I. Introduction

A. Current trends of the condition

Intestinal obstruction

Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through.

Causes

Obstruction of the bowel may due to:

A mechanical cause, which simply means something is in the way Ileus, a condition in which the bowel doesn't work correctly but there is no

structural problem

Paralytic ileus, also called pseudo-obstruction, is one of the major causes of intestinal obstruction in infants and children. Causes of paralytic ileus may include:

Chemical, electrolyte, or mineral disturbances (such as decreased potassium levels)

Complications of intra-abdominal surgery Decreased blood supply to the abdominal area (mesenteric artery ischemia) Injury to the abdominal blood supply Intra-abdominal infection Kidney or lung disease Use of certain medications, especially narcotics

In older children, paralytic ileus may be due to bacterial, viral, or food poisoning (gastroenteritis), which is sometimes associated with secondary peritonitis and appendicitis.

Mechanical causes of intestinal obstruction may include:

Abnormal tissue growth Adhesions or scar tissue that form after surgery Foreign bodies (ingested materials that obstruct the intestines) Gallstones Hernias Impacted feces (stool) Intussusceptions Tumors blocking the intestines Volvulus (twisted intestine)

Symptoms

Abdominal distention Abdominal fullness, gas Abdominal pain and cramping Breath odor Constipation Diarrhea Vomiting

Site of Obstruction Cause Relative Incidences (%)

Small intestine [85%]

Adhesions 60

Hernia 15

Tumors 15

miscellaneous 10

Large Intestine [15%]

CA colon 65

Diverticulitis 20

Volvolus 5

miscellaneous 10

Life cycle of Ascaris lumbricoides.Epidemiology

Frequency

United StatesIn the United States, approximately 4 million people are believed to be infected. High-risk groups include international travelers, recent immigrants (especially from Latin America and Asia), refugees, and international adoptees. Ascariasis is indigenous to the rural southeast, where cross-infection by pigs with the nematodeAscaris suum is thought to occur. (Children aged 2-10 years are thought to be more heavily infected in this and all other regions.)

InternationalWorldwide, 1.4 billion people are infected with A lumbricoides, with prevalence among developing countries as low as 4% in Mafia Island, Zanzibar, to as high as 90% in some areas of Indonesia. Local practices (eg, termite mound–eating in Kenya[3] ) may predispose to ascariasis in some populations. Other risk factors like dog/cat ownership, presence of pets within the house, and a previous history of geophagia have been noted. In some regions, Ascaris infection is thought to contribute significantly to the burden of abdominal surgical emergencies.

Mortality/Morbidity

The rate of complications secondary to ascariasis ranges from 11-67%, with intestinal and biliary tract obstruction representing the most common serious sequelae. Although infection with A lumbricoides is rarely fatal, it is responsible for an estimated 8,000-100,000 deaths annually, mainly in children, usually from bowel obstruction or perforation in cases of high parasite burden. Due to similarities in the means of infection, many individuals infected with Ascaris are also co-infected with other intestinal parasites.

Race

No racial predilection is known. A genetic predisposition has been described in a study of families from Nepal.

Sex

Male children are thought to be infected more frequently, owing to a greater propensity to eat soil.

Age

Children, because of their habits (eg, directly or indirectly consuming soil), are more commonly and more heavily infected than adults. Neonates may be infected by transplacental infection. Frequently, families may be infected and reinfected in group fashion due to shared food and water sources as well as hygiene practices.

History

Most patients are asymptomatic. When symptoms occur, they are divided into 2 categories: early (larval migration) and late (mechanical effects).

In the early phase (4-16 d after egg ingestion), respiratory symptoms result from the migration of larvae through the lungs. Classically, these symptoms occur in the setting of eosinophilic pneumonia (Löffler syndrome).o Fevero Nonproductive cougho Dyspneao Wheezing

In the late phase (6-8 wk after egg ingestion), gastrointestinal symptoms may occur and are more typically related to the mechanical effects of high parasite loads.o Passage of worms (from mouth, nares, anus)o Diffuse or epigastric abdominal paino Nausea, vomitingo Pharyngeal globus, "tingling throat"o Frequent throat clearing, dry cougho Complications - Biliary and intestinal obstruction, appendicitis, pancreatitis

Physical

General Fever Jaundice (in biliary obstruction) Cachexia (due to malnutrition) Pallor (anemia) Urticaria (early infection)

Pulmonary Wheezing Rales Diminished breath sounds

Abdominal Abdominal tenderness, which may be diffuse (in obstructive infections), or localized

to the right lower (appendicitis) or right upper quadrant (hepatobiliary infections) Peritoneal signs in cases of bowel perforation Obstructive symptoms (nausea/vomiting/constipation/distention)

Migrating larvae may transmit other organisms, causing bacterial pneumonia orcholangitis. Rare cases of airway obstruction have also been reported. Other much less common presentations include lacrimal drainage obstruction, small bowel intussusception, acute interstitial nephritis, and encephalopathy. Causes

Symptoms are typically associated with early larval migration, heavy intestinal burdens of adult worms, or aberrant worm migration. Worm migration may be stimulated by anesthetic agents, fever, or subtherapeutic anthelmintic treatment, or by use of certain anthelmintics (eg, pyrantel pamoate).

