Our Lady of Fatima University

College of Nursing
Valenzuela Campus

Intestinal Obstruction Partial Probably sec to Colonic

Malignancy
In Partial Fulfillment of requirements of NCM 107B RLE leading to the degree of Science in Nursing

A Case Study
Presented to:
Ms. Vanessa O. Umali, R.N. MAN

Presented by:
Maria Paula M. Bungay
July 26, 2015
TABLE OF CONTENTS

I. Introduction
II. Objectives
III. Patients Profile
IV. Anatomy and Physiology
V. Pathophysiology
VI. Laboratory Examination Results
VII. Gordons Assessment
VIII. Nursing Care Plans
IX. Drug Study
X. Health Teachings

I. Introduction

In the present generation, we cannot deny the reality that different diseases sprout as
life progresses. The world is in the generation where diseases are widespread and the medical
fields are doing their further research in order to stop them. Being responsible for ones health is
very important for it builds the foundation of a healthy body. It is our choice to live a disease free
body. It is always our choice of what food will you eat, how much sleep you need, etc. There are
a lot of fashion trends in the world that will make each individuals life a masterpiece, but the
best fashion trend at present is a fit, healthy body.
Intestinal obstruction is significant mechanical impairment or complete arrest of the
passage of contents through the intestine. Symptoms include cramping pain, vomiting,
constipation, and lack of flatus. Diagnosis is clinical, confirmed by abdominal x-rays. Treatment
is fluid resuscitation, nasogastric suction, and, in most cases of complete obstruction, surgery.
According to Bordeianou and Yeh of Wolters Kluwers, Bowel obstruction occurs when
the normal flow of intraluminal contents is interrupted. Obstruction can be functional (due to
abnormal intestinal physiology) or due to a mechanical obstruction, which can be acute or
chronic. Advanced small bowel obstruction leads to bowel dilation and retention of fluid within
the lumen proximal to the obstruction, while distal to the obstruction, as luminal contents pass,
the bowel decompresses. If bowel dilation is excessive, or strangulation occurs, perfusion to the
intestine can be compromised leading to necrosis or perforation, complications, which increase
the mortality, associated with small bowel obstruction.
The most common causes of mechanical small bowel obstruction are postoperative
adhesions and hernias. Other etiologies of small bowel obstruction include disease intrinsic to
the wall of the small intestine (eg, tumors, stricture, intramural hematoma) and processes that
cause intraluminal obstruction (eg, intussusception, gallstones, foreign bodies).
Acute, mechanical small bowel obstruction is a common surgical emergency. It is
estimated that over 300,000 laparotomies per year are performed in the United States for
adhesion-related obstructions. Ischemia, which complicates 7 to 42 percent of bowel
obstructions, significantly increases mortality associated with bowel obstruction.
The small bowel is involved in about 80 percent of cases of mechanical intestinal
obstruction. The incidence is similar for males and females. In one Polish study of adult

patients, the average age of patients with acute obstruction was 64 years, women comprised 60
percent of the group, and the small bowel was affected in 76 percent.
In addition, I have learned and gained new knowledge regarding on Intestinal
obstruction. The in-depth understanding of the etiology, pathophysiology, clinical manifestations,
diagnosis, treatment and prevention of this condition has yield and enhanced my acquired
knowledge. As a student nurse, I also believed that actual interaction with the patient who has
the condition being studied can make it easier to understand. Also, to be able to learn
completely, one must be able to know how the concepts learned be applied into the actual
clinical practice.
The knowledge I acquired through this study will give me the opportunity to improve my
capability to deliver efficient and appropriate interventions and information to a variety of
population. The knowledge, skills and attitude that comprise an effective nurse will be of high
regard to promote a reduction in the morbidity and mortality rate. (http://www.uptodate.com/).

II. Objectives
Nurse-Centered

After the completion of this case study, the nurse will be able to:
1.

Understand the current statistics and latest trend regarding Intestinal Obstruction
partial probably sec to Colonic Malignancy.

2.

Describe factually, the personal and pertinent family history of the patient and relate it to the
present condition.

3.

Perform comprehensive physical assessment.

4.

Trace the book-based and client-centered pathophysiology of Intestinal Obstruction partial

probably sec to Colonic Malignancy.

5.

Determine the predisposing and precipitating factors and the signs and symptoms and
relate to the disease process.

6.

Enumerate and describe the diagnostic and laboratory procedures as well as the nursing
responsibilities in relation to the disease condition

7.

Enumerate the different treatment modalities and their indication specifically for the patients
condition.

8.

Identify the pharmacologic treatment provided to the patient, relate the actions of each drug
with the disease process and evaluate the patients response to the medications given.

9.

Identify nursing diagnoses, formulate short-term goals, carry out appropriate interventions
and evaluate the plan.

10. Appraise the effectiveness of medical and surgical nursing management in treating the
patient.
11. List the preventive measure for the occurrence of Intestinal Obstruction partial probably sec
to Colonic Malignancy for the benefit of the general public.
Patient Centered
After the completion of this case study, the patient will be able to:
1. Report understanding of the disease process.
2. Understand the indications of the different diagnostic procedures and medical
management involved in her care.
3. Cooperate with the necessary medical and nursing interventions.
4. Adhere with the health teachings provided.
5. Understand the different ways of health promotion and prevention in relation to the
disease condition.

6. Demonstrate improved conditions as evidenced by absence of further complications.

III. Patients Profile
Name: Mr. Isaw
Age: 62 years old
Birthday: February 18, 1952
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Married
Date Admission: July 2, 2015
Time of Admission: 12:15 PM
Chief Complaint's: Abdominal Pain
Initial Diagnosis: Intestinal Obstruction Partial Probably sec to Colonic Malignancy
Final Diagnosis: None

HISTORY OF PAST ILLNESS

During the previous years, Mr. Isaw was diagnosed Hypertensive in 2014 and a
history of vehicular accident 20 years ago, which affected his Left femur. He is a non-smoker
and non-alcoholic. As for childhood illness, he had chicken pox and measles. He also
experienced coughs and colds for common illness. To relieve symptoms, he would take
different herbal plants or purchase over-the-counter drugs. For the herbal plants, he
prepares decoction with one to two glasses of water for fifteen minutes or until one half of
the liquid is left. Then, he will drink it. He also experienced fever once in a while in which he
takes over-the-counter drugs. Mr. Isaw, has no family history of hypertension, Diabetes,
Arthymias, Pulpomonary Tuberculosis, and Cancer. For food allergies, crab and shrimp are
contraindicated but no allergies to drugs.
HISTORY OF PRESENT ILLNESS
Prior to admission, Mr. Isaw complained of sudden onset abdominal pain described as
bloatedness more prominent in the epigastric and right periumbilical area. There was no

associated nausea, vomiting, change in bowel habits, hematochezia, melena, jaundice and
fever. Patient consulted at PGH, Abdominal X-ray revealed dilated small bowels. He was then
referred to the institution for further management.
PHYSICAL ASSESSMENT
Physicians Physical Assessment done by the Resident on Duty (July 2, 2015, lifted from the
patient's chart)
Height: 56
Weight: 81 kg
Vital Signs as follows:
T: 36.9 C

PR: 116 bpm

RR: 18cpm

BP: 150/90 mmHg

SAO2: 97%

GENERAL SURVEY
Mr. Isaw, Assessed/received patient lying on bed, awake, conscious, responsive, and
coherent. With the following vital signs:
Temperature: 36.7 C
Heart rate: 70 bpm
Respiratory rate: 20 bpm
Blood Pressure: 140/90 mmHg
SAO2: 96%
NUTRITIONAL STATUS
Upon admission, Mr. Isaw was placed on NPO and IVF of D5LR 1 x Q8. CBC, BT,
PTPTT, FBS, BUN, CREA, Na, K, Cl, 12-LECG, Chest X-ray PA, abdominal series, and
Urinalysis were requested. NGT and Foley Catheter were inserted.

SKIN

> Pallor noted.

