AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

OBJECTIVES

General Objectives After the case presentation, we the nursing students will be able to acquire new knowledge, improve learned skills and develop desirable attitude towards the care of a patient who underwent incision and drainage for scrotal abscess with cellulitis at hypogastric area.

Specifically, we are able to:

Knowledge y y Define and describe scrotal abscess and cellulitis. Discuss the Anatomy and Physiology of male reproductive system, skin and abdomen. y Explain the pathophysiology of the scrotal abscess with cellulitis in relation to the patients condition. y Compare laboratory results with normal values and diagnostic tests results and identify their clinical significance. y y Formulate nursing care plan that address clients identified problem. Enumerate medications to be administered and know its dosage, actions, adverse/side effects, contraindications and nursing responsibilities involved.

Skills y y Implement the planned care plan to achieve optimal functioning. Apply effective therapeutic communication in conversing with the client as well as to his significant others. y Educate family members about the risk factors for developing scrotal abscess with cellulitis. y Evaluate patients response to medical and nursing interventions.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Attitude y Develop understanding about the clients behavior in relation to experienced illness and help him identify how to cope with it. y Show positive attitude when interacting with the patient who has scrotal abscess with cellulitis. y Maintain positive regards on setting limits in obtaining or unconcealing sensitive information concerning patients reproductive system.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

INTRODUCTION SCROTAL ABSCESS WITH HYPOGASTRIC CELLULITIS  An abscess is a localized collection

of dead neutrophils that has accumulated in a cavity formed by the tissue in which the pus resides due to an infectious process (usually caused by parasites or bacteria: staphylococcus or streptococcus) or other foreign materials (e.g., splinters, bullet wounds, or injecting needles). It is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body. (http://en.wikipedia.org/wiki/Abscess).

Types of Abscess

1. Septic Abscess- abscesses that result from infection.

2. Sterile Abscess- abscesses that is milder in form of the same process caused not by bacteria but by non-living irritants such as drugs.

 Scrotal abscess is an abscess that can be either superficial or intrascrotal, usually the result of infection at the time of castration and absence of drainage from the site. May be accompanied by extensive local cellulitis.  Superficial Scrotal Abscess- abscess is infected hair follicles and infections of scrotal lacerations or minor scrotal surgeries.  Intrascrotal abscess- most commonly arises from bacterial epididymitis, but may also be related to tuberculous infection of the epididymis, a testicular abscess that ruptures through the tunica albuginea, or drainage of appendicitis into scrotum through a patent processus vaginalis.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

 Cellulitis is an inflammation of the connective tissue underlying the skin, that can be caused by a bacterial infection. Cellulitis may be superficial affecting only the surface of the skin but cellulitis may also affect the tissues underlying the skin and can spread to the lymph nodes and bloodstream. (https://www.healthonlineasia.com/forum/forum_posts.asp?TID=50)

 Cellulitis can be complicated by abscess formation. A maxim in microbiology states, "The hallmark of staph infection is abscess formation." This has become a significant concern due to changing patterns of antibiotic resistance in S aureus, particularly MRSA.  It is important to note that patients with diabetes are susceptible to oral sensory, periodontal and salivary disorders, which could increase their risk of developing new and recurrent dental caries. These caries can in turn lead to periapical pathologies like periapical abscess, which is an acute condition presenting as a round to oval pus filled swelling in the alveolar mucosa. It is an extremely painful condition and should be treated immediately, otherwise leading to complications like space infections & cellulitis.  Scrotal abscesses can also occur as a result of extravasation of infected urine from the urethra in patients with a urethral stricture and neurogenic bladder using an external collection device.  Individuals presenting with a scrotal abscess may have symptoms related to the etiology of the abscess such as symptoms of a urinary tract infection or sexually transmitted disease, such as frequency, urgency, dysuria, penile discharge. The diagnosis of a scrotal abscess is often made by history and physical examination. The scrotum is often erythematous and edematous. Scrotal fluctuance may be palpable. Tenderness of the affected epididymis and/or testis may be present. If epididymitis is the source of the abscess, the scrotal wall may be fixed to the underlying epididymis. Scrotal ultrasound is helpful in diagnosing an intrascrotal abscess when an inflammatory mass is present. Scrotal ultrasound can localize the involvement of the abscess to the scrotal wall, epididymis, and/or testis.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Etiology Causes of Scrotal Abscess  Staphylococcus Aureus and Group A Beta Hemolytic Streptococci Causes of Cellulitis  Streptococcus pyogenes or Staphylococcus aureus. Cellulitis  incidence rate of 246/1000 person-years  higher incidence among males  Age (45- 64 years old).  Most common site of infection is lower extremeties (39 %).  Majority of patients were seen in an outpatient setting (738%), and most (820%) had only one episode of cellulitis during the 5-year period studied. There was a very low incidence of cellulitis complications, including necrotizing fasciitis. Cellulitis is fairly common, usually treated in outpatient settings, and is infrequently complicated by erysipelas, lymphadenitis, lymphangitis, or necrotizing fasciitis

