acute pancreatitis resolved cholecystolithiasis
TRANSCRIPT
Angeles University FoundationAngeles City
Case StudyACUTE PANCREATITIS secondary to
Cholecystolithiasis
Submitted By:Amansec, Ma. Carmina A.
Bautista, ChristopherBontogon, James Russel
Submitted To:Mrs. Abigail A. Buan. R.N.
Date of submission:September 18, 2007
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I. INTRODUCTION
In our generation today, fast foods are ubiquitous, junk foods, high caloric foods and salty foods are the favorites of the majority especially the young generation. People often neglect the possible complication that can possibly occur with their routine of eating.
The current complication that often arises today are: diabetes mellitus, hypertension, and cardiovascular diseases . . . . One of which is pancreatitis or the inflammation of the pancreas.
Before our duty in every rotation ends, we are obliged to present a case study with regards to the patient that we have handled. And fortunately we had this case regarding Acute Pancreatitis resolved Cholecystolithiasis. Our main objective in conducting this case study is to come across about the causes and other factors that caused the patient to have this acute pancreatitis. By merely establishing rapport to gain the patient’s trust and together with the significant others we were able to gather data and information that will be of help for our case study. The first thing we did is the student nurse- patient interaction and as well as interacting with the significant others, then reviewing the patient’s chart.
A. Current trends about the disease condition.
Statistical data:
Country/Region Extrapolated Incidence
Population Estimated Used
Acute Pancreatitis in North America (Extrapolated Statistics)
USA 86,369 293,655,4051
Canada 9,561 32,507,8742
Mexico 30,870 104,959,5942
Acute Pancreatitis in Caribbean (Extrapolated Statistics)
Puerto Rico 1,146 3,897,9602
Acute Pancreatitis in South America (Extrapolated Statistics)
Brazil 54,147 184,101,1092
Colombia 12,444 42,310,7752
Venezuela 7,358 25,017,3872
Acute Pancreatitis in Northern Europe (Extrapolated Statistics)
Denmark 1,592 5,413,3922
Finland 1,533 WARNING! (Details)
5,214,5122
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Sweden 2,643 8,986,4002
Acute Pancreatitis in Western Europe (Extrapolated Statistics)
Britain (United Kingdom) 17,726 60,270,708 for UK2
Belgium 3,043 10,348,2762
France 17,771 60,424,2132
Ireland 1,167 3,969,5582
Netherlands (Holland) 4,799 16,318,1992
United Kingdom 17,726 60,270,7082
Wales 858 2,918,0002
Acute Pancreatitis in Central Europe (Extrapolated Statistics)
Austria 2,404 8,174,7622
Germany 24,242 82,424,6092
Poland 11,360 38,626,3492
Switzerland 2,191 7,450,8672
Acute Pancreatitis in Eastern Europe (Extrapolated Statistics)
Russia 42,345 143,974,0592
Acute Pancreatitis in the Southwestern Europe (Extrapolated Statistics)
Portugal 3,095 10,524,1452
Spain 11,847 40,280,7802
Acute Pancreatitis in the Southern Europe (Extrapolated Statistics)
China 382,014 1,298,847,6242
Hong Kong. 2,016 6,855,1252
Japan 37,450 127,333,0022
Taiwan 6,691 22,749,8382
Acute Pancreatitis in Southeastern Asia (Extrapolated Statistics)
Malaysia 6,918 23,522,4822
Philippines 25,365 86,241,6972
Singapore 1,280 4,353,8932
Thailand 19,078 64,865,5232
Vietnam 24,312 82,662,8002
Acute Pancreatitis in Oceania (Extrapolated Statistics)
Australia 5,856 19,913,1442
New Zealand 1,174 3,993,8172
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*These statistics are calculated extrapolations of various prevalence or incidence rates against the populations of a particular country or region. The statistics used for prevalence/incidence of Acute Pancreatitis are typically based on US, UK, Canadian or Australian prevalence or incidence statistics, which are then extrapolated using only the population of the other country. This extrapolation calculation is automated and does not take into account any genetic, cultural, environmental, social, and racial or other differences across the various countries and regions for which the extrapolated Acute Pancreatitis statistics below refer to.
*The extrapolation does not use data sources or statistics about any country other than its population. As such, these extrapolations may be highly inaccurate (especially for developing or third-world countries) and only give a general indication (or even a meaningless indication) as to the actual prevalence or incidence of Acute Pancreatitis in that region. These statistics are presented only in the hope that they may be interesting to some people.
Coffee Can Reduce Risk Of Pancreatitis, Scientists Discover
Article Date: 16 Mar 2006 - 10:00 PDT
Scientists at the University of Liverpool have found how coffee can reduce the risk of alcohol-induced pancreatitis.
Pancreatitis is a condition in which the pancreas becomes inflamed, causing severe abdominal pain. It is often triggered by alcohol consumption which causes digestive enzymes to digest part of the pancreas.
Scientists have known for some time that coffee can reduce the risk of alcoholic pancreatitis, but have been unable to determine how. Researchers at the University have now discovered that caffeine can partially close special channels within cells, reducing to some extent the damaging effects of alcohol products on the pancreas.
Professor Ole Petersen and Professor Robert Sutton, from the University's Physiological Laboratory and Division of Surgery, have found that cells in the pancreas can be damaged by products of alcohol and fat formed in the pancreas when oxygen levels in the organ are low. Under these conditions, excessive amounts of calcium are released from stores within the cells of the pancreas. Special organelles, called mitochondria, also become damaged and cannot produce the energiser that normally allows calcium to be pumped out of the cells. The excess calcium then activates protein breakdown, destroying the cells in the pancreas.
Professor Petersen explains: "The primary cause of the build up in calcium ion concentration is movement of calcium ions from a store inside the cells into the cell water through special channels in the store membrane. We have found that caffeine, present in
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drinks such as coffee can at least partially close these channels. This explains why coffee consumption can reduce the risk of alcoholic pancreatitis. The caffeine effect, however, is weak and excessive coffee intake has its own dangers, so we have to search for better agents.
"At the moment there is no specific pharmacological treatment for pancreatitis. As a result of this research however, we can, for the first time, begin to search for specific chemical agents that target the channels causing the excessive liberation of calcium ions inside the cells, which is where the problem originates. We are also hoping that these findings can be used to warn against the dangers of binge drinking. Some of the effects of the non-oxidative alcohol products on isolated pancreatic cells cannot be reversed, explaining why excess alcohol intake can be so dangerous."
B. Reasons for choosing such case for presentation.
To find out and apprehend the significance of concerning the family, society and government in achieving the wellness of the patient is one of the reasons in choosing this case. Essentially, it is about the outcome of proper nursing care and the provision of giving consistent information or knowledge concerning the disease. Enriching and elevating the quality of nursing as a call, career, vocation or a profession is one of the major errands and the foundation of nursing profession
The reason and enthusiasm of the group in choosing the case for presentation is to hold close with the information and management of the condition for the group to give their full and quality service as student- nurse to their patients.
For the group the only way to carry out the different nursing interventions is obtaining full range of knowledge and the only way to meet it is personal interest by curiosity.
As well as to have an experience and be familiar in handling, managing and providing compassionate health services to a patient who has it and provide any intervention or management indicated based on the specific etiology.
C. Objectives
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C.1. (Nurse- centered)
o Formulate nursing care plans based on the prioritized health needs of the patient.
o Assist patient and family to participate in patient’s care as circumstances allow.
o Determine the personal and pertinent family history of the patient and relate it to
the present state.
o Gain proper knowledge and understanding about the existing disease condition,
its pathophysiology, sociology, etiology and risk factors involve in its acquisition
and progression.
o Analyze the different laboratory and diagnostic procedure, its indication and their
essential relationship to the disease condition.
C.2. (Patient- centered)
o Describe the disease process, diagnostic procedures, treatment regimen and
nursing care based on her level of understanding.
o Cooperate in the necessary medical and nursing interventions
II. NURSING ASSESSMENT
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Personal History
Ms. Snowhite 23 years old is the 4th eldest child of Mr. and Mrs. Usher who loves to ate junk foods 10 times a day and to drink 8 oz of soft drink 3 times a day. She lives at Juliana, CSFP. She is a Filipina and a roman catholic. She was born on January 05, 1984 at Riverside Ormoc city, Leyte. Ms. Snowhite is a High school Graduate of central school at Leyte. She and her family is not allowed to sweep, wash clothes and to take a bath when someone from the family died. Also believes that when a person bite his or her tongue means that someone remembers you and lizards are bad luck,
Has an unhealthy body that’s why she can’t play in her friends. She only gets inside of her house watching TV and after that sleeping. At the age of 8 years old, she started to experience body malaise. She had to use pain reliever like Alaxan. She said that using alaxan is the best way to have enough energy. But up until she reached the age of 20 body weakness has not already been stopped until the other manifestation occur which is abdominal pain. Mrs. Beyonce taught that this is only normal. Maybe because she is supplying her body enough fluid.
Ms. Snowhite easily gets tired that was she can’t engage in recreation together with her friends. She only gets inside their house watching T.V and after that just takes e rest then afterwards, sleeps. At the age of 8 years old, she started to experience body malaise. She had use analgesics like alaxan for his. But up until she reached the age of 20, body weakness hasn’t stopped until other manifestation occurs which is abdominal pain. Ms. Snowhite thought that is only normal to experience abdominal pain one in a while.
Upon assessing her together with the Significant others, we also jotted down notes especially those potential factors that could contribute to her disease. Starting at their house, originally, they have house in Leyte, but due to unreasonable decision, they migrated here at pampanga last 2000. Where they resided at Juliana, CSFP near their relatives and occupied an apartment which has an area of 300 meter square, and estimating the area, dividing 300 meter square into 9 persons which will result into 33 square meter each. And it is adequate to their family. Their apartment is concrete and consists of 3 windows, which more than 20% of adequate ventilation. And they do not have any problem regarding to their electrical and water bills. As mentioned a while ago, they have some relatives who has been very supportive to their family in terms of financial crisis.
While their source of lighting is coming from a fluorescent bulb. Their source of water is coming from NAWASA and they store it on a pitcher. They don’t usually prepare foods, but they buy cooked foods from outside and they store their food on a plate with cover. They don’t tend to consult to the near health clinic if illness occurs. But they only consult to a hospital when illness persist.
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Past Illness
Mrs. Snowhite had a fever and headache when she was two years old. Mrs. Usher, her mother, sends her to the health center near their residence. And unfortunately when they reached the center, the midwife was not around so what they did is self-medicate. Mr. Usher give her daughter Biogesic for this, If they do not have enough money to avail medicines during times of sickness they usually take paracetamol such as Biogesic. They resort in using “herbal medicine”, like Yerba Buena for headache and they usually make use of the decoction in preparing for this. At the age of eight, she experienced having measles that lasted for a week. According to Mr. Usher (Mrs. Snowhite’s father), their physician prescribed antibiotic for her measles, but they can’t recall what specific name of antibiotics was given.
When she was ten years old, she had mumps, which lasted for a month; they applied TINA on the mumps. When she was in her 2nd year high school, she acquired Chicken fox that lasted for two weeks. According to Mrs. Usher took egg and salt as a form of healing for the chicken pox. Mr. Usher, reported that Mrs. Snowhite’s uterus was diagnosed with benign myoma through checkup at Makabali. She said that she can’t recall. It was treated through taking of the medicines that was prescribed by her physician but she can’t remember the name of the drugs anymore.
Present Illness
At the age of twenty-three, Ms. Snowhite was diagnosed of acute pancreatitis due to the gall bladder stone formation. She is experiencing abdominal pain a month prior to the admission. According to her she just sleeps when she had abdominal pain. She said that she can still tolerate the pain at this time. Three weeks prior to the admission, Ms. Snow white experience remittent abdominal pain, which also diminishes upon sleeping? She feels the same way two weeks prior to admission. Then three days before the admission she had severe abdominal pain, that was not tolerable by sleeping. She was not able to stand and was cramping with pain, according to her she screams when this pain happened. The pain she experience was usually at the epigastric region. That is why her brother Shriek, decided to send her to the hospital. Their first choice of hospital was at Makabali but because there is no available bed she was not admitted their, making them to transfer her to Jose B. Lingad.
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FAMILY HEALTH-ILLNESS HISTORY
Mother Father
Died @ old age age
Died @ old age
Died @ old age
Died @ old age
Sis 1 Sis 2Bro 1
Bro 2
SnowhiteAcute Pancreatitis, mumps and benign uterine myoma
Bro 3
Mother Father “Hypertension
”
A1 A2 A3 A4 A5 A6
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Family Health-illness History:
Ms. Snowhite’s family has a few history of pertinent illness. Her grandparents on both maternal and paternal side have died due to old age. It means that they don’t die on such illnesses that commonly geriatric would have experienced such as renal impairment or heart attack. While Mr. Usher (Ms. Snowhite father), has no siblings meaning to say that he is the only child of his parents. But Mr. Usher is noted to be hypertensive.
On the other hand, Mrs. Usher (Ms. Snowhite mother) is the third sibling on their family. And she is the only girl among seven children of her parents. But all of them has have not experienced any serious health-illness. They were all healthy and normal.
When Mr. and Mrs. Usher got marriage, they were blessed with 6 children. Which are 3 girls and 3 boys in ratio. All of their children are well and in good health except for Ms. Snowhite which suffering from acute pancreatitits. Aside from her present disease, she had a past illness such as childhood illness like mumps. And she has been diagnosed of benign uterine myomas. Until, she has been diagnosed of Acute Pancreatititis secondary to cholecystolithiasis.
