Colegio San Agustin-

Bacolod

In partial fulfillment of the requirement in

Related Learning Experience

The Doctors Hospital, Incorporated

A Grand Case Presentation on

Complete Bowel Obstruction 2 to Left Sided Colonic Mass with Cecal Perforation

Submitted by:

GROUP 1 OF BSN-3A

GiaCamia May Aloro Mariel Fagela

Joanna Marie Belleza Joan Flores

Maria NenaBenlot Hazel JheanGhofulpo

Aya Bolinas Enna Mae Gimotea

Krachel Faith Ceballos Edison Mark Galvan

Dawn Thea Escobar Jeffrey Quiliquili

JherbongTermil
 INTRODUCTION

An obstruction can occur when there is no open passageway for food or digested food
waste to move through the bowel, or intestine. It can occur anywhere in the small or large
intestine, and there can be a partial or complete blockage.

When an obstruction occurs, undigested food, liquids and digestive secretions accumulate
above the blockage, the bowel section involved in the blockage becomes distended and the
segment can collapse. The normal functions of the bowel wall are compromised and the
distended section gets progressively worse. A completely blocked large bowel is a medical
emergency.

There are a number of causes that could be responsible for a bowel obstruction, both
mechanical and non-mechanical.

Paralytic ileus refers to a non-mechanical obstruction where the rhythmic muscle

contractions of the intestine, known as peristalsis, stops. The bowel becomes dilated and can no
longer move the contents to the anus. It may occur when there is another medical condition such
as a chest infection, acute heart attack, stroke, acute kidney failure, trauma,
severe hypothyroidism, electrolyte disturbance or a complication of diabetes. Ileus can
sometimes occur after some types of surgery or during the postnatal period (the 6 weeks after a
woman gives birth).

Adhesions, or scar tissue, that can form after abdominal surgery and trap a section of the
bowel, are one of the most common causes of a mechanical bowel obstruction. Other common
types of mechanical obstruction of the small bowel include a hernia (where part of the bowel
pushes through a weak area in the abdominal wall) or volvulus (where the bowel becomes
twisted). A mechanical obstruction in the large bowel is most often caused by a malignant
tumour (they also occur in the small bowel but only very rarely) with the risk of obstruction
increasing the further along the bowel the tumour is sited. Volvulus can also occur in the large
bowel, most often in the sigmoid colon.

Other possible causes of bowel obstruction include:

Impacted stools from severe constipation

Diseases that affect the intestinal wall such as Crohn's disease or diverticular disease

Gallstones

A swallowed item
 Intussusception, where part of the intestine folds in on itself

Congenital malformation of the bowel

The symptoms of bowel obstruction vary, with some symptoms being more prevalent or
appearing earlier than others, depending on the location and type of
obstruction. Vomiting usually occurs early on, followed by constipation, when the small bowel is
involved, but the early onset of constipation followed by vomiting is more characteristic of a
large bowel obstruction. The symptoms of a small bowel blockage tend to progress more quickly,
while those of the large bowel are usually milder and develop more gradually. Symptoms
include:

Intermittent pain in the middle abdominal area when there is a blockage in the small
bowel; it is more severe the higher the blockage, but paralytic ileus pain may be less or even
absent.

Lower abdominal cramps in obstruction of the large bowel.

Abrupt onset of continuous pain, sometimes with superimposed waves, in volvulus.

Vomiting, early on when there is a high-level obstruction; vomiting of faecal matter

indicates a lower obstruction.

Abdominal distension, or swelling, more apparent the lower the obstruction is.

Failure to pass stools, early on in a large bowel blockage and later if the blockage is
higher up; there may also be an inability to pass wind.

Diarrhea if there is a partial blockage; passing of a liquid stool provides temporary relief.

The doctor will need to do a physical examination of the abdomen to help make a
diagnosis of an obstruction and determine the cause, and also to rule out other conditions such
as gastroenteritis or pancreatitis.

Blood samples may be taken to test for infection, anaemia, kidney and liver function, and
a plain X-ray of the abdomen may help to confirm a diagnosis. An ultrasound may be useful in
examining the small bowel. A contrast dye enema X-ray may help in detecting a low-level
obstruction or adhesions in the small bowel. CT scanning may be used to determine the need for
surgery in a small bowel obstruction.
 The treatment will depend on the cause of the obstruction. For example, in a case of
paralytic ileus, treatment may involve inserting a flexible tube (nasogastric tube) down the throat
to drain fluids from the stomach as well as correcting fluid and electrolyte imbalances.

In most cases a partial blockage will not require surgery, but a complete blockage will.
The type of surgery will depend on the type of blockage and its location.

A laparotomy, where an incision is made into the abdomen while under general
anesthesia, may be performed to search for the cause of an obstruction and/or to remove or
manage it.

Laparoscopy, or keyhole surgery, in which a laparoscope (a small tube with a light and
camera on the end) is inserted into a small incision, may be an option for treating a small bowel
obstruction or removing adhesions.

Endoscopic stenting, where a self-expanding stent is inserted to help keep the

passageway open, may be considered in the elderly and in palliative care ofcancer patients.

A sigmoidoscopy or colonoscopy involves inserting a thin flexible tube with a small

camera and light attached on one end through the rectum into the bowel, along with a flatus tube
(a long rubber tube), to decompress and untwist the bowel.

Our client undergone both Exploratory Laparotomy and Appendectomy last August 2,
2016. She also undergone ileostomy. This is a case of client, J.M.Z, a 32 year-old female who
was diagnosed with Complete bowel obstruction secondary to left sided colonic mass. According
to the client, the abdominal pain started 3 months ago and she sought for consultation at the OPD
Department. She was eventually admitted at The Doctors Hospital, Incorporated last July 31,
2016 at 3:04 PM with a chief complaint of abdominal pain. We chose this for our Grand Case
Presentation because it got our interests and we want to further explore on the client and her
disease condition.
OBJECTIVES

Within 30 days of preparing and devising a case study regarding Bowel Obstruction, we BSN-4A
Group 1 will be able to:

Cognitive:

Define Complete Bowel Obstruction comprehensively.

