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Nursing Care Assessment

I: Assessment
Demographic Profile
Name: J. P.C.
Room No.: 3082 Ward: San Rafael Ward
Chief Complaint:
Diagnosis: Generalized Peritonitis
Surgery: Wound Closure
A. Biographical data
Age: 61
Sex: Female
Nationality: Filipino
Catholic
Birthdate: February 12, 1955
Civil Status: Married
Attainment: College Graduate
Address: 386 Camp III Brgy. Kita-kita San Jose City, Nueva Ecija
B. History of Present Illness

Religion: Roman
Educ.

C. Past Health History


August 28, 2016
-She had a case of Mullerian Adenocarcinoma s/p TAHBSO with spindle cell metastasis to the omentum s/p tumor
debulking and DT bilateral stent insertion
-She has multiple electrolyte imbalance due to Gi losses (peritoneum and ileus) and use of diuretics with albumin
infusion for the hypoalbuminemia
August 30, 2016
-Had an Emergency Exploratory Laparotomy, Peritoneal toilette, Segmental Ileal Resection, TAHBSO and double
bowel Ileostomy surgery

-During the emergency exploratory laparotomy, the patient was seen with copious sero-purulent fluid in the
entire abdominal cavity and have done bowel running. Observed perforation on the ileum and perform ileostomy
immediately.
D. Family Health History

E. Significant Laboratory and Diagnostic Examinations


Blood Chemistry Test (September 2, 2016)
Potassium:
2.79 mmol/L (Conventional Range: 3.5-5.1 mmol/L) -Low
Inorganic Phosphate: 1.89 mmol/L (Conventional Range: 2.4-4.7 mmol/L) -Low
Ionized Calcium
1.08 mmol/L (Conventional Range: 1.12-1.32 mmol/L) -Low
1.) Since the patient had undergone double bowel ileostomy surgery and also currently taking diuretic
medications, her potassium levels will eventually drop. When colon is removed, (Double Bowel Surgery08/20/2016) theres a greater risk for electrolyte imbalance which can cause dehydration to the patient
2.) Ionized calcium/ free calcium is the most active form of calcium and it is measured in order to know if you
have any symptoms for cancer, parathyroid gland and kidney diseases. Having such can cause the patient to
have abdominal and muscle cramps
3.) Inorganic phosphates function as buffer salts to maintain the acid-base balance in blood, saliva, urine, and
other body fluids. And since the patient had undergone to a stomach surgery (Emergency Exploratory
Laparotomy- 08/20/2016), it can be a contributing factor on why the phosphate level of the patient dropped.
Critically low level phosphate (1 below) can cause you to have breathing or respiratory problems, confusion,
irritability, or worse, coma.
Complete Blood Count (August 31, 2016)
Hemoglobin:
96 g/l (Reference Range- 120-160)
Lymphocyte Count: 0.05 (Reference Range- .55-.65)
Neutrophils:
0.94(Reference Range- .50-.70)

1.) Hemoglobin count is generally low which may be due to the loss of blood after series of surgeries. It may
cause fatigue and weakness to the patient.
2.) The patient has an infection as indicated by the sero-purulent fluid which was seen on the patients abdominal
cavity. Then, it would simply justify on why the patient has a high neutrophil count and low lymphocyte count
which may be due to old age. Anyway, high neutrophil count suggest for an indication of infection while
having low lymphocyte count indicates for fewer white blood cells in fighting infection.
Blood Type Test (August 28, 106): Blood Type AB
Culture and Sensitivity Bactec Fx (August 29, 2016): Specimen: Peritoneal Fluid
Result: No growth after 5 days of incubation
Tertiary closure was done to prevent bacterial contamination from the site which was due to the sero-purulent
peritoneal fluid (sure sign of infection) that was seen during its emergency exploratory laparotomy. Having said
so, culture and sensitivity test was done to determine the time when will it will be closed, because ideally surgical
closure is done 4 days after of tertiary closure.
F: Nurses Notes
09/05/2016
D:61 years old femal, past 5 day emergency ex lap, peritoneal toilette, segmental ileal resection, double
bowel ileostomy with
right and left of abdomen JP drain, indwelling catheter, colostomy and ileostomy.
A: Colostomy and ileosotomy care was given. Catheter was remaining patent. Jp Drain was kept on
negative pressure every 2 hours. Indwelling catheter drainage every hor. Administered prescribed
medications. Kept side rails raised. Encourage deep breathing exercises
R: Able to drain from JP 20-30 cc of pinkish colored output. Indwelling catheter decline with 50 -100 dark
yellow urine output. Ileostomy drained 360 cc. Colostomy is brownish and all procedures are well tolerated
II: Anatomy of Digestive System
Peritoneum. Wall of the abdominal cavity and the abdominal organs are covered with serous membranes.
The serous membrane that covers the organs is the visceral peritoneum /serosa. The serous membrane
that lines the wall of the abdominal cavity is parietal peritoneum. The mesentery connecting the lesser
curvature of the stomach to the liver and diaphragm is the lesser omentum, and the mesentery connecting
the greater curvature of the stomach to the transverse colon and the posterior body wall is greater
omentum. Mesentery is a general term referring to the serous membranes attached to the abdominal
organs
Stomach. The stomach is a muscular sac that is located on the left side of the abdominal cavity, just
inferior to the diaphragm. In an average person, the stomach is about the size of their two fists placed next
to each other. This major organ acts as a storage tank for food so that the body has time to digest large
meals properly. The stomach also contains hydrochloric acid and digestive enzymes that continue the
digestion of food that began in the mouth.

