Intestinal Obstruction a case study

INTESTINAL OBSTRUCTION

Group 4, n-407

INTESTINAL OBSTRUCTION

is a blockage of your small intestine or colon that prevents food and fluid from passing through.

can be caused by many conditions, including fibrous bands of tissue in the abdomen (adhesions), hernias and tumors.

Alternative names: Paralytic ileus; Intestinal volvulus; Bowel obstruction; Ileus; Pseudo-obstruction - intestinal; Colonic ileus.

Etiology of bowel obstruction is pathological prevention of passage of gastrointestinal luminal content from passing distally.

http://www.healthline.com/galecontent/ileus

http://www.healthline.com/adamcontent/volvulus-childhood

http://www.healthline.com/galecontent/intestinal-obstructions

The signs and symptoms of intestinal obstruction are Abdominal swelling, Constipation, Severe abdominal cramps, Intermittent abdominal cramps, nausea and Vomiting, Green vomit, Fecal vomiting (vomit that looks like feces) Blood-stained mucus passed, Passing jelly-like mucus

Diseases and conditions that can increase your risk of intestinal obstruction include: Abdominal or pelvic surgery, which often causes adhesions — a common cause of intestinal obstruction. Crohn's disease — an inflammatory condition that can cause the intestine's walls to thicken, narrowing its passageway. Cancer within your abdomen, especially if you've had surgery to remove an abdominal tumor or radiation therapy

http://www.wrongdiagnosis.com/sym/abdominal_swelling.htm

http://www.wrongdiagnosis.com/sym/abdominal_swelling.htm

http://www.wrongdiagnosis.com/sym/constipation.htm

http://www.wrongdiagnosis.com/sym/severe_abdominal_cramps.htm

http://www.wrongdiagnosis.com/sym/stomach_cramps.htm

http://www.wrongdiagnosis.com/sym/vomiting.htm



http://www.wrongdiagnosis.com/sym/bloody_stool.htm

http://www.wrongdiagnosis.com/sym/mucus_stool.htm

http://www.wrongdiagnosis.com/sym/mucus_stool.htm

OBJECTIVES (NURSE-CENTERED)

Upon completion of this case study, the student nurse should be able to:

COGNITIVE

Recognize and understand the disease condition. Identify predisposing and precipitating factors that could

possibly contribute to the occurrence of the disease. Understand the normal anatomy and physiology of the

organs that are affected by the underlying disease condition.

Review literature and background of the signs and symptoms manifested by the client.

Identify specific theoretical and/or research-based causes and clinical manifestations of the disease, and trace the pathophysiology of the disease condition.

AFFECTIVE

Establish rapport with the client and SO. Maintain sound communication by making use of self as a

therapeutic agent.

PSYCHOMOTOR

Assess the following such as:Personal history such as demographic dataPertinent family health and history by making use of a

diagramHistory of past and present illness

Formulate nursing diagnosis that address the needs of the patient and plan nursing interventions to meet those needs.

Conduct physical assessment (cephalo-caudal approach, review of systems)

Review and monitor diagnostic and laboratory results Construct individualized nursing care plans. Do discharge planning

II NURSING HISTORY

Personal History Demographic Data Mr. P, is a 39 year old male, he was born on December 1, 1971. He is married and blessed with 3 children. He is a Filipino citizen, currently living at Lubao, Pampanga together with his wife and children. His religious view is Roman Catholic. He is a college undergraduate of Bachelor of Science in Education, in Don Honorio Ventura College of Arts and Trades.

b.Socio-Economic and Cultural Factors Mr. P’s family source of daily expenses comes from the money he earns as a tricycle driver and from her wife’s mini grocery at home. They are earning a total of P10,000.Mr.P’s weekly expenses are:Food 2000x( 4) = 8000/month Monthly Income = 10000Electric Bill 1000/month Monthly Expenses = 9400Water Bill 400/month 600

He wakes up at 5:00 a.m. to take a bath and eat breakfast. By 6:00 am he will drop by and pick up the 3 elementary students at their house and he will send them to school. From 8:00 am to 3:00 pm he will stay at the terminal and pick up passengers. Then at 4:00 p.m he will fetch the students from school and bring them back home. At 5:00 pm onwards he will watch t.v., eat, or sometimes go to his neighbors. He usually sleeps at 10:00 in the evening.