(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870381/) Signs and Symptoms of Scrotal Abscess  low-grade fever  chills  heavy sensation in the testicle.  Discharge from the urethra (the opening at the end of the penis)  Discomfort in the lower abdomen or pelvis  Fever  Groin pain  Lump in the testicle  Pain during ejaculation  Pain or burning during urination  Painful scrotal swelling (epididymis is enlarged)

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

 Tender, swollen groin area on affected side  Testicle pain that gets worse during a bowel movement

A physical examination may show:  Presence of pus in the scrotum and in the sorrounding tissues  Tender and enlarged testicle on the affected side

Tests may include:  Complete blood count (CBC)  Testicular ultrasound  Tests to screen for chlamydia and gonorrhea (urethral smear)  Urinalysis  Urine culture (clean catch) -- may need several samples, including initial stream, midstream, and after prostate massage

A scrotal abscess is a suppurative mass with surrounding erythema involving the superficial layers of the scrotal wall. The usual history is of progressive swelling of a small pustule or papule followed by increasing pain and induration or fluctuance.

The incision and drainage of a superficial scrotal abscess can often be performed by infiltrating the area with an anesthetic and intravenous narcotic use. The surgical treatment of an intrascrotal abscess often requires general or spinal anesthesia. Using local anesthesia, simply make a stab incision and drain the abscess. The patient is then instructed to use a sitz bath and to change the dressing frequently. An alternative method of treatment is to unroof the abscess by circumferential excision. This ensures that there is

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

adequate wound drainage. Immunocompromised patients may require intravenous antibiotics and admission.

Fournier gangrene most frequently occurs in a middle-aged diabetic male who presents with swelling, erythema, and severe pain of the entire scrotum, but it is also known to occur in females. In males, the scrotal contents often cannot be palpated because of the marked inflammation. The patient has constitutional symptoms with fever and frequently is in shock. There is often a history of recent urethral instrumentation, an indwelling Foley catheter, or perirectal disease. A localized area of fluctuance cannot be appreciated. These patients require aggressive fluid resuscitation and early surgical consultation for immediate debridement and surgical drainage. Broad-spectrum antibiotics effective against gram-positive, gram negative, and anaerobic organisms should be given as soon as possible in the emergency department.There is anecdotal experience that treatment is enhanced by hyperbaric oxygen.

The management of an intrascrotal abscess, regardless of the cause, requires surgical drainage abscess cavities must be opened and drained, including the testis if it is involved. The cavity should be left open and packed. Fournier gangrene

(necrotizing fasciitis) requires prompt resuscitation and surgical exploration and debridement as well as aggressive antibiotics. Superficial abscesses also require incision and drainage but may be treated in the emergency room/at the bedside depending on the size of the abscess.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

No contraindications to the drainage of an intrascrotal abscess exist, outside of the patient being too ill to withstand surgery. Patients with Fournier gangrene (necrotizing fasciitis) require aggressive resuscitation and institution of broad-spectrum antibiotics at the time of identification and prompt surgical intervention.

ANATOMY AND PHYSIOLOGY

The Male Reproductive System Reproductive system: or genital system is a system of organs within an organism which work together for the purpose of reproduction. Many non-living substances such as fluids, hormones, and pheromones are also important accessories to the reproductive system. Unlike most organ systems, the sexes of differentiated species often have significant differences. These differences allow for a combination of genetic material between two individuals, which allows for the possibility of greater genetic fitness of the offspring. Male reproductive organ (Organa Genitalia Virilia) The organs of the male reproductive system are specialized for the following functions:
y

To produce, keep, and release sperm cells (the male reproductive cell) and semen (the fluid which acts as a protective agent to keep the sperm alive)

y y y

To ejaculate or discharge semen containing sperm To secrete and produce the male sex hormones To produce, keep healthy, and transmit the male reproductive cells and transport it within a protective fluid called semen