> Good skin turgor in both upper and lower extremities; the skin returns to its previous state
immediately after being tented.
> warm moist skin, no active dermatoses.
HAIR
> Hair is black and is evenly distributed.
> Silky and smooth hair.
> No areas of hair loss noted.
> Thick hair strands.
NAILS
> Trimmed clean nails.
> Concave shaped; with a nail plate angle of about 160 degrees.
> Smooth in texture.
> Intact epidermal lining around the nails.
> Capillary Refill Test less than 3 seconds.
SKULL AND FACE
> Rounded (normocephalic and symmetrical with frontal, parietal and occipital
prominences).
> Head has no cervical lymphadenophaties
> No nodules or masses upon palpation.
EYES AND VISION

> Eyebrows and eyelashes are evenly distributed.

> Eyelids are intact
> Pink palpebral conjuctiva
> Sclera appears white.
> Pale conjunctiva.
> No discharges and discoloration noted.
> Blink reflex intact.
EARS AND HEARING
> Ears are symmetrical in size and in line with the outer canthus of the eyes.
> Color of ears is the same with the facial skin.
> No discharges and foul odor noted upon inspection.
> Pinna and ear canal are clean.
> Auricles are firm and recoil to previous state when folded.
> No nodules or masses noted upon palpation
NOSE AND SINUSES
> No nasal discharge
> No tenderness masses and pain noted upon palpation
OROPHARYNX (Mouth and Throat)
> Dry and pale lips noted upon inspection
> Tongue is able to move freely

> Good oral hygiene.

> Thyroid gland moves with deglutition
NECK
> Jugular vein is not visible
> Muscles are equal in size with the head centered
> Slow muscle movement
> Lymph nodes are not palpable
CARDIOVASCULAR AND PERIPHERAL SYSTEM
> Skin color of palm of the hand and feet is pink.
> Pink nail beds upon inspection.
> Symmetric pulse volumes, full pulsations of peripheral pulses.
> Heart rate is 70 beats per minute.
> Blood Pressure is 140/90 mmHg
> (Vital signs taken during the time of assessment July 2, 2015 at 0715H)
RESPIRATORY SYSTEM
> + DOB
> Symmetric chest expansion
> Skin and chest wall are intact and has uniform temperature
> No tenderness and masses noted upon palpation
> Regular breathing pattern

10

> Presence wheezing and crackles sound upon auscultation

> Full and symmetric chest wall expansion
BREAST AND AXILLAE
> Breasts are symmetrical in size; color is the same as with the abdomen.
> Both nipples are symmetrical in size.
> No discharges noted.
> No tenderness, masses, and nodules noted upon palpation.
ABDOMEN
> Direct tenderness at epigastric area.
> Abdominal skin is intact.
> Distended abdomen noted.
> Audible bowel sound upon auscultation.
> Abdominal dullness upon percussion.
MUSCULOSKELETAL
> Posture is good, able to stand straight and can walk alone properly but slowly
> Scar at left thigh and right medial leg and foot
NEUROLOGIC
>with a GCS of 15
> Patient has times of looking in the distance and is slow in response when a question
asked.

11

> Patient was able to answer well when asked of her complete name, birth date and age.
URINARY SYSTEM
> Patient has indwelling Foley Catheter
REPRODUCTIVE SYSTEM
> The patient refused to be assessed with her external reproductive organ but she
verbalized that she has minimal vaginal bleeding and complain of pain when secretions are
expelled.
REVIEW OF SYSTEM
Integumentary System
The patient has no history of bruises in both upper and lower extremities.
Head
The patient had no history of any form of head injuries.
Eyes
Patient had no history of any eye problems.
Ears and Hearing
Patient had no history of smelly discharges on both ears, and no complaints of hearing
impairment.
Breast and Axillae
The patient had no history of breast nodules, no enlargement, no tenderness, no pain and
unusual discharges.
Respiratory System

12

The patient has no history of asthma or other respiratory problems.

Cardiovascular System
The patient has a history of hypertension.
Genitourinary System
The patient had no history of any genital problems. Usually urinates 5 times a day.
Gastrointestinal System
The patient had experienced abdominal pain.
Musculoskeletal System
Patient has no history of joint pain.
Neurologic System
Patient had no history of any major mental problems.

Cranial Nerve Assessment:

13

CRANIAL NERVE

ASSESSMENT
TECHNIQUE

EXPECTED
OUTCOME

ACTUAL FINDINGS

I: Olfactory
Type: Sensory
Function: Smell

Ask the client to

identify a scented
object that you are
holding.

Client is able to
identify different
smell with each
nostril separately
and with eyes
closed unless such
condition like colds
is present.

The client was able to

identify the aromas of
cologne and alcohol
that she had smelled.

II: Optic
Type: Sensory
Function: Vision

Provide adequate
lighting and ask client
to read words on a
newspaper held at a
distance of 36 cm (14
inches) with each eye
first then both eyes.

The client should be

able to read with
each eye and both
eyes.

The client was able to

read the words in the
newspaper at 14
inches.

III: Oculomotor, IV:

Trochlear & VI:
Abducens
Type: Motor
Function: Upward
and Downward
movement of Pupils.

-Hold a penlight 1 ft.

-Clients eyes should
in front of the clients be able to follow the
eyes. Ask the client to penlight as it moves.
follow the movements
of the penlight with
the eyes only. Move
the penlight upward,
downward, sideward
and diagonally.
-Ask the client to look
straight ahead then
approach the pupil
with a penlight and
observe for pupil
constriction.

-The clients eyes will

have a normal
reaction for PERRLA.

-Both eyes of the

client were able to
follow the Penlights
movements.

-The client had a

normal reaction to
PERRLA as Pupils
are equally round,
reactive to light and
accommodation.

V: Trigeminal
Type: Sensory
Function: Sensation
of cornea

While client looks

upward, lightly touch
the lateral sclera of
eye to elicit blink
reflex.

Client should have a

positive corneal
reflex.

The client was able to

elicit corneal reflex.

VII: Facial
Type: Motor
Function: Facial
movements

Ask client to: smile,

frown and wrinkle
forehead, show teeth,
puff out cheeks,

Client should smile,

frown and wrinkle
forehead, show teeth,
puff out cheeks,

The client was able to

do the facial
movements
symmetrically.

14

purse lips, raise

eyebrows, close eyes
tightly against
resistance

purse lips, raise

eyebrows, close eyes
tightly against
resistance.
Movements are
symmetrical.

VIII:
Vestibulocochlear/
acoustics
Type: Sensory
Function: Hearing

Have the Client

occlude one ear. Out
of the clients sight,
place a tickling watch
2 cm. Ask what the
client can hear and
repeat with the other
ear.

Client should be able

to hear the ticking of
the watch in both
ears.

The client was able to

hear the ticking of the
watch in both ears.

IX. Glossopharyngeal
& X: Vagus
Type: Motor
Function:
Swallowing and
Speaking

Ask the client to

swallow and say its
name.

The client should be

able to swallow
without difficulty and
speak audibly.

The client was able to

swallow without
difficulty and speak
audibly.

XI. Spinal Accessory

Type: Motor
Function: strength
and resistance

-Ask client to shrug

the shoulders against
your hands.

-There is symmetric,
strong contraction of
the trapezious
muscles.

The client was able to

symmetrically
contract the
trapezious muscle.

-Ask client to turn the

head against
resistance, first to the
right then to the left,
to assess the
sternocleidomastoid
muscle.

-There is strong
contraction of the
sternocleidomastoid
muscle on the side
opposite to the turned
face.

-The client was able

to contract
strenocleidomastoid
muscleon the side
opposite to the turned
face.

Ask the client to

protrude the tongue
and move in different
directions.

The client will be able

to protrude her
tongue and move in
different directions.

The client was able to

protrude his tongue
and move it in
different directions.

XII: Hypoglossal
Type: Motor
Function: Movement
and strength of
tongue

15

IV. Anatomy and Physiology

The digestive system, sometimes called the gastrointestinal tract, alimentary tract, or gut,
consists of a long hollow tube which extends through the trunk of the body, and its accessory
structures: the salivary glands, liver, gallbladder, and pancreas. The digestive tract is divided
into two sections, the upper tract, consisting of the mouth, esophagus, and stomach, and the
lower tract, consisting of the intestines.
FIGURE 20-1 Anatomy of the digestive system with associated events.