Recognize the predisposing and precipitating factors of Bowel Obstruction correctly.

Correlate the significance of the diagnostic tests and procedures done to the clients
disease condition correctly.

Formulate a concrete and systematic pathophysiology of Bowel Obstruction.

Construct an effective plan of care appropriate for the client comprehensively.

Determine the management and drugs given regarding the disease condition of the client
appropriately.

Formulate a comprehensive discharge plan based on the clients level of understanding.

Evaluate the effectiveness of nursing care rendered.

Psychomotor:

Gather all significant data comprehensively.

Perform a thorough physical assessment utilizing Gordons Functional Assessment,

Cephalocaudaland Systems approach.

Utilize therapeutic communication with client and folks effectively.

Organize data gathered systematically.

 Assess the clients level of understanding regarding present health condition.

Present a well-organized and detailed case study effectively.

Devise a presentation strategy based on the students comprehension appropriately.

Affective

Manifest the values of a globally competitive Augustinian nurse at all times.

Establish trust, open communication and teamwork within the members of the group

throughout the study.

Demonstrate self confidence in presenting the case.
Recognize the efforts and contributions of each group member throughout the study.
Respect clients rights, beliefs, norms and values at all times.
Exhibit enthusiasm, patience and optimism during the formulation of the study.
Maintain confidentiality regarding the clients condition at all times.
Accept constructive criticisms and recommendations by the panelists positively.
I. Vital Information
A. Clients Name: J. M. Z.
B. Age: 32 years old
C. Height: 164cm (5ft)
D. Weight: 33kg (73lbs)
E. Sex: Female
F. Civil Status: Single
G. Religion: Roman Catholic
H. Nationality: Filipino
I. Birth Date: January 15, 1984
J. Birthplace: Hinigaran City
K. Current Address: Brgy. 4 Municipality of Hinigaran
L. Educational Attainment: Graduated BS Information Technology at Binalbagan
City College
M. Present Occupation: Contractor at Kitchen Fire Suppression System Inc.
N. Date and Time of Admission: July 31,2016 3:04 pm
O. Accompanied by: Female cousin
P. Attending physician: Dr. M.D.R
Q. Medical Diagnosis: Complete Bowel Obstruction 2 to Left Sided Colonic Mass
with Cecal Perforation
R. Drug and Food Allergy: No known drug and food allergy
S. Sources of Information: Patient, folks, and patients chart
T. Person to be contacted in case of emergency: Father
U. Health Status upon Admission
1. Manner of admission: Ambulatory
2. Level of consciousness: Alert, conscious and responds to questions appropriately. Client
is oriented to time, place and person.
a. Mood upon admission: Upon admission, the client was anxious and is exhibiting
facial grimace.
3. Vital Signs upon admission:
Temperature: 36 C
HR: 62 bpm
RR: 22 cpm
BP: 120/80 mmHg
I. History of Present Illness

According to the patient, she experienced abdominal pain 3 months ago with a

pain scale of 8/10. The pain was intermittent and the client described it as a dull pain

in her umbilical region. She cant eat due to the pain. She cant defecate whenever

shes in pain and according to her, she feels ill if she cant defecate. She also vomits

to a greenish vomitus. The pain will only just subside if she takes Buscopan. The

client mentioned that she self-medicates like taking pain relievers (Buscopan,

paracetamol, mefenamic acid). According to the patient as last July 31, 2016, the pain

worsened. She sought for consultation at the Out Patient Department together with

her cousin and was eventually advised for admission. Patient JMZ was admitted last

July 31, 2016 at 3:04 pm.

II. Past Medical History

The client was hospitalized a week ago, prior to her latest hospitalization. She was

diagnosed with nutritional anemia. She was then discharged after 9 days. She was

instructed to remain on soft diet until her follow-up check-up. The client undergone

TB treatment and was given TB drugs such as Rifampicin, Isoniazid, Pyrazinamide

and Ethambutol. She completed the treatment course for TB.

The client also mentioned that she always experiences hyperacidity. She also

added that she has both internal and external hemorrhoids. According to the client,

there would be a presence of blood in her stool whenever she experiences

constipation. The client also mentioned that she self-medicates by using laxatives.

III. Past Surgical History

The patient didnt undergo any surgery before.

IV. Psychosocial History

She seldom bonds with her friends and when she does, she likes to hang out with

her close friends in high school and she also likes to travel with her co-workers.
According to the patient, she has a good relationship with her family and they live

together in one compound. Her neighbors dont pay close attention to them and the

client added that their neighbors are not really interactive with them.
V. Occupational History
 The client first worked on Aguila glass after she graduated from college as an

account executive but she didnt stayed there for long because according to her, she is

not used to discrimination and below the belt accusations. She also worked as an

English tutor for Koreans for 1 month but decided to stop when she had diarrhea and

after that she has been a cashier at Lopues Hinigaran for 1 year. Before her

hospitalization, she was a contractor at Kitchen Fire Suppression System for a year

now, she does paper works, proposal and travels to Kalibo, Aklan every year and the

client also mentioned that she really enjoys her work because it has less pressure than

some of the jobs that she worked at.

VI. Family History

Both of the clients parents have hypertension. Her mother also had stomach ulcer

and died at the age of 63 years old due to Myocardial Infarction. Aside from

hypertension, her father also has asthma. The client also added that her elder sister

was diagnosed with depression and is medically treated at home. She also mentioned

that her aunt has hemorrhoids and her another aunt has goiter.

VII. Predisposing/Precipitating factors/ Psychological Stressors

According to the client, there is no history of Bowel Obstruction in her family and

relatives. She also mentioned that she is fond of eating salty foods, grilled chicken and pork

and also raw foods like kinilaw. The client also added that she can finish 1 liter of coke in

one sitting. According to the client, she stays up late whenever she has proposals and

requirements to submit. She would sleep at around 1:00AM and wake up around 5:00 AM

because her work starts at 7:30AM.

