A CASE STUDY FOR HEPATIC ABSCESS

A Case Study
Presented to the Faculty
Of the College of Nursing
Capitol University, CDOC

In Partial Fulfillment of the Subject:

RLE 7

By:
Abada, Joana Marie Z.
Sogoc, Windel A.
Soon, Richelle Anne B.
Sosmeña, Vannessa M.
Sugarol, Kristine Mae U.
Sunico, Kennelyn A.
Sumile, April Rose G.
Supangan, Dan A.
Supnet, Eden Rhea J.
Tabasan, Robert Y.
Tadlas, Bonimar R.
Taganas, Ronna Marie R.

Submitted to:

Rick Wilson Bunao, RN

Clinical Instructor

January 2010
 Introduction
The liver is subject to a variety of disorders and diseases. One is Abscesses

which is caused by acute appendicitis; those occurring in the bile ducts may result from

gallstones or may follow surgery. The parasite that causes amebic dysentery in the

tropics can produce liver abscesses as well. Various other parasites prevalent in

different parts of the world also infect the liver. Certain drugs may also damage the liver,

producing jaundice.

A common sign of impaired liver function is jaundice, a yellowness of the eyes and skin

arising from excessive bilirubin in the blood. Jaundice can result from an abnormally

high level of red blood cell destruction (hemolytic jaundice), defective uptake or

transport of bilirubin by the hepatic cells (hepatocellular jaundice), or a blockage in the

bile duct system (obstructive jaundice). Failure of hepatic cells to function can result

from hepatitis, cirrhosis, tumors, vascular obstruction, or poisoning. Symptoms may

include weakness, low blood pressure, easy bruising and bleeding, tremor, and

accumulation of fluid in the abdomen. Blood tests can reveal abnormal levels of

bilirubin, cholesterol, serum proteins, urea, ammonia, and various enzymes. A specific

diagnosis of a liver problem can be established by performing a needle biopsy.

Bacterial abscess of the liver is relatively rare. It has been described since the time of

Hippocrates (400 BC), with the first published review by Bright appearing in 1936. In

1938, Ochsner's classic review heralded surgical drainage as the definitive therapy;

however, despite the more aggressive approach to treatment, the mortality rate

remained at 60-80%.

The development of new radiologic techniques, the improvement in microbiologic

identification, and the advancement of drainage techniques, as well as improved

supportive care, have decreased mortality rates to 5-30%; yet, the prevalence of liver

abscess has remained relatively unchanged. Untreated, this infection remains uniformly

fatal.
Prior to the antibiotic era, liver abscess was most common in the fourth and fifth

decades of life, primarily due to complications of appendicitis. With the development of

better diagnostic techniques, early antibiotic administration, and the improved survival of

the general population, the demographic has shifted toward the sixth and seventh

decades of life. Frequency curves display a small peak in the neonatal period followed

by a gradual rise beginning at the sixth decade of life. Cases of liver abscesses in

infants have been associated with umbilical vein catheterization and sepsis. When

abscesses are seen in children and adolescents, underlying immune deficiency, severe

malnutrition, or trauma frequently exists.

 Goals and Objectives of the study

1. To have an in-depth understanding of the Hepatic abscess disease.

2. Give appropriate application of physical assessment to detect actual and

potential health problems which are to be given priority

3. Promote health education in relation to the health condition of the patient.

4. To determine the proper intervention regarding the health care management

on the presenting disease and its associated complication.

 CLIENT’S PROFILE
Name: Mr. A
Address: Balingasag, Misamis Oriental
Sex: Male
Age: 29 years old
Height: 5 feet and 5 inches / 168cm
Weight: 149 pounds/ 68 kilograms
Occupation: Farmer
Civil Status: Married
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: January 10, 2010
Admitting Diagnosis: Hepatic Abscess
Chief Complaint: Intermittent epigastric pain.

History of Present Illness:

One week before admission, patient A noted onset of moderate grade fever
associated with chills and epigastric pain. Patient a tolerated his condition and no
consult done. Two days prior to admission, the patient would still have recurrence of
fever episodes and increasing abdominal pain. Thus finally consulted at Balingasag
Medical hospital and was admitted as a case of urinary tract infection. Eventually
referred at Northern Mindanao Medical Center, hence admitted.

Personal, Environmental and Psychosocial History:

Mr. A’s educational attainment was limited up to Grade 5 thus prompted him to
work as a farmer in Balingasag, Misamis Oriental. He was married to Mrs. A in 2000.
Mrs. A manages a small convenient store near their house. The couple have two
daughters and all of them are still dependent on the family.
During the assessment, Mr. P stated that he has been a tobacco user for eleven
years and smokes half to 1 pack per day. He also added that he has been drinking
alcoholic beverages mostly five bottles thrice a week. He takes coffee occasionally for
at least one glass per day. He has no known allergies. He doesn’t exercise but plays
basketball leisurely.
Physical Assessment:
Initial Assessment: January 14, 2010
Final Assessment: January 16, 2010

General Survey
Initial Assessment Final Assessment
Mr. A was lying on his bed in a semi- Mr. A was sitting at the right side of his
fowlers position; considerable in size; bed; ambulatory; 46 kilograms. Wearing a
48 kilograms, 5 feet and 5 inches in white t-shirt and generally appears clean;
height; and generally appears dusky; fully conscious and aware of
fully conscious and aware of surroundings; still with ongoing
surroundings; hoarse voice, with intravenous fluid of PNSS at 900 level
ongoing intravenous fluid of Plain running at 30 drops per minute, patent
Normal Saline Solution (PNSS) at 600 and infusing well at the left metacarpal
milliliters level, running at 30 drops per vein. Mr. A was accompanied by his wife.
minute, patent and infusing well at the
left metacarpal vein. Mr. A was
accompanied by his wife.