Small Intestine. The small intestine is a long, thin tube about 1 inch in diameter and about 10 feet long
that is part of the lower gastrointestinal tract. It is located just inferior to the stomach and takes up most of
the space in the abdominal cavity. The entire small intestine is coiled like a hose and the inside surface is
full of many ridges and folds. These folds are used to maximize the digestion of food and absorption of
nutrients. By the time food leaves the small intestine, around 90% of all nutrients have been extracted
from the food that entered it.
Duodenum. The foremost and shortest part, it is functionally very important as major portion of the
chemical digestion takes place here. Varying in length from 10 to 15 centimeter, it is, on the anterior
end, connected with stomach, while the posterior end touches jejunum.
o Jejenum. Constituting the second part of your small bowel, located between duodenum and ileum,
it has the average length of about 8.4 feet or two and a half meter in adult humans. The enterocytes
are the specialized cells present in the lining of the canal that are actively involved in the absorption
of small particles of food that were digested by enzymes in duodenum.
o Ileum: This final section of small gut, on one hand, continues with jejunum, while on the other, it
makes a connection with colon through ileocecal valve. In adult humans, it may vary from 7 to 14
feet in length. Major function is to absorb any nutrients that were not absorbed in the preceding
sections of the gut. However, it is particularly involved in the absorption of bile salts and vitamins
(vitamin B12).
Large Intestine. The large intestine is a long, thick tube about 2 inches in diameter and about 5 feet
long. It is located just inferior to the stomach and wraps around the superior and lateral border of the small
intestine. The large intestine absorbs water and contains many symbiotic bacteria that aid in the breaking
down of wastes to extract some small amounts of nutrients. Feces in the large intestine exit the body
through the anal canal.
o