Inside this tube, ingested food and fluid, along with secretions from various glands, are
efficiently processed. First, they are broken down into their separate constituents; then the
desired nutrients, water, and electrolytes are absorbed into the blood for use by the cells, and
waste elements are eliminated from the body. Within this system, the liver can reassemble the

component nutrients into new materials as they are needed by the body. For example, the
proteins in milk are digested by enzymes in the digestive tract, producing the component amino
acids, which are then absorbed into the blood. The individual amino acids are used by the liver
cells to produce new proteins, such as albumin or prothrombin, or they may circulate as they are
in the amino acid pool in the blood to be taken up by individual cells as necessary.
The peritoneal cavity refers to the potential space between the parietal and visceral
peritoneum. A small amount of serous fluid is present in the cavity to facilitate the necessary
movement of structures such as the stomach. Numerous lymphatic channels drain excessive
fluid from the cavity.
Because serous membranes are normally thin, somewhat permeable, and highly
vascular, the peritoneal membranes are useful as an exchange site for blood during peritoneal
dialysis in patients with kidney failure. However, such an extensive membrane may also facilitate
the spread of infection or malignant tumor cells throughout the abdominal cavity or into the
general circulation.
The mesentery is a double layer of peritoneum that supports the intestines and
conveys blood vessels and nerves to supply the wall of the intestine. The mesentery attaches
the jejunum and ileum to the posterior (dorsal) abdominal wall. This arrangement provides a
balance between the need for support of the intestines and the need for considerable flexibility
to accommodate peristalsis and varying amounts of content.
The greater omentum is a layer of fatty peritoneum that hangs from the stomach like an
apron over the anterior surface of the transverse colon and the small intestine. The lesser
omen-tum is part of the peritoneum that suspends the stomach and duodenum from the liver.
When inflammation develops in the intestinal wall, the greater omentum, with its many lymph
nodes, tends to adhere to the site, walling off the inflammation and temporarily localizing the
source of the problem. Inflammation of the omentum and peritoneum may lead to scar tissue
and the formation of adhesions between structures in the abdominal cavity, such as loops of
intestine, restricting motility and perhaps leading to obstruction.
Intestinal Obstruction
Intestinal obstruction refers to a lack of movement of the intestinal contents through
the intestine. Because of its smaller lumen, obstructions are more common and occur more
rapidly in the small intestine, but they can occur in the large intestine as well. Depending on the
cause and location, obstruction may manifest as an acute problem or a gradually developing
situation. For example, twisting of the intestine could cause sudden total obstruction, whereas

a tumor leads to progressive obstruction. FIGURE 20-37 Colostomy. A, sigmoid colostomy-a

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

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

Colon
The colon is the last part of the digestive system in most vertebrates; it extracts water
and salt from solid wastes before they are eliminated from the body, and is the site in which
flora-aided (largely bacteria) fermentation of unabsorbed material occurs. Unlike the small
intestine, the colon does not play a major role in absorption of foods and nutrients. However,
the colon does absorb water, potassium and some fat soluble vitamins.
In mammals, the colon consists of four sections: the ascending colon, the transverse
colon, the descending colon, and the sigmoid colon (the proximal colon usually refers to the
ascending colon and transverse colon). The colon, cecum, and rectum make up the large
intestine.
The location of the parts of the colon are either in the abdominal cavity or behind it

in

the retroperitoneum. The colon in those areas is fixed in location.

Arterial supply to the colon comes from branches of the superior mesenteric artery (SMA) and
inferior mesenteric artery (IMA). Flow between these two systems communicates via a
"marginal artery" that runs parallel to the colon for its entire length. Historically, it has been
believed that the arc of Riolan, or the meandering mesenteric artery (of Moskowitz), is a
variable vessel connecting the proximal SMA to the proximal IMA that can be extremely

important if either vessel is occluded. However, recent studies conducted with improved
imaging technology have questioned the actual existence of this vessel, with some experts
calling for the abolition of the terms from future medical literature.
Venous drainage usually mirrors colonic arterial supply, with the inferior mesenteric vein
draining into the splenic vein, and the superior mesenteric vein joining the splenic vein to form
the hepatic portal vein that then enters the liver.
Lymphatic drainage from the entire colon and proximal two-thirds of the rectum is to the
paraaortic lymph nodes that then drain into the cisterna chyli. The lymph from the remaining
rectum and anus can either follow the same route, or drain to the internal iliac and superficial
inguinal nodes. The pectinate line only roughly marks this transition.
Ascending colon
The ascending colon, on the right side of the abdomen, is about 25 cm long in humans.
It is the part of the colon from the cecum to the hepatic flexure (the turn of the colon by the
liver). It is secondarily retroperitoneal in most humans. In ruminant grazing animals, the cecum
empties into the spiral colon.
Anteriorly it is related to the coils of small intestine, the right edge of the greater
omentum, and the anterior abdominal wall. Posteriorly, it is related to the iliacus, the iliolumbar
ligament, the quadratus lumborum, the transverse abdominis, the diaphragm at the tip of the
last rib; the lateral cutaneous, ilioinguinal, and iliohypogastric nerves; the iliac branches of the
iliolumbar vessels, the fourth lumbar artery, and the right kidney. The ascending colon is
supplied by parasympathetic fibers of the vagus nerve (CN X).
Arterial supply of the ascending colon comes from the ileocolic artery and right colic artery,
both branches of the SMA. While the ileocolic artery is almost always present, the right colic
may be absent in 515% of individuals.
Transverse colon
The transverse colon is the part of the colon from the hepatic flexure to the splenic
flexure (the turn of the colon by the spleen). The transverse colon hangs off the stomach,
attached to it by a wide band of tissue called the greater omentum. On the posterior side, the
transverse colon is connected to the posterior abdominal wall by a mesentery known as the
transverse mesocolon.
The transverse colon is encased in peritoneum, and is therefore mobile (unlike the parts
of the colon immediately before and after it). Cancers form more frequently further along the
large intestine as the contents become more solid (water is removed) in order to form feces.
The proximal two-thirds of the transverse colon is perfused by the middle colic artery, a
branch of SMA, while the latter third is supplied by branches of the IMA. The "watershed" area

between these two blood supplies, which represents the embryologic division between the
midgut and hindgut, is an area sensitive to ischemia.
Descending colon
The descending colon is the part of the colon from the splenic flexure to the beginning of
the sigmoid colon. The function of the descending colon in the digestive system is to store food
that will be emptied into the rectum. It is retroperitoneal in two-thirds of humans. In the other
third, it has a (usually short) mesentery. The arterial supply comes via the left colic artery.
Sigmoid colon
The sigmoid colon is the part of the large intestine after the descending colon and before
the rectum. The name sigmoid means S-shaped (see sigmoid). The walls of the sigmoid colon
are muscular, and contract to increase the pressure inside the colon, causing the stool to move
into the rectum.
The sigmoid colon is supplied with blood from several branches (usually between 2 and 6) of
the sigmoid arteries, a branch of the IMA. The IMA terminates as the superior rectal artery.
Sigmoidoscopy is a common diagnostic technique used to examine the sigmoid colon.
Redundant colon
One variation on the normal anatomy of the colon occurs when extra loops form,
resulting in a longer than normal organ. This condition, referred to as redundant colon, typically
has no direct major health consequences, though rarely volvulus occurs resulting in obstruction
and requiring immediate medical attention.[4] A significant indirect health consequence is that
use of a standard adult colonoscope is difficult and in some cases impossible when a
redundant colon is present, though specialized variants on the instrument (including the
pediatric variant) are useful in overcoming this problem.
Standing gradient osmosis
Water absorption at the colon typically proceeds against a transmucosal osmotic
pressure gradient. The standing gradient osmosis is a term used to describe the reabsorption
of water against the osmotic gradient in the intestines. This hypertonic fluid creates an osmotic
pressure that drives water into the lateral intercellular spaces by osmosis via tight junctions and
adjacent cells, which then in turn moves across the basement membrane and into the
capillaries.
Functions of the Colon