PHYSICAL ASSESSMENT

I. General Survey

Area Normal Findings Abnormal Findings Abnormal Findings

(Book view) (Actual Assessment) (Actual Assessment)
August 2, 2016 October 17, 2016

General General appearance: She is pale in She has fair skin.

appearance The skin complexion of appearance. She has a Absence of bipedal
Hygiene Filipinos is fair skinned. pitting edema Grade 1. edema. Upon
 (grooming) assessment the patient
Manner of has gained weight.
dressing
Body weight Hygiene: The principle The patient appears The patient appears
Body built, of maintaining clean and well- clean and well-
stature, posture, cleanliness and groomed. Her hair was groomed. Her hair is
gait, mood and grooming of the external combed neatly. No foul neatly combed. No
affect, speech body odor noted. foul odor noted.

Weight: A persons The client weighs 33kg The client gained

weight averages 160 or 72.6 lbs. She 15kg and now she
pounds appears so skinny. Her weighs 48kg or 105.6
BMI result is 12.27 lbs. Her BMI result is
(underweight) 17.84 (underweight)

Body Stature: The Clients height is 164 Clients height is 164

average height of an cm. cm.
adult is 160 cm.

Body posture: The As observed the client As observed the

means of is slouching whenever client is slouching
communication in she walks. whenever she walks.
addition facial
expressions, personal
distance, gestures and
body movement
Client was Upon home visit the
Body gait: bipedal,
cooperative; every client shows
biphasic forward
time we talked to her cooperation during
propulsion of center of
she answers the the interview. She
gravity of the human
questions answered the
body, in which there are
appropriately. Shell questions
alternate sinuous
just inform us that appropriately and
movements of different
shes tired and that we comprehensively.
segments of the body
have to stop
with least expenditure of
interviewing her and
energy.
give her time to rest.
Client talks clearly and
was able to share what
she feels and about her
life experiences.

Gordons Functional Assessment

Functional Area Normal Findings Abnormal Findings

(Bookview)

Health Perception-Health The actions people take to The client drinks her vitamins
Management
Nutritional- Metabolic Pattern
Elimination Pattern
Activity- Exercise Pattern
understand their health scale,
maintain an optimal state of
health, prevent illness and
injury and reach their
maximum physical and mental
potential. Health behavior is
intended to prevent illness or
disease or to provide for early
detection
Clients pattern of food and
fluid consumption relative to
metabolic need and pattern.
Clients pattern of excretory
function (bowel, bladder, and
skin). Includes clients
perception of normal function.
Perceived regularity or
irregularity of elimination.
Changes in quality and
quantity of excretions. Normal
bowel elimination is 1-2 daily.
Normal amount of urine
excretion should be 30ml or
above every hour
Clients pattern of exercise,
everyday. The client is also
aware of the possible
consequences she might
encounter if she considers to
practice unhealthy lifestyle
and include unhealthy foods in
her daily diet. She verbalized
that she doesnt care about
what would happen regarding
her health as long as she is
satisfied of what she eats. She
mentioned that despite her
unhealthy practices, she still
believes that health is wealth
and it should not be taken for
granted because everything
would fall out of its place if
health is aggravated.
The client is not fond of eating
vegetables but occasionally
eats citrus fruits such as
oranges. She prefers eating
fatty foods such as pork
barbecue. She also drinks
carbonated beverages such as
soda in every meal and she
added that she can even finish
1 liter of coca-cola in one
sitting. According to her, she
usually consumes at least one
cup of rice every meal. She
drinks 5-8 glasses of water
everyday.
The client stated that prior her
present condition, she
normally defecates 2-3 times a
day usually in the morning
and evening. But when she got
sick, she verbalized that it
now takes 2-3 days before she
can defecate. She also added
that she has an alternating
diarrhea and constipation. She
urinates 3-4 times a day
approximately 200 ml each
voiding episode.
The client works as a

Sleep- Rest Pattern
Cognitive- Perceptual Pattern
Self- Perception- Self-
Concept Pattern
Role Relationship Pattern
activity, and recreation.
Activity of daily living that
restores energy and
expenditure.
Clients pattern of sleep, rest,
and relaxation. Perception of
quality of sleep and rest.
Patterns of sleep and rest or
relaxation in a 24 hour period.
Normal hours of sleep in
adults is 6-8 hours.
The sensory-perceptual and
cognitive pattern of a person.
Adequacy of vision, hearing,
taste, touch and smell. Clients
language, judgment, and
memory.
Clients self concept pattern
and perception of self.
Attitude about self. Perceived
abilities, worth, self-image,
emotions. Body posture and
movement, eye contact, voice
and speech patterns.
Clients pattern of role
contractor in a company.
According to her, she doesnt
engage in any sports activities
and exercises. During her
leisure time, she would prefer
to go out with her friends and
colleagues at work or do
household chores.
The client usually sleeps
around 9:00PM and wakes up
at 5:00 AM. However,
whenever she has proposals to
submit, she stays up late. She
would sleep at 1:00AM and
wake up at 5:00 AM because
her work starts at 7:30 AM.
She graduated at Hinigaran
Elementary School in her
primary education and
finished her secondary
education at Hinigaran
National High School. She
finished her vocational study
as computer and data
processing at Binalbagan
Catholic College in the year
2003.
There were no signs of any
hearing problems as we talked
spontaneously. There was a
good exchange of ideas in the
conversation. She actively
responds to different questions
asked to her during the
assessment and answers
appropriately.
The client maintains eye
contact as we speak to her.
According to what she has
shared to us, she seems
knowledgeable of herself. She
perceives herself as one that
has a good self-control. She
verbalized that she could
easily build a good
relationship with everyone.
According to the client, she