To transmit sperm cells within the female reproductive system

Unlike the female reproductive system, most of the male reproductive system is located outside of the body. These external structures include the penis, scrotum, and testicles. Penis: This is the male organ used in sexual intercourse. The body of the penis is cylindrical in shape and consists of three circular shaped chambers. These chambers are made up of special, sponge-like tissue. This tissue contains thousands of large spaces that fill with blood when the man is sexually aroused. As the penis fills with blood, it becomes rigid and erect,

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

which allows for penetration during sexual intercourse. The skin of the penis is loose and elastic to accommodate changes in penis size during an erection. It has three parts: y y Root- which attaches to the wall of the abdomen. Body- shaft of the penis which is composed of fleshy structure which becomes hard when filled with blood during erection. y Glans- which is the cone-shaped part at the end of the penis. Is also called the head of the penis and is covered with a loose layer of skin called foreskin. This skin is sometimes removed in a procedure called circumcision. Testes: are two glandular organs, which secrete the semen; they are suspended in the scrotum by the spermatic cords. The left testis hanging somewhat lower than the right. The average dimensions of the testis are from 4 to 5 cm. in length, 2.5 cm. in breadth, and 3 cm. in the antero-posterior diameter; its weight varies from 10.5 to 14 gm. Each testis is of an oval form, compressed laterally, and having an oblique position in the scrotum. At an early period of fetal life the testes are contained in the abdominal cavity, behind the peritoneum. Before birth they descend to the inguinal canal, along which they pass with the spermatic cord, and, emerging at the subcutaneous inguinal ring, they descend into the scrotum, becoming invested in their course by coverings derived from the serous, muscular, and fibrous layers of the abdominal parietes, as well as by the scrotum. The coverings of the testes are the:  Scrotum: is a cutaneous pouch which contains the testes and parts of the spermatic

cords. It is divided on its surface into two lateral portions by a ridge or raph, which is continued forward to the under surface of the penis, and backward, along the middle line of the perineum to the anus. Of these two lateral portions the left hangs lower than the right, to correspond with the greater length of the left spermatic cord. Its external aspect varies under different circumstances: thus, under the influence of warmth, and in old and debilitated persons, it becomes elongated and flaccid; but, under the influence of cold, and in the young and robust, it is short, corrugated, and closely applied to the testes.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

The Function of the Scrotum -The function of the scrotum appears to be to keep the temperature of the testes slightly lower than that of the rest of the body about one or two degrees Celsius below body temperature (around 37 degrees Celsius or 99 degrees Fahrenheit); higher temperatures may be damaging to sperm count. The temperature is controlled by the scrotum moving the testicles closer to the abdomen when the ambient temperature is cold, and further away when it is hot. Moving the testes away from the abdomen and increasing the exposed surface area allow a faster dispersion of excess heat. This is done by means of contraction and relaxation of the cremaster muscle in the abdomen and the dartos fascia (muscular tissue under the skin) in the scrotum. However, this may not be the main function of the scrotum. The volume of sperm produced by the testes is small (0.1-0.2 ml). In situation were testes are situated within the abdominal cavity that they would be subjected to the regular changes in abdominal pressure that is exerted by the abdominal muscles, this squeezing and relaxing would result in the more rapid emptying of the testes and epididymis of sperm before the spermatozoa were matured sufficiently for fertilization.  Intercrural Fascia: (intercolumnar or external spermatic fascia) is a thin membrane,

prolonged downward around the surface of the cord and testis. It is separated from the dartos tunic by loose areolar tissue.

Cremaster: consists of scattered bundles of muscular fibers connected together into a

continuous covering by intermediate areolar tissue.

 fascia. 

Infundibuliform Fascia: (tunica vaginalis communis [testis et funiculi spermatici]) is

a thin layer, which loosely invests the cord; it is a continuation downward of the transversalis

Tunica Vaginalis: (tunica vaginalis propria testis) is the serous covering of the testis.

It is a pouch of serous membrane, derived from the saccus vaginalis of the perineum.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Vessels and Nerves of the covering of testes

Superficial and deep external pudendal branches of the femoral. Superficial perineal branch of the internal pudendal. Cremasteric branch from the inferior epigastric.