B. Reason for choosing the case

Having a disease can greatly affect the functioning of the body but the reason behind

why such case happen can create confusion. To motivate and provide continuity of

learning in the nursing profession, the student-nurses had chosen this case

presentation to enlighten them as to have a single condition which can lead to serious

disease and can create complications that prevents the individual from functioning well.

The student-nurses chose this case for them to disseminate the appropriate teachings

to the significant others to prevent exacerbation, decrease the incidence ad for the

student nurses to be effective nurses in preventing the illness. The information that were

gathered may also serve as a guide in promoting health to the patients.. With this in

mind, the student nurses intend to find out all the necessary data to draw a conclusion

on what caused this to happen and to serve as a way to inform the public regarding the

disease condition through the presentation of this particular case through a nursing

perspective.

The student-nurses would like to be of great help to the patient and her family in

terms of shedding light with regards to what the patient is suffering from and why. The

student-nurses understand that the information that would be shared to the patient and

her family would bring clarity to them.

Enhancing the student nurses understanding and competence for they to be able to

impart the best possible care to their patient is another justification to be considered.

The student nurses believed that learning should not only be confined in the four

corners of our classrooms, but it should also be derived from the people we bestow our

utmost concerns. This will widen their knowledge because new uncommon diseases

and how to deal with it. To identify what is the best intervention for a patient who suffers

such disease.

II. Nursing AssessmentA. Personal History

1. Demographic Data

To secure confidentiality with our patient, he will be referred as “Jelly ace” is a five year old boy of Kapampangan descent and was born on June 27,2007. He lives at Abacan Malabañas Balibago. They’re only two in the family and he is the oldest. He was admitted at the hospital on June 21,2012.

2. Socio-economic and Cultural factors

b.1 Income and expenses (occupation)He grew up with his grandmother who is 54 years old. They’re eleven in the

house. Her grandmother stays in the house while his grandfather was working “mamisaling kalakal”. His two sons, works too as construction workers. Some of her children were separated with her including the parents of angel.b.2 Educational attainmentJelly ace is studying at Tinio Elementary School. He is currently in preparatory level.b.3 Religion AffiliationAccording to his grandmother, their religion was Catholic.

b.4 Cultural factors affecting health of the familyWhenever the family members are sick, they sometimes resort to “herbolarios”

for fever, cough and stomach pains where they are given different herbal

plants or “helot” . They p repare the leaves by bo i l ing them in one o r two g lasses o f water fo r f i f teen minutes or until one-half of the liquid is left, then they will be drinking it. But most of the time, they purchase over-the-counter (OTC) drugs such as paracetamol for fever, Neozep for colds and carbocisteine for cough. And there are also some instances that these herbal plants and OTC drugs don’t make them feel better, so when these things are not working to them, they’ll go to the nearest public hospital

.B. Family Health-Illness History

Jelly Ace’s grandparents on maternal side are still alive but they are both hypertensive. The siblings of Jelly Ace’s mother, including her, are living healthy. On the other hand, on the paternal side, Jelly Ace’s grandparents are both alive. His grandfather is also hypertensive. And Jelly Ace’s father and his siblings do not have any disease present. Lastly, our client is currently diagnosed with intestinal obstruction secondary to parasitism.

C. History of Past Illness

During the previous years, Jelly Ace has not experienced any disease or illness. Coughs and colds were the common illness he experienced. Sometimes, he experience stomach pain. To relieve the pain, he was given different herbal plants or they buy over-the-counter drugs. For the herbal plants, they prepare the leaves of the plant then boil it with one to two glasses of water for fifteen minutes or until one half of the liquid is left. Then, he will drink it. He also experienced fever once in a while in which he takes over-the-counter drugs.

D. History of Present Illness

Prior to admission, the patient had experienced abdominal pain associated with episodes of LBM. Jelly Ace first went to the nearest center in their barangay and advised the grandparents to admit him at the hospital. His chief complaint was abdominal pain and LBM.

E. PHYSICAL EXAMINATION

Physical Assessment

Jellyace was seen lying on bed, looks weak, with an IVF of D5IMB 500 cc x 44gtts/min @ 450

level infusing well on the left hand. He was wearing a sando and a short . He looks weak. His

fingernails were clean.

Vital signs:

PR: 94 bpm T: 36.2 C

RR: 24

SKIN:

Upon inspection, there was no swelling, lesions and nodules. Skin color was even with the other

parts of the body. Palpation revealed no signs of masses, nodules or lesions. Skin felt warm and

dry. Upon assessment of skin turgor, the skin sprung back to its previous state for less than a

second. There was no more edema present in upper and lower extremities but there were

some scars present in lower extremities.

HAIR:

Hair appeared to black and short. It was well distributed throughout the scalp. Jelly ace hair was

wet and uncombed. There was no infection and no flaking, sores, lice, nits, and ringworms were

present.

NAILS:

Amber’s nails were cut clean and intact the angle of the nail plate’s curvature was approximately

160° and convex in shape which was negative of any clubbing and produced a diamond shape

when asked to perform Shamroth’s test. The nail beds were highly vascular as evidenced by

having pinkish nails no factors of cyanosis or pallor were noted. Capillary refill was less than 3

seconds. Nails were smooth no terry’s nails or beau’s lines were present as well as

discoloration of any sort. Tissues surrounding the nails were intact and absent of infections and

sores.