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A. Physical Examination
General Appearance
The patient has a proportionate body built, characterized by a normal body figure. The patient has synchronized body movements though an attack of abdominal pain causes her to twitch at times. She is cooperative and exhibits thought association. She responds appropriately to every question asked to her at moderate pace and as long as she can tolerate the pain.
Physical Assessment (August 23, 2007)
T- 36.8*C R- 20bpm
P- 80bpm B/P- 110/80mmHg
August 23,2007
Physical AssessmentThe Integument
Skin[] Has no odor[] Has a uniform brown to whitish complexion[] Ha a good skin turgor[] skin is warm to touch within normal limits[] Presence of scar in the left lower leg[] absence of edema
Hair[] Evenly distributed black hair Extends until below the shoulder[] Thick and silky[] Absence of Pediculosis
Nails[] Long and dirty finger nails and toe nails.[] Light brown to pink in color [] Convex curve[] Good capillary refill (less than 4 seconds)
The Head Skull
[] Rounded, normocephalic, and symmetrical[] Smooth and uniform in consistency[] Absence of nodules or masses
Face[] Symmetrical facial movements (can smile frown, close eyes, raise eyebrows, wrinkle, forehead, show teeth, purse lip, and puff cheeks)
Scalp[] presence of dandruff[] Absence of Pediculosis
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The eyes and visionEyebrow
[] Hair evenly distributed with the skin intact[] Symmetrically aligned equal movement
Eyelashes[] Equally distributed[] Curled slightly outward
Eyelids[] Skin intact[] Absence of discharges and discoloration [] Closes symmetrically[] 10-15 blink/min
Bulbar Conjunctiva[] Transparent[] Capillaries are evident[] whitish sclera[] Palpebral Conjunctiva[] Shiny and smooth
Lacrimal gland, Lacrimal sac,And Nasolacrimal duct[] Absence of tenderness[] Absence of tearing when palpated[] Cornea[] Transparent, smooth and shiny details of iris visible
Pupils[] Equally round and reactive to light accommodation
Visual[] patient can see objects in the periphery even when looking straight ahead[] able to read printed words at a distance of 14 inches
Extra ocular Muscles[] coordinated movements of both eyes
The Ear and Hearing Auricles
[] same as facial skin[] symmetrical[] aligned with the outer canthus of the eye[] firm and not tender[] pinna recoils after it is folded
External Ear Canal[] presence of dry to wet cerumen [] normal voice tone audible [] able to hear watch thick on both ears
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[] able to speak out whispered words
The Nasal CavityNose
[] symmetrical and straight[] absence of discharges or flaring [] air moves freely as patient breaths through the nares The Mouth and Oropharynx Lips and Buccal Mucosa[] Pinkish in color but lips[] able to purse lip
Inner lip and front teeth[] complete number of teeth[] smooth and white[] shiny tooth enamel[] pinkish moist gums[] firm texture
Buccal Mucosa and Back teeth[] no retraction of gums[] absence of plaque and tartar[] tongue located in the midline[] not able to protrude tongue fully
Hard/Soft Palates[] pink, smooth palate [] no discharges or flaring
Uvula[] located midline of soft palate Oropharynx and tonsils[] no discharges[] slightly pink and smooth[] Gag reflex
The Neck and Lymph nodesNeck
[] Muscles equal in size and strength[] head centered[] can freely move the head
Lymph Nodes[] not palpable
The Thorax and Lungs[] full and symmetric chest expansion[] spine vertically aligned[] spinal column straight[] left and right shoulders are of the same height
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[] absence of abnormal breath sounds\
The Heart[] symmetric pulse volumes[] full pulsations thrusting quality[] cardiac beating remains the same when the patients breaths
The Peripheral Pulses[] symmetric pulse volumes [] full pulsations[] limbs not tender[] skin in the peripheries is uniformly pink in color[] temperature not excessively warm and cold[] no edema
The Breast and Axillae[] round; generally symmetric[] unequal[] no discharges[] both nipples are not inverted and is present[] no tenderness, masses, or nodules
The Abdomens[] normal bowel sound[] no presence of binder
The Bones and Joints[] no swelling or tenderness[] no signs of crepitation[] absence of nodules[] joints move smoothly
The Extremeties[] symmetrical in shape, firm, smooth[] with coordinated muscle movement[] No tenderness or swelling [] No deformities noted
Cranial Nerve Assessment
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Cranial Nerve AssessmentTechnique
Expected Outcome
Responses
Cn1: Olfactory {sensory}
Ask client to identify different aromas with each nostrilSeparately with eyes close.
The client will be able to identify to different aromas unless such conditions like cold is present.
Patient was able to identify different aroma like cologne, alcohol,
Cn2: Optic {sensory}
Ask the client to read words on a piece of paper with each eye first then both eyes.
The client will be able to read the words.
Patient was able to read the words written on a paper “olfactory”
Cn3: Oculomotor {motor}
Ask client to look straight ahead then approach the pupil with a penlight and observe for pupil constriction
Pupil will constrict upon introduction of light.
Pupils are equally round and reacted to light accommodation
Cn4: Trochlear {motor}
Ask client to hold the head still and follow the penlight as it moves in the six cardinal eye movements.
The client will be able to follow the movement of the penlight.
Has good coordination of eye movement and able to follow the movement of the penlight
Cn5: Trigeminal {motor}
Ask the client to make chewing movements, open the mouth against resistance, move jaw from side to side and open mouth widely.
The client will be able to make chewing movements, open the mouth against resistance move jaw from side to side and open mouth widely.
The client was able to elicit chewing movements, open the mouth against resistance move jaw from side to side and open mouth widely.
Cn6: Abducens {motor}
Have the client to hold his head steady and follow the penlight direction
The client will be able to follow the movement of penlight
The client has a good coordination of eye movements, and able to follow the movement of the penlight.
Cn7: Facial{sensory and motor}
Ask the client to smile, frown, raise eyebrow, puff the cheeks and show teeth.
The client will be able to smile, frown, raise eyebrow, puff the cheeks and show
The client was able to smile, frown, raise eyebrow, puff the cheeks and show teeth.
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teeth.Cn8:Vestibulocochlear/Acoustic {sensory}
Have the client to repeat the whispered few words at the clients back.
The client will able be to hear and repeat the words whispered to him.
the client was able to hear and repeat the words whispered to him/her.
Cn9:Glossopharyngeal{sensory and motor}
Ask the client to swallow the open mouth widely and say “AH”
Client elicits gag reflex
The client was able to elicits gag reflex.
Cn10: Vagus {motor}
Ask the client to cough and say it name
The client will be able state name without hoarseness of voice.
The client cannot cough effectively
Cn11: Accessory {motor}
Ask the client to elevate shoulders against the resistance and turn head from side to side.
The client will be able to elevate the shoulders against the resistance and turn the head from side to side.
The client was able to elevate the shoulders against the resistance and turn the head from side to side.
Cn12: Hypoglossal {motor}
Ask the client to protrude the tongue
The client will be able to protrude this tongue
The client was able to protrude his/her tongue.
B. August 31,2007
Physical Assessment (August 3123, 2007)
T- 36.4*C RR- 23bpm
PR- 78bpm B/P- 120/80mmHg
Skin[] Has no odor[] Has a uniform brown to whitish complexion[] Ha a good skin turgor[] skin is warm to touch within normal limits[] Presence of scar in the left lower leg[] absence of edema
Hair[] Evenly distributed black hair Extends until below the shoulder[] Thick and silky[] Absence of Pediculosis
Nails[] Long and dirty finger nails and toe nails.[] Light brown to pink in color [] Convex curve
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[] Good capillary refill (less than 4 seconds)The Head Skull
[] Rounded, normocephalic, and symmetrical[] Smooth and uniform in consistency[] Absence of nodules or masses
Face[] Symmetrical facial movements (can smile frown, close eyes, raise eyebrows, wrinkle, forehead, show teeth, purse lip, and puff cheeks)
Scalp[] presence of dandruff[] Absence of Pediculosis
The eyes and visionEyebrow
[] Hair evenly distributed with the skin intact[] Symmetrically aligned equal movement
Eyelashes[] Equally distributed[] Curled slightly outward
Eyelids[] Skin intact[] Absence of discharges and discoloration [] Closes symmetrically[] 10-15 blink/min
Bulbar Conjunctiva[] Transparent[] Capillaries are evident[] whitish sclera[] Palpebral Conjunctiva[] Shiny and smooth
Lacrimal gland, Lacrimal sac,And Nasolacrimal duct[] Absence of tenderness[] Absence of tearing when palpated[] Cornea[] Transparent, smooth and shiny details of iris visible
Pupils[] Equally round and reactive to light accommodation
Visual[] patient can see objects in the periphery even when looking straight ahead[] able to read printed words at a distance of 14 inches
Extra ocular Muscles[] coordinated movements of both eyes
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The Ear and Hearing Auricles
[] same as facial skin[] symmetrical[] aligned with the outer canthus of the eye[] firm and not tender[] pinna recoils after it is folded
External Ear Canal[] presence of dry to wet cerumen [] normal voice tone audible [] able to hear watch thick on both ears[] able to speak out whispered words
The Nasal CavityNose
[] symmetrical and straight[] absence of discharges or flaring [] air moves freely as patient breaths through the nares The Mouth and Oropharynx Lips and Buccal Mucosa[] Pinkish in color but lips[] able to purse lip
Inner lip and front teeth[] complete number of teeth[] smooth and white[] shiny tooth enamel[] pinkish moist gums[] firm texture
Buccal Mucosa and Back teeth[] no retraction of gums[] absence of plaque and tartar[] tongue located in the midline[] not able to protrude tongue fully
Hard/Soft Palates[] pink, smooth palate [] no discharges or flaring
Uvula[] located midline of soft palate Oropharynx and tonsils[] no discharges[] slightly pink and smooth[] Gag reflex
The Neck and Lymph nodes
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Neck[] Muscles equal in size and strength[] head centered[] can freely move the head
Lymph Nodes[] not palpable
The Thorax and Lungs[] full and symmetric chest expansion[] spine vertically aligned[] spinal column straight[] left and right shoulders are of the same height[] absence of abnormal breath sounds\
The Heart[] symmetric pulse volumes[] full pulsations thrusting quality[] cardiac beating remains the same when the patients breaths
The Peripheral Pulses[] symmetric pulse volumes [] full pulsations[] limbs not tender[] skin in the peripheries is uniformly pink in color[] temperature not excessively warm and cold[] no edema
The Breast and Axillae[] round; generally symmetric[] unequal[] no discharges[] both nipples are not inverted and is present[] no tenderness, masses, or nodules
The Abdomens[] normal bowel sound[] no presence of binder
The Bones and Joints[] no swelling or tenderness[] no signs of crepitation[] absence of nodules[] joints move smoothly
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The Extremities[] symmetrical in shape, firm, smooth[] with coordinated muscle movement[] No tenderness or swelling [] No deformities noted
Cranial Nerve Assessment
Cranial Nerve AssessmentTechnique
Expected Outcome
Responses
Cn1: Olfactory {sensory}
Ask client to identify different aromas with each nostrilSeparately with eyes close.
The client will be able to identify to different aromas unless such conditions like cold is present.
Patient was able to identify different aroma like cologne, alcohol,
Cn2: Optic {sensory}
Ask the client to read words on a piece of paper with each eye first then both eyes.
The client will be able to read the words.
Patient was able to read the words written on a paper “olfactory”
Cn3: Oculomotor {motor}
Ask client to look straight ahead then approach the pupil with a penlight and observe for pupil constriction
Pupil will constrict upon introduction of light.
Pupils are equally round and reacted to light accommodation
Cn4: Trochlear {motor}
Ask client to hold the head still and follow the penlight as it moves in the six cardinal eye movements.
The client will be able to follow the movement of the penlight.
Has good coordination of eye movement and able to follow the movement of the penlight
Cn5: Trigeminal {motor}
Ask the client to make chewing movements, open the mouth against resistance, move jaw from side to side and open mouth widely.
The client will be able to make chewing movements, open the mouth against resistance move jaw from side to side and open mouth widely.
The client was able to elicit chewing movements, open the mouth against resistance move jaw from side to side and open mouth widely.
Cn6: Abducens {motor}
Have the client to hold his head steady and follow the penlight
The client will be able to follow the movement of penlight
The client has a good coordination of eye movements, and able to follow
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direction the movement of the penlight.
Cn7: Facial{sensory and motor}
Ask the client to smile, frown, raise eyebrow, puff the cheeks and show teeth.
The client will be able to smile, frown, raise eyebrow, puff the cheeks and show teeth.
The client was able to smile, frown, raise eyebrow, puff the cheeks and show teeth.
Cn8:Vestibulocochlear/Acoustic {sensory}
Have the client to repeat the whispered few words at the clients back.
The client will able be to hear and repeat the words whispered to him.
the client was able to hear and repeat the words whispered to him/her.
Cn9:Glossopharyngeal{sensory and motor}
Ask the client to swallow the open mouth widely and say “AH”
Client elicits gag reflex
The client was able to elicits gag reflex.
Cn10: Vagus {motor}
Ask the client to cough and say it name
The client will be able state name without hoarseness of voice.