Central Nervous System

Initial Assessment Final Assessment
Fully conscious and aware of Alert and oriented to time, place and
surroundings; communicates verbally person; with a GCS of 15; sensory
and actively; with Glasgow Coma Scale functions intact, no numbness, tingling or
(GCS) of 14 (spontaneous eye opening, burning sensation reported; motor
4; oriented and converses clearly, 5; functions were intact; can maintain
and localizes painful stimuli, 5); balance and stance for more than 5
sensory functions intact, no seconds when asked to stand.
numbness, tingling or burning
sensation reported; motor functions
were intact;

Cardiovascular System
Initial Assessment Final Assessment
Mr. A showed cardiac rate of 67 beats Cardiac rate of 65 bpm, oxygen saturation
per minute, oxygen saturation of 95%; of 95%.Blood pressure of 120/80mmH,
blood pressure of 120/90 mmHg taken with pulse pressure of 40. Capillary refill
on the right arm, with pulse pressure of 2 seconds. Pinkish nail bed. Peripheral
of 30; jugular vein was not visible; on pulses with regular rate and rhythm.
auscultation, no heart murmurs heard; Jugular vein was not visible. Flat
no evidence of bleeding; with a precordial area.
capillary refill of 3 seconds; pale nail
beds, no clubbing noted; with regular
rate and rhythm of peripheral pulses;

Respiratory System
Initial Assessment Final Assessment
Head of the bed elevated to 35-45 Breathing pattern with respiratory of 24
degree angle; with evidence of cpm. Lung expansion symmetrical as well
difficulty of breathing; nasal flaring as tactile fremitus. Still with no
noted. With a respiratory rate of 30 endotracheal and mechanical ventilator
cycles per minute; no mechanical attached.
ventilator and endotracheal tube in
place; symmetrical chest expansion;
use of accessory muscles were
evident; no barrel chest noted. Spine
was ventrically aligned; chest wall
intact, no tenderness noted.

Gastrointestinal System
Initial Assessment Final Assessment
Upon inspection, abdomen was Abdomen was uniform in color. Still no
uniform in color, rounded; no palpation palpation and percussion allowed.
and percussion of abdomen as ordered
by the physician.

Urinary System
Initial Assessment Final Assessment
No urinary catheter noted urine output No urinary catheter noted; Mr. A reported
was 100mL for the last two hours; no that he had no difficulty in urinating; he
hematuria noted; bladder not added that he urinated thrice in the last
distended. two hours and failed to measure it;
bladder not distended.

Integumentary System
Initial Assessment Final Assessment
Uniform deep brown skin color except No pressure sores, wounds, abrasions or
in areas exposed to the sun; no other lesions noted; with good elasticity.
pressure sores, wounds, abrasions or
other lesions noted; skin sprang back
to previous state when pinched.
 Musculoskeletal System
Initial Assessment Final Assessment
Equal size on both sides of the body; Full range of motion, equally strong in
no weakness or paralysis; no muscle tone and strength. Spine is in
contracture in muscles and tendon; midline.gait is coordinated.
tremors was not evident; muscles were
firm at rest with equal strength on each
body side; no deformities; no
tenderness noted; full range of motion;
no joint pain or stiffness; was able to
turn from side to side.
Psychosocial System
Initial Assessment Final Assessment
Mr. A expressed that it was hard for Patient has understood the nature of his
him to be hospitalized and experienced illness but still eager to get well and to
difficulties due to his disease. recover soon since he misses the quiet
However, he was hopeful that he can environment at home.
recover very soon as he modifies and
strengthens his lifestyle by complying
with his medical regimen. His support
system was not adequate tho.
ANATOMY AND PHYSIOLOGY

LIVER
The Liver: Anatomy and Functions

Anatomy of the liver:

The liver is considered the largest organ in the body and is located in the upper right-
hand portion of the abdominal cavity, beneath the diaphragm, and on top of the
stomach, right kidney, and intestines. Shaped like a cone, the liver is a dark reddish-
brown organ that weighs about 3 pounds.

There are two distinct sources that supply blood to the liver, including the following:

• oxygenated blood flows in from the hepatic artery

• nutrient-rich blood flows in from the hepatic portal vein

The liver holds about one pint (13 percent) of the body's blood supply at any given
moment. The liver consists of two main lobes, both of which are made up of thousands
of lobules. These lobules are connected to small ducts that connect with larger ducts to
ultimately form the hepatic duct. The hepatic duct transports the bile produced by the
liver cells to the gallbladder and duodenum (the first part of the small intestine).

The liver has a multitude of important and complex functions. Some of these functions
are to:

• Manufacture (synthesize) proteins, including albumin (to help maintain the

volume of blood) and blood clotting factors

• Synthesize, store, and process (metabolize) fats, including fatty acids (used for
energy) and cholesterol

• Metabolize and store carbohydrates, which are used as the source for the sugar
(glucose) in blood that red blood cells and the brain use

• Form and secrete bile that contains bile acids to aid in the intestinal absorption
(taking in) of fats and the fat-soluble vitamins A, D, E, and K.
 • Eliminate, by metabolizing and/or secreting, the potentially harmful biochemical
products produced by the body, such as bilirubin from the breakdown of old red
blood cells and ammonia from the breakdown of proteins

• Detoxify, by metabolizing and/or secreting, drugs, alcohol, and environmental

toxins

The liver synthesizes and transports bile pigments and bile salts that are needed for fat
digestion. Bile is a combination of water, bile acids, bile pigments, cholesterol, bilirubin,
phospholipids, potassium, sodium, and chloride. Primary bile acids are produced from
cholesterol. When bile acids are converted or "conjugated" in the liver, they become bile
salts.

Bilirubin is the main bile pigment that is formed from the breakdown of heme in red
blood cells. The broken-down heme travels to the liver, where is it secreted into the bile
by the liver. Bilirubin production and excretion follow a specific pathway. When the
reticuloendothelial system breaks down old red blood cells, bilirubin is one of the waste
products. This "free bilirubin" is a lipid soluble form that must be made water-soluble to
be excreted. The conjugation process in the liver converts the bilirubin from a fat-soluble
to a water-soluble form. The liver also plays a major role in excreting cholesterol,
hormones, and drugs from the body.