SKULL AND FACE

The skull was normocephalic. No nodules, masses, depressions were palpated in the sides of

the head. Related muscles of the face were functioning properly and symmetry of facial

movements was noted as Jelly ace was asked to smile, blow, frown, and pout. There was no

cracking or locking of the temporo-mandibular joint when he was asked to open the mouth.

Eyebrows were aligned and had equal movement as well as the eyelashes which were well and

equally distributed, curled slightly outward. Eyes were symmetrical and no presence of edema.

Pupils were responsive to light and accommodation. The irises were black which the normal

color was generally. There was no discoloration of sclera and remained to be transparent. The

palpebral conjunctiva appeared to be shiny, smooth, and red. The cornea also appeared to be

transparent, shiny and smooth; the details of the irises were also visible. Amber blinked when

the cornea was touched. Both eyes move in unison, with parallel alignment when instructed to

follow the movement of the penlight. No unstable movement and jerking of eyes were noted.

Lacrimal gland appeared to be intact and absent of any edema or infection. Lacrimal gland and

nasolacrimal duct were absent of any tenderness or tearing.

EARS AND HEARING

Ears appeared to have the same color with the rest of the facial skin and were aligned with the

outer cantus of the eyes. No lesions or flakes and scales were noted. No inflammation and

tenderness was noted upon palpation. Pinna recoils after it is folded. The distal thirds of the ear

canal contained hair follicles there were no discharges. There was a dry cerumen on both

ears. Jelly ace had no difficulty hearing normal voices and responded immediately upon hearing

the tick of the watch in both ears.

NOSE AND SINUS

The nose appeared to be straight and aligned; color was similar to facial skin. No lesions

discharges or flaring. No tenderness, masses, or displacement of cartilages or bones were

palpated. Air moved freely as the client breathed through the nares. The mucosa of the nose

was pink, no lesions. Nasal septum was intact and in midline. Facial sinuses were not tender

upon palpation.

MOUTH AND OROPHARYNX

Outer lips were uniform pink color, soft, moist, smooth texture. There was symmetry of contour.

Inner lips appeared to be pink as well, moist, smooth, soft, glistening, and elastic texture. Jelly

ace had teeth (10 up, 10 down), and presence of visible dental caries was noted. He had

pink and moist gums. There were no retractions of gums. The buccal mucosa had no lesions or

signs of infections. It was smooth, pink, and intact. The tongue was in the center of the mouth

and pink in color. It moved freely and frenulum was attached to the floor of the mouth. The soft

palate was light pink and smooth. The hard palate appeared to be lighter pink and had a more

irregular texture. The uvula was positioned in midline of soft palate. The oropharynx appeared to

have a smooth posterior wall. The tonsils were absent of any signs of infections and appeared

to be pink and smooth as well.

NECK

Neck had no edema, lesions or masses and when inspected and palpated. Jelly ace had no

discomfort when moved the chin to chest and when instructed to turn the head from left to right

against the applied force of the student nurse. Supraclavicular lymph nodes were not palpable.

Trachea was midline of the neck; thyroid gland was neither visible upon inspection nor palpable.

THORAX AND LUNGS

Anteroposterior to transverse diameter of the thorax was in 1:1. Jelly ace had no barrel chest

or pigeon chest. Spine curved vertically. Spinal column is straight, right and left shoulders and

hips are at same height. Upon palpation, the thorax had uniform temperature. Chest wall was

intact, no tenderness; no masses. Full and symmetric chest expansion when he took a deep

breath. No adventitious breath sounds were heard. Breathing patterns were quiet, rhythmic, and

effortless respirations. Costal angle was at 90°. Percussion notes resonated except at the

scapula. Lowest point of resonance was at the diaphragm. Percussion of the ribs elicited

flatness.

ABDOMEN

Jelly ace abdomen was round and symmetric contour. No tenderness upon light palpation.

Bowel sounds were active in all four quadrants; aortic pulsations were not visibly present. There

were no friction rubs as well. No signs of enlargement of liver or spleen were present.

Cranial Nerve Type and

Function

Assessment

Procedure

Expected Result Actual Result

I. Olfactory Sensory

Sense of

smell

Ask client to

close eyes and

identify differed

aromas

Client is

expected to

identify the

different odors

presented like

alcohol and

hydrogen

peroxide,

Jelly ace was

able to identify

the aroma

asked without

difficulty

perfume.