The client cannot cough effectively
Cn11: Accessory {motor}
Ask the client to elevate shoulders against the resistance and turn head from side to side.
The client will be able to elevate the shoulders against the resistance and turn the head from side to side.
The client was able to elevate the shoulders against the resistance and turn the head from side to side.
Cn12: Hypoglossal {motor}
Ask the client to protrude the tongue
The client will be able to protrude this tongue
The client was able to protrude his/her tongue.
F. Diagnostic and Laboratory Procedures
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Diagnostic/ Laboratory Procedures
Date ordered
Date Results
Indications or Purposes
Results Normal Values
Analysis and Interpretation
of Results
BLOOD COUNT
Hemoglobin
BLOOD COUNT
Hematocrit
WBC
DO: 08-18-07 DR:08-18-07
DO:08-21-07DR:08-21-07
DO: 08-18-07 DR:08-18-07
DO:08-21-07DR:08-21-07
DO: 08-18-07DR:08-18-07
This test, usually performed as part of a cbc, measure the grams of hemoglobin found on a deciliter (100 ml) of whole blood
- Measures the percentage by volume of packed red blood cells in a whole blood sample
- To check the volume of RBC in the blood.
-To aid diagnosis of abnormal states of hydration, polycythemia, and anemia.
- Part of the CBC is the WBC reports the number of white cells found in
127 g/L
0.38
5.9
115-155g/L
0.38 – 0.48
-There is a normal level of Hgb, which means tat there is no alterations in the blood Hgb of the patient.
-There is a normal level of Hematocrit, which means that there is a normal concentration in the contents of blood that indicates absence of abnormality.
-There is a normal level of WBC, which implies that there is no presence of infection.
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Lymphocyte
Neutrophils
DO:08-21-07DR:08-21-07
DO: 08-18-07DR:08-18-07
DO:08-21-07DR:08-21-07
DO: 08-18-07DR:08-18-07
DO:08-21-07DR:08-21-07
micro liter (cubic millimeter of whole blood cell)
- - To determine infection or inflammation.
- Are important humeral and cell mediated immunity. It compromises majority of WBC.
-Are in first line defense against infection. It is the primary cell to respond during an acute inflammatory response.
-Capable of ingesting and
0.09
0.76
5- 10 x 10 g/l
0.20- 0.35
0.45- 0.65
-This indicates that the patient has a debilitating illness or immunodeficiency.
-.
- There is an increase in the level of neutrophils due to impairment in the immune system or inflammatory response.
-There is a normal level of creatinine, which means that the kidney is functioning
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Creatinine
Alkaline Phospatase
DO:08-18-07 DR:08-18-07
DO:08-18-07 DR:08-18-07
-To evaluate renal function and disorder
- To detect and monitor liver and/or bone disease.
- The test provides, a more sensitive measure of renal damage than blood urea nitrogen levels because renal impairment is virtually the only cause of creatinine metabolism.
- The primary importance of measuring alkaline phosphatase is to check the possibility of bone disease or liver disease. Since the mucosal cells that line the bile system of the liver are the source of alkaline phosphatase, the free flow of bile
62.9
127.5
58- 100 mmol/L
64- 306 IU/L
well.
- The Alkaline Phosphatase level is within normal range, which means there is no bone or liver/kidney disease present. Pancreatic cancer raised ALP levels and increase may indicate biliary abstraction.
24
BUN (blood urea nitrogen):
SGOT
DO:08-18-07 DR:08-18-07
DO:08-18-07 DR:08-18-07
through the liver and down into the biliary tract and gallbladder are responsible for maintaining the proper level of this enzyme in the blood.
- The uric acid tests are used to evaluate the blood levels of uric acid for gout and to assess uric acid levels in the urine for kidney stone formation.
- Released into blood when the liver or heart is damaged.
- This test is used to evaluate the possibility of coronary occlusive heart disease or liver disease.
1.81
34.2
1.7- 8.3 mmol/L
10- 40 IU/L
- The blood uric acid level is normal, which indicates that there is no presence or formation of kidney stones.-Increased renal disease, dehydration, urinary tract abstraction and increase CHON catabolics.-decrease severe hepatic damage, malnutrition, over hydration
- There is a normal SGOT level, which
25
SGPT
LDH (Lactic dehydrogenase)
RBS
DO:08-18-07 DR:08-18-07
DO:08-18-07 DR:08-18-07
DO:08-18-07 DR:08-18-07
- This test is used to identify liver disease and to distinguish between the liver and red blood cell hemolysis as the source of jaundice.
- Measured to check for tissue damage
- This test measures the intracellular enzyme LDH which, when present in the blood, can support the detection of injury or disease.
- To test the sugar level- Good indicative of diabetes
31.5
406.5
4.73
0-39 IU/L
225- 450 IU/L
3.83- 9.0 mmol/L
means that there is no presence of any heart damage or any possibility that can lead to coronary occlusive heart disease or liver disease.
- There is a normal SGPT level, which means that the liver is functioning in its optimum level.
- There is a normal level of LDH, which means that an injury or disease can be easily detected.
26
- There is a normal level of RBS, which means that the sugar levels are within normal limits and not prone in acquiring diabetes.
Nursing Responsibilities:Prior:
Explain the procedure to the patient’s SO. Inform the SO that there are no food or fluid restrictions. Inform the SO that the test requires blood sample, tell who will do the test and
when. Tell that there will be discomfort from the needle that will be inserted and
pressure from the tourniquet.
During: Wipe with cotton balls and alcohol the site where insertion is done. Tell the client’s SO when the needle will be inserted for them to get prepared. Try to get a sample once.
After: Apply pressure on the puncture site. Send the specimen immediately to the laboratory
27
Urinalysis
-Routine U/A is an important, commonly used screening test for urinary and systematic pathologies
DO: 08-23-07 Routine urinalysis serves many functions. It can be used to screen patients for kidney and urinary tract disease and can help detect metabolic or systemic disease. Results of urine test are based on the elements that make up urine. Even with normal findings, these elements have certain characteristics.
Color: dark brown to red
Transparency: turbid
Sugar: negative
Albumin: +3
PH: neutral
Specific gravity: 1.030
Pus cell: 6-8/HPF
Color: dark yellow
Transparency: turbid
Sugar: negative
Albumin: negative
PH: acidic
Specific gravity: 1.005-1.035
Pus cell:1.2/ HPF
-Indicates that the patient lacks water and has a concentrated urine due to the protein in the glomerulus’s / maybe due to the patients diet, drug and disease.
-normal
-normal
-due to the protein in the glomerulus’s normal increase value indicates infection.
-normal
-Genitourinary tract infection.
Nursing Responsibilities:Prior:
Explain the procedure to the patient's significant others that these test assess response to treatment.
Tell the patient's significant others that specimen will be taken.
During: Plan to obtain the specimen when the patient is calm and physically still. Instruct the SO to collect urine specimen. Collect urine by clean catching.
After:
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If there is a necessary urine collection, instruct SO to collect the urine in every urisnation and put it in the bedside.
Ultrasound Report:
The liver is not enlarged. Parenchyma is homogenous in echopattern and normal in echogenecity. Intrahepatic ducts are not dilated. No definite focal hepatic mass seen,
The gallbladder measures 63 x 16 mms. The coomon ducts is 4mms in luminal diameter. Multiple calcific foci, 3- 9mm size are seen in the gallbladder body and neck. Gallbladder wall is not thickened.
Impression:Sonographically right liver cholecystolithiasis.Please correlate and follow- up.
III. ANATOMY AND PHYSIOLOGY
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Where is the pancreas located?
The pancreas is located deep in the abdomen, sandwiched between the stomach and the spine. It lies partially behind the stomach. The other part is nestled in the curve of the duodenum (small intestine). To visualize the position of the pancreas, try this: Touch the thumb and "pinkie" finger of your right hand together, keeping the other three fingers together and straight. Then, place your hand in the center of your belly just below your lower ribs with your fingers pointing to the left. Your hand will be at the approximate level of your pancreas.
Because of the pancreas' deep location, tumors are rarely palpable (able to be felt by pressing on the abdomen.) It also explains why many symptoms of pancreatic cancer often do not appear until the tumor grows large enough to interfere with the function of nearby structures such as the stomach, duodenum, liver, or gallbladder.
Fig. 1-1
Parts of Pancreas
The pancreas is made up of glandular tissue and a system of ducts. The main duct is the pancreatic duct, which runs the length of the pancreas. It drains the pancreatic fluid from the gland and carries it to the duodenum. The main duct is about one-sixteenth of an inch in diameter and has many small side branches. The pancreatic duct merges with the bile duct to form the ampulla of Vater (a widening of the duct just before it enters the duodenum.)
30
Fig. 1-2
Your doctor will probably refer to different parts of the pancreas when discussing your situation. The part of the pancreas that a tumor arises in will effect how it is treated. For descriptive purposes, there are two ways the pancreas is divided into parts: by parts of the overall shape and by the function of its cells.
Pancreas is the part of the gland that bends backwards and underneath the body of the pancreas. There are two very important blood vessels, the superior mesenteric artery and vein cross in front of the uncinate process.
Head is the widest part of the gland. It is found in the right part of abdomen, nestled in the curve of the duodenum, which forms an impression in the side of the gland. Neck is the thin section between the head and the body of the gland. Body is the middle part of gland between the neck and the tail. The superior mesenteric blood vessels run behind this part of the gland. Tail is the thin tip of gland in the left part of abdomen in close proximity with the spleen.
Function of the Pancreas
The pancreas can also be thought of as having different functional components, the endocrine and exocrine parts. Tumors can arise in either part. However, the vast majority arises in the exocrine (also called non-endocrine) part. Since the parts have different normal functions, when tumors interfere with these functions, different kinds of symptoms will occur.
Fig. 1-3
Islets of Langerhans.
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These are the endocrine (endo= within) cells of the pancreas that produce and secrete hormones into the bloodstream. The pancreatic hormones, insulin and glucagon work together to maintain the proper level of sugar in the blood, the sugar glucose is used by the body for energy.
Acinar cells. These are the exocrine (exo= outward) cells of the pancreas that produce and
transport chemicals that will exit the body through the digestive system. The chemicals that the exocrine cells produce are called enzymes. They are secreted in the duodenum where they assist in the digestion of food.
Fig. 1-4
The pancreas is an integral part of the digestive system. The flow of the digestive system is often altered during the surgical treatment of pancreatic cancer. Therefore it is helpful to review the normal flow of food before reading about surgical treatment.Food is carried from the mouth to the stomach by the esophagus. This tube descends from the mouth and through an opening in the diaphragm. (The diaphragm is a dome shaped muscle that separates the lungs and heart from the abdomen and assists in breathing.)Immediately after passing through the diaphragm's opening, the esophagus empties into the stomach where acids that break down the food are produced. From the stomach, the food flows directly into the first part of the small intestine, called the duodenum. It is here in the duodenum that bile and pancreatic fluids enter the digestive system.
32
What is bile?
Fig. 1-5(Flow of bile indicated by green arrows.)
Bile is a greenish-yellow fluid that aids in the digestion of fats. After being produced by cells in the liver, the bile travels down through the bile ducts, which merge with the cystic duct to form the common bile duct. The cystic duct runs to the gallbladder, a small pouch nestled underneath the liver. The gallbladder stores extra bile until needed. The common bile duct actually enters the head of the pancreas and joins the pancreatic duct to form the ampulla of Vater, which then empties into the duodenum.
What is pancreatic fluid
Instead of carrying bile, the pancreatic duct carries the pancreatic fluid produced by the acinar cells (exocrine) of the pancreas. The pancreatic duct runs the length of the pancreas and joins the common bile duct in the head of the pancreas. These ducts join to form the ampulla of Vater, which then empties into the duodenum.
Fig. 1-6(Flow of pancreatic fluid indicated by dark yellow arrow.)
33
The food, bile and pancreatic fluid travels through many more feet of continuous intestine including the rest of the duodenum, jejunum and ileum, which comprise the small intestine, then through the cecum, large intestine, rectum, and anal canal.
IV. THE PATIENT’S ILLNESS
A. Synthesis of the disease1. Definition of the disease
The pancreas is located in the midline of the back of the abdomen, closely associated with the liver, stomach, and duodenum (the first part of the small intestine). The pancreas is considered a gland. A gland is an organ whose primary function is to produce chemicals that pass either into the main blood circulation (called an endocrine function), or pass into another organ (called an exocrine function). The pancreas is unusual because it has both endocrine and exocrine functions. Its endocrine function produces three hormones. Two of these hormones, insulin and glucagon, are central to the processing of sugars in the diet (carbohydrate metabolism or breakdown). The third hormone produced by the endocrine cells of the pancreas affects gastrointestinal functioning.
This hormone is called vasoactive intestinal polypeptide (VIP). The pancreas's exocrine function produces a variety of digestive enzymes (trypsin, chymotrypsin, lipase, and amylase, among others). These enzymes are passed into the duodenum through a channel called the pancreatic duct. In the duodenum, the enzymes begin the process of breaking down a variety of food components, including, proteins, fats, and starches.Acute pancreatitis occurs when the pancreas suddenly becomes inflamed but improves. Patients recover fully from the disease, and in almost 90% of cases the symptoms disappear within about a week after treatment. The pancreas returns to its normal architecture and functioning after healing from the illness. After an attack of acute pancreatitis, tissue and cells of the pancreas return to normal. With chronic pancreatitis, damage to the pancreas occurs slowly over time. Symptoms may be persistent or sporadic, but the condition does not disappear and the pancreas is permanently impaired. Pancreatic tissue is damaged, and the tissue and cells function poorly.