He smokes 1 pack per day of Philips since he was 27 y/o, but he stopped smoking 3 years ago. And he drinks 1 1/2 bottle a day of Red Horse.

Pack years = # of packs/day x # of years smoked = 1 pack/day x 5 = 9 pack years

He only self-medicate when he has headache and fever by taking Biogesic every 4 hours until the symptoms subside. They also seek help to a “manghihilot” if they have fever. They also utilize herbal medicines like oregano and guava whenever one of their family members is having cough and colds and stomach ache respectively, in which they boil the leaves for 5 to 10 minutes and drinks 1 glass 3x/day until it subsides.

II. Family Health Illness History

It was revealed in the diagram that on father side, Mr. T’s grandfather is hypertensive and has Diabetes mellitus, and his grandmother died because of old age. On the other hand, on his mother side, Mr. P’s grandparents are both alive, his grandmother has heart disease while his grandfather is living healthy. His father was also hypertensive and his mom has heart disease. In addition his eldest sister is hypertensive and she was diagnosed of Diabetes mellitus Type II.

Lastly, our client was currently diagnosed of Partial Intestinal Obstruction secondary to ileocecal tumor. Patient claimed that aside from those, there are no significant hereditary familial disease like asthma, bone disease and etc.

III. History of Past Illness

The patient has been hypertensive for the past 2 years, according to him he was taking Norvasc 5mg once a day. He has also irregular bowel habits for the past 3 months. The patient has also experienced minor illness such as cough and colds and drinks 2 tablespoon of oregano 3x/day until symptoms subside. He also experienced having fever once in a while in which he self medicates by taking Biogesic every four hours until fever is gone.

History of Present Illness

One month prior to admission patient had generalized abdominal pain associated with 2 episodes of watery diarrhea and 2-3 episodes of vomiting and he noticed abdominal distention. Patient consulted to the nearest hospital and was admitted with a chief complaint of abdominal pain. NGT inserted to relieve his abdominal distention. After 9 days he decided to be discharged when his abdominal distention was relieved, he signed a refusal form and was advised by the doctor just to come back once pain persists. Patient had on and off pain after 2 days of being discharged followed by abdominal distention, with a pain scale of 7/10. He went back to the said hospital, thus, admitted again to have his operation, Explore Laparatomy, Right Hemicolectomy.

PHYSICAL ASSESSMENT

III. DIAGNOSTICS AND LABORATORY PROCEDURES

Diagnostic / Laboratory Procedure

Indications or Purpose

Date OrderedDate Results were released

Results Normal Values

Analysis and Interpretation of the Results

Hematology

Hct (%)

Hgb (g/dL)

To aid in diagnosing anemia and to monitor blood loss and infection

This represents the percentage of total blood volume composed of RBC This indicates the amount of hemoglobin in a given blood volume. Hemoglobin is the component of the blood that gives its red color.

9-7-10 9-7-10

.23 120

.40-.52 125-175 g/L

Hematocrit is below the normal range. This may be due to the intestinal obstruction which leads to digestive inflammation.

Hemoglobin is slightly decreased. This may be due to the intestinal obstruction which leads to digestive inflammation.

WBC (x10 9/L) The patient has a bacterial infection so it is important that the WBC be determined which is responsible to fight against infection.

9-7-10 12.4 5-10 x 109/L White Blood Cell is Increased which may indicate infection.

Neutrophils(%) Neutrophils are the most common type of white blood cell, comprising about 50-70% of all white blood cells. They are phagocytic, meaning that they can ingest microorganism. Neutrophils are the first immune cells to arrive at a site of infection.