The nerves are the:

Ilioinguinal and lumboinguinal branches of the lumbar plexus Two superficial perineal branches of the internal pudendal nerve Pudendal branch of the posterior femoral cutaneous nerve The veins follow the course of the corresponding arteries while lymphatics end in the inguinal lymph glands. The internal organs of the male reproductive system, also called accessory organs, include the following:
y

Epididymis: The epididymis is a long, coiled tube that rests on the backside of each testicle. It transports and stores sperm cells that are produced in the testes. It also functions to bring the sperm to maturity, since the sperm that emerge from the testes are immature and incapable of fertilization. Consists of a central portion or body; an upper enlarged extremity called the head (globus major) which is intimately

connected with the upper end of the testis by means of the efferent ductules of the gland; and a lower pointed extremity, the tail (globus minor), which is continuous with the ductus deferens, the duct of the testis. The tail is connected with the lower end by cellular tissue, and a reflection of the tunica vaginalis.
y

Vas deferens: is a long, muscular tube that travels from the epididymis into the pelvic cavity, to just behind the bladder. It transports mature sperm to the urethra, the tube that carries urine or sperm to outside of the body, in preparation for ejaculation. Ejaculatory ducts: there are two ejaculatory ducts that are short tubes about 1 cm to terminate at the urethra. These are formed by the fusion of the vas deferens and the seminal vesicles. It empty into the urethra.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

y

Urethra: The urethra is the tube that carries urine from the bladder to outside of the body. In males, it has the additional function of ejaculating semen when the man reaches orgasm. When the penis is erect during sex, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm.

Seminal vesicles- The seminal vesicles are sac-like pouches that attach to the vas deferens near the base of the bladder. It produce a sugar-rich fluid (fructose) that provides sperm with a source of energy to help them move. The fluid of the seminal vesicles makes up most of the volume of a man's ejaculatory fluid, or ejaculate.

Prostate gland: The prostate gland is a walnut-sized structure that is located below the urinary bladder in front of the rectum. The prostate gland contributes additional fluid to the ejaculate. Prostate fluids also help to nourish the sperm. The urethra, which carries the ejaculate to be expelled during orgasm, runs through the center of the prostate gland.

Bulbourethral glands: Also called Cowper's glands, these are pea-sized structures located on the sides of the urethra just below the prostate gland. These glands produce a clear, slippery fluid that empties directly into the urethra. This fluid serves to lubricate the urethra and to neutralize any acidity that may be present due to residual drops of urine in the urethra.

Integumentary System:
Integumentary system is a term used to denote the skin and its appendages. Function: y y y y y y y Protection Sensation Flexibility Excretion Hormone (Vitamin D) production Immunity Homeostasis of body temperature

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Structure of the skin The skin is a thin, relatively flat organ classified as membrane the cutaneous membrane. Two Primary Layers of the Skin Epidermis: superficial primary layer of the skin; made up entirely of keratinized stratified squamous epithelium; derived from ectoderm; also includes hairs , sweat gland, sebaceous glands. Dermis: the deep primary layer of the skin ; made up of fibrous tissue; also includes some blood vessels , muscles, and nerves; derived from mesoderm. Subcutaneos: also called the subcutaneous layer. It is not part of the skin, but lies deep to the dermis and thus forms a connection between the skin and the underlying structures of the body. Nine Regions of the Abdomen 1. Right hypochondriac region 2. Epigastric region 3. Left hypochondriac region 4. Right lumbar region 5. Umbilical region 6. Let lumbar region 7. Right iliac (inguinal) region 8. Hypogastric region 9. Left iliac (inguinal) region

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

PATHOPHYSIOLOGY # 1

Precipitating Factors: -Poor personal hygiene (bathing 2-3 times per week) - Eat 3 or more meals a day with several snacks in between usually accompanied with coke

Predisposing Factors -Age (74)

Low energy expenditure ratio to fat and carbohydrate consumption

Hyperglycemia

Insulin release by beta cells in the pancreas become resistance due to increase in blood glucose

Less glucose enter the cell and results to chronic increase of glucose in the intravascular space; blood become viscous

Type 2 DM develops; manifestation develops

(+) proteinuria

Glucosoria (Sugar +1)

delayed wound healing

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

PATHOPHYSIOLOGY # 2 Precipitating Factors: -Poor personal hygiene (bathing 2-3 times per week) - Sugar + 1 -Spinal injury (C4-C5)from fall y Weakness of both lower extremities resulting to inability to ambulate. y Reduced/limited ability to perform ADL

Predisposing Factors -Age (74)

Exposure to soiled underwear that causes your jock itch characterized by severe itchiness of inguinal and scrotal area.

