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College of Nursing
R.N.P. Blvd., Carmen Cagayan de Oro City
NCM501x
First Semester
In Partial Requirement for NCM501x
Submitted by:
x)x
x
Table of Contents
I. INTRODUCTION ……………………………………………………
X. PATHOPHYSIOLOGY ……………………………………………..
In 1875, in St. Petersburg, Russia, Fedor Losch was credited with the
initial documentation of amebae in stool. Losch described the amebae in the
stool as having a "round, pear shaped or irregular form and which are in a state
of almost continuous motion."
In 1890, Sir William Osler reported the first North American case of
amebiasis, when he observed amebae in stool and abscess fluid from a
physician who had previously resided in Panama.
In 1913, in the Philippines, Walker and Sellards documented the cyst form of
E histolytica as the infective form of the parasite; in 1925, Dobell further
described
Name: ?
Birthdate: ?
Address: ?
Age: 38 years old
Sex: female
Height: 5’ 4”
Weight: 55 kilograms
Civil Status: Married
Allergy: No known food and drug allergy
Chief complaint: LBM, VOMITING AND FEVER
Diagnosis: Acute Infectious Diarrhea with some dehydration, amoebiasis
Physician: ?
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: College Level
Occupation: ?
Income: 4 thousand plus per month
Name of Spouse: ?
Number of Children: 4
Vital signs: (during the first day of assessment)
BP: 90/870 mmHg
Temperature: 36.5 C
Pulse: 96 bpm
Respiration: 24 cpm
III. DEVELOPMENTAL DATA
Based on Sigmund Freud’s theory, Mr. ?belongs to the Genital Stage (13
years and after) since he is 48 years old already in this stage energy is directed
toward attaining a mature sexual relationship. This stage involves a reactivation
of the pre-genital impulses. These impulses are usually displaced and the
individual passes to the genital stage of maturity. An inability to resolve conflicts
can result in sexual problems, such as frigidity, impotence and the inability to
have a satisfactory sexual relationship obviously, Mrs? is a married and has a
good relationship with her husband because I can see it the way Mrs. ? tell us
abut her family. I can see that she is good at decision making and know how to
handle things, but theirs anxiety right now because of his situation so constant
encouragement need to be done.
HISTORY OF PAST AND PRESENT ILLNESS
A case of ? a 48 year old female, married from ? who was diagnosed with
Intestinal Amebiasis with some Dehydration. Patient had her recent amebiasis
when she was just 2 months old and was hospitalized. Two years after her
hospitalization in 1956, she also had a disease namely scabies. Condition started
a day prior to admission as sudden onset of f LBM, soft to watery, mucoid stools
with vomiting and abdominal pain. The patient started to consult at PHS and had
her stool examination and the result showed that she is positive for Amebiasis.
She then started to take metronidazole 1 tab once daily. Signs and symptoms of
amebiasis still persisted and fainted thus the client sought for admission last
December 3, 2006 at 10 o’clock in the evening. Upon admission the patient’s BP
was 90/70 mmHg and a temperature of 36.5 degrees Celsius. Upon physical
examination there was absence of abdominal pain. She was very weak, her eyes
was sunken, her skin was dry and skin turgor was poor. She emphasized that
she used to eat anywhere.
December 5, 2006
11pm
December 6,2006
December 7,2006
December 8, 2006
COMPLETE BLOOD
COUNT
01 2-3 Infection
• Eosinophil
FECALYSIS
URINALYSIS
Generic Date Classification Dosage Mechanism of Indication Contraindication Side Effects Nursing
Name ordered Action Precaution
(Brand
Name)
Metronidaz Decem Antiamoebic 500mg Synthetic For the Contraindicated vertigo, Monitor signs
ole IV ber 5, every 8 compound treatment in: blood headache, and symptoms
500mg 2006 hours with direct of dyscrasias, restlessness, of sodium
every 8 IVT by trichomocidal amebiasi active CNS weakness, retention
hours IVT piggyba and s and disease, first fatigue, Administer dru
by ck to amebicidal other trimester of drowsiness g before or
piggyback IVF activity against intraabdo pregnancy. after meals.
to IV amoeba and minal Cautious use in:
other diarrheal infections coexistent
diseases. Also . candidiasis,
exhibits alcoholism,
antibacterial hepatic
activity against diseases.
obligate
anaerobic
bacteria,
gram-negative
anaerobic
bacilli and
clostridia.