II. Optic Sensory

Sense of

vision

Ask client to read

fine prints at a

distance of 14

inches

Check visual

fields by

confrontation

Client will be

able to read

fine prints

(ABCD)

Able to see

objects in the

periphery when

looking straight

ahead

Jelly ace was

able to see

without

difficulty. He

was also able

to see objects

within the

peripheral while

looking straight

ahead

III. Oculomotor Motor

Extra-

ocular eye

movement

of

sphincter

of pupil

movement

of ciliary

muscles of

lens

Assess the six

oculomotor

movements of

the eyes and

pupil reaction

Client is

expected to

move eyes

from left to

right, upward

laterally and

downward

laterally

Jelly ace was

able to follow

the movement

of the penlight

without head

movement

(+PERRLA)

IV. Trochlear Motor

EOM;

specificall

y moves

eyeball

downward

and

laterally

Assess superior

oblique muscle

by downward

lateral movement

of each eye

Client will be

able to move

eyes

downward and

laterally

Jelly ace was

able to move

eyes downward

and laterally

V. Trigeminal Sensory

(opthalmic

branch)

Sensation

Test light

sensation by

having client

close eyes and

Client is

expected to

identify the

sensation felt

Jelly ace was

able to identify

the sensation

felt and the

of cornea,

skin of

face and

nasal

mucosa

Sensory

(maxillary

branch)

Sense of

the face

and

anterior

oral cavity

and

anterior

oral cavity

Motor and

sensory

(mandibul

ar branch)

Jaw

movement

- chewing

and

masticatio

n

wiping a wisp of

cotton over

clients forehead,

cheek and chin

To test deep

sensation, use

alternating blunt

and sharp ends

of safety pin over

the same area

Assess the

muscles of

mastication while

chewing food

and the

location where

the cotton or

safety pin was

placed

location where

the cotton or

safety pin

touched. Client

was also able

to chew without

difficulty

VI. Abducens Motor

EOM;

Lateral

movement

of the eye

Assess lateral

rectus muscle by

the movement of

each eye

Client will be

able to move

eyes laterally

Jelly ace was

able to follow

the movement

of the penlight

VII. Facial Sensory Ask client to do Client is Jelly ace was

Sense of

taste on

the

anterior

two thirds

of the

tongue

Motor

Movement

of the

muscles of

the face

different facial

expressions and

identify various

taste on the tip

and sides of the

tongue

expected to

raise

eyebrows,

frown, smile,

puff out

cheeks, close

eyes tightly

and be able to

identify various

taste on the tip

and sides of

tongue like

sweet candy

and salt

able to show,

frown and raise

eyebrows

without exerting

effort. He was

able to identify

tastes placed

on the tip and

sides of his

tongue.

VIII. Vestibuloco

chlear

Sensory

(vestibular

branch)

Equilibriu

m

Sensory

(cochlear

branch)

Sense of

hearing

Allow the client

to listen to the

ticking of a watch

on each ear

while she has

both eyes

closed.

Instruct client to

walk in a straight

line

Client must be

able to identify

and hear the

ticking sound

of the

wristwatch on

each ear

Jelly ace was

able to hear

and identify the

ticking sound of

the wristwatch

on each ear

and also

maintain

balance

IX. Glossophary

ngeal

Sensory

Sense of

taste on

the

posterior

one third

of the

tongue

Assess

swallowing, gag

reflex and

posterior tongue

The client is

expected to

elicit gag reflex

and identify

bitter taste

Jelly ace was

able to identify

different

flavours placed

on the posterior

portion of the

tongue and he

was able to

move his

Motor

Pharynge

al

movement

and

swallowin

g

tongue; side to

side and up

and down

X. Vagus Motor and

sensory

Sensation

of pharynx

and larynx

The student

nurse asked the

client to state

name and

determines

hoarseness of

voice

Client must be

able to state

his/her name

without

hoarseness of

voice

Jelly ace was

able to verbally

state his name

without

hoarseness of

voice

XI. Accessory Motor

Movement

of

shoulders

muscle

Assess

shrugging of

shoulders and

movement of

head from side

to side against

resistance

The client must

be able to

shrug

shoulders and

move head

from side to

side against

applied

resistance

Jelly ace was

able to shrug

his shoulder

against applied

resistance

XII. Hypoglossal Motor

Movement

of the

tongue or

strength of

the tongue

Ask client to

protrude tongue

and move it from

side to side

The client is

expected to

protrude

tongue and

move it from

side to side

Jelly ace was

able to protrude

his tongue and

move it from

side to side and

in and out

III. Anatomy of the Digestive System

The digestive system, sometimes called the gastrointestinal tract, alimentary tract, or gut, consists of a long hollow tube which extends through the trunk of the body, and its accessory structures: the salivary glands, liver, gallbladder, and pancreas (Fig. 20-1). The digestive tract is

divided into two sections, the upper tract, consisting of the mouth, esophagus, and stomach, and the lower tract, consisting of the intestines.

FIGURE 20-1 Anatomy of the digestive system with associated events.

Inside this tube, ingested food and fluid, along with secretions from various glands, are efficiently processed. First, they are broken down into their separate constituents; then the desired nutrients, water, and electrolytes are absorbed into the blood for use by the cells, and waste elements are eliminated from the body. Within this system, the liver can reassemble the component nutrients into new materials as they are needed by the body. For example, the proteins in milk are digested by enzymes in the digestive tract, producing

the component amino acids, which are then absorbed into the blood. The individual amino acids are used by the liver cells to produce new proteins, such as albumin or prothrombin, or they may circulate as they are in the amino acid pool in the blood to be taken up by individual cells as necessary.

The peritoneal cavity refers to the potential space between the parietal and visceral peritoneum. A small amount of serous fluid is present in the cavity to facilitate the necessary movement of structures such as the stomach. Numerous lymphatic channels drain excessive fluid from the cavity.