The liver plays an important role in metabolizing nutrients such as carbohydrates,

proteins, and fats. The liver helps metabolize carbohydrates in three ways:

• Through the process of glycogenesis, glucose, fructose, and galactose are

converted to glycogen and stored in the liver.
• Through the process of glycogenolysis, the liver breaks down stored glycogen to
maintain blood glucose levels when there is a decrease in carbohydrate intake.
• Through the process of gluconeogenesis, the liver synthesizes glucose from
proteins or fats to maintain blood glucose levels.

The liver synthesizes about 50 grams of protein each day, primarily in the form of
albumin. Liver cells also chemically convert amino acids to produce ketoacids and
ammonia, from which urea is formed and excreted in the urine. Digested fat is
converted in the intestine to triglycerides, cholesterol, phospholipids, and lipoproteins.
These substances are converted in the liver into glycerol and fatty acids, through a
process known as ketogenesis.

Prothrombin and fibrinogen, substances needed to help blood coagulate, are both
produced by the liver. The liver also produces the anticoagulant heparin and releases
vasopressor substances after hemorrhage.

Liver cells protect the body from toxic injury by detoxifying potentially harmful
substances. By making toxic substances more water soluble, they can be excreted from
the body in the urine. The liver also has an important role in vitamin storage. High
concentrations of riboflavin or Vitamin B1 are found in the liver. 95% of the body's
vitamin A stores are concentrated in the liver. The liver also contains small amounts of
Vitamin C, most of the body's Vitamin D stores, and Vitamins E and K.
 Pathophysiology
Predisposing Factor:
Age: 29 y.o.
Gender: Male
Chronic alcohol drinker (for
almost 11 years) Precipitating Factor:
Occupation: Farmer Unsanitary food handing
Poor hygiene

Infection of liver

Activation of inflammatory
response

Release of kinins, histamine, and

other chemicals (chemical “alarms”)

Blood vessels dilate Capillaries become “leaky” Neutrophils, monocytes and

other WBCs enter the area

Increased blood flow Decreased albumin

into the area
 Decreased oncotic pressure,
Increased hydrostatic pressure

Redness Heat
Fluids and proteins leave the blood
• Paracetamol Fever vessel going to interstitial spaces of
500mg, PO tissue

Increased metabolic Edema

rate of tissue cells

Pain Swelling
Malaise

Abdominal pain Tramadol 50 mg,

(RUQ) q8h, IVTT

Failure of inflammatory
mechanism
Medical Management:
• metronidazole q8h, Hematology Report: (Jan. 10,
IVTT 2010)
• ciprofloxacin 500mg Severe infection
• WBC-20.9 x 10^3/uL
1 tab, bid, PO
 Uncleared area
of debris

Sac of pus (mixture of dead

neutrophils, broken-down
tissue cells, dead pathogens)

Pus are walled off

the liver

HEPATIC ABSCESS

Blockage of bile duct

Prevents bile from entering

small intestine

Bile accumulates and

Hepatomegaly backs-up into the liver

Pressure on liver cells

Proteins enter bloodstream Bile salts and bile pigments
enter bloodstream

Circulation of proteins
Circulation of bile pigments

Enters kidney circulation

Jaundice Icteric sclera

Protein in urine Lab Result:

(Proteinuria) Protein (+2)
 LABORATORY RESULTS

Blood Chemistry
Dr. Sarmiento 01-13-10

RESULTS REFERENCE INTERPRETATI

ON
Blood urea nitrogen = 15.22 (4.6 – 23.4) mgs. % Normal

Creatinine = 0.73 (0.6 – 1.2) mgs. % Normal

Potassium = 3.27 (3.5 – 5.3)mmol/L Low potassium
resulting to
have muscle
weakness,
muscle aches,
and muscle
cramps.

Sodium = 134.2 (135 – 148)mmol/L Hyponatremia,

result to
experience
nausea,
vomiting,
headache and
malaise.

ULTRASOUND REPORT
January 13, 2010
Tentative Diagnosis:
FINDINGS:
The left lobe is enlarged. A complex hypoechoic mass measuring 9.6 cm x 8.8 cm x
7.3 cm seen in its medial aspect. The right hepatic lobe is uremarkable.
Gallbladder is normal in size. Its wall is not thickened. No intraluminal mass or
lithiasis seen.
Pancreas is unremarkable.

DIAGNOSIS:
1.) COMPLEX, HYPOECHOIC MASS, MEDIAL ASPECT OF THE LEFT
HEPATIC LOBE, POSSIBLY AN ABCESS
2.) NON – REMARKABLR ULTRASOUND FINDINGS IN THE
GALLBLADDER AND PANCREAS
INTERPRETATION:

Hypoechoic on ultrasound means dark, in liver at times

there is inhomogenous fat deposition which appear which appears
bright and areas of sparing appear dark or hypoechoic and can
times mimic mass on ultasound

URINALYSIS REPORT
January 14, 2010
INTERPRETATION
PHYSICAL PROPERTIES:

Color yellow Excess sweating,

also a sign that
patient is not been
drinking enough
liquids
Clarity Hazy Detected albumin,
globulins, and
Bence-Jones protein
at low
concentrations
pH 7.5 Alkaline, a risk for
infection
Specific gravity 1.015 Normal, within the
range from 1.003 –
1.030
CHEMICAL PROPERTIES:

proteins trace Normal

Glucose negative Normal
SEDIMENT/MICROSCOPIC EXAMINATION

Epithelial cells Moderate Normal

Puss cells (WBC) 2-3
Red blood cells 4-6 Kidney or bladder
injury or UTI
Bacteria Few UTI
 URINALYSIS REPORT
January 10, 2010
INTERPRETATION
PHYSICAL PROPERTIES:

Color Dark yellow Liver problems or

jaundice
Clarity Cloudy Excessive cellular
material or protein in
the urine
pH 5.0 Acidic, normal
Specific gravity 1.030 normal
CHEMICAL PROPERTIES:

proteins +2 May have kidney

damage, an
infection, alteration
of liver function
Glucose negative Normal
SEDIMENT/MICROSCOPIC EXAMINATION

