: Nursing Care Plans by Marilyn Doenges states that impaired verbal communication may be related to impaired cerebral circulation, neuromuscular impairment, and loss of oral/facial/muscle tone / control or generalized weakness. In Elena Baldos case, her childhood head trauma could be the cause of this impairment due but due to the fact that she did not have and seek medical attention at that time and she does not express this in her own words, this summary is not yet conclusive.

PLANNING Long Term Goal/ Short Term Goal

NURSING ACTION Nursing Interventions with Rationale Independent, Dependent, & Interdependent Independent: 1. Assess type/degree of dysfunction. R: Helps determine difficulty that patient has with any or all steps of communication process. 2. Provide alternative methods of communication. R: Provides for communication of needs/desires based on individual situation. 3. Anticipate and provide for patients need. R: Helps in decreasing frustration when dependent on others and unable to communicate desires. 4. Encourage SO/visitors to persist in efforts to communicate with patient. R: To reduce patients isolation and promotes establishment of effective communication pattern. Interdependent: 1. Consult with or refer to speech therapist. R: Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits/therapy needs.

OUTCOME Evaluation/Revision

LTG: At the end of 1 days nursing intervention, the client will be able to establish a method of communication which needs can be expressed. STG: At the end of 1 hours nursing intervention, the client should be able to indicate an understanding of the communication problems.

Evaluation of effectivity of care plan is through the clients establishment of a means to communicate needs and desires.

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CONCLUSION The study of Abdominal Aortic Aneurism (AAA) was a real challenge to me for several reasons: 1. It is the first time I have ever encountered this disease in the ER or in any ward for that matter; 2. It was a very time-constricted research for me; 3. I was alone in my research; 4. The interaction with the client was very fast-paced; and, 5. My client died. But through all these challenges, I have learned and experienced so much. In dealing with AAA, I conclude the following: 1. To render effective nursing care to an AAA patient must be done promptly and with compassion. 2. That we should not only think of nursing as a job to do, especially in AAA clients whose needs and concerns are immediate. 3. That AAA is a very serious illness that comes rarely but gravely. 4. It is essential that we do not wait for an AAA to rupture because this would have very austere repercussions, most of the time such as in the case of my client, death is a real possibility.

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DISCHARGE PLAN M Instruct patient on medication the proper medicine, route, dosage, and duration. E Instruct about proper financial and social assistance for economic needs. T Treatments should be continued for prescribed time for continued effectivity. H Health teachings should focus on maintaining optimum lood pressure to avoid continues enlargement and subsequent rupture of aneurism. O Out-patient or home care should be continued for check-ups and diagnostic procedures (ultrasound every 6 months) D Diet should restrict salty and cholesterol-rich food.

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REFERENCES Anderson, Kenneth N. et. al., 1990, Mosbys Pocket Dictionary, 3rd ed., St. Louis, Missouri, The CV Mosby Company, pp. 52, 66, and 135. Black, Joyce M. et. al., 1993, Luckmann and Sorensens Medical-Surgical Nursing 4th ed. Vol. 2, United States of America, W.B. Saunders Company, pp. 1295-1297. Charnogursky, Gerald A. et.al., 1999, Handbook of Diseases 2nd ed.,Pennsylvania, Springhouse Corporation, pp. 44-46. Doenges, Marilynn E. et. al., 1993 Nurses Pocket Guide, 4th ed., Philadelphia, F.A. Davis Company, pp. 105-108, 109-115, 126-134, 193-196, and 306-309. Doenges, Marilynn E. et. al., 2002, Nursing Care Plans 6th ed.,Thailand, F.A. davis Company, pp. 65-67, 234-236, 506-507, 595-596, and 654-655. Lemone, Priscilla et. al., 2004, Medical-Surgical Nursing 3rd ed. Vol. 2, New Jersey, Pearson Education, Ltd., pp. 994-996. Marieb, Elaine N., 2002, Essentials of Human Anatomy & Physiology 6th ed., Singapore, Addison Wesley Longman, pp. 313-330. McFarland, Mary B. et. al., 1991, Nursing Implications of Laboratory Test 6th ed, New York, Delmar Publishers, pp. 19-38 and 166-177. Roth, Linda S. et. al., 2004, Mosbys Nursing Drug Refernce, 2004 ed., Missouri, Mosby Inc., pp. 174-175, 400-403, 665-667, 702-704, and 871-873. Smeltzer, Suzanne C. et. al., 1996, Medical-Surgical Nursing 8thed. Vol 1, Philadephia, Lippincott, pp. 738-741.

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