Because serous membranes are normally thin, somewhat permeable, and highly vascular, the peritoneal membranes are useful as an exchange site for blood during peritoneal dialysis in patients with kidney failure (see Chapter 21). However, such an extensive membrane may also facilitate the spread of infection or malignant tumor cells throughout the abdominal cavity or into the general circulation.

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

The greater omentum is a layer of fatty peritoneum that hangs from the stomach like an apron over the anterior surface of the transverse colon and the small intestine. The lesser omen-tum is part of the peritoneum that suspends the stomach and duodenum from the liver. When inflammation develops in the intestinal wall, the greater omentum, with its many lymph nodes, tends to adhere to the site, walling off the inflammation and temporarily localizing the source of the problem. Inflammation of the omentum and peritoneum may lead to scar tissue and the formation of adhesions between structures in the abdominal cavity, such as loops of intestine, restricting motility and perhaps leading to obstruction.

Intestinal Obstruction

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

FIGURE 20-37 Colostomy. A, sigmoid colostomy-a surgically created opening into the colon through the abdominal wall. B, The stoma is the new opening on the abdomen. It is always red and moist, is not painful, but may bleed easily. C, A plastic pouch to collect stools is attached to the stoma. (Courtesy of Hollister Incorporated, Patient Education Series.)

Intestinal obstruction occurs in two forms. Mechanical obstructions are those resulting from tumor, adhesions, hernias, or other tangible obstructions (Fig. 20-38). Functional, or adynamic, obstructions result from neurologic impairment, such as spinal cord injury or lack of propulsion in the intestine, and are often referred to as paralytic ileus. While the end result can be the same, these types manifest somewhat differently and require different treatment.

IV. THE PATIENT AND HIS ILLNESS

A. Pathophysiology

Schematic Diagram

Risk Factors for Ascariasis: Children less than 10 years old (more

likely to play in dirt) Warm climate (eg. Tropical areas) Poor sanitation (human feces mixed in

soil)

Risk Factors for Bowel Obstruction Abdominal or pelvic surgery which often

cause adhesions Crohn’s disease – narrows intestinal

passageways due to thickening Abdominal Cancer Ad

Increased fluid and gas

Abdominal distention

Increased peristalsis attempts to force contents past obstruction

2 types of obstructions

Mechanical:Physical obstruction or increased pressure from walls creating a blockage

Functional:Intestinal muscles cannot propel the contents along the bowel

Increased pressure on intestinal wall causes more fluid to enter intesting

Severe vomiting & pain

Dehydration & Electrolyte Imbalance

Decreased blood pressure & hypovolemic shock

Continued pressure on intestinal wall causes edema, ischemia and decreased peristalsis

Prolonged ischemia causes increased permeability and necrosis of wall. Intestinal bacteria & toxins leak into blood.

Ingestion of ascariasis eggs: Contaminated soil Hand-to-mouth contact Eating uncooked fruits or vegetables

grown in contaminated soil

Migration Larvae hatch in small intesting Penetrate intestinal wall and travel

through to lungs through blood and lymph vessels

After 1 week of maturation, travel into throat and back to intestines

Maturation Grow into male and female worms. Females > 40cm long and < 6mm in

diameter Males generally smaller

Reproduction Females produce 200,000 eggs a

day Eggs expelled in feces

When mechanical obstruction of the flow of intestinal contents occurs, a sequence of events develops (Fig. 20-39) as follows:

1. Gases and fluids accumulate in the area proximal to the blockage, distending the intestine. Gases arise primarily from swallowed air but also from bacterial activity in the intestine;

2. Increasingly strong contractions of the proximal intestine occur in an effort to move the contents onward;

3. The increasing pressure in the lumen leads to more secretions entering the intestine and also compresses the veins in the wall, preventing absorption, as the intestinal wall becomes edematous;

4. The intestinal distention leads to persistent vomiting with additional loss of fluid and electrolytes. With small intestinal obstructions, there is no opportunity to reabsorb fluid and electrolytes, and hypovolemia quickly results;

5. If the obstruction is not removed, the intestinal wall becomes ischemic and necrotic as the arterial blood supply to the tissue is reduced by pressure. If twisting of the intestine (e.g., volvulus) has occurred or if immediate compression of arteries (e.g., intussusception or strangulated hernia) results from the primary cause of obstruction, the intestinal wall becomes rapidly necrotic and gangrenous;

6. Ischemia and necrosis of the intestinal wall eventually lead to decreased innervation and cessation of peristalsis. A decrease in bowel sounds indicates this change;

7. The obstruction promotes rapid reproduction of intestinal bacteria, some of which produce endotoxins. As the affected intestinal wall becomes necrotic and more permeable, intestinal bacteria or toxins can leak into the peritoneal cavity (peritonitis) or into the blood supply (bacteremia and septicemia); and

8. In time, perforation of the necrotic segment may occur, leading to generalized peritonitis.

FIGURE 20-38 A–E, Causes of intestinal obstruction.

FIGURE 20-39 Effects of intestinal obstruction.

Functional obstruction or paralytic ileus usually results from neurologic impairment. Peristalsis ceases and distention of the intestine occurs as fluids and electrolytes accumulate in the intestine. In this type of obstruction, reflex spasms of the intestinal muscle do not occur, but the remainder of the process is similar to that of mechanical obstruction.