9-7-10

.88 .45-.65 Neutrophils is increased which may indicate bacterial infection.






Lymphocytes

A small white blood cell (leukocyte) that plays a large role in defending the body against disease.

9-7-10

.12

.20-.35

The infection is caused by bacteria. However, the lymphocytes are low since this is indicated for viral infections

Platelet (x10 9/L)

Indicates the amount of platelets present in a given amount of blood, the platelets are the ones responsible for blood clotting and stop bleeding.

9-7-10

.387

150-400 x 109/L

Platelet count is within the normal range.






NURSING RESPONSIBILITIES

Prior Administration: Check the doctor’s order. Prepare the needed materials for laboratory test. Explain the purpose and indication of laboratory test to the patient.

During Administration: Instruct the patient to cooperate fully and to follow directions. Direct

the patient to breathe normally and to avoid unnecessary movements. If the patient has a history of severe allergic reaction to latex, care

should be taken to avoid the use of equipment containing latex. Remove the needle and apply pressure dressing on the puncture site.

After Administration: Label the blood specimen with the name, age and diagnosis of the

patient. Bring the blood specimen immediately to the laboratory Document the laboratory test performed. Attach the laboratory test result in the patient’s chart.






Blood Chemistry RBS

Blood chemistry tests are often ordered prior to surgery or a procedure to examine the general health of a patient. Random glucose test is a blood sugar test taken from a non-fasting subject. This is ordered since the patient manifests some signs and symptoms of diabetes mellitus such as polydipsia, polyuria, and weight loss.

9-7-10

10.26

3.85 – 9.0 mmol/L

There is an increased blood sugar which could indicate diabetes mellitus. This could also be attributed to stress brought by the disease condition.

BUN The blood urea nitrogen test is a measure of the amount of nitrogen in the blood in the form of urea, and a measurement of renal function.

9-7-10 12.8 1.7-8.3 mmol/L

A high level may indicate that the kidneys are functioning less than normal.

Sodium It may be ordered to determine if a disease or condition involving the brain, lungs, liver, heart, kidney, thyroid, or adrenal glands is causing or being exacerbated by a sodium deficiency or excess.

9-7-10 125.1 136-145 mmol/L

Sodium electrolyte is below the normal range. This may be due to diarrhea, excessive urination, and vomiting prior to admission.











Potassium Essential to regulate heartbeat, facilitate normal muscle contraction, regulate the transfer of nutrients to cells, and regulate kidney function and stomach juice secretion,

9-7-10 3.16 3.5-5 mmol/L

Potassium electrolyte is below the normal range. This may also be due to diarrhea, excessive urination, and vomiting prior to admission.

Chloride This test shows the level of chloride in the blood. Chloride binds with electrolytes including potassium and sodium in the blood and plays a role in maintaining the proper pH of the blood. Chloride levels can vary widely if the patient is dehydrated or overly hydrated, if the kidneys are not functioning properly.

9-7-10 76.7 101-111 mmol/L

Serum Chloride is below the normal range. This may also be due to diarrhea, excessive urination, and vomiting prior to admission.






Alkaline Phosphatase

Alkaline phosphatase (ALP, ALKP) is a hydrolase enzyme responsible for removing phosphate groups from many types of molecules, including nucleotides, proteins, and alkaloids.

9-7-10 119.7 64-306 IU/L The alkaline phosphatase is within the normal range.

SGOT/AST SGOT: Serum glutamic oxaloacetic transaminase, an enzyme that is normally present in liver and heart cells. SGOT is released into blood when the liver or heart is damaged.

9-7-10 48 10-40 IU/L The SGOT is elevated which may indicate a liver or heart problem.






SGPT/ALT Alanine transaminase or ALT is a transaminase enzyme (EC 2.6.1.2). It is also called serum glutamic pyruvic transaminase (SGPT) specific test for liver function. Since the patient is taking anti-TB drugs, it is important to check for liver function since one of its side effects is hepatotoxicity.