Puss cells (WBC) 4-6 Pyuria, infection in

either the upper or
lowe urinary tract
Red blood cells 2-3 Kidney or bladder
injury or UTI
Coarsely granular 0-2 high salt
concentration
Mucus threads few Mucus threads are
usually present in
small numbers.
Increased numbers
are indicative of
chronic inflammation
of the urethra and
bladder.
 FECALYSIS
January 10, 2010
INTERPRETATION
PHYSICAL CHARACTERISTIC
Color and character yellow Normal
consistency watery Diarrhea
PARASITIC ORGANISM
Negative for any amoeba and other intestinal parasitic ova Normal

HEMATOLOGY REPORT
January 13, 2010

TEST RESULT UNIT REFERENCE INTERPRETAION

WHITE BLOOD 14.1 10^3/uL 5.0 – 10. Infection
CELS
RED BLOOD 3.68 10^6/uL 4.2 – 5.4 Anemic
CELLS
HEMOGLOBIN 11.0 g/dL 12.0 – 10.0 Normal
HEMATOCRIT 32.8 % 37.0 – 47.0 signal
conditions
such as
anemia, bone
marrow
problems,
dehydration
MCV 89.1 fL 82.0 – 98.0 Normal
MCH 29.9 Pg 27.0 – 31.0 Normal
MCHC 33.5 g/dL 31.5 – 35.0 Normal
RDW-CV 15.8 % 12.0 – 17.0 Normal
PDW 10.0 fl 9.0 – 16.0 Normal
MPV 8.6 fL 8.0 – 12.0 Normal

DIFFERENTIAL
COUNT
Lymphocyte (%) 18.2 % 17.4 – 48.2 Normal
Neutrophil (%) 66.0 % 43.4 – 76.2 Normal
Monocyte (%) 15.8 % 4.5 – 10.5 Infection
Eusinophils (%) 0.0 % 1.0 – 3.0 infection or an
inflammatory
process in the
body
Basophils (%) 0.0 % 0.0 – 2.0 Normal
Bands/scabs (%) % 1.0 – 2.0 ---
PLATELET 264 10^3/uL 150 - 400 Normal
REMARKS
 TEST RESULT UNIT REFERENCE INTERPRETATION
WHITE BLOOD 20.9 10^3/uL 5.0 – 10. Infection
CELS
RED BLOOD 4.50 10^6/uL 4.2 – 5.4 Normal
CELLS
HEMOGLOBIN 13.0 g/dL 14.0 – 16.0 poor
diet/nutrition
or
malabsorption
HEMATOCRIT 40.4 % 37.0 – 47.0 Normal
MCV 89.8 fL 82.0 – 98.0 Normal
MCH 30.0 Pg 27.0 – 31.0 Normal
MCHC 33.4 g/dL 31.5 – 35.0 Normal
RDW-CV % 12.0 – 17.0 ---
PDW fl 9.0 – 16.0 ---
MPV fL 8.0 – 12.0 ---
DIFFERENTIAL
COUNT
Lymphocyte (%) 7.3 % 17.4 – 48.2 Risk for
infrction
Neutrophil (%) 82.0 % 43.4 – 76.2 Elevated levels
of neutrophils
may occur
when the body
is fighting a flu
or other
infection
Monocyte (%) 10.7 % 4.5 – 10.5 infection
Eusinophils (%) % 1.0 – 3.0 ---
Basophils (%) % 0.0 – 2.0 ---
Bands/scabs (%) % 1.0 – 2.0 ---
PLATELET 221 10^3/uL 150 - 400 Normal

HEMATOLOGY REPORT
January 10, 2010
 NURSING CARE PLAN
Nursing Diagnosis
Ineffective Tissue Perfusion related to interruption of venous flow

Assessment Data
Subjective:
“Maglisod ko ug ginhawa bisan maghigda.” as verbalized by the patient

Objective:
• Capillary refill of about 3 seconds assessed
• Pallor
• Muscle wasting

Goals and Objectives:

Long term goal:
 After 2 days of nursing care, the patient will be able to demonstrate lifestyle
changes to improve circulation.
Short term goal:
 After 4 hours of nursing care, the patient will be able to demonstrate increased
perfusion as appropriate, as evidenced by:
a. Respiration within normal range
b. Balanced intake and output

Nursing Interventions:

Independent:

• Assist patient in ROM exercises

(exercises prevent venous stasis)

• Proper positioning of patient, change every 2 hrs.

(This promotes optimal ventilation and perfusion)

• Teach patient breathing relaxation technique

(to improve oxygen demand of patient)

• Elevate head of bed.

Rationale: To increase gravitational blood flow

• Encourage use of relaxation techniques

Rationale: To decrease tension level

Dependent:
• Emphasize importance of avoiding use of aspirin, some OTC drugs, vitamins
containing potassium, mineral oil or alcohol when taking anticoagulants.
Rationale:

Evaluation:

Goals partially met, as evidenced by:

• 24 cpm
• Capillary refill 2 sec
• Demonstrate proper breathing relaxation technique
NURSING DIAGNOSIS

- Ineffective breathing pattern related to pain

ASSESSMENT DATA (SUBJECTIVE AND OBJECTIVE CUES

Subjective:
“Usahay galisod ko og ginhawa maam” as verbalized
Objective:
- Tachypnea RR = 30
- Nasal Flaring
- Use of accessory muscle
- Pallor
- pain scale 10/10

GOALS AND OBJECTIVE

Short term Goal:

At the end of 30 minutes of nursing intervention the patient will:
- Have adequate ventilation as evidenced by:
a.respiration within normal range from 30 cpm to 20 cpm
b.absence of nasal flaring
c.do not use of accessory muscle
Long term goal:
At the end of 1 day of nursing intervention the patient will:
- demonstrate appropriate coping behavior

NURSING INTERVENTION
• Independent
• Elevate head of bed or position patient in a semi fowler’s position
(to promote physiological/psychological ease of maximal inspiration)

• Encourage deep breathing exercise by using purse-lip technique

(to take control of the situation)

• Assist client in the use of relaxation technique like breathing

exercise
(to promote rest)

• Provide comfort position to patient

(to prevent uneasiness )

• Ambulate patient and assist in exercise as tolerated

(maximize patient’s level of functioning)

•Encourage adequate rest period between exercise

(to prevent fatigue)
 Dependent
• Administer analgesic, if recommended by the physician
(promotes respiration)

EVALUATION
Goals partially met
- The patient’s respiration is 24 cpm
- absence of nasal flaring and use muscle accessory
 NURSING CARE PLAN

NURSING DIAGNOSIS:
Acute Pain related to presence of pus in the liver.