Etiology

Functional obstruction or paralytic ileus is com-mon in the following situations:

▪ after abdominal surgery, in which the effects of the anesthetic combined with inflammation or ischemia in the operative area interfere with conduction of nerve impulses;

▪ in the initial stage of spinal cord injuries (spinal shock);

▪ with inflammation related to severe ischemia;

▪ in pancreatitis, peritonitis, or infection in the abdominal cavity; or

▪ with hypokalemia, mesenteric thrombosis, or toxemia

Mechanical obstruction may result from the following:

▪ adhesions (from previous surgery, infection, or radiation) that twist or constrict the intestine, the most common cause of obstruction;

▪ hernias (protrusion of a section of intestine through an opening in the muscle wall) (Fig. 20-40);

▪ strictures caused by scar tissue;

▪ masses, such as tumors or foreign bodies;

▪ intussusception (the telescoping of a section of bowel inside an adjacent section). Intussusception may occur secondary to polyps or tumors that pull a section of bowel forward with them (see Fig. 20-40 B );

▪ volvulus (twisting of a section of intestine on itself), which may be linked to adhesions. In many cases, the cause of intussusception or volvulus is unknown;

▪ Hirschsprung's disease, or congenital megacolon, a condition in which parasympathetic innervation is missing from a section of the colon, impairing motility and leading to constipation and eventually obstruction. Hirschsprung's disease often occurs in conjunction with other anomalies; and

▪ gradual obstruction from chronic inflammatory conditions, such as Crohn's disease or diverticulitis

Signs and symptoms

With mechanical obstruction of the small intestine, severe colicky abdominal pain develops as peristalsis increases initially. Borborygmi (audible rumbling sounds caused by movement of gas in the intestine) and intestinal rushes can be heard as the intestinal muscle forcefully contracts in an attempt to propel the contents forward. The signs of paralytic ileus differ significantly in that bowel sounds decrease or are absent, and pain is steady.

FIGURE 20-40 A, Hernia with infarcted intestine. The sac consists of the abdominal wall covered by skin (a) at a site weakened by scar tissue, forming a protrusion into which a loop of intestine is compressed (b). This protrusion obstructs the blood flow to the intestinal wall (c) (black infarcted area) as well as the flow of feces inside the intestine. (Courtesy of R. W. Shaw, MD, North York General Hospital, Toronto, Ontario, Canada.) B, Intussusception due to an adenocarcinoma (light colored circular mass) causing acute intestinal obstruction. (B, From Cooke RA, Stewart B: Colour Atlas of Anatomical Pathology, 3rd ed. Sydney, Churchill Livingstone, 2004).

Vomiting and abdominal distention occur quickly with obstruction of the small intestine. Vomiting is recurrent and consists first of gastric contents and then bile-stained duodenal contents. No stool or gas is passed.

Restlessness and diaphoresis with tachycardia are present initially. As hypovolemia and electrolyte imbalances progress, signs of dehy-dration, weakness, confusion, and shock are apparent.

Obstruction of the large intestine develops slowly and signs are mild. Constipation and mild lower abdominal pain are common, followed by abdominal distention, anorexia, and eventually vomiting and more severe pain.

Treatment

The underlying cause is treated, and fluids and electrolytes are replaced. Surgery and antimicrobial therapy are required as soon as possible for any strangulation; paralytic ileus may require decompression by suction.

(Gould, Barbara E.. Pathophysiology for the Health Professions, 3rd Edition. W.B. Saunders Company, 032006. 20.9.6). <vbk:1-4160-0210-3#outline(20.9.6)>

Background

Intestinal nematode infections affect one fourth to one third of the world's population. Of these, the intestinal roundworm Ascaris lumbricoides is the most common. While the vast majority of these cases are asymptomatic, infected persons may present with pulmonary or potentially severe gastrointestinal complaints. Ascariasis predominates in areas of poor sanitation and is associated with malnutrition, iron-deficiency anemia, and impairments of growth and cognition.

Ascaris lumbricoides is shown in the image below.

Adult Ascaris lumbricoides.

Pathophysiology

A lumbricoides is the largest of the intestinal nematodes affecting humans, measuring 15-35 cm in length in adulthood. Infection begins with the ingestion of embryonated (infective) eggs in feces-contaminated soil or foodstuffs. Once ingested, eggs hatch, usually in the small intestine, releasing small larvae that penetrate the intestinal wall. Larvae migrate to the pulmonary vascular beds and then to the alveoli via the portal veins usually 1-2 weeks after infection, during which time they may cause pulmonary symptoms (eg, cough, wheezing). During the time frame of pulmonary symptoms, eggs are not being shed, and thus diagnosis via stool ovas and parasites is not possible. Eggs are not shed in stool until roughly 40 days after the development of pulmonary symptoms.

After migrating up the respiratory tract and being swallowed, they mature, copulate, and lay eggs in the intestines. Adult worms may live in the gut for 6-24 months, where they can cause partial or complete bowel obstruction in large numbers, or they can migrate into the appendix, hepatobiliary system, or pancreatic ducts and rarely other organs such as kidneys or brain. From egg ingestion to new egg passage takes approximately 9 weeks, with an additional 3 weeks needed for egg molting before they are capable of infecting a new host.