9-7-10 25.8 0-39 IU/L The SGPT is within normal range.


Prior Administration:

Check the doctor’s order. Prepare the needed materials for laboratory test. Explain the purpose and indication of laboratory test to the patient.

During Administration: Instruct the patient to cooperate fully and to follow directions. Direct the

patient to breathe normally and to avoid unnecessary movements. If the patient has a history of severe allergic reaction to latex, care

should be taken to avoid the use of equipment containing latex. Remove the needle and apply pressure dressing on the puncture site.

After Administration: Label the blood specimen with the name, age and diagnosis of the

patient. Bring the blood specimen immediately to the laboratory Document the laboratory test performed. Attach the laboratory test result in the patient’s chart.






Urinalysis To check components of the urine

D.O: 09-07-10 D.R: 09-07-10

Color: yellow Transparency: Turbid Albumin: (-) Sugar: (-) Specific gravity: 1.005 Puss cells: 12-16/ HPF

Usual colors are colorless, straw, yellow, amber; less commonly pink, red, brown. Usual appearances (opacity) are clear or hazy; less commonly turbid, cloudy and opaque 1.010 – 1.025

3-6/HPF

This indicates that the urine is concentrated. Urine normally is clear. Mucus and lipid may cause turbidity in normal urine. Increased numbers of cells, crystals, casts, or organisms can increase the turbidity of urine in disease conditions. The specific gravity is lower than the normal range which indicates that the urine is concentrated. This may be due to problem in the urine concentration of the kidneys.

An increase in pus cell may indicate

an infection.

NURSING RESPONSIBILITIESPrior Administration:

Check the doctor’s order.Prepare the needed materials for laboratory test.Explain the purpose and indication of laboratory test to

the patient.

During Administration:A urine sample is collected in an unused disposable

plastic cup with a tight-fitting lid. A randomly voided sample is suitable for routine urinalysis although the first-voided morning urine is most concentrated and therefore, preferred.

After Administration:Label the urine specimen with the name, age and

diagnosis of the patient.Bring the urine specimen immediately to the laboratoryDocument the laboratory test performed.Attach the laboratory test result in the patient’s chart.






Chest X-Ray

To evaluate the lungs, as well as the chest cage, for the presence of abnormalities.To evaluate the size of the heart.To establish the size and location of an abnormality prior to performing other tests, such as a biopsy.

9-7-10 9-7-10

(+) cardiomegaly

The lungs look normal in size and shape, and the lung tissue looks normal. No growths or other masses can be seen within the lungs. The pleural spaces also look normal.The heart looks normal in size, shape, and the heart tissue looks normal. The blood vessels leading to and from the heart also are normal in size, shape, and appearance.The bones including the spine and ribs look normal. The diaphragm looks normal in shape and location.

Results show cardiomegaly or enlargement of the heart which may indicate that the patient has a heart problem.

http://www.health.com/health/library/mdp/0,,zm2208,00.html#zm2208-sec






Electrocardiography

Symptoms generally indicating use of electrocardiography include: Cardiac

murmurs

Syncope or collapse

Seizures

Perceived dysrhythmia]

Symptoms of myocardial infarction

9-7-10 9-7-10

Sinus tachycardia

Normal sinus rhythm: each P wave is followed by a QRS; P wave rate is not more than 150 bpm

Results show a fast heartbeat which is attributed to the heart enlargement since the heart needs to compensate in order to pump enough blood.


Instruct client that hospital gown will replace all clothing on the upper body.

All jewelry must be removed.

Pregnant women and should use protective lead aprons during the procedure because there is minimal exposure to radiation.

Ask client to take a deep breath and hold it without moving while an X-ray picture is taken.