Microaerophili
c streptococci
and most
aerobic
bacteria are
resistant.
ANATOMY AND PHYSIOLOGY
VIII. PATHOPHYSIOLOGY
Definition:
Amebiasis
Is caused by transmission by ingestion of fecally contaminated food or
water, or sexually by anal intercourse.
It is caused by a protozoan called Entamoeba histolytica.
It is characterized by diarrhea, vomiting and abdominal pain.
Predisposing Factors
Age (48 years old)
History of amebiasis at the age of 2 years old
Precipitating Factors
Environmental factors (lives near the market)
Improper water sanitation
Eating of foods anywhere
Clinical Manifestations
LBM
Abdominal pain
Vomiting
Sunken eyes
Poor skin turgor
Dry skin
(+) Entamoeba histolytica in stool examination result
Schematic Diagram
Ingestion of protozoa
s
(Entamoeba Histolytica)
S/sx: (+)
Invasion in the entamoeba
intestines histolytica in S/E
result
S/sx: Increase
Release of endotoxins gastric
secretions
Inflammation of S/sx:
the intestines - Abdominal
pain
- Fever
Decreased S/sx:
water absorption Increased
intestinal motility
Passage pf Vomiting
S/sx: LBM watery stools
S/sx:
Dehydration -Sunken eyes
-Poor skin turgor
-Dry skin
-Weak in
appearance
XI. IDEAL NURSING MANAGEMENT
INTERVENTIONS:
INTERVENTIONS:
Weigh daily.
Encourage bedrest and/or limited activity during acute
phase of illness.
Recommend rest before meals.
Provide oral hygiene.
Serve foods in well-ventilated, pleasant surroundings,
with unhurried atmosphere, congenial company.
Avoid/limit foods that might cause/exacerbate abdominal
cramping, flatulence (e.g., milk products, foods high in
fiber or fat, alcohol, caffeinated beverages, chocolate,
peppermint, tomatoes, orange juice).
Record intake and changes in symptomatology.
Promote patient participation in dietary planning as
possible.
Encourage patient to verbalize feelings concerning
resumption of diet.
NURSING DIAGNOSIS: Pain, acute
May be related to
Hyperperistalsis, prolonged diarrhea, skin/tissue irritation, perirectal excoriation,
fissures, fistulas
INTERVENTIONS:
“S”
• “Basa pa gyapon akung tae” , as verbalized by the client
“O”
• dry and pale skin
• weak
• watery stool
“A”
• Fluid volume deficit related to vomiting and watery stools
“P”
• At the end of the shift (8hrs.} the pt. will be able to maintain fluid
volume at a functional level as evidenced by a balanced intake &
output record.
“I”
• Maintained bed rest to prevent vomiting and straining at stool.
• Monitored pt’s intake and output. This provides guidelines for fluid
replacement.
• Provided clear/ bland diet and avoid dark-colored, caffeinated and
carbonated beverages. Caffeine and carbonated beverages stimulates
hydrochloric acid production..
• Administered fluids/ volume expanders as prescribed to replace lost
fluids.
• Administered medications as indicated such as famotidine to reduce
gastric acid production & irritation.
“E”
• Goal partially met. The pt was able to receive adequate fluids
throughout the shift but still claims to have defecated watery stools in a
minimum amount. But other than that, the patient was able to maintain
normal vital signs.
“S”
• “Sakit akong tiyan usahay”, as verbalized by the patient.
“O”
• facial grimace
• moderate pain
“A”
• Pain related to irritation of the gastric mucosa
“P”
• At the end of 30 minutes, the patient will verbalize relief of pain and
demonstrates relaxed body posture.
“I”
• Encouraged pt. to verbalize concerns. Reduction of anxiety can
promote relaxation/comfort.
• Encouraged use of relaxation techniques (deep breathing). Help pt. to
rest more effectively and refocuses attention thereby reducing pain
and discomfort.
• Administered medication as indicated analgesics. Relieves pain,
enhances comfort and promote rest.