Skin abrasion occur due to excessive scratching of the irritated area

Break in the continuity of the skin and promotes entrance of microorganisms into the skin

Microorganisms kills the local cell of skin by releasing toxic substances

Neutrophils invade the microorganism by phagocytosis by releasing enzymes that digest it; triggers the release of cytokines that promote inflammatory response

Cytokines also digests body tissues that result to thick, yellow liquid or pus that result to the blockage of the duct that drains the secretion to the skin

Formation of abscess; may devolop complications such as cellulitis

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

PATIENTS DEMOGRAPHIC DATA Clients Name: Mr. J. G. R. Age: 74 years old Sex: Male Civil Status: Married Religion: Roman Catholic Birth date: May 29, 1937 Birth place: Banga, Aklan Current Address: Mangan, Banga, Aklan Educational attainment: College undergraduate (3rd Year Commerce in ACC) Occupation: Farmer, former-Barangay Captain Chief Complaint: swelling and painful scrotum Date and time of admission to E.R.: November 11, 2011, 9:15PM Mode of transportation upon admission: Transported via tricycle with assistance Accompanied by: Son Emotional/mental status upon admission: Alert, oriented and cooperative Admission vital signs: T- 36.9oC (axilla); PR-91 beats per minute; RR-22 breaths per minute; BP- 140/90 mm Hg Medical diagnoses: Scrotal Abscess with Cellulitis: Hypogastric Area Attending physician: Dr. R. A.(General Surgeon) and Dr. W. E. (Medical Doctor) Number of hospital admissions: 3 1. Northwestern Iloilo Hospital (August 1994) 2. Orthopedic Manila Hospital (October 1994) 3. ACMH (November 21, 2011) Ward and bed number: Male Ward Food and drug allergies: shrimps and crabs (seafoods) Height: 5 8 Weight: 74 kgs. Source of information: Primary: Client Secondary: Patients chart; daughter; wife; close relatives.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

II. History of Present Illness The following information was verbalized by the client himself, his wife and daughter. On November 1, 2011 (Tuesday), early in the morning, Mr. J. G. R. felt weak and experienced mild pain on his scrotal area. He scored the pain as 3 using the Pain Rating Scale of 1-10 that is alleviated by rest and can be tolerated thus he did not take any medication or treatment for this. Three days later, the pain worsened, from 3/10 to 6 out of 10 as he scored. He added that this time, his scrotum became inflamed and swollen. He described it as tolerable and can still be alleviated with rest. As days passed by, the client still complains of pain. He described the pain as excruciating and radiating to his hips and hypogastric region. His daughter verbalized that his scrotum increased in size and has a foul odor. As an intervention, she cleans it daily with expired dextrose (D5 NSS), boiled guava leaves and betadine solution. On November 18, 2011, they went to Dr. S.F. for check-up since pain and swelling are still present. As verbalized by the daughter, the physician informed them that there are plenty of pus in the clients scrotum that caused wounds and enlargement of its size. He prescribed them with Arcoxia 90 mg TID and Lasix 40 mg OD. He also ordered them to admit Mr. J. G. R. in hospital after 3 days for further examination and treatment. On November 21, 2011, (3 days after check-up) the client who was accompanied by his son left home at around 8 PM, transported via tricycle and arrived at ACMH ER at around 9 PM. He was conscious, alert and oriented when he was admitted at 9:15PM.

Based on the information from his chart, he was received in ER per wheelchair with assistance accompanied by his son under the service of Dr. R. A. and Dr.W. E. Vital signs taken with RR-22bpm, PR-91bpm, BP-140/90mmHg and Temp-36.90C/axilla. IVF started with PNSS 1 L for 16 hours. Tetanus Toxoid 0.5 ml was injected immediately at right deltoid muscle. Foley catheter inserted and attached to urobag. CBC, CBG, BUN, Lipid Profile, Na, K, FBS, CXR-AP, U/A were requested and taken. The following medications were prescribed: y y y Ciprofloxacin 500mg IVTT q8h Arcoxia 120 mg 1 cap TID Humulin-R 16 units

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

y y y

Ranitidine 50mg IVTT q8h Metronidazole 500mg IVTT q8h Silgram 1.5mg IVTT q8h

He was then transferred to Male Ward in complete bed rest without bathroom privileges. His intake and output were monitored and recorded.