V. THE PATIENT AND HIS CAREA. Medical Management

a. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, etc.

Medical Management Treatment

Date OrderedDate(s) PerformedDate changed / D/C

General Description

Indication(s) or Purpose(s)

Clients Respone to the treatment

D5 .03 NaCl x 59-60 gtts/min.

D5 .03 NaCl x 44 gtts/min.

DO: June 21, 2012

DG: June 21, 2012

DG: June 25, 2012DG: June 26, 2012

A hypotonic solution that has greater concentration of free water molecules that are found inside the cell rather than on its surrounding. Hypo-osmolality possible with infusion because solutions have a lower concentration of electrolytes than plasma does.Transcend all membranes from vascular space to tissue.

Purpose of

hypotonic

solution is to give

up their water to

a dehydrated cell

so it can return

to isotonic

equilibrium.

Sodium and

chloride

depletion.

The patient good hydration status was maintained. Sign and symptoms of decreased fluid volumes were reduced and intravenous medication were given.

Medical Management Treatment

Date OrderedDate(s) PerformedDate changed / D/C

General Description

Indication(s) or Purpose(s)

Clients Respone to the treatment

D5 IMB 500cc x 8®

D5 IMB 500 cc x11®

DO: June 22, 2012

DG: June 22, 2012

DG: June 23, 2012DG: June 24, 2012DG: June 25, 2012DG: June 26, 2012DG: June 27, 2012

It is a sterile, non pyrogenic solutionEach 100 ml contains, hydrous 5g: Na lactate, anhydrous 260 mg: KCl 141 mg: magnesium Cl. Hyxahydrate 30 mg: monobasic potassium phosphate, anhydrous 15 mg : and monobasic sodium.

It is indicated to replace and balance fluids and electrolytes because the patient experienced deficiencies such as blood loss.

The patient willingly accepted treatment and is kept hydrated as evidenced by continuous infusion, improvement in her condition and good skin turgor. There were no negative effects noted.

Nursing Responsibilities

Before:

Before preparing the infusion, the nurse first verifies the primary care provider’s

order indicating the type of solution, the amount to be administered, the rate of

flow of the infusion, and any client allergies (e.g., to tape or povidone iodine).

Prepare necessary equipments.

Prior to initiating the IV infusion, consider how long the client is likely to have the

IV, what kinds of fluids to be infused, and what kinds of medications the client will

be receiving or is likely to receive. These factors may affect the choice of vein

and catheter size.

Prior to performing the procedure, introduce self and verify the client’s identity

using agency protocol. Explain the procedure to the client. A venipuncture can

cause a discomfort for a few seconds, but there should be no discomfort while

the solution is flowing. Use a doll to demonstrate for children, and explain the

procedure to parents. Clients often want to know how long the process will last.

The primary care provider’s order may specify the length of time of the infusion.

Unless initiating IV therapy is urgent, provide any scheduled care before

establishing the infusion to minimize movement of the affected limb during the

procedure. Moving the limb after the procedure has been established could

dislodge the catheter.

Make sure the clients clothing or gown can be removed over the IV apparatus if

necessary.

During:

Open and prepare the infusion set using sterile technique.

Clean the area of the infusion site using topical antiseptic swab then using

antiseptic technique insert the catheter and initiate the infusion, use dressing

appropriately.

Ensure appropriate infusion flow.

Hang the solution container on the pole suspended about 1m (3 ft) above the

clients head.

Apply IV information label to the solution container.

After:

Document the relevant data, including assessment.

Position the client appropriately.

Check routinely the IVF site for any problems and IVF tubing for any infiltrations.

b. Drugs

Name of drugs-Generic name-Brand name

Generic Name: AmpicillinAmpicillin Sodium

Brand Name: Novo-Ampicillin (CAN), Principen

Generic Name: Diphenhydramine Hydrochloride

Brand Name: Benadryl

Date OrderedDate taken or givenDate changed / D/C

DO: June 21, 2012

DG: June 21-25, 2012

DO: June 21, 2012

DG: June 21, 2012

Route of Admin. Dosage and frequency

320mg SIVP q 6°

14mg SIVP PRN

General Action Functional class’n Mechanism of action

AntibioticPenicillin

Belonging to the penicillin group of beta-lactam antibiotics. It differs from penicillin only by the presence of an amino group. That amino group helps the drug penetrate the outer membrane of gram-negative bacteria.

Bactericidal action against sensitive organism; inhibits synthesis of bacterial cell wall, causing cell death.

AntihistamineAnti-motion sickness drugAntiparkinsonianSedative-hypnotic

Diphenhydramine is a first generation antihistamine used to treat a number of conditions

Clients response to the medication with actual side effects

The patient was prevented for some bacterial invasion and there was no sign of infection.

The patient willingly accepted treatment and did not manifest certain allergic reactions.

Generic Name: Ranitidine Hydrochloride

Brand Name: Apo-Ranitidine, Zantac

DO: June 21, 2012

DG: June 21-26, 2012

14 mg SIV q 8°

including: allergic symptoms and itchiness, the common cold, insomnia, motion sickness, and extrapyramidal symptoms.

Diphenhydramine also has antiemetic properties which make it useful in treating the nausea that occurs in motion sickness. As it causes marked sedation in many individuals, the less sedating drug dimenhydrinate may be preferred for this purpose.