Sexual- Reproductive Pattern
Coping Stress- Tolerance
Pattern
Value Belief Pattern
Growth and Development
Pattern
engagement and relationships.
Perception of major roles,
relationships and
responsibilities in current life
situation. Satisfaction with or
disturbances in roles and
relationships.
Patterns of satisfaction and
dissatisfaction with sexuality
pattern and reproductive
pattern
Clients general pattern and
effective pattern in terms of
stress tolerance. Capacity to
resist challenges to self
integrity. Methods of handling
stress, support systems and
perceived ability to control
and manage situations
Pattern of values, beliefs
including spiritual goals that
guide clients choices or
decisions. Perceived conflicts
in values, beliefs and
expectations that are health
related
The client is 32 years old and
according to Erik Eriksons
has a good relationship with
everyone including her family,
friends, relatives and
colleagues at work. She stated
that she has a very good and
strong relationship to both of
her parents. She added that
when her mother died, she got
even closer and more open to
her father. She verbalized that
she sometimes ventilates her
concerns and problems to her
friends.
Since the client is staying here
in Bacolod because of her
work, she went home in
hinigaran every week.
According to the client, she
doesnt engage in any sexual
activities.
According to the client, she
prefers to ventilate her
feelings towards her father
every time she is stressed. She
also stated that she manages to
overcome stress by diverting
her attention to different
recreational activities such as
going out with friends, going
to malls and eating in different
fast-food restaurants.
The client is a Roman
Catholic. According to her,
she has great faith in God and
attends mass every Sunday.
She believes in a saying what
you do will absolutely come
back to you. The client
doesnt believe in quack
doctors or in any form of
traditional healing.
She also added that she reads
bible and pray everyday.
According to the client, even
though she doesnt have a
 Psychosocial Stages of
Development, the client is
under Intimacy vs. Isolation
Stage.
At the young adult stage,
people tend to seek
companionship and love.
Some also begin to "settle
down" and start families,
although seems to have been
pushed back farther in recent
years. Young adults seek deep
intimacy and satisfying
relationships, but if
unsuccessful, isolation may
occur. Significant
relationships at this stage are
with marital partners and
friends.
Cephalocaudal Approach
Normal Findings Abnormal Assessment
(Book View) August 3, 2016
(Actual)
Skin No edema, no abrasions I: Skin is pale
and other lesions; appearance.
moisture in skin folds No lesions noted.
and the axillae (varies P: No dryness of skin (36.5oC). Surgical incision
with environmental noted. No
temperature and palpated.
humidity, body P: not applicable
temperature, and A: not applicable
activity); when pinched
skin back to previous
state
boyfriend, she stated that the
love and companionship that
she found in her friends and
family is already enough for
her to be happy. She found a
sense of belongingness in her
family. She stated that she is
not rushing to find her special
someone because according to
her the right one will come at
the right time. She added that
if the right person for her will
come along, she would
probably be more happier and
inspired. She is satisfied with
her loved ones and she is
focusing on her relationship
with them.
Latest Assessment
(Actual)
(October 17, 2016)
in I: clients skin is uniform in
color. Has good skin turgor.
Temperature is normal
nodules scar noted at the abdomen.
Skin dryness not noted.
P: No dryness of skin noted.
No nodules palpated.
P: not applicable
A: not applicable
Head Rounded normocephalic I: Normocephalic in shape I: Normocephalic in shape
and symmetrical, with and symmetrical. Head is and symmetrical. Head is in
frontal, parietal, and in proportion with the proportion with the body. No
occipital prominences; body. deformity and visible mass
smooth skull contour; P: No nodules, lesions and noted.
absence of nodules and masses palpated P: No nodules, lesions and
masses; symmetric or No protrusion of veins masses palpated
slightly asymmetric noted. No protrusion of veins noted.
facial features; palpebral P: Not applicable P: Not applicable
fissures equal in size; A: Not applicable A: Not applicable
symmetric nasolabial
folds

Hair Evenly distributed hair, I: Color of hair is blonde I: Color of hair is light brown
thick, silky, resilient, no and appears thin and and appears to be healthy.
infection or infestation, brittle. Hair is evenly distributed and
variable amount of body P: Not applicable has a variable amount of
hair P: Not applicable body hair.
A: Not applicable P:Not applicable
P:Not applicable
A:Not applicable

Face Symmetric or slightly I: Face is symmetrical and I: Face is symmetrical,

asymmetric facial has uniform color appears to be smooth and has
features; palpebral consistency. Skin uniform color consistency.
fissures equal in size; pigmentation is not noted. Skin pigmentation is not
symmetric nasolabial P: No nodules or masses noted.
folds noted P: No presence nodules or
P: Not applicable masses noted
A: Not applicable P: Not applicable
A: Not applicable

Eyes Eyelids intact, no I: Iris is black in I:Iris is black in appearance.

discharges, no appearance. No No discoloration of sclera
discoloration; lids close discoloration of sclera noted. No presence of ocular
symmetrically; sclera noted. No presence of discharges. Pupil is reactive
appears white; no edema ocular discharges. Pupil is to light and accommodation.
or tenderness over reactive to light and P:Not applicable
 lacrimal gland; pupils accommodation. P:Not applicable
constrict when looking P: Not applicable A:Not applicable
at near objects, pupils P: Not applicable
dilate when looking at A: Not applicable
far objects, pupils
converge when near
object is moved toward
the nose.

Ears Color is same as facial I: Pinna are symmetrical I: Pinnas are symmetrical
skin, symmetrical; and are the same color and are the same color with
auricle aligned with with the facial skin. No the facial skin. No discharges
outer canthus of eye, discharges noted. No noted. No hearing
about 10 from vertical, hearing impairment. impairment.
mobile firm, and not P: No tenderness noted. P: No tenderness noted.
tender; pinna recoils P: Not applicable P:Not applicable
after it is folded; sound A: Not applicable A:Not applicable
is heard in both ears.