There are differences in the large intestine between different organisms, the large
intestine is mainly responsible for storing waste, reclaiming water, maintaining the water
balance, absorbing some vitamins, such as vitamin K, and providing a location for flora-aided
fermentation.Vitamin K is essential as a coagulation factor.
By the time the chyme has reached this tube, most nutrients and 90% of the water have
been absorbed by the body. At this point some electrolytes like sodium, magnesium, and
chloride are left as well as indigestible parts of ingested food (e.g., a large part of ingested
amylose, protein which has been shielded from digestion heretofore, and dietary fiber, which is
largely indigestible carbohydrate in either soluble or insoluble form). As the chyme moves
through the large intestine, most of the remaining water is removed, while the chyme is mixed
with mucus and bacteria (known as gut flora), and becomes feces. The ascending colon
receives fecal material as a liquid. The muscles of the colon then move the watery waste
material forward and slowly absorb all the excess water. The stools get to become semi solid
as they move along into the descending colon. The bacteria break down some of the fiber for
their own nourishment and create acetate, propionate, and butyrate as waste products, which
in turn are used by the cell lining of the colon for nourishment. No protein is made available. In
humans, perhaps 10% of the undigested carbohydrate thus becomes available; in other
animals, including other apes and primates, who have proportionally larger colons, more is
made available, thus permitting a higher portion of plant material in the diet. This is an example
of a symbiotic relationship and provides about one hundred calories a day to the body. The
large intestine produces no digestive enzymes - chemical digestion is completed in the small
intestine before the chyme reaches the large intestine. The pH in the colon varies between 5.5
and 7 (slightly acidic to neutral).

Colonic Carcinoma / Colon Carcinoma / Colon Cancer

Definition:
It is a disease in which malignant (cancer) cells form in the tissues of the colon.
The colon is part of the body's digestive system. The digestive system removes
and processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) from
foods and helps pass waste material out of the body. The digestive system is made up of the
esophagus, stomach, and the small and large intestines. The first 6 feet of the large intestine
are called the large bowel or colon. The last 6 inches are the rectum and the anal canal. The
anal canal ends at the anus (the opening of the large intestine to the outside of the body).
Risk Factors:
Age and health history can affect the risk of developing colon carcinoma .
Risk factors include the following:

Age 50 or older.

A family history of carcinoma of the colon or rectum.

A personal history of carcinoma of the colon, rectum, ovary, endometrium, or breast.

A history of polyps in the colon.

Signs and Symptoms:

A change in bowel habits.

Blood (either bright red or very dark) in the stool.

Diarrhea, constipation, or feeling that the bowel does not empty completely.

Stools that is narrower than usual.

Frequent gas pains, bloating, fullness, or cramps.

Weight loss for no known reason.

Feeling very tired.

Vomiting.
A specimen removed from a patient with colonic carcinoma

V. Pathophysiology
Pathophysiology of Intestinal obstruction

Risk Factors for Intestinal obstruction

Crohns disease narrows intestinal

passageways due to thickening
Abdominal Cancer

2 types of obstructions

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

(+) Increased fluid and gas

Functional:
Intestinal muscles
cannot propel the
contents along the
bowel

Increased pressure on
intestinal wall causes
more fluid to enter
intestine

(+) Severe vomiting

& pain

(+) Dehydration &

Electrolyte
Imbalance

Decreased blood
pressure &pressure on
Continued
hypovolemic
shock
intestinal
wall causes
edema, ischemia and
decreased peristalsis

(+) Increased peristalsis

attempts to force contents
past obstruction

(+) Abdominal distention

Prolonged ischemia causes

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

(+) mass in the

small intestine

Pathophysiology of Colon Cancer

Predisposing factors:

(+) Age (56% >70yrs

old)

Colorectal polyps

Family history

Previous colorectal
cancer

Ulcerative colitis
/colonic crohns
disease

Diagnostic test:

Fecal occult blood

test

SigmoIdoscopy

Digital Rectum
Exam

Surgical Treatment:

Colonoscopy

Virtual Colonoscopy

Precipitating factors:
Patient broke her right leg
due to falling on the stairs
Precipitating factors:

Diet high fat/low

fiber

Smoking

Alcohol drinking

(+)Lack of exercise

Etiology:
Unknown

Abnormal
proliferation of cells
in the colon area

Signs and Symptoms:

Rectal bleeding

Bloody stools

(+) Abdominal pain

(+) Fatigue

Constipation

(+)Diarrhea

Arising from
epithelial lining of the
intestine

Benign polyps occur

(+) Nausea and

Vomiting

Continuous plorifetation of
cells in the polyps

Polypectomy
Reduction likelihood
of regrowth

Increase in size of the polyps

Exposure to carcinogens

Development of malignant tumor

Uncontrolled
Increase in
proliferation
COLON
CANCER
size
of cells in
the tumor

Complications
DEATH occur

Diagnostic test:

SigmoIdos
copy

VI.

Laboratory Examination

Results
Diagnostic/
Laboratory
Procedures

Date ordered Date

results in

1. Complete Blood
Count

Indications or
Purposes

Results

Normal Value (Units

used in the hospital)

Analysis and
Interpretation of
results

Hgb: 153

N: 115-175 g/L

The hemoglobin level is

normal. This indicates
that RBC is capable of
carrying O2 and CO2
throughout the body.

Hct: 0.44

N: 0.40-0.52

The result indicates

there
is
normal
concentration of RBC
within
the
blood

CBC is a
screening test,
used to diagnose
and manage
numerous
diseases. The
results can reflect
problems with
fluid or loss of
blood.

a. Hemoglobin

Date ordered/
Date of Results:
July 2, 2015

b. Hematocrit

Date ordered/
Date of Results:
July 2, 2015

Hemoglobin
determines the
RBC that carries
oxygen and
carbon dioxide
throughout the
body

Hematocrit
determines the

concentration of
RBC within the
blood volume
c. RBC
Date ordered/
Date of Results:
July 2, 2015

volume.

RBC: 4.93

N:4.5-6.2

The result is within

normal range which
indicates
that
the
body's
RBCs
containing hemoglobin,
carrying oxygen to the
body's
tissues
are
functioning normally.

WBC: 13.0

N: 5-10x 109/L

WBC is high which

indicates that there is
infection presented in
the body.

An RBC count is
a blood test that
measures
how
many red blood
cells (RBCs) you
have.
RBCs
contain
hemoglobin,
which
carries
oxygen.
How
much
oxygen
your body tissues
get depends on
how many RBCs
you have and
how well they
work.

d. WBC
Date ordered/
Date of Results:
July 2, 2015

White blood cells

(WBCs),
also
called leukocytes,
are an important
part
of
the
immune system.
These cells help

fight infections by
attacking
bacteria, viruses,
and germs that
invade the body.
White blood cells
originate in the
bone marrow, but
circulate
throughout
the
bloodstream.

DIFFERENTIAL
COUNT

a. Segmenters
Segmenters: 0.84
Date ordered/
Date of Results:
July 2, 2015

A type of white
blood cell that
respond
to
bacterial
infections. Where
the blood count
has high levels of
segmenters, this
indicates
the
presence of a
bacterial infection.
Where there is a
low
level
of
segmenters, the
patient is likely to
be suffering from
a viral infection or

N: 0.55-0.65

The result is higher

than the normal range.
Which
indicates
presence of bacterial
infection.

an autoimmune
disease.

b.Lymphocytes

Lymphocytes: 0.27
Date ordered/
Date of Results:
July 2, 2015

Lymphocytes are
responsible
for
immune
responses. There
are two main
types
of
lymphocytes:
B
cells and T cells.
The B cells make
antibodies
that
attack
bacteria
and toxins while
the T cells attack
body
cells
themselves when
they have been
taken over by
viruses or have
become
cancerous.
Lymphocytes
secrete products
(lymphokines)
that modulate the
functional
activities of many
other types of
cells and
are
often present at
sites of chronic
inflammation.