ASSESSMENT DATA:
SUBJECTIVE CUE:
“ Sakit akoang tiyan sa tuo dapit,”as verbalized.
OBJECTIVE CUES:
- Observed evidence of pain

- Muscle guarding noted with pain scale of 10/10.

- Facial Grimace noted.

- Expressive behavior observed ( sighing )

- Doctor ordered not to palpate patient abdomen

GOALS AND OBJECTIVE:

Short term goal:
• After 30 minutes of nursing interventions, the patient pain will decreased from
10/10 to 5/10.
Long term goal:
• After 8 hours of nursing intervention, the patient’s pain will be relieved from 5/10
to 0.
NURSING INTERVENTIONS:
• Accept client’s description of pain. Acknowledge the pain experience
and convey acceptance of client’s response to pain. R: pain is
subjective experience and cannot be felt by others.

• Observe nonverbal cues/pain behaviors (e.g., how the patient walks,

holds body, sits; facial expression; cool fingertips/toes, which can mean
constricted blood vessels) and other objective cues, as noted. R:
observations may/may not be congruent with verbal reports or
may be only indicator present when client is unable to
verbalize.

• Determine patient’s acceptable level of pain/pain control goals. R: it

may vary to individuals coping capabilities.

• Provide comfort measures (e.g., touch, repositioning, use of heat/cold

packs, nurse’s presence) quiet environment, and calm activities. R: to
promote nonpharmacological pain management.

• Instruct patient to encourage use of relaxation techniques such as

focused breathing, imaging and listening to calming music. Encourage
also diversional activities. R: to distract attention and reduce
tension.
 • Administer analgesics, as indicated, to maximum dosage, as needed.
R: to maintain acceptable level of pain. Notify the physician if
regimen is in adequate to meet pain control goal.

EVALUATION:
GOALS PARTIALLY MET ,as evidenced by:
Pain scale of 5/10.
 NURSING CARE PLAN

Nursing Diagnosis
- Hyperthermia related to increased metabolic rate

Assessment Data
Subjective:
“Sugod pa ko gihilantan atong pag-admit nako”, as verbalized by the patient.

Objective:
• Increased body temperature (T= 37.8°C) assessed
• Skin is warm and dry to touch noted
• Increased respiratory rate (RR= 30 cpm) assessed
• Firm skin turgor noted

Goals and Objectives:

Long term goal:
 At the end of 30 minutes, the patient will be able to display signs of wellness,
as evidenced by reduced body temperature from 37.8°C to 37.5C.
Short term goal:
 After 1 hour of nursing care, the patient will be able to identify contributing
factors and importance of treatment.

Nursing Interventions:

Independent:
• Monitor vital signs.
Rationale: To provide a baseline data

• Promote surface cooling by means of tepid sponge bath

Rationale: To promote heat loss by means of evaporation

• Discuss importance of adequate fluid intake.

Rationale: To prevent dehydration

• Maintain bedrest.
Rationale: To reduce metabolic demands and oxygen consumption

Dependent:
• Administer antipyretics, as ordered.
 paracetamol 500mg 1 tab, q4hrs for T≥38.0

• Administer medications as indicated to treat underlying cause.

 Ciprofloxacin 500mg 1tab, twice a day
• Indication: For treatment of infections caused by susceptible gram-
negative bacteria, including Escherichia coli

Evaluation:

GOALS MET. The patient’s temp. is 37.5.

 NURSING CARE PLAN

Nursing Diagnosis
- Imbalanced Nutrition: Less than body requirements related to increased
metabolic demands.

Assessment Data
Subjective: " magsakit akong tiyan kung magkaon" as verbalized by the patient.

Objective:
• Body mass index: 17.5
• pale conjunctiva
• Abnormal laboratory findings
a. RBC 3.68

Goals and Objectives:

Long term goal:
 At the end of 8 hours, patient will be able to demonstrate behaviors,
lifestyle changes to regain and maintain appropriate weight.
Short term goal:

 At the end of 1 hours patient will be able to verbalized understanding of

causative factors when known and necessary interventions.

Nursing Interventions:

Independent:
• Provide small frequent meals.
Rationale: To prevent nausea and vomiting.
• Served high fiber diet.
Rationale: To prevent constipation.
• Increase fluid intake to 2-3 liters/ day.
Rationale: To manage fluid imbalanced.
• Encouraged exercise as tolerated like passive ROM.
R: To improve metabolism.
Dependent:
• Use flavoring agents.
Rationale: To enhance food satisfaction and stimulate appetite.
Collaborative:
• Consult a dietitian/ nutritional team as indicated.
Rationale: To implement interdisciplinary team management.