Nose Symmetric, no I: Nose is symmetric in I: Nose is symmetric in

discharges or flaring; appearance. No discharges appearance. No discharges
not tender; no lesions; noted and no nasal flaring noted and no nasal flaring
mucosa is pink; nasal noted noted
septum intact and in P: No tenderness noted P:No tenderness noted
midline. P: Not applicable P:Not applicable
A: Not applicable A:Not applicable

Muscles equal in size;

Throat head centered; I:No visible mass and I:No visible mass and lesions
coordinated, smooth lesions noted noted
movements with no P: Regular pulsation noted P:Regular pulsation noted
discomfort. P: Not applicable P:Not applicable
A: Not applicable A:Not applicable
 Nails Convex curvature; angle I: Capillary refill is 4 I: Client has a pinkish nail
of nail plate about 160; seconds; no discoloration appearance and is cut a
Smooth texture; intact noted straight and appeared clean.
epidermis; prompt P: Not applicable Capillary refill is 2 seconds;
return of pink or usual P: Not applicable no discoloration noted.
color (generally less A: Not applicable P:Not applicable
than 4 seconds. P:Not applicable
A:Not applicable
Chest symmetric, chest I: Use of accessory
wall intact, no muscles when breathing
Chest/Thorax tenderness, no masses noted I: Use of accessory muscle
P: Not applicable when breathing not noted
P: Not applicable P:Not applicable
A: No abnormal lung P:Not applicable
sounds noted A:No abnormal lung sounds
noted
Patient refused to be
assessed
Rounded shape; slightly
unequal in size;
generally symmetric; Patient refused to be assessed
Breast skin uniform in color,
smooth and intact;
nipples are rounded,
everted, and equal in
size; similar in color;
soft and smooth; both I: No visible mass noted;
nipples point in the stoma is reddish in
same direction; no appearance; incision site
tenderness, masses, or is dry and intact.
nodules A: borborygmus sound
noted.
Uniform color; flat P: Tenderness noted upon
rounded (convex), or palpation.
scapoid (concave) P: tympanic
Abdomen contour; symmetric sound noted I: No visible mass noted.
contour; audible bowel Presence of ileostomy at the
sounds; absence of right lumbar area. Stoma is
 arterial bruits; absence protruding and is pinkish in
of friction rub appearance. Incision scar
noted and is not keloidal.
Abdominal girth is 26
inches.
A: borborygmus sound
noted.
P:Tenderness noted upon
palpation.
A:tympanic
sound noted

Systems Approach

Normal Findings August 3, 2016 Latest Assessment

(Book View) (Actual) (Actual)
Integumentary Consist of skin, hair I: Skin is pale in (October 17, 2016)
and nails. Skin provides appearance. I: clients skin is
a physical barrier
No lesions noted. uniform in color. Has
between underlying
tissues and the external P: No dryness of good skin turgor.
environment; excretion skin noted. No Temperature is normal
through perspiration;
nodules palpated. (36.5oC). Surgical
temperature regulation
and sensory perception. P: not applicable incision scar noted at
Hair protects the scalp A: not applicable the aabdomen. Skin
from excessive heat
dryness not noted.
loss. Nails protects the
dorsal tips of fingers P: No dryness of skin
and toes and site of noted. No nodules
assessing the capillary palpated. Abdominal
refill.
incision scar is not
keloidal.
P: No abnormalities
noted
A: Not applicable

I: Not applicable
P: Minimal
I: Not applicable
enlargement of
 cervical lymph P: Minimal
Composed of organs nodes. enlargement of
Lymphatic System that helps maintain P: Not noted cervical lymph nodes.
homeostasis by A: Not applicable P: Not noted
conserving water and A: Not applicable
dissolved substances.
Lymphatic system helps
maintain water balance
in the body. It also
protects the body I: No nasal
against pathogens that discharges noted;
may invade the body. Respiratory rate I: No nasal discharges
of 25 cpm. No noted; Respiratory rate
nasal flaring of 18cpm. No nasal
Respiratory System The purpose of the noted. No flaring noted. No
respiratory system is to wheezes noted. wheezes noted.
keep the body P:Not applicable P:Not applicable
constantly supplied P: Not noted P: Not noted
with oxygen and to A: No abnormal A: No abnormal lung
remove the carbon lung sounds sounds noted.
dioxide. It consists of noted.
the nasal passages,
pharynx, larynx,
trachea, bronchi, and
lungs. Within the lungs
are tiny air sacs. It is
through the thin walls
of these air sacs that
gases are transported to
and from the blood. The
normal respiratory rate I: Normal chest
is 16-20 cpm. contour, blood
pressure is 110/70
mmHg. Pulse rate I: Normal chest
is 62 contour, blood pressure
bpm( August 3, is 120/80 mmHg. Pulse
Cardiovascular The primary organ are 2016) rate is 70
System heart and blood vessels. P: Not applicable bpm( October 17,
Using blood as the P: Not applicable 2016)
transporting fluid, the A: Not heart P: Not applicable
cardiovascular system murmurs noted. P: Not applicable
carries oxygen, A: Not heart murmurs
nutrients, hormones, or noted.
other substances to and
from tissue cells where
exchanges are made.
The heart acts as the
blood pumps,
propelling blood out its
chambers into the blood
 vessels to the
transported to all body
tissue. The normal
cardiac rate is 60-100
bpm. I: No deformities
noted, no
swelling noted,
mobile joints
noted
P: No masses and I: No deformities
tenderness noted noted, no swelling
Musculoskeletal The skeletal system P: Not noted noted, mobile joints
System serves as the supporting A: Not applicable noted
framework of the body, P: No masses and
and it performs several tenderness noted
other important P: Not noted
functions such as the A: Not applicable
body shape,
mechanisms of
movement, and the
erect posture in
humans. Muscle tissue
is specialized for
contraction. I: No visible mass
Contraction of muscle noted; stoma is
produces the reddish in
movements of the body appearance;
and body parts. incision site is dry
and intact.
A: borborygmus I: No visible mass
sound noted. noted; stoma is pinkish
Gastrointestinal P: Tenderness in appearance; upon
System It is the tube running noted upon assessment incision
through the body from palpation. scar was noted.
the mouth to anus. The P: tympanic A: borborygmus sound
role of digestive system sound noted noted.
is to break down food P: Tenderness noted
and deliver the products upon palpation.
to the blood for P: tympanic
dispersal to the body sound noted
cells. The undigested
food that remains in the
I: Alert, oriented
tract leaves the body
to time and place.
through the anus as
Responds to
feces.
stimuli.
P: Not applicable
P:Not applicable
A: Not applicable
I: Alert, oriented to
time and place.
 Responds to stimuli.
Neurologic System The nervous system P: Not applicable
consists of the brain, P:Not applicable
spinal cord, sensory A: Not applicable
organs, and all of the
nerves that connect
these organs with the
rest of the body.
Together, these organs
are responsible for the I: attached to
control of the body and foley catheter
communication among with urine output
the parts. of 30cc/hr.
Patient refused to
our request to
assess the area
P: not noted
P: Not noted I:.Patient refused to
Genitourinary System The body produces A: Not noted our request to assess
wastes as by-product of the area. During the
its normal functions, interview the patient
and these wastes must states that she urinates
be disposed of. One 5-7 times a day.
type of waste contains P: not noted
nitrogen, which results P: Not noted
when the body cell A: Not noted
break down proteins
and nucleic acids. The
urinary system removes
the nitrogen containing
wastes from the body in
urine. It is also called
excretory system.