II: Physiology of Digestive System

Ingestion. The first function of the digestive system is ingestion, or the intake of food. The mouth is
responsible for this function, as it is the orifice through which all food enters the body. The mouth and
stomach are also responsible for the storage of food as it is waiting to be digested. This storage capacity
allows the body to eat only a few times each day and to ingest more food than it can process at one time.
Secretion In the course of a day, the digestive system secretes around 7 liters of fluids. These fluids
include saliva, mucus, hydrochloric acid, enzymes, and bile. Saliva moistens dry food and contains salivary
amylase, a digestive enzyme that begins the digestion of carbohydrates. Mucus serves as a protective
barrier and lubricant inside of the GI tract. Hydrochloric acid helps to digest food chemically and protects
the body by killing bacteria present in our food. Enzymes are like tiny biochemical machines that
disassemble large macromolecules. Finally, bile is used to emulsify large masses of lipids into tiny globules
for easy digestion.
Mixing and Movement. The digestive system uses 3 main processes to move and mix food:
Swallowing. Swallowing is the process of using smooth and skeletal muscles in the mouth, tongue, and
pharynx to push food out of the mouth, through the pharynx, and into the esophagus.
Peristalsis. Peristalsis is a muscular wave that travels the length of the GI tract, moving partially digested
food a short distance down the tract. It takes many waves of peristalsis for food to travel from the
esophagus, through the stomach and intestines, and reach the end of the GI tract.
Segmentation. Segmentation occurs only in the small intestine as short segments of intestine contract
like hands squeezing a toothpaste tube. Segmentation helps to increase the absorption of nutrients by
mixing food and increasing its contact with the walls of the intestine.
Digestion. the process of turning large pieces of food into its component chemicals. Mechanical digestion
is the physical breakdown of large pieces of food into smaller pieces. This mode of digestion begins with
the chewing of food by the teeth and is continued through the muscular mixing of food by the stomach
and intestines. Bile produced by the liver is also used to mechanically break fats into smaller globules.
While food is being mechanically digested it is also being chemically digested as larger and more complex
molecules are being broken down into smaller molecules that are easier to absorb. Chemical digestion
begins in the mouth with salivary amylase in saliva splitting complex carbohydrates into simple
carbohydrates. By the time food has left the duodenum, it has been reduced to its chemical building blocks
fatty acids, amino acids, monosaccharides, and nucleotides.
Absorption. Once food has been reduced to its building blocks, it is ready for the body to absorb.
Absorption begins in the stomach with simple molecules like water and alcohol being absorbed directly
into the bloodstream. Most absorption takes place in the walls of the small intestine, which are densely
folded to maximize the surface area in contact with digested food. The large intestine is also involved in
the absorption of water and vitamins B and K before feces leave the body.

Excretion. The final function of the digestive system is the excretion of waste in a process known as
defecation. Defecation removes indigestible substances from the body so that they do not accumulate
inside the gut.

III. Pathophysiology:

Emergency
Exploratory
Laparotomy

Running
of
Bowels

Perforation
on ileum

Leakage of
contents from
the abdominal
cavity

Peritoneal
fluid is
turbid

Surgery
performed

Mullerian
Cancer
metastasize
on omentum

Diagnostic
Paracente
sis
Performed
(+)

Bacterial
proliferation
occurs

Infection

Edema of the
tissues

Exudation of
fluid

Diagnostic
test
performed

Culture and
Sensitivity
Bactec Fx
(Peritoneal

Increase
amount of
WBC and Cell
debris

Peritonitis
IV: Discussion of OR Procedure
Tertiary Closure (Delayed Primary Closure)
Rationale: Wound Closure delayed for several days to prevent wound infection where there is:
o Bacterial contamination
o Foreign bodies
o Extensive Tissue Trauma

CBC:
High
lymphocyte
Count

Significant Discussion
During the emergency exploratory laparotomy procedure,
surgeons have noticed that the patient has copious seropurulent peritoneal fluid on its entire abdominal cavity; which is
actually a good indicator that there is infection happening.
Primary closure of the wound wont be the option for this
scenario since it will promote bacterial infection which can add
more risk to the ondition of patient. That is why there is a
delayed surgical wound repair happened (Tertiary closure);
wherein we are going to wait for the infection to disappear.
Usually, it will take for 3-4 days for the infection to disappear,
and we need to verify this by conducting diagnostic paracentesis
procedure. If the results were okay then we can proceed to its
closure.
Positive and Negative Aspects
Positive:
Prevents wound infection especially on
animal bites
Control of locally necrotic tissue and environmental dirt/debris
Indicated if there is poor circulation in the area affected
Negative:
Slower healing time
Uncomfortable to the patient because it leaves a large mark
Unacceptable cosmetic result

O.R. Technique
1. Patient supine
7. Double barrel ileostomy
2. Asepsis and Antisepsis 8. Draining
3. Sterile Draping
9. Closure of incision
4. Bogota Removed
10. Sterile Dressing
5. Peritoneal Toilette
6. Segmental Ileal Resection

Generic Name

Brand Names

Mechanism of Action

Reason/Rationale

Nursing Care/Measur

Omeprazole

Losec or
Prilosec

An antisecretory compound
that is a gastric acid pump
inhibitor. Suppresses gastric
acid secretion by inhibiting
the H+, K+-ATPase enzyme
system [the acid (proton
H+) pump] in the
parietal cells.

Suppresses gastric acid


secretion
relieving
gastrointestinal
distress
and
promoting
ulcer
healing.