Evaluation:
Goals not met. Weight of patient below normal range of body mass index
17.5.
 Drug Study

NURSING
MECHANISM OF ADVERSE EFFECTS
DRUG ORDER INDICATIONS CONTRAINDICATIONS RESPONSIBILITIES/
ACTION OF THE DRUG
PRECAUTIONS

Generic name: An analgesic that binds Management of Acute alcohol Seizures have been Check the prescribed
Tramadol to mu-opioid receptors moderate to moderately intoxication, concurrent reported in patients medication for 3 time on
hydrochloride and inhibits reuptake of severe pain. use of centrally acting receiving tramadol the first encounter,
norepinephrine and analgesics, hypnotics, within the recommended before and after
serotonin reduces the opioids, or psychotropic dosage range. withdrawing the med
Brand name: intensity of pain stimuli drugs, hypersensitivity Overdose results in R> so that the medicine
Ultram reaching sensory nerve to opioids. respiratory depression is properly checked
endings. and seizures. Tramadol according to the doctor’s
may not have prolonged prescription.
Classification: Therapeutic Effect: duration of action and
Analgesic Alters the perception of cumulative effect in Give first health
and emotional response patients with hepatic or teaching before giving
to pain. renal impairment. the patient.
Dosage: R> to make the patient
50mg prepare and know what
to expect

The med should be

Route: given in IVTT route
IVTT according to the doctor
R> Follow the doctor’s
Frequency: order as prescribed to
q8h the patient.
 NURSING
MECHANISM OF ADVERSE EFFECTS
DRUG ORDER INDICATIONS CONTRAINDICATIONS RESPONSIBILITIES/
ACTION OF THE DRUG
PRECAUTIONS

Generic name: A nitroimidazole For treatment of Hypersensitivity to otherPeripheral neuropathy, Check the prescribed
Metronidazole derivative that disrupts anaerobic infection (skin nitroimidazole manifested as medication for 3 time on
bacterial and protozoal and skin structures, derivatives. numbness and tingling the first encounter,
Brand name: DNA, inhibiting nucleic CNS, lower respiratory in hands or feet, is before and after
Metronidazole acid synthesis. tract, bone and joints). Cautions: blood usually reversible if withdrawing the med
Benzoate dyscrasias, severe treatment is stopped R> so that the medicine
Therapeutic Effect: Treatment of hepatic dysfunction, immediately after is properly checked
Classification: Produces bactericidal, trichomoniasis, CNS disease, neurologic symptoms according to the doctor’s
Antibacterial, antiprotozoal, amebiasis, antibiotic- predisposition to edema. appear. Seizures occur prescription.
antiprotozoal amebicidal, and associated ocassionally.
trichomonacidal effects. pseudomembranous Give first health
Produces anti- colitis (AAPC). teaching before giving
Dosage: inflammatory and the patient.
750mg immunosuppressive R> to make the patient
effects when applied prepare and know what
topically. to expect
Route:
IVTT The med should be
given in IVTT route
Frequency: according to the doctor
q8h R> Follow the doctor’s
order as prescribed to
the patient.

Question for
hypersensitivity on
metronidazole
R> to determine if the
med is applicable to
patient.
 NURSING
MECHANISM OF ADVERSE EFFECTS
DRUG ORDER INDICATIONS CONTRAINDICATIONS RESPONSIBILITIES/
ACTION OF THE DRUG
PRECAUTIONS

Generic name: A fluoroquinolone that For treatment of Hypersensitivity to Superinfection, Question for
Ciprofloxacin inhibits the enzyme infections due to E. coli, ciprofloxacin or other pephropathy, hypersensitivity for the
hydrochloride DNA gyrase in K. pneumoniae, E. quinolones; for cardiopulmonary arrest, medicine
susceptible bacteria, cloacae, P. mirabilis, P. ophthalmic chest pain, and cerebral R> since it will harm the
Brand name: interfering with bacterial vulgaris, H. influenzae, administration: vaccinia, thrombosis may occur. patient
Ciloxan cell replication. Shigella species, S. varicella. Hypersensitivity
typhi including intra- reaction, including Monitor for any
Therapeutic Effect: abdominal, bone and Cautions: renal photosensitivity (as dizziness, headache,
Classification: Bactericidal joint, lower respiratory impairment, CNS evidenced by rash, visual changes, tremors.
Anti-infective tract, skin and skin- disorders, seizures, pruritus, blisters, edema R> to determine client’s
structure, and urinary those taking caffiene. and burning skin) have response to the med.
tract infections, occurred in patients
Dosage: infectious diarrhea, receiving fluoronolones. Do not take with
500mg 1 tab protastitis, sinusitis, antacids
typhoid fever febrile R> since it could reduce
neutropenia. or destroy the drug’s
effectiveness.
Route:
Oral

Frequency:
BID
 NURSING
MECHANISM OF ADVERSE EFFECTS
DRUG ORDER INDICATIONS CONTRAINDICATIONS RESPONSIBILITIES/
ACTION OF THE DRUG
PRECAUTIONS

Generic name: An antiulcer agent that For short term treatment History of acute Reversible hepatitis and Obtain baseline
Ranitidine inhibits histamine action of duodenal ulcer. porphyria. blood dyscrasias occur liver/renal function tests.
hydrochloride 2 receptors of gastric Prevention of duodenal rarely. R> to determine if the
parietal cells. ulcer recurrence. Cautions: renal or patient’s organ could
hepatic impairment, metabolize the drug
Brand name: Therapeutic Effect: elderly.
Zantac Inhibits gastric acid Assess mental status of
secretion when fasting, the elderly
at night, or when R> to determine if the
Classification: stimulated by food, drug affects the mental
Antiulcer caffeine, or insulin. state of the patient
Reduces volume and
hydrogen ion Inform or give health
Dosage: concentration of gastric teachings to patient on
150mg 1 tab juice. what to expect after
drug administration like
headache
Route: R> so that the patient
Oral would be aware about
the side effects that he
would experience
Frequency:
BID
 NURSING
MECHANISM OF ADVERSE EFFECTS
DRUG ORDER INDICATIONS CONTRAINDICATIONS RESPONSIBILITIES/
ACTION OF THE DRUG
PRECAUTIONS