N: 0.25-0.35

Normal
count
of
lymphocytes indicates
that
there
is
no
presence of infection in
the body

c. Eosinophils

N: 0.02-0.04
0.00
Date ordered/
Date of Results:
July 2, 2015

Eosinophils are a
specific type of
white blood cell
that protects your
body against
certain kinds of
germs, mainly
bacteria and
parasites. They're
also what causes
you to have
allergic reactions.

d. Monocytes
Date ordered/
Date of Results:
July 2, 2015

The result is below the

normal range. Which
indicates no significant.

0.06
Monocytes are a
type
of
white
blood cell that
fights off bacteria,
viruses and fungi.
Monocytes
are
the biggest type
of white blood cell
in the immune
system. Originally
formed in the
bone
marrow,
they are released
into our blood and
tissues.
When
certain
germs
enter the body,
they quickly rush

N: 0.03-0.06

The result is normal.

Which indicates that
the body can fights off
bacteria, virus and
fungi,

to the
attack.

site

for

e. Basophils
Date ordered/
Date of Results:
July 2, 2015

N: 0.00-0.01

Platelet Count:
311

Platelet Count:
150- 400 x 109/L

Basophils
are
granulocytic white
blood cells that
are active in the
inflammatory
response.
They
are mostly found
in the skin and
mucosa tissues,
which are the
tissues lining the
openings into the
body.
They
represent about
1% of all white
blood cells in the
body.

Platelet Count
Date ordered/
Date of Results:
July 2, 2015

0.00

A platelet count is
a test to measure
how
many
platelets you have
in your blood.
Platelets are parts
of the blood that
help the blood
clot. They are
smaller than red

The result is normal,

which indicates that
body is active for
inflammatory response.

The result is within the

normal range indicates
that there is enough
platelet produces for
coagulation.

or white
cells.

blood

Nursing Responsibilities:
BEFORE
1. Explain to the patient the procedure and its purposes.
2. If the patient has eaten a meal with high sodium content in the past 24 hours, this should
be noted.
3. Be sure not to draw blood, which has infused IVF.
4. Note if patients on a diet that restricts sodium and other nutrients.
5. Note other conditions such as diabetes.
6. Carefully watch for signs of electrolyte imbalance.
7. Perform a complete cephalocaudal assessment especially cardiac assessment and vital
signs.
8. Make sure to have the right patient, specimen and method.
DURING
1. Clean injection site with alcohol.
2. Lower the patients arm to dilate the veins.
3. Apply tourniquet and ask the patient to open and close fist.
4. Remove the tourniquet when drawing the final tube of blood.
AFTER
1. Note for any signs of discomfort or bruising at the puncture site.
2. Provide pressure at the puncture site to stop bleeding and reduce bruising.
3. Apply warm compress to puncture site to relieve discomfort.
4. Send the specimen at the laboratory.

B. Blood Chemistry
Diagnostic/ Laboratory
Procedures

Date ordered
Date results in

Indications or
Purposes

Date ordered:

A serum creatinine
test which
measures the level
of creatinine in your
blood can
indicate whether
your kidneys are
working properly.

70.10 umol/L

It regulates body
water along with
potassium. It is
responsible
for
nerve
conduction
and contraction of
muscle.

Na: 141

Results

Normal Value
(Units used in
the hospital)

Analysis and
Interpretation of
results

2. CLINICAL
CHEMISTRY TEST

Creatinine

July 2, 2015
Date of Results:
July 2, 2015

Sodium

Date ordered:
July 2, 2015
Date of Results:
July 2, 2015

N: 71-115
umol/L

The result is lower

than the normal
range which
indicate that the
kidney has a
slightlyl glomerular
filtration and renal
damage. Creatinine
is more accurate for
renal condition.

N: 135-148
mmol/L

The result is within

normal range, it
indicates
no
presence
of
hypernatremia
or
hyponatremia

Potassium

Date ordered:
July 2, 2015
Date of Results:
July 2, 2015

Chloride

Date ordered:
July 2, 2015
Date of Results:
July 2, 2015

It is a mineral,
which with Sodium
and
Calcium
maintains
normal
heart rhythm and
regulates
water
balance.
A chloride test
measures the level
of chloride in your
blood or urine.
Chloride is one of
the most important
electrolytes in the
blood. It helps keep
the amount of fluid
inside and outside
of your cells in
balance. It also
helps maintain
proper blood
volume, blood
pressure, and pH of
your body fluids.
Tests for sodium,
potassium, and
bicarbonate are
usually done at the
same time as a
blood test for
chloride.

K: 4.10

104.4

N: 3.5-5.3
mmol/L

N: 98-107
mmol/L

The result is within

normal
range,
which indicates no
presence
of
hyperkalemia
or
hypokalemia

The result is within

normal range,
which indicates
there is normal
functioning of the
muscles, heart, and
nerves. Which is
also essential for
normal fluid
absorption and
excretion.

Alanine Aminotrans
liquid

Date ordered:
July 2, 2015
Date of Results:
July 2, 2015

Aspartate Aminotrans
liquid

Date ordered:
July 2, 2015
Date of Results:
July 2, 2015

The blood test for

aspartate
aminotransferase
(AST) and alanine
aminotransferase
(ALT) are usually
used to detect liver
damage. It is often
ordered to screen
for and/or help
diagnose liver
disorders. In the
patients case, liver
function is
monitored due to
metastasis of his
cancer to his liver.
The blood test for
aspartate
aminotransferase
(AST) and alanine
aminotransferase
(ALT) are usually
used to detect liver
damage. It is often
ordered to screen
for and/or help
diagnose liver
disorders. In the
patients case, liver
function is
monitored due to
metastasis of his
cancer to his liver.

19.0 U/L

18.6 U/L

N:10.0-44.0

N: 10.0-34.0

The result is within

the normal range.
Which indicates
that liver is
functioning
normally.

The result is within

the normal range.
Which indicates
that liver is
functioning
normally.

Calcium Gen 2

Date ordered:
July 2, 2015
Date of Results:
July 2, 2015

The Calcium Gen.2

assay is an in vitro
diagnostics reagent
system intended for
the quantitative
determination of
calcium in human
serum, plasma, and
urine on
Roche/Hitachi
cobas c systems.
Calcium
measurements are
used in the
diagnosis
and treatment of
parathyroid
disease, a variety
of bone diseases,
chronic renal
disease, and
tetany.

2.18 mmol/L

N: 2.20-2.75

The result is within

the normal range.

NURSING RESPONSIBILITIES
BEFORE
1. Confirm the patients identity using two patient identifiers according to facility policy.
2. Explain the procedure and the indication.
3. Inform the patient that the test requires blood sample, and explain that he may
experience slight discomfort from the tourniquet and the needle puncture.
4. Instruct the patient that he doesnt need to restrict food and fluids. For triglycerides she
should not eat 12 hours before procedure.
5. Notify the laboratory and practitioner about any medications the patient is taking that
may affect test results; they may need to be restricted.
DURING
1. Perform venipuncture and collect the sample in a 3- or 4-mL clot activator tube.
2. Handle sample gently to prevent hemolysis.
AFTER
1. A report of the results will be sent to the requesting Health Care Provider, who will
discuss the results with the patient.
2. Depending on the results of this procedure, additional testing may be performed to
evaluate or monitor progression of the disease process and determine the need for a
change in therapy.
3. Evaluate test results in relation to the patient's symptoms and other tests performed.

Diagnostic/
Laboratory
Procedures

Date ordered
Date results
in

2. Urinalysis

Date ordered:
July 2, 2015
Date of
Results:
July 2, 2015

Indications or
Purposes

Urinalysis yields
a large amount
of information
about possible
disorders of the
kidney and lower
urinary tract, and
systemic
disorders that
alter urine
composition

Results

Color:

Normal Value
(Units used in
the hospital)

Analysis
Interpretation

Yellow

The result has

color

Amber

The result is

Yellow

Transparenc
y:
Slightly
turbid

clear 4.8-7.8

SP Gravity:

1.015-1.025

1.020

Sugar:

Negative

There is no pr
suga

Negative

There is no pr
protei

negative

Protein: +2
RBC: 2.5

Pus cells: 13
Epithelial

0.1/HPF

Indicates no pr
infectio
0.2/HPG

Few

cells:
few
Mucus
threads:
few

Indicate p
Infectio

Few

The kidney is in
function.