• We let the patient applied local massage gently to affected areas.\
helps reduce muscle tension.
“E”
• Goal met. The patient was able verbalize relief of pain and demonstrated a
relaxed body posture and is able to sleep or rest.
“S”
• “Cge lagi ko ug libang-linang:, as verbalized by the pt.
“O”
• dry and pale skin
• weak
• watery stool
“A”
• Diarrhea related to
“P”
• At the end of the shift (8hrs.}pt. will verbalized the relief of diarrhea
“I”
• Monitored vital signs; persistent diarrhea may be a sign of bleeding..
• Restrict foods and fluids that promote diarrhea: raw vegetables,
fruits, whole grain cereals, and carbonated drinks.
• Administered fluids/ volume expanders as prescribed to replace lost
fluids.
• Monitored pt’s intake and output. This provides guidelines for fluid
replacement.
• Increased fluid intake of 2500-3000 mL/day. To assist in improving
stool consistency and helps maintain hydration.
“E”
• Goal was partially met. Patients diarrhea reduces it was no longer
like yesterday. Pt. verbalizes that he was improving of getting well.
“S”
• “Gamay raman ang akong gakan-on kay usahay mawala akong
gana sa pag-kaon”, as verbalized by the patient.
• “Niniwang ko karon” as verbalized by the patient.
“O”
• weight=
• dry and pale skin
• vomitus
“A”
• Altered nutrition less than body requirements related to altered absorption of
nutrients.
“P”
• At the end of two days, the patient will be able to attain an optimum
level of nutrition as evidenced by an increase in appetite and
willingness to eat.
“I”
• Encouraged bedrest and limited activity during illness. Decreasing
metabolic needs and in presenting caloric depletion and conserves
energy.
• Recommended rest before meals. Quiets peristalsis and increases
available energy for eating.
• Provided oral hygiene {gurgle water or brushing teeth}. A clean
mouth can enhance the taste of food.
• Resumeed diet as indicated, e.g. clear liquids, bland, low residue
and high protein and calorie.
“E”
• Goal partially met. The patient was able to show willingness to eat
even though he claimed that he doesn’t have the appetite to eat.
“S”
• Luya paman akong lawas”, as verbalized by the patient.
“O”
• Weak
• ambulates with assistance
“A”
• Activity intolerance related to a decrease in energy due to lack of
appetite
“P”
• At the end of the shift the patient will be able to increase his activity level
and perform activities of daily living.
“I”
• Provided adequate rest periods to preserve energy.
• Facilitated range of motion activities both passive and active to
increase muscle strength.
• Assisted the patient in performing his activities of daily living.
• Instructed patient how to do unfamiliar activities and alternate ways
of doing familiar activities to promote independence.
• Give vitamins as prescribed to facilitate trapped energy within the
cells.
“E”
• Goal partially met. Adequate rest and exercises were provided and
the patient was able to perform her activities of daily living but only to
a minimum level.
DISCHARGE PLANS (HEALTH TEACHINGS)
Doenges, M., & Moorhouse M.F Nurse’s Pocket Guide: Nursing diagnosis With
the Interventions, 4th ed. F.A. Davi’s Company Philadelphia USA.
Doenges, M., & Moorhouse M.F Nurse’s Pocket Guide: Nursing diagnosis With
the Interventions, 8th ed. F.A. Davi’s Company Philadelphia USA.
Deglin, J.H & Harvard Vallerand A.H Davi’s Drug guide for Nurses, 8th edition
F.A, Davi’s Company, Philadelphia USA.
Mosby’s Medical and Nursing Dictionary, 2nd ed. The C.V, Mosby Company.
11830 Westline Industrial St. Louis Missouri 63146.
Karch, Amy, 2005, Nursing Drug Guide, Lippincott Williams & Wilkins
Philadelphia, USA
Smeltzer & Bare, medical Surgical Nursing, 10th ed. Vol. 1, Lippincott Williams &
Wilkins, Philadelphia, USA pp.856-857, 581-582
Port, Carol Hattson, concepts of Altered Health Status, 6th ed, lippincott &
Williams, Philadelphia USA, pp.464-465, 583,0634-635
Tortora, Grabinski, 2003, Principles of Anatomy and Physiology 10th ed., John
Wiley & Sons