Generic name: A fat-soluble vitamin Antidote for hemorrhage Hypersensitivity. A severe reaction Inform patient and SO
Vitamin K that promotes hepatic induced by oral (cramplike pain, chest that discomfort may
formation of coagulation coagulants, pain, dyspnea, facial occur with parenteral
Brand name: factors I, II, VII, IX, and hypoprothrombinemic flushing, dizziness, rapid administration.
AquaMEPHYTON X. states due to vitamin K or weak pulse, rash R> to be aware what will
deficiency. diaphoresis, be the expexted affect
Classification: Therapeutic Effect: hypotension progressing after administration of
Nutritional Essential for normal to shock, cardiac arrest) med
supplement, clotting of blood. occurs rarely just after
antidote, IV administration. Do not use OTC
antihemorrhagic medication without
physician’s approval
R> this may interfer with
Dosage: platelet aggregation
1 ampule
Assess for decrease in
Route: BP, increase in PR,
IVTT complaint of abdominal
or back pain, severe
Frequency: headache
q24h R> this may be
evidence of hemorrhage
 NURSING
MECHANISM OF ADVERSE EFFECTS
DRUG ORDER INDICATIONS CONTRAINDICATIONS RESPONSIBILITIES/
ACTION OF THE DRUG
PRECAUTIONS

Generic name: Paracetamol exhibits For treatment of mild to Hypersensitivity. Nausea, allergic The medication should
Paracetamol analgesic action by moderate pain and reaction, skin rashes, be given in orally
peripheral blockage of fever. acute renal tubular R> this is according to
Brand name: pain impulse generation. necrosis. the doctor’s order.
Boigesic It produces antipyresis
by inhibiting the Potentially Fatal: Very Assess patient for any
hypothalamic heat – rare, blood dyscrasias drug allergy to the
Classification: regulating center. Its (e.g., thrombocytopenia, medicine.
Analgesics and weak anti-inflammatory leukopenia, R> to determine if the
Antipyretics activity is related to neutropenia, patient is allergic to drug
inhibition of agranulocytosis); liver
prostaglandin synthesis damage. Intruct the patient/ give
Dosage: in the CNS. first health teaching
500mg before giving the patient.
R> to make the patient
prepare and know what
Route: to expect
Oral
Give only the med for
Frequency: presence of fever or
PRN or q4h for pain
temp.380C R> overdose could lead
to drug-resistance
 HEALTH TEACHINGS
Treatment of hepatic abscess condition can be life-threatening in 10-30% of
patients. The risk is higher in people who have many abscesses. That’s why treatment
usually consists of surgery or going through the skin with a needle or tube
(percutaneous) to drain the abscess. Along with the procedures, the patient will also
receive long-term antibiotic therapy (usually 4 - 6 weeks), because sometimes
antibiotics alone can cure the infection. If not, life-threatening sepsis can develop. That’s
why we stress the importance of the following:

• Explain the disease process, causes, contributing factors, care and treatment. In
order for the patient to understand his condition and for him to be able to
participate in improving it.

• Discuss the proper use medication. Explain the purpose, dosage, schedule, and
route of administration of any prescribed drugs, as well as side effects to report
to the physician or nurse.

• Teach signs and symptoms that require immediate medical attention. Such as
chalk-colored stool, dark urine, fever, chills, loss of appetite, nausea, vomiting,
and pain in right abdomen (more common) or through out the abdomen, &
unintentional weight loss.

• Explain the importance of maintaining fluid and electrolytes balance.

 Monitoring for fluid and electrolytes balance
 Assess intake and output.
 Weigh
patient daily. Tell the client and family members to maintain the ideal
body weight of the patient, by weighting the client daily and record the
result if necessary.
 Assess presence and extent of edema.
 Encouraging patient to increase fluid intake.

• Discuss and encourage proper techniques in preventing further infection and

injury.
 Promoting proper skin and wound care.
 Maintaining good personal hygiene.
 Avoiding stress which can aggravate symptoms.
 Encouraging activity within prescribed limits but avoid fatigue.
 Protecting from injury when carrying out activities.
 Protecting patient from exposure to infectious agents.
 Maintaining good asepsis during treatments and procedures.
 Encouraging proper diet.

• Teach the family of how to promote comfort.

 Medicating patient as needed for pain.
 Providing comfort measures and relaxation techniques.
 Encouraging good oral hygiene.
 Encouraging rest for fatigue.
 Providing calm, supportive environment

• Tell the family to assist with coping in life-style and self-concept.

 Promoting hope
 Providing opportunity for patient to express feelings about self.
 Therapeutic passes - Passes help the patient adjust to the home
environment and to practiced self care activities at home and help the
family adjust to living with patient and to any alterations in physical,
cognitive, and emotional functioning (after discharge). Remind also the
family members to support the patient in his activity of daily living, and
let them explain to the patient how it benefits for him to be as
independent as possible. Tell also the family members to encourage
the patient, within his condition’s capacity, to perform many self-care
activities as possible.
 DISCHARGE PLAN
Medications: Patient is advised to take all the
medications prescribed by the physicians as
to the prescribed dosage, prescribed route,
prescribed time and as on how many days
will it be consumed. This will help the
patient for fast recovery and prevention to
further complication.
Exercises >regular exercises like walking, stretching
and other form of activities that would help
maintain joint mobility & enhance circulation

>Avoiding strenuous activities.

Treatment: Very important treatment includes strict

compliance to the prescribed medication most
especially antibiotic therapy and the
significance of nutritional supplements
promoting healing of the damage liver cells
and improves general nutritional status.

Health teaching: With emphasis on:

>compliance to medication regimen

> importance of proper diet.

>avoidance of alcoholic beverages

> importance of immediate consultation

whenever symptoms of complications or
progression of disease occurs like, vomiting
and seizures, painful abdomen, trouble
breathing all of the sudden, or any.

>importance of good hygiene

>significance of adequate rest

Out-Patient: Patient should return to the institution one or

two-weeks after discharge for follow-up
check-up on his physician for health
assessment, and faster recovery
Diet: >Patient encouraged having adequate
nutritional supplements.

>Encouraged to eat variety of healthy foods

such as fruits, vegetables, whole-grain breads,
low-fat dairy products, beans, lean meat and
fish. Eating healthy foods may help him have
more energy and heal faster.