Clean the skin and clip hair in the area where the electrode tabs will be placed to ensure adherence and reduce discomfort during removal

Attach the adhesive electrode tabs to the skin where the electrode wires will be fastened.

Avoid touching the adhesive tabs over bones, scars, and breast tissues.

After the procedure, wipe the area or the electrode tabs especially when lubricant is used.

SURGICAL MANAGEMENT

Surgical Management General Description Indications/ Purpose Date Ordered, Date Performed

Client’s response to treatment

Exploratory Laparotomy with Hemicolectomy

A laparotomy is a large

incision made into the

abdomen. Exploratory

laparotomy is used to

visualize and examine the

structures inside of the

abdominal cavity.

Hemicolectomy (also

referred to as right or left

hemicolectomy) is a

partial colon-removal

procedure in which

surgeons excise the right

(ascending) part of the

colon or the left

(descending) side of the

colon.

Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure may be recommended for a patient who has abdominal pain of unknown origin or who has sustained an injury to the abdomen.

The procedure is relatively common for treating diverticulitis, inflammatory bowel disease, benign or malignant polyps of the colon, and colon cancer. The hemicolectomy procedure traditionally begins with an incision in the abdomen, opening the area for access to the colon. Thereafter, the surgeon cuts away the infected or injured portions of the colon and reattaches the remaining tissue.

Date ordered:

September 8, 2010

Date Performed:

September 9, 2010

The patient complains of pain on the incision site.

NURSING RESPONSIBILITIESPrior

Explain to the patient how the procedure will be done or what the results will mean.

Ask him Ask her to sign the inform consent. Make sure that the patient should understand the nature and purpose of the diagnostic procedure or treatment, its risks and benefits, and alternatives, including the option of not proceeding with the test or treatment.

Ask him to fill out the medical test information form to understand the importance of the surgery.

Ask the patient if : Are allergic to any medications, including anesthetics. Have had bleeding problems or take blood thinners, such as aspirin or

warfarin (Coumadin). Get the complete blood count (CBC) and bleeding factors. NPO post-midnight before surgery. Ask the patient to remove dentures, eyeglasses or contact lenses,

hearing aids, wigs, makeup, and jewelry before the biopsy. Ask him to empty bladder


During Maintain aseptic technique.After He may be required to lie flat for two hours

following the procedure to prevent the risk of bleeding.

Checks the patient's status at two-hour intervals. Monitor vital signs. Inform the patient that he should report

immediately if the he experiences extreme pain, light-headedness, or difficulty breathing after the procedure.

Advise to keep the incision site covered and dry for 48 hours.

PATHOPHYSIOLOGY

MEDICAL MANAGEMENT

POST-OP DRUGS

Generic andBrand name

General Description

Indication (s) /Purpose (s)

Nursing Responsibilities

Client’s Response to treatment

GN: Metronidazole BN: Flagyl Initially, 15 mg/kg I.V., followed by 7.5 mg/kg I.V. q 6 hours, not to exceed 4 g/day for 7 to 10 days

Disturbs DNA synthesis in susceptible bacterial organisms.It is converted to reduction products that interact with DNA to cause destruction of helical DNA structure and strand leading to a protein synthesis inhibition and cell death in susceptible organisms.

It is prescribed in the treatment of a variety of infections such as bacterial infections.

>Compute the ordereddosage of the drug twice. > Monitor I.V. site. Avoid prolonged use of indwelling catheter.

> Evaluate hematologic studies, especially in patients with history of blood dyscrasias. >Advise patient to report fever, sore throat, bleeding, or bruising. >Inform patient that prolonged use may result in fungal or bacterial superinfection. > document and sign for the time of administration.

The patient responded well with no signs of infection.


General Description




GN: Celecoxib BN: Celebrex 200 mg b.i.d.

Exhibits anti-inflammatory, analgesic, and antipyretic action due to inhibition of COX-2 enzyme

It is prescribed for the treatment of acute pain.