Medical Management:

DOCTORS ORDERS

Date Doctors Order Significance

July 31,2016 Please refer and admit - for co-management
under Dr. Monte de Ramos
Weight -33kg and Dr. Tabuga for co-
Temperature 36.7 management
Hct -164 - to decrease the amount
Medication: omeprazole of acid produced in the
(Zeflon) stomach
40 mg IV - for hydration and
OD electrolyte replacement
IVF: PNSS 1L X 100 cc/hr -to evaluate health and
detect wide range of
 Laboratory: CBC with PC
Urine
analysis
Potassium
Albumin
Standing order:
Monitor vital signs every 4
hours and record
Informed Dr. Monte de
Ramos And Dr. Tabuga
4:40 pm Refer accordingly
Please retrieve old chart
decrease IVF to 80 cc/hr
For low pressure enema
once only
Give Buscopan 1 amp PRN
7:35 pm for pain
Untolerated by patient Start Cebraun 1 gm IVTT
every 12 hour after (-) IV
test
8 pm
May hold enema
8:30 pm temporarily
Rectal tube insertion
IVF PNSS 1L X 80cc/hr
disorders
-to screen and detect
some disease
-to measure amount of
potassium in the blood
-to measure amount of
albumin in the blood
-to monitor health status
-for co-management
-for therapeutic cleansing
of the colon, to stimulate
stool evacuation
-to relieve smooth muscle
spasm
- for treatment of bacterial
infection in the abdomen
-to facilitate rectal tube
insertion
-to remove gas from the
lower intestines or to
remove contain fecal
matter
- for hydration and
electrolyte replacement
August 1,2016
10 am Give Nubain 5ml now -for moderate or severe
pain

2 pm Schedule for exploratory

laparotomy once cleared -to examine the
For cardiopulmonary abdominal organs
clearance care off Dr.
Tenirefe
4 pm
Dr. Tenirefe unavailable -for co-management
Refer to Dr. ShielaVillar for
cardiopulmonary
7:30 pm clearance
-to replace blood lost
Blood pressure -110/70 Please transfuse 1 unit -for compatibility
mmHg PRBC of patients blood
Temperature -36.3 type properly screened
Pulse rate 80 bpm and crossmatched to run
Respiratory rate 21 cpm for 4 hours -to facilitate transfusion

Close mainline while on -to prevent complication

blood transfusion
Blood transfusion -to monitor blood
precaution please transfusion complication
Monitor vital signs every
15 minutes until stable
Refer for signs of dyspnea,
tachycardia or allergic
reactions
August 2,2016
2 am Number 4 IVF to follow -for fluid and electrolyte
D5NM 1L X 120 cc/hr replacement

3:30 am Please schedule 2D echo -to monitor heart

tomorrow at 11 am care functioning
off Dr. Tenerife
Sterofundin 1L X 20 drops
per minute -for fluid and electrolyte
and replacement
8 am Suggest CT scan of the
abdomen with contrast if -to visualize the organs in
okay with Monte de the abdomen
Ramos
Okay with suggestion of
Dr. Tabuga

For CT scan of the -for approval of the

abdomen with consent procedure to be perform
2:30 pm
Moderate risk for surgery; -for surgery procedure
may go on ahead
3 pm
Schedule for exploratory -for surgery procedure
 laparotomy possible
resection today 4 pm
3:10 pm
Temperature 39.1
Give paracetamol 300mg
IVTT now
Pre-op medicines:
Ranitidine 1 ampule now
Diphenhydramine 1
ampule now
August 3,2016
7:10 pm Continue morphine
Mild dehydration precaution; monitor heart
rate, respiratory rate
every 15 minutes for 2
hours then every hour
thereafter
For respiratory rate of 12
cpm, please give 1
ampule naloxone PNSS
slow rate by 3 minutes;
start oxygen 5 cpm by
face mask
7:30pm
Sterofundin at 10 drops
per minute
100 cc sterofundin
Post-op order:
Monitor vital signs every
15 minutes for 2 hours
Every 30 minutes until
stable
Every hour thereafter
Nothing per orem
Oxygen inhalation 3 liters
per minutes
Discontinue once fully
awake
Present IVF sterofundin 1L
at 20 20 drops per minute
right hand
6am-6pm
Random blood sugar
determination every 12
hour
Morphine 2.5 mg via
epidural 5pm
-for the relief of fever,
minor aches and pain
-to treat ulcer of the
intestines
-to reduce pre-operative
nausea and vomiting
-to monitor adverse
reaction and monitor
health status
-for treatment of
respiratory depression
- for fluid and electrolyte
and replacement
-to monitor health status
after the procedure
-to rest the
gastrointestinal function
and prevent normal
gastrointestinal function
-to aid in breathing
- for fluid and electrolyte
and replacement
-to determine the amount
of sugar in the blood
-for pain
-for treatment of bacterial
infection in the abdomen
-for pain
-for body aches and pain
 Medications:
1. ceftriaxone (Cebraun)
1gm IVTT every 8 hour
2. ketorolac (Ketadol)
30gms IVTT every 6 hours
by 6 doses
3. paracetamol 30mg IVTT
every 4 hours
4. Nubain 5g IVTT every 4
hours PRN for severe pain
-for severe pain
- to evaluate health and
detect wide range of
disorders
-to monitor morphine
toxicity