Nursing Responsibilities for Urinalysis:

BEFORE
1. Check the doctors order.
2. Check the right client.
3.

Encourage the SO to increase the fluid intake of the patient.

4. Apply warm on hypogastric region.

DURING
1. Provide privacy.
2. Decrease discomfort, and anxiety, allows adequate time.
3. Tell the patient to assume a normal voiding position.
4. Introduce stimuli for voiding.
5. Pour warm water over the perineum.
6. Collect a clean catch urine sample during midstream urination.
AFTER
1. Ensure that the specimen label and laboratory requisition form are filled out
correctly.
2. Securely attach the label to the container.
3. Send the specimen to the laboratory at once.
4. Document what you have done.

VII. Gordons Assessment

A.

B.

C.

D.

Health Perception and Management

o

Patient can recall being completely immunized

Visits a doctor for consultation

Takes OTC drugs and herbal medications

Nutrition/Metabolism
o

Eats more of fruits and vegetables

Eats dried /preserved fish

Eats his meals three times a day

Allergic to sea foods

Elimination
o

Voids usually five times a day

Urine color is yellow

Defecates usually once a day during morning

Activity/Exercise
o

Patient does household chores

Able to bathe himself

He does simple exercises such as arm exercises by means of shaking

and stretching

E.

F.

G.

Sexuality/Reproductive
o

Married

A father of 3 children

No history of STDs

Cognitive/Perceptual
o

Oriented to people, time and place

Responds to stimuli verbally and physically

Able to read and write

College graduate

In normal thought process

Roles/Relationship
o

Married

With 3 children

H.

I.

J.

Well-supported by the family

Loves his family so much

Self Perception/Self-Concept
o

Hopeful to be relieve and treated

Manages to practice healthy lifestyle

Value/Belief
o

A Roman Catholic

Has a strong faith in God

Attends Sunday mass

Coping/Stress
o

Experienced MVC IN 1995

Copes up with problems by talking about it with the family and finds ways
to resolve it together

K.

L.

Sleep/Rest
o

No difficulties in sleeping

Have enough rest intervals

Medication History
o

Over the counter medication (buscopan) before admissio

VIII. Nursing Care Plans

PROBLEM # 1: Decrease cardiac output related to altered heart rate/rhythm
ASSESSMENT

S:

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

Decrease
cardiac output

Occlusion in the artery

O : The patient

related to altered

Decreased blood

manifested the

heart rate/rhythm

supply

following:
Afebrile
Conscious and
coherent
Pale palpebral

Decreased venous
return

Decreased

conjunctiva

amount of blood

With capillary refill

expelled by ventricles

time of 3
seconds

manifest:
Decreased skin
turgor
Sunken eyeballs
Sudden weight
loss

Short term:

NURSING
INTERVENTIONS
1.

Establish

RATIONALE

1.

EXPECTED
OUTCOME

To gain

Short term:

After 1-2 hours of

therapeutic

trust of the

The patient

nursing

relationship

patient

shall have

interventions, the

To note any

participated in

patient will

patients

abnormaliti

activities that

participate in

general

es

reduce the

activities that reduce

condition

To have

workload of the

Take and

baseline

heart.

record the

data

the workload of the

2.

3.

heart.

Assess

patients vital
.
4.

Decreasedcardiac
output

The patient may

OBJECTIVES

5.

2.

3.

4.

For comfort

signs

and

Provide

hygiene to

morning care

the patient

Evaluate

5.

To assess

client reports

for signs of

and evidence

poor

of extreme

ventricular

fatigue,

function

intolerance of

and/or

activity and

impending

progressive

cardiac

shortness of

failure

Decreased urine
output

breath
6.

Monitor

6.

To note

cardiac

effectivene

Vital signs

rhythm

ss of

taken:

continuously

medication

Decrease

T:36.9

7.

RR: 21

stimuli;

HR: 116

provide quiet

7.

adequate

environment

BP: 150/170
8.

9.

Schedule

To promote
rest

8.

To

activities and

maximize

assessments

rest periods

Instruct client

9.

Which can

to avoid/limit

cause

activities

changes in

10. ncourage
relaxation
techniques
11. Provide for

cardiac
pressures
10. To reduce
anxiety and

diet

conserve

restrictions

energy

12. Encourage

11. To maintain

changing

adequate

positions

nutrition

slowly,

12. To reduce

dangling legs

risk for

before

orthostatic

standing

hypotensio

13. Give
information

n
13. To provide

about

encourage

positive signs

ment

of
improvement

PROBLEM # 2: Ineffective Peripheral Tissue Perfusion related to decreased cardiac output

ASSESSMENT

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EXPECTED
OUTCOME

S:

Ineffective

Ineffective tissue

Short term:

1.

Establish

1.

To build a

Short term:

Peripheral Tissue perfusion is the decrease

After 1-2 hours

therapeutic

good and

O : The patient

Perfusion related

in oxygen resulting in

of nursing

relationship

trusting

shall have

manifested the

to decreased

failure to nourish tissues

interventions,

Assess patients

relationship

verbalized

following:

cardiac output

at the capillary level. An

the patient will

general condition

with the

understanding

abrupt increase in

verbalize

Take and record the

patient

of condition,

pressure brings about a

understanding

patients vital signs

To assess for

therapy

Vital signs

rapid and reversible

of condition,

that contributes to

complications

regimen, side

taken:

vasoconstriction of small

therapy

the patients

To note and

effects of

T:36.9

resistance vessels due to

regimen, side

complaint.

assess for

medications,

RR: 21

their inherent myogenic

effects of

Note current

complicatons

and when to

HR: 116

tone. Prolonged

medications,

situation or

Affecting

contact

BP: 150/170

elevations of pressure

and when to

presence of

systemic

healthcare

can cause a range of

contact

conditions that can

circulation or

provider.

The patient may

more lasting changes in

healthcare

affect perfusion to

perfussion

manifest:

the microcirculation, 2 of

provider.

Hypertension

2.

3.

all body systems

3.

4.

Client at

olyguria

which, remodeling of

capillary refill

small arteries and

conditions

venous

arterioles and rarefaction

associated with

stasis, vessel

of arterioles and

thrombus or emboli

wall injury

Note location of

and

restrictive clothing,

hypercoagula

pressure dressings,

bility

time more
than 3
seconds
warm extremities

capillaries, will be

4.

2.

5.

considered briefly below.

cyanosis and

edema

higher risk for

circular wraps, cast,

pallor on
extremities

Determine history of

6.

5.

That may

or traction device

restrict

Compare skin

circulation to

temperature and

limb. Helps

The patient

paresthesia

7.

color with other limb

differentiate

when assessing

type of

extremity circulation

problems

Assess presence,

6.

location, and degree

identifying or

of swelling or

quantifying

edema formation.

edema in

Measure capillary

involved

time
8.

9.
10.
11.
12.

13.
14.

Useful in

Note clients

extremity
7.

To determine

nutritional and fluid

adequacy of

status

systemic

Inspect lower
extremities for skin
texture
Palpate arterial
pulses
Determine pulse
equality, as well as
intensity
Determine time that
symptoms are
worse, precipitating,
or aggravating
events
Assess motor and
sensory function
Administer
medications such as
antiplatelet agents,
thrombolytics,
antibiotics.

circulation
8.

Protein
energy
malnutrition
and weight
loss make
ischemic
tissues more
prone to
breakdown

9.

That often
accompany
diminished
peripheral
perfusion

10. To determine

level of
circulatory
blockage
11. To evaluate
distribution
and quality of
blood flow,
and success
or failure of
therapy
12. To help
isolate and
differentiate
problems
13. Problems
with
ambulation;
hypersensitivi
ty or loss of
sensation
and
numbness
and tingling
are changes
that can
indicate
neurovascula
r dysfunction

14. To improve
tissue
perfusion or
organ
function

PROBLEM # 3: Acute Pain as evidence by abdominal pain in the epigastric area secondary to intestinal obstruction

NURSING

SCIENTIFIC

S>O

DIAGNOSIS
Acute Pain as

EXPLANATION
Intestinal obstruction

O>patient

evidence

refers to a lack of

After 1-2 hours

condition.

manifested:

abdominal

movement

of

of

Monitor

>pain scale of

pain

intestinal

contents

7/10

epigastric area

through the intestine.

patientt will be

>bloatedness

secondary

Because

able to report

> + epigastric

intestinal

smaller

pain

obstruction

obstructions

ASSESSMENT

after

in

by
the
to

the

of

its

lumen,
are

OBJECTIVES
Short term:

interventions,

pain

in

epigastric

Vital signs

occur more rapidly in

area.

taken:

the small intestine,

T:36.9

but they can occur in

RR: 21

the large intestine as

BP: 150/170

the

cause

location,

Assess

2.

the

3.