Patients with gallstones fall into three groups – those who have symptoms, those who do not have symptoms, and those whose condition is complicated by, for example, cholecystitis, pancreatitis, or obstructive jaundice.
Asymptomatic gallstones--Many gallstones are asymptomatic and many go undiagnosed. Increasingly, asymptomatic stones are discovered incidentally during investigations of other problems. This trend reflects the increasing use of abdominal imaging, particularly ultrasonography, in the investigation of non-specific abdominal
34
symptoms. Most gallstones that are asymptomatic remain so. Roughly 10% of patients with asymptomatic stones will develop symptoms within five years of diagnosis and roughly 20% by 20 years.30 31 The rate of symptom development is maximal in the early years after diagnosis. This then tapers off to give an annual rate of 1-2% of asymptomatic patients becoming symptomatic.32 Small bile duct stones may also be asymptomatic and may pass spontaneously, but choledocholithiasis increases the rate of symptom development and the incidence of complications such as obstructive jaundice and pancreatitis to around 20% over five years.
Comparison of Cholelithiasis and Cholecystitis:
A. Cholelithiasis Epigastric pain Heartburn Right upper abdominal pain – radiation to scapular. Jaundice – obstruction of bile ducts Intolerance to fatty foods.
B. Cholecystitis Fever Increase WBC Abdominal guarding with rebound tenderness- peritoneal
involvement. Increase Serum Bilirubin Increase Alkaline Phosphatase Increase serum amylase and lipase (pancreas involved)
2. Predisposing/ Precipitating Factors
** Predisposing Factors: Family history - Abnormalities in one or more genes may
predispose some people to pancreatitis.
Age – teenagers are more prone in having gallstones due to excessive eating of high in sodium foods like junk foods.
Sex - Pancreatitis occurs more frequently in men, possibly because men are more likely to abuse alcohol than women are.
Ethnicity - Black Americans are more likely to develop pancreatitis.
Other medical conditions - Certain inherited diseases, particularly cystic fibrosis, increase your risk of pancreatitis.
35
**Precipitating Factors: High fat diets - most especially an increase in sodium foods results
in the formation of gallstones.
Obesity – having a high fat diet increases your risk in being obese.
Sedentary lifestyle – lacks exercise and other physical activities that contribute to the increase in fat accumulation in the body.
Smoking - Some researchers theorize that the stress of metabolizing drugs, tobacco and even pollution may damage your pancreas.
Signs and Symptoms
Acute pancreatitis usually begins with a sharp, severe pain in the upper abdomen that may last for a few days. It may be constant pain that is just in the abdomen or it may reach to the back and other areas. The pain may be sudden and intense or it may begin as a mild pain that is aggravated by eating and slowly gets worse. In addition, the abdomen may be swollen and very tender. Other symptoms may include nausea, vomiting, fever and an elevated pulse.
Pancreatitis typically presents with the following signs and symptoms:
Abdominal pain – is the major symptom of pancreatitis. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas, which stimulate the nerve endings.
Ecchymosis (bruising)- in the flank or around the umbilicus may indicate severe pancreatitis.
Hypotension – typical and reflects hypovolemia and shock caused by the loss of large amounts of protein- rich fluid into the tissues and peritoneal cavity.
Abdominal distension leading to cyanosis
Jaundice- accumulation of bile due impaired excretion from the liver and to the skin.
Nausea and Vomiting-due to reflux of bile from common bile duct which will stimulate the CTZ of the labyrinth of the brain.
36
Boring epigastric pain, which is exacerbated in the supine position; it is poorly localized and radiates to the back.
3. Health Promotion and Preventive Aspects of the Disease
Most people with acute pancreatitis recover completely. But even if you experience no lingering symptoms, it's important to take steps to keep your pancreas as healthy as possible:
o Avoid excessive alcohol use – Overuse of alcohol is the leading cause of chronic pancreatitis and a contributing factor in many acute attacks. If you can't voluntarily stop drinking alcohol, get treatment for alcoholism. Abstaining from alcohol may or may not reduce your pain, but it will reduce your risk of dying of your disease.
o Stop smoking – Tobacco use increases your risk of pancreatitis, especially if you also drink alcohol.
o Limit fat in your diet - Eating a high-fat diet can raise your blood-fat levels and increase your risk of gallstones — both risk factors for pancreatitis. A healthy diet emphasizes fresh fruits and vegetables, whole grains, and lean protein, and limits fats, especially saturated fats such as butter. Limiting fat will help reduce loose and oily stools that result from a lack of pancreatic enzymes. Discuss with your doctor or a dietitian how much fat to eat each day because some fat is essential.
o Eat smaller meals - The more you eat during a meal, the greater the amount of digestive juices your pancreas must produce. Instead of large meals, eat smaller, more frequent meals.
o Drink plenty of liquids - be sure to drink enough liquids so that you don't become dehydrated. Dehydration may aggravate your pain by further irritating your pancreas.
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Pathophysiology Book-based Acute Pancreatitis 2nd to Cholecystolithiasis
Predisposing Factors: Precipitating Factors:Family history High fat diets Age ObesitySex Sedentary lifestyle, Ethnicity Long term alcohol abuse, smoking and drugsOther medical conditions
Types of stones
Pigment
Unconjugated pigments in the bile
Cholesterol (insoluble)
Decrease bile acid synthesis
Increase cholesterol synthesis in liver
Bile super saturation with cholesterol
Precipitate to form stones
Liver cancer
Infection
Hemolysis
Gallstone formed
38
Gallstone formation
Cholelithiasis Acute Pancreatitis
Pancreatic Duct obstructed
Obstructed cystic duct
Gall bladder contracts
Bile duct obstructed already
Gall bladder becomes distended
Fundus of the gallbladder
Inflammation Infection
Release of chemical mediator
Fever occurs
Becomes in contact in the abdominal wall At 9th and 10th
IC Cartilage
Common bile duct obstructed
Lodge @ the ampulla of vater
Spasm &
edema
Pancreatic juice
Reflux of bile
Activation of Trypsin and secretin
Vasodilatation
Increase vascular
permeability
Erosion
Necrosis
Hemorrhage
Irritation occurs/ edema
Over distention causes pain
Radiating in the back
Tenderness in right upper quadrant (RUQ)
During deep inspiration
39
Shorter deep shallow inspiration
Abdominal tenderness
40
Pathophysiology (Book-based):
Before cholecystitis occurs, there would be first a trigger that will cause the inflammation of the gall bladder. And these are the stones that formed and will lodges to the duct. Sooner, it will accumulate on the common bile duct where it will occlude the release of enzyme that aids in carbohydrate, protein and fat digestion. According to research, there are two types of stones where different origin has; it is either pigment stone or cholesterol stone. Let’s first differentiate these two before proceeding to the physiology of it.
The first stone that is known is called pigment stone. According to the research, there are different factors which contribute to the formation of pigment stone. It’s either due to hemolysis, liver cancer or infection. Due to these conditions, there are affectations occurs. For example, if the patient has liver cancer, all we known that liver aids in fats and bile emulsification. So, if the liver is impaired, there is no hepatocytes that will release and aid in emulsification. Thus, it’s creating unconjugated bile after which sooner or later, it will form a gall stone.
The last known cause of gall stone formation is due to supersaturated cholesterol. If there is an abnormal decrease in level of bile acid that will emulsify cholesterol. There is a tendency that fat deposition occurs, because there is already no substance that will emulsify fats thus it will only become supersaturated and will form stone.
So gall stone formed, there is an occlusion will occur either on the cystic duct or on the pancreatic duct. Again, dividing this occlusion into two will help us to understand the disease.
First, if the gall stone will lodge in the cystic duct where gall bladder passes its enzyme, it will now call it obstructed cystic duct. So, as the process goes on and on, too many factors that will contribute to the formation of the stone then lodge on the duct, and accumulate etc... In the next time that the patient will eat and digest foods. Gall bladder will contract in order to facilitate that digestion. However, there is already an obstruction that will make the gall bladder distended. In order to analyze it very well, I will compare the gall bladder to a gall bladder that when a balloon is over inflated, there is a tendency that it will burst. That’s how gall bladder it will look like if that scenario happens. Then due to over distention, inflammation occurs that will result to release of chemical mediators such as histamine and serotonin that will cause fever due to vasodilation and increase in blood vessel permeability that will attract other WBC cells to migrate from the site of infection. So, as the result of infection, fever occurs. Now, due to over distention of the gall bladder, the fundus of the gall bladder will come in contact with the abdomen that will cause pain that will radiating on the back due to over pressure that applies on the nociceptor. Also, the over distended fundus will affect the 9th and 10th Intercostals cartilage that will result to tenderness on the Right Upper Quadrant, so one of the manifestation of the disease is dyspnea.
41
Secondly, if the gall stone will lodge on the pancreatic duct (duct where common bile duct consist), there would be a tendency that it will obstruct the common bile duct or either the ampulla of vater. And Acute Pancreatitis will likely to occur. Let assume that the ampulla of vater obstructed, there will be over spasm on the area thus it will lead to edema. Due to spasm, there will be a reflux of bile and pancreatic juice.
Then assuming that the patient will attempt to eat again food, there will be the activation of trypsin and secretin that also aid in digestion. But obstruction impede the release thus it will cause autodigestion. Due to this, there will be inflammation and fever occurs. But the severe result may cause necrosis or erosion on the lining that will cause hemorrhage thus irritation occurs and abdominal pain occurs.
So, summarizing the manifestations, the common manifestation of acute pancreatitis is abdominal pain. Now, it will only depend on the person of how she/he can tolerate the pain that inflicting to it.
42
Pathophysiology (Patient-centered)Acute Pancreatitis 2nd to Cholecystolithiasis
Predisposing Factors: Precipitating Factors:Family history High fat diets Age ObesitySex Sedentary lifestyle, Ethnicity Long term alcohol abuse, smoking and drugs
Other medical conditions e.g. mumps
Cholesterol stone Eat a lot of junk foods rich in fats
Decrease Water intake and increase carbonated soft drinks
Past illness due to mumps
Decrease bile acid synthesis
Increase cholesterol
synthesis in the liver
43
Super saturation of bile occurs with cholesterol
Cholelithiasis Occurs
Obstructed cystic duct Pancreatic Duct obstructedAcute Pancreatitis
Gall bladder contracts
Bile duct obstructed already
Gall bladder becomes distended
Fundus of the gallbladder
Inflammation
Becomes in contact in the abdominal wall
At 9th and 10th IC Cartilage
Over distention causes pain
Common bile duct obstructed
Lodge @ the ampulla of
vater
Spasm & edema
Reflux of bile that triggers Nausea and
vomiting
Activation of Trypsin and secretin
44
Radiating in the back that manifested last year (2006) and reoccurs last month.
Tenderness in right upper quadrant (RUQ)
During deep inspiration
Shorter deep shallow inspirationAs evidenced by Respiratory rate ranging from 23-28 breaths per minutes.
Vasodilatation
Increase vascular
permeability
Erosion
Necrosis
Hemorrhage
Irritation occurs/ edema
Abdominal tenderness that manifested last
year (2006) and reoccurs last month.
45
Pathophysiology (Patient-centered)
Before cholecystitis occurs, there would be first a trigger that will cause the inflammation of the gall bladder. And these are the stones that formed and will lodges to the duct. Sooner, it will accumulate on the common bile duct where it will occlude the release of enzyme that aids in carbohydrate, protein and fat digestion. The patient fond of eating junks foods and drinking carbonated soft drinks that contribute to the disease. Partly, previous illness shows that the patient experienced mumps which causes by virus that may consider a probable cause of the disease.
The gall stone formation is due to supersaturated cholesterol. The patient had an abnormal decrease in level of bile acid that will emulsify cholesterol due to over consumption of carbonated drinks. There is a tendency that fat deposition occurs, because there is already no substance that will emulsify fats thus it will only become supersaturated and will form stone.
So gall stone formed, there is an occlusion will occur either on the cystic duct or on the pancreatic duct. Again, dividing this occlusion into two will help us to understand the disease.
First, the gall stone was lodged in the cystic duct where gall bladder passes its enzyme; it will now call it obstructed cystic duct. So, as the process goes on and on, too many factors that will contribute to the formation of the stone then lodge on the duct, and accumulate etc... In the next time that the patient ate and digested foods. Gall bladder will contracted in order to facilitate that digestion. However, there is already an obstruction that will make the gall bladder distended. Then due to over distention, inflammation occurs Now, due to over distention of the gall bladder, the fundus of the gall bladder will come in contact with the abdomen that will cause pain that will radiating on the back due to over pressure that applies on the nociceptor. Also, the over distended fundus will affect the 9th and 10th Intercostals cartilage that will result to tenderness on the Right Upper Quadrant, so one of the manifestation of the disease is dyspnea. This symptoms were already manifested last year but reoccurred last month.
Secondly, the gall stone was lodged on the pancreatic duct (duct where common bile duct consist), there would be a tendency that it will obstruct the common bile duct or either the ampulla of vater. And Acute Pancreatitis will likely to occur. The ampulla of vater obstructed, there will be over spasm on the area thus it will lead to edema. Due to spasm, there will be a reflux of bile and nausea and vomiting occurs.