III. PAST MEDICAL HISTORY According to Mr. J. G. R., he is dreadful pain and felt weak prior to admission. Hes completely immunized. He has a BCG scar on his right shoulder yet could not remember the specific date or age when he was immunized. He had experienced childhood illnesses such as cough, flu and chickenpox (age and date unrecalled). Last August 14, 1994, their Barangay had a Clean and Green program, he climbed up a mahogany tree (approximately 30 feet high) to cut off dead branches that might cause accident on the road. But because of strong wind, he fell from the tree. According to his wife, they brought him to DRSTMH but the staff refused their admission since they dont have enough equipments and facilities for his treatment. Mr. J. G. R. was then brought and admitted to Northwestern Iloilo Hospital. He went diagnostic tests such as MRI, CT scan and Xray in different views. It was found out that there was fracture of the cervical spine (C4, C5) which caused him to be temporary paralyzed as verbalized by his wife. After two months, he has been transferred to Orthopedic Manila Hospital for further treatment and rehabilitation. He had been admitted there for 6 months but because of financial constraint, his family decided to bring him back to Mangan and just take care of him at home. He sometimes experiences cough and colds. As an intervention, he increases his fluid intake and took OTC drugs like Paracetamol and Bioflu. He applies liniment (eficascent oil) for muscle aches. He is allergic to seafoods such as shrimps and crabs but no known allergies to medications. As verbalized by his daughter, he usually have rashes and itchiness when he has allergic reactions; then takes Cilistamine (antihistamine) as treatment.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

IV. Lifestyle or Current Health Status Mr. J.G.R. is almost dependent with routine activities of daily living. He needs assistance in performing those activities such as eating, grooming, dressing, bathing and toileting. According to him, sitting on his wheelchair while watching TV is one form of his relaxation at home. He rarely complains of sleeping problem or changes in sleeping pattern. He usually sleeps in supine position with one pillow supporting the head and neck and another pillow on his side. He does not use any sleeping aides. He regularly consumes whole serving of meals usually soft diet. Whenever he is hungry, he eats biscuits such as sky flakes and drink a glass of milk afterward. He has no dentures and no problem with chewing and swallowing as claimed by the patient. Furthermore, he is able to drink approximately 2 to 3 liters of water per day from NAWASA. Upon admission, he weighs 74 kgs but he denies weight loss or gain in the past 6 months. He has bladder and bowel continent, usually defecates 1 to 2 times a day with brownish, well-formed stool and voids 3 to 4 times a day with slightly yellow colored urine. He claimed that he rarely experienced constipation, diarrhea, or other abnormalities in defecation and urination. Mr. J.G.R is drinking alcoholic beverage for about 5 to 10 ml mixed in a cup of coffee every other night before going to sleep and he is not smoking According to him, he is not using eyeglasses for reading and daily activities. He further stated that he does not smoke, likewise, he is not also using eyeglasses.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

V. Family History

Legend: VI: Personal and Social History Mr. J.G.R. is currently living alone since her wife was in manila before he was admitted. He has 7 adult children living independently. His child who is living near his house is the one who prepares his food and attends to his needs such as bathing and during elimination. They are nuclear type of family and mainly patriarchal in terms of decision making. He claimed that he owned a rice field and had other people managed it which served as his source of income for his daily expenses. He is also financially supported by his working children. Mr. J.G.R. was a college undergraduate (3rd year college) last 1959. He is a former Barangay Captain and served for almost 20 years at their barangay. He usually takes his nap at around 2 or 3 PM and spent most of his time eating whenever he felt hungry. He is a Roman Catholic and usually attends Sunday mass together with his child. As claimed by Mr.J.G.R., faith in GOD and prayers are the most important source of his strength in daily living.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

VII. Stressors Physiological (Rest and Comfort) y y y Presence of IVF and catheter. A limited movement to perform ADLs which needs assistance. Disturbed sleep and rest especially at night when taking vital signs and special procedures requiring the client to stay awake. y Copes by constantly telling himself that it is for his own good and God is always there for him. Psychological (Mental and Emotional) y Verbalized that hospitalization is an added financial constraints to him and his family. y Copes with the financial support from his children and family members.

PHYSICAL ASSESSMENT
General Survey Mr. J.G.R. is a 74 years old Filipino. He is conscious and alert, lying on bed on supine position and wearing hospital gown and with adult diaper. He is approximately 58and weighs 74 kgs. He has proportionate body built with symmetrical facial contour. The client has an IVF of D5NM + ketoprofen 100 mg @ the level of 850 ml @ right cephalic vein, patent and infusing well. With foley catheter attached, urobag emptied draining 100 ml amber colored urine.

Skin y y y Dry skin and warm to touch on face and extremities. Fair complexion. There are discrete pigmentations (freckles) on face and some parts of upper extremities. y y Presence of cellulitis in the hypogastric and inguinal area. Have non-prominent scars on both temporal sides of the head both an inch in diameter related to surgical procedure (unrecalled) as stated by his wife.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Use soap during bath, lotion right after bathing, and liniments like efficascent oil as stated by the client.