Spiritual: Significant others were reminded to continue

offer emotional support to patient and help to
strengthen his spiritual faith so that patient
will both have spiritual and emotional outlet
to avoid depression.
 LEARNING EXPERIENCE
As new day arises, new trials are challenging us, testing every learning and
knowledge we obtain in the previous days. There are many choices that surround us but
it specifies on two questions: To do good? Or do it badly. After, it leads us to many
channels, despite the harshness of reality, we are always reminded not to be enticed
with worldly matters. Yes, life may be short, but we should use our freedom wisely. We
have to be careful of our actions each day for the days are sometimes evil. A few of us
know the importance of living life positively, yet, in the end; we will realize that
regardless of everything that is going on, you are on your own. We make our life. This
Duty reminded us that life is too short to keep on committing the same mistakes all over
again. We should start making a move, whether many will hinder our path, we have to
put impact on every good thing that we do. If you want your life to have an impact, you
have to focus on it. Make life with less regrets, do good, be wise and strengthen your
faith, brave enough to win success.
At a short period stay at (NMMC) Northern Mindanao Medical Center,
Medical ward, we are student nurses on action. It is where we put all of what we are in
extreme preparation. You should not waste time doing senseless distractions, rather
gain from your opportunities, reading, handling cases and interactions are just a few
that we have mastered. Although change does not happen overnight, it is a good feeling
to know that you have controlled yourself and leading it to make a difference. As our
duty progresses, we have established a great bond among our group mates. We learn
together, we work together and care for each other. That is the beauty in our group. We
never fail to be concerned towards each other. It is more than just a group, we are
family.
Whatever trials, difficulties, temptation, consequences that we have right
now, it serves as a reminder to trust in ourselves and our God. We should not give up.
Life is great and beautiful and we realize it when we are open to learning and never are
afraid to take challenges and opportunities that come along the way. One of this if we
call it a trial is the challenge of making a case study on trisomy 21 disorder. Many may
know if not all that this type of disorder is hard to accept in the parenting side.

DOCTOR’S ORDER
 • Jan. 10 2010  Start_____: PNSS 1L @ 60
6pm gtts/min_ongoing
BP 110/70  IVF TF: 1. D5NR 1l @40 gtts/min.
HR 80 2. D5NR !L @ 40gtts/min.
RR 10 Diagnostic: CBC with pH
T 37 U/A, stool exam Urea, BUN, Na, K,
Alk, Phos,, SGPT, SGOT
CXR: PAT
UTZ: HBT
Therapeutic:
Paracetamol 500mg 1 tab now,
then q 4 hrs for T≥38.0
Tramadol 50mg IVTT q8 hrs.
Metronidazole 750 mg IVTT now,
then 750 mg IVTT q 8 hrs.
Ranitidine 150 mg 1 tab. BID
Vit. K 1 am. IVTT now then Q 24
hr.-given 1st done
 Watch out for severe abdominal
pain, SOB, or any unusualiies and
refers to MROD
 Refer accordingly

• Jan. 11, 2010  Continue present meds.

4:30 pm  IVF TF: PNSS 1L @ 30gtts/min.
BP- 100/60 PNSS 1L @ 30 gtts/min.
HR 80 Refer accordingly
RR 20
Still with fver episodes
(+) tenderness RUQ

• Jan. 12, 2010  Schedule for UTZ- HOT tomorrow

11:30 pm AM pls. facilitate transport
BP:120/80  Cont. present medications
HR:76  IVF TT: D5NR 1L @ 20gtts/min
RR:20 D5NR 1L @ 20gtts/min
Dec. poin RUQ area Refer accordingly
↓fever episode
• Jan. 13, 2010  For utz of HBT today
s- 1 week undocumented on and  for repeat Na,K, Creat, BUN CBC
off fever with chils and nausea with platelet
(+) epigastric pain  Repeat PTPA-Partial
 Requests:
1. Cipro 7
2. Metronidazol 750 mg
3. Ranitidine 100mg 1 tab. BID
4. Tramadol 50mg IVTT q8 hr.
5. Paracetamol PRN if 38 deg.
Celsius
6. Vita k 1 amp.
 Monitor VS q2 hr. refer if with
abdominal pain and severe
hypotension
 D5LR 1L @ 20 gtts/min x 2 cycles
 Refer accordingly

• Jan. 14 2010  Continue present meds.

9 am  Avoid vasalva maneuver(straining,
Pt. seen in the ward
 Check-epigastric pain and fever
up to 40 hr
UT2- consider abcess(liver)
carrying heavy objects) and
abdominal manipulation
 Monitor VSq 4hr. & chart
 IVTT D5LR 1L @ 30gtts/min
D5LR 1L @ 30gtts/min
 ↑ IVF to 40 gtts( present IVF)
 Refer accordingly

• 10:20 pm  For referral to surgery for

Awake, afebrile abdominal evaluation if possible
DHS, murmur transfer of service
UT2 noted
 Continue meds
Refer accordingly
• Jan. 15, 2010  Continue meds.
11:25  IVTT D5LR 1L @ 30gtts/min x 2
-afebrile cycle
-C/C  For referral to surgery
-DAT  Refer accordingly

3pm
 Pt seen and examined
 HX & PE received
 Lab and UTZ notedexamined and
febrile noted in resp. distress
 + flat abdomen, soft + tenderness
 Non swollen abdomen as of
examiner
 Will do UTZ- aspiration of Hepatic
abscess “emergency”
 Secure consent to procedures
 To secure 3-way stop
 To secure Epidoral needle for
aspiration

• Jan. 16, 2010  Pls. facilitate aspiration of hepatic

7am abscess as ordered by SROD
↓abdominal pain  Pls. secure consult to procedure
Awke febrile  Pls. inform SROD once 3-way stop
cock in available
 Give paracetamol nonce a day 1
tab. Q4hr then q4hr. PRN for
nfever there after
 For repeat CBCOH, Na , K, crea.,
ROPA, SGPT, SGOT, Alk phosphate
 Give tramadol Prn for pain
9:30 am
(-) adbdominal pain
 Continue meds: IVTT D5LR !L @
Afebrile
30gtts/min. x 3 cycle
For possible aspirationof hepatic
abscess today