Then assuming that the patient attempted to eat again food, there will be the activation of trypsin and secretin that also aid in digestion. But obstruction impeded the release thus it will cause autodigestion. Due to this, there will be inflammation and fever occurs. But the severe result may cause necrosis or erosion on the lining that will cause hemorrhage thus irritation occurs and abdominal pain occurs.
46
V. THE PATIENT AND HIS CARE
A. MEDICAL MANAGEMNETa. IVF’s
Medical management/treatment
Date ordered/Date
performed/Date Changed
General description Indications or purposes
Clients response to the treatment
1. D5 LRS (Lactating Ringer’s Solution)---Hypertonic
Date Ordered:
Aug 18-22, 2007
Date Performed:
Aug 18-22, 2007
Date Changed:
Aug 23, 2007
General Description: fluid and electrolyte supplement/replacement
LR solution is given to the patient
because it induces blood/fluid loss due to over distention of the tissue site on her gall bladder due to
secretion of cholecystokinin that allows contraction on the gall bladder that causes trauma or over spasm. The LR is used because the byproducts of
lactate metabolism in the liver
counteract acidosis, which is a chemical
imbalance that occurs with acute
fluid loss.
Upon administering the IVF solution, the patient did not manifest any untoward responses. Nor did not also show any progress to her hematocrit level.
However, her electrolytes level did not change. As evidenced by:
Electrolytes: Sodium: 138 normal: 136- 145 mmol/LPotassium: 3.8 normal: 3.5- 5.0 mmol/LChloride: 108 normal: 101- 111 mmol/L
It means that her ideal level of electrolytes is still sustainable to function on different body parts. It also educes the risk of edema. Thus, through regulation of urine output. It also stabilizes her Blood Pressure within normal range.
47
Noticing that her Hematocrit level is on border of low to normal level. It means that due to fluid/blood loss, the amount of solute (RBC) is higher than the solvent, which is the plasma that acts as a suspension.
Solute Solvent
Due to Fluid loss of the patient, plasma tends to go out side the blood cell that makes it hypotonic (solute is greater inside than the outside).
So it happens that the patient is at risk for Dehydration and electrolyte losses due to over-spasm of the pancreas or excretion problem
48
that led to inadequate blood volume which, in turn, may result from a combination of fluid loss from vomiting, internal bleeding, or oozing of fluid from the circulation into the abdominal cavity in response to the pancreas inflammation, a phenomena known as Third Spacing
Nursing responsibilities: Prior:
1. Prepare the necessary equipments.2. Wash hands thoroughly.3. Explain the procedure to the patient.4. Check to see if there are any special circumstances surrounding administration to the patient.5. Be certain that you know the expected action, safe dosage, range, and special instruction for administration. And adverse
effects associated with it.6. For inserting IV bottles to an IV line: Do not touch the upper head of the IV. Instead, hold the neck of it properly as you
inserting the IV line into the bottle.7. Be careful in inserting the needle if vein for insertion is detected. Just be calm, and stay on focus on the procedure.
49
8. After needle was inserted, properly place the micro pore on the respective area and for aesthetic purpose. 9. Check if there’s doctor’s order of KVO (Keep vein out).
During:1. Always observe aseptic technique in preparing and administering2. Regulate the flow rate or drop rate as the doctor’s order3. Always check the needle of the IV, if it is in the vein:
a. Bring the IV bottle lower than the patient’s arm.b. Pinch the IV tubing
*If the needle is in the vein, observe for the backflow of blood in the distal portion of the IV tubing.After:
1. Assess for any signs of edema or bulging of vein if it is not properly inserted. 2. Chart the procedure including time, name and dosage and the patient’s response to the administration.3. Properly put all used materials after the insertion on the garbage.
50
Medical management/treatment
Date ordered/Date performed/
Date Changed
General description Indications or purposes
Clients response to the treatment
2. D5 0.9 % NaCl (Sodium Chloride)---Hypertonic
Date Ordered:
Aug 23, 2007
Aug 24, 2007
Aug 25, 2007
Date Performed:
Aug 23, 2007
Aug 24, 2007
Aug 25, 2007
Date Changed: ------
(Continue meds)
General Description: fluid replacements.
D5 .9% NaCl solution or in simple term “Saline”. It is given to the patient because she cannot tolerate to intake foods or either oral fluids and has NPO DIET from August 18-20, 24 and 25,this was ordered to prevent from further activation of the pancreas and the gall bladder to secretes certain enzyme that causes acute inflammation, as an example is that, if the patient starts to eat some foods that is rich in fats, her pancreas and gall bladder will stimulates enzymes (Exocrine) that will breaks down large molecules to small
When patient was administered saline solution, it shows good hydration on her body. If you notice that her electrolytes level were still in normal range:
Electrolytes: Sodium: 138 normal: 136- 145 mmol/LPotassium: 3.8 normal: 3.5- 5.0 mmol/LChloride: 108 normal: 101- 111 mmol/L
Interpreting her result, it means that there is no any sign of dehydration occurs due to normal level of electrolytes. There is no abruptly decrease of electrolytes level.
51
molecules, but due to the obstructed portion on the gall bladder, there will be an accumulation and formation that causes inflammation. She may experience some symptoms of inflamed gall bladder like vomiting, abdominal pain and nausea. Due to vomiting and abdominal pain, there is large possibilities that her body might loss fluids and at the same time, electrolytes. To replenish her body from mush fluid loss.
52
Nursing responsibilities: Prior:
1. Prepare the necessary equipments.2. Wash hands thoroughly.3. Explain the procedure to the patient.4. Check to see if there are any special circumstances surrounding administration to
the patient.5. Be certain that you know the expected action, safe dosage, range, and special
instruction for administration. And adverse effects associated with it.6. For inserting IV bottles to an IV line: Do not touch the upper head of the IV.
Instead, hold the neck of it properly as you inserting the IV line into the bottle.7. Be careful in inserting the needle if vein for insertion is detected. Just be calm,
and stay on focus on the procedure.8. After needle was inserted, properly place the micro pore on the respective area
and for aesthetic purpose. 9. Check if there’s doctor’s order of KVO (Keep vein out).During:
1. Always observe aseptic technique in preparing and administering2.Regulate the flow rate or drop rate as the doctor’s order3. Always check the needle of the IV, if it is in the vein:
c. Bring the IV bottle lower than the patient’s arm.d. Pinch the IV tubing
*If the needle is in the vein, observe for the backflow of blood in the distal portion of the IV tubing.After:
1. Assess for any signs of edema or bulging of vein if it is not properly inserted. 2. Chart the procedure including time, name and dosage and the patient’s response
to the administration.3. Properly put all used materials after the insertion on the garbage.
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b. Drugs
Name of drugs/generic
name/brand name
Date ordered/Date Performed/Date
Changed
Route of administration/Dosage/frequency of
administration
Indications or purposes
Clients response to the treatment
1.Meperidine/Demerol/Stadol/Talwin/Pethanol
Date Ordered:
Aug 18-25, 2007
Date performed:
Aug 18-25, 2007
Date Changed: -----(Continue Meds)
Route/dosage/frequency:
Meperidine 25 mg IV NOW
Route/dosage/frequency:
Meperidine TAB 1 tab OD
General action: analgesics
Meperidine is indicated for the treatment of moderate to severe pain. Due to its mechanism of action which act as an agonist at the kappa-opioid recpetor site. Which at the same time, an anticholinergic stimulator.
When the patient stimulates an unpleasant stimuli either mechanical due to trauma on
Client feels relieve from pain upon painkiller administered. As evidenced by report of gradual decrease in pain severity and unguarded abdominal area. And no side effect documented on the patient.
54
the pancreas and gall bladder, and chemical which either due to secretion of enzyme trypsin/secretin which was occluded due to obstructed ampulla of Vater to the common bile duct going to the gall bladder that resulted to autodigestion on the pancreas. That stimulates an unpleasant sensory impulses, then the nociceptor (pain recpetor) sense the stimuli which will send action (nerve-pain impulse) from the nerve-endings going to the higher brain, then the nerve-pain
55
impulse travels into either Neospinothalamic (Fast pain) which consist of a-delta fibers that has wide diameter. Or to the Paleospinothalamic (Slow pain) which consist of C-fibers and a-beta fibers together with substantia gelatinosa that has small diameter, to travel along to the Dorsal root of ganglion going to the CNS, and if a-delta fibers reaches first. It tends to close the opening of the ganglion in order to blocked the passing of C-fibers. Now, the action of here
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Drug is that before nerve-pain impulse reaches the brain, meperidine content already binds to the terminal nerve-endings of the brain which either periphery or centrally which prevents of further transmission of impulses.
Specific Nursing responsibilities:1. Assess also for has a history of seizures or epilepsy, has an enlarged prostate or urinary retention problems, or suffers from
hyperthyroidism, asthma, or Addison's disease.2. Advise patient that the drug may impair mental and/or physical ability required for the performance of potentially hazardous
tasks (e.g., driving, operating heavy machinery).3. Discourage use of MAOI’s drug such as sibutramine, procarbazine or phenelzine which when administered together may cause
dangerous side-effects such as suffer agitation, delirium, headache, convulsions, and/or hyperthermia.4. Women of childbearing potential who become, or are planning to become pregnant should be advised to consult their
physician regarding the effects of analgesics and other drug use during pregnancy on themselves and their unborn child.5. Patients should be advised to report pain and adverse experiences occurring during therapy. Individualization of dosage is
essential to make optimal use of this medication.
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General Nursing responsibilities:Prior:
1. Check the written medication order for completeness. It should include the drug name, dosage, and route of administration, frequency and duration of the therapy.
2. Wash your hands.3. Inform the patient about the action of the drug and what are the expected side effects on it.4. Assess for renal function, it must not given for patient having renal failure.5. Use with caution, such as noting for any color, shape and precipitating color of the drug (If IV use).6. Assess for Hepatic function, as the liver is responsible for detoxifying harmful substances. 7. Keep in mind for the TEN R’s for administering drugs such as right Patient, amount/dosage, and right route.8. Assess for history of medication used. 9. Be certain that you know the expected action, safe dosage, range, special instruction for administration. And adverse effects
associated with the drugs.10. Do not touch label or capsule with your hands. Pour the required no. Into the bottle cap then into the medication cup.
During:1. Read the desired route for administering the drug. 2. If IV ordered, check for the patency of the IV if it is flowing.3. Assess for edema on the IV site.4. Do not confuse on the other contraptions attached on the IV fluid.5. If Oral route desired, offer the patient Ice cube to suck so that to prevent any unwanted taste of the drug. 6. Also for oral route, follow up water or liquids after the medication is administered.
After:1. Instruct patient to take the medication as directed for the full course of the therapy. 2. Document Response to the medication. 3. Advise Patient to increase Fluid intake if permitted. Due to adverse-effects of the medication such as constipation and dry
mouth
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Name of drugs/generic name/brand
name
Date Ordered/Date
Performed/Date Changed
Route of administration/Dosage/frequency of
administration
Indications or purposes
Clients response to the treatment
2.Omeprazole/Losec/Prilosec/Prilosec OTC./Zegerid
Date Ordered:
Aug 18-22, 2007
Date Performed:
Aug 18-22, 2007
Date Reperformed:
Aug 24, 2007
Aug 25, 2007
Date Changed/Discontinued:
Aug 23, 2007
Route/dosage/frequency:
Omeprazole 40 mg IV OD
General action: Anti-ulcer agent.
Omeprazole was ordered to the patient to avoid further complication.
As the General action implies, it prevents the patient from acquiring ulcerative form. Due to low lymphocyte level, the patient has a low immune system that causes neutrophil to increase in value, which means the patient
Upon administering the medication, patient has not elicited any untoward or undesired response to the medication. No signs of dizziness, drowsiness and fatigue, which are the side effects of the drug.
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is at risk for infection. Omeprazole was given to prevent any further infections that can cause ulcer, such as peptic ulcer, or duodenal ulcer. Although ph content stomach is very acidic due to secretion of gastrin that secretes pepsinogen, HCl, intrinsic factor and parietal cells, some bacterial infections can live. H. Pylori, they are thought be a acidophile bacteria (2-4 ph)
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Specific Nursing Responsibilities:1.Do not confuse with Prisolec with Prinivil.2. Capsules should not be swallowed nor crushed or chewed.3. For patients who have difficulty swallowing capsules, the contents of a PRILOSEC Delayed-Release Capsule can be added
to applesauce.4. PRILOSEC Delayed-Release Capsules should be taken before eating.5. Assess for renal and hepatic function in order to evaluate the functional ability of the organs.
General Nursing Responsibilities:Prior:
1. Inform the patient about the action of the drug and what are the expected side effects on it 2. Assess patient routinely for epigastric or abdominal pain and frank occult of blood in stool or emesis. 3. Check Laboratory test CBC with differential count, upon the therapy.4. Assess for renal function, it must not given for patient having renal failure.5. Use with caution, such as noting for any color, shape and precipitating color of the drug (If IV use).6. Assess for Hepatic function, as the liver is responsible for detoxifying harmful substances. 7. Keep in mind for the TEN R’s for administering drugs such as right Patient, amount/dosage, and right route.8. Assess for history of medication used.