4.

made

of

about

3.

interventio
n is more

as soon as it

likely to be

begins

successful

provide comfort

in
alleviating

position

-flank pain

example, twisting of

-distraction/

the

guarding

cause sudden total

behaviors

obstruction, whereas

-increased

provide

such

pain

of

4.

non-

quiet,

relaxing

pharmacol

environment

ogical pain

6.

5.

encourage

which

-diaphoresis

and discomfort.

activities

-sleep
disturbance

7.

to provide
adequate

diversional

could lead to pain

to provide

mgmt.

progressive

-pallor

timely

pt to report pain

situation.

obstruction

the

pain. Instruct the

-weakness

elevated BP

be

choices

change

or

info

encourage

gradually developing

PR,RR,

exact

treatment

manifest:

to

shall reported

pain

measures

leads

data

in

acute problem or a

could

the

can

of

rest

like

socialization with

periods

others and slow,

and

rhythmic

prevent

breathing

fatigue

6.

Administer
analgesics
ordered

as

OUTCOME
Short
term:

baseline

assessment

may

5.

gather

significant

may manifest as an

tumor

To

comprehensive

The patient

For

2.

perform

feelings

and

1.

and

verbalization

obstruction

intestine

pts

record pts VS

decreased

more common and

well. Depending on

1.

EXPECTED

RATIONALE

INTERVENTIONS

nursing

eating

HR: 116

NURSING

to

these
could draw
the

pts

attention
away from
the pain

patient

decreased
flank pain

in

PROBLEM #4: Activity intolerance r/t pain

ASSESSMENT
s>

NURSING
DIAGNOSIS
Activity
intolerance r/t

o> the patient

EXPLANATION
Pain is an unpleasant
sensory and emotional

Short term:
After 2 hours

NURSING INTERVENTIONS
1. Establish rapport
2. Monitor VS
3. Note patients response

of NI, the patient

primarily associated

will identify

with tissue damage or

negative factors

describe in terms such

affecting activity

as damage, or both

intolerance and

Vital signs taken:

that can be a stressor

eliminate or

and move about and

T:36.9

in performing activities

reduce their

degree of assistance

Pain scale of 7/10

Complaints of pain

RR: 21

of daily living due to

HR: 116

the pain being

BP: 150/170

experienced with
certain movements.

The patient may

manifest:

OBJECTIVES

experience which I

manifested:

pain

SCIENTIFIC

May acquire risks

related with

immobility
Further difficulty with

mobility
May develop
insomnia due to
severe pain

effects when
possible.

of weakness, fatigue,
pain, difficulty
accomplishing tasks
and/or insomnia
4. Ascertain ability to stand

necessary/use of
equipment
5. Provide comfort
measures and provide
for relief for pain
6. Encourage patient to
maintain positive
attitude.
7. Instruct patient/SO (s) in
monitoring response
to activity
8. Plan for progressive
increase of activity
level, as tolerated by
the patient
9. Involve patient/SO (s) in
planning of activities

RATIONALE
1. To gain patient and
trust and
cooperation
2. To obtain baseline
data
3. Symptoms may be
result of/or
contribute to
activity
intolerance
4. To determine
current status
and needs
associated with
participation in
needed/desired
activities
5. Enhance ability to
participate in
activities
6. To enhance sense of
well being
7. To indicate need to
alter activity level
8. Both activity
tolerance and
health status may
improve with
progressive

EXPECTED
OUTCOME
Short term:
The patient
shall have
identified negative
factors affecting
activity intolerance
and eliminate or
reduce their
effects when
possible

PROBLEM #5: Readiness for enhanced knowledge as evidence by expressing interest in learning about disease
condition
ASSESSMENT

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

OBJECTIVES

NURSING
INTERVENTIONS
1.

S:

Establish

RATIONALE
1.

EXPECTED
OUTCOME

To build a

Readiness for

The first requirement in

Short term:

therapeutic

good and

Short term:

enhanced

for wellness is a desire

After 1 hour of

relationship

trusting

The patient

O : The patient

knowledge as

to attain a higher level

nursing

Assess patients

relationship

shall have

manifested the

evidence by

of well being. The

interventions, the

general condition

with the

verbalized

following:

expressing

patient must express

patient will

patient

understanding

interest in

readiness to engage

verbalize

the patients vital

To assess

of information

to health

learning about

and learn interventions

understanding of

signs

for

gained.

teachings

disease

that will help him reach

information

Verify clients

complicatio

given

condition

that next level.

gained.

level of

ns

Listens intently

2.
3.

4.

Take and record

2.

Assessing a patients

knowledge about

knowledge

readiness to respond to

specific topic

assess for

of the topic

wellness diagnosis

Assist client to

complicatio

Explains

5.

involves patient

identify learning

The patient

interviews and

goals

may manifest:

interaction. And

Anxiety
Restlessness
Fear

To note and

ns
4.

Provides

Ascertain

opportunity

readiness for enhanced

preferred

to ensure

management describes

methods of

accuracy

a patient who is willing

learning

and

Assist client to

completene

in her own treatment by

identify ways to

ss of

following

integrate and use

knowledge

recommendations and

information in all

base for

helping set new goals

appropriate areas

future

and able to participate

6.

3.

7.

for herself.

learning
5.

Helps to
frame or
focus
content to
be learned

6.

Identifies
best
approach to
facilitate
learning

7.

Ability to
apply or
use
information
increases
desire to
learn and
retain
information

IX. Drug Study

Medical Management
IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, etc.
a. IVF
MEDICAL

DATE ORDERED,

MANAGEMENT/

DATE PERFORMED,

TREATMENT

DATE CHANGE

GENERAL

INDICATION OR

DESCRIPTION

PURPOSES

D5LR 1L X 8 HRS

Date ordered:
July 2, 2015

For daily maintenance

of body fluids and
nutrition, and for
rehydration.

Treatment for
persons
needing extra
calories who

Date of Results:

cannot tolerate

July 2, 2015

fluid overload.

CLIENTS
RESPONSE TO
TREATMENT
The patient willingly
accepted treatment
and is kept hydrated
as evidenced by
continuous infusion,

Treatment of

improvement in his

shock.

condition and good

skin turgor. There
were no negative
effects noted.

NURSING RESPONSIBILITIES:
BEFORE THE PROCEDURE:
1. Assess vital signs for baseline data, skin turgor, bleeding tendencies, disease or
2.
3.
4.
5.
6.
7.

injury to extremities, status of veins to determine appropriate puncture site.

Consider:
How long the patient is likely to have IV
What kinds of fluids will be infused
What medications the patient will be receiving or is likely to receive
Prepare equipment needed
Perform hand hygiene

DURING THE PROCEDURE:

1. Prepare the client: Introduce self and verify clients activity
2. Explain the procedure to the client (IV infusion can cause discomfort for a few
seconds, but no discomfort while the solution is flowing)
3. Make sure that the clients clothing or gown can be removed over IV apparatus, if
necessary
4. Clean the skin site of entry
5. Assess IV site for any redness, swelling, tenderness, or drainage
6. Ensure appropriate IV flow
AFTER THE PROCEDURE:
1. Label the IV with date and time of attachment
2. Document the time of the start of infusion, flow rate, amount and type of solution
and clients general response
3. Teach the client ways to maintain the infusion system
4. Instruct the client to inform any side effects
5. Monitor patient frequently for:
6.
7.
8.
9.

Signs of infiltration/sluggish flow

signs of phlebitis/infection
well time of catheter and need to be replaced
Condition of catheter dressing

10. Check the level of the IVF:

Correct solution, medication, and volume.