Hair y y y y Nails y y y Untrimmed and dirty on all extremities. Capillary refill at 2 seconds on both upper and lower left extremities. No clubbing of fingers. Hair loss more prominently on the frontal area. Has more gray hairs on the scalp, smooth in texture and are brittle. Use shampoo when taking a bath as claimed by his daughter. Hair are evenly distributes at the body and all extremities.

Head and Face: y y Neck: y y y y y Symmetrical, proportion to head and shoulder. Trachea at midline Can perform full ROM. No distention of jugular vein noted. Had scars on the lower cervical area, no visible pulsations, masses, swelling or lymph node enlargement noted. Head is normocephalic, symmetrical, facial features equal in size. Had scars on both temporal sides of the head.

Eyes: y y Eyes are symmetrical, aligned, and simultaneously closes and opens. Eyebrows and eyelashes are thick and evenly distributed, symmetrical and move equally. y Eyelids closes symmetrically, are intact with no redness, inflammation or lesions noted.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

y y y y Ears: y y y

Corneas are clear and with no lesions noted. Conjunctivas are clear and shiny. Pupils are equally round and responsive to light and accommodation. The client cant see clearly however he is not wearing eyeglasses at present as claimed by the client.

Color is same as the facial skin, symmetrical, firm and not tender. No lesions, tenderness, redness or swelling noted on the auricle and mastoid area. Presence of few dry cerumen in the ear canal with no discharges, redness, nodule or foul odor noted.

Nose and Sinuses: y y y y Nose is in the midline. Color is same as the facial skin. No discharge, flaring, tenderness, lesions or swelling noted. Has no reduced olfaction as stated by the client. No difficulty in breathing.

Mouth and Pharynx: y y y y Lips are light pink in color, dry and slightly cracked. Tongue is in midline and can be move with full ROM. Oral mucosa is pinkish, smooth, moist and free from lesions and unusual odor. Absence of left lower second molar, right lower first pre-molar, and right upper second molar. Has tooth decay on right lower second pre-molar.

Lungs and Thorax: y y y Respiration rate of 22 breaths per minute. Chest expansion is symmetrical and proportion. Claimed that they have a history of asthma.

Chest and Axillae: y y Presence of hair on the axillae. No lesions noted.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Cardiovascular System: y y y Heart rate of 60 beats per minute. Blood pressure of 90 / 60 mm Hg post operatively. Diagnosed as having DM-2 during course of hospitalization.

Musculoskeletal System: y y Hand grasp (grip strength) score of 3 at both hand. Claimed of having history of fall and resulting to cervical injury to C4-C5 which leads to his inability to ambulate independently. y Has a very limited mobility of both lower extremities (cannot initiate locomotion).

Male Genitourinary System and Rectum: y y Claimed that he experience pain and pruritus in his scrotal area. Has testicular enlargement (scrotal abscess) apprx. 4 inches in diameter, is pus filled (about 2/3 of the scrotum), with open wound (related to incision and drainage procedure). y Diagnosed as having UTI during course of hospitalization.

Neurologic System: y y Conscious. Has history of cervical injury from fall resulting to reduced capability in mobilizing lower extremities.

Cognition/Mental/ Emotional Status: y Able to comprehend and respond appropriately to every nurses questions (immediate pre-op)

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

DISCHARGE PLAN
MEDICATION y Encourage continuous compliance to regimen as prescribed and to always have a supply medication on hand. Rationale: to ensure effectiveness of drug regimen. To reduced duration of the disease state. y Teach the family to watch out for the adverse effects of the medication as manifested by untoward symptoms Rationale: To become aware of when to seek medical attention. ENVIROMENT y Encourage the family to decrease environment stimuli like noise.

Rationale: To provide restful environment for the patient. HYGIENE y Encourage the family to assist in performing proper hygienic measures like bathing, trimming of nails, cleaning of ears, and changing of diaper once soiled. Rationale: To promote comfort and prevent the spread of infection. y Encourage the client to have adequate rest periods. Rationale: To prevent fatigue. y Educate the family about proper wound care. Rationale: To prevent further infection and complication to the patient. DIET y Encourage the family to prepare nutritious foods such as vegetables and fruits. Rationale: Provide more energy, vitamins and minerals necessary in preventing illnesses and repair of damage tissues.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Advice the family to give client foods and drinks rich in vitamin C such as oranges and calamansi juice. Rationale: Vitamin C helps boost patients immunity.

Recommend the restrictions of caffeine and alcohol. Rationale: Because this substance could lessen the effectiveness of the drug.

OUT- PATIENT REFFERAL y Advise the family to ask for financial help from the government officials. Rationale: To reduce financial burden in case they have to return in the hospitals. SOCIAL SUPPORT SYSTEM y Encourage the family to see church leaders for spiritual advice.