During: 1. Administer the dose before meals, preferably in the morning. Capsules should be swallowed whole, do not cruch or chew. 2. Maybe adminitered concurrently with antacids.3. Read the desired route for administering the drug. 4. If IV ordered, check for the patency of the IV if it is flowing.5. Assess for edema on the IV site.6. Do not confuse on the other contraptions attached on the IV fluid.7. Always check the needle of the IV, if it is in the vein before administering the drug by any of the following method:
a. Bring the IV bottle lower than the patient’s arm.b. Pinch the IV tubing
*If the needle is in the vein, observe for the backflow of blood in the distal portion of the IV tubing
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8. Clean the injection port with cotton swab without alcohol.9. Inserted the needle into the injection port and inject the drug slowly for a period of 1-7 minutes. 10. Regulate the drop rate as desired.
After: 1. Instruct patient to take the medication as directed for the full course of the therapy. 2. Document Response to the medication. 3. Instruct patient to increase in fluid intake as permitted. 4. Caution patient to avoid other activities requiring alertness until response is known to the medication.5. Advise patient to avoid alcohol, NSAID’s drug or aspirin that may increase GI irrtitation.6. Advise Patient to report onset of stools, diarrhea, abdominal if experience.
Name of drugs/generic
name/brand name
Date ordered/Date Performed/Date
Changed
Route of administration/
Dosage/frequency of administration
Indications or purposes Clients response to the treatment
3.Metronidazole/APO-Metronidazole/ Metric21/MetroCream/Metro Gel/Flagyl
Date Ordered:
Aug 18, 2007
Aug 19, 2007
Aug 20, 2007
Date Performed:
Aug 18, 2007
Aug 19, 2007
Route/dosage/frequency:
Metronidazole 500 mg q 6 hrs.
General action: anti-infective.
Metronidazole was given to the patient due to its
neutrophil value, which is low. Due to an acute inflammation of the Pancreas, neutrophil
accumulates on the site of inflammation to phagocytes (cell eating) any invading
microorganism such as
From the very first day the medication is administered, it showed a relatively value that infection is impending so the action of drug is needed in immediate time. As evidenced by laboratory results of:
Aug 18, 2007WBC Count: 13.4 normal: 5- 10 x 10 g/l
Neutrophils: 0.91
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Aug 20, 2007
Date Changed:
Aug 21, 2007
bacteria or virus. The action of the drug to the patients
body (Pharmacodynamic) is to convert any aerobic
bacteria to an anaerobic form by the enzyme redox enzyme pyruvate-
ferredoxin oxidoreductase that disrupting the Helical
DNA structure of the Bacteria that inhibiting nucleic acid synthesis.
And If this so happen to the patient, metronidzole potent
effect will do.
normal: 0.45- 0.65
Lymphocytes: 0.09 normal: 0.20- 0.35
After 3 days of continuous medications of the patient, laboratory exam were taken and results were as follows:
C. Aug 21, 07
WBC Count: 5.9 Normal: 5- 10 x 10 g/l
Neutrophils: 0.76 Normal: 0.45- 0.65
Lymphocytes: 0.24 Normal: 0.20- 0.35
Results shows that Lymphocyte and WBC count of the patient came back to normal value except for neutrophils, which still has a high count, means that the patient is still at risk for infection. As far as we remember, the action of the neutrophil is that during the acute phase of inflammation, particularly as a result of bacterial infection,
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neutrophils leave the vasculature and migrate toward the site of inflammation in a process called chemotaxis.
Specific Nursing responsibilities:1. Assess for infection at the beginning and duing the theapy.2. Obtain specimen for culture and sensitivity. 3. Monitor Neurologic status duing and after the administration.4. Monitor intake and output and daily weight the patient especially for patient on sodium restriction.5. Administer on a empty stomach
General Nursing Responsibilities:Prior:
1. Prepare the necessary equipments.2. Wash hands thoroughly.3. Inform the patient about the action of the drug and what are the expected side effects on it 4. Explain the procedure to the patient.5. Be certain that you know the expected action, safe dosage, range, and special instruction for administration. And adverse
effects associated with the drugs.6. Check Laboratory test for the result of AST, ALT AND LDH that may be altered. 7. Assess for renal function, it must not given for patient having renal failure.8. Use with caution, such as noting for any color, shape and precipitating color of the drug (If IV use).9. Assess for Hepatic function, as the liver is responsible for detoxifying harmful substances. 10. Keep in mind for the TEN R’s for administering drugs such as right Patient, amount/dosage, and right route.11. Assess for history of medication used.12. obtain a history of culture and sensitivity beofre initiating therapy.
During:
1. Administer on an empty stomach, or may administered with food or milk to minimize GI irritation.
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2. Tablets may crushed for patient with difficulty of swallowing (dyspahgia)3. Always check the needle of the IV, if it is in the vein before administering the drug by any of the following method:
a. Bring the IV bottle lower than the patient’s arm.b. Pinch the IV tubing
*If the needle is in the vein, observe for the backflow of blood in the distal portion of the IV tubing.4. Always observe aseptic technique in preparing and administering drugs.5. Regulate the flow rate or drop rate as the doctor’s order
After:1. Chart the procedure including time, name and dosage of drug and the patient’s response to the administration.2. Advise patient not to perform any activities, which requires massive movement. Due to adverse-effect of lightheadedness, this
puts patient at risk for injury.Caution patient not to take alcoholic beverages at least 1 day after the treatment.
Name of drugs/generic
name/brand name
Date ordered/Date Performed/Date
Changed
Route of administration/Dosage/frequency of
administration
Indications or purposes
Clients response to the treatment
4. Vamine Glucose Date Ordered:
Aug 18-20, 2007
Date Re-ordered:
Aug 22-25, 2007
Date performed:
Aug 18-20, 2007
Route/dosage/frequency:
Vamine Glucose 500 cc IV in AM to run for 8 hours.
General action: glucose supplement.
Vamine glucose is given to the patient because she has restricted parenteral nutrition, insufficient or is contra-indicated.It has Glucidic and nitrogenized caloric intake (acid amino of
When vamine glucose was administered, it shows that patient expected reaction was seen, such as able to answer questions appropriately, when she was asking or underwent assessment because a sign of decrease glucose level in the brain is that being manifested by confusion, irritability and decrease mental capacity to initiate a response, considering her condition, the glucose which is
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Date reperformed:
Aug 22-25, 2007
Date Changed: -----(Continue Meds)
the series L).
Our patient was kept on NPO for a number of days. Due to absence of any nutrition that she needs, especially, carbohydrates, proteins and fats. As we know, carbohydrates serve as our energy source, which will be converted into glucose after a series of conversion that after which, will be release on the islet of langerhan in the form of glucagons by gluconeogenesis which will be facilitate by gluconeolysis particularly in the alpha cells. Vamine glucose will act as glucose replacement for those patients who have disorder in the Gastrointestinal tract
essential for functioning sustained in her body. Although there are certain times, that patient became irritable due to the pain that she feels. It does not alter the proper level of functioning.
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such as the condition of the patient. Due to administering intravenously, vamine glucose do not need to undergo directly to the mucosal line of the GI that may initiate an activation of organs related to it which will again may cause an secretion of digestive enzymes. Thus it will flow directly into the veins, which will be distributed to those particular parts of the body, without initiating any activation.
Nursing responsibilities:Prior:
1. Prepare the necessary equipments.2. Wash hands thoroughly.3. Inform the patient about the action of the drug and what are the expected side effects on it 4. Explain the procedure to the patient.5. Keep in mind for the TEN R’s for administering drugs such as right Patient, amount/dosage, and right route.6. Assess for history of medication used. That may cause cross-sensitivity of the patient on it.7. do not confuse on othe rcontraptions that were attached on the main line.
During:
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1. Always observe aseptic technique in preparing and administering2. Regulate the flow rate or drop rate as the doctor’s order3. Always check the needle of the IV, if it is in the vein:
a. Bring the IV bottle lower than the patient’s arm.b. Pinch the IV tubing
*If the needle is in the vein, observe for the backflow of blood in the distal portion of the IV tubingAfter:
1. Assess for any signs of edema or bulging of vein if it is not properly the needle is not properly inserted. 2. Chart the procedure including time, name and dosage and the patient’s response to the administration.
3. Properly put all used materials after the procedure on the garbage.
Name of drugs/generic
name/brand name
Date ordered/Date Performed/Date
Changed
Route of administration/Dosage/frequency of
administration
Indications or purposes
Clients response to the treatment
5. Intralipid Date Ordered:
Aug 18-20, 2007
Date Re-ordered:
Aug 22-25, 2007
Date performed:
Aug 18-20, 2007
Date reperformed:
Aug 22-25, 2007
Route/dosage/frequency:
Intralipid 500 cc IV in PM to un for 8 hours
General action: nutritional supplement (especially fats)
As previously stated a while ago, just like Vamine glucose. Intralipid also was given to the patient in order to prevent the gall bladder from activating the enzyme cholecystokinin to emulsifies fats and
When Intralipid was administered, it did not manifest any loss of nutrients or electrolytes either. Based on the result:
Electrolytes: Sodium: 138 normal: 136- 145 mmol/LPotassium: 3.8 normal: 3.5- 5.0 mmol/LChloride: 108 normal: 101- 111 mmol/L
It shows that the medication that was given to her is effective. But were not only considering this result, because
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Date Changed: -----(Continue Meds)
neutralized acids in the digested foods. As the result of dislodged/occlusion on the gall stone in either on the ampulla of Vater or on the common bile duct. In which the over-distended organ will be inflammed as soon as there any stimulation.
The purpose also of giving intralipid intravenously is that her lipase level is in high value. Which inhibiting the stimulation of different enzyme from digestion process.
Lipase:RESULT:Hi – 510 U/LNORMAL RANGE:2.3 - 300
there are certain instances that the effectively of the drugs may not be potent enough. As notice, Intralipid was being alter to Vamine glucose, its synergism effect help each other sustain body’s functioning.
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Nursing responsibilities:Prior:
1. Prepare the necessary equipments.2. Wash hands thoroughly.3. Inform the patient about the action of the drug and what are the expected side effects on it 4. Explain the procedure to the patient.5. Keep in mind for the TEN R’s for administering drugs such as right Patient, amount/dosage, and right route.6. Assess for history of medication used. That may cause cross-sensitivity of the patient on it.7. Do not confuse on othe rcontraptions that were attached on the main line.
During:1. Always observe aseptic technique in preparing and administering2. Regulate the flow rate or drop rate as the doctor’s order3. Always check the needle of the IV, if it is in the vein:
A. Bring the IV bottle lower than the patient’s arm. B. Pinch the IV tubing *If the needle is in the vein, observe for the backflow of blood in the distal portion of the IV tubingAfter:
1. Assess for any signs of edema or bulging of vein if it is not properly the needle is not properly inserted. 2. Chart the procedure including time, name and dosage and the patient’s response to the administration 3. Properly put all used materials after the procedure on the garbage.
Name of drugs/generic name/brand
name
Date ordered/Date
Performed/Date Changed
Route of administration/Dosage/frequency of
administration
Indications or purposes
Clients response to the treatment
6. Tramadol/Ultram
Date Ordered: Aug 23-25, 2007
Date performed:
Route/dosage/frequency:
Tramadol 50 mg IV q 8 hours
General actions: Analgesia for moderate to
moderately severe pain.
Client feels relieve from pain upon painkiller administered. As evidenced by report of gradual decrease in pain severity and unguarded abdominal
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Aug 23-25, 2007
Date changed: -----(Continue Meds)
Just like meperidine, Tramadol was also given to the patient. But the only differences it has is that it binds on the mu-opioids receptors (which has high affinity to enkephalins and beta-beta-endorphine) that inhibit the reuptake of serotonin and norepinephrine. They are commonly located presynaptically or postsynaptically. As the process, when the patient stimulates an unpleasant stimuli either mechanical due to trauma on the pancreas and gall bladder, and chemical which either due to secretion of enzyme trypsin which was occluded due to obstructed ampulla of Vater to the common
area.
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bile duct going to the gall bladder that resulted to autodigestion on the pancreas. That stimulates an unpleasant sensory impulses, then the nociceptor (pain recpetor) sense the stimuli which will send action (nerve-pain impulse) from the nerve-endings going to the higher brain, then the nerve-pain impulse travels into either Neospinothalamic (Fast pain) which consist of a-delta fibers that has wide diameter. Or to the Paleospinothalamic (Slow pain) which consist of C-fibers and a-beta fibers together with substantia gelatinosa that has small diameter, to travel
72
along to the Dorsal root of ganglion going to the CNS, and if a-delta fibers reaches first. It tends to close the opening of the ganglion in order to blocked the passing of C-fibers. Now, the action of here Drug is that before nerve-pain impulse reaches the brain, meperidine content already binds to the terminal nerve-endings of the brain which either periphery or centrally which prevents of further transmission of impulses.
Specific Nursing responsibilities:1. Monitor patient for seizures. May occur within recommended dosage range.2. Assess Blood pressure and Respiratory rate during and periodically.3. Assess Bowel function routinely. Because the common side effect of the drug is constipation.4. Prepare an antidote, which is Narcan if overdosing occurs. 5. May be administered without meals.
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General Nursing Responsibilities:Prior:
1. Prepare the necessary equipments.2. Wash hands thoroughly.3. Inform the patient about the action of the drug and what are the expected side effects on it 4. Explain the procedure to the patient.5. Keep in mind for the TEN R’s for administering drugs such as right Patient, amount/dosage, and right route.6. Assess for history of medication used. That may cause cross-sensitivity of the patient on it.7. do not confuse on othe rcontraptions that were attached on the main line.8. Assess the type, location, and intensity of pain before and 2-3 hours (peak) after administration.9. may cause an increase in creatinine, liver enzymes, decrease hemoglobin, and proteinuria.