Check and regulate the drop rate.
Change the IVF solution if needed.
Do not connect flexible plastic.

b. Drugs

NAME OF

DATE

ROUTE OR

DRUGS,

ORDERED,

ADMINISTRATION

GENERIC

DATE

DOSAGE AND

NAME, BRAND

TAKEN/GIVEN,

FREQUENCY OF

NAME

DATE CHANGED

ADMINISTRATION

GENERAL

CLIENTS

ACTION,

INDICATION OR

RESPONSE TO

MECHANISM OF

PURPOSES

THE

ACTION

MEDICATION

General action:
Generic name:

Date ordered:

OMEPRAZOLE

July 2, 2015

Brand names:
LOSEC

Date of Results:
July 2, 2015

Antiulcer

It is use to

The patient did

decrease the

not experience

Mechanism of

amount of acid

any adverse

Action:

produced in the

effect.

40 mg TIV O.D.

Inhibits proton pump

PRILOSEC

activity by
binding to
hydrogenpotassium
adenosine
triphosphatase,
located at
secretory
surface of
gastric parietal
cells, to
suppress
gastric acid
secretion.
Nursing Responsibilities
BEFORE
1. Observe 10 Rs of administration of drugs
2. Check doctors order three times and verify the patient
3. Check the label of the drug, its name and its expiration date
4. Wash hands before handling the medication

stomach

5. Assess patients vital signs prior to administering the medication

DURING
1. Administer as indicated (right drug, right dosage, right frequency)
2. Clean the IV insertion for medication with a cotton ball with alcohol.
3. Gradually inject the drug into the port. Slow IV push to prevent infiltration and
phlebitis.
4. Administer cautiously and slowly with aseptic technique.
AFTER
1. Observe for the sensitivity and side effects to the drug
2. Reassess patients level of pain at least 15 and 30 minutes after parenteral
administration
3. Monitor circulatory and respiratory status and bladder and bowel function.
4. Caution ambulatory patient about getting out of bed or walking.

NAME OF

DATE ORDERED,

DRUGS,

DATE

GENERIC NAME,

TAKEN/GIVEN,

BRAND NAME

DATE CHANGED

ROUTE OR
ADMINISTRATION
DOSAGE AND
FREQUENCY OF
ADMINISTRATION

GENERAL
ACTION,
MECHANISM OF
ACTION

INDICATION
OR
PURPOSES

Generic name:

Date ordered:

CEFUROXIME

July 2, 2015

Brand names:

Serious lower

Antibiotic

respiratory tract
infection, UTI,

Mechanism of

skin or skin-

Action:

structure

CEFTIN,

Inhibits cell-wall

infections, bone

ZINACEF

synthesis,

of joint

promoting osmotic

infection,

instability; usually

septicema,

bactericidal.

meningitis and

KEFUROX,

Date of Results:

750 g TIV Q8

General action:

July 2, 2015

gonorrhea
- Pharyngitis
and tonsillitis
- Early lyme
disease

Nursing Responsibilities
BEFORE
6. Observe 10 Rs of administration of drugs
7. Check doctors order three times and verify the patient
8. Check the label of the drug, its name and its expiration date
9. Wash hands before handling the medication
10. Assess patients vital signs prior to administering the medication
DURING
5. Administer as indicated (right drug, right dosage, right frequency)
6. Clean the IV insertion for medication with a cotton ball with alcohol.
7. Gradually inject the drug into the port. Slow IV push to prevent infiltration and
phlebitis.
8. Administer cautiously and slowly with aseptic technique.
AFTER
5. Observe for the sensitivity and side effects to the drug
6. Reassess patients level of pain at least 15 and 30 minutes after parenteral
administration
7. Monitor circulatory and respiratory status and bladder and bowel function.
8. Caution ambulatory patient about getting out of bed or walking.

NAME OF DRUGS,
GENERIC NAME,
BRAND NAME

DATE ORDERED,
DATE
TAKEN/GIVEN,
DATE CHANGED

ROUTE OR
ADMINISTRATION
DOSAGE AND
FREQUENCY OF
ADMINISTRATION

GENERAL
ACTION,
MECHANISM OF
ACTION

INDICATION

OR PURPOSE

Generic name:
METRONIDAZOLE

Date ordered:
July 2, 2015

500 mg TIV Q8

General action:

- Amebic Liver

Antiprotozoal

abscess
- Intestinal

Brand names:
FLAGYL, FLAGYL

Date of Results:
July 2, 2015

Mechanism of

amebiasis

action:

- Trichomonias

ER, FLORAZOLE

Direct acting

ER, NOVO-

trichomonicide and

NIDAZOLE,

amebicide that

FLAGYL IV RTU

works inside and

outside the
intestines. It's
thought to enter the
cells of
microorganisms
that contain
nitroreductase.
forming unstable
compounds that
binds to DNA and
inhibit synthesis,
causing cell death.

Nursing Responsibilities
BEFORE
11. Observe 10 Rs of administration of drugs
12. Check doctors order three times and verify the patient
13. Check the label of the drug, its name and its expiration date
14. Wash hands before handling the medication
15. Assess patients vital signs prior to administering the medication
DURING
9. Administer as indicated (right drug, right dosage, right frequency)
10. Clean the IV insertion for medication with a cotton ball with alcohol.
11. Gradually inject the drug into the port. Slow IV push to prevent infiltration and
phlebitis.
12. Administer cautiously and slowly with aseptic technique.
AFTER
9. Observe for the sensitivity and side effects to the drug
10. Reassess patients level of pain at least 15 and 30 minutes after parenteral
administration
11. Monitor circulatory and respiratory status and bladder and bowel function.
12. Caution ambulatory patient about getting out of bed or walking.

c. Diet
TYPE OF DIET

DATE ORDERED,

GENERAL

INDICATION

DATE

DESCRIPTION

SPECIFIC FOOD

CLIENT'S

TAKEN

RESPONSE AND

TAKEN/GIVEN,

REACTION TO

DATE CHANGED

THE DIET
NPO

NPO (Nothing per

Date ordered:

Orem)

July 2, 2015

stands

for

Nothing Per Orem

take food or drink

which

through mouth.

means

nothing by mouth.
Date of Results:
July 2, 2015

Patient cannot

Doctors use this

on

orders

when

they do not want

the patient to take
in any type of food
or liquid by mouth.
For instance, when
a patient is getting
ready

for

surgery, they are

ordered for NPO.

None

Patient cannot eat

by mouth thought
he can still receive
nutrients needed
by his body via
NGT

Nursing Responsibilities (NPO):

Before:
Check for the doctors order for type of diet preferred.
Explain the importance and purpose of the prescribed diet.
Place an NPO sign on the bed.
Remove all foods at bedside and emphasize strict compliance on the diet
regimen.
During:
Monitor patient closely for compliance of the diet.
Reiterate diet frequently to the patient or SO.
Check bedside for presence of food, remove if necessary.
After:
Assess patients condition.
Document

TYPE OF DIET

NGT

DATE ORDERED,

GENERAL

DATE

DESCRIPTION

INDICATION

SPECIFIC FOOD

CLIENT'S

TAKEN

RESPONSE AND

TAKEN/GIVEN,

REACTION TO

DATE CHANGED

THE DIET

Date ordered:
July 2, 2015
Date of Results:
July 2, 2015

These are special

It It is indicated to
preparations for
patients who are
prevent further
unable to digest
increase in the
solid foods.
patients blood
pressure and to
lower down
cholesterol levels.

none only

As stated by the

medications

patient, there's a
feeling of
discomfort.

IX. Health Teachings

METHOD
M: instructed the patient to take the following
Omeprazole
Cefuroxime
Metronidazole
E: Instructed the client to have adequate bed rest
T: Instructed the client on strict compliance to medication and therapy
H: Instructed patient to always have adequate rest periods in a comfortable
position
Instructed patient to avoid high fat and high sodium content food
Instructed patient to schedule regular follow-up check-up appointments
with physician to monitor progress
O: Instructed client to continue therapy
D: Instructed client on low fat low salt diet