>Advise patient to immediately report bloody stools, vomiting of blood, or signs or symptoms of liver damage (nausea, fatigue, lethargy, pruritus, yellowing of eyes or skin, tenderness in upper right abdomen, or flulike symptoms).

>Instruct patient to take drug with food or milk.

>Tell patient to avoid aspirin and other NSAIDs (such as ibuprofen and naproxen) during therapy. > document and sign for the time of administration.

The patient’s pain scale decreased from 6 to 3.


General Description Indication (s) /Purpose (s)



GN: Morphine sulfateBN: Roxanol 2 to 10 mg/70 kg I.V. p.r.n. given slowly over 4 to 5 minutes.

Interacts with opioid receptor sites, primarily in limbic system, thalamus, and spinal cord. This interaction alters neurotransmitter release, altering perception of and tolerance for pain.

Indicated for severe to moderate pain.

>Compute the ordereddosage of the drug twice. > Monitor I.V. site. Avoid prolonged use of indwelling catheter.

> For best response, give at pain onset. >Tell patient and caregiver that drug may cause respiratory depression. Instruct them to immediately report respiratory rate of 10 breaths/minute or less.

> Inform patient that drug may cause constipation or urinary retention. Encourage high-fiber diet and high fluid intake.>Stress importance of taking drug only as prescribed. Point out that drug may cause psychological or physical dependence.

>Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, vision, and alertness.

>Teach patient and caregiver about appropriate safety measures to prevent injury.

> Caution patient to avoid alcohol and other CNS depressants during and for 24 hours after therapy.

> Advise patient to avoid herbs, which may worsen adverse CNS effects.

> As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above. > document and sign for the time of administration.

The patient’s pain scale decreased from 6 to 3.


General DescriptionIndication (s) /Purpose (s)



GN: Promethazine Hcl BN: Phenergan 25 to 50 mg I.V. at bedtime

Blocks effects but not release of histamine and exerts strong alpha-adrenergic effect. Also inhibits chemoreceptor trigger zone in medulla and alters dopamine effects by indirectly reducing reticular stimulation in CNS.

Used as an adjunct to postoperative analgesia and provide sedation.

>Compute the ordereddosage of the drug twice. >Monitor I.V. site. Avoid prolonged use of indwelling catheter. >Monitor neurologic status. Stay alert for signs and symptoms of neuroleptic malignant syndrome (high fever, sweating, unstable blood pressure, stupor, muscle rigidity, and autonomic dysfunction).

> In long-term therapy, assess for other adverse CNS effects, including extrapyramidal reactions.

>Monitor CBC and liver function tests. >Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, vision, alertness, and motor skills.

>As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.

> document and sign for the time of administration.



General Description




GN: Ampicillin sodium and Sulbactam sodium BN: Unasyn 1.5 to 3 g I.V. q 6 hours

Destroys bacteria by inhibiting bacterial cell-wall synthesis during microbial multiplication. Addition of sulbactam enhances drug's resistance to beta-lactamase, an enzyme that can inactivate ampicillin.

To treat intra-abdominal, and skin-structure infections caused by susceptible beta-lactamase-producing strains.

>Compute the ordereddosage of the drug twice. > Monitor I.V. site. Avoid prolonged use of indwelling catheter. >Instruct patient to immediately report signs and symptoms of hypersensitivity reaction, such as rash, fever, or chills.

>Tell patient to report signs and symptoms of infection or other problems at injection site.

>Inform patient that drug lowers resistance to certain infections. Instruct him to report new signs or symptoms of infection, especially in mouth or rectum. >Tell patient to promptly report unusual bleeding or bruising.

>Instruct patient to avoid activities that can cause injury. Advise him to use soft toothbrush and electric razor to avoid gum and skin injury.

>Inform patient that he may need to undergo regular blood testing during therapy.

>As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above. > document and sign for the time of administration.


VI. CLIENT’S DAILY PROGRESS

NURSING CARE PLAN

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Intestinal Obstruction a case study

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