During:1. Do not confuse with tramadol and Toradol.2. Regularly administered doses may be more effective than prn administration. 3. May be given without regards to meals.4. Should be discontinued gradually after long-term use to prevent withdrawal symptoms.
After:1. Instruct the patient on how and when to ask for pain medication.2. caution patient to avoid driving or other activities that require alertness until response to medication is known. Because side-
effect of tramadol is dizziness.3. advise patient to changes position slowly to minimize orthostatic hypotension.4. avoid patient to avoid concurrent use of alcohol.5. encourage patient to turn, cough,a nd breathe every 2 hours to prevent atelectasis.
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Name of drugs/generic
name/brand name
Date ordered/Date Performed/Date
Changed
Route of administration/Dosage/frequency of
administration
Indications or purposes Clients response to the treatment
7. Buscopan/ Butylscopolamine/scopolamine butylbromide hyoscine butylbromide
Date ordered:
Aug 23-25, 2007
Date performed:
Aug 23-25, 2007
Date changed: -----(Continue Meds)
Route/dosage/frequency:
Buscopan 1 ampule IV q 8 hours
General action: anti-spasmodic
Buscopan was given to the patient in order to prevent further contraction of the smooth muscle located on the common bile duct, which is sometimes called colic.
Due to the over-spasm of the patient’s gall bladder , “again” which is because of occluded calculi/gallstone, the organ tend to contract more to dislodged or to get rid of out the occlusion of the duct. And may be, due to over crowded number of calculi that stuck into it, then it tends abrupt severely. Due to it, the result is involuntary
When buscopan was administered, NO signs of spasm occur such as pain. As evidenced by, no report of pain upon peak of action of the medication. Patient does not guarded her abdomen. No side-effect documented.
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contraction of it thus resulting into sudden burst of pain. Buscopan does not relieve pain since it doesn't 'mask' or 'cover over' the pain, but rather works to prevent painful cramps and spasms from occurring in the first place.
Specific Nursing responsibilities:1. Assess the Bowel sound routinely.2. May be given without regards to meals.3. Monitor Vital signs Every 1 hour.
Nursing responsibilities:Prior:
1. Prepare the necessary equipments.2. Wash hands thoroughly.3. Inform the patient about the action of the drug and what are the expected side effects on it 4. Explain the procedure to the patient.5. Keep in mind for the TEN R’s for administering drugs such as right Patient, amount/dosage, and right route.6. Assess for history of medication used. That may cause cross-sensitivity of the patient on it.7. Do not confuse on other contraptions that were attached on the main line.
During:1. Regularly administered doses may be more effective than prn administration.
2. Should be discontinued gradually after long-term use to prevent withdrawal symptoms.After:
1. Instruct the patient on how and when to ask for pain medication. 2. Avoid patient to avoid concurrent use of alcohol.
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c. Diet
Type of Diet
Date ordered/date performed/date
changed
General descriptio
n
Indication(s) or
purposes
Specific foods taken
Client response
and reaction
to the medicatio
n
1. NPO (NOTHING PEROREM/NOTHING BY MOUTH)
Date ordered:
Aug 18, 2007Aug 19, 2007Aug 20, 2007
Date reordered:
Aug 24, 2007Aug 25, 2007
Date Performed:
Aug 18, 2007Aug 19, 2007Aug 20, 2007
Date reperformed:
Aug 24, 2007Aug 25, 2007
Date changed:Aug 21, 2007Aug 22, 2007Aug 23, 2007
No foods that are must be taken.
Prevent further stimulation different enzymes that would lead to auto digestion of the pancreas and the gall bladder.
NO FOODS ALLOWED TO BE TAKEN
Upon restricting patient from intake of any forms of foods which either solid or liquid form. Due to the feelings that patient experiences, she restricts herself from eating foods. Because it may cause irritation to her inflamed bodily organs.
Nursing Responsibilities:Prior:
1. Check the doctor’s order.2. Assure IV fluid therapy if patient is NPO.3. Instruct SO not to give anything through the mouth.
During:
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1. Assure that nothing is taken through the mouth either liquid or solid.2. Assess client’s condition.3. Place “NPO” sign on the on the bed where the patient can see it always.4. Remove foods and drinks on patient’s side.
After: Observe patient’s response on the diet.
Type of diet
Date ordered/date
performed/date changed
General description
Indication(s) or purposes
Specific foods taken
Client response
and reaction to
the medication
2. SOFT LIQUID DIET
Date ordered:
Aug 21, 2007Aug 22, 2007Aug 23, 2007
Date Performed:
Aug 21, 2007Aug 22, 2007Aug 23, 2007
Date changed:
Aug 24, 2007
Food tolerances vary with individuals. Tender foods (not ground or pureed) are used unless the individual needs additional modifications to the diet. Most raw fruits and vegetables and course breads and cereals are eliminated.
The purpose of these is to designed patient that who cannot tolerate general diet.
Foods moderately low in fibers, soft texture and moderately seasons. Avoid fried foods and spicy foods.
The following are recommended:
>milk, coffee, tea, fruit juice
>all fruit juices
>cooked or ready cereals
>cooked vegetables
>potatoes without skin.
The patient is able to tolerate soft liquid diet as far she can. Also the Soft liquid diet also aids in giving good hydration of the patient. That’s one good reason that risk for dehydration was rid-out.
Nursing Responsibilities:
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1. Explain the purpose of the diet.2. Emphasize the importance of it.3. Monitor patient Intake and output.4. Chart the I & O of the patient if needed.5. Give the patient according to what are prescribed. 6. Do not tolerate the patient if she’s requesting foods that are not under soft liquid
diet.7. Determine any degree of circumstances such as the patient is ongoing NGT
feeding. Inform the patient about the condition.
d. Activity/ ExerciseType of Exercise
Date orderedDate performedDate changed
General Description
Indications orPurposes
Client’s response to the
activityMay turn side to side
08-18-07 The patient may move on bed as tolerated.
This is to facilitate recovery to normal functioning of the body.
The patient complained of pain when moving. With a pain scale of 9/10 and facial grimaces.
Nursing Responsibilities:Prior:
1. Check the physician’s order.2. Explain to the purpose of positioning for his safety.3. Place a draw sheet and rubber sheet under patient’s back and head.
During:1. Logroll patient to one side every 2 hours.2. Place a small pillow under the patient’s head. 3. Place pillow or rolled towel behind the patient’s back.4. Put a pillow between patient’s legs and on the abdomen.5. Run your hand under the patient’s dependent shoulder and move the shoulder
slightly forward.
After:1 Inspect the patient’s skin.2 Assess patient’s comfort.3 Lower height of the bed and elevate side rails.4 Document patient’s reaction and compliance.
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Cues Nursing Diagnosis
Specific Explanation
Objectives Nursing Intervention
Rationale Expected Outcome
“S” = O
“O” IVF of D5 0.9% NaCl at 500 cc level regulated at 60- 61 gtts/min,
Patient manifested:>() Abdominal pain> Guarded her abdomen>Moaning when pain attacks>Irritability & anxiety>Appears restless>Dilated pupils>Skin is pale
Patient may manifest:>Difficulty in turning.> Limited to perform motor
Acute Pain R/T inflamed body organs secondary to cute pancreatitis resolved cholecysto- lithiasis
Pancreatitis is commonly described as auto digestion of the pancreas. When the pt’s pancreatic duct becomes temporarily obstructed due to obstruct gall bladder that has calculi or stones along the duct. And accompanied by hyper secretion of the exocrine gland of the pancreas, specifically the trypsin. Then the enzyme enters the bile duct, where they are activated and together with bile, back up into the pancreatic duct, then the pt. Experiences
Short Term:
After 3 hrs. of nursing interventions the pt will demonstrate diversional activities to direct pain.
Long Term:
After one day of nursing interventions, the pt. will verbalize methods I relieving pain.
>Establish rapport.
>Monitor vital signs.
>Assess patient’s condition.
>Perform pain assessment comprehend-sively (pqrst).
>Note for non- verbal cues.
>Provide diversional activities like chatting.
>Encourage adequate rest
> To gain the trust of the client and gain cooperation.
>To obtain baseline data
>To obtain a baseline data and know the needs of the patient.
>To know the location and quality of pain.
>To know the level of pain.
>To reduce tension that is occurring, thus reduce intensity of pain.
>To regain loss energy due to
Short Term:
After 3 hrs. of nursing interventions, the patient demonstrated diversional activities to direct pain.
Long Term:
After one day of nursing interventions, the patient verbalized methods and techniques in relieving pain.
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skills. abdominal pain. periods. untolerated pain.
3. NURSING MANAGEMENTCues Nursing
DiagnosisSpecific
ExplanationObjectives Nursing
InterventionRationale Expected Outcome
PQRST Pain Assessment:
P- provoked by trauma on her abdomen upon moving.Q- stabbing painR- on her left upper quadrantS- 10 out 10 ratingsT- 4:00pm>May manifest increase pulse, increase RR, elevated BP>Vital signs taken and recorded:
Temp: 36.7 cPR: 81 bpmRR: 22 bpmBP: 110/ 60 mmHg
Pain serves as a mechanism to warm us about the potential for physical harm. Pain is caused by actual tissue damage that stimulates the receptive normal receptors. Once the receptors are stimulated the impulse they discharge travels as electrical activity to the spinal cord and on the brain and this becomes the experience of pain, in normal pathways for these impulses is blocked pain since, it doesn’t
>Stretch linens for comfort.
>Instruct use of non- pharmacologic techniques such as relaxation, distraction.
>Administer medications as ordered by the doctor.
>Acknowledge reality of situation and feelings of the client.
>Reduce factor that aggravates the pain.
>To increase the release of endorphins and enhance the therapeutic effects of it.
>To improve pt’s condition.
>To establish therapeutic relationship.
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>fetal position when pain attacks
reach the brain. There would be damage on pain system causing pain.
Cues Nursing Diagnosis
Specific Explanation
Objectives Nursing Intervention
Rationale Expected Outcome
“S” = O
“O” =
Patient manifested:>() Restlessness> Weakness>Difficulty in going to the comfort room.>Bed rest the whole day>Slowed movement>Small steps
Patient may manifest:
Activity intolerance r/t generalized body weakness secondary to disease condition.
Activity Intolerance a psychological or physiological energy to endure or complete required or desired daily activities. And because she experienced hemorrhage due to previous blood loss through menstruation. Decreased oxygen supply, that result to decreases muscle tone and result to
Short Term:
After 3 hrs of nursing interventions patient will verbalize understanding and identify factors affecting activity intolerance.
Long Term:
After one day of nursing interventions patient will demonstrate
>Monitor vital signs.
>Assess patient’s condition.
>Assisted pt. to learn and demonstrate appropriate safety measures.
>Emphasize importance of adequate
>To obtain baseline data
>To obtain a baseline data and know the needs of the patient.
> To prevent further possible injuries.
>To be able to regain strength.
Short Term:
After 3hrs of nursing interventions patient identified techniques to enhance activity intolerance within her physical limitations.
Long Term:
After one day of nursing interventions
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>Irritability most of the time> Limited to perform motor skills >Shortness of breath
body weakness. compliance and able to increase comfort while performing activities
periods of rest.
>Encourage pt. to do activity with appropriate rest periods.
>Assist pt. in going to the comfort room.
>Acknow ledge the feelings of the client.
>To reduce fatigue.
>To avoid further injury and decrease level of pain that is experienced.
>To establish therapeutic relationship.
patient participated willingly in the desired activities.
Cues Nursing Diagnosis
Specific Explanation
Objectives Nursing Intervention
Rationale Expected Outcome
>Instruct SO to support pt’s ADL’s.
>Administered medications as indicated.
>Encouraged mix of desired activities or stimuli such as
>To prevent the aggravation of pain.
>To improve the pt’s condition.
>To stimulate observation as well as involvement and
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reading magazines, or listening to music.
>Supported affected body parts.
participation in activity.
> To maintain position and reduce risk of pressure.
Cues Nursing Diagnosis
Specific Explanation
Objectives Nursing Intervention
Rationale Expected Outcome
“S” = O
“O” =
Patient may manifest:> Statement of misconception> Information misinterpretation.> Unfamiliarity of information resources.
Knowledge deficit r/t lack of understanding of medical and disease condition.
Knowledge deficit is the lack of cognitive information related to specific topic. Which where the patient ask of about her illness, because she do not fully understand its condition.
Short Term:
After 3 hrs of nursing interventions patient will identify individually appropriate interventions to promote sleep.
Long Term:
After one day of nursing interventions patient will report improvement in
>Determine pt’ s ability to learn.
>Review disease process/prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern.
>Provide
>To check his level of capability in learning.
>Provides knowledge base from which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing. >To reinforces
Short Term:
After 3hrs of nursing interventions patient identified appropriate interventions in promoting sleep.
Long Term:
After one day of nursing interventions patient reported an improvement in
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sleep or rest patterns.
written information / guidelines for the patient.
>Provide explanations of/ reasons for test procedures and preparation needed.
>Provide information relevant to his situation.
learning process.
>Information can decrease anxiety.