Rationale: To continue strengthen their relationship to God and to give some advice in making decisions.

Encourage family members to assist and support the client in meeting his needs and allow open communication. Rationale: To enhance coordination and continuity of care.

Advise significant others of the client the ways in which they can assist client and reduce precipitating factors that may cause or increase pain.

Rationale: To let the folks of the client adjust to the present situation and be able to cooperate through the healing period.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

DRUG STUDY Generic Name: ketoprofen Brand Name: Orudis Dosage and Route: 100 mg IVTT stat Mechanism of Action: Inhibits prostaglandin and leukotriene synthesis and has antibradykinin and lysosomal membrane stabilizing actions. Indications: Relief of mild to moderate pain. Side Effects: CNS: fatigue, tiredness, somnolence, drowsiness GI: diarrhea, vomiting, flatulence GU: dysuria Respiratory: dyspnea, bronchospasm, rhinitis Dermatologic: flushing Adverse Effects: CNS: headache, dizziness GI: nausea, GI pain, constipation Dermatologic: rash, pruritus, sweating, dry mucous membranes Other: peripheral edema, local irritation Nursing Interventions with Rationale: Keep client safe by placing and securing the arm on padded arm board before the operation. Rationale: To prevent falls and promote clients safety. Check the patency of the IV line.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Rationale: Obstructed tubing may alter the administration of the drug.

Assess for redness or inflammation on the IV site. Rationale: Presence of redness or inflammation may suggest local irritation.

Generic Name: bupivacaine Brand Name: Sensorcaine Dosage and Route: 1 ampule for Spinal Anesthesia Mechanism of Action: Bupivacaine binds to the intracellular portion of sodium channel and blocks sodium influx into nerve cells, which prevent depolarization and transmission of pain. Indications: to induce anesthesia on the site of application as well as on the distal part. Adverse Effects: CNS: tinnitus, nervousness, tingling of mouth, tremor, blurred vision, seizure CV: bradycardia, hypotension, cardiotoxicity, arrhytmias, cardiac arrest HEMATOLOGY:hypoxemia RESPIRATORY: apnea, reapiratory depression DERMATOLOGIC: flushing Side Effects: CNS: dizziness, drowsiness GI: nausea and vomiting OTHER: stinging and burning sensation numbness, double vision

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Nursing Interventions with Rationale: Keep client safe by placing and securing the arm on padded armboard before the operation. Rationale: To prevent falls and promote clients safety. Instruct the significant others to keep the client in flat position for 6 to 12 hours after operation. Rationale: To minimize risk of headache. Do not give food or drink for 1 hour after the procedure. Rationale: Possibly gag reflex hasnt return yet which may caused aspiration Instruct the patient and significant others to report any signs of respiratory distress such as difficulty of labored breathing after the operation. Rationale: To immediately provide prompt intervention.

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

DIAGNOSTIC TEST Normal Values 120180g/dL

Date November 21, 2011

Name of Test Specimen Capillary Blood Glucose Blood To the

Rationale determine level of

Result 378g/dL

Singnificance Increased: signifies hyperglycemia. This

glucose in the blood.

November 22, 2011

Complete Blood Count

Blood

To

determine Platelet of 411 x 109/L 150 400 x Increased:This 109/L may indicate thrombocytosis.

significant deviation blood components from values.

normal Hemoglobin 111g/L

135 180g/L

- Decrease:

This

signifies anemia.

Hematocrit 0.33 volFr

0.40 - 0.54 Decreased: volFr

This

signifies anemia.

RBC 3.5 x 10 /L
12

4.6 6.2 x Decreased: 10 /L

12

This

signifies anemia.

Increased: WBC 19.1 x 109/L 109/L

This

4.5 11 x signifies infection as evidence by the presence of pus formation.

Decreased:

This

AKLAN POLYTECHNIC COLLEGE Kalibo, Aklan College of Nursing

Lymphocyte 09

22 40

signifies infection.

Segmenters November 22, 2011 Fasting Blood Sugar Blood To the determine level of 87 11.62 -

50 70

Increased:

This

signifies infection 4.1 5.9 Increased: signifies hypergylcemia. This

glucose in the blood Urinalysis Urine To determine Sugar of +1 not present

significant deviation urine components from values.

Positive: signifies glucosuria.

This

normal Albumin +1

not present

Positive:

This

signifies increase glomerular permeability. (nephropathy)

Reference: Brunettes and Sudarts, Medical Surgical Nursing vol. 2 pages 2212- 2229.