Repeat CBC in 8am

Morphine precaution
Monitor heart rate, -for the treatment of
respiratory rate every respiratory depression
hour and record
Refer if heart rate below
60 per minutes,
respiratory rate of 12 per
minutes -for peripheral parenteral
For respiratory rate of 12 nutrition; for low glucose
per minutes please give 1 nutrition therapy
(-) signs of dehydration ampule Narcan diluted 3cc - to decrease the amount
(-) flatus PNSS IVTT by 3 minutes; of acid produced in the
(-) bowel sounds Start oxygen 5 cycles per stomach
minute by face mask -to monitor lung status
Revise fluid plan
Start Nutriflex
1400kilocalories to run for
24 hours 78cc/hour

Omeprazole 40mg IVTT -to continues monitoring

once a day 6am of health status
8pm Auscultate lung sounds
every 2 hours and refer of -to monitor lung status
rales and wheezes
10pm Refer for signs of
pulmonary congestion
-to monitor fluid retention
Continue monitoring vital in the body
signs every every2 hours -to monitor for oliguria
to include sign of
congestion
Auscultate lung and refer
for rales and wheezes, -to treat fluid retention in
dyspnea and tachycardia the body

Strict monitoring of intake - for fluid and electrolyte

and output and replacement
Refer urine output of less
than 30cc/hour by 3 -treatment of low blood
consecutive hours pressure
 Fast drip 200cc now -to monitor for oliguria
Give furosemide 20mg IV
now
-for continuous hydration
Fast drip 300cc now then and electrolyte
regulate sterofundin at 20 replacement and
drops per minute intravenous fluid access
Start dopamine 200/250
at 10 drops per minute -to treat fluid retention
Refer if urine output is less
than 30cc per hour for 3
consecutive hours
Nutriflex to consume then
hook PNSS 1L at 10 drops
per minute
IVF to follow Sterofundin
1L by 20 drops
Furosemide 20mg now
August 4,2016 Revise fluid plan -to regulate fluid
2:30pm Discontinue every 22 IV consumption
catch
Every 18 sterofundin 30 -to incorporate drug for
drops per minute side drip the low blood pressure
dopamine 10 drops per
minute -for continuous monitoring
Continue monitoring of of intake and output
intake and output every
hour and record -to monitor for oliguria
Refer if urine output less
than 30cc/hour for 3
consecutive hours -for pain
For sever pain tramadol
3:30pm 50g
Continue morphine -for fever and minor aches
precaution and pain

6pm Paracetamol 300mg IVTT

every 6 hours by 3 doses
then PRN every 4 hours
for fever
Give D50W 50ml IVTT now
-to increase serum blood
glucose level
-to facilitate normal
urination and approval of
the patient

Remove foley catheter per -to monitor for oliguria

patients report
Secure signed waiver -for fluid replacement and
Refer no urine output after hydration
6 hours
IVF to follow sterofundin
August 5,2016
9am Discontinue dopamine -for fluid and electrolyte
drip shift to D2LR 1L at 30 replenishment and caloric
drops supply
Discontinue Random
 Blood Sugar monitoring
4pm Algesia 1tab every 8 hours
Number 6 IVF to follow
D5LR 1L by 30 drops
10pm
Number 7 IVF to follow
D5LR 1L by 30 drops per
minute
August 6,2016 IVF to follow D5LR 1L 30
10am drops per minute
Release 2 units available
blood
August 7,2016
6:30am Start IV omeprazole to
oral 40mg once a day
ante cebum
Number 10 IVF to follow
D5LR 1L by 30 drops per
7 am minute
May have arrozcaldo
7:40pm today
For Carcinoembyonic
antigen today
Number 11 IVF to follow
D5LR 1L by 30 drops per
minute
August 8,2016
2am Number 12 IVF to follow
6am D5LR 1L by 30 drops per
minute
Give last dose of antibiotic
at 10am today then shift
to cefuroxime 500mg 1
tablet twice a day
IVF to consume then shift
to heplock
Discontinue IVF once
consume
Start JuvenAid per sachet
twice a day dissolve in
250ml water
August 9,2016 Start streptomycin sulfate
9:30am 0.5gms intramuscular
once a day
11am
May go home
August 13,2016 Full regular diet
II. LABORATORY RESULTS
For pain
-for fluid and electrolyte
replenishment and caloric
supply
-for fluid and electrolyte
replenishment and caloric
supply
-for fluid and electrolyte
replenishment and caloric
supply
- to decrease the amount
of acid produced in the
stomach
-to begin into a soft diet
-to check for the presence
of cancer
- for fluid and electrolyte
replenishment and caloric
supply
- for fluid and electrolyte
replenishment and caloric
supply
-to treat for bacterial
infection
-for easy access in the
vein
-nutritional drink to build
up lean body mass
-for the treatment of
tuberculosis
-for normal diet
DATE EXAMINATION RESULT REFERENCES SIGNIFICANC
E
July 31, 2016 CBC 0.00-0.00
5:24 PM Hemoglobin 102 120-160.00 10^12/L
RBC Count 3.90 4.00-5.30 (L) Caused by
Hematocrit 0.32 0.37-0.47 (L) nutritional anemia

Blood Type 0.00-0.00

RH Type 13.2 0.00-0.00
WBC Count 5.00-10.00 10^9/L (H) WBC may be
elevated with a
left shift in simple
or strangulated
obstructions

Differential Count 0.00-0.00 Increase by an

STAB 0.00-0.00 infection
Segmenters 91 50.00-70.00 % (H) Normal
fight against
Monocytes 5 2.00-6.00 % infection and
Eosinophils 0 1.00-4.00 % (L) inflammation
process.