Clindamycin
Cleocin
HCL

Citicoline
Citicholine

Inhibits bacterial
synthesis

protein

Antibiotics
in
the
macrolide group affect
Macrolides
Hinders or kills susceptible ribosomes.
block
only
bacterial
bacteria.
ribosomes and prevent
them
from
building
proteins. Since proteins do
all the cells work, a
bacterium
that
cannot
build
proteins
cannot
Enhances the action of the survive.
brain stem ciliary body
especially the ascending
ciliary
body
activating It is usually known that
especially
system, which is closely phospholipid,
decreases
related to consciousness. lecithin,
following
decline
in brain
Citicoline increases cerebral
activity
with
cerebral
blood flow and oxygen
trauma.
Citicoline,
which is
consumption of the brain
a
co-enzyme,
accelerates
and
improves
cerebral
circulation and metabolism. the biosynthesis of lecithin
in the body.

V: Drug Analysis: Pre op medications

Monitor urinalysis for


hematuria and protein
Periodic liver function t
with prolonged use.
Report any changes in
elimination such as pa
discomfort associated
urination, or blood in u
Do not breast feed whi
taking this drug.
Before giving first dose
specimen for culture a
sensitivity test, begin t
pending results.
monitor renal, hepatic,
hematopoetic function
prolonged therapy.
be alert for adverse re
and drug interactions-i
adverse GI reactions o
monitor patients hydr
Citicoline may be taken
without food. Take it w
between meals.
The supplement should
taken in the late aftern
at night because it can
difficulty sleeping.
Women who are pregn
trying to become preg
should consult with the
doctor before taking th
supplements

Intra op Medication

Generic
Name

Brand
Names

Nalbuphi
ne

Nubain

Mechanism of Action

Sevorane
Sevoflura
ne

An opiate analgesic with


both narcotic agonist and
antagonist
actions.
Analgesic potency is about
equal to that of morphine,
and antagonist potency is
about
1/
25
that
of
naloxone.
May
cause
sphincter of Oddi spasm.
Does
not
increase
pulmonary artery pressure,
systemic
vascular
resistance, or myocardial
work load.
induces a state in which the
CNS is altered so that
varying degrees of pan
relief,
depression
of
consciousness,
skeletal
muscle relaxation and reflex
reduction are produced

Reason/Rationale
Suppresses gastric acid
secretion
relieving
gastrointestinal
distress
and
promoting
ulcer
healing.

Blocks
signals
from
getting to the brain. Pain
and other messages travel
through
the
nervous
system
as
electrical
impulses. They work by
setting up an electrical
barricade by binding to
the protein in neuron cell
membranes
that
let
charged particles in and
out and lock out positively
charged particles. Block
pain signals, so patients
can be numb to the pain
effects.

Nursing Care/Measures

Precautions
Pregnancy Category B .
Lactation: Excreted in breast m
Renal Function
Duration of action may be prolonge
in patients with renal function
impairment; may need to reduce
dose.
Hepatic Function
Duration of action may be prolonge
in patients with hepatic function
impairment; may need to reduce
dose.

Monitor all the body systems.


Continuous monitoring of pulse
oximetry.
Postural BP should be taken
Take note of that time that the
drug has expired.
Stop durg immediately, adminis
oxygen.
Start rapid fluid
resuscitation>Make sure client
well ventilated
Seizure precaution
Administer epinephrine

Generic
Name

Brand
Names

Paraceta
mol

Calpol

Mechanism of Action

Decreases fever and pain

Reason/Rationale
Inhibiting the effects of
pyrogens
on
the
hypothalamus
heat
regulating centers & by a
hypothalamic
action
leading to sweating &
vasodilatation.
Inhibiting
prostaglandin
synthesis at the CNS but
does
not
have
antiinflammatory
action
because of its minimal
effect
on
peripheral
prostaglandin synthesis.

Post Op Medications

Nursing Care/Measures

Assess patients fever or pain:


typeof pain, location, intensity,
duration, temperature, and
diaphoresis.
Assess allergic reactions: rash,
urticaria; if these occur, drug m
have to be discontinued.
Teach patient to recognize signs
chronic overdose: bleeding,
bruising, malaise, fever, sore
throat.
Tell patient to notify prescriber for
pain/ fever lasting for more than 3
days.

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