>To correct beliefs and promote more reliable information
sleeping patterns.
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Cues Nursing Diagnosis
Specific Explanation
Objectives Nursing Intervention
Rationale Expected Outcome
“S” = O
“O” =
Patient manifested:> Irritable> Presence of pain> Poor eye contact> Restlessness
Anxiety r/t situational crisis, perceived to actual threat to health
The client is in the state of anxiety because of the problem she is experiencing. Which was her first time to be hospitalized and experienced severe dizziness. Involving the worries of her family care. And also a big threat to her health.
Short term:
After 3 hours of nursing intervention the pt. will verbalize understanding about her situation and able to build up trust with her.
Long term:After one day of nursing intervention the pt. will verbalize concerns and fears; works with the student nurses to correct and compensate with her present problem and participate in treatment regimen.
>Monitor and record V/S.
>Allow client to verbalize feelings and concerns. Assess for possible feelings related to cause of her condition.
>Approach the client in a calm, consistent, unhurried manner.
>Include client in treatment process and inform her about the things ahead of time if possible.
>To have a baseline data.
>Verbalization and assessment of feelings provide a safe outlet for emotions.
>Using calm, unhurried approach with explanations helps to minimize the threat of the situation.>Client’s participation enhances client’s control over the situation and may help to instill hope and promote decision-making.
Short term:
After 3 hours of nursing intervention the pt. verbalized understanding about her situation and able to build up trust with her.
Long term:After one day of nursing intervention the pt. verbalized concerns and fears; worked with the student nurses, corrected and compensated with her present problem and participated in treatment regimen.
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> Explain to the patient her condition as well as the treatment and procedures.
> To promote trust and cooperation of the patient and helping to alleviate her problems.
Cues Nursing Diagnosis
Specific Explanation
Objectives Nursing Intervention
Rationale Expected Outcome
“S” = O
“O” =
Patient manifested:> Irritable> Presence of pain> Poor eye contact> Restlessness
Self care deficit related to pain
The deficit may be a result of transient limitations, such as those that the patient experiences like acute pain. Careful examination of the patient’s deficit is required in order to be certain that the patient is not failing self- care because of lack of materials with arranging the environment to
Short term:After 3hours of nursing interventions patient will be able to verbalize understanding on the importance of self care.
Long term:After one day of nursing interventions patient will safely perform self- care activities.
Assess ability to carry out ADL’s like dressing, grooming, bathing etc.
Provide privacy during dressing.
Provide frequent encouragement and assistance as needed with dressing.
The patient may only require assistance with some self- care measures.
Patient may take longer to dress and maybe fearful of breaches in privacy
This will reduce energy expenditure and frustration.
Short term:After 3hours of nursing interventions, patient was able to verbalize the importance of self- care.
Long term:After one day of nursing interventions patient was able to perform safely self- care activities.
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suit the patient’s physical limitations.
Encourage pt. to comb her own hair.
Encourage pt. to perform minimal- facial hygiene whenever she cannot tolerate to do so.
This enables the pt. to maintain autonomy for as long as possible.
These will reduce energy expenditure and prevents fatigue and exacerbation.
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2. ACTUAL SOAPIE’s
August 23, 2007
S = O
O = Received patient lying on bed sleeping with ongoing IVF of D5 0.9% NaCl 1L x 60 gtts/ min @ 900 cc level infusing well on the right arm. Stabbing pain provoked by trauma on her abdomen upon moving and radiating on her Left upper quadrant, with a pain scale of 10/ 10.
() Abdominal pain() Guarded her abdomen() Irritability() Moaning when pain attacks
Vital signs were taken and recorded:Temp: 36.7 CPR: 81 bpmRR: 22 bpmBP: 110/ 60 mmHg
A = Acute Pain
P = After 3 hrs. of nursing interventions, the patient will demonstrate diversional activities to divert pain.
I > Established rapport > Monitored Vital signs > Stretched linens for comfort > Assessed patient’s condition > Performed pain assessment comprehensively (pqrst) > Determined possible pathophysiological causes like pancreatitis & cholecystolithiasis > Noted client’s behavior towards pain. > Provided diversional activities such as chatting > Encouraged verbalization of pain > Kept patient as NPO as ordered by the doctor. > Noted medications that are to be taken on time E = Goal met, as evidenced by demonstrated diversional activity.
August 25, 2007 S = O
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O = Received patient lying on bed with an IVF of 0.9 NaCl with a level of 500 mL regulated at 60 gtts/min, infusing well on the right cephalic vein with a side drip if Intralipid 10% regulated at 62- 63 gtts/min.
() Restlessness
Vital signs were taken and recorded:Temp: 37.8 CPR: 62 bpmRR: 27 bpmBP: 110/ 70 mmHg
A = Acute Pain
P = After 3 hrs. of nursing interventions, the patient should verbalize a decrease in pain from 8/10 to 6/10.
I > Established rapport > Monitored Vital signs > Stretched linens for comfort > Assessed patient’s condition > Assessed level of pain > Encouraged verbalization of feelings towards pain > Observed for non- verbal cues > Regulated the IV Fluid > Assisted patient in going to the comfort room > Provided comfort measures > Noted medications that are to be administered on time. > Prescribed medication that is to be taken.
E = After 3 hrs. of nursing interventions patient verbalized a decrease in pain from 8/10 to 3/10.
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D. VI. Client’s Daily Progress in the Hospital
Admission (Aug 18,
2007)
Day 2 (Aug 19,
2007)
Day 3 (Aug 20,
2007)
Day 4 (Aug 21, 2007)
Day 5 (Aug 22,
2007)
Day 6 (Aug 23, 2007)
Day 7 (Aug 24,
2005)
Day 8 (Aug 25, 2007)
Nursing Problems: according to prioritization:
1. Acute Pain2.Imbalanced nutrition3.Activity Intolerance4.Self-care deficit5.Anxiety
*
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**
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**
***
**
***
**
***
**
***
**
***
**
***
Vital Signs:
1. Temp.2. Pr3. Rr4. BP
Temp: 37.3Pr: 76 bpmRr: 26 bpmBp: 110/ 70mmHg
Temp: 37.1Pr: 68bpmRr:22bpmBp:100/ 70 mmHg
Temp:36.9Pr: 71bpmRr: 28bpmBp: 110/ 70mmHg
Temp: 37Pr: 60bpmRr:25bpmBp:100/ 70 mmHg
Temp: 37.2 Pr: 64 bpmRr: 24 bpmBp: 100/ 70 mmHg
Temp: 36.7Pr: 81 bpmRr: 22 bpmBp: 100/ 60 mmHg
Temp: 37.1Pr: 81Rr: 22 bpmBP: 110/70 mmHg
Temp: 37.5 Pr: 80 bpmRr: 23 bpmBp: 110/ 70 mmHg
Diagnostic/Lab procedures:
1.CBC *
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2. creatinine3. Alkaline phosphatase4.BUN5. SGOT6. SGPT7.LDH8. RBS
**
*****
Medical management
1. IVF’S2. Blood
Transfusion3. NGT feeding
1. D5 LRS 1L x 30- 31 gtts/ min
1. D5 LRS 1L x 30- 31 gtts/ min
1. D5 LRS 1L x 30- 31 gtts/ min
1. D5 LRS 1L x 30- 31 gtts/ min
1. D5 LRS 1L x 30- 31 gtts/ min
1. D5 0.9 % NaCl x 60 gtts/ min
1. D5 0.9 % NaCl x 60 gtts/ min
1. D5 0.9 % NaCl x 60 gtts/ min
DRUGS1.Meperidine 25 mg
2.Omeprazole 40g
3.Metronidazole 500mg
4. Vamine Glucose x 8 hrs. alternate with Intralipid x 8 hrs. B.I.D.
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
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5. Tramadol 50 mg IV q 8 hrs.
6 .Buscopan 1amp IV q 8 hrs.
DIETNPO
SOFT LIQUID DIET
ACTIVITY/EXERCISES
May turn side to side
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
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Discharge Planning
SO- Received patient on bed conscious and
Body malaise Restlessness Pain felt on the abdominal are Facial grimaces Irritability
V/ST- 37.3 RR- 19
PR-98 BP- 130/80
A = Home Maintenance and Management
P = After 3 hours of nursing interventions, patient will be able to verbalize understanding
on the health teachings for promotion and maintenance of health.
I = METHOD Medications: Instructed patient the following home medication
Omeprazole (Anti-ulcer) 40mg two tablets three times a day. Report any sign of adverse effects.
Exercise: Instructed to avoid strenuous and stressful activities such as laundry, straining and
bending over and lifting heavy objects. Encouraged to perform tolerable exercises of activities of daily living such as
sweeping the floor and cooking.
Treatment: Emphasized to patient strict compliance to medical regimen. Take home medications as ordered
Health Teachings: Instructed to go to JBLMRH for check- up once a month. Instructed to avoid foods that are high in fats, cholesterol, oily foods and most
especially salty foods. Encouraged rest in between periods of activities Instructed to avoid lifting heavy objects Encouraged relaxation technique such as listening to radio and watching
television. Emphasized the importance of taking medications strictly as ordered
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Stressed the importance of compliance to medical regimen
OPD follow-up: Instructed to come back on September 3, 2007 at Medicine-OPD section near the
gate. Diet: Instructed to eat low fat, low salt diet
VII. CONCLUSIONS AND RECOMMENDATIONS
Acute pancreatitis is an acute inflammatory condition of the pancreas that may extend to local and distant extra pancreatic tissues. Acute pancreatitis is sudden inflammation of the pancreas that may be mild or life threatening but that usually subsides. The exact cause of acute pancreatitis may differ among different patients, but in general it is not well understood. It is thought that enzymes normally secreted by the pancreas in an inactive form become activated inside the pancreas and start to digest the pancreatic tissue. Generally the patient needs hospitalization with administration of intravenous fluids to help restore blood volume. Medication for pain and nausea are provided to ease these symptoms and food is withheld until these symptoms have subsided considerably.
As a student nurse, it is our responsibility to be knowledgeable enough about the disease our patients have. This is very important to understand their condition and to know why they experience such. Enough information about diseases will help us to know the proper interventions we can provide to our patients. Learn to care and love the patients we are handling, this will help us lessen the pressure and tiredness especially during toxic days of duty. We should also keep our experiences with every patient, because we might encounter the same case in the future.
Upon concluding this study, I am fortunate enough to understand the disease condition of our patient. It helps me a lot to read more topics about her condition and find ways to help her. It also gives me awareness that Acute pancreatitis resolved cholecystolithiasis is not only a ordinary illness. It is an illness that can threaten life and puts a person into a danger. It also helps me to understand her different medications that she has, and how it would affect her normal functioning.
I only recommend to the different concern citizen to be more aware about the cause of this illness. Let us learn from the experience of our patient, excessive intake of junkfood and carbonated drinks would lead to her illness. Recommend them to be consciously enough to limit Fatty rich foods, or foods rich in monosodium glutamate (MSG). and know priorities of what foods are essential.
After conducting this case study concerning Acute Pancreatitis, we recommend this in particular with the chain- smokers, alcoholics and other folks that are fond of eating high sodium foods, high caloric diet.
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VIII. BIBLIOGRAPHY
http://www.medicinenet.com/pancreatitis/article.htm
http://www.facs.org/spring_meeting/gs09murr.pdf
http://www.emedicine.com/radio/byname/pancreatitis-acute.htm
http://www.medscape.com/viewarticle/488046_2
http://en.wikipedia.org/wiki/Acute_pancreatitis
http://www.pancreasfoundation.org/Docs/pancreatitisinchildhood2.doc
http://pathology2.jhu.edu/pancreas/digestsy.cfm
*http://en.wikipedia.org/wiki/
*http://wrongdiagnosis.com/
*http://www.medicinenet.com/script/main/hp.asp
*Davis’s drug guide for nurses, tenth edition by Judith Hopfer Deglin and April Hazard Vallerand
*Medical-surgical Nursing by Brunner and Suddarth.
*^ Ginsburg, Ph.D., J.N. (2005-08-22). "Control of Gastrointestinal Function", in Thomas M. Nosek, Ph.D.: Gastrointestinal Physiology, Essentials of Human Physiology. Augusta, Georgia, United State: Medical College of Georgia, p. 30. Retrieved on 2007-06-29.
*^ Laboratory 38. Stomach, Spleen and Liver, Step 14. The Gallbladder and the Bile System. Human Anatomy (Laboratory Dissections). SUNY Downstate Medical Center, Brooklyn, NY (2003-11-17). Retrieved on 2007-06-29.
*Abdominal dissection, gall bladder position emphasized (JPG). Human Anatomy (Laboratory Dissections). SUNY Downstate Medical Center, Brooklyn, NY (2003-11-17). Retrieved on 2007-06-29.
*Slide 5: Gall Bladder. JayDoc HistoWeb. University of Kansas. Retrieved on 2007-06-29.
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*Physiology at MCG 6/6ch2/s6ch2_30
*New Standard Encyclopedia, 1988. Volume P Page 68
*Cutler, Anne G., et al., eds. Stedman's Medical Dictionary. Baltimore: The William and Wilkins Company, 1976 ed.
*Norman/Georgetown pancreas
*Histology at BU 10404loa
*Harper, Douglas. Pancreas. Online Etymology Dictionary. Retrieved on April 4, 2007.
*http://www.moondragon.org/nutrition/diet/softdiet.html
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