Lymphocyte 4 25.00-40.00 % (L) Many disorder

0 0.00-1.00% increase o. of
lymphocytic in
the blood but
viral infection and
under nutrtion are
the most common

Basophil 0 Normal
The body
Platelet 523 150.00-450.00 compensate by
10^9/L(H) increase platelet
Clotting Time 2.00-7.00 count due to
Bleeding time 1.00-5.00 bleeding platelet
aids in helping
blood to form a
clot to stop
bleeding. When
there is a damage
July 31, 2016 in blood vessel.
6:11 Pm
Potassium 3.66 3.50-5.30 mEq/ L Normal
Albumin 1.8 3.50-5.00 g/dl (L) Possible poor
nutritional state
August 1, because of
2016 decrease protein
12:59 AM intake

RBS 60 65.00-130.00 mg/dl (L)

August 1,
2016
5:11 PM RBS 76 65.00-130.00 mg/dg Normal

August 1.
2016 Creatinine 0.7 0.60-1.00 mg/dl (L) Normal
10:45 PM SGPT/ ALT 22 0.00-35.00 U/L

August Clotting Time 5 minutes, 31 2.00-7.00

1,2016 seconds
11:05 PM

Bleeding Time 2 minures,15 1.00-5.00

seconds

August
3,2016
6:30 AM CBC 0.00-0.00
Hemoglobin 116 120.00-160.00 10^ Client has
12/L nutritional
anemia.

Hematocrit 0.37 Normal

0.37-0.47
WBC Count 13.3 Indicates an
5.00-10.00 10^9/L (H) increase in
disease fighting
August cell in our blood
3,2016
9:12 AM Segmenters 94 Increase by an
50.00-70.00 % (H) infection
Monocyte 3 Normal
Eosinophil 1 2.00-6.00 % Normal
Lymphocyte 40 1.00-4.00 % Many disorder
25.00-40.00 % (L) increase o. of
lymphocytic in
 the blood but
viral infection and
under nutrtion are
the most common
Platelet 376 Normal
Clotting time 150.00-450.00 10^9/L
Bleeding time 2.00-7.00
1.00-5.00

PHYSICAL AND CHEMICAL MICROSCOPIC FINDINGS

Color STRAW Red Blood Cells 6-12/HPF

Transparency Hazy Pus Cells 10-15/HPF
Reaction 6.0 Epithelial Cells
Specific Gravity 1.025 Squamous Moderate
Glucose Negative Mucous Thread Moderate
Protein Negative Bacteria Moderate

DATE Examination Results

August 1, 2016 Cross matching Patient Blood type A POSITIVE

6:10 PM NVBSP 2016 0096830 A POSITIVE

RESULT: COMPATIBLE

August 1, 2016 Donor Antibody NVBSP 2016 0096841: A Rh POSITIVE

10:12 PM Screening RESULT: NEGATIVE

ELECTROCARDIOGRAM

Remarks:

Normal left ventricle dimension and wall thickened with adequate contractility and normal
systolic function (WEF= 67%)

Normal right ventricle with adequate contractility.

Normal left atrium and right atrium

Thickened mitral valve leaflets with no restriction of motion.

Structurally normal aortic root, tricuspid and pulmonic valves.

Normal aortic root and main pulmonary artery.

No thrombus or pericardial effusion.

DOPPLER ULTRASONOGRAPHY

No valvular regurgitation

CT SCAN REPORT
Fatty infiltration of the liver.

Tiny nephrolithiasis, right.

Omental stranding with nodule in the left side maybe inflammatory in nature.
DRUG STUDY
Pathophysiology
Problem List
Nursing Care Plan
 Discharge Plan

EVALUATION
 We all live in a modern world where in we no longer care of whats going to happen in
the future. And humans as we are, we tend to neglect the importance of the life that was given to
us.

On our 3 days of ward exposure at The Doctors Hospital, we have encountered different
patients with different cases. We chose this case because we believe that we can be of help to our
patient and this is also a challenge to us as level 4 to enhance the knowledge, skills and attitude
that we have gained throughout our nursing journey. Its true; it takes a lot of brain to be a nurse.
This duty week taught us that it takes a lot of effort and patience and it requires a lot of passion
to be an effective nurse. Our patient opened our eyes to the exemplary example of how people
disregard the importance of health nowadays. She shared to us her lifestyle before and how she
neglected the importance of her health. From the time that she was hospitalized she shared that
she regrets doing such things. She also shared to us her fears in the future; if she can still
continue to work normally or this is already a sign that her life will never be normal. Yet, with all
these negative perceptions she has about herself and her life she still showed us that being strong
is the only way to fight all the fears of the future. She is the best example of bravery. After all the
procedures she underwent, she still manages to smile and continue to stay strong for herself and
for all the people around her.

On our home visit last October 17, 2016, we are very happy to see the changes on our
patient. She has gained weight and she states that she accepts her current situation. She also
shared that she is now conscious with her diet and lifestyle. After she was hospitalized she
started to avoid drinking soft drinks and other carbonated beverages (like coffee and beer).
Despite of the things that she experienced, she still managed to have a positive outlook in her
life. She also thanked us for everything the care that we have shown her during her
hospitalization. And as student nurses, we are very lucky to be part of the healing process of our
patient.

During this entire preparation for our grand case presentation, we have learned that being
a nurse is more than just a job. Aside from rendering care to our patients, we also serve as the
pillars of our patients. They tend to look for strength from us. And as student nurses, we are here
not just to take vital signs and other nursing responsibilities that we usually do. We are also here
to give them hope, love and encouragement because we believe that if being a nurse is difficult,
being a patient is not also easy. We have learned that being a nurse is a very influential and
rewarding profession. Aside from promoting health, preventing illness and educating the public,
we are also here through illness, injury, pain, loss, dying, grieving, birth, growth, aging and
health of our patients. This also strengthened our relationship as a group. Despite of the hectic
schedule that we have, deadlines that need to be rush, and a lot of barriers along the way, we still
managed to work as a group.
 We grew maturely together after being exposed to different rotations. We have learned
that as a group, we should also be the pillars and strength of each one. Because as they saying
stated above, it takes a lot of brain to be nurse; it also takes a lot of teamwork to reach our goals.
REFERENCES:

Brunner and Suddarth; Medical-Surgical Nursing; 10th edition; JB. Lippincott Company, 2008

Smeltzer, Suzanne C., et al; Medical-Surgical Nursing; 10th edition; JB Lippincott Company,

2004

Doenges, Moorehouse, et al; Nurses Pocket Guide: Diagnosis, Intervention and Rationale; 9th

edition; FA Davis Company, 2004