Histamine-2(H2) antagonist

Inhibits basal gastric acid secretion and gastric secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin and pentagastrin.

Reduces gastric acid secretion and increases gastric mucus and bicarbonate production,

The patient willingly accepted treatment and did not manifest certain allergic reactions.

Generic Name: Acetaminophen

Brand Name: Paracetamol, Tempra, Tylenol

DO: June 21, 2012

DG: June 22 and 24, 2012

145 mg IV q 4° x T ≥ 37.8

creating a protective coating on gastric mucosa.

AnalgesicAntipyretic

Paracetamol is a widely used over-the-counter analgesic (pain reliever) and antipyretic (fever reducer). It is commonly used for the relief of fever, headaches, and other minor aches and pains, and is a major ingredient in numerous cold and flu remedies. In combination with non-steroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics, paracetamol is used also in the management of more severe pain (such as cancer or postoperative pain).

The patient experienced relief of pain as an action of the medication. He was more relaxed and there were less complains of pain, facial grimaces and guarding behavior.

Nursing Responsibilities

Before

Observe 10 R’s of administration of drugs

Check doctor’s order three times and verify the patient

Check the label of the drug, its name and its expiration date

Wash hands before handling the medication

Assess patient’s vital signs prior to administering the medication

During

Administer as indicated (right drug, right dosage, right frequency)

Clean the IV insertion for medication with a cotton ball with alcohol.

Gradually inject the drug into the port. Slow IV push to prevent infiltration and

phlebitis.

Administer cautiously and slowly with aseptic technique.

After

Observe for the sensitivity and side effects to the drug

Reassess patient’s level of pain at least 15 and 30 minutes after parenteral

administration

Monitor circulatory and respiratory status and bladder and bowel function.

Caution ambulatory patient about getting out of bed or walking.

c. Diet

Type of Diet Date General

Description

Indication Specific foods

taken

Client’s

response

and/or

reaction to

the diet

NPO

(Nothing per

Orem)

Clear Liquid

DO: June

21, 2012

June 26,

2012

A diet wherein

the patient will

not take in food

or liquids by

mouth.

A clear or full

liquid diet, or a

It was ordered

to prepare the

patient for

further

observation

and to avoid

complication

of aspiration.

Was ordered to

None

Fruit juices

no carbonated

drinks

The patient

seems to be

irritated most

probably due

to hunger.

.

The patient

complied with

diet containing

no solid foods, is

often prescribed

for

gastrointestinal

illness or before

or after certain

types of surgery

involving the

mouth or

gastrointestinal

tract.

A clear liquid diet

consists of

transparent

liquid foods, and

no carbonated

drinks. Soda's

carbonation

expands the

gastrointestinal

tract.

prepare the

patient for

certain

medical tests,

more

commonly

bloodwork. It is

very helpful

when a patient

is expereince

nausea and

has trouble

keeping things

down. Also

used before

and after

surgery.

the type of

diet without

any complain.

Nursing Responsibilities (NPO):

Before:

Check for the doctor’s order for type of diet preferred.

Explain the importance and purpose of the prescribed diet.

Place an NPO sign on the bed.

Remove all foods at bedside and emphasize strict compliance on the diet regimen.

During:

Monitor patient closely for compliance of the diet.

Reiterate diet frequently to the patient or SO.

Check bedside for presence of food, remove if necessary.

After:

Assess patient’s condition.

Document

Nursing Responsibilities (DAT):

Before:

Check the doctor’s order.

Instruct the client about the prescribed diet ordered by the physician.

Explain purpose or importance of the diet and what specific foods are allowed for the

patient.

Explain also the appropriate foods not to be taken such as during NPO: not to eat

anything; and during liquid and soft diet: not to eat fibrous or hard to digest food such as

vegetables and the like.

During:

Assist the patient when eating.

As much as possible, promote independence.

If appropriate and tolerated, allow the patient to sit in a semi-fowler’s or high fowler’s

position to reduce the risk for aspiration.

After:

Monitor the reaction of the patient such as dysphagia, anorexia, and intolerance of food.

Note patient about the prescribed drugs taken orally but still under NPO.

D. Activity/Exercise

Type of Exercise Date ordered Date Performed Date changed

General Description

Indication, Initial Reaction, Purpose

Client response to activity exercise

Ambulation May sit on side of bed a n d w a l k a r o u n d t h e room

Ambulation is an essential activity that prevents respiratory, circulatory, and gastrointestinal problems. It also helps the patient to prevent general muscle weakness.

The patient gradually increased activity performance as evidenced by the patient tolerated activity such as sitting, standing and walking.

Nursing Responsibilities:Prior to:

Check for the doctor’s order  Assess patient’s condition Assess for Vital signs. Explain the benefit that the patient may get from this activity.

During: Assist patient in the activity

Advise the patient to have rest periods to avoid fatigue. Instruct the patient to gradually increase activities as tolerated.

After: Monitor patient’s vital signs. Advise patient to report to the physician any unusual fatigability to the

physician because this may indicate activity intolerance. Monitor for vital signs to assess for tolerance to activity.

Provide health teaching regarding the proper food to be taken to provide